Every finding on record at Tarzana Health and Rehabilitation Center

Based on interview and record review, the facility failed to ensure a resident's right to be honored by not assigning Certified Nursing Assistant 1 (CNA 1) to one of four sampled residents (Resident 4). This deficient practice had the potential to affect the residents' sense of self-worth, self-esteem, and the resident's rights.Findings: During a review of Resident 4's admission Record, the admission Record indicated the facility originally admitted Resident 4 on 1/25/2025 and readmitted the resident on 4/2/2026 with diagnoses that included diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing), paraplegia (loss of movement and/or sensation, to some degree, of the legs), and spondylosis (the natural, age-related wear and tear of the bones and cushioning discs in the backbone). During a review of Resident 4's Minimum Data Set (MDS- a resident assessment tool) dated 7/7/2026, the MDS indicated Resident 4's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience and the senses) was intact. The MDS indicated Resident 4 was dependent on staff with toileting hygiene, shower, lower body dressing, and chair/bed to transfer, and required moderate assistance with oral hygiene, upper body dressing, personal hygiene, and bed mobility (movement). The MDS also indicated that Resident 4 was always incontinent (losing control of the bladder or bowels, leading to accidental leaks) with bowel movement. During a review of Resident 4's Grievance Reporting form dated 6/15/2026, the Grievance Reporting form indicated that Resident 4 requested a change of CNA and did not want CNA 1 to work with the resident, and the corrective actions were not to assign CNA 1 any longer to Resident 4. During a review of Nursing Staffing Assignment and Sign-in Sheet (11 p.m.-7 a.m. shift) dated 8/6/2026, the assignment sheet indicated that CNA 1 was assigned to Resident 4. During a review of Resident 4's Documentation Survey Report, or CNA flow sheet (a daily checklist used by nursing aides to write down routine resident care) for 8/2026, the CNA flow sheet indicated that CNA 1 served Resident 4 on 8/6/2026 during the 11 p.m.-7 a.m. shift. During a concurrent interview on 8/13/2026 at 8:43 a.m., with Resident 4 and Restorative Nursing Assistant 1 (RNA 1) in the resident room, Resident 4 stated that the resident requested not to assign CNA 1 to the resident about two to three months ago, but about a week ago CNA 1 was assigned to Resident 4 and wanted to know why CNA 1 was assigned again to the resident even though the facility promised not to assign CNA 1 to Resident 4. During a concurrent interview and record review on 8/13/2026 at 12:07 p.m., with the Social Services Director (SSD), reviewed Resident 4's Grievance Reporting Form dated 6/15/2026. The SSD stated that Resident 4 concerns was with CNA 1's services during the nighttime, and was determined to not assign CNA 1 to the resident, and the SS Department shared with the Nursing Department and Resident 4 was satisfied with that decision. The SSD would investigate how CNA 1 was assigned to Resident 4 on 8/6/2026, and the facility should have not assigned CNA 1 to honor the resident's wishes and would work on a better system. During a concurrent interview and record review on 8/13/2026 at 12:28 p.m., with Scheduler 2, reviewed Resident 4's Grievance Reporting Form dated 6/15/2026. Scheduler 2 stated that Scheduler 2 did not receive a list from Scheduler 1 for the residents' preferences with the CNA assignments and did not know that CNA 1 should not be assigned to Resident 4, so, on 8/6/2026 for the 11 p.m.-7 a.m. shift, Scheduler 2 scheduled CNA 1 to serve Resident 4. During a concurrent interview and record review on 8/13/2026 at 5:03 p.m., with the Director of Nursing (DON) and the Director of Staff Development (DSD), reviewed Resident 4's Grievance Reporting Form dated 6/15/2026. The DSD stated that the DSD was not aware that CNA 1 should not have been assigned to Resident 4. The DSD reviewed the nursing assignment dated 8/6/2026 for the 11 p.m.-7 a.m. shift and stated that CNA 1 was assigned to Resident 4 that night, but CNA 1 knew that the CNA should not be assigned to Resident 4, so CNA 1 should have informed the licensed nurses and should have asked to change the assignment. During a review of the facility's policy and procedure titled, Resident rights, last reviewed on 4/30/2026, the policy indicated, The right to be-informed in advance, of the care to be furnished and the type of care giver or professional that will furnish care. The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences, except when to do so would endanger the health or safety of the resident or other residents.

Based on observation, interview, and record review, the facility failed to dispose of garbage and refuse properly when: 1. Two dumpsters (a movable waste container designed to be brought and taken away by special collection vehicles, or to a bin that specially designed garbage truck lifts) were overflowing with garbage and were not completely closed when not in use. 2. The area surrounding the dumpsters contained scattered debris on the ground including green beans, carrots, soiled gloves, empty food containers, and plastics. These failures had the potential to attract pests such as rats, cockroaches, flies, and ants, which may spread diseases to 165 of 165 residents living in the facility. Findings: During a concurrent observation and interview on 6/17/2026 at 8:43 a.m., of the dumpster area with the Dietary Supervisor (DS) outside the facility, observed two (2) black dumpsters overflowing with garbage, with their lids not completely closed while not actively being used by the facility staff. The DS stated the lids of the dumpsters were not completely closed. The DS stated the dumpsters need to be completely closed to prevent the trash from attracting flies and rats. The DS further stated pests such as rats carry germs and may potentially spread infection to the residents of the facility. During a concurrent observation and interview on 6/17/2026 at 8:48 a.m., of the dumpster surroundings with the DS outside the facility, observed the area surrounding the dumpsters contained scattered debris on the ground such as green beans, carrots, soiled gloves, empty food containers, and plastics. The DS stated there were food particles of green beans and carrots on the ground in front of the dumpsters and it is not acceptable because leftover foods may attract pests such as rats, which could spread infection to the residents. During a concurrent observation and interview on 6/17/2026 at 9:01 a.m., of the dumpster area with the Housekeeping Supervisor (HS) outside the facility, observed the area surrounding the dumpsters containing scattered debris on the ground such as green beans, carrots, soiled gloves, and trash bags. The HS stated there were food particles left on the ground. The HS stated they clean the dumpster surroundings using a leaf blower and they sweep it after. The HS stated they would not be able to clean the food debris on the ground with the use of a leaf blower. The HS further stated it is important to maintain the cleanliness of the dumpsters' surroundings to prevent the spread of germs to the residents and prevent the dumpster from attracting pests. The HS further stated that it was important for the dumpster lids to be closed to prevent the germs from spreading in the air because when it was open and it could smell. During a review of the facility's policy and procedure (P&P) titled, Disposal of Garbage and Refuse, dated 5/28/2026, the P&P indicated, The facility shall properly dispose of kitchen garbage and refuse Refuse containers and dumpsters are kept outside the facility shall be designed and constructed to have tight fitting lids, doors, or covers. Containers and dumpsters shall be kept covered when not being loaded. Surrounding areas shall be kept clean so that accumulation of debris and insect/rodent attractions are minimized. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 5-501.116 Cleaning Receptacles. Proper storage and disposal of garbage and refused are necessary to minimize the development of odors, prevent such waste from becoming an attractant and harborage of breeding places for insects and rodents, and prevent the soiling of food preparation and food service areas. Improperly handled garbage creates nuisance conditions, makes housekeeping difficult, and may be possible source of contamination of food, equipment, and utensils. Outside receptacles must be constructed with tight-fitting lids or covers to prevent the scattering of the garbage or refuse by birds, the breeding of flies, or the entry of rodents. Proper equipment and supplies must be made available to accomplish thorough and proper cleaning of garbage storage areas and receptacles so that unsanitary conditions can be eliminated.

Based on observation, interview, and record review, the facility failed to ensure the confidential personal information of residents were protected by failing to ensure documents (menu tickets) containing protected information ([PHI]- any health information that can be used to identify specific individual which must remain confidential to prevent harmful consequences) were shredded prior to disposing in the waste container. This deficient practice had the potential to violate 157 of 167 residents' rights for privacy and confidentiality of personal and medical records. Findings: During an observation on 6/16/2026 at 9:16 a.m., of the dishwashing process in the dishmachine area, observed Dietary Aide 2 (DA 2) throwing the leftover foods, plastic and menu tickets into the grey trash can. During an observation on 6/16/2026 at 9:20 a.m., of DA 2 dishwashing process, observed DA 2 throw a menu ticket in the trash. During an observation on 6/16/2026 at 9:21 a.m., of DA 2 dishwashing process, observed DA 2 throw two (2) menu tickets in the trash. During an observation on 6/16/2026 at 9:22 a.m., of DA 2 dishwashing process, observed DA 2 throw 2 menu tickets in the trash. During an observation on 6/16/2026 at 9:24 a.m., of DA 2 dishwashing process, observed DA 2 throw a menu ticket in the trash. During a concurrent observation and interview on 6/16/2026 at 9:25 a.m., of the dishwashing process with the Dietary Supervisor (DS), observed DA 2 continue throwing the menu tickets in the trash while stripping the trays (removing trays from the cart and clearing from the solid waste and food leftovers). The DS stated DA 2 breaks down the tray from food leftovers, and trash. The DS stated the trash goes to the dumpster outside. The DS stated DA 2 threw the meal tickets in the trash and it was not okay as the meal tickets contained residents' names, food preferences, diet, room number, date, likes and dislikes. The DS further stated resident's name is personal information and it was not appropriate to throw it in the trash due to Health Insurance Portability and Accountability Act (HIPPA, a federal law designed to protect sensitive patient health information from being disclosed without the resident's consent). The DS stated HIPPA protects residents' information and they did not protect personal information of the residents by throwing the information in the trash. The DS stated the right process was for DA 2 to separate meal tickets for shredding prior to discarding. During a review of the facility's policy and procedure (P&P) titled, Safeguard of Resident Identifiable Information, dated 5/28/2026, the P&P indicated, It is the facility's policy to implement reasonable and appropriate measures to protect and maintain the safety and confidentiality of the resident's identifiable information and to safeguard against destruction or unauthorized release of information and records. During a review of the facility's P&P titled, Confidentiality of Personal and Medical Records, dated 5/28/2026, the P&P indicated, This facility honors the resident's right to secure and confidential personal and medical records. This includes the right to confidentiality of all information contained in a residents' records, regardless of the form of storage or location of the record. Policy explanation and compliance guidelines: Personal and medical records include all types of records the facility might keep on a resident, whether they are medical, social, fund accounts, automated, or other. Keep confidential is defined as safeguarding the content of information including written documentation, video, audio, or other computer stored information from unauthorized disclosure without the consent of the individual and/or individual's surrogate or representative.

Based on observation, interview, and record review, the facility failed to ensure: 1. Licensed nurses practiced professional standards of practice by failing to carry out the physician's order to have the right arm sling (a supportive medical device designed to immobilize and protect the arm) on at all times during two observations for one of three sampled residents (Resident 2) investigated under position and mobility. This deficient practice resulted in the resident not receiving the necessary care and services in accordance with the professional standards of practice. 2. One of one sampled resident (Resident 12) received treatment and care in accordance with professional standards of practice when a licensed nurse did not assess, document, notify the doctor, obtain orders, and initiate a care plan for a new wound to the resident's left lower leg. This deficient practice resulted in the resident not receiving the necessary care and services in accordance with the professional standards of practice and had the potential to result in Resident 12 experiencing complications including infection and poor wound healing. Findings: a. During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 11/5/2025 with diagnoses including osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage) and a history of falling. During a review of Resident 2's History and Physical (H&P) dated 11/3/2025, the H&P indicated Resident 2 did not have the capacity to understand and make decisions. During a review of Resident 2's Minimum Data Set (MDS- a resident assessment tool) dated 5/15/2026, the MDS indicated the resident is usually understood and usually understood by others. The MDS indicated that Resident 2 is dependent (helper does all the effort) on staff for bathing, upper/lower body dressing, and toileting. During a review of Resident 2's physician orders, the physician orders indicated an order for right arm sling at all time, every shift ordered on 5/22/2026. During a concurrent observation and interview on 6/15/2026 at 9:18 a.m., with Certified Nursing Assistant 2 (CNA 2) in Resident 2's room, CNA 2 stated Resident 2 used to wear a sling all the time on his right arm but has not noticed it lately. CNA 2 stated the sling is meant to help support the resident's arm and prevent pain. During a concurrent observation and interview on 6/16/2026 at 1:22 p.m., in Resident 2's room with Licensed Vocational Nurse 3 (LVN 3), LVN 3 stated there should be a sling on Resident 2's right arm at all times according to the physician's order and was not sure why it was not on at this time. LVN 3 stated the sling is used to immobilize the arm to support his arm and prevent pain. During an interview on 6/16/2026 at 1:26 p.m., with Family Member 2 (FM 2), who was visiting Resident 2, FM 2 stated Resident 2 needs to have his sling on at all times to prevent his arm from hurting. During an interview on 6/18/2026 at 11:46 a.m., with the Director of Nursing (DON), the DON stated licensed nurses and CNAs must follow the physician's orders and clarify if there is any confusion. The DON stated her staff did not follow the physician's order by not applying Resident 2's right arm splint. During a review of the facility`s policy and procedure (P&P) titled, Prevention of Decline in Range of Motion, last reviewed on 5/28/2026, the P&P indicated that the facility will provide treatment and care in accordance with professional standards of practice including appropriate equipment (braces or splints). The P&P further indicates preventative care such as limb immobilization after an injury or surgical procedure to decrease a decline in range of motion. b. During a review of Resident 12's admission Record, the admission Record indicated the facility originally admitted the resident on 9/5/2025 and most recently readmitted the resident on 5/8/2026 with diagnoses including, but not limited to, toxic encephalopathy (brain dysfunction caused by toxic exposure), generalized muscle weakness, and cellulitis (a skin infection that causes swelling and redness) to both legs. During a review of Resident 12's MDS dated [DATE], the MDS indicated the resident had moderately impaired cognition (trouble with thinking, learning, and remembering clearly). The MDS indicated Resident 12 was dependent (helper does all of the effort) on staff for dressing and putting on and taking off footwear and required substantial assistance (helper does more than half of the effort) from staff for toileting and bathing. During an observation and interview on 6/17/2026 at 1:35 p.m., with Certified Nursing Assistant 5 (CNA 5) at Resident 12's bedside, CNA 5 stated Resident 12 did not have any active open wounds that she knew of. CNA 5 then lifted the resident's blankets off her legs and Resident 12 had an adhesive dressing on her left lower leg. Resident 12 stated someone put the dressing on her leg over the weekend but no one had looked at the dressing since then. During a concurrent observation and interview on 6/17/2026 at 2:31 p.m., with Treatment Nurse 1 (TN 1) at Resident 12's bedside, observed Resident 12 had an open wound to the left lower leg. TN 1 stated when he removed the adhesive dressing, there was an open wound under the dressing with a moderate amount of serosanguinous drainage (clear, thin, and pale red liquid that comes from a wound). TN 1 measured the wound and stated the area of the wound was 3.0 x 2.0 centimeters (cm- unit of measurement) and 0.1 cm deep. TN 1 stated the wound type was an open wound due to the resident having fragile skin. TN 1 stated he had not seen the wound before, he did not know who put the adhesive dressing over the wound, and there was no documentation of the wound. TN 1 stated an adhesive dressing should not have been used on the resident's leg because Resident 12 has fragile skin and the adhesive risks causing further damage. TN 1 stated when the wound was first found it should have been measured, documented, and the physician should have been notified. TN 1 stated physician's orders should have been obtained for a treatment and the wound should have been followed up on. TN 1 stated the wound could have potentially become larger and risked becoming worse or infected as it wasn't monitored and treatment wasn't continued after the first bandage was placed. During an interview on 6/18/2026 at 11:28 a.m., with TN 2, TN 2 stated she had worked over the weekend and she was not aware of Resident 12's left lower leg wound until TN 1 told her about it. TN 2 stated there was no way to know when the wound started or who but the original dressing on it. TN 2 stated the doctor should have been notified and an order obtained before a dressing was put on the wound. TN 2 stated the wound could have become worse or gotten bigger since those things were not done. During an interview on 6/18/2026 at 1:16 p.m., with the Director of Nursing (DON), the DON stated she was unaware of who put the first bandage on or why but they should have called the doctor, gotten a treatment order, assessed the wound, developed a plan of care, and reassessed the skin for any other problems. The DON stated those procedures need to be followed to make sure the wound is treated appropriately so the wound doesn't deteriorate or get infected. During a review of the facility's policy and procedure (P&P) titled, Skin Assessment, last reviewed 5/28/2026, the P&P indicated when assessing skin the following should be documented: type of wound, wound measurements, color, type of tissue in wound bed, drainage, odor, pain and other information as appropriate. During a review of the facility's P&P titled, Provision of Quality Care, last reviewed 5/28/2026, the P&P indicated each resident will be provided care and services to attain or maintain his/her highest practicable physical, mental, and psychosocial well-being.

Based on observation, interview, and record review, the facility failed to ensure residents receive proper assistive devices to maintain vision and hearing abilities for three of three sampled residents (Resident 43, Resident 79, and Resident 87) by failing to: 1. Ensure Resident 43 and Resident 79 wore hearing aids (a device worn in or behind the ear designed to amplify sound for individuals who have difficulty hearing) inserted in the ear canal (a small pathway that runs from the outer ear to the middle ear and helps a person hear) as ordered by the physician. This deficient practice had the potential to result in Resident 43 and Resident 79 inability to maintain hearing ability. 2. Ensure ophthalmology (branch of medicine dealing with the diagnosis, treatment, and surgery of eye disorders and visual diseases) consultation was arranged for Resident 87. This deficient practice resulted in a delay in care and potential for worsening vision for Resident 87. Findings: 1.a. During a review of Resident 43's admission Record, the admission Record indicated the facility admitted the resident on 5/1/2022 and re-admitted the resident on 7/5/2022 with diagnoses including but not limited to displaced fracture of surgical neck of left humerus (a break in the upper arm bone near the shoulder joint), urinary tract infection (UTI- an infection in the bladder/urinary tract), and metabolic encephalopathy (a brain dysfunction caused by illness or chemical imbalance). During a review of Resident 43's History and Physical (H&P) dated 12/11/2025, the H&P indicated Resident 43 had decreased hearing and dementia and can make needs known but cannot make medical decisions. During a review of Resident 43's Minimum Data Set (MDS- a resident assessment tool) dated 3/16/2026, the MDS indicated Resident 43 used hearing aids and had moderate difficulty hearing if hearing aids are normally used. The MDS further indicated that the resident was dependent on activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily), and needs substantial or maximal assistance from others. During a review of Resident 43's physician order dated 2/27/2026, the physician order indicated application of hearing aids daily or as needed, turn on at 8:00 a.m., and turn off at 8:00 p.m. Charge after removal one time a day and remove per schedule. During a review of Resident 43's Care Plan (a document that summarizes a resident's needs, goals, and care/treatment) revised 1/6/2026, the Care Plan indicated interventions to ensure the availability and functioning of hearing aids and monitor hearing impairment. During a concurrent observation and interview on 6/18/2026 at 11:46 a.m., with Registered Nurse 1 (RN 1) 1 in the rehabilitation room, observed Resident 43 with both hearing aids not inserted in the ear canal. RN 1 stated the morning Charge Nurse puts the hearing aids on the resident in the morning, and nursing staff should monitor that the hearing aids are in place throughout the day to ensure the resident is able to hear. b. During a review of Resident 79's admission Record, the admission Record indicated the facility admitted the resident on 9/19/2023 with diagnoses including but not limited to conversion disorder with seizures and convulsions (a condition where a person experiences physical or neurological symptoms that are unexplained), hyperlipidemia (high amounts of fats in the blood), and hypertension (HTN-high blood pressure). During a review of Resident 79's H&P dated 9/9/2025, the H&P indicated Resident 79 can make needs known but cannot make medical decisions. During a review of Resident 79's physician order, dated 5/1/2026, the physician order indicated to place hearing aids in ears every day shift; and remove hearing aids, store and charge, every evening shift. During a review of Resident 79's Care Plan dated 6/18/2026, the Care Plan indicated Resident 79 had potential for communication problems related to hearing impairment and wears hearing aids. During an interview on 6/18/2026 at 11:29 a.m., with Licensed Vocational Nurse 7 (LVN 7), LVN 7 stated the morning shift nurse administers the hearing aids when the residents wake up or during first morning medication administration pass; then the evening Charge Nurse collects them at bedtime, places them their case to store them in the medication cart or put them to charge. LVN 7 stated licensed nursing staff receive hearing aids training from the vendor/person who delivers the hearing aids to the facility. During a concurrent observation and interview on 6/18/2026 at 11:33 a.m., with Resident 79 in the hallway outside Resident 79's room, observed Resident 79 sitting in a wheelchair listening to music from a radio without wearing hearing aids; the resident requested increased volume on the radio and stated, I can't hear well, please increase the volume. During a concurrent observation and interview on 6/18/2026 at 11:36 a.m., with LVN 7 in Resident 79's hallway, observed Resident 79 not wearing hearing aids. LVN 7 stated the hearing aids were not administered to Resident 79 during that morning medication pass and should be provided as ordered. During a review of the facility's policy and procedure (P&P) titled, Care and Use of Hearing Aids, revised 4/20/2026, the P&P indicated it is the practice of the facility to assist residents who wear hearing aids with insertion into the ear, to monitor function, provide cleaning and care, and depending on the hearing aid, to routinely check for poor tubing connections. 2. During a review of Resident 87's admission Record, the admission Record indicated that the facility initially admitted Resident 87 on 4/8/2022 with diagnoses including type two (2) diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), cardiomyopathy (a disease of the heart muscle that makes it harder for the heart to pump blood to the rest of the body), hypertension (HTN- high blood pressure), and hyperlipidemia (abnormally high levels of fats in the blood). During a review of Resident 87's MDS dated [DATE], the MDS indicated that Resident 87's cognition (mental action or process of acquiring knowledge and understanding) was intact. The MDS indicated that Resident 87's ability to see in adequate light was adequate (sees fine details, such as regular print in newspapers/books). The MDS indicated Resident 87 required ranging from supervision/touching assistance to maximal assistance (helper does more than half the effort) for physical assistance from staff for activities of daily living (ADLs – activities related to personal care). During a review of Resident 87's progress note dated 12/8/2025, the progress note indicated that Resident 87 had reported vision loss in the left eye and diminishing vision in the right eye, with a history of retinal detachment in the left eye. The progress note also indicated that the plan of care includes consultation with a specialist. During a review of Resident 87's Order Summary Report, the Order Summary Report indicated the following physician orders: -May see ophthalmologist (medical doctor that specialized in eye and vision care), initiated on 2/28/2023. During a review of Resident 87's Social Service assessment dated [DATE], the Social Service Assessment indicated in the Optometry/Ophthalmology and Dental Consult status that resident was referred to ancillary services (supplemental or diagnostic services provided in support of, or in addition to, care delivered by a primary clinician). During a review of Resident 87's care plan (a document that summarizes a resident's needs, goals, and care/treatment) titled, Impaired Visual Function, initiated on 4/11/2022, the care plan indicated interventions including scheduling consultations with eye specialists as needed, identifying factors that may impact visual function, and regularly observing, recording, and reporting any signs or symptoms of acute eye problems. Such symptoms could involve changes in the ability to carry out daily activities, decreased mobility, sudden vision loss, dilated pupils, a gray or milky appearance in the eyes, seeing halos around lights, double vision, tunnel vision, blurred vision, or hazy vision. During an interview on 6/15/2026 at 10:33 a.m., with Resident 87, Resident 87 stated being blind in her left eye, able to see only shadows, and said her right eye's vision was deteriorating. During an interview on 6/17/2026 at 10:10 a.m., with the Social Service Director (SSD), the SSD stated her responsibilities were to interact with residents and collaborating with all departments. Additionally, the SSD stated she coordinates and assists with care planning and addresses residents' needs, including arranging ancillary referrals, transportation, and appointments. During a concurrent interview and record review on 6/17/2026 at 10:50 a.m., with the SSD, reviewed Resident 87's ophthalmology records titled, Evaluation and Management Report, dated 4/28/2026. The SSD stated that although the ophthalmologist was at the facility on 4/28/2026, Resident 87 was not seen because insurance authorization was required beforehand. The evaluation and management report indicated that, To be seen by contracted provider or with authorization. The SSD stated she admitted she missed this step and accepted full responsibility. The SSD stated she will start the insurance authorization process to make sure Resident 87 can be seen by the ophthalmologist, as completing referrals was important. The SSD also emphasized that maintaining vision is crucial for Resident 87's quality of life and failure to do so could risk loss of eyesight. During an interview on 6/18/2026 at 12:41 p.m., with the Director of Nursing (DON), the DON stated that social services are responsible for arranging and scheduling referrals for ancillary services. The DON emphasized the importance of timely ophthalmology consultations to ensure residents receive appropriate assessments and address their needs related to vision maintenance or corrective eyewear. Furthermore, the DON stated that delays in addressing these needs may lead to worsening visual problems. During a review of the facility's Policy and Procedure (P&P) titled, Hearing and Vision Services, reviewed on 5/28/2026, the P&P indicated to ensure residents have access to hearing and vision services as well as adaptive equipment, when appropriate. The facility employs a comprehensive assessment process to identify and evaluate residents' sensory abilities to deliver person-centered care. This process involves gathering historical information from medical records, families, and residents; conducting MDS and care area assessments; ongoing observation of sensory issues; and developing, implementing, and evaluating individualized Care Plans. Staff members are required to refer any identified needs for hearing or vision services or devices to the social worker or social service designee. The social worker or designee is responsible for assisting residents and their families in locating and utilizing available resources to meet vision and hearing needs. Once such services are identified, the social worker or designee will support residents by scheduling appointments and arranging transportation as necessary.

Based on observation, interview, and record review, the facility failed to follow the menu and did not meet nutritional needs when: 1. Staff did not follow the recipe for green beans. 2. Staff did not follow the portion size of three (3) ounces (oz, unit of measurement) and served two (2) oz for pork roast recipe to regular and therapeutic diets (a specialized meal plan prescribed by a healthcare provider or registered dietician to treat a medical condition, manage symptoms, or aid in recovery). 3. Staff did not follow the portion size for large portion diet and served five (5) oz instead of 4.5 oz and for small portion diet served 1.5 oz instead of two (2) oz. This failure had the potential to result in decrease in food flavor, decrease and increase in food and nutrient intake to 157 of 167 residents on regular, therapeutic diets, resulting in unplanned weight loss or unplanned weight gain. Findings: 1. During a review of the facility's menu spreadsheet (a sheet containing the kind and amount of food each diet would receive) titled, Diet Spreadsheet Spring 2026, dated 6/15/2026, the spreadsheet indicated residents on regular texture diet would include the following foods on the tray: Pork roast with gravy three (3) oz Oven roasted potatoes 1/2 cup (c, a household measurement) [NAME] beans 1/2 c Bread or roll with margarine one each French silk pie 1/12 pie Choice of beverage eight (8) fluid oz During an observation on 6/15/2026 at 12:01 p.m., observed dietary staff adding three (3) scoops of butter on the green beans on trayline (an area where foods were assembled from the steamtable [kitchen appliance that keeps food warm at a safe temperature for serving] to resident's plates). During a concurrent interview and record review on 6/15/2026 at 12:28 p.m., with the Dietary Supervisor (DS), reviewed the facility's standardized recipe titled, [NAME] Beans, dated 5/28/2026. The recipe indicated, to add 1 1/2 pounds (lbs., a unit of measurement) to four (4) gallon and three (3) quarts of green beans. The recipe further indicated the steps of cooking were as follows: Add green beans to large stockpot or saucepan Add margarine stir to combine [NAME] 8-10 minutes or until heated through. The DS stated it is important to follow the recipe to provide the right nutrition for the residents. The DS stated they follow the recipe for 150 portions of green beans by using 4 gallon and 3 quarts of green beans then adding 1 1/2 lbs. of butter. The DS further stated adding 3 scoops of butter is not okay as it would be good to measure it to make sure it's the right amount of butter. The DS stated the potential outcome for not measuring ingredients would be not providing the right nutrition to the residents and it could be more nutrients or less nutrients given to the residents. The DS stated the taste would be affected if recipes were not followed. During a review of the facility's policy and procedure (P&P) titled, Standardized Recipes, dated 5/28/2026, the P&P indicated, Standardized recipes will be used for all products prepared and will note appropriate seasonings in order to assure acceptance from the residents. Procedure: Use standardized recipes provided with menu cycle. Standardized recipes will have adjustments for yields needed. Standardized recipes will be adjusted for therapeutic and consistency modifications. 2. During a concurrent observation and interview on 6/15/2026 at 12:09 p.m., of the roast pork in trayline with [NAME] 1, observed one pan of pork roast on the steamtable. [NAME] 1 stated she cooked the roast pork from scratch, and she weighed it after cooking it. During a concurrent observation and interview on 6/15/2026 at 12:10 p.m., of roast pork portion sizes with [NAME] 1, observed [NAME] 1 place the scale to zero (0) then placed the following random pieces of roast pork on the scale with the readings of: first roast pork 2.2 oz second roast pork 2.4 oz third roast pork 2.2 oz During an interview on 6/15/2026 at 12:21 p.m., with the DS, the DS stated the portion size of the roast pork is three (3) oz and two (2) oz for the gravy which are indicated on the spreadsheet and recipes. The DS stated they cut the meat themselves and [NAME] 1 weighed it today to ensure that it is in the right portion size. The DS further stated after [NAME] 1 cuts the roast pork into portions, they are placed back in the oven, so it shrinks. During a review of the facility's standardized recipe titled, Roast Pork with Gravy, dated 5/28/2026, the recipe indicated, portion size 3 oz + gravy. During a review of the facility's menu spreadsheet titled, Diet Spreadsheet Spring 2026, dated 6/15/2026, the spreadsheet indicated residents on small portion diet (diet providing less calorie and protein by reducing portion sizes of food intended for residents needing to lose weight) would include two (2) oz of pork roast with gravy. During a review of the facility's menu spreadsheet titled, Diet Spreadsheet Spring 2026, dated 6/15/2026, the spreadsheet indicated residents on large portion diet (diet providing more calorie and protein by increasing the portion sizes of food intended for residents needing to gain weight) would include 4.5 oz of pork roast with gravy. 3. During an observation on 6/15/2026 at 12:12 p.m., of the roast pork portions, observed there was only one pan of roast pork and there were no separate pans for small portions of roast pork and large portions of roast pork. During an interview on 6/15/2026 at 12:32 p.m., with the DS, the DS stated small and large portion diets roast pork pieces should be in a separate pan to easily identify what to serve small and large portion diets. During an interview on 6/15/2026 at 12:36 p.m., with [NAME] 1 and the DS, [NAME] 1 stated the way she serves large portion diets is getting two (2) oz portion of meat and then another portion of meat. [NAME] 1 stated this meat portions would add up to four (4) oz. [NAME] 1 placed both roast pork portions on the facility food weighing scale, and it read five (5) oz. [NAME] 1 stated she serves a small piece of roast pork for small portion diets and placed it on the scale, and it was two (2) oz. The DS stated [NAME] 1 did not measure the pork roast correctly and the expectation is for [NAME] 1 to follow the spreadsheet. The DS further stated [NAME] 1 should have large and small portions of pork roast separated so she already knows what to serve the residents versus eyeballing. The DS stated eyeballing would lead to inaccurate serving portions. During a review of the facility's P&P titled, Diet Manual, dated 5/28/2026, the P&P indicated, A current therapeutic diet manual approved by the Registered Dietician (RD) and medical director is readily available to attending physicians, nursing, and dining services department personnel in order to ensure that all therapeutic diets are prepared as ordered by the attending physician. During a review of the facility's diet manual titled, Small Portions, dated 5/28/2026, the diet manual indicated, Small portions maybe requested by residents with small appetites or who are overwhelmed by regular portions. Small portions must be physician ordered. Ensure residents are being met and the weight can be sustained. Meat suggested portion two (2) oz. During a review of the facility's diet manual titled, Large or Double Portions, dated 5/28/2026, the diet manual indicated, Large portions area available for residents whose calorie or preference needs require larger quantities of food. Large portions must be physician ordered. Meat suggested portion size four (4) oz.

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: 1. Reach in refrigerator gasket was torn. 2. Kitchen and storage areas were not free from dirt and debris. a. Reach-in refrigerator bottom shelves contained bread, cheese and other food debris. b. The walk-in refrigerator shelves had dust buildup. c. Reach-in freezer had dirt and food debris. d. Condiment container had salt, sugar, pepper and artificial sweeteners debris accumulation. e. The can opener has metal shaving residues f. Ice scoop storage had brownish particles. 3. Four (4) of 4 dented cans (a packaged metal food containers that have been physically deformed or crushed) were found with non-dented cans. 4. Dietary Aide 1 (DA 1) did not handwash after touching the lid of the trash can and before touching the packaged bread. 5. Pans were stacked wet in the storage area. 6. Kitchen equipment and surfaces are not of cleanable surface. a. Can opener has black electrical tape b. Knife container had cracks and dirt debris. c. Ten (10) of 10 resident's tray had cracks and chips d. Ice scoop holder is not a cleanable surface 7. The lid container was not covered, and it was stored near the red bucket with sanitizer. 8. Refrigerator in the water room was at 50 degrees Fahrenheit ( F, a scale of temperature). 9. Resident's refrigerator and freezer thermometers were broken. These failures had the potential to result in harmful bacterial growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) in 157 of 167 medically compromised residents who received food and ice from the kitchen. Findings: 1. During an initial kitchen tour observation on 6/15/2026 at 8:25 a.m., of the snack reach-in refrigerator, observed a torn gasket. During an interview on 6/15/2026 at 8:41 a.m., with the Dietary Supervisor (DS), the DS stated they maintain the refrigerator gasket and ensure it was not ripped and there were no holes to maintain the cold refrigerator temperatures. The DS further stated gasket prevents air from going inside the refrigerator resulting in temperatures going up. The DS stated food could get spoiled and residents could potentially get sick from eating spoiled food. During a review of the facility's policies and procedure (P&P) titled, Equipment Maintenance, dated 5/28/2026, the P&P indicated, The maintenance department is responsible for foodservice equipment maintenance. Procedure. 1. The maintenance department is responsible for inspecting equipment annually, or more often, if needed to ensure proper working order. 2. The food and nutrition department should notify maintenance if equipment is not working properly. 2. a. During an initial kitchen tour observation on 6/15/2026 at 8:25 a.m., of the snack reach-in refrigerator, observed bread and cheese debris on the bottom shelves and bread debris on the trays. During an interview on 6/15/2026 at 8:33 a.m., with the DS, the DS stated the dietary staff cleans the refrigerator at the end of the shift but if the staff seen debris they should clean it right away. The DS stated the bread debris on the shelves and crumbs on the trays were probably from the staff who prepared the sandwiches. The DS further stated it was important to maintain the cleanliness of the refrigerator to prevent cross-contamination. The DS stated when food gets contaminated and consumed by the residents, residents could get sick of possible stomach pain and diarrhea. b. During an observation on 6/15/2026 at 8:52 a.m., of the walk-in refrigerator, observed the two (2) silver shelves had dust buildup. During an interview on 6/15/2026 at 11:45 a.m., with the DS, the DS stated there was dust accumulation on the silver shelves inside the walk-in refrigerator and it was not okay due to cross-contamination to food. c. During an observation on 6/15/2026 at 11:26 a.m., of the reach-in freezer, observed food and dust debris on the bottom shelves. During an interview on 6/16/2026 at 11:46 a.m., with the DS, the DS stated there were boxes debris on the bottom of the freezer shelves and it needed to be cleaned to prevent cross contamination of food. The DS stated the dietary staff last cleaned the freezer yesterday because it was delivery day. d. During an observation on 6/15/2026 at 8:42 a.m., of the brown condiment container, observed accumulation of sugar, salt, pepper and artificial sweeteners particles. During an interview on 6/16/2026 at 11:48 a.m., with the DS, the DS stated the condiment container must be clean so it would not contaminate the food and does not attract insects, roaches in the kitchen. The DS stated there were loose condiments accumulation in the containers, so the dietary staff probably did not clean it. e. During an observation on 6/15/2026 at 8:46 a.m., of the can opener, observed dirt and hair-like particles near its blade. During an interview on 6/15/2026 at 8:53 a.m., with the DS, the DS stated the can opener was last used this morning before breakfast and the dietary staff clean it before breakfast serving time. The DS stated there is metal shavings debris on the can opener and it was not okay as it could be a physical contaminant. f. During a concurrent observation and interview on 6/17/2026 at 9:14 a.m., of the ice scoop container with the DS, observed brown residue on the container. The DS stated there should not be brown residue in the scoop container because it could contaminate the ice. During a review of the facility's P&P titled Cleaning Schedules, dated 5/28/2026, the P&P indicated, The Food and Nutrition Service staff shall maintain the sanitation of the Food and Nutrition Department through compliance with written, comprehensive cleaning schedules developed for the community by the Director of Food and Nutrition Services or other clinically qualified nutrition professional. During a review of the facility's P&P titled, Sanitation Inspection, dated 5/28/2026, the P&P indicated, It is the policy of this facility, as part of the department's sanitation program to conduct inspection to ensure food service areas are clean, sanitary and in compliance with applicable state and federal regulations. 1. All food service areas shall be kept clean, sanitary, free from litter, rubbish and protected from rodents, roaches, flies and other insects. 5. Inspections will be conducted but not limited to the following areas: a. dry storage b. freezer c. refrigerator d. dishroom e. compartment sink area f. main production area g. food production area h. general dietary observations. During a review of the facility's P&P titled, Ice Machine, dated 5/28/2026, the P&P indicated, Clean and sanitize ice scoop daily. During a review of Food Code 2022, the Food Code 2022 indicated, 4-602.13 Nonfood-Contact Surfaces. Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. During a review of Food Code 2022, dated 1/18/2022, the Food Code 2022 indicated, 4-601.11 (A) Equipment Food Contact Surfaces and utensils shall be cleaned: (1) Except as specified in (B) of this section, before use with a different type of raw animal food such as beef, fish, lamb, pork or poultry; (2) Each time there is a change from working with raw foods to working with ready-to-eat food; (3) Between uses with raw fruits and vegetables and with time/temperature control for safety food. (4) Before using or storing a food temperature measuring device, and (5) At the time during the operation when contamination may have occurred. During a review of Food Code 2022, the Food Code 2022 indicated, 4-601.11 (E) Except when dry cleaning methods are used as specified under S 4-603.11, surfaces of utensils and equipment contacting food that is not time/temperature control for safety food shall be cleaned: (1) At anytime when contamination may have occurred; (2) At least every 24 hours for iced tea dispensers and consumer self-service utensils such as tongs, scoops, or ladles; (3) Before restocking consumer self-service equipment and utensils such as condiment dispensers and display containers; and (4) In equipment such as ice bins and beverage dispensing nozzles and enclosed components of equipment such as ice makers, cooking oil storage tanks and distribution lines, beverage and syrup dispensing lines or tubes, coffee bean grinders, and water vending equipment: (a) At a frequency specified by the manufacturer, or (b) Absent manufacturer specification, at a frequency necessary to preclude accumulation of soil or mold. 3. During an observation on 6/15/2026 at 11:30 a.m., of the dry storage area, observed a designated area for dented cans, labeled dented cans. During a concurrent observation and interview on 6/15/2026 at 11:40 a.m., of the canned foods with the DS, found four (4) dented cans stored with non-dented cans. The DS stated it was important to separate the dented cans from non-dented cans because the food inside a dented can is contaminated and it was not safe to eat. During an interview on 6/16/2026 at 8:39 a.m., with the DS, the DS stated dented cans caused toxins and botulism (rare but serious illness caused by bacteria leading to difficulty breathing, muscle paralysis and it could be fatal if not treated promptly) that is why it was not safe for consumption. During a review of the facility's P&P titled, Dented or Damaged Cans, dated 5/28/2026, the P&P indicated, Upon delivery, all canned food products should be inspected for safe transport and quality upon receipt. Procedure: Inspect all canned food products for safety and quality upon receipt. Evaluate any dented or damaged cans and return to distributor for credit as needed. During a review of the facility's P&P titled, Dented or Damaged Cans, dated 5/28/2026, the P&P indicated, Cans with Class 1 and 2 defects should be placed on Damaged Goods Shelf. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 3-101.11 Safe Unadulterated, and Honestly Presented. Food shall be safe, unadulterated, and, as specified under 3-601.12, honestly presented. 3-201.11 Compliance with Food Law. A primary line of defense ensuring that food meets the requirements of S3-101.11 is to obtain food from approved sources, the implications of which are discussed below. However, it is also critical to monitor food products to ensure that, after harvesting, processing, they do not fail victim to conditions that endanger their safety, make them adulterated, or compromise their honest presentation. The regulatory community, industry, and consumers should exercise vigilance in controlling the conditions to which foods are subjected and be alert to signs of abuse. FDA considers food in hermetically sealed containers that are swelled or leaking to be adulterated and actionable under the Federal Food, Drug, and Cosmetic Act. Depending on the circumstances, rusted, and pitted or dented cans may also present a serious potential hazard. 4. During an observation on 6/15/2026 at 12:52 p.m., of the food preparation, observed Dietary Aide 1 (DA 1) hold the trash can cover then went to the dry storage area and got the bread without washing her hands. During an interview on 6/15/2026 at 1:00 p.m., with the DS, the DS stated staff should wash their hands when: changing task, as needed when coming from outside, they start cooking they pick up something from the floor hands become dirty. The DS stated dietary staff need to clean and sanitize their hands to prevent cross-contamination and DA 1 should have washed her hands after touching the lid of the trash can before touching the bread to prevent cross-contamination. During a review of the facility' P&P titled, Dietary Employee Personal Hygiene, dated 5/28/2026, the P&P indicated, It Is the policy of this facility to utilize the following as guidelines for employee personal hygiene to prevent contamination of food by food service employee. 3. Hand and Fingernails. a. Hands must be washed prior to beginning of work. b. Hands must always be washed after using the restroom, eating or drinking, smoking, coughing, sneezing, blowing nose, before putting on gloves and after removing gloves. During a review of the facility's P&P titled, Handwashing Guidelines for Dietary Employees, dated 5/28/2026, the P&P indicated, Handwashing is necessary to prevent the spread of bacteria that may cause foodborne illnesses. Dietary employees shall clean their hands in a handwashing sink or approved automatic handwashing facility and may not clean hands in a sink used for food preparation, warewashing, or in a service sink used for the disposal of mop water or similar waste. 6. Frequency of handwashing: dietary employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single service and single use articles and also in the following situations: after hands have touched anything unsanitary i.e., garbage, soiled utensils/equipment, dirty dishes, etc. while preparing food, as often as necessary to remove soil and contamination and to prevent cross contamination when changing task. 5. During an observation on 6/16/2026 at 8:44 a.m., of the pots and pans storage area, observed pans were stacked wet. During an interview on 6/16/2026 at 8:49 a.m., with the DS, the DS stated there were still water droplets on the pans and it was not appropriate to stack the pans wet. The DS stated it was important to air dry the pots and pans before storing because bacteria could grow if they are stacked wet. During a review of the facility's P&P titled, Dish and Utensil Procedure, dated 5/28/2026, the P&P indicated, 6. Dishes, trays and utensils shall be air dried before storage. Do not towel dry. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 4-901.11 Equipment and Utensils, air-drying required. After cleaning and sanitizing equipment and utensils: (A) Shall be air-dried or used after adequate draining as specified in the first paragraph of 40 CFR 180.940 tolerance exemptions for active and inert ingredients for use in antimicrobial formulations (food-contact surface sanitizing solutions), before contact with food and; (B) May not be cloth dried except that utensils that have been air-dried may be polished with cloths that are maintained clean and dry. 6.a. During an observation on 6/16/2026 at 8:46 a.m., of the can opener, observed an electrical tape on the body of the can opener. During an interview on 6/16/2026 at 8:53 a.m., with the DS, the DS stated the electrical tape was used to cover the pointed edges because the staff could bump into it and they replaced the tape every week. The DS stated the electrical tape is not a cleanable surface and if they do not clean the surface, it could build bacteria resulting in cross contamination. During a review of the facility's P&P titled, Manual Warewashing, dated 5/28/2026, the P&P indicated, when cleaning fixed equipment (example: mixers, slicers, and other equipment that cannot be readily be immersed in water): remove parts will be washed and sanitized. b. non-removable parts will be cleaned with detergent and hot water, rinsed, air-dried and sprayed with sanitizing solution. b. During an observation on 6/16/2026 at 8:48 a.m., the knife container had cracks and dirt debris. During an interview on 6/16/2026 at 9:02 a.m., with the DS, the DS stated there was white particles coming off from the knife container when she touched it. The DS stated the knife container has chips and it was not a cleanable surface which could build bacteria. During a review of the facility's P&P titled, Manual Warewashing, dated 5/28/2026, the P&P indicated, Ware washing is the cleaning and sanitizing of utensils and food-contact surfaces of equipment. c. During a concurrent observation and interview on 6/16/2026 at 9:33 a.m., of the resident's trays with the DS, observed 10 of 10 trays with cracks and chips. The DS stated the residents' trays were cracked, broken and had chips and it was not a cleanable surface. The DS stated the trays should not be cracked or chipped because they could cause bacterial contamination of food. During a review of the facility's P&P titled, Dish and Utensil Procedure, dated 5/28/2026, the P&P indicated, 7. Chipped or cracked dishes shall be discarded. d. During an interview on 6/17/2026 at 9:23 a.m., with Certified Nursing Assistant 6 (CNA 6), CNA 6 stated he used cloth-like material as an ice scoop holder but it was not a good scoop holder because it was open and its infection control. CNA 6 stated they do not clean the scoop holder and he was not sure how to clean it. During an interview on 6/17/2026 at 9:25 a.m., with the DS, the DS stated the cloth-like material scoop holder was not a good scoop holder because they do not clean it and it could cause cross contamination to ice and spread infection to the residents. During a review of the facility's P&P titled, Ice Machine, dated 5/28/2026, the P&P indicated, 5. Store ice scoop free from ice in sanitary closed container . Clean and sanitize ice scoop daily. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 4-202.11 Food-Contact Surfaces. (A) Multiuse Food-contact surfaces shall be (1) Smooth (2) Free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections. (3) Free of sharp internal angles, corners, and crevices, (4) Finished to have smooth welds and joints. 7. During a concurrent observation and interview on 6/16/2026 at 9:13 a.m., of the lid storage area with the DS, observed the lid storage was not covered and there was a red bucket with QUAT sanitizer near it. The DS stated the container where the lids were stored was not covered and the chemical could contaminate the lids and it was not okay due to chemical contamination. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 3-307.11 Miscellaneous Sources of Contamination. Food shall be protected from contamination that may result from a factor or source not specified under subparts 3-391 - 3-306. 8. During an observation on 6/17/2026 at 9:07 a.m., of the refrigerator at the water room, observed the inside thermometer refrigerator was at 50 F and the DS placed a new thermometer inside the refrigerator. During an interview on 6/17/2026 at 10:12 a.m., with the DS, the DS stated the thermometer in the refrigerator was not working and it's important to have a working thermometer in the refrigerator to maintain food temperature and not for the food to spoil. During a review of the facility's P&P titled, Calibrating Thermometers, dated 5/28/2026, the P&P indicated, The purpose of this policy is to prevent foodborne illness by ensuring that the appropriate type of thermometer is used to measure internal product temperatures and that thermometers used are correctly calibrated for accuracy. If a thermometer cannot be calibrated, stop using it and replace it with a new thermometer. 9. During a concurrent observation and interview on 6/17/2026 at 9:39 a.m., of the resident's refrigerator with the DS, observed the thermometer inside of the freezer was broken. The DS stated she checked the temperature of the resident's freezer at 5 a.m. this morning and it was important to have a working thermometer in the freezer and refrigerator to check the temperature of the food storage for infection control. The DS stated it was important to maintain the temperature of the refrigerator and freezer so food could not be spoiled. The DS stated residents could potentially get sick and have stomach issues when consuming spoiled foods. During an observation on 6/17/2026 at 9:56 a.m., of the resident's refrigerator, observed the resident's refrigerator temperature at 62 F. During an interview on 6/17/2026 at 10:13 a.m., with the DS, the DS stated the refrigerator thermometer is not working. During a review of the facility's P&P titled, Monitoring of Refrigerator and Freezer Temperature, dated 5/28/2026, the P&P indicated, It is the policy of this facility to maintain temperatures of refrigerator and freezers at the appropriate temperature to promote food safety. This policy also addresses refrigerated storage. All refrigerated storage must be maintained at or below 45 F. All frozen storage must be maintained at a temperature of 0 F. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 4-204.112 Temperature Measuring Devices. (A) In a mechanically refrigerated or hot food storage unit, the sensor of a temperature measuring device shall be located to measure the air temperature or a simulated product temperature in the warmest part of a mechanically refrigerated unit and in the coolest part of a hot food storage unit. (B) Except as specified in (C) of this section, cold or hot holding equipment used for time/temperature control for safety food shall be designed to include and shall be equipped with at least one integral or permanently affixed temperature measuring device that is located to allow easy viewing of the device's temperature display.

Based on observation, interview, and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices for three of thirty-three sampled residents (Resident 1, Resident 10, and Resident 87) by failing to maintain complete and accurate documentation when: 1. Resident 1's 2025 influenza (a contagious respiratory illness caused by influenza viruses that infect the nose, throat, and lungs) vaccine (medications used to prevent diseases usually given by injection or by mouth) status was not in the medical record. 2. Resident 10 was incorrectly documented as English speaking instead of Spanish speaking. 3. Resident 87's active medical diagnosis for vision loss and retinal detachment of the left eye was nit documented on the resident's admission Record. These deficient practices resulted in Resident 1, Resident 10, and Resident 87's medical record containing incomplete and inaccurate information which had the potential to negatively affect Resident 1, Resident 10, and Resident 87's care in the facility. Findings: 1. During a review of Resident 1's admission Record, the admission Record indicated the facility originally admitted the resident on 2/15/2025 and most recently readmitted the resident on 4/2/2026 with diagnoses including, but not limited to, hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) following cerebral infarction (an obstruction of blood flow in the brain that leads to tissue damage) and chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing) with exacerbation (a sudden flare up of symptoms). During a review of Resident 1's Minimum Data Set (MDS – a resident assessment tool) dated 4/7/2026, the MDS indicated the resident had moderately impaired cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) and required substantial assistance (helper does more than half of the effort) from staff for most activities of daily living (ADLs- activities related to personal care). During a concurrent interview and record review on 6/17/2026 at 3:57 p.m., with the Infection Prevention Nurse (IPN), reviewed Resident 1's vaccine record. The IPN stated there was no record of Resident 1 receiving the influenza vaccine in 2025 in the facility medical record. During an interview on 6/18/2026 at 10:02 a.m., with the IPN, the IPN stated Resident 1 received the influenza vaccine at an outside hospital on 7/18/2025 but this was not reflected in Resident 1's facility medical record. The IPN stated the date Resident 1 received the influenza vaccine should be documented so staff are aware the resident got the vaccine and so they don't accidentally administer the vaccine again when it is not needed. During an interview on 6/18/2026 at 12:59 p.m., with Assistant Director of Nursing 1 (ADON 1), ADON 1 stated the facility should have a record of Resident 1's vaccine administration so the facility can provide the record to the resident if they request it and so they don't accidentally give the vaccine to the resident twice. During a review of the facility's policy and procedure (P&P) titled, Influenza Vaccination, last reviewed 5/28/2026, the P&P indicated the resident's medical record will include that the resident received or did not receive the vaccination due to medical contraindication or refusal. 2. During a review of Resident 10's admission Record, the admission Record indicated the facility admitted the resident on 1/27/2026 with diagnoses including, but not limited to, metabolic encephalopathy (the loss of brain function due to a chemical imbalance in the blood) and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). The admission Record indicated the resident's primary language was English. During a review of Resident 10's MDS, dated [DATE], the MDS indicated Resident 10 had severe cognitive impairment. The MDS indicated Resident 10 was dependent (helper does all of the effort) on staff for toileting, bathing, lower body dressing, and putting on and taking off footwear. The MDS indicated Resident 10 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance) for oral hygiene and personal hygiene. The MDS indicated Resident 10's preferred language was Spanish and that she needed or wanted an interpreter to communicate with health care staff. During an interview on 6/15/2026 at 11:29 a.m. with Resident 10, Resident 10 stated she only speaks Spanish. During an interview on 6/15/2026 at 12:37 p.m., with Licensed Vocational Nurse 5 (LVN 5), LVN 5 stated Resident 10 only speaks Spanish. LVN 5 stated she is able to communicate with Resident 10 because she speaks a little bit of Spanish, and she understands Resident 10 enough to provide her care. During a concurrent interview and record review on 6/18/2026 at 12:59 p.m., with ADON 1, reviewed Resident 10's admission Record. ADON 1 stated Resident 10's admission Record should indicate that the resident speaks Spanish, not English. ADON 1 stated there could be miscommunication since Resident 10's language is not listed on the admission Record. During a review of the facility's P&P titled, Documentation in Medical Record, last reviewed on 5/28/2026, the P&P indicated documentation in the medical record will be accurate, relevant, complete, and timely. 3. During a review of Resident 87's admission Record, the admission Record indicated that the facility initially admitted Resident 87 on 4/8/2022 with diagnoses including type two (2) diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), cardiomyopathy (a disease of the heart muscle that makes it harder for the heart to pump blood to the rest of the body), hypertension (HTN- high blood pressure), and hyperlipidemia (abnormally high levels of fats in the blood). During a review of Resident 87's MDS dated [DATE], the MDS indicated that Resident 87's cognition (mental action or process of acquiring knowledge and understanding) was intact. The MDS indicated that Resident 87's ability to see in adequate light was adequate (sees fine details, such as regular print in newspapers/books). The MDS indicated Resident 87 required ranging from supervision/touching assistance to maximal assistance (helper does more than half the effort) for physical assistance from staff for activities of daily living (ADLs – activities related to personal care). The MDS also indicated Resident 87 had no vision related active diagnosis. The MDS also indicated that Resident 87 had no broken or loose teeth, mouth or facial pain. During a review of Resident 87's progress note dated 12/8/2025, the progress note indicated that Resident 87 had reported vision loss in the left eye and diminishing vision in the right eye, with a history of retinal detachment in the left eye. The progress note also indicated that the plan of care includes consultation with a specialist. During a review of Resident 87's Order Summary Report, the Order Summary Report indicated the following physician orders: -May see dentist (medical doctor that specialized in oral care), initiated on 2/28/2023. -May see ophthalmologist (medical doctor that specialized in eye and vision care), initiated on 2/28/2023. During a review of Resident 87's Social Service assessment dated [DATE], the Social Service Assessment indicated in the Optometry/Ophthalmology and Dental Consult status that resident was referred to ancillary services (supplemental or diagnostic services provided in support of, or in addition to, care delivered by a primary clinician). During a review of Resident 87's record titled, Onsite Skilled Dental Care, dated 5/22/2026, the record indicated in the treatment notes that Resident 87 had loose upper bridge teeth. During a review of Resident 87's care plan (a document that summarizes a resident's needs, goals, and care/treatment) titled, Impaired Visual Function, initiated on 4/11/2022, the care plan indicated interventions including scheduling consultations with eye specialists as needed, identifying factors that may impact visual function, and regularly observing, recording, and reporting any signs or symptoms of acute eye problems. Such symptoms could involve changes in the ability to carry out daily activities, decreased mobility, sudden vision loss, dilated pupils, a gray or milky appearance in the eyes, seeing halos around lights, double vision, tunnel vision, blurred vision, or hazy vision. During a concurrent observation and interview on 6/15/2026 at 10:33 a.m., with Resident 87, Resident 87 was awake, attentive, and capable of expressing her needs. Observed Resident 87's upper three left teeth were loose. Resident 87 stated being blind in her left eye, able to see only shadows, and said her right eye's vision was deteriorating. During a concurrent interview and record review on 6/17/2026 at 10:10 a.m., with the MDS Nurse (MDSN), reviewed Resident 87's MDS dated [DATE], progress notes dated 12/8/2025, and admission Record. The MDSN stated that her responsibilities include conducting assessments and evaluations and completing both the MDS and care plan documentation. The MDSN stated that according to the MDS assessment, Resident 87's vision and dental status showed no concerns, and there was no active diagnosis of vision loss or retinal detachment. However, the MDSN stated that there should have been an active diagnosis for Resident 87's vision loss and retinal detachment along with proper documentation of vision and dental status. The MDSN stated the importance of documenting the resident's active medical diagnoses in both the admission Record and the MDS, is so that the healthcare team remains informed about the resident's medical history and can monitor ongoing treatments. Additionally, the MDSN stated that if medical diagnoses, along with current vision and dental status, are not documented accurately, necessary care for residents' vision and dental needs might be missed. During an interview on 6/18/2026 at 12:41 p.m., with the Director of Nursing (DON), the DON stated that there were inaccuracies in both the assessment and documentation of vision and dental status for Resident 87, and the resident's active medical diagnoses for vision and dental health were not reflected. The DON stated that inaccuracies in documentation may hinder Resident 87 from obtaining essential services and could result in delayed care. During a review of the facility's Policy and Procedure (P&P) titled, Documentation in Medical Record, reviewed 5/28/2026, the P&P indicated that licensed staff and interdisciplinary team (IDT- a group of health care professionals with various areas of expertise who work together toward the goals of the residents' care plan) members must record all assessments, observations, and services in the resident's medical record according to state law and facility policy. The P&P outlines documentation principles such as being factual, objective, and focused on the resident; prohibiting false entries; and requiring descriptive, objective information based on direct knowledge of the assessment or service provided. It also emphasizes that documentation should be accurate, relevant, and complete, with enough detail about the resident's care or responses to care. During another review of the facility's P&P titled, Dental Services, reviewed 5/28/2026, the P&P indicated that the residents' dental needs are identified through both physical and MDS assessments, and subsequently incorporated into each resident's care plan. The P&P further stated that oral and dental status must be documented based on assessment findings.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan (a document that outlines a resident's healthcare needs, goals, and the interventions planned to achieve those goals) for two of 33 sampled residents (Resident 3 and Resident 10) by failing to: 1. Address Resident 3's communication impairment. 2. Address Resident 10's primary language (Spanish). This deficient practice had the potential for Resident 3 and Resident 10 to be unable to make their needs known, understand staff, or receive adequate care. Findings: a. During a review of Resident 3's admission Record, the admission Record indicated the facility originally admitted Resident 3 on 3/23/2026 and re-admitted the resident on 5/11/2026 with diagnoses that included toxic encephalopathy (damage to the brain caused by exposure to a harmful substance), acute (sudden onset) respiratory failure (a condition where the lungs cannot release enough oxygen into the blood) with hypoxia (an insufficient amount of oxygen in your body tissues), and dysphagia (difficulty swallowing) following a cerebral infarction (a stroke, loss of blood flow to a part of the brain). During a review of Resident 3's Minimum Data Set (MDS – a resident assessment tool) dated 5/15/2026, the MDS indicated Resident 3 had moderate cognitive (mental action or process of acquiring knowledge and understanding) impairment. The MDS indicated Resident had unclear speech (slurred or mumbled words), usually understood (difficulty communicating some words or finishing thoughts but is able if prompted or given time) and usually understands (misses some part/intent of message but comprehends most conversations). The MDS indicated vision is adequate and does not wear corrective lenses (contacts, glasses, or magnifying glass). The MDS indicated Resident 3 was dependent (helper does all of the effort) with activities of living (ADL – routine activities such as bathing, dressing, and toileting a person performs daily) and mobility. During a review of Resident 3's History and Physical (H&P) dated 5/13/2026, the H&P indicated Resident 3 was non-verbal. The H&P indicated Resident 3 does not have the capacity to understand and make decisions. During an observation on 6/16/2026 at 10:08 a.m., observed Resident 3 lying in bed looking at the television. Resident 3 made eye contact when greeted and offered no verbal response. Observed a sign above Resident 3's head of bed which indicated, Use Communication Board, (a physical or digital communication tool that displays pictures, symbols, letters, or words). Observed there was no communication board present in Resident 3's room. During a concurrent interview and record review on 6/17/2026 at 10:30 a.m., with Assistant Director of Nursing 1 (ADON 1), reviewed Resident 3's care plan titled, The resident has a communication problem and has a communication board related to dysphagia following cerebral infarction, initiated 6/16/2026. ADON 1 stated Resident 3's communication impairment was present before 6/16/2026. ADON 1 stated that Resident 3 would make eye contact with her and nod her head to communicate yes or no. ADON 1 stated a communication care plan for Resident 3 should have been developed when the communication problem was first identified so the appropriate resident specific interventions could have been identified and implemented timely. ADON 1 stated that not having a communication care plan for Resident 3 until 6/16/2026 delayed identifying Resident 3's communication needs and implementing interventions addressing Resident 3's condition. During an interview on 6/18/2026 at 2:07 p.m., with the Director of Nursing (DON), the DON stated care plans are for all the staff to know resident's needs and be able to provide the appropriate care. The DON stated that if care plan is not developed for a specific problem, there is a potential for the problem to be unaddressed or necessary care to be delayed. The DON stated that Resident 3's care plan had not been comprehensive when there was no care plan developed for Resident 3's communication impairment. The DON stated care plans should be comprehensive and personalized for each resident to ensure person-centered care. b. During a review of Resident 10's admission Record, the admission Record indicated the facility admitted the resident on 1/27/2026 with diagnoses including, but not limited to, metabolic encephalopathy (the loss of brain function due to a chemical imbalance in the blood) and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 10's MDS, dated [DATE], the MDS indicated Resident 10 had severe cognitive impairment. The MDS indicated Resident 10 was on staff for toileting, bathing, lower body dressing, and putting on and taking off footwear. The MDS indicated Resident 10 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance) for oral hygiene and personal hygiene. The MDS indicated Resident 10's preferred language was Spanish and that she needed or wanted an interpreter to communicate with health care staff. During an interview on 6/15/2026 at 11:29 a.m. with Resident 10, Resident 10 stated she only speaks Spanish. During an interview on 6/15/2026 at 12:37 p.m., with Licensed Vocational Nurse 5 (LVN 5), LVN 5 stated Resident 10 only speaks Spanish. LVN 5 stated she is able to communicate with Resident 10 because she speaks a little bit of Spanish, and she understands Resident 10 enough to provide her care. During a concurrent interview and record review on 6/18/2026 at 12:59 p.m., with Assistant Director of Nursing 1 (ADON 1), reviewed Resident 10's care plans. ADON 1 stated Resident 10's care plan did not identify the resident's primary language as Spanish and did not indicate any interventions staff should take regarding the resident's language. ADON 1 stated there should be a care plan addressing Resident 10's language and interventions staff should take. ADON 1 stated for example staff may misunderstand the resident and she might not get her needs met. During a review of the facility's policy and procedure (P&P) titled, Comprehensive Care Plans, last reviewed 5/28/2026, the P&P indicated, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental psychosocial needs that are identified in the resident's comprehensive assessment.The care planning process will include an assessment of the resident's strengths and needs, and will incorporate the resident's personal and cultural preferences in developing goals of care.The comprehensive care plan will describe, at a minimum, the following: The services that are furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.Resident specific interventions that reflect the resident's needs and preferences and align with the resident's cultural identity, as indicated. If the resident is non English speaking, the facility will identify how communications will occur with the resident. The care plan will identify the language spoken and tools used to communicate.

Based on observation, interview, and record review, the facility failed to provide proper care and treatment to maintain or improve a resident's communication abilities for one of one sampled residents (Resident 3) investigated under communication-sensory care area by failing to ensure Resident 3 had a communication board. This deficient practice had the potential to cause psychological distress for Resident 3 and delayed the provision of necessary care and treatment. Findings: During a review of Resident 3's admission Record, the admission Record indicated the facility originally admitted Resident 3 on 3/23/2026 and re-admitted the resident on 5/11/2026 with diagnoses that included toxic encephalopathy (a general malfunction, disease, or damage to the brain caused by exposure to a harmful substance), acute (sudden onset) respiratory failure (a condition where the lungs cannot release enough oxygen into the blood) with hypoxia (an insufficient amount of oxygen in your body tissues), and end stage renal disease (ESRD- chronic irreversible kidney failure). During a review of Resident 3's Minimum Data Set (MDS - a resident assessment tool) dated 5/15/2026, the MDS indicated Resident 3 had moderate cognitive (mental action or process of acquiring knowledge and understanding) impairment. The MDS indicated Resident had unclear speech (slurred or mumbled words), usually understood (difficulty communicating some words or finishing thoughts but is able if prompted or given time) and usually understands (misses some part/intent of message but comprehends most conversations). The MDS indicated vision is adequate and does not wear corrective lenses (contacts, glasses, or magnifying glass). The MDS indicated Resident 3 was dependent (helper does all of the effort) with activities of living (ADL - routine activities such as bathing, dressing, and toileting a person performs daily) and mobility. During a review of Resident 3's History and Physical (H&P) dated 3/15/2026, the H&P indicated Resident 3 was non-verbal. The H&P indicated Resident 3 does not have the capacity to understand and make decisions. During an observation on 6/16/2026 at 10:08 a.m., observed Resident 3 lying in bed looking at the television. Resident 3 made eye contact when greeted and offered no verbal response. Observed a sign above Resident 3's head of bed which indicated, Use Communication Board, (a physical or digital communication tool that displays pictures, symbols, letters, or words). Observed there was no communication board present in Resident 3's room. During a concurrent observation and interview on 6/16/2026 at 10:12 a.m., with Certified Nursing Assistant 4 (CNA 4), in Resident 3's room, CNA 4 stated that a communication board is a book used to help with communications when a resident is non-verbal or speech cannot be understood. CNA 4 stated that Resident 3 had been moved two (2) days prior from another room and was not sure if the sign above Resident 3 indicating to use communication board was meant for Resident 3. CNA 4 stated that if the sign above the head was for Resident 3, there should have been a communication board placed with the sign. CNA 4 stated there was no communication board found in Resident 3's room. During an interview on 6/16/2026 at 10:30 a.m., with Licensed Vocational Nurse 6 (LVN 6), LVN 6 stated a communication board is a paper laminated tool used for communication by residents who have language deficit or impairment. LVN 6 stated that if residents need to use a communication board and it is not available, the residents would not be able to communicate their needs. LVN 6 stated that the communication board is very important for Resident 3, who is non-verbal, to be able to pinpoint on the communication board that has pictures what Resident 3 needs. LVN 6 stated that not having a communication board to communicate can cause frustration and stress to Resident 3. LVN 6 stated that as a result, there may be delays in the delivery of care from Resident 3's increased frustration and stress, leading to reluctance in accepting care. During an interview on 6/17/2026 at 10:30 a.m., with Assistant Director of Nursing 1 (ADON 1), ADON 1 stated that Resident 3 is non-verbal and communicates by nodding her head to communicate yes or no. ADON 1 stated that a communication board would help Resident 3 communicate by pointing to the pictures on the board. During an interview on 6/18/2026 at 2:07 p.m., with the Director of Nursing (DON), the DON stated that Resident 3, who is non-verbal, was not provided with a communication board. The DON stated that the communication board is essential for understanding Resident 3's thoughts, such as if the resident is experiencing pain or has specific requests. The DON stated that without the communication board, staff would not know what Resident 3 wants or needs, causing delays in care and preventing timely assistance. The DON further emphasized the importance of the communication board, noting that lack of communication can contribute to feelings such as frustration, depression, sadness, and embarrassment, thereby negatively impacting Resident 3's self-esteem. During a review of the facility's policy and procedure (P&P) titled, Effective Communication - Deaf Resident, last reviewed 5/28/2026, the P&P indicated, 'Effective communication' describes a process of dialogue between individuals. The skills including speaking to others in a way they can understand and active listening and observation of verbal and non-verbal cues. Understanding what the resident is trying to communicate is essential to giving a response.Adaptive techniques include, but are not limited to: Using communication boards or writing materials. During a review of the facility's P&P titled, Promoting/Maintaining Resident Dignity, last reviewed 5/28/2026, the P&P indicated, It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. During a review of the facility's P&P titled, Resident Rights, last reviewed 5/28/2026, the P&P indicated, The resident has a right to be treated with respect and dignity, including: the right to receive services in the facility with reasonable accommodation of resident needs and preferences, except when to do so would infringe upon the rights or health and safety of other residents.

Based on interview and record review, the facility failed to ensure Registered Nurse 2 (RN 2) maintained a current cardio-pulmonary resuscitation (CPR - an emergency, life-saving technique performed when someone's breathing or heartbeat has stopped) certification from a CPR provider whose training includes a hands-on session in accordance with accepted national standards for one of six staff members investigated under competent nurse staffing task. This deficient practice allowed for staff without the appropriate CPR certification to work alongside 165 medically vulnerable residents. Findings: During an employee file review on [DATE] at 1:34 p.m., with the Director of Staff Development (DSD), reviewed RN 2's employee file. The DSD stated RN 2's Basic Life Support (BLS- a sequence of foundational medical procedures used to sustain life during critical emergencies) certification was obtained from an online CPR provider. The DSD stated she (DSD) did not know if RN 2's CPR certification was all web based without the required in-person hands on component. During an interview on [DATE] at 3:24 p.m., with RN 2, RN 2 stated that the BLS course she completed was entirely online. RN 2 stated the BLS training consisted of reading materials, watching videos, and answering questions. RN 2 stated there was no hands-on component or requirement to demonstrate CPR skills. During an interview on [DATE] at 12:46 p.m., with the DSD, the DSD stated RN 2 needed to obtain BLS certification that had the hands-on component where skills are validated. The DSD stated this ensures competency of staff with performing CPR. During a review of the facility's policy and procedure (P&P) titled, Cardiopulmonary Resuscitation (CPR), last reviewed [DATE], the P&P indicated, Staff will maintain current CPR certifications for healthcare providers through a CPR provider whose training include a hand-on session either in physical or virtual instructor lead setting in accordance with accepted national standards. CPR certification which includes an online knowledge component yet still requires in-person skills demonstrations to obtain certification or recertification is also acceptable.

Based on observation, interview, and record review, the facility failed to provide an environment that is free from accident hazards for three of eight sampled residents (Resident 36, Resident 58, and Resident 168) investigated for accidents by failing to: 1. Ensure Resident 36 did not have a nightstand and bedside commode (portable toilet chair) on the floor mat (a mat placed on the floor next to a resident's bed or chair to minimize the impact of a fall). This deficient practice placed Resident 36 at increased risk for injury in the event of a fall. 2. Ensure a water pitcher and food were not at Resident 168's bedside who had a gastrostomy tube (g-tube -feeding tube surgically placed directly into the stomach) and a physician's order for nothing by mouth (NPO-not to eat or drink anything). This deficient practice had the potential to place Resident 168 at increased risk of aspiration (accidentally inhaling food or liquids into the airway and lungs, potentially causing lung infection) and choking (foreign body airway obstruction) and potential to have serious health complications. 3. Ensure Resident 58 had a floor mat placed at Resident 58's bedside. This deficient practice placed Resident 58 at increased risk for injury in the event of a fall. Findings: 1. During a review of Resident 36's admission Record, the admission Record indicated that the facility initially admitted Resident 36 to the facility on [DATE] with diagnoses including unsteadiness on feet, lack of coordination, nondisplaced comminuted (broken bone that has shattered in at least two places) fracture (a break, crack or crush injury) of right tibia (shin bone) and fibula (calf bone) and nondisplaced fracture of lateral (sideways) malleolus (ankle bone) of left fibula. During a review of Resident 36's Minimum Data Set (MDS- a resident assessment tool) dated 6/3/2026, the MDS indicated that Resident 36's cognition (mental action or process of acquiring knowledge and understanding) was moderately impaired. The MDS indicated Resident 36 required ranging from supervision (helper provides touching or contact guard assistance) to dependent (helper does all of the effort) physical assistance from staff for activities of daily living (ADLs – activities related to personal care). The MDS also indicated that Resident 36 used a wheelchair and walker (walking support tool) for mobility devices. During a review of Resident 36's Order Summary Report, the Order Summary Report indicated an order to apply floor safety mat at bedside, dated 12/5/2025. During a review of Resident 36's Care Plan (a document that summarizes a resident's needs, goals, and care/treatment) titled, At risk for falls, revised on 6/15/2026, the care plan identified Resident 36 as being at high risk for falls. The care plan interventions included maintaining a safe environment by keeping floors free from spills and clutter, providing adequate lighting, ensuring that floor mats are properly positioned and flat to avoid tripping hazards, and placing the call light and personal items within easy reach. During a concurrent observation and interview on 6/15/2026 at 11:01 a.m., with Certified Nursing Assistant 1 (CNA 1) in Resident 36's room, observed a nightstand and bedside commode placed on top of the left side floor mat. CNA 1 stated that the floor mat was used for fall precautions. During an interview on 6/15/2026 at 12:14 p.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated that there should not be any objects on top of the floor mats, as these items could create tripping hazards, and cause injuries if the resident hit themselves with it. LVN 1 stated that all nursing staff are responsible for ensuring that floor mats are free from any object or furniture. During an interview on 6/18/2026 at 12:41 p.m., with the Director of Nursing (DON), the DON stated that the floor mat is utilized as a preventative measure for fall precautions. The DON indicated that positioning the floor mat may reduce injury should a resident fall out of bed. Furthermore, the DON stated that nothing should be placed on top of the floor mat, as doing so would negate its intended purpose and could potentially increase the risk of harm if a fall were to occur. During a review of facility's Policy and Procedure (P&P) titled, Fall Prevention Program, reviewed on 5/28/2026, the P&P indicated implement universal environmental interventions that decrease the risk of resident falling, including but not limited to a clear pathway to the bathroom and bedroom doors. The P&P also indicated that each resident's risk factors and environmental hazards will be assessed when creating their comprehensive care plan. 2. During a review of Resident 168's admission Record, the admission Record indicated that the facility initially admitted Resident 168 on 5/21/2025, with diagnoses including type two (2) diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), hypertension (HTN-high blood pressure), and cerebral infarction (loss of blood flow to part of the brain). During a review of Resident 168's MDS dated 5/28/2026, the MDS indicated that Resident 168's cognition (mental action or process of acquiring knowledge and understanding) was intact. The MDS also indicated Resident 168 required ranging from setup or clean-up assistance to supervision/touching assistance for physical assistance from staff for ADLs. The MDS indicated that Resident 168 was on feeding tube. During a review of Resident 168's Order Summary Report dated 6/17/2026, the Order Summary Report indicated the following physician orders: -NPO diet, initiated on 5/21/2025. -Enteral feed (tube feeding) order every shift continuous enteral feeding formula rate: 50 milliliter (ml-unit of measurement) per hour times 20 hours. Start at: On at 2 p.m., off at 10 a.m. or until specify ml has infused to provide 1000ml/1500 kilocalories (kcal-unit of measurement for energy) per day, initiated on 10/17/2025. -Enteral feed order every six (6) hours flush enteral tube with 180 ml of free water via feeding pump every six hours total flush of 720 ml per day. -Enteral feed order every shift enteral feeding: flush enteral tube with 15-30 ml water before and after medication administration, initiated on 5/21/2025. During a review of Resident 168's record titled, speech video swallow study, dated 7/18/2025, the speech video swallow study findings indicated mild oral and severe pharyngeal phase dysphagia (difficulty swallowing in the throat) observed during thin liquid trials, with evidence of potential aspiration events following swallowing. The recommended course was to maintain g-tube feeding as the primary method for nutrition and hydration. During a review of Resident 168's record titled, esophagram (video X-ray of throat and esophagus when you swallow), dated 5/29/2026, the esophagram impression indicated, incomplete esophagram due to determination of the procedure after the patient aspirated contrast into his trachea (windpipe) and left lung bronchi (main breathing tubes inside the lungs). During a review of Resident 168's care plan titled, gastrostomy tube related to dysphagia, revised on 5/30/2025, the care plan indicated that the primary goal is for the resident to remain free from aspiration. Interventions include administering tube feeding as prescribed, addressing any concerns regarding tube feeding with the resident and their family, discussing advantages, disadvantages, and potential complications, monitoring tolerance of tube feeding, arranging for speech therapist evaluation and treatment as ordered, and appropriately observing, documenting, and reporting any signs or symptoms of aspiration. During a concurrent observation and interview on 6/15/2026 at 9:51 a.m., with Certified Nursing Assistant 2 (CNA 2) in Resident 168's room, observed Resident 168 with three water pitchers at Resident 168's bedside table. Resident 168 stated he wants to eat. CNA 2 stated Resident 168 was always requesting to eat. CNA 2 stated that Resident 168 was not allowed to eat anything by mouth and was on g-tube feeding. CNA 2 asked Resident 168 if he was drinking water and Resident 168 stated yes. During a subsequent interview on 6/15/2026 at 2:49 p.m., with CNA 2, CNA 2 stated that about a month ago, he observed Resident 168 drinking water from the pitcher. CNA 2 stated that he reported this to the charge nurse but does not remember which member of the nursing staff he notified. During an interview on 6/16/2026 at 11:24 a.m., with Resident 168, Resident 168 stated that he had previously received water from the nursing staff, but nursing staff removed it. Resident 168 also stated that he was drinking about a pitcher of water daily. Resident 168 stated that he had a recent esophagram/swallow evaluation but had not been informed of the results. Resident 168 further stated that although aware of the physician's order prohibiting oral intake, he believed he could eat now. During an interview on 6/16/2026 at 1:23 p.m., with the Speech Therapist (ST-assess and treat issues related to speech and swallowing disorder), the ST stated that Resident 168 had three previous video swallow evaluations but did not pass for all of them. The ST stated that Resident 168 should continue to be NPO and stay on enteral feeding. The ST stated that he has potential to develop aspiration pneumonia (lung infection caused by inhaling something other than air into your lungs) due to severe aspiration risk from his medical diagnosis. During a concurrent observation and interview on 6/17/2026 at 12:24 p.m., with Resident 168, Resident 168 was observed with an unopened bag of chips and crackers placed on his bedside table. Resident 168 stated that he purchased both the chips and the crackers. During an interview on 6/17/2026 at 12:31 p.m., with the DON and ADON 1, the DON reported that nursing staff had informed her Resident 168 had a water pitcher at bedside. The DON subsequently educated staff to avoid providing water pitchers to residents who are NPO or receiving enteral feeding. The DON also educated the risk of aspiration with Resident 168. ADON 1 stated that monitoring for changes in condition should have occurred, along with initiating an interdisciplinary team (IDT- a group of health care professionals with various areas of expertise who work together toward the goals of the residents' care plan) conference with Resident 168 and his representative, communicating the esophagram results from 5/29/2026, notifying the resident representative, and revising the care plan. ADON 1 explained there was no justification for the lack of documentation and acknowledging these actions should have been completed the previous day but were not. Additionally, ADON 1 further stated that they will be initiating the IDT conference process and educating Resident 168 and their representative. The DON indicated there was a lapse in communication among nursing staff regarding Resident 168's non-compliance with prescribed dietary restrictions, which could place the resident at risk for aspiration. During a telephone interview on 6/18/2026 at 10:39 a.m., with Resident 168's Family Member 1 (FM 1), FM 1 stated that she was never made aware that Resident 168 was drinking or eating prior to the IDT conference on 6/17/2026. During an interview on 6/18/2026 at 12:41 p.m., with the DON, the DON stated the staff did not complete essential steps, such as monitoring for changes in condition, initiating an IDT conference, informing Resident 168 about the esophagram result, and notifying the responsible party when Resident 168 had three water pitchers on 6/15/2026. The DON further stated that the lack of assessment, monitoring, and education regarding the physician's order prohibiting oral intake, based on Resident 168's diagnosis, posed a potential risk of harm to the resident. During a review of the facility's P&P titled, Therapeutic Diet (a diet ordered by a physician, or delegated registered or licensed dietitian, as part of treatment for a disease or clinical condition) Orders, reviewed 5/28/2026, the P&P indicated that therapeutic diets, including mechanically altered diets when suitable, will be tailored to each resident's unique needs based on their assessment. Therapeutic diets may be used in situations such as inadequate nutrition, weight loss, medical conditions, or swallowing difficulties. Additionally, the P&P indicated that dietary and nursing staff are responsible for providing these diets in the correct form and with the proper nutritional content as prescribed. During a review of the facility's P&P titled, Notification of Changes, reviewed on 5/28/2026, the P&P indicated that the facility is required to inform the resident, consult with the resident's physician, and/or notify the resident's family member or legal representative when a change necessitating such notification occurs. The P&P outlined situations warranting notification, including accidents resulting in injury or those with the potential to require physician intervention, as well as significant changes in the resident's physical, mental, or psychosocial condition, which may encompass life-threatening conditions or clinical complications. During a review of facility's P&P titled, Incidents (occurrence or situation that is not consistent with the routine care of a resident or with the routine operation of the organization) and Accidents (any unexpected or unintentional incident, which results or may result in injury or illness to a resident), reviewed 5/28/2026, the P&P indicated that incident reporting serves to facilitate the prompt implementation of appropriate interventions and corrective measures, thereby reducing the likelihood of recurrence and enhancing resident care management. Additionally, the P&P indicated that the resident's family or representative shall be informed of the incident or accident, including any medical orders issued or if hospital transport becomes necessary. 3. During review of Resident 58's admission Record, the admission Record indicated the facility originally admitted the resident on 12/17/2025 and re-admitted the resident on 5/23/2026 with diagnosis that included acute respiratory failure (sudden inability of the lungs to maintain normal respiratory function) with hypoxia (body tissue and organs do not receive enough oxygen to function properly) atelectasis (a partial or complete collapse of a lung) and chronic obstructive pulmonary disorder (COPD - a chronic inflammatory lung disease that causes obstructed airflow from the lungs). During review of Resident 58's History and Physical (H&P) dated 5/24/2026, the H&P indicated Resident 58 does not have the capacity to understand and make decisions. During review of Resident 58's MDS dated [DATE], the MDS indicated Resident 58 had severely impaired cognition; usually made self-understood and sometimes understood others. The MDS indicated that Resident 58 required partial/moderate assistance (helper does less than half the effort) with dressing, shower/bathe self, toileting hygiene and required supervision or touching assistance (helper provides verbal cues and/or touching/steadying/contact guard assistance as resident completes activity) with personal hygiene and oral hygiene. The MDS indicated Resident 58 required partial/moderate assistance with functional mobility. During an observation on 6/16/2026 at 11:20 a.m., observed Resident 58 lying in bed, wearing a risk for falls wrist band. There was no floor mat observed at Resident 58's bedside. During an interview on 6/16/2026 at 4:08 p.m., with CNA 3, CNA 3 stated that Resident 58 is at risk for falls. CNA 3 stated that interventions for residents at risk for falls include ensuring call light within reach. CNA 3 stated that Resident 58 did not have floor mats, what she described as a cushion placed by resident's bed to prevent injury during fall, as she does not find that the facility uses floor mats. During a concurrent interview and record review on 6/17/2026 at 8:37 a.m., with the Assistant Director of Nursing 1 (ADON 1), reviewed Resident 58's Fall Risk Assessment dated 5/23/2026, and care plan (a document that outlines a resident's healthcare needs, goals, and the interventions planned to achieve those goals) titled, Resident at risk for re-occurrence of fall and injury due to the following. initiated 12/17/2025 and last revised 4/21/2026. The Fall Risk Assessment indicated a score of 18. ADON 1 stated that score meant Resident 58 is at risk for falls. The care plan indicated an intervention to apply floor mat at bedside. ADON 1 stated that no floor mats were present in Resident 58's bedside. ADON 1 stated that Resident 58 may sustain injuries in the event of a fall without floor mats applied at Resident 58's bedside. During an interview on 6/18/2026 at 2:15 p.m., with the Director of Nursing (DON), the DON stated the floor mats should have been placed at Resident 58's bedside because it was part of the fall prevention intervention when resident was identified at risk for falls. The DON stated that the floor mat's function is to lessen the impact of the fall in case of a fall incident. The DON stated that the absence of the floor mat during a fall can result in severe injury to Resident 58. During a review of the facility's policy and procedure (P&P) titled, Fall Prevention Program, last reviewed 5/28/2026, the P&P indicated, Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls.The nurse and/or interdisciplinary team will initiate interventions on the resident's care plan, in accordance with the resident's level of risk. During a review of the facility's P&P titled, Resident Rights, last reviewed 5/28/2026, the P&P indicated, Safe environment: The resident has a right to safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and support for daily living safely.

Based on observation, interview, and record review, the facility failed to ensure two of two sampled residents (Resident 49 and Resident 187) did not have a loop or kink (unwanted twist or bend) in their urinary catheter tubing (a hollow tube inserted into the bladder to drain or collect urine). This deficient practice had the potential for the residents to develop a urinary tract infection (UTI- an infection in the bladder/urinary tract). Findings: a. During a review of Resident 187's admission Record, the admission Record indicated the facility admitted the resident on 6/14/2026 with diagnoses including but not limited to metabolic encephalopathy (a brain dysfunction caused by illness or chemical imbalance), severe sepsis with septic shock (a life-threatening blood infection), and abnormalities of gait and mobility (an irregular and unsteady pattern of walking or moving). During a review of Resident 187's History and Physical (H&P) dated 6/16/2026, the H&P indicated Resident 187 had fluctuating capacity to understand and make decisions. During a review of Resident 187's Order Summary Report, dated 6/14/2026, the Order Summary Report indicated a physician order for urinary catheter for 45 days from admission, unless otherwise specified. During an observation on 6/15/2026 at 10:51 a.m., in Resident 187's room, Resident 187's urinary catheter tube was observed with a loop and urine not draining into the urine drainage bag. During a concurrent observation and interview on 6/15/2026 at 11:32 a.m., with Licensed Vocational Nurse 1 (LVN 1), in Resident 187's room, observed Resident 187's urinary catheter tube. LVN 1 stated the urinary catheter tubing should not have a loop because urine will not flow into the urine drainage bag; and the accumulation of urine in the tubing may cause infection. During a concurrent observation and interview on 6/15/2026 at 11:36 a.m., with LVN 5, in Resident 187's room, observed Resident 187's urinary catheter tube. LVN 5 stated Resident 187's urinary catheter tubing should not have loops because the accumulation of urine can cause bacteria growth and infection. b. During a review of Resident 49's admission Record, the admission Record indicated the facility admitted the resident on 5/29/2026 with diagnoses including but not limited to chronic respiratory failure (condition in which not enough oxygen passes from your lungs into your blood), hemiplegia and hemiparesis (a condition that affects the body movement, muscle use, and partial weakness), and functional quadriplegia (paralysis [complete or partial loss of muscle function] of all four limbs). During a review of Resident 49's Minimum Data Set (MDS - a resident assessment tool) dated 6/10/2026, the MDS indicated Resident 49 is dependent on activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily) and had an urinary catheter and UTI in the last 30 days. During a review of Resident 49's Care Plan (a document that summarizes a resident's needs, goals, and care/treatment) initiated 6/9/2026, the care plan indicated an intervention to monitor and report any signs and symptoms of urinary tract infections. During a review of Resident 49's physician order dated 6/9/2026, the physician order indicated an order for urinary catheter due to neurogenic bladder dysfunction (when a person lacks bladder control due to brain, spinal cord or nerve problems). During an observation on 6/15/2026 at 2:14 p.m., in Resident 49's room, Resident 49's urinary catheter tube was observed with a loop and urine not draining into the urine drainage bag. During a concurrent observation and interview on 6/15/2026 at 2:20 p.m., with LVN 7, in Resident 49's room, Resident 49's urinary catheter tube was observed with a loop and urine not draining into the urine drainage bag. LVN 7 stated the urinary catheter should not have loops because urine can back up and cause UTI. During a review of the facility's policy and procedure (P&P) titled, Appropriate Use of Indwelling Catheters, revised on 4/30/2026, the P&P indicated that indwelling urinary catheters will be utilized in accordance with current standards of practice, with interventions to prevent complications to the extent possible.including but not limited to urinary tract infection.

Based on observation, interview, and record review, the facility failed to provide appropriate care and services to provide respiratory care for two of two sampled residents (Resident 14 and Resident 58) investigated under respiratory care area by: 1. Failing to ensure Resident 58 and 14's oxygen nasal cannula (NC - a device that delivers supplemental oxygen directly into the nostrils through two small prongs that rest inside the nostril) was correctly applied. 2. Failing to assess Resident 14's baseline oxygen saturation level before applying PRN (given as needed) oxygen and re-assess oxygen saturation level post-application of PRN oxygen. These deficient practices had the potential to cause Resident 14 and Resident 58 complications associated with oxygen therapy, such as causing oxygen desaturation (the condition of a low blood oxygen concentration and unmonitored oxygen toxicity (too high of blood oxygen concentration), that may result in tissue or organ failure. Findings: a. During review of Resident 58's admission Record, the admission Record indicated the facility originally admitted the resident on 12/17/2025 and re-admitted the resident on 5/23/2026 with diagnosis that included acute respiratory failure (sudden inability of the lungs to maintain normal respiratory function) with hypoxia (body tissue and organs do not receive enough oxygen to function properly) atelectasis (a partial or complete collapse of a lung) and chronic obstructive pulmonary disorder (COPD - a chronic inflammatory lung disease that causes obstructed airflow from the lungs). During review of Resident 58's History and Physical (H&P) dated 5/24/2026, the H&P indicated Resident 58 does not have the capacity to understand and make decisions. During review of Resident 58's Minimum Data Set (MDS - a resident assessment tool) dated 3/25/2026, the MDS indicated Resident 58 had severely impaired cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses); usually made self-understood and sometimes understood others. The MDS indicated that Resident 58 required partial/moderate assistance (helper does less than half the effort) with dressing, shower/bathe self, toileting hygiene and required supervision or touching assistance (helper provides verbal cues and/or touching/steadying/contact guard assistance as resident completes activity) with personal hygiene and oral hygiene. The MDS indicated Resident 58 required partial/moderate assistance with functional mobility. The MDS indicated Resident 58 is on oxygen treatment while a resident at the facility. During a review of Resident 58's physician orders dated 5/23/2026, the physician orders indicated an order for oxygen via NC two (2) liters per minute (LPM- unit of measurement for oxygen), may titrate (adjust) to maintain SPO2 (measurement of oxygen circulating in the blood) greater or equal to 92% every shift. During a review of Resident 58's care plan (a document that summarizes a resident's needs, goals, and care/treatment) titled, The resident has continuous oxygen therapy related to acute respiratory failure, initiated 1/7/2026, the care plan indicated an intervention to monitor for sign and symptoms of respiratory distress and report to MD PRN: Respirations, pulse oximetry (measure of oxygen saturation). During a concurrent observation and interview on 6/16/2026 at 11:32 a.m., with Licensed Vocational Nurse 4 (LVN 4), in Resident 58's room, Resident 58 was observed wearing oxygen at two (2) LPM via NC. The NC tubing was looped and secured around Resident 58's ears, with one prong inserted into the left nostril and the other resting externally against the left nostril. LVN 4 stated both prongs should be inside Resident 58's nose for the oxygen to be properly delivered to the resident. LVN 4 stated that improper placement of the oxygen NC prevents Resident 58 from receiving the supplemental oxygen she requires. LVN 4 stated that insufficient oxygen could lead to hypoxia, resulting in inadequate oxygen supply to the body and organs, potential loss of consciousness (state of being aware of one's surroundings), and other complications due to reduced oxygenation of the brain. During an interview on 6/18/2026 at 2:19 p.m., with Director of Nursing (DON), the DON stated the oxygen NC must be placed correctly, with both prongs inside the resident's nose, with the tubing securely looped around the resident's ears. The DON stated that improper placement of the NC may prevent the resident from receiving the intended amount of oxygen, which could result in decreased oxygen saturation (the amount oxygen circulating in the blood) and shortness of breath. b. During review of Resident 14's admission Record, the admission Record indicated the facility originally admitted the resident on 3/8/2016 and re-admitted the resident on 4/10/2026 with diagnosis that included pneumonia (an infection/inflammation in the lungs), pleural effusion (water in the lungs), and COPD. During review of Resident 14's H&P dated 5/14/2026, the H&P indicated Resident 14 does not have the capacity to understand and make decisions. During review of Resident 14's MDS dated [DATE], the MDS indicated Resident 14 had severely impaired cognition; usually made self-understood and sometimes understood others. that Resident 14 was dependent (helper does all of the effort) with activities of daily living and functional mobility. The MDS indicated Resident 14 is on oxygen treatment while a resident at the facility. During a review of Resident 14's care plan titled, The resident has PRN oxygen therapy related to respiratory failure, unspecified with hypoxia, initiated 5/14/2026, the care plan indicated an intervention of oxygen via NC at two (2) liters per minute, may titrate oxygen to maintain SPO2 greater or equal to 92% as needed and to monitor for sign and symptoms of respiratory distress and report to MD (physician) PRN: respirations, pulse oximetry (measure how much oxygen in the blood), increased heart rate. During a concurrent observation and interview on 6/17/2026 at 10:15 a.m., with Assistant Director of Nursing 1 (ADON 1), observed Resident 14 lying in bed with oxygen NC tubing looped around Resident 14's ears, with the oxygen prongs resting on Resident 14's chin. The oxygen concentrator was turned on and set at one (1) liter per minute. The ADON stated the oxygen cannula is not positioned correctly and the prongs should be placed inside Resident 14's nose. During a concurrent interview and record review on 6/17/2026 at 10:17 a.m., with ADON 1, reviewed Resident 14's physician order dated 5/14/2026 and pulse oximetry reading dated 6/17/2026 at 00:22. The physician order indicated an order for oxygen at one (1) LPM via NC PRN to keep SPO2 greater or equal to 92% every shift. The pulse oximetry reading dated 6/17/2026 at 00:22 indicated 93% Room Air. The ADON stated a measurement of Resident 14's oxygen saturation should have been assessed by the nurse before applying the PRN oxygen and re-assessed after it was applied. The ADON stated that these were not done. During an interview on 6/17/2026 at 10:25 a.m., with LVN 4, LVN 4 stated that she received Resident 14 from the night shift (11 p.m.-7 a.m. shift) wearing oxygen. LVN 4 stated she did not know when the prn oxygen was applied. During an interview on 6/17/2026 at 10:41 a.m., with the ADON, the ADON stated that Resident 14's oxygen saturation should have been checked at the start of the day shift. The ADON stated that since the order for oxygen was PRN, Resident 14 needed to be evaluated to determine whether supplemental oxygen was necessary or not. The ADON explained that PRN oxygen is administered only as needed; if the resident doesn't require it, it shouldn't be used. The ADON stated to make this determination, the resident's oxygen saturation must be assessed. During a review of the facility's policy and procedure (P&P) titled, Oxygen Administration, last reviewed 5/28/2026, the P&P indicated, Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences.The residents care plan shall identify the interventions for oxygen therapy, based upon the resident's assessment and orders, but not limited to:.d. Monitoring of SPO2 (oxygen saturation) levels and/or vital signs, as ordered.The equipment needed for oxygen administration will depend on the type of delivery system ordered. Types of delivery systems include: a. Nasal Cannula - Oxygen is administered through plastic cannulas in the nostrils. Staff shall notify the physician of any changes in the resident's condition, including changes in vital signs, oxygen concentrations, or evidence of complications associated with the use of oxygen.

Based on observation, interview, and record review, the facility failed to ensure a window screen did not have a gap in a shared resident room affecting two of five sampled residents (Residents 67 and 91) investigated under the Environment task. This deficient practice created an entry point and access for insects to get inside the building which can potentially transmit insect borne illnesses and negatively affect the residents' quality of life. Findings: During a review of Resident 67's admission Record, the admission Record indicated the facility originally admitted the resident on 3/2/2016 and most recently readmitted the resident on 4/12/2026 with diagnoses including, but not limited to, encounter for attention to gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) and congestive heart failure (a condition where the heart can't pump enough blood to meet the body's needs). During a review of Resident 67's Minimum Data Set (MDS - a resident assessment tool) dated 5/22/2026, the MDS indicated the resident was cognitively intact (able to think, learn, and remember clearly). The MDS indicated Resident 67 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) for most activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 91's admission Record, the admission Record indicated the facility originally admitted the resident on 3/7/2017 and most recently readmitted the resident on 11/11/2021 with diagnoses including, but not limited to, atherosclerotic heart disease (a condition where plaque builds up in the arteries of the heart, reducing blood flow to the heart muscle) and osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage) of both hips. During a review of Resident 91's MDS dated [DATE], the MDS indicated the resident had severe cognitive impairment (trouble with thinking, learning, and remembering clearly). The MDS indicated Resident 91 required substantial assistance (helper does more than half of the effort) for most ADLs. During an observation on 6/17/2026 at 11:15 a.m., in Resident 67 and Resident 91's shared room, observed the window screen for the window facing outside the facility was bent creating a gap between the window screen and the window. During a concurrent observation and interview on 6/18/2026 at 12:25 p.m., with the Maintenance Supervisor (MS) outside the facility next to the window of Resident 67 and Resident 91's shared room, the MS validated the window screen was bent. The MS stated there was an approximate inch wide gap at the side of the screen. The MS stated the window does slide open and the screen shouldn't be like that because pests could get into the room. During an interview on 6/18/2026 at 12:59 p.m., with Assistant Director of Nursing 1 (ADON 1), ADON 1 stated the screen should be intact and not have a gap to ensure the residents are safe and comfortable. During a review of the facility's policy and procedure (P&P) titled, Pest Control Program, last reviewed on 5/28/2026, the P&P indicated the facility will maintain an effective pest control program utilizing a variety of methods to control certain seasonal pests such as flies. During a review of the facility's P&P titled, Preventative Maintenance Program, last reviewed on 5/28/2026, the P&P indicated a preventative maintenance program shall be developed and implemented to ensure the provision of a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. The P&P indicated the Maintenance Director is responsible for developing and maintaining a schedule of maintenance services to ensure that the buildings, grounds, and equipment are maintained in a safe and operable manner.

Based on observation, interview, and record review, the facility failed to ensure the Minimum Data Set (MDS - a resident assessment tool) assessment accurately reflected the vision and dental status and active diagnosis of vision loss and retinal detachment (the thin layer of tissue at the back of the eye [retina] pulls away from its usual position) of the left eye and diminishing vision of the right eye was reflected for one of thirty-three sampled residents (Resident 87). This deficient practice resulted in Resident 87 having an inaccurate MDS assessment and had the potential to negatively affect in the plan of care and treatment. Findings: During a review of Resident 87's admission Record, the admission Record indicated that the facility initially admitted Resident 87 on 4/8/2022 with diagnoses including type two (2) diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), cardiomyopathy (a disease of the heart muscle that makes it harder for the heart to pump blood to the rest of the body), hypertension (HTN- high blood pressure), and hyperlipidemia (abnormally high levels of fats in the blood). During a review of Resident 87's MDS dated [DATE], the MDS indicated that Resident 87's cognition (mental action or process of acquiring knowledge and understanding) was intact. The MDS indicated that Resident 87's ability to see in adequate light was adequate (sees fine details, such as regular print in newspapers/books). The MDS indicated Resident 87 required ranging from supervision/touching assistance to maximal assistance (helper does more than half the effort) for physical assistance from staff for activities of daily living (ADLs - activities related to personal care). The MDS also indicated Resident 87 had no vision related active diagnosis. The MDS also indicated that Resident 87 had no broken or loose teeth, mouth or facial pain. During a review of Resident 87's progress note dated 12/8/2025, the progress note indicated that Resident 87 had reported vision loss in the left eye and diminishing vision in the right eye, with a history of retinal detachment in the left eye. The progress note also indicated that the plan of care includes consultation with a specialist. During a review of Resident 87's Order Summary Report, the Order Summary Report indicated the following physician orders: -May see dentist (medical doctor that specialized in oral/mouth care), initiated on 2/28/2023. -May see ophthalmologist (medical doctor that specialized in eye and vision care), initiated on 2/28/2023. During a review of Resident 87's Social Service assessment dated [DATE], the Social Service Assessment indicated in the Optometry/Ophthalmology and Dental Consult status that resident was referred to ancillary services (supplemental or diagnostic services provided in support of, or in addition to, care delivered by a primary clinician). During a review of Resident 87's record titled, Onsite Skilled Dental Care, dated 5/22/2026, the record indicated in the treatment notes that Resident 87 had loose upper bridge teeth. During a review of Resident 87's care plan (a document that summarizes a resident's needs, goals, and care/treatment) titled, Impaired Visual Function, initiated on 4/11/2022, the care plan indicated interventions including scheduling consultations with eye specialists as needed, identifying factors that may impact visual function, and regularly observing, recording, and reporting any signs or symptoms of acute eye problems. Such symptoms could involve changes in the ability to carry out daily activities, decreased mobility, sudden vision loss, dilated pupils, a gray or milky appearance in the eyes, seeing halos around lights, double vision, tunnel vision, blurred vision, or hazy vision. During a concurrent observation and interview on 6/15/2026 at 10:33 a.m., with Resident 87, Resident 87 was awake, attentive, and capable of expressing her needs. Observed Resident 87's upper three left teeth were loose. Resident 87 stated being blind in her left eye, able to see only shadows, and said her right eye's vision was deteriorating. During a concurrent interview and record review on 6/17/2026 at 10:10 a.m., with the MDS Nurse (MDSN), reviewed Resident 87's MDS dated [DATE], progress notes dated 12/8/2025, and active medical diagnosis. The MDSN stated that her responsibilities include conducting assessments and evaluations and completing both the MDS and care plan documentation. The MDSN stated that the assessment process involves seeing each resident to conduct the MDS assessment, which covers vision, dental, and hearing status. The MDSN added that to ensure accuracy, she reviews physician progress notes and orders, comparing them with medical diagnoses in the records. The MDSN stated that according to Resident 87's MDS assessment dated [DATE], Resident 87's vision and dental status showed no concerns, and there was no active diagnosis of vision loss or retinal detachment. The MDSN stated that Resident 87's MDS assessment was not accurate and there should have been an active diagnosis for Resident 87's vision loss and retinal detachment along with proper documentation of vision and dental status. The MDSN further stated that failing to produce an accurate MDS assessment may lead to missing a targeted care plan and delayed care delivery. During an interview on 6/18/2026 at 12:41 p.m., with the Director of Nursing (DON), the DON stated that MDSNs are responsible for conducting MDS assessments. The DON explained that there were inaccuracies in both the assessment and documentation of vision and dental status for Resident 87, and the resident's active medical diagnoses for vision and dental health were not reflected. The DON stated that the MDSN failed to validate the assessment, which could result in delayed care and potentially prevent Resident 87 from receiving necessary services due to these inaccuracies. During a review of the facility's P&P titled, Documentation in Medical Record, reviewed 5/28/2026, the P&P indicated that licensed staff and interdisciplinary team (IDT- a group of health care professionals with various areas of expertise who work together toward the goals of the residents' care plan) members must record all assessments, observations, and services in the resident's medical record according to state law and facility policy. The P&P outlines documentation principles such as being factual, objective, and focused on the resident; prohibiting false entries; and requiring descriptive, objective information based on direct knowledge of the assessment or service provided. It also emphasizes that documentation should be accurate, relevant, and complete, with enough detail about the resident's care or responses to care. During another review of facility's P&P titled, Dental Services, reviewed 5/28/2026, the P&P indicated that the residents' dental needs are identified through both physical and MDS assessments, and subsequently incorporated into each resident's care plan. The P&P further stated that oral and dental status must be documented based on assessment findings.

Based on interview and record review, the facility failed to report timely to the State Survey Agency (the Department) an acute fracture of the tip of the right olecranon process (a break in the bone of the tip of the elbow) with associated soft tissue swelling and a suspected fracture involving the greater tuberosity of the right humerus (a break in the bony prominence at the top of your upper arm bone) from an unknown cause for one of three sampled residents (Resident 1). This deficient practice resulted in a delay of investigation to rule out abuse.During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included metabolic encephalopathy (when the brain has trouble working due to an underlying condition and can cause confusion and memory loss), unspecified psychosis (a mental health symptom where a person struggles to tell the difference between what is real and what is not) and unspecified dementia (a loss of brain function that affects memory, thinking, language, and reasoning). During a review of Resident 1's History and Physical Examination, dated 11/3/2025, the History and Physical Examination indicated Resident 1 does not have the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 5/15/2026, the MDS indicated Resident 1 had severely impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). During a review of Resident 1's Physician's Orders, the Physician's Orders indicated Resident 1 had an order dated 5/5/2026 for a stat (derived from the Latin word statim, meaning immediately or without delay) X-ray (a test that takes pictures of the inside of your body using a small amount of radiation) of the right shoulder and elbow related to pain. During a review of Resident 1's Radiology (a branch of medicine that uses imaging technology such as X-rays to diagnose and treat diseases) Results Report for the right elbow dated 5/5/2026, the Radiology Results Report indicated an acute fracture of the tip of the olecranon process with associated soft tissue swelling. During a review of Resident 1's Radiology Results Report for the right shoulder dated 5/5/2026, the Radiology Results Report indicated a suspicion of a fracture involving the greater tuberosity of the right humerus. During a review of Resident 1's Nurses Progress Note dated 5/7/2026 at 2:38 a.m., the Nurses Progress Note indicated Resident 1's X-ray results were reported to Resident 1's physician and Resident 1 was transferred to the emergency room (ER - part of a hospital where people go when they are seriously sick or injured and need treatment quickly) for further evaluation and treatment. During a review of Resident 1's Transfer Form dated 5/7/2026, the Transfer Form indicated Resident 1 was transferred to the ER for further evaluation and treatment due to a fracture (a crack or break in a bone). During an interview on 6/4/2026 at 12:40 p.m., with the Director of Nursing (DON), the DON stated Resident 1 did not have any witnessed falls or accidents. The DON further stated Resident 1 did not have the cognitive ability to explain the cause of the right shoulder and right elbow pain and the resulting injuries. The DON stated Resident 1's abnormal X-ray results dated 5/5/2026 were not reported or investigated because she (DON) had not been informed of Resident 1's abnormal X-ray results. The DON further stated that had she been notified of Resident 1's abnormal X-ray results dated 5/5/26, she would have conducted an investigation and would have reported the incident to the appropriate entities, as this was a case of an injury of unknown origin/source. During a review of the facility's policy and procedure (P&P) titled, Unexplained Injuries, last reviewed/revised on 4/20/2026, the P&P indicated that all unexplained injuries, including bruises, abrasions, and injuries of unknown source will be investigated. The P&P also indicated an injury should be classified as an injury of unknown source when both of the following conditions are met:The source of the injury was not observed by any person, or the source of injury could not be explained by the resident; andThe injury is suspicious because of:The extent of the injury orThe location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma) orThe number of injuries observed at one particular point in time orThe incidence of injuries over time. The P&P further indicated if the injury is of an unknown source, reporting and investigation procedures shall be implemented in accordance with the facility's abuse policies and procedures. During a review of the facility's P&P titled, Compliance with Reporting Allegations of Abuse/Neglect/Exploitation, last reviewed/revised on 4/20/2026, the P&P indicated it is the policy of the facility to report all allegations of abuse/neglect/exploitation or mistreatment, including injuries of unknown sources and misappropriation of resident property immediately to the Administrator of the facility and to other appropriate agencies in accordance with current state and federal regulations within prescribed timeframes. The Administrator or designee will notify appropriate agencies immediately; as soon as possible but no later than 24 hours after discovery of the incident. In the case of serious bodily injury, no later than 2 hours after discovery or forming the suspicion.

Based on observation, interview and record review, the facility failed to develop a comprehensive person-centered care plan (a written course of action that helps a resident achieve outcomes that improve their quality of life) for one of three sampled residents (Resident 1) to address the use of a right arm sling (a supportive device, usually made of fabric, used to hold an injured arm, wrist, or shoulder in a resting position to relieve pain and prevent further injury) following an injury. This deficient practice had the potential to result in unmet care needs and negatively affect the delivery of care and services to Resident 1. During a review of Resident 1's admission Record, the admission Records indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included metabolic encephalopathy (when the brain has trouble working due to an underlying condition and can cause confusion and memory loss), unspecified psychosis (a mental health symptom where a person struggles to tell the difference between what is real and what is not) and unspecified dementia (a loss of brain function that affects memory, thinking, language, and reasoning). During a review of Resident 1's History and Physical Examination, dated 11/3/2025, the History and Physical Examination indicated Resident 1 does not have the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 5/15/2026, the MDS indicated Resident 1 had severely impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). During a review of Resident 1's Order Summary Report, the Order Summary Report indicated Resident 1 had a physician's order dated 5/22/2026 for Resident 1 to wear a right arm sling at all times. During a review of Resident 1's Medication Administration Record (MAR - a report detailing the medications administered to a resident by the licensed nurse in the facility) from 5/22/2026 to 6/9/2026, the MAR indicated Resident 1's right arm sling was in place at all times as ordered. During an observation on 6/3/2026 at 10:50 a.m., Resident 1 was observed in his room, sitting in a wheelchair, with a black sling in place on the right arm. During an interview on 6/4/2026 at 11:14 a.m., with the Director of Rehabilitation (DOR), the DOR stated Resident 1 was transferred to the hospital on 5/7/2026 for evaluation and treatment following X-ray (a test that takes pictures of the inside of your body using a small amount of radiation) findings obtained at the facility on 5/5/2026 that indicated fractures (crack or break in a bone) of the right shoulder and right elbow. The DOR stated Resident 1 returned from the hospital (did not specify) on 5/7/2026 with a sling in place on the right arm. The DOR further stated Resident 1's physician placed an order for Resident 1 to wear the sling at all times until Resident 1's orthopedic (branch of medicine that focuses on the musculoskeletal system that includes the bones, joints, ligaments, tendons, and muscles) appointment to determine whether continued use of the sling was necessary. During a concurrent interview and record review on 6/4/2026 at 9:35 a.m., with the Medical Records Director (MRD), Resident 1's care plans from 11/3/2025 to 6/3/2026 were reviewed. The MRD stated the care plans reviewed were all the care plans that were in Resident 1's medical records as of the morning of 6/3/2026. The MRD stated there was no care plan in Resident 1's medical records addressing Resident 1's right arm sling. During a concurrent interview and record review on 6/4/2026 at 12:40 p.m., with the Director of Nursing (DON), Resident 1's care plans from 11/3/2025 to 6/3/2026 were reviewed. The DON stated there was no care plan developed to address Resident 1's right arm sling. The DON stated that a care plan should have been developed to address Resident 1's right arm sling and related care needs. The DON further stated care plans are important to set appropriate goals and provide necessary services and interventions for residents. During a review of the facility's policy and procedure titled, Comprehensive Care Plans, last reviewed/revised on 4/30/2026, the P&P indicated it is the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychological needs that are identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented, as needed.

Based on interview and record review, the facility failed to maintain complete medical records by failing to document a change of condition (COC - any significant improvement or decline in a resident's physical, mental or functional health) for one of three sampled residents (Resident 1). This deficient practice placed Resident 1 at risk of not receiving appropriate care due to incomplete resident medical care information.During a review of Resident 1's admission Record, the admission Records indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included metabolic encephalopathy (when the brain has trouble working due to an underlying condition and can cause confusion, memory loss and loss of consciousness), unspecified psychosis (a mental health symptom where a person struggles to tell the difference between what is real and what is not) and unspecified dementia (a loss of brain function that affects memory, thinking, language, and reasoning). During a review of Resident 1's History and Physical Examination, dated 11/3/2025, the History and Physical Examination indicated Resident 1 does not have the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 5/15/2026, the MDS indicated Resident 1 had severely impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). During a review of Resident 1's Physician's Orders, the Physician's Orders indicated Resident 1 had an order dated 5/5/2026 for a stat (derived from the Latin word statim, meaning immediately or without delay) X-ray (a test that takes pictures of the inside of your body using a small amount of radiation) of the right shoulder and elbow related to pain. During a review of Resident 1's Nurses Progress Note dated 5/7/2026 at 2:38 a.m., the Nurses Progress Note indicated Resident 1's X-ray results were reported to Resident 1's physician and Resident 1 was transferred to the emergency room (ER - part of a hospital where people go when they are seriously sick or injured and need treatment quickly) for further evaluation and treatment. During a review of Resident 1's Transfer Form dated 5/7/2026, the Transfer Form indicated Resident 1 was transferred to the ER for further evaluation and treatment due to a fracture (a crack or break in a bone). During a concurrent interview and record review on 6/4/2026 at 9:51 a.m., with the MDS Coordinator (MDSC), Resident 1's electronic medical record was reviewed. The MDSC stated she looked through Resident 1's nursing progress notes and could not find any documentation as to why the physician was contacted on 5/5/2026 that resulted in a stat X-ray order. The MDSC stated that based on the physician's order for the stat X-ray dated 5/5/2026, the reason for the stat X-ray was due to pain, however, there were no progress notes in Resident 1's medical record documenting Resident 1's complaints of pain that prompted the physician notification on 5/5/2026. The MDSC further stated that because Resident 1 subsequently required transfer to the hospital on 5/7/2026, Resident 1's medical record should have included a nursing progress note or Change of Condition Form (COC Form - a document used to officially record and report a new medical, physical, or mental shift in a resident) documentation describing Resident 1's change in status and the events leading to the hospital transfer on 5/7/2026. During an interview on 6/4/2026 at 12:40 p.m. with the Director of Nursing (DON), the DON stated she reviewed Resident 1's electronic medical record and was unable to find any documentation regarding why Resident 1's physician was contacted on 5/5/2026, resulting in the stat X-ray order. The DON stated the licensed nurses caring for Resident 1 should have documented the resident's condition, assessment findings, and physician notification in the progress notes or created an SBAR (Situation, Background, Assessment, Recommendation - a communication tool that allows healthcare team members to provide essential, concise information about an individual's condition) to establish a timeline of events leading to the physician contact because obviously something happened with Resident 1 that resulted in calling Resident 1's physician on 5/5/2026. The DON further stated documentation is so important, especially if there is a change in condition, to ensure there is no delay in the care of the resident and to ensure proper treatment is provided accordingly. During a review of the facility's policy and procedure (P&P) titled, Documentation in Medical Record, last reviewed/revised on 4/30/2026, the P&P indicated each resident's medical record shall contain a representation of the experiences of the resident and include enough information to provide a picture of the resident's progress. The P&P further indicated licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy. Documentation shall be accurate, relevant, and complete, containing sufficient details about the resident's care and/or responses to care.

Based on interview and record review, the facility failed to assist and arrange transportation services for a follow-up neurosurgery (the medical specialty focused on diagnosing and treating disorders of the nervous system) specialist appointment as ordered by the physician for one of five sampled residents (Resident 1). This deficient practice had the potential to negatively affect the residents' continuity of care and treatment.Findings: During a review of Resident 1's admission Record, the admission Record indicated that the facility admitted Resident 1 on 12/9/2025 with diagnoses that included low back pain, anxiety disorder (mental health conditions that involve excessive fear, worry, or nervousness that interfere with daily life), and history of transient ischemic attack (TIA - known as a mini-stroke, and happens when a blood clot temporarily blocks blood flow to a part of the brain). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 2/24/2026, the MDS indicated that Resident 1's cognition (ability to think, reason, and function) was severely impaired, and the resident required moderate assistance from staff for showering, and required supervision or touching assistance for toileting hygiene, upper and lower body dressing, bed mobility (movement) and transferring. During a review of Resident 1's General Acute Care Hospital 1 (GACH 1) Discharge summary dated [DATE] and signed 12/9/2026, the GACH 1 discharge summary indicated Resident 1 to follow-up with a neurosurgery specialist. During a review of Resident 1's physician order dated 12/18/2025, the physician order indicated that Resident 1's physician ordered a neuro consult (a primary doctor refers the residents to a neurologist for a variety of brain, spine, or nerve-related issues) for the resident on 12/22/2025 at 9:15 a.m. During a review of Resident 1's physician progress notes dated 1/13/2026, the physician progress notes indicated that the physician's assessment and plan included a follow-up with neurosurgery for Resident 1's low back pain with small lumbar 3-4 (L1, L2, L3, L4, and L5 refer to the five individual bones that make up the lumbar spine, commonly known as your lower back) infarction (the death of tissue in the body caused by a lack of oxygen and nutrients). During a review of Resident 1's physician progress notes dated 2/5/2026, the physician progress notes indicated that the physician's assessment and plan included the follow-up with neurosurgery for Resident 1's lower back pain with small L3-4 infarction. During a review of Resident 1's physician order dated 2/5/2026, the physician order indicated that Resident 1's physician ordered to follow up with neurosurgery for the resident's L3-4 infarction. During a concurrent interview and record review on 6/3/2026 at 12:33 p.m., with the Social Services Director (SSD), reviewed Resident 1's progress notes. The SSD stated that Resident 1 had only one appointment to follow-up with a neurosurgery specialist, which was on 12/22/2025, but the SSD could not locate the documents indicating if Resident 1's appointment was done or not, so that the SSD needed to check with the SSD's assistants. During a concurrent interview and record review on 6/3/2026 at 2:14 p.m., with the Director of Nursing (DON), reviewed Resident 1's GACH 1 Discharge summary dated [DATE] and signed 12/9/2025, physician orders, and progress notes. The DON stated that the facility made the appointment for 12/22/2025, but there was no documentation about Resident 1 going out to a clinic for that appointment. During an interview on 6/3/2026 at 2:38 p.m., with Social Service Assistant 2 (SSA 2), SSA 2 stated the Social Service department arranges transportation after appointments are made by the nursing department or case manager personnel. SSA 2 stated there was not enough time to arrange Resident 1's transportation for their appointment. SSA 2 stated the transportation request form was returned to Case Manager Assistant 1 (CMA 1). SSA 1 stated transportation was never arranged by the Social Service department for Resident 1's appointment. During a concurrent interview and record review on 6/3/2026 at 2:50 p.m., with the DON and the Medical Records Director (MRD), the DON stated that the follow-up appointment with a neurosurgery specialist for Resident 1 was not done, and the resident was discharged from the facility on 2/24/2026. The DON stated that the facility scheduled the appointment on 12/22/2025, but it was not completed due to transportation issues. The DON stated the facility should have rearranged Resident 1's follow-up neurosurgery appointment as soon as possible, but it was not done. During a concurrent interview and record review on 6/3/2026 at 3:26 p.m., with CMA 1, reviewed the Transportation Confirmation form documented from 12/12/2025 to 2/3/2026. CMA 1 stated that CMA 1 rearranged Resident 1's neurosurgery appointment for 12/22/2025 on 12/18/2025, and the transportation requisition form was given to SSA 1 on the same day (12/18/2025). CMA 1 further stated that CMA 1 thought that the appointment was done and was not informed of Resident 1's missing follow-up neurosurgery appointment by the nursing staff or the Social Services department personnel. CMA 1 stated Resident 1's follow-up neurosurgery appointment was not rescheduled. During an interview on 6/3/2026 at 4:05 p.m., with SSA 1, SSA 1 stated that CMA 1 informed SSA 1 about Resident 1's 12/22/2025 appointment on 12/18/2025 and stated that was not enough time to arrange Resident 1's transportation service. SSA 1 stated SSA 1 returned back Resident 1's original transportation requisition form to CMA 1 to rearrange Resident 1's follow-up neurosurgery specialist appointment for another day. SSA 1 stated there was no documentation indicating that and stated SSA 1 was not informed to follow up. During a review of the facility's policy and procedure (P&P) titled, Provision of Physician Ordered Services, last reviewed on 4/30/2026, the P&P indicated, The purpose of this policy is to provide a reliable process for the proper and consistent provision of physician ordered services according to professional standards of quality. Follow-up appointments: Facility staff will assist residents in scheduling and attending follow-up appointments as ordered by the physician, physician assistant, nurse practitioner, or clinical nurse specialist. Necessary documentation of scheduled appointments and resident attendance may be maintained. During a review of the facility's P&P titled, Social Services, last reviewed on 4/30/2026, the P&P indicated, The facility, regardless of size, will provide medically-related social services to each resident, to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The social worker, or social services and designee, will pursue the provision of any identified need for medically related social services of the resident. Making referrals and obtaining needed services from outside entities. Transitions of care services.

Based on interview and record review, the facility failed to protect the resident's right to remain free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) for one of three sampled residents (Resident 1), when on 4/16/2026, Resident 2 punched Resident 1 in the face several times with a closed fist (a person's hand when the fingers are bent in toward the palm and held there tightly). This deficient practice resulted in Resident 1 being subjected to physical abuse by Resident 2 while under the care and supervision of the facility. Resident 1 sustained a loose tooth and bleeding gums.During a review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident on 7/20/2023, with diagnoses that included hypertensive heart disease (heart damage caused by long-term high blood pressure) with heart failure, osteoporosis (bone disease that makes the bones weak, increasing the risk for fractures [break in the bone]) and bed confinement status (a person's inability to leave their bed without significant assistance, typically due to illness, injury, or frailty [significant decline in physical, mental, or physiological [relating to how the physical body and its parts work] function]). During a review of Resident 1's History and Physical Examination (H&P - medical evaluation consisting of a detailed resident interview regarding their health history and a structured physical assessment) dated 12/10/2025, the H&P indicated Resident 1 can make needs known but cannot make medical decisions. During a review of Resident 1's Physician Progress Notes dated 4/18/2026, the Physician Progress Notes indicated that on 4/16/2026 Resident 1 reported that another resident (Resident 2) walked up to him and hit him (Resident 1) on the face, unprovoked (an action, attack, or outburst that occurs without any identifiable cause, justification, or warning). The Physician Progress Notes further indicated that Resident 1 is bedbound (when a person is unable to get out of bed without significant assistance due to illness, injury, or severe weakness). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 3/24/2026, the MDS indicated Resident 1 had intact cognition (ability to think and make decisions). The MDS further indicated Resident 1 required extensive assistance with activities of daily living (ADLs- activities related to personal care such as bathing, dressing and toileting). During a review of Resident 1's Progress Notes dated 4/16/2026, timed at 2:54 p.m., the Progress Notes indicated that on 4/16/2026 Resident 1 sustained bleeding gums and a loose tooth after his roommate (Resident 2) became aggressive (an active, forceful, or hostile approach intended to intimidate or harm the other person) toward him. During a review of Resident 1's Progress Notes dated 4/16/2026, timed at 3:46 p.m., the Progress Notes indicated that on 4/16/2026 Resident 1 was witnessed being punched. The Progress Notes further indicated Resident 1 was lying in bed when his roommate (Resident 2) walked over and punched him repeatedly in the face. Blood was observed in Resident 1's mouth and was cleansed with sterile water (highly purified water) and gauze. During a review of Resident 1's Change in Condition Evaluation dated 4/16/2026, the Change in Condition Evaluation indicated that on 4/16/2026, Resident 1 was physically attacked by his roommate (Resident 2). The Change in Condition Evaluation further indicated a Certified Nursing Assistant (CNA 1) witnessed Resident 1 being punched in the face by the roommate (Resident 2). Upon assessment, bleeding was noted from Resident 1's gums. During a review of Resident 1's Interdisciplinary (IDT - a group of health care professionals with various areas of expertise who work together toward the goals of the residents' care plan) Care Conference Notes dated 4/20/2026, the IDT Care Conference Notes indicated Resident 1 expressed feeling very disturbed about the incident with his roommate (Resident 2) that occurred on 4/16/2026. The IDT Care Conference Notes further indicated that when the police arrived at the facility to investigate the incident, Resident 2 was removed from the facility. During a review of Resident 2's admission Record, the admission Record indicated the facility admitted the resident on 4/10/2026, with diagnoses that included polyneuropathy (a condition in which a person's peripheral nerves [nerves located outside of the brain and spinal cord] are damaged causing tingling, numbness and/or pain in the hands and feet), epilepsy (brain disorder in which nerve cells in the brain sometimes send the wrong signals and cause seizures [a sudden burst of electrical activity in the brain that can cause changes in behavior, movements, feelings and levels of consciousness]) and depression (mood disorder that causes a constant, deep feeling of sadness and a loss of interest in activities). During a review of Resident 2's H&P, dated 4/12/2026, the H&P indicated diagnoses that included violent behavior and anxiety disorder (mental health condition characterized by persistent, excessive, and uncontrollable fear or worry that interferes with daily life). The H&P further indicated Resident 2 exhibited acute agitation (a state of severe restlessness, worry, or mental distress accompanied by physical tension), verbal aggression (using hostile, insulting, or threatening language to attack someone else's self-concept with the intent to cause psychological pain, dominate them, or gain control) and physical aggression (the use of physical force or actions intended to harm, injure or intimidate another person) at his previous facility. During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2 had intact cognition. During a review of Resident 2's Progress Notes dated 4/16/2026, timed at 4:34 p.m., the Progress Notes indicated that on 4/16/2026 Resident 2 was witnessed punching his roommate (Resident 1) in the face. The Progress Note further indicated Resident 2 stated he (Resident 2) was tired of talking and hit Resident 1 in the face. During a review of Resident 2's Change in Condition Evaluation dated 4/16/2026, the Change in Condition Evaluation indicated that on 4/16/2026, at approximately 2:30 p.m., a CNA (CNA 1) witnessed Resident 2 striking his bedbound roommate (Resident 1) in the face multiple times with a closed fist. During a review of Local Law Enforcement 1's calling card dated 4/16/2026 at 4:00 p.m., the calling card indicated an arrest of Resident 2 was made for elder abuse. During a review of the facility's conclusion letter regarding the resident-to-resident physical altercation (a physical confrontation or conflict between two residents, includes any unwanted physical interaction) between Resident 1 and Resident 2 dated 4/20/2026, the conclusion letter indicated the facility's IDT concurred that the resident-to-resident physical altercation did occur and resulted in injury to Resident 1. The conclusion letter further indicated Resident 2 was taken to the local police department by law enforcement officers on 4/16/2026. During an interview on 5/4/2026 at 10:34 a.m., with Resident 1, Resident 1 stated he remembered the incident involving his roommate (Resident 2). Resident 1 stated that for no reason, his roommate (Resident 2) attacked him. Resident 1 stated his roommate (Resident 2) was yelling and cursing at him before repeatedly punching him in the face, causing bleeding in his mouth and loosening one of his teeth. Resident 1 was observed wiggling his upper left incisor (a sharp, flat, front tooth used for cutting and biting food), indicating that it was loose. Resident 1 stated The guy (Resident 2) was an insane person. Resident 1 further stated that he (Resident 1) was startled and felt scared during the altercation. Resident 1 stated he only feels okay now because the police arrested Resident 2 after the incident. Resident 1 stated That man (Resident 2) is a criminal, and I'm glad he went to jail. During an interview on 5/5/2026 at 9:10 a.m., with CNA 1, CNA 1 stated that on 4/16/2026, he was charting when another CNA (did not specify) informed him that his two residents in Room A were yelling at each other. CNA 1 stated he immediately went to Room A to see what was happening and saw Resident 2 punching Resident 1. CNA 1 stated Resident 1 was lying in bed while Resident 2 was standing on the right side of the bed, punching Resident 1 with his closed fist. CNA 1 stated he observed approximately two to three punches land on Resident 1's face before he (CNA 1) was able to separate Resident 2 from Resident 1. CNA 1 stated Resident 2 was punching Resident 1 with only one hand, his (Resident 2's) right hand. CNA 1 stated he could not remember where exactly the punches landed on Resident 1's face but did see blood in Resident 1's mouth. During an interview on 5/5/2026 at 9:46 a.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated that on 4/16/2026, she was passing medications when a CNA (did not specify) alerted her that that her residents in Room A were fighting. LVN 1 stated by the time she arrived at the room, CNA 1 was already holding back Resident 2. LVN 1 stated that when she asked Resident 2 what happened, Resident 2 stated he punched Resident 1 because Resident 1 was talking nonstop while he was trying to sleep. LVN 1 stated that when she assessed Resident 1, she observed bleeding from the upper, front gums. LVN 1 stated she did not observe a specific wound but noted blood around and between Resident 1's upper front teeth. During an interview on 5/5/2026 at 4:10 p.m., with the Director of Nursing (DON), the DON stated that she (DON) was involved in the investigation of the physical altercation that occurred between Resident 1 and Resident 2 on 4/16/2026. The DON stated that Resident 2 walked from his bed, located near the door of the room, to Resident 1's bed, located near the window, and punched Resident 1 in the face several times. The DON stated Resident 2's actions towards Resident 1 were willful and intentional. The DON stated that the incident between Resident 1 and Resident 2 constituted physical abuse. During a review of the facility's policy and procedure titled, Abuse, Neglect (failure to provide necessary care, supervision, or basic needs to a resident) and Exploitation (illegal, improper, or unauthorized use of a resident's funds, property or assets for someone else's personal profit or advantage), last reviewed and revised on 4/24/2025, indicated, it is the policy of the facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedure that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. According to the policy and procedure, abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. The policy and procedure further indicated physical abuse includes, but is not limited to hitting, slapping, punching, biting, and kicking.

Based on interview and record review, the facility failed to protect the resident ' s right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm by one resident towards another) for one of three sampled residents (Resident 4) when on 10/17/2024 at around lunch time, Registered Nurse 2 (RN 2) witnessed Resident 5 punched Resident 4 with his (Resident 5) closed fist twice on the right side of face while Resident 4 was sitting on the wheelchair. This deficient practice resulted in Resident 4 being subjected to physical abuse by Resident 5 while under the care of the facility. Based on the Reasonable Person Concept (the usual behavior of an average person under the same circumstances), due to Resident 4 ' s severely impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) and medical condition, an individual subjected to physical abuse may have physical pain, psychological pain (mental or emotional) effects including feelings of hopelessness (a feeling or state of despair or lack of hope), helplessness (the belief that there is nothing that anyone can do to improve a bad situation, and humiliation (the feeling of being ashamed or losing respect for own self). Findings: During a review of Resident 4's Admission Record, the Admission Record indicated the facility admitted Resident 4 on 12/6/2022 with diagnoses that included hemiplegia (total or partial paralysis [loss of the ability to move] of one side of the body) and hemiparesis (one-side muscle weakness) following cerebral infarction (damage to the tissues in the brain due to a loss of oxygen to the area) affecting right dominant side and dysphagia (difficulty swallowing) following cerebral infarction. During a review of Resident 4's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 8/16/2024, the MDS indicated Resident 4 had severely impaired cognition. The MDS also indicated Resident 4 required partial or moderate assistance (helper does less than half the effort) with eating, and is dependent with oral hygiene, toileting hygiene, and personal hygiene. During a review of Resident 4 ' s Change in Condition (COC- a significant change in resident ' s health status) Evaluation, dated 10/17/2024, timed at 4:36 p.m., the COC indicated the resident (Resident 4) received punch from another resident (Resident 5) while sitting in wheelchair. During a review of Resident 5 ' s Admission Record, the Admission Record indicated Resident 5 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included schizophrenia (a mental illness that affects a person ' s thoughts, feelings, and behaviors), unspecified mood disorder (a mental health condition that primarily affects a person ' s emotional state), and personal history of traumatic brain injury (a brain injury caused by an external force such as a blow, jolt or impact to the head). During a review of Resident 5's MDS dated [DATE], the MDS indicated Resident 5 had severely impaired cognition. The MDS also indicated Resident 5 required partial/moderate assistance with eating and oral hygiene, dependent with toileting hygiene, and required substantial/maximal assistance (helper does more than half the effort) with personal hygiene. During a review of Resident 5 ' s Change in Condition Evaluation dated 10/17/2024, timed at 1:19 p.m., indicated the resident (Resident 5) was noted with episode of attempting to attack another resident (Resident 4). During a review of Resident 5 ' s Physician Orders dated 10/17/2024, timed at 7:12 p.m., the Physician Order indicated to transfer Resident 5 to General Acute Care Hospital 1 (GACH 1) due to physical aggression (behavior directed toward another person that results in physical harm or has the potential to cause physical harm) towards the other Resident. During an interview on 11/4/2024 at 11:41 a.m., with Certified Nursing Assistant 3 (CNA 3), CNA 3 stated that on 10/17/2024 around lunch time, he (CNA 3) was washing his hands in station 4. CNA 3 heard Resident 5 yell and when he (CNA 3) turned around, CNA 3 witnessed Resident 5 punched Resident 4 with his (Resident 5 ' s) closed fist twice on the right side of Resident 4 ' s face. During an interview on 11/4/2024 at 3:45 p.m., with RN 2, RN 2 stated that on 10/17/2024 at around lunch time, RN 2 witnessed Resident 5 punched Resident 4. RN 2 stated that RN 2 was at station 4 at around lunch time RN 2 witnessed Resident 4 being wheeled next to Resident 5, Resident 5 reached over and pulled Resident 4 ' s wheelchair close to Resident 5 and punched Resident 4 with a closed fist twice in the face. During an interview on 11/5/2024 at 10:51 a.m., with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated she (LVN 2) was assigned to Resident 5 on 10/17/2024. LVN 2 stated that on 10/17/2024 at around lunch time, LVN 2 witnessed Resident 5 punched Resident 4 with his (Resident 5 ' s) closed fist twice on the right side of Resident 4 ' s face. During a follow-up interview on 11/5/2024 at 11:00 a.m., with LVN 2, LVN 2 stated that physical abuse did occur because Resident 5 was witnessed punching Resident 4 in the face. During an interview on 11/5/2024 at 1:48 p.m., with the Social Services Director (SSD), when asked if the incident (Resident 5 punched Resident 4 in the face on 10/17/2024) between Resident 4 and Resident 5 was physical abuse, the SSD stated that he (SSD) did not feel comfortable answering the question. The SSD stated that Resident 5 had history of aggressive behavior and that the facility should have been more proactive in monitoring Resident 5 ' s behavior to ensure other residents were not within range for Resident 5 to punch or hit. A review of the facility ' s policy and procedure titled, Abuse, Neglect (fail to care properly), and Exploitation (taking advantage of a resident), last reviewed in 9/25/2024, indicated it is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect

Based on observation, interview, and record review, the facility failed to ensure that one of 23 sampled residents (Resident 139) was kept free from accident and failed to provide a safe environment free from accident hazards (elements of the resident environment that have the potential to cause injury or illness) for the residents, staff, and visitors, as indicated in the facility's policies and procedures by: 1. Failing to identify that one of 23 sampled residents (Resident 139) had a torch lighter (a device that creates a flame that is hotter [reaching 2,500 degrees Fahrenheit { F- a unit of measure}] and more intense than a soft flame lighter (a device that procedures a small, soft, yellow flame reaching temperatures of 1400 F, that is not as powerful as a torch flame) in possession while admitted in the facility. 2. Failing to ensure one of 23 sampled residents (Resident 139) capability to smoke and safely use a lighter independently was assessed taking into account the resident's functional, cognitive (relating to the mental process involved in knowing, learning, and understanding things), and medical factors as per facility policy and procedure. 3. Failing to provide safe water temperatures of less than 121 degrees F in two of two sampled resident restroom hand sinks (room [ROOM NUMBER] and room [ROOM NUMBER]). 4. Failing to provide safe water temperatures of less than 121 F in two of four shower rooms (Shower room [ROOM NUMBER] and Shower room [ROOM NUMBER]). 5. Failing to ensure the circulating pump (used to circulate hot water within the pipes to allow instant access to hot water when the hot water faucet fixture [used to control the flow of water for sinks] is opened) for one of five water heaters (Water Heater 3) was in good working order. 6. Failing to ensure the cold-water shutoff valve (also called under-sink shut off valve, used to turn off the water to the sink without having the use of the main shutoff) under a resident hand sink was not partially closed for one of two sampled resident restroom hand sink (room [ROOM NUMBER]). These deficient practices placed Resident 139 at increased risk for severe burns and life-threatening injuries from the use of a torch lighter and had the potential for residents, staff, and visitors to sustain burns, scalding (injury from hot liquid or steam), and uncomfortable water temperatures. On 6/27/2024 at 8:28 p.m., the State Survey Agency (SSA) called an Immediate Jeopardy (IJ- a situation in which the facility's non-compliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death of a resident) situation for the facility's failure to ensure that Resident 139, who had a diagnosis of dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), was kept free from accident hazards in the presence of the Administrator (Admin), Director of Nursing (DON) and Resource Nurse Consultant (RNC). On 6/28/2024 at 5:48 p.m., the SSA called a second IJ situation for the facility's failure to provide a safe environment free from accident hazards for the residents, staff, and visitors in the presence of the Admin and the DON. On 6/29/2024 at 6:50 p.m., the SSA notified the Admin, DON, RNC, Social Service Director (SSD), and Director of Staff Development (DSD) that the IJ situation was not removed, while onsite, after the facility submitted an IJ Removal Plan that was not accepted. On 7/2/2024 at 4:13 p.m., the Department accepted the IJ Removal Plan (Version 4) for the facility's failure to provide a safe environment free from accident hazards for the residents, staff, and visitors. On 7/3/2024 at 12:03 p.m., the Department accepted the IJ Removal Plan (Version 6) for the facility's failure to ensure that Resident 139 was kept free from accident. On 7/3/2024 at 7:19 p.m. after confirming the facility's implementation of the accepted IJ Removal Plans (Version 4 and Version 6), the Department removed the IJ while onsite, in the presence of the Admin and the DON. The acceptable IJ Removal Plan for the facility's failure to provide a safe environment free from accident hazards for the residents, staff, and visitors included the following: - On 6/28/2024, the Admin and Maintenance Supervisor (MS) checked the water temperature for all resident rooms, shower rooms and where there are water resources. - On 6/28/2024, the MS inspected the five water heaters in the facility. - On 6/28/2024, the Admin, DON, and designees(s) interviewed all residents if they experienced any uncomfortable water temperature when using the hand sinks or while being showered. - On 6/28/2024, the DON and designee(s) assessed the residents in rooms [ROOM NUMBERS], and residents who had their shower on 6/28/2024 for any signs of alteration in skin integrity from water temperature. - On 6/28/2024, the facility-contracted plumber assessed hot water heater 3. On 6/29/2024 the circulating pump for hot water heater 3 was replaced by contracted plumber. - On 6/28/2024, the DSD educated Activities, Dietary, Housekeeping, Medical Records, Nursing, Social Services, and administrative staffs which include Business Office, Payroll, and Reception regarding providing safe environment for residents with emphasis on providing safe water temperatures between 105 degrees Fahrenheit and 120 degrees Fahrenheit. - On 6/28/2024, a facility-contracted plumber assessed the water temperature for the hand sinks in rooms [ROOM NUMBERS], and resident shower rooms [ROOM NUMBERS]. The plumber replaced the cold-water valve and handle under the hand sink in room [ROOM NUMBER] and ensured the cold-water valve under the hand sink in room [ROOM NUMBER] was fully open and in good working condition. - On 6/29/2024 the hand sinks in resident room [ROOM NUMBER] and 51 were noted producing water temperatures less than 89 F. On 6/29/2024, the DSD in-serviced staff not to utilize the hand sinks in room [ROOM NUMBER] or room [ROOM NUMBER] until further notice due to low water temperatures. - On 6/29/2024, shower room [ROOM NUMBER] was identified having a temperature of over 120 F. The maintenance assistant removed the shower head so that the shower stall could not be utilized. On 6/29/2024 the second plumber adjusted the hot water heater for shower room [ROOM NUMBER]. All three shower stalls now register water temperatures between the safe water temperature range of 105 degrees Fahrenheit and 120 degrees Fahrenheit. - On 6/29/2024, a second contracted plumber was contacted and came in the same day to assess the hand sinks in resident room [ROOM NUMBER], resident room [ROOM NUMBER] and all four shower rooms. The plumber checked the hot water system (recirculates heated water through a system of pipes to radiators or air handler units, which then release the heat to the surrounding air), adjusted the hot water heater thermostat (control center of your water heater and the hot water supply in your home) for resident room [ROOM NUMBER], room [ROOM NUMBER] and shower room [ROOM NUMBER], The plumber also adjusted the mixing valves (a device that combines two or more fluid streams at different temperatures to produce a mixed stream at a desired temperature) for the hand sinks in room [ROOM NUMBER] and 51. - On 6/29/2024 to ensure that ADL care needs such as bathing/showering are provided to the residents, the scheduler divided the assigned showers between the 7:00 a.m. to 3:00 p.m. shift and the 3: 00 p.m. to 11:00 p.m. shift in shower room [ROOM NUMBER] and 4 which were functioning on 6/29/2024. - On 6/29/24 the Director of Staff Development (DSD) in-serviced the CNAs to not utilize the hand sinks in resident room [ROOM NUMBER] or 51 until notified otherwise. - On 6/29/2024 the DSD initiated education to licensed staff and CNA's on how to obtain water temperature to include competency as well as the safe water temperature range between 105 degrees Fahrenheit and 120 degrees Fahrenheit. - On 6/29/2024, the second plumber in-serviced the Admin, MS and Maintenance Assistant on ensuring that water temperatures fall within the safe temperature range between 105 degrees Fahrenheit to 120 degrees Fahrenheit, ensuring that all water heaters are inspected weekly, and ensuring that these visual inspections are documented on a log. - Starting on 6/30/24 the Certified Nursing Assistants (CNAs) will check the water temperature prior to giving showers and/or bed bath and log it utilizing water temperature form located in each shower room for showers or at the nurse's station for bed baths. The acceptable IJ Removal Plan for the facility's failure to ensure that Resident 139 was kept free from accident included the following: - On 6/27/2024, licensed nurses made rounds of all resident smokers' rooms to ensure that lighters were being properly stored and to ascertain if any additional residents were in possession of a torch lighter. - On 6/27/2024, the Care Plan Coordinator(s) (CPCs) ensured all residents identified as smokers had safety measures such as wearing apron, storing smoking supplies appropriately, designated smoking area with fire blanket (a safety device designed to extinguish incipient [starting] fires), and fire extinguisher, smoking schedule, and providing supervision during smoking if needed. - On 6/27/2024, the DON or designee will audit new admissions daily to ensure the Smoking Assessment has been completed upon admission by licensed nurse and that risk factors, safety measures, and resident-specific interventions are reflected on the care plan. The audit will be completed for admissions, annual and/or if there is a significant change with the resident. - On 6/28/2024, the DSD in-serviced licensed nurses, CNAs, and SSD regarding Inventory of Personal Effects (an itemized list of each and every belonging of a resident). - On 6/29/2024, the DON provided education regarding Smoking Safety Assessment and facility policy and procedures related to smoking to the Assistant Director of Nursing (ADON), Minimum Data Set (MDS) Nurses (or nurse assessment coordinator, collects and assesses information for the health and well-being of residents in Medicare or Medicaid-certified nursing homes), and Quality Assurance Nurse (QAN) who were directly involved in the resident's smoking assessments moving forward. The Activities Director (AD) will no longer be involved in the completion of Smoking Safety Assessments - On 6/30/2024, the RNC presented to the resident an alternative lighter and the torch lighter was removed agreeably from Resident 139's possession. To meet the resident's preference of a lighter that can be easily used in wind, moving forward Resident 139 will be utilizing an electric flameless lighter that has a cover to cover the heating element. Findings: 1. A review of Resident 139's Admission Record indicated that the facility originally admitted Resident 139 on 5/2/2024 with diagnoses that included muscle weakness, hemiplegia (paralysis [inability to move] that affects only one side of the body) and hemiparesis (the weakness or inability to move one side of the body) following cerebral infarction (also known as a stroke or cerebrovascular accident [CVA- brain tissue death caused by a lack of blood flow to the brain]) affecting the right dominant side. A review of Resident 139's History and Physical (HP) dated 5/4/2024 completed by Medical Doctor 1 (MD 1) indicated that Resident 139 had a diagnosis of dementia due to CVA. The HP further indicated that Resident 139 had fluctuating capacity to understand and make decisions. A review of Resident 139's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 5/8/2024 indicated that Resident 139 had intact cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). The MDS indicated that Resident 139 required partial to moderate assistance (facility staff does less than half the effort) with personal hygiene, lower body dressing, putting on and taking off footwear, and oral hygiene. The MDS further indicated that Resident 139 required substantial to maximal assistance (facility staff does more than half the effort) with toileting hygiene and bathing. A review of Resident 139's Occupational Therapy (OT - a program designed to improve a resident's ability to perform daily tasks) Evaluation and Plan of Treatment dated 5/3/2024 indicated that Resident 139's right upper extremity strength was impaired. A review of Resident 139's Inventory of Personal Effects dated 5/2/2024 did not indicate that Resident 139 was in possession of a torch lighter upon admission. The form was completed and documented by Certified Nursing Assistant 2 (CNA 2) and counter signed (a signature attesting the authenticity of a document already signed by another) by Registered Nurse 2 (RN 2). During an observation on 6/24/2024 at 9:53 a.m. inside Resident 139's room, observed a torch lighter placed on top of Resident 139's nightstand. During a concurrent observation and interview on 6/26/2024 at 9:46 a.m. with Registered Nurse 1 (RN 1) and Resident 139, inside Resident 139's room, observed Resident 139 with a torch lighter. RN 1 attempted to collect Resident 139's torch lighter, but Resident 139 refused. RN 1 stated that a torch lighter should not be kept at the resident's beside because a torch lighter can burn down the facility. During an interview with the Activity Assistant (AA) on 6/26/2024 at 10:18 a.m., the AA stated that a torch lighter is very dangerous, and that Resident 139 should not have a torch lighter in his (Resident 139) possession. During an interview with the ADON on 6/26/2024 at 10:24 a.m., the ADON stated that torch lighters are not allowed in the facility because they are a fire hazard. During an interview with Resident 139 on 6/26/2024 at 10:45 a.m., Resident 139 stated that the torch lighter has been in his (Resident 139) possession since he was admitted to the facility (5/2/2024). Resident 139 stated that the Admin has always been aware of Resident 139's torch lighter. During an interview with Certified Nursing Assistant 1 (CNA 1) on 6/27/2024 at 5:08 p.m., CNA 1 stated that she (CNA 1) has on multiple occasions been assigned to provide care to Resident 139. CNA 1 stated that while assigned to Resident 139, CNA 1 will occasionally take the resident to the designated smoking area. CNA 1 stated that from her (CNA 1) recollection, Resident 139 used a regular (referring to a soft flame lighter) lighter when smoking. CNA 1 stated that she (CNA 1) is familiar with what a torch lighter is and did not see Resident 139 use a torch lighter when smoking. CNA 1 stated that a torch lighter produces a flame at a high concentration and can burn through things such as a cigarette much quicker because the flame is stronger. CNA 1 stated that she (CNA 1) would be concerned if CNA 1 was to observe Resident 139 with a torch lighter because it is much more dangerous than a soft flame lighter. During a concurrent observation and interview with Resident 139 on 6/27/2024 at 6:24 p.m., the surveyor observed Resident 139 inside the Administrator's office. Resident 139 stated that he (Resident 139) has had the torch lighter since Resident 139's admission to the facility (on 5/2/2024). Resident 139 stated that he (Resident 139) uses a torch lighter while smoking because Resident 139's right hand is limited and that he (Resident 139) cannot really use the right hand. The surveyor observed Resident 139 slowly open and close his (Resident 139) right hand, and then slowly move his (Resident 139) right hand in small circular motions. Resident 139 stated that upon Resident 139's admission to the facility, the facility's staff did not thoroughly check and document his (Resident 139) belongings. Resident 139 stated that had the facility's staff thoroughly check Resident 139's belongings, they would have found the torch lighter in Resident 139's pocket. When asked which facility staff checked Resident 139's belongings upon the resident's admission, Resident 139 stated he (Resident 139) was unable to recall. During an interview with MD 1 on 6/27/2024 at 6:43 p.m., MD 1 stated that he (MD 1) completed Resident 139's HP dated 5/4/2024. MD 1 stated that Resident 139's HP dated 5/4/2024 that included Resident 139's diagnosis of dementia due to CVA and Resident 139's fluctuating capacity to understand and make decisions was an accurate assessment made by MD 1. MD 1 stated that MD 1 was not made aware until today (6/27/2024) that Resident 139 was in possession of a torch lighter. MD 1 stated that a torch lighter should be kept in a safe place such as a locked box. When MD 1 was asked if he (MD 1) was aware that Resident 139's torch lighter was found on top of the resident's nightstand unattended on 6/24/2024, MD 1 stated that he (MD 1) was not aware. MD 1 stated that because Resident 139's torch lighter was not in a locked box, and was left unattended on the resident's nightstand, the torch lighter increased the risk for danger for the facility. MD 1 stated Resident 139's torch lighter would especially be dangerous if a confused resident obtained the torch lighter while it was left unattended. During a concurrent interview and record review with RN 2 on 6/27/2024 at 7:39 p.m., reviewed Resident 139's Inventory of Personal Effects dated 5/2/2024. RN 2 stated that there was no torch lighter listed on the inventory of personal effects form of Resident 139. RN 2 stated that he (RN 2) admitted Resident 139 to the facility on [DATE]. When RN 2 was asked how the facility checks for the inventory of a resident upon admission, RN 2 stated that upon admission, a Certified Nurse Assistant (CNA) will take inventory and itemize all the belongings that is brought in by the resident. RN 2 stated that after a CNA has completed the Inventory of Personal Effects form, the assigned Registered Nurse (RN) will counter sign the form as a confirmation check that the CNA completed the form. RN 2 reviewed Resident 139's Inventory of Personal Effects dated 5/2/2024 and stated that RN 2 counter signed the form and then pointed to CNA 2's signature. RN 2 stated that it was CNA 2 who completed and documented Resident 139's Inventory of Personal Effects dated 5/2/2024. When RN 2 was asked about Resident 139's torch lighter, and if RN 2 knew the difference between a torch lighter and a soft flame lighter, RN 2 stated he (RN 2) knows the difference between a soft flame lighter and a torch lighter. RN 2 stated that the intensity of the flame is much higher in a torch lighter. RN 2 stated that the heat and flame size produced by the torch lighter would make it more likely for an injury or a burn to occur. RN 2 stated there are safety concerns as well such as if a torch lighter is left unattended and a confused resident was able to obtain the torch lighter. RN 2 stated that he (RN 2) would not leave a torch lighter with a resident even if the resident was alert and oriented (refers to a person's level of awareness of self, place, time, and situation) because it is a safety issue. During an interview on 6/27/2024 at 7:39 p.m. with the DON, the DON stated that there is no safety issues or concerns with Resident 139 possession or use of a torch lighter while admitted to the facility because Resident 139 knows how to use a torch lighter. DON stated that even though a torch lighter, which has a higher intensity and concentrated flame, and is able to burn through things faster than a soft flame lighter; a torch lighter is not any more dangerous nor does it impose any more of a safety risk than a soft flame lighter. The DON further stated that she is just now learning about what a torch lighter is. During an interview on 6/27/2024 at 7:39 p.m. with the Admin, the Admin stated that there is no increased risk for safety or injury when comparing a torch lighter to a soft flame lighter. The admin stated that even though a torch lighter has a higher intensity and more concentrated flame, and even though a torch lighter can burn through things much faster than a soft flame lighter, a torch lighter does not increase the risk of injury or safety when compared to a soft flame lighter. During an interview on 6/27/2024 at 8:28 p.m. with the Admin and DON, the Admin and DON stated that the SSA and the surveyors are to be blamed for putting the facility's residents at risk because the surveyors did not inform the Admin and the DON of Resident 139's torch lighter sooner and did not inform the Admin and DON sooner of the dangers and concerns of Resident 139's torch lighters. The Admin again stated and repeated that it was the SSA that put the safety of the residents of the facility at risk. A review of the facility's policy and procedure titled Resident Smoking, reviewed date 12/19/2023 indicated that it is the policy of the facility to provide a safe and healthy environment for residents, visitors, and employees, including safety as related to smoking. 2. A review of Resident 139's Initial Smoking Safety form dated 5/7/2024 documented by AD indicated that Resident 139 can smoke independently. The form identifies Risk Factors (a characteristic, condition, or behavior that increases the likelihood of getting a disease or injury) of smoking under safety factors and concerns to assess the following: a. Burn skin, clothing, furniture or other, b. Cognitive deficit (impairment in an individual's mental processes that lead to the acquisition of information and knowledge, and drive how an individual understands and acts) c. Drops ashes on self, d. Impaired gait (pattern of walk) and balance e. Impaired vision f. Insufficient fine motor skills (the coordination of small muscles in movement with the eyes, hands, and fingers) needed to securely hold cigarette, g. Is on medication that affects alertness and function, h. Lethargic (a condition marked by drowsiness and an unusual lack of energy and mental alertness), falls asleep easily during tasks or activities, i. Total or limited Range of Motion (ROM - the extent or limit to which a part of the body can be moved around a joint or a fixed point) in arms or hands, j. Unable to extinguish (to put out) a cigarette safely, k. Unable to hold a cigarette safely, l. Unable to light a cigarette safely, m. Unable to use ashtray to extinguish a cigarette, During an interview and concurrent record review with the Activities Director on 6/27/2024 at 4:16 p.m. with the Admin, DON, and RNC present in the room, reviewed Resident 139's HP dated 5/7/2024 and Initial Smoking Safety form dated 5/7/2024. Admin stated that he (Admin) along with his team (DON and RNC) will be joining any facility staff that will be interviewed by Surveyor 1. AD stated that she (AD) completed Resident 139's Initial Smoking Safety Form dated 5/7/2024. When asked about AD's professional background and how AD is able to assess the risk factors listed on the facility's Smoking Safety form such as a resident's cognition, the types of medications that affect the alertness and function of a resident, or the total or limited ROM in the arms or hands of a resident; AD stated that she is not a professional and that a professional such as a nurse is suppose to complete a follow up smoking safety assessment after the AD's initial assessment. AD stated that it is the nurse's responsibility to assess a resident's cognition, medications, and range of motion and ultimately determine if the resident has the capability to smoke independently. AD stated that she (AD) does not assess the resident's range of motion or a resident's medication regimen (a treatment plan that specifies the dosage, schedule, and the duration of treatment) when completing the facility's Smoking Safety form. AD stated that the facility pressures AD to complete the Smoking Safety form for the residents. When the AD was asked how the AD assesses the cognition of a resident when completing the Smoking Safety Form, AD stated that she (AD) asks the residents questions such as where the resident was born, the resident's occupation, the education background of the resident, and the religious preference of the resident. AD stated that based on her assessment of Resident 139 on 5/7/2024, AD determined that Resident 139 did not need supervision and could smoke independently. When AD was asked what cause AD to have concerns regarding a resident's ability to smoke independently, AD stated that if the resident was confused or had dementia, which Resident 139 was neither, AD would be concerned regarding the resident's ability to smoke independently because the risk for safety and injury is increased. When AD was asked to read the diagnosis listed under Resident 139's HP dated 5/7/2024, AD stated she was unable to read the diagnosis. When the DON was asked to read the diagnosis listed under Resident 139's HP dated 5/7/2024, the DON stated that the diagnosis listed is dementia. AD stated that AD never looks at the resident's HP when completing the Smoking Safety form. When the AD was asked how then was AD able to reach the determination that Resident 139 is able to smoke independently if AD states that dementia would be a cause of concern in relation to a residents capability to smoke independently, and the fact that AD does not assess the resident's medication and range of motion as indicated in the Smoker Safety form, AD stated that it is the nurse's responsibility to complete a follow up Smoke Safety form to determine a residents capability to smoke independently. During an interview with MD 1 on 6/27/2024 at 6:43 p.m., MD 1 stated that he (MD 1) completed Resident 139's HP dated 5/4/2024. MD 1 stated that Resident 139's HP dated 5/4/2024 that included Resident 139's diagnosis of dementia due to CVA and the determination that Resident 139's fluctuating capacity to understand and make decisions was an accurate assessment conducted by MD 1. During an interview on 6/27/2024 at 7:39 p.m. with the DON, the DON stated that there is no documented evidence that a licensed nurse conducted a follow up Smoking Safety form for Resident 139 after AD completed the Initial Smoking Safety form dated 5/7/2024. During an interview on 6/27/2024 at 7:39 p.m. with the RNC, the RNC stated that moving forward, only a licensed nurse will complete the Initial Smoking Safety form of a resident. RNC stated there is no way to prove that a licensed nurse completed a Smoking Safety form after AD's Initial Smoking Safety form dated 5/7/2024 because there is no documented evidence. RNC states that if something is not documented, that means it was not done. A review of the facility's policy and procedure titled Resident Smoking reviewed date 12/19/2023 indicated that it is the policy of the facility provide a safe and healthy environment for residents, visitors, and employees, including safety as related to smoking. The policy further indicated that documentation to support decision making regarding smoking will be included in the medical record, including but not limited to: . b. Assessment of relevant functional and cognitive factors affecting ability to smoke safely. 3. During an interview with the MS on 6/28/2024 at 12:30 p.m., the MS stated that the facility has five water heaters. Water heaters 1, 2, and 3 supplies hot water to resident restroom hand sinks, shower rooms, and nursing stations. Water Heater 3 supplies hot water to rooms [ROOM NUMBERS]. During a concurrent observation and interview with MS on 6/28/2024 at 12:52 p.m., in the courtyard near room [ROOM NUMBER], observed Water Heater 3 with a temperature control display indicating a temperature of 136 F (safe water temperature: less than 121 degrees F). The MS stated that Water Heater 3 had a temperature set at 136 F, before the water reaches the mixing valve (a mechanical device that mixes cold water with hot water to deliver mixed, or tempered, water downstream). The MS stated while pointing to the circulating pump motor connected to Water Heater 3 that the circulating pump motor might be the problem as the motor gets too hot. The MS stated that the circulating pump motor of Water Heater 3 was keeping the water hotter than usual. The MS also stated that the water heater was not equipped with a high temperature alarm. During a concurrent observation and interview with the MS on 6/28/2024 at 1:15 p.m. in room [ROOM NUMBER], the MS measured the water temperature by turning on the hot water faucet fixture in the resident restroom hand sink and placing a probe thermometer (a thermometer [an instrument for measuring and indicating temperature {the measure of hotness or coldness}] that has a pointy metal stem) through the running water. The surveyor observed a water temperature reading of 138 F after having the water ran for one minute. The MS confirmed the finding by stating that the thermometer reading was 138 F. The surveyor observed that there were no warning signs posted to indicate water exceeding 125 F near the hand sink. The MS confirmed the observed finding that there were no warning signs posted to indicate water exceeding 125 F near the hand sink. During an interview with the MS on 6/28/2024 at 2:40 p.m., the MS stated that the water temperature in shower rooms and resident hand sinks should be between 108 F to 120 F. The MS stated that the water temperature should be no more than 120 F because the residents could burn themselves after 120 F. The MS stated that if the water temperature exceeds 120 F, we (the facility) need to put caution sign and we (the facility) do not have that. During a concurrent observation and interview with the MS on 6/28/2024 at 2:58 p.m. in room [ROOM NUMBER], the MS re-tested the water temperature by turning on the hot water faucet fixture in the resident restroom hand sink and placing a probe thermometer through the running water. The surveyor observed steam coming from the running hot water. The MS stated that the thermometer reading was 137.8 F and that he (MS) see the steam coming out. During a concurrent observation and interview with the MS on 6/28/2024 at 3:05 p.m. in room [ROOM NUMBER], the MS measured the water temperature by turning on the hot water faucet fixture in the resident restroom hand sink and placing a probe thermometer through the running water. Observed a water temperature reading of 131 F after having the water ran for four minutes. The MS confirmed the finding by stating that the thermometer reading was 131 F. There were no warning signs posted to indicate the water temperature exceeding 125 F near the hand sink. The MS confirmed the observed finding that there were no warning signs posted to indicate the water temperature exceeding 125 F near the hand sink. During a facility tour with MS on 6/28/2024 at 3:11 p.m., MS measured the water temperatures by turning on the hot water faucet fixture in resident restroom hand sinks and placing a probe thermometer through the running water. The following were observed: a. In room [ROOM NUMBER], a water temperature reading of 131 F was observed after having the water ran for less than one minute. MS confirmed the finding by stating the thermometer reading was 131 F. b. In room [ROOM NUMBER], a water temperature reading of 138 F was observed after having the water ran for less than two minutes. MS confirmed the finding by stating the thermometer reading was 138 F. During an interview with the MS on 6/28/2024 at 4:51 p.m., the MS stated that the water temperature of 131 F and 138 F in the resident restroom hand sinks were not okay. The MS stated the water temperatures were too hot and should not exceed 120 F. A review of Resident 137's Admission Record indicated the facility admitted Resident 137 on 4/25/2024 with diagnoses that included malignant neoplasm of retroperitoneum (a rare type of cancer that develops from the body's connective tissues, such as fat, muscle, blood vessels and fibrous tissue), low back pain, other abnormalities of gait (manner of walking) and mobility, and abnormal posture (positioning). A review of Resident 137's HP dated 4/27/2024, indicated that Resident 137 has the capacity to understand and make decisions. A review of Resident 137's MDS dated [DATE], indicated R

Based on observation, interview and record review, the facility failed to maintain the kitchen in a clean, safe, and sanitary condition in which food was stored, prepared, and served in accordance with professional standards of food service safety. The facility did not: 1. Eradicate (destroy/kill) cockroach (small insects that carry and spread infectious diseases) infestation (presence of an unusually large number of cockroach population) in the kitchen and the employee lounge room. 2. Eliminate harborage conditions (locations and conditions where pests can live, thrive [grow strong], reproduce, and feed) such as holes, gaps, cracks, crevices (narrow openings) in the walls and floors, trash on the floor, debris on the meat slicer and grease and grime (layer of dirt) on different surfaces throughout the kitchen affecting 99 of 103 residents who received food from the kitchen. This deficient practice placed a total of 99 residents at risk of food-borne illness (eating live bacteria, food containing toxins [harmful substance] from bacteria) and vector-borne diseases (diseases that result from an infection transmitted to human by insects such as cockroaches) from ingesting (drinking/eating) contaminated food and unsanitary food preparation and storage that could lead to life-threatening complications and death. On 5/19/2021 at 4:57 p.m., an Immediate Jeopardy (IJ - a situation in which the provider's non-compliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment or death of a resident or residents) was declared in the presence of the Director of Nursing (DON). On 5/24/2021 (five days later) at 3:43 p.m., the IJ situation was abated (removed) in the presence of the Administrator and DON after an on-site verification of the implementation of a written acceptable Plan of Action (POA, interventions to immediately correct the deficient practice), through observation, interview, and record review. The acceptable POA included the following: a. Structural problems were repaired and cleaned. b. Pest control service was provided immediately c. Food and beverages were obtained from a sister facility and qualified food providers, while the kitchen was closed for pest elimination. d. All non-sealed food items were disposed of immediately e. The kitchen and all kitchen equipment were deep cleaned. f. New systems were established for daily inspecting, monitoring, and reporting presence of pest. g. Staff was provided with training in kitchen sanitation and infection control. Findings: On 5/19/2021 at 12:00 p.m., the Los Angeles County (LAC) Department of Public Health (DPH) Environmental Health (EH) District Surveillance and Enforcement (DSE) Branch (department responsible for ensuring food provided for human consumption is safe and free of contamination) notified the State Agency (SA)about the closure of the facility kitchen due to cockroach infestation. A review of the Environmental Health Specialist 1 (EHS 1 - inspector) Official Inspection Report, dated 5/19/2021, indicated EHS 1 observed: - Three live adult German cockroaches (a small species of cockroach that can access food items and carry serious diseases) on the wall beneath the two-compartment sink, - Cockroach fecal (bowel movement) spotting under the two-compartment sink, - One live adult German cockroach on the floor under the kitchen oven, - One live adult German cockroach and egg attached located within a shelf under the steamtable (where cooked food is held before meal service), - Six live adult German cockroaches under the dishwashing machine drainboard, - One live nymph (baby) German cockroach on the wall under the dishwashing machine, and - One live German cockroach and two dead cockroaches on the floor of the mop sink room. On 5/19/2021, at 2:50 p.m., during an observation of the kitchen the following was found: - Two live adult cockroaches on the floor in the mop sink room (kitchen cleaning supply room), - Cracks on the wall under the dishwashing machine and drainboard, - Damaged base coving throughout the kitchen, - Broken tiles and gaps on the wall under the dishwashing sink, - Cracks in between the tiles (missing grout) on the floor next to stove and the two-compartment sink, - Grease and food debris on the surfaces of walls, - Grease and grime accumulated under the dishwasher machine drainpipes, - Grease and grime covering the garbage disposal, - Trash on the floor under the two-compartment sink, - Grease and grime attached to the drains under the two-compartment sink, - Dirt and grease on the stove control knobs, - Old and dirty dishwashing sponges, - Debris on the meat slicer, and - A block of plywood holding the drainpipe under the two-compartment sink. On 5/19/2021, at 3:15 p.m., during an interview, Infection Preventionist (IP) Nurse stated her role in the kitchen was to make sure staff have good handwashing practices and she checked on refrigerator temperatures and food temperatures. IP Nurse stated she did not monitor the kitchen for presence of pest as that was not her role. IP Nurse acknowledged presence of pest in the kitchen or anywhere in the facility presented infection risks for the residents. On 5/19/2021, at 3:20 p.m., during an interview, District Manager (DM) stated she was overseeing the kitchen because the Kitchen Supervisor (KS) resigned two weeks ago and the new hired KS was off. DM denied seeing cockroaches in the kitchen prior to 5/19/2021 and did not receive report from kitchen staff about cockroach sighting. On 5/19/2021 at 3:30 p.m., during an interview and concurrent observation in the kitchen, Dietary Aid 1 (DA 1) stated in the past few weeks (did not remember dates) she had seen cockroaches in the kitchen and pointed at the two-compartment sink. Upon closer look, underneath the sink there were two nymph (babies) cockroaches on a piece of plywood which was holding the drain in place. DA 1 stated whenever she saw cockroaches, she killed them and notified the KS. On 5/19/2021 at 3:45 p.m., during an interview, Cook 1 stated in the past few weeks (did not remember dates) she had seen cockroaches in the kitchen and had reported the sightings to the KS. On 5/19/2021, at 4:26 p.m., during an interview, DON stated she was not aware there were cockroaches in the kitchen. DON stated the KS would communicate with Maintenance Supervisor (MS) if there were pest issues and would report to pest control company. On 5/19/2021 at 4:42 p.m., during an interview, MS stated the facility had a contract with a pest control company to service monthly and the technician provided the service report after each visit. MS stated he did not review the reports because it was the KS's responsibility. MS stated the Administrator designated staff to conduct daily rounds in the facility including, the kitchen, residents' rooms, and common areas but the rounds did not include monitoring for pests. On 5/19/2021 at 5:29 p.m., an interview with MS and a concurrent review of the monthly pest control Customer Service Report forms from 10/4/2020 to 4/16/2021 was conducted. Each month, the report indicated there were structural concerns such as: - Holes or gaps under the steamtable, on multiple areas of the door frame of the storage closet (mop sink room). - Gaps under the dish machine area. - Missing or loose base coving under the dish area. Each month, the report included the recommendation for the facility to repair the structural concerns to eliminate potential pest harborage and breeding sites. MS stated he was aware of the recommendations to fix the structural problems in the kitchen, but he had not done the repairs yet. On 5/19/2021 at 5:49 p.m., during an interview, Registered Dietitian (RD) consultant stated no food or beverages should be used from the kitchen due to contamination from cockroach infestation. RD consultant stated she conducted monthly sanitation audits in the kitchen and had not seen any cockroaches. On 5/19/2021 at 7:20 p.m., during an interview, DM stated the kitchen did not have a cleaning schedule. On 5/20/2021 at 10:50 a.m., during an interview, Administrator stated there should be a communication log for kitchen staff to report pest sightings. On 5/20/2021 at 12 p.m., during a kitchen observation, there were two live cockroaches in the mop sink room. On 5/20/2021 at 5:20 p.m., during a dinner observation and concurrent interview with RD Consultant, coffee was prepared in the employee lounge area, adjacent to the kitchen. RD consultant stated the coffee was being prepared in the employees' breakroom since the kitchen remained closed. On 5/20/2021 at 5:25 p.m., during an observation of the employees' breakroom adjacent to the kitchen, there were two live cockroaches on the countertop next to the coffee maker. On 5/21/2021 at 11 a.m., during a kitchen observation and concurrent interview with the IP Nurse, there were three live cockroaches, two dead cockroaches, and one live nymph cockroach were observed in the mop sink room. IP Nurse confirmed the cockroaches sighting. On 5/22/2021 at 11:49 a.m., during a kitchen observation and concurrent interview with DON, four dead cockroaches were under the dishwashing area and one dead cockroach by the door of the dry storage area. DON confirmed the cockroaches sighting. On 5/24/2021 at 3:38 p.m., during an interview, the Administrator stated it was the administrator's responsibility to ensure the facility was clean and free from pests. Administrator stated he should have done frequent kitchen rounds and should have had more communication with the kitchen staff and pest control company. A review of the kitchen audit tool titled, Sanitation Audit Report dated 5/3/2021, indicated the audit did not include monitoring for presence of pest. A review of the 2017 U.S. Food and Drug Administration Food Code 6-202.15 indicated, insects and rodents are vectors of disease-causing microorganisms (living thing that is too small to be seen with the naked eye) which may be transmitted to humans by contamination of food and food contact surfaces. Food establishment shall be protected against the entry of insects and rodents by filling or closing holes and other gaps along floors, walls, and ceilings; closed, tight fitting windows and solid self-closing tight fitting doors. A review of the 2017 U.S. Food and Drug Administration Food Code 4-402.11 indicated, the inability to adequately or effectively clean areas under equipment could create a situation that may attract insects and rodents and accumulate pathogenic (disease-causing) microorganisms that are transmissible through food. A review of the Centers for Disease Control and Prevention (CDC), Guidelines for Environmental Infection Control in Health Care Facilities, updated on 7/23/2019, indicated the guidelines were recommendations for the prevention and control of infectious diseases that are associated with healthcare environments. Pest Control included cockroaches found in health-care facilities that can serve as agents for the mechanical transmission of microorganisms, or as active participants in the disease transmission process by serving as a vector (carrier that transfers an infectious organism from one host to another). A review of the undated job description for KS indicated, provides leadership, support and guidance to ensure that food quality standards, inventory levels, food safety guidelines and customer service expectations are met. Ensures that established sanitation and safety standards are maintained. A review of the job description for IP Nurse, revised in 2018, indicated the duties and responsibilities included, Assesses infection prevention areas for improvement and makes recommendations for corrective action. Monitors or oversees infection prevention practices and employee compliance for all departments and personnel. A review of the job description for MS dated 7/19/2012 indicated the MS was responsible and accountable for maintaining the physical plant. A review of the facility's policy and procedures titled, Infection Prevention Program Overview, revised 2/2018, indicated the goals of the infection prevention program was to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection. A review of the facility's policy and procedures titled, Preventive Maintenance program, revised in 2010, indicated preventive maintenance was performed according to schedule and in compliance with regulations. A successful preventive maintenance system was dependent on a routine schedule. Areas that required preventive maintenance and on routine schedule were base coving, tiles, and oven. A review of facility's policy and procedures titled, Pest Control, revised in 2/2018, indicated the purpose of the policy was to provide an environment free of pest with emphasis on the pest control program in kitchens and other areas prone to infestation such as areas of overgrowth in adjoining property. Dining Services Director (Kitchen Supervisor) would coordinate with maintenance to arrange pest control services monthly, or as needed. All food preparation, service, and storage areas would be monitored regularly for any signs of pest. Monitoring of the environment will be done by the facility staff. Pest control problems will be reported promptly to the contractor. A review of facility's policy and procedures titled, Environment, revised 9/2017, indicated the Dinning Services Director (Kitchen Supervisor) would ensure the kitchen is maintained in a clean and sanitary manner, including floors, walls, ceilings, lighting, and ventilation and a routine cleaning schedule is in place for all cooking equipment, food storage areas and surfaces. All equipment would be routinely cleaned and maintained in accordance with manufacturer's directions. All non-food contact equipment would be clean and free of debris. A review of the facility's policy and procedures titled Preventative Maintenance Program, revised 12/2010, indicated preventative maintenance is performed according to schedule and in compliance with applicable regulation.

Based on observation, interview, and record review, the facility failed to ensure an effective infection prevention and control program, led by the Infection Preventionist [IP] Nurse, to provide a safe and sanitary environment by having: 1. Cockroach (small insects that carry and spread infectious diseases) infestation (presence of an unusually large number of cockroach population) in the kitchen and the employee lounge room affecting 99 of 103 residents who receive food from the kitchen. 2. Harborage conditions (locations and conditions where pests can live, thrive [grow strong], reproduce, and feed) such as holes, gaps, cracks, crevices (narrow openings) in the walls and floors, trash on the floor, and grease and grime (layer of dirt) on different surfaces throughout the kitchen affecting 99 of 103 residents who receive food from the kitchen. This deficient practice placed a total of 99 residents at risk of food-borne illness (eating live bacteria, food containing toxins from bacteria) and vector-borne diseases (diseases that result from an infection transmitted to human by insects such as cockroaches) from ingesting (drinking/eating) contaminated food and unsanitary food preparation and storage that could lead to life-threatening complications and death. On 5/19/2021 at 4:57 p.m., an Immediate Jeopardy (IJ - a situation in which the provider's non-compliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment or death of a resident or residents) was declared in the presence of the Director of Nursing (DON). On 5/24/2021 (five days later) at 3:43 p.m., the IJ situation was abated (removed) in the presence of the Administrator and DON after an on-site verification of the implementation of a written acceptable Plan of Action (POA, interventions to immediately correct the deficient practice), through observation, interview, and record review. The acceptable POA included the following: a. Structural problems were repaired and cleaned. b. Pest control service was provided immediately c. Food and beverages were obtained from a sister facility and qualified food providers, while the kitchen was closed for pest elimination. d. All non-sealed food items were disposed of immediately e. The kitchen and all kitchen equipment were deep cleaned. f. New systems were established for daily inspecting, monitoring, and reporting the presence of pest . g. Staff was provided with training in kitchen sanitation and infection control. Findings : On 5/19/2021 at 12:00 p.m., the Los Angeles County (LAC) Department of Public Health (DPH) Environmental Health (EH) District Surveillance and Enforcement (DSE) Branch (department responsible for ensuring food provided for human consumption is safe and free of contamination) notified the State Agency (SA)about the closure of the facility kitchen due to cockroach infestation. A review of the Environmental Health Specialist 1 (EHS 1 - inspector) Official Inspection Report, dated 5/19/2021, indicated EHS 1 observed: - Three live adult German cockroaches (a small species of cockroach that can access food items and carry serious diseases) on the wall beneath the two-compartment sink, - Cockroach fecal (bowel movement) spotting under the two-compartment sink - One live adult German cockroach on the floor under the kitchen oven, - One live adult German cockroach and egg attached located within a shelf under the steamtable (where cooked food is held before meal service), - Six live adult German cockroaches under the dishwashing machine drainboard, - One live nymph (baby) German cockroach on the wall under the dishwashing machine, and - One live German cockroach and two dead cockroaches on the floor of the mop sink room (a utility sink with a floor drain). On 5/19/2021, at 2:50 p.m., during an observation of the kitchen the following was found: - Two live adult cockroaches on the floor in the mop sink room (kitchen cleaning supply room), - Cracks on the wall under the dishwashing machine and drainboard, - Damaged base coving through out the kitchen, - Broken tiles and gaps on the wall under the dishwashing sink, - Cracks in between the tiles (missing grout) on the floor next to stove and the two-compartment sink, - Grease and food debris on the surfaces of walls, - Grease and grime accumulated under the dishwasher machine drainpipes, - Grease and grime covering the garbage disposal, - Trash on the floor under the two-compartment sink, - Grease and grime attached to the drains under the two-compartment sink, - Dirt and grease on the stove control knobs, and - A block of plywood holding the drainpipe under the two-compartment sink. On 5/19/2021, at 3:15 p.m., during an interview, IP Nurse stated her role in the kitchen was to make sure staff have good handwashing practices and she checked on refrigerator temperatures and food temperatures. IP Nurse stated she did not monitor the kitchen for presence of pest as that was not her role. IP Nurse acknowledged presence of pest in the kitchen or anywhere in the facility presented infection risks for the residents. On 5/19/2021, at 3:20 p.m., during an interview, District Manager (DM) stated she was overseeing the kitchen because the Kitchen Supervisor (KS) resigned two weeks ago and the new hired KS was off. DM denied seen cockroaches in the kitchen prior to 5/19/2021 and did not receive report from kitchen staff about cockroach sighting. On 5/19/2021 at 3:30 p.m., during an interview and concurrent observation of the kitchen, Dietary Aid 1 (DA 1) stated in the past few weeks (did not remember dates) she had seen cockroaches in the kitchen and pointed at the two-compartment sink. Upon closer look underneath the sink, there were two nymph (babies) cockroaches on a piece of plywood which was holding the drain in place. DA 1 stated whenever she saw cockroaches, she killed them and notified the KS. On 5/19/2021 at 3:45 p.m., during an interview, Cook 1 stated in the past few weeks (did not remember dates) she had seen cockroaches in the kitchen and had reported the sightings to the KS. On 5/19/2021, at 4:26 p.m., during an interview, DON stated she was not aware there were cockroaches in the kitchen. DON stated the KS would communicate with Maintenance Supervisor (MS) if there were pest issues and would report to contracted pest control company. On 5/19/2021 at 5:29 p.m., during an interview, MS stated he was aware of the structural problems in need of repair in the kitchen, but he had not done the repairs yet. On 5/19/2021 at 5:49 p.m., during an interview, Registered Dietitian (RD) consultant stated no food or beverages should be used from the kitchen due to contamination from cockroach infestation. RD consultant stated she conducted monthly sanitation audits in the kitchen and had not seen any cockroaches. On 5/19/2021 at 7:20 p.m., during an interview, DM stated the kitchen did not have a cleaning schedule. On 5/20/2021 at 10:50 a.m., during an interview, Administrator stated there should be a communication log for kitchen staff to report pest sightings. On 5/20/2021 at 12 p.m., during a kitchen observation, there were two live cockroaches in the mop sink room. On 5/20/2021 at 5:20 p.m., during a dinner observation and concurrent interview with RD Consultant, coffee was prepared in the employee lounge area, adjacent to the kitchen . RD consultant stated the coffee was being prepared in the employees' breakroom since the kitchen remained closed. On 5/20/2021 at 5:25 p.m., during an observation of the employees' breakroom adjacent to the kitchen, there were two live cockroaches on the countertop next to the coffee maker. On 5/21/2021 at 11 a.m., during a kitchen observation and concurrent interview with the IP Nurse, there were three live cockroaches, two dead cockroaches, and one live nymph cockroach were observed in the mop sink room. IP Nurse confirmed the cockroaches sighting. On 5/22/2021 at 11:49 a.m., during a kitchen observation and concurrent interview with DON, four dead cockroaches were under the dishwashing area and one dead cockroach by the door of the dry storage area. DON confirmed the cockroaches sighting. On 5/24/2021 at 3:38 p.m., during an interview, the Administrator stated it was the administrator's responsibility to ensure the facility was clean and free from pests. Administrator stated he should have done frequent kitchen rounds and should have had more communication with the kitchen staff and pest control company. A review of the kitchen audit tool titled, Sanitation Audit Report dated 5/3/2021, indicated the audit did not include monitoring for presence of pest. A review of the 2017 U.S. Food and Drug Administration Food Code 6-202.15 indicated, insects and rodents are vectors of disease-causing microorganisms (living thing that is too small to be seen with the naked eye) which may be transmitted to humans by contamination of food and food contact surfaces. Food establishment shall be protected against the entry of insects and rodents by filling or closing holes and other gaps along floors, walls, and ceilings; closed, tight fitting windows and solid self-closing tight fitting doors. A review of the 2017 U.S. Food and Drug Administration Food Code 4-402.11 indicated, the inability to adequately or effectively clean areas under equipment could create a situation that may attract insects and rodents and accumulate pathogenic (disease-causing) microorganisms that are transmissible through food. A review of the Centers for Disease Control and Prevention (CDC), Guidelines for Environmental Infection Control in Health Care Facilities, updated on 7/23/2019, indicated the guidelines were recommendations for the prevention and control of infectious diseases that are associated with healthcare environments. Pest Control included cockroaches found in health-care facilities that can serve as agents for the mechanical transmission of microorganisms, or as active participants in the disease transmission process by serving as a vector (carrier that transfers an infectious organism from one host to another). A review of the undated job description for KS indicated, provides leadership, support and guidance to ensure that food quality standards, inventory levels, food safety guidelines and customer service expectations are met. Ensures that established sanitation and safety standards are maintained. A review of the job description for IP Nurse, revised in 2018, indicated the duties and responsibilities included, Assesses infection prevention areas for improvement and makes recommendations for corrective action. Monitors or oversees infection prevention practices and employee compliance for all departments and personnel. A review of the job description for MS dated 7/19/2012 indicated the MS was responsible and accountable for maintaining the physical plant. A review of the facility's policy and procedures titled, Infection Prevention Program Overview, revised 2/2018, indicated the goals of the infection prevention program was to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection. A review of the facility's policy and procedures titled, Preventive Maintenance program, revised in 2010, indicated preventive maintenance was performed according to schedule and in compliance with regulations. A successful preventive maintenance system was dependent on a routine schedule. Areas that required preventive maintenance and on routine schedule were base coving, tiles, and oven. A review of facility's policy and procedures titled, Pest Control, revised in 2/2018, indicated the purpose of the policy was to provide an environment free of pest with emphasis on the pest control program in kitchens and other areas prone to infestation such as areas of overgrowth in adjoining property. Dining Services Director (Kitchen Supervisor) indicated would coordinate with maintenance to arrange pest control services monthly, or as needed. All food preparation, service, and storage areas would be monitored regularly for any signs of pest. Monitoring of the environment will be done by the facility staff. Pest control problems will be reported promptly to the contractor. A review of facility's policy and procedures titled, Environment, revised 9/2017, indicated the Dinning Services Director (Kitchen Supervisor) would ensure the kitchen is maintained in a clean and sanitary manner, including floors, walls, ceilings, lighting, and ventilation and a routine cleaning schedule is in place for all cooking equipment, food storage areas and surfaces. All equipment would be routinely cleaned and maintained in accordance with manufacturer's directions. All non-food contact equipment would be clean and free of debris.

Based on observation, interview, and record review, the facility failed to remain free of pests by not ensuring an effective pest control. The facility did not: 1. Eradicate (destroy/kill) cockroach (small insects that carry and spread infectious diseases) infestation (presence of an unusually large number of cockroach population) in the kitchen and the employee lounge room affecting 99 of 103 residents who received food from the kitchen. 2. Eliminate harborage conditions (locations and conditions where pests can live, thrive [grow strong], reproduce, and feed) such as holes, gaps, cracks, crevices (narrow openings) in the walls and floors, trash on the floor, debris on the meat slicer and grease and grime (layer of dirt) on different surfaces throughout the kitchen affecting 99 of 103 residents who received food from the kitchen. These deficient practices placed a total of 99 residents at risk of food-borne illness (eating live bacteria, food containing toxins from bacteria) and vector-borne diseases (diseases that result from an infection transmitted to human by insects such as cockroaches) from ingesting (drinking/eating) contaminated food and unsanitary food preparation and storage that could lead to life-threatening complications and death. On 5/19/2021 at 4:57 p.m., an Immediate Jeopardy (IJ - a situation in which the provider's non-compliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment or death of a resident or residents) was declared in the presence of the Director of Nursing (DON). On 5/24/2021 (five days later) at 3:43 p.m., the IJ situation was abated (removed) in the presence of the Administrator and DON after an on-site verification of the implementation of a written acceptable Plan of Action (POA, interventions to immediately correct the deficient practice), through observation, interview, and record review. The acceptable POA included the following: a. Structural problems were repaired and cleaned. b. Pest control service was provided immediately c. Food and beverages were obtained from a sister facility and qualified food providers, while the kitchen was closed for pest elimination. d. All non-sealed food items were disposed of immediately e. The kitchen and all kitchen equipment were deep cleaned. f. New systems were established for daily inspecting, monitoring, and reporting presence of pest. g. Staff was provided with training in kitchen sanitation and infection control. Findings: On 5/19/2021 at 12:00 p.m., the Los Angeles County (LAC) Department of Public Health (DPH) Environmental Health (EH) District Surveillance and Enforcement (DSE) Branch (department responsible for ensuring food provided for human consumption is safe and free of contamination) notified the State Agency (SA)about the closure of the facility kitchen due to cockroach infestation. A review of the Environmental Health Specialist 1 (EHS 1 - inspector) Official Inspection Report, dated 5/19/2021, indicated EHS 1 observed: - Three live adult German cockroaches (a small species of cockroach that can access food items and carry serious diseases) on the wall beneath the two-compartment sink, - Cockroach fecal (bowel movement) spotting under the two-compartment sink, - One live adult German cockroach on the floor under the kitchen oven, - One live adult German cockroach and egg attached located within a shelf under the steamtable (where cooked food is held before meal service), - Six live adult German cockroaches under the dishwashing machine drainboard, - One live nymph (baby) German cockroach on the wall under the dishwashing machine, and - One live German cockroach and two dead cockroaches on the floor of the mop sink room. On 5/19/2021, at 2:50 p.m., during an observation of the kitchen the following was found: - Two live adult cockroaches on the floor in the mop sink room (kitchen cleaning supply room), - Cracks on the wall under the dishwashing machine and drainboard, - Damaged base coving throughout the kitchen, - Broken tiles and gaps on the wall under the dishwashing sink, - Cracks in between the tiles (missing grout) on the floor next to stove and the two-compartment sink, - Grease and food debris on the surfaces of walls, - Grease and grime accumulated under the dishwasher machine drainpipes, - Grease and grime covering the garbage disposal, - Trash on the floor under the two-compartment sink, - Grease and grime attached to the drains under the two-compartment sink, - Dirt and grease on the stove control knobs, and - A block of plywood holding the drainpipe under the two-compartment sink. On 5/19/2021, at 3:15 p.m., during an interview, Infection Preventionist (IP) Nurse stated her role in the kitchen was to make sure staff have good handwashing practices and she checked on refrigerator temperatures and food temperatures. IP Nurse stated she did not monitor the kitchen for presence of pest as that was not her role. IP Nurse acknowledged presence of pest in the kitchen or anywhere in the facility presented infection risks for the residents. On 5/19/2021, at 3:20 p.m., during an interview, District Manager (DM) stated she was overseeing the kitchen because the Kitchen Supervisor (KS) resigned two weeks ago and the new hired KS was off. DM denied seeing cockroaches in the kitchen prior to 5/19/2021 and did not receive report from kitchen staff about cockroach sighting. On 5/19/2021 at 3:30 p.m., during an interview and concurrent observation in the kitchen, Dietary Aid 1 (DA 1) stated in the past few weeks (did not remember dates) she had seen cockroaches in the kitchen and pointed at the two-compartment sink. Upon closer look, underneath the sink there were two nymph (babies) cockroaches on a piece of plywood which was holding the drain in place. DA 1 stated whenever she saw cockroaches, she killed them and notified the KS. On 5/19/2021 at 3:45 p.m., during an interview, Cook 1 stated in the past few weeks (did not remember dates) she had seen cockroaches in the kitchen and had reported the sightings to the KS. On 5/19/2021, at 4:26 p.m., during an interview, DON stated she was not aware there were cockroaches in the kitchen. DON stated the KS would communicate with Maintenance Supervisor (MS) if there were pest issues and would report to contacted pest control company. On 5/19/2021 at 4:42 p.m., during an interview, MS stated the facility had a contract with a pest control company to service monthly and the technician provided the service report after each visit. MS stated he did not review the reports because it was the KS's responsibility. MS stated the Administrator designated staff to conduct daily rounds in the facility including, the kitchen, residents' rooms, and common areas but the rounds did not include monitoring for pests. On 5/19/2021 at 5:29 p.m., an interview with MS and a concurrent review of the monthly pest control Customer Service Report forms from 10/4/2020 to 4/16/2021 was conducted. Each month, the report indicated there were structural concerns such as: - Holes or gaps under the steamtable, on multiple areas of the door frame of the storage closet (mop sink room). - Gaps under the dish machine area. - Missing or loose base coving under the dish area. Each month, the report included the recommendation for the facility to repair the structural concerns to eliminate potential pest harborage and breeding sites. MS stated he was aware of the recommendations to fix the structural problems in the kitchen, but he had not done the repairs yet. On 5/19/2021 at 5:49 p.m., during an interview, Registered Dietitian (RD) Consultant stated no food or beverages should be used from the kitchen due to contamination from cockroach infestation. RD consultant stated she conducted monthly sanitation audits in the kitchen and had not seen any cockroaches. On 5/20/2021 at 12 p.m., during a kitchen observation, there were two live cockroaches in the mop sink room. On 5/20/2021 at 5:20 p.m., during a dinner observation and concurrent interview with RD Consultant, coffee was prepared in the employee lounge area, adjacent to the kitchen. RD consultant stated the coffee was being prepared in the employees' breakroom since the kitchen remained closed. On 5/20/2021 at 5:25 p.m., during an observation of the employees' breakroom adjacent to the kitchen, there were two live cockroaches on the countertop next to the coffee maker. On 5/21/2021 at 11 a.m., during a kitchen observation and concurrent interview with the IP Nurse, there were three live cockroaches, two dead cockroaches, and one live nymph cockroach were observed in the mop sink room. IP Nurse confirmed the cockroaches sighting. On 5/22/2021 at 11:49 a.m., during a kitchen observation and concurrent interview with DON, four dead cockroaches were under the dishwashing area and one dead cockroach by the door of the dry storage area. DON confirmed the cockroaches sighting. On 5/24/2021 at 3:38 p.m., during an interview, the Administrator stated it was the administrator's responsibility to ensure the facility was clean and free from pests. Administrator stated he should have done frequent kitchen rounds and should have had more communication with the kitchen staff and pest control company. A review of the kitchen audit tool titled, Sanitation Audit Report dated 5/3/2021, indicated the audit did not include monitoring for presence of pest. A review of the 2017 U.S. Food and Drug Administration Food Code 6-202.15 indicated, insects and rodents are vectors of disease-causing microorganisms (living thing that is too small to be seen with the naked eye) which may be transmitted to humans by contamination of food and food contact surfaces. Food establishment shall be protected against the entry of insects and rodents by filling or closing holes and other gaps along floors, walls, and ceilings; closed, tight fitting windows and solid self-closing tight fitting doors. A review of the 2017 U.S. Food and Drug Administration Food Code 4-402.11 indicated, the inability to adequately or effectively clean areas under equipment could create a situation that may attract insects and rodents and accumulate pathogenic (disease-causing) microorganisms that are transmissible through food. A review of the Centers for Disease Control and Prevention (CDC), Guidelines for Environmental Infection Control in Health Care Facilities, updated on 7/23/2019, indicated the guidelines were recommendations for the prevention and control of infectious diseases that are associated with healthcare environments. Pest Control included cockroaches found in health-care facilities that can serve as agents for the mechanical transmission of microorganisms, or as active participants in the disease transmission process by serving as a vector (carrier that transfers an infectious organism from one host to another). A review of the undated job description for KS indicated, provides leadership, support and guidance to ensure that food quality standards, inventory levels, food safety guidelines and customer service expectations are met. Ensures that established sanitation and safety standards are maintained. A review of the job description for IP Nurse, revised in 2018, indicated the duties and responsibilities included, Assesses infection prevention areas for improvement and makes recommendations for corrective actions. Monitors or oversees infection prevention practices and employee compliance for all departments and personnel. A review of the job description for MS dated 7/19/2012 indicated the MS was responsible and accountable for maintaining the physical plant. A review of the facility's policy and procedures titled, Infection Prevention Program Overview, revised 2/2018, indicated the goals of the infection prevention program was to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection. A review of the facility's policy and procedures titled, Preventive Maintenance program, revised in 2010, indicated preventive maintenance was performed according to schedule and in compliance with regulations. A successful preventive maintenance system was dependent on a routine schedule. Areas that required preventive maintenance and on routine schedule were base coving, tiles, and oven. A review of facility's policy and procedures titled, Pest Control, revised in 2/2018, indicated the purpose of the policy was to provide an environment free of pest with emphasis on the pest control program in kitchens and other areas prone to infestation such as areas of overgrowth in adjoining property. Dining Services Director (Kitchen Supervisor) would coordinate with maintenance to arrange pest control services monthly, or as needed. All food preparation, service, and storage areas would be monitored regularly for any signs of pest. Monitoring of the environment will be done by the facility staff. Pest control problems will be reported promptly to the contractor. A review of facility's policy and procedures titled, Environment, revised 9/2017, indicated the Dining Services Director (Kitchen Supervisor) would ensure the kitchen is maintained in a clean and sanitary manner, including floors, walls, ceilings, lighting, and ventilation and a routine cleaning schedule is in place for all cooking equipment, food storage areas and surfaces. All equipment would be routinely cleaned and maintained in accordance with manufacturer's directions. All non-food contact equipment would be clean and free of debris.

Based on interview and record review, the facility failed to provide acceptable in quality or quantity nutrition (food for health and growth) to meet the recommended daily nutritional intake and prevent weight loss and dehydration for one of three sampled residents (Resident 1) by failing to: 1. Notify the physician of Resident 1's low fluid intake not meeting the assessed needs. 2. Implement the plan of care on Nutrition by not referring Resident 1 to the RD for evaluation. 3. Refer Resident 1 to the Registered Dietitian (RD) for evaluation and recommendations when the resident sustained [REDACTED]. These deficient practices resulted in Resident 1 having a sudden change in condition, requiring transfer to General Acute Care Hospital 1 (GACH 1) on [DATE] where she was diagnosed with [REDACTED]. Resident 1 expired at GACH 1 two days later on [DATE] due to acute [MEDICAL CONDITION] (rapid loss of renal function due to damage to the kidneys). Findings: A review of Resident 1's Admission Record (Face Sheet) indicated the facility admitted the resident on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 1's Nutrition Registered Dietician Assessment, dated [DATE], signed by the RD indicated Resident 1's daily fluid requirement ranged from 1400 to1680 milliliters (ml- unit of measurement) per day. A review of Resident 1's Nutritional Data Collection form, dated [DATE], electronically signed by the RD indicated Resident 1's usual body weight was 120 pounds. The record did not indicate the ideal body weight. A review of Resident 1's Care Plan initiated on [DATE] for the resident's risk for altered nutrition related to [DIAGNOSES REDACTED]. The interventions included providing therapeutic diet as ordered, honoring dietary preferences, encouraging oral intake, and referring to RD as needed. A review of Resident 1's Care Plan initiated on [DATE] for the resident's deficit with ADL (activities of daily living) self-care performance deficit related to physical limitations, activity intolerance, limited mobility secondary to aging process, indicated the resident required assistance to eat. A review of Resident 1's Weights and Vitals Summary, indicated on [DATE], Resident 1 weighed 123 pounds. A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated [DATE], indicated Resident 1 weighed 123 pounds. A review of Resident 1's Care Plan initiated on [DATE] for the resident's deficit with ADL (activities of daily living) self-care performance deficit related to physical limitations, activity intolerance, limited mobility secondary to aging process, indicated the resident required assistance to eat. A review of Resident 1's MDS, dated [DATE], indicated the resident was able to understand and make decisions and did not have memory problems. Resident 1 required limited assistance with eating and extensive assistance with bed mobility, dressing, toilet use, and personal hygiene. Resident 1 weighed 119 pounds. A review of Resident 1's Nutrition Status Review record, dated [DATE], indicated Resident 1 was re-evaluated by the RD on [DATE] due to a weight loss of greater than 5% in 30 days, the most recent weight was 119 pounds. Resident 1 had a variable intake and recommended staff to encourage intake. A review of Resident 1's Weights and Vitals Summary, indicated on [DATE], Resident 1 weighed 113 pounds, a weight loss of 10 pounds or 11% weight in six months. A review of Resident 1's Meal Consumption Report indicated the resident's measured fluid intake during the month of ,[DATE] Resident 1's fluid intake ranged from 700 to 850 milliliters per day (ml/day). On ,[DATE] Resident 1's total intake of fluids was 200 ml in 24 hours; on ,[DATE] the total was 860 ml, on ,[DATE] the total was 410 ml and on [DATE], Resident 1 received a total of 180 ml/day. Resident 1 was consuming less than the assessed daily fluid needs (1400 to1680 ml). There was no documentation Resident 1 was monitored for signs and symptoms of dehydration. A review of Resident 1's the Situation, Background, Assessment, Recommendation (SBAR) Communication Form and Progress Note, dated [DATE], timed at 5:30 p.m., indicated Resident 1 had change of condition including altered level of consciousness (non-responsive as usual, difficult to arouse), [MEDICAL CONDITION](increased heart rate), and desaturation (low oxygen in blood). The blood pressure was ,[DATE] millimeters of mercury (mmHg - normal below ,[DATE] mmHg and above ,[DATE] mmHg), the heart rate was 121 beats per minute (bpm - normal 60 to 100 bpm), the oxygen saturation was 85% (normal above 94%). Resident 1 was transferred to GACH 1 at 5:52 p.m. via paramedics (emergency medical transportation). A review of Resident 1's GACH 1's laboratory results dated [DATE] at 7:10 p.m., indicated Resident 1's sodium (one of the body's electrolytes, increased level can be indicative of dehydration) level was155 milliequivalents per liter (mEq/L - normal range 135 to 145 mEq/L). A review of Resident 1's GACH 1's Discharge Summary dated [DATE], indicated Resident 1's primary [DIAGNOSES REDACTED]. Resident 1's condition clinically declined during the duration of the stay at the hospital as she was transferred to intensive care unit (ICU) and became DNR (Do not resuscitate - allow natural death), developed cardiopulmonary arrest (the heart stopped working) and expired on [DATE] at 7:40 p.m. A review of Resident 1's Certificate of Death dated [DATE], indicated Resident 1's immediate cause of death was acute [MEDICAL CONDITION]. On [DATE], at 11:45 a.m., during an interview, the RD stated she conducts initial nutritional screening, within seven days from admission, to newly admitted residents and conducts quarterly follow up assessments. The RD stated the licensed nurses would notify her when residents have inadequate food and fluid intake and when residents have unplanned weight loss for her to reassesses the residents' nutritional needs. The RD stated Resident 1 sustained a 10-pound weight loss by [DATE], had inadequate daily fluid intake for four days in ,[DATE] but the licensed nursed did not inform her. On [DATE], at 1 p.m , during an interview and concurrent record review, Licensed Vocational Nurse 1 (LVN 1) stated she was assigned to Resident 1 on ,[DATE], ,[DATE], and [DATE] during the 7 a.m. to 3 p.m. shift. LVN 1 stated Certified Nursing Assistant 1 (CNA 1) notified her about Resident 1's low meal and fluid consumption. LVN 1 stated she did not update the nutritional care plan to attempt new interventions, did not notify the physician or the RD. On [DATE], at 4:40 p.m , during an interview and concurrent record review, the Director of Nursing (DON) confirmed the fluid intake of Resident 1 from ,[DATE] - [DATE] was low. The DON stated the licensed nurse should have documented a change of condition and notified the physician and the RD. The DON did not find documentation the licensed nurses monitored Resident 1 for signs and symptoms of dehydration The DON confirmed there was no documentation the physician was made aware of Resident 1's low fluid intake. On [DATE], at 10:01 a.m., during an interview, the DON confirmed there was no documented care plan developed for Resident 1's dehydration risk. The DON stated the care plan should have been developed on admission and interventions should have followed. On [DATE], at 2:29 p.m., during an interview, Resident 1's attending physician (Physician 1) ) stated the licensed nurses did not notify him about Resident 1's weight loss, low fluid intake, and deterioration in condition before Resident 1's emergency transfer on [DATE]. Physician 1 further stated since he was not aware, he did not order intravenous fluid for hydration. On [DATE], at 3:19 p.m., during an interview, CNA 1 stated she was assigned to the COVID-19 (coronavirus-contagious disease) designated unit and cared for Resident 1 from ,[DATE] to [DATE] during the 7 a.m. to 7 p.m. shift. CNA 1 stated she assisted with feeding Resident 1 with her meals and fluids and documented Resident 1's food and fluid intake in the Meal Consumption Report and notified LVNs 1 and 2 about Resident 1's low food and fluid intake. CNA 1 stated Resident 1 did not have nutritional supplement drinks ordered. A review of the facility's policy on Hydration Management dated ,[DATE], indicated residents are provided with sufficient fluid intake to maintain proper hydration and nutritional status. Residents' hydration will be monitored on a regular basis. Sufficient fluid means the amount of fluid needed to prevent dehydration and maintain health. The amount needed is specific for each resident, and fluctuates as the resident's condition fluctuates (e.g., increase fluids if resident has fever or diarrhea). A general guideline for determining baseline daily fluid needs is to multiply the resident's body in kilograms times 30 ml, except for residents with renal or cardiac distress. A review of the facility's policy on Changes in Resident Condition, revised on ,[DATE], indicated nursing staff, the resident, the attending physician, and the resident's legal representative are notified when changes in the resident's condition occur. A significant change in the resident's physical, mental, or psychosocial status, including a deterioration in health, mental, or psychosocial status in either life threatening conditions or clinical complications; or a need to alter treatment significantly. The SBAR Communication Form and the Progress Note are used to assess and document changes in condition in an efficient and effective manner; provide assessment information to the physician and provide clear comprehensive documentation. Changes in the resident's status that affect the problems/goals or approaches on his or her care plan, are documented as revisions and communicated to the interdisciplinary caregivers.

Based on interview and record review, the facility failed to effectively manage a resident's pain for one of three sample residents (Resident 1), including 1. Failure to monitor and assess appropriately for effectiveness of the pain management including monitoring the resident's symptoms and degree of pain relief. 2. Failure to notify physician after Resident 1 experienced excruciating pain unrelieved by the pain medication administered as ordered by the physician for four days, (from (MONTH) 21, (YEAR) until (MONTH) 24, (YEAR)). 3. Failure to revise the Care Plan to reflect additional interventions needed to relieve Resident 1's severe pain level. 4. Failure to implement the facility's policy on Pain Management, by not doing follow-up observations post-intervention to determine the effectiveness of pain interventions. As a result, after four days of ineffective pain management, Resident 1 was sent to a general acute care hospital (GACH) for the treatment of [REDACTED]. Findings: On (MONTH) 31, (YEAR), at 8:30 a.m., an unannounced complaint visit was conducted at the facility regarding a quality of care concern. A review of Resident 1's admission information indicated Resident 1 was admitted to the facility, on (MONTH) 17, (YEAR), and was readmitted on (MONTH) 26, (YEAR), with [DIAGNOSES REDACTED]. A review of the History and Physical, dated (MONTH) 19, (YEAR), indicated Resident 1 was capable of decision making. A review of Resident 1's Brief Interview for Mental Status (BIMS), dated (MONTH) 17, (YEAR), indicated Resident 1 had a score of 15. A BIMS score of 15 indicated the resident was cognitively intact. A review of Resident 1's care plan titled, Resident has Potential/Actual Pain related to: Disease Process, initiated on (MONTH) 18, (YEAR), indicated a goal of Resident 1's pain would be alleviated with both pharmacological and non-pharmacological interventions with evidence of pain relief through both verbal and non-verbal indicators. The care plan indicated the facility staff will observe for signs and symptoms of verbal and non-verbal indicators at each medication pass, and periodically. The care plan interventions indicated the staff would notify the doctor of unrelieved pain, provide medication as ordered, and document effectiveness results of medication administration. A review of Resident 1's Order Summary Report indicated the following physician orders: 1. [MEDICATION NAME] (pain medication) tablet 325 milligrams (mg) give two tablets by mouth every 4 hours as needed for mild pain (pain scale 1-3), Observe and document 0 for no pain, 1-2 for mild pain, 3-6 for moderate pain, 7-10 for severe pain. If pain present, treat initially with non-pharmacological intervention 0 = N/A (non applicable) 1= positioning/support, 3 = music, 4=relaxation, 5 = toileting. If pain persist use medication intervention, ordered 5/17/2018. 2. [MEDICATION NAME] (pain medication which contains [MEDICATION NAME])/[MEDICATION NAME] tablet ([MEDICATION NAME]) 10-325 mg give one tablet by mouth every six hours for pain. If pain persist use medication intervention [MEDICATION NAME] 10/325 one tablet every six hours prn (as needed), ordered 5/17/2018. 3. [MEDICATION NAME]/[MEDICATION NAME] tablet 5-325 mg give one tablet by mouth every four hours as needed for moderate pain, ordered 5/17/2018. A review of Resident 1's Medication Administration Record [REDACTED] On (MONTH) 21, (YEAR), [MEDICATION NAME]-[MEDICATION NAME] 10-325 mg tablet was administered for pain level of 6/10, during the night shift, at 12 a.m. On (MONTH) 21, (YEAR), [MEDICATION NAME]-[MEDICATION NAME] 10-325 mg tablet was administered for pain level of 2/10, during the day shift at 6 a.m. On (MONTH) 22, (YEAR), [MEDICATION NAME]-[MEDICATION NAME] 10-325 mg tablet was administered for pain level of 6/10, during the night shift at 6 a.m. On (MONTH) 22, (YEAR), [MEDICATION NAME]-[MEDICATION NAME] 10-325 mg tablet was administered for pain level of 8/10, at noon time. On (MONTH) 23, (YEAR), [MEDICATION NAME]-[MEDICATION NAME] 10-325 mg tablet was administered for pain level of 4/10, at 7 p.m. A review of Resident 1's Pain Level Monitoring for (MONTH) (YEAR), indicated the following: On (MONTH) 21, (YEAR), Resident A's pain level was 7/10 during the day shift, 8/10 during the evening shift, and 6/10 during the night shift. On (MONTH) 22, (YEAR), Resident A's pain level was 8/10 during the day shift, 8/10 during the evening shift, and 6/10 during the night shift. On (MONTH) 23, (YEAR), Resident A's pain level was 8/10 during the day shift. On (MONTH) 24, (YEAR), Resident A's pain level was 10/10 during the day shift. There was no documented evidence of the pain medication effectiveness after the pain medication [MEDICATION NAME] 10-325 was administered with the follow up codes of I=Ineffective or E=Effective, as indicated in the record after the nurses' initials. There was no documented evidence of a follow-up pain evaluation after the pain medication, [MEDICATION NAME]-[MEDICATION NAME], was administered from (MONTH) 21, (YEAR), until (MONTH) 24, (YEAR), from the licensed nurses in the record tiled Progress Notes. A review of Resident 1's Progress Notes, dated (MONTH) 24, (YEAR), indicated the following nurses' notes: 5/24/2018 09:31 (9:31 a.m.) .Resident c/o (complained of) 8/10 abdominal pain unrelieved of pain meds. Resident didn't want to be touched upon assessment. Refused to body skin check. There was no documented evidence the physician was notified of Resident 1's unrelieved severe pain levels prior to Resident 1's hospitalization on (MONTH) 24, (YEAR). A review of Resident 1's physician telephone order dated 05/24/2018 09:30 a.m. indicated to send Resident 1 to ER (emergency room ) for further evaluation (unrelieved abdominal pain) 8/10 scale. A review of the acute care hospital's record titled, Consultation Report, dated (MONTH) 25, (YEAR), at 11:49 a.m., indicated, Reason for consultation, Pancreatitis. This is a [AGE] year old, male patient who was admitted to the ED (emergency department) last night with intermittent pain x 2 d (for two days), chest pain, shortness of breath, dizziness, and N/V (nausea and vomiting) x 2 (two times). A review of Resident 1's re-admission physician order [REDACTED]. There was no documented evidence the pain care plan was updated and revised after Resident 1 returned to the facility on (MONTH) 26, (YEAR). On (MONTH) 31, (YEAR), at 9:57 a.m., the Licensed Vocational Nurse (LVN 1) was interviewed. The LVN 1 stated Resident 1 was transferred to the hospital because of this pain and the pain doesn't ease with pain medication. LVN 1 stated Resident 1 came back to the facility for a few hours and the doctor changed his [MEDICATION NAME] to [MEDICATION NAME] (a narcotic, controlled substance, can cause respiratory distress and death when taken in high doses or when combined with alcohol). LVN 1 stated Resident 1's pain was better and she was calmer after the change of medication. On (MONTH) 31, (YEAR), at 10:40 a.m., the Registered Nurse (RN 1) was interviewed. RN 1 stated when Resident 1 was first admitted to the facility, the nurses were administering [MEDICATION NAME] for pain. RN 1 stated the nurses were required to give pain medication for severe pain and assess the pain level after the pain medication. During a concurrent interview and Resident 1's record reviewed with RN 1, she stated the pain effectiveness documentation should be in the progress notes whether the pain level (medication) was effective or not. RN 1 stated if Resident 1's pain level was severe and there was no additional medications available then the nurses needed to call the doctor for more pain medication. On (MONTH) 31, (YEAR), at 11:28 a.m., Resident 1 was interviewed in his room. Resident 1 stated his day had been terrible. Resident 1 stated when he was transferred to the hospital his pain level was a 10/10, (on a pain rating scale of zero being no pain and 10 being the worst pain possible.) Resident 1 stated he was on [MEDICATION NAME] ([MEDICATION NAME]/[MEDICATION NAME] narcotic pain medication) for pain before the hospitalization . The resident stated the hospital had changed his pain medicine and it took four hours for effective pain management. During an interview, on (MONTH) 31, (YEAR), at 11:55 a.m., with the Director of Clinical Services (DCS) and the Administrator, the DCS stated Resident 1's care plan should be updated to reflect the changes of the pain medication and the acute care hospitalization , but it was not. On (MONTH) 31, (YEAR), the facility's policy titled, Pain Management, dated (YEAR), was reviewed. The document indicated Practice Guidelines .The Pain Evaluation will be completed in the following circumstances. Resident reports inadequate pain control. Resident is identified with a new onset of pain or displays new signs or symptoms of pain. Following the pain evaluation, the nurse will notify the Physician/Licensed Practitioner of the findings and document on the SBAR Communication Form and Progress Note (UDA), and implement new orders, if received. Each resident identified with pain management needs will have a Pain Management Care Plan initiated. The Care Plan will have individualized interventions related to that resident's individual control of pain. The Plan is updated as needed. The Care Plan should include both pharmacological and non-pharmacological pain management interventions. The policy indicated the licensed nurse will observe for pain during each shift and document interventions and outcomes. Pharmacological interventions will be documented in the Medication Administration Record [REDACTED]. The licensed nurse will communicate new onset or change of resident's pain through the 24-Hour Report process. The policy indicated Pain Management Care Plan will be updated, as indicated. The licensed nurse, when administering PRN pain medications, will record the drug administration and the following information in the MAR. Pain level using a 0-10 numerical rating scale. Follow-up observations post-intervention to determine the effectiveness of PRN pain interventions. At any time through the process of Pain Management, the IDT (interdisciplinary team) may conduct an At Risk Review Meeting regarding the resident, in conjunction with other Risk areas reviewed.

Based on interviews and record reviews, the facility failed to identify and evaluate accident risks and hazards, and did not develop a smoking plan of care for one of three sampled residents (Resident 1). For Resident 1, who was at risk for falls, the facility failed to accurately assess the resident for safe smoking privileges, failed to develop an initial plan of care with interventions to address safe smoking, and failed to assist the resident with ambulation as needed to move around the facility, per the activities of daily living plan of care. These deficient practices resulted in Resident 1 suffering a fall with injuries, which included a right knee abrasion and an acute left frontal subdural hemorrhage (a clot of blood that develops between the surface of the brain and the dura mater, the brain's tough outer covering, usually due to a head injury suddenly jolts or shakes the brain), which required a surgical craniotomy (surgical opening to the skull) procedure. Findings: A review of Resident 1's admission record (face sheet) indicated the resident was admitted , on 2/24/16, with a [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS - an assessment and care planning tool), dated 2/24/16, indicated Resident 1 required supervision oversight or cueing during transfer. The MDS indicated Resident 1 was a non- smoker. A review of the Activity of Daily Living (ADL) care plan, dated 2/25/16, indicated Resident 1 had weakness / history of falls, muscle weakness, difficulty walking, and recent decline in function. The care plan goal indicated the resident would be assisted with ADL's daily for 30 days and the care plan intervention indicated to assist with ambulation in room or corridor as needed, and assist to move around the unit/facility as needed. During an interview with Resident 1, on 3/16/16, at 5 p.m., she stated she fell , on 2/29/16 (five days after admission), coming from the skilled nursing facility's smoking area and the door closed on her. Resident 1 stated after her admission to the skilled nursing facility, the nursing staff accompanied her to the smoking area for about a day or two, then determined she no longer needed supervision, because she was alert, oriented, and independent. A review of the clinical record indicated there was no smoking plan of care for Resident 1 to indicate the degree of supervision necessary and the education and options for smoking cessation activities that were offered. During an interview with the social worker (SW), on 3/17/16, at 11:40 a.m., the SW stated she did not complete a safe smoker assessment or a smoking plan of care for Resident 1, per the facility policy, because the initial admission assessment (MDS) indicated Resident 1 was a non-smoker. A review of the general acute care emergency department (ED) notes, dated 2/29/16, indicated Resident 1 presented to ED for evaluation of head injury. The ED notes indicated Resident 1 lost her balance, fell , and hit the right side, back of her head. The ED notes indicated Resident 1 complained of a mild dull headache. Under [DIAGNOSES REDACTED]. outer covering, usually due to a head injury suddenly jolts or shakes the brain). The ED note indicated immediate consultation was obtained with neurosurgery, with plans to take Resident 1 to the operating room the next day. A review of the general acute care History and Physical form, dated 2/16/16, indicated Resident 1 was a current every day smoker who had been smoking 0.25 packs / day for [AGE] years. This indicated a discrepancy in the assessment of Resident 1's history compared to the skilled nursing facility's MDS. A review of the post operative notes, dated 3/1/16, indicated Resident 1 had a craniotomy (surgical opening to the skull) and remained in stable condition until discharge from the general acute care facility back to the skilled nursing facility on 3/7/16. The facility policy and procedure titled, Standards of Nursing Practice, revised 12/2005, indicated under Assessment - the nurse collects data regarding the resident's current health status and potential risk areas. Data was obtained through direct resident assessment and health history, as well as interaction with family members and other healthcare providers. During an interview with the Director of Nursing (DON), on 3/17/16, at 2 p.m., the DON stated the charge nurse was responsible for completing the admission assessment. The DON also stated the DON or the assistant DON was responsible for ensuring the accuracy of the admission assessment. A review of the facility policy titled, Safe Smoking, dated 11/ 2011, indicated the interdisciplinary team members determine if a resident was a safe or unsafe smoker before the resident exercised the privilege to smoke. An evaluation was conducted for all smokers upon admission. The policy indicated the resident's care plan would reflect the resident was a smoker, the degree of supervision necessary, and the education and options for smoking cessation activities that were offered to the resident. The policy indicated all unsafe smokers should be supervised at all times.

Based on observations, interviews, and record reviews, the facility failed to take immediately action for infection control measures and precautions to prevent the spread of a highly communicable form of scabies (crusted), a condition caused by mites (human skin parasite) for four of 24 sampled residents (4,15,17,20) and four randomly selected residents (28, 30,41,42), failed to implement its own policy and procedure on infection control by failing to observe proper infection control practices related during incontinence care, such as appropriate hand hygiene, for one randomly selected resident (38), failed to ensure that the sphygmomanometer (blood pressure apparatus) that was used between residents was sanitized or cleaned before using for another resident for two randomly selected residents (43,44) during a scabies outbreak, with resident's who were potentially infected with scabies. The facility failed to ensure that single use disposable pitchers and cups were not washed in the dishwasher, redistributed and reused by other residents that had the potential to transmit and spread disease and infections to residents throughout the facility, and failed to clean the shower chairs and wheelchairs between each resident's use to maintain sanitary resident equipment that had the potential to result in infections. Cross Refer to F281- The facility failed to use proper infection control procedures to introduce an indwelling urinary catheter (a device inserted into the bladder to collect urine) for one sample resident (14) out of 24 sample residents and for one Randomly Selected Resident, (45). This deficient practice resulted in the potential for urinary tract infections due to cross-contamination (the process by which bacteria or other microorganisms are unintentionally transferred) for Resident 14 and RSR 45. The facility failed to: 1. Maintain an effective infection control program to identify and prevent the spread of infection, when residents with scabies (a highly contagious skin condition caused by an infestation of itch mite Sarcoptes scabiei) were diagnosed , and when other residents who were exposed to scabies but were not diagnosed but exhibited signs and symptoms of scabies, and adequately and treat in a timely manner four out of 24 sample residents (4, 15, 17, 20), and four randomly selected residents (28, 30, 41, 42). Resident 15 was not diagnosed with [REDACTED]. The resident had signs and symptoms of scabies for over nine weeks while she was at the SNF, but was not diagnosed by the dermatologist. Residents 41 and 42 were roommates of Resident 15, were not provided with treatment interventions effective to prevent development of scabies. Resident 41 and 42 developed signs and symptoms of scabies while at the SNF. Resident 30 exhibited signs and symptoms consistent with scabies after she was admitted to the SNF. Resident 30 was the roommate of Resident 4 from May 17, 2016 to May 20, 2016. Resident 30 exhibited signs and symptoms of itching from May 17, 2016 to May 31, 2016. The facility failed to identify, test, [MEDICATION NAME] treat, or plan to treat Resident 30 who was exposed to scabies by her roommates (Resident 4 and Resident 17) from May 17, 2016 to May 20, 2016. The resident was not in an isolation room. Resident 20 was readmitted to the facility on [DATE], and developed a rash on May 12, 2016, on her right upper back and the back of her right arm while she was at the SNF, but she was not placed in isolations. The resident was not treated for [REDACTED]. Resident 4 was diagnosed with [REDACTED]. The resident had scabies on the upper middle chest on April 1, 2016. The facility failed to implement contact isolation precautions for Resident 4 in December 2015 and January 2016. This resulted in actual transmission of scabies to other residents and had the potential to transmit scabies to other residents, direct care givers, and visitors. Resident 17 developed a rash at the SNF on April 29, 2016, but was not placed in isolation. A dermatology (skin doctor) consult was not done until three weeks later on May 20, 2016. The dermatology consult indicated the resident's condition was clinically consistent with scabies. Resident 28 was identified with generalized body rashes while at the SNF on May 24, 2016. The resident was diagnosed with [REDACTED]. 2. Monitor and assess on an ongoing basis the residents' skin condition for effectiveness of the treatment after the residents were treated for [REDACTED]. 3. Ensure that the residents who were diagnosed with [REDACTED]. 4. Ensure that the facility maintained an effective infection control committee as required, designed to help prevent the development and transmission of disease and infections, that recognizes, investigates, controls, and uses records of infection incidents to improve its infection control processes and outcomes by taking corrective actions, as indicated; and to make infection control measure recommendations timely during infectious outbreaks in the facility, and ensure its infection control policies and procedures were carried out fully to include provision of supplies necessary to enable and allow healthcare personnel to provide care in a sanitary environment. 5. Implement its infection control policy and procedure that included the use of personal protective equipment (gowns, gloves, disposable footwear), the initiation of contact isolation in a timely manner, resident/family teaching, terminal disinfection (the act of destroying disease causing organisms), and conducting infection control surveillance (tracking the residents, employees, family members, visitors) to identify resident, facility staff members who were exposed to scabies and to develop a plan of care accordingly. 6. To systematically assess personnel adherence to the infection prevention practices such as using transmission- based precautions and standard precautions, using surveillance and investigation to prevent the spread of infection, and implementing hand hygiene (hand washing) practices consistent with accepted standards of practice, to reduce the spread of infections and prevent cross-contamination. Assessment of adherence should be conducted by direct observation of healthcare personnel during the performance of their duties. These deficient practices resulted in actual harm by the transmission of scabies to other residents who were susceptible to acquire scabies due compromised immune systems, and had the potential to spread, and significantly increase the transmission by cross-contamination to health care workers/employees, families, visitors, service providers, and had the potential to spread to the community for four out of 24 sample residents (4,15,17,20) and seven randomly selected residents (28,30,38,41,42,43,44). An Immediate Jeopardy (IJ) situation was called on May 27, 2016, at 5:25 p.m. The Administrator and the Director of Nursing were informed. A written plan of correction for the IJ situation was accepted on May 27, 2016, at 11:30 p.m. The IJ was lifted on May 30, 2016, at 5:25 p.m. with the Director of Clinical Services and the Interim Director of Nursing (IDON). Findings: a. According to the admission record, Resident 4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS a comprehensive assessment and screening tool) assessment dated [DATE], indicated Resident 4 was cognitively intact, needed extensive one person assistance with bed mobility, transfer, dressing, and personal hygiene. The MDS also indicated that Resident 4 needed extensive assistance with moving between locations in her room and the adjacent corridor on the same floor, and if in a wheelchair, self-sufficiency once in the chair. A review of the dermatologist progress notes indicated a [DIAGNOSES REDACTED].>- crusted scabies on the palm of the left hand on December 11, 2015 with a prescription of [MEDICATION NAME] (a cream used to treat scabies), 5 % topical (on the skin) cream and Ivermectin (a medication used to treat scabies) 3 milligrams (mg) tablet oral - scabies on the palm of the left hand on January 4, 2016 with a prescription of [MEDICATION NAME] 5 % topical cream and Ivermectin 3 mg tablet oral - scabies on the upper middle chest on April 1, 2016 with a prescription of [MEDICATION NAME] 5 % topical cream and Ivermectin 3 mg tablet oral A review of the medication administration record (MAR) indicated [MEDICATION NAME] 5 % topical cream was applied December 11, 2015, December 18, 2015, and January 6, 2016. There was a nursing progress note dated January 13, 2016, that indicated [MEDICATION NAME] (a cream used to treat scabies) was applied that evening. During an interview with the assistant director of nursing (ADON) on May 27, 2016 at 2:06 p.m., she stated there was no care plan in Resident 4's medical record regarding skin rashes, scabies, and/or contact isolation. During an interview on May 27, 2016 at 6:57 p.m., the DON stated she reviewed Resident 4's medical record and could not find any documented evidence that Resident 4 was placed on contact isolation precautions (used for infections, diseases, or germs that are spread by touching the patient or items in the room) during the month of December 2015 and January 2016. A review of the facility policy and procedure titled contact precautions, dated 2009, indicated the facility is to use contact precautions in addition to standard precautions for residents known or suspected to have serious illness easily transmitted by direct residents contact or by contact with item's in the resident's environment. Another facility policy dated April 15, 2016 titled contact precautions indicated that the precautionary period for scabies is 24 hours following the initiation of effective therapy. b. According to the admission record, Randomly Selected Resident 30 (RSR 30) was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the facility census indicated RSR 30 was roommate with Resident 4 (with confirmed [DIAGNOSES REDACTED]. A review of RSR 30's physician history and physical progress note, dated May 24, 2016, indicated RSR 30 was alert and oriented to person, place, and time. During an interview on May 31, 2016 at 12:05 p.m., RSR 30 stated he had generalized itchiness which started in the facility. RSR 30 stated he notified the staff, but was told it was dry skin. The staff had been applying lotion with no relief of the itchiness. In regards to other interventions related to the itchiness, RSR 30 stated the nurses gave him three pills which helped a little, but the symptoms of itchiness were still persistent. During a concurrent observation and interview with RSR 30, the resident was scratching his head, right ears, left and right forearms, left elbow, right axillary folds, and upper chest area. RSR 30's skin was dry, scaly, with white patches (circular and linear shapes). A review of RSR 30's skin assessment progress note dated May 27, 2016 indicated rash and dry skin on the left chest. A review of RSR 30's skin assessment progress note dated May 28, 2016 indicated itchiness on the chest and left arm. A review of RSR 30's physician order dated May 27, 2016 indicated an order for [REDACTED]. A review of RSR 30's medication administration record (MAR) indicated [MEDICATION NAME] 25 mg was administered orally on May 27, 2016 at 8:57 p.m. On May 31, 2015 at 10:24 a.m., during an interview the director of nursing (DON) stated RSR 30 was not included in the line listing (information summary about persons that may be associated with an outbreak) provided by the facility on May 31, 2016, (after the IJ was called), because the resident did not exhibit signs and symptoms of scabies, but would follow up with the resident. The facility did not plan to test or treat [MEDICATION NAME] (preventatively) RSR 30 for scabies even though the resident had symptoms that were suspicious for scabies, such as body itchiness to prevent further spread of scabies. c. A review of the admission record indicated Resident 17 was originally admitted to the facility on [DATE] and readmitted on [DATE] and with [DIAGNOSES REDACTED]. Resident 17 was diagnosed by the dermatologist to have scabies on May 20, 2016. A review of the Minimum Data Set (MDS), an assessment and care screening tool, dated March 5, 2016, indicated Resident 17 was cognitively intact and required extensive assistance with activities of daily living such as transfer, ambulation, dressing, and hygiene. During a record review of Resident 17's Progress Notes dated April 29, 2016, he was noted to have left arm rash and was prescribed [MEDICATION NAME] (a cream effective in the treatment of [REDACTED]. The Skin/Wound Progress Notes dated May 15, 2016, indicated the treatment was changed to [MEDICATION NAME] (a skin cream used to treat the inflammation and itching) two times a day for rash on left arm. The Skin/Wound Progress Notes dated May 17, 2016, indicated Resident 17 was seen by a physician and had an order to consult a dermatologist for further evaluation for the rash on the left arm. The dermatology consult done on May 20, 2016, indicated that Resident 17's condition was clinically consistent with scabies. [MEDICATION NAME] 5% (a skin cream used for the treatment of [REDACTED]. During a review of Resident 17's Treatment Administration Record (TAR), [MEDICATION NAME] cream was administered on May 20, 2016 at 9:26 pm. On May 21, 2016, at 11:30 am, Resident 17 was transferred to General Acute Care Hospital (GACH) because of change in condition. However, there was no documented evidence the SNF upon transfer alerted the GACH that Resident 17 had scabies in order to minimize the chance of transmission of scabies to others. A record review of Resident 17's History and Physical from GACH dated May 21, 2016, at 4:41 pm indicated [DIAGNOSES REDACTED]. Resident 17 was placed in isolation and was given Ivermectin 9 milligram (mg) orally for scabies on May 21, 2016 at 11:06 pm. Resident 17 was discharge from GACH on May 23, 2016. Resident 17 was readmitted to the skilled nursing facility on May 23, 2016, where he was placed in an isolation room because of generalized rashes. During observation on May 27, 2016 at 8:00 am, Resident 17 was in the isolation room with a roommate, Resident 28. During an interview with LVN 2 on May 27, 2016 at 11:00 am, she stated that Resident 17, was in isolation because of generalize rashes and stated she was not sure if the resident had scabies. During interview with the director of nurses (DON) on May 27, 2016 at 2:10 pm, she stated that she did not know Resident 17 was diagnosed with [REDACTED]. She also stated that she just learned that Resident 17 had scabies upon readmission, and that was why the resident was placed in an isolation room. The DON also stated scabies was not yet reported to the Department. On May 27, 2016 at 3:15 pm, CNA 4 was observed to remove his protective gown and gloves and leave Resident 17's isolation room without washing his hands. CNA 4 proceeded to Nurse's Station 4, after coming out of the room, and started talking to LVN 11. At the same time, during an interview, CNA 4, stated that he did not wash his hands before coming out of the room and that he was planning to wash his hands at the nurses station. During an observation on May 27, 2016 at 5:30 pm, Resident 17 was in his room scratching his arm. During the interview Resident 17 verbalizes that he was itching because the facility Used dirty linen on him. On May 30, 2016 at 3:33 pm, CNA 5 was observed coming out of the isolation room, (Resident 17's room), not wearing protective gloves, holding a white plastic cup. At the same time, during an interview, CNA 5 stated she would bring the cup to the kitchen to be washed and refilled with water. On May 30, 2016 at 3:50 pm, CNA 5 was observed carrying a blood pressure (BP) apparatus (a device used to determine blood pressure) out of Resident 17's room and placed it in the hallway in front of the Director of Staff Development's (DSD) office. At the same time, during an interview with CNA 5, she stated that the BP apparatus came from the isolation room, but she did not use it. CNA 5 also added that she would clean it later. During an interview with RN 2 on May 30, 2016 at 3:53 pm, she stated that there should be a separate BP apparatus for the isolation room and the BP apparatus should be cleaned before and after each use. A review of the facility's policy and procedure titled Scabies Care dated 2012, for contact precautions indicates wearing gloves and a gown if in close contact with an infested person or things (such as applying gloves, bedding, etc.). Hand hygiene is the best technique for protection of oneself and others. Unwashable items should be placed in a plastic bag and sealed for seven days (label bag with name, date, etc.). d. 1 A review of the admission record, indicated Randomly Selected Resident (RSR) 28 was admitted to the facility on [DATE], and with [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS), an assessment and care screening tool, dated March 23, 2016, indicated RSR 28 had severe cognitive impairment and required extensive assistance with his activities of daily living such as transfer, ambulation, dressing, and hygiene. A record review of RSR 28's Progress Notes dated May 24, 2016 at 10:51 pm, indicated the resident was noted to have generalized body rashes. RSR 28 was seen by Physician 1 on the same day and was ordered [MEDICATION NAME] Cream 5% to apply from neck to toe topically at bedtime for general rashes for 1 day, then shower in the morning, repeat in one week. On May 25, 2016, RSR 28 was transferred to an isolation room with Resident 17. [MEDICATION NAME] Cream was administered to RSR 28 by LVN 11 on May 25, 2016, and was given a shower the following day (May 26, 2016). During an observation on May 27, 2016 at 5:10 pm, RSR 28 was observed sitting on a wheel chair being wheeled into the isolation room by CNA 3. CNA 3 was not wearing any personal protective equipment (PPE) like gloves, mask, and gown, even though the resident did not complete his repeat treatment for [REDACTED]. During an interview at the same time, when asked why she did not wear any PPE into the room, CNA 3 did not answer. On May 27, 2016 at 5:12 pm, RSR 28 was being transported out of the SNF in a wheel chair. Upon interview with the outside transporter, he stated no one from the facility told him that the RSR 28 was on isolation. During an interview with RN 2 on May 27, 2016 at 6:30 pm, she stated whenever a resident is being transported out of the facility, the nurse should notify the person who picks up the resident (of the isolation). On May 27, 2016 at 6:35 pm, in an interview with LVN 11, she stated she was the nurse who sent RSR 28 for a dermatology consult, and also stated she did not notify the transport person that the resident was on isolation. A review of the RSR 28's Dermatology Consult Notes dated May 27, 2016, indicated Dermatologist 1 diagnosed RSR 28 with scabies. A record review indicated that RSR 28's went out on pass on May 21, 2016 at 4:20 pm, and returned to the SNF on the same day at 9:15 pm, to attend a family social event. During an interview with the ADON on May 31, 2016 at 2:40 pm, she stated the resident's daughter is aware that RSR 28 was on isolation for generalize rash but the family was not yet informed that RSR 28 was diagnosed with [REDACTED]. The ADON agreed that there is a possibility that family, relatives and visitors might have been exposed to scabies during the resident's attendance to his family social event. There was no evidence the facility staff notified RSR 28's family of the possibility that family, relatives and visitors might have been exposed to scabies or notified the transport person that the resident was in isolation in order to prevent the spread of scabies or minimize the risk of further spreading scabies into the community. d. 2 During a medication pass observation on May 24, 2016 at 8:55 am LVN 3 was observed to use a blood pressure apparatus (BP) on two different residents, RSR 43 and RSR 44 without sanitizing or cleaning the BP apparatus between residents. During an interview with LVN 3, he stated he should clean the BP apparatus before and after each use (to prevent the spread of infection). On May 24, 2016 at 9:20 am, during a medication pass observation LVN 10 was observed to not sanitize or clean the BP apparatus before and after each use for Resident 8. During an interview with LVN 10, he stated he should clean the BP apparatus before and after use. e. On May 23, 2016, after the initial tour observation, during the survey team's daily meeting, infection control was identified as a concern in the facility. A review of the list of residents on isolation precautions was provided to the survey team as requested by Surveyor 2 on May 24, 2016. The list indicated Resident 17 was the only resident on isolation precautions in the facility. Resident 17 was placed on contact isolation precautions for generalized rash - scabies-like. On May 26, 2016, at 10:40 a.m., during an interview and observation of Resident 15, in the smoking patio with his family member, Resident 15 showed his arm to Surveyor 1 and stated, I have been telling the facility about the rashes and itching, but they have not done anything about it. The resident's family member confirmed the resident's statement. On May 26, 2016, at 4:30 p.m., during an observation and interview of Resident 15, in his room, he had dry, flat, rashes and lesions on his trunk, back, down part of the shoulders, legs, and groin. There were small brown lumps also present in the resident's skin. There were a few thick, scaly lesions noted. The resident was observed with aggressive itching and kept scratching as he spoke. As the resident was being interviewed by Surveyor 2, Resident 15 stated Help me, help me. Do not leave me, please. Do something. I am so itchy. He stated that he was given creams for itching but nothing happened. The resident was not in an isolation room. On May 26, 2016, at 4:45 p.m., during an interview with Licensed Vocational Nurse 9 (LVN 9), he stated Resident 15 had multiple rashes on the left arm, right leg, back, chest, abdomen, pelvis, and groin. The rashes started on March 30, 2016. The physician was notified of the rashes and the resident was prescribed [MEDICATION NAME] cream (a cream used to treat itching, redness, dryness, crusting, scaling, inflammation, and discomfort of various skin conditions) and the treatment was changed to [MEDICATION NAME] (used in reducing itching, redness, and swelling associated with many skin conditions) on May 11, 2016. LVN 9 stated the resident's rashes worsened. On May 26, 2016, at 5 p.m., during an observation, Resident 15 was standing at the corridor, close to his room, he was scratching himself and showed his chest and back to Surveyor 1. The resident was begging Surveyor 1 to do something because he cannot stand his skin condition and said it was very painful. Resident 15 stated Please, please, please, do something. Both instances were reported to the survey's team leader and to the survey team and Surveyor 1 asked for an investigation. Resident 15's back and chest, including his arm had blister-like rashes. On May 26, 2016, at 5:10 p.m., during an interview with the Assistant Director of Nursing (ADON), she stated the roommates of Resident 15 (Resident 41 and Resident 42) were both itching. Resident 41 complained of itching on and off on his right arm and upper back. Resident 42 was itching on his buttocks. He was prescribed [MEDICATION NAME] (used to treat skin infections such as athlete's foot, jock itch, ringworm, and other fungal skin infections) cream. A review of the clinical record of Resident 41 and Resident 42 did not indicate that the residents' itching were addressed. A review of the admission record, indicated Resident 15 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS) assessment dated [DATE], indicated the resident's cognitive patterns were intact. The resident was able to self-perform bed mobility, transfer, walking in the room and corridor, locomotion on and off the unit with no support from staff members. The skin conditions (Section M), indicated one of the above were present that included other problems such as open lesions or rashes. For skin and ulcer treatments, indicated applications of ointments/medications other than to feet was marked. A review of Resident 15's physician's orders indicated the following: 1. [MEDICATION NAME] tablet 25 milligrams (mg) by mouth every six hours as needed for body itchiness dated March 19, 2016. 2. [MEDICATION NAME] 25 mg by mouth every six hours as needed for itching dated April 26, 2016. 3. Loratidine 10 mg by mouth one time a day for itching dated April 26, 2016. 4. [MEDICATION NAME] 50 mg by mouth every six hours as needed for pain dated April 27, 2016. 5. [MEDICATION NAME] cream 0.1 percent was ordered on May 9, 2016 and was discontinued on May 11, 2016. Apply to multiple sites topically two times a day for itching on arms, abdomen, back, and legs. 6. [MEDICATION NAME] propionate cream 0.05 percent dated May 11, 2016. Apply to multiple sites topically two times a day for rashes on arms, abdomen, back, and legs for 21 days until finished. A review of the Medication Administration Record (MAR) dated May 2016, indicated Loratidine, [MEDICATION NAME], and [MEDICATION NAME] was administered to Resident 15 as ordered by the physician. A review of the Treatment Administration Record (TAR) dated May 2016, indicated [MEDICATION NAME] and [MEDICATION NAME] was administered to Resident 15 as ordered by the physician. A review of Resident 15's Progress Notes (Nursing Note) indicated the following: 1. On March 22, 2016, at 3:32 a.m., Resident 15 was still noted with body itch. Medicated for itch. Will continue to monitor resident. 2. On March 22, 2016, at 2:15 p.m., Resident 15 was alert and oriented and was able to make needs known. Monitored for itchiness. As needed medication was given for itching as ordered and was well tolerated. Will continue monitoring. 3. On March 23, 2016, at 3:04 a.m., Resident 15 still with itchiness of body. No rash noted. Medicated as ordered by the physician. Relief noted. 4. On March 28, 2016, Resident 15 had adjusted well socially. He joined activities, eats in the dining room, and can make food selection. Family also bring food from home. Encouraged more to socialize. 5. On March 29, 2016, at 11:29 p.m., [MEDICATION NAME] was administered to Resident 15 for body itchiness and was effective. 6. On March 30, 2016, at 2:09 p.m., Resident 15 was monitoring for itchiness, resident noted with scattered redness with itch on his back, bilateral arm, bilateral leg, and abdomen. The Nurse Practitioner (NP) was aware with a new order for [MEDICATION NAME] cream 0.5 percent to apply twice a day. New order will be noted and carried by the treatment nurse. Will continue monitoring. 7. On March 30, 2016, at 5:35 p.m., Resident 15 acquired itch on March 20, 2016 SBAR (a significant change of condition note) follow-up. Redness noted; scattered on the bilateral arm, abdomen, back, and bilateral leg. Skin intact, flat red color. The physician was notified and ordered [MEDICATION NAME] cream twice a day noted and carried out. A review of Resident 15's care plan initiated on March 30, 2016, indicated redness scattered on multiple sites on bilateral arm, abdomen, back, and bilateral leg. The interventions included to inform resident to avoid scratching and keep hands and body parts from excessive moisture; notify the physician for worsening of condition; reevaluate treatment per facility policy or as ordered; observe skin rashes for increased spread or signs of infection; treatment as ordered; and weekly skin documentation and observe for any changes. A review of the Progress Notes (Nursing Note) indicated the following: 1. On April 29, 2016, Resident 15 complained of itchiness in the morning. Medications were given and resident tolerated it well. 2. On May 1, 2016, Resident 15 came back from out on pass accompanied by brother in stable condition. 3. On May 11, 2016, Resident 15's treatment for [REDACTED]. The physician, responsible party, and charge nurse were notified. A review of the Skin Weekly Non-Pressure Condition Record dated May 25, 2016, indicated Resident 15 had an existing non-pressure skin condition with an onset date of March 30, 2016, on multiple sites that was acquired at the facility. A review of the Progress Notes (Nursing Note) dated May 26, 2016, indicated Resident 15 was a bit itchy with on-going anti-itch medication and on-going topical treatment as ordered. The physician was notified. The resident will be transferred to the general acute care hospital (GACH) for further evaluation of general rashes. The family was notified by phone regarding the transfer. Will continue to monitor. A review of the GACH's ER clinical record dated May 26, 2016, indicated Resident 15 presented to the emergency room with pruritus (severe itching of the skin), described as a rash that was generalized for over two months. The resident denied any other complaints. The resident stated that he had been given creams for it in the nursing home but did not know which ones. The resident had generalized [DIAGNOSES REDACTED]tous, (redness of the skin or mucous membranes, caused by hyperemia (increased blood flow) in superficial capillaries. It occurs with any skin injury, infection, or inflammation.) scaly rash with some involvement between the fingers. The resident had a rash that was very suspicious for scabies. The ER physician was concerned of possible Norwegian (crusted) scabies. The resident lived in a nursing home and therefore the admission to a contact isolation environment was appropriate until a similar environmen

Based on observation, interviews, and record review, the facility failed to prevent injuries from falls for residents assessed at a high risk for falls and had multiple falls for one Random Sample Resident 27 (RSR 27) and for two out of 24 sample residents (Resident 22, 2) by failing to: 1. Continuously monitor, supervise the residents and anticipate their needs for assistance (RSR 27) including assistance to the bathroom (Resident 22) and to implement fall precautions as indicated in the residents' plan of care. 2. Provide frequent scheduled nursing rounds to monitor the resident's safety. 3. Provide a safe transfer for Resident 2 from a bed to a shower chair in accordance with the plan of care and facility policy. This had a potential to result in a fall for Resident 2. These failures resulted in fractures to the right hips, to both RSR 27 and Resident 22, severe pain due to the injuries that required transfers of the residents to the general acute care hospital (GACH) and a surgical repair of the fractured bones under a general anesthesia. This placed Resident 22 and RSR 27, at risk for serious complications to surgery such as bleeding, infection, heart attack, pneumonia, and other conditions. RSR 27 was hospitalized for [REDACTED]. Resident 22 was hospitalized for [REDACTED]. Findings: a. On May 27, 2016, at 10 a.m., during an observation of the facility's therapy room, RSR 27 was on a stationary bicycle and moving his legs slowly with difficulty. On May 27, 2016, at 10:15 a.m. during an interview, RSR 27's family member 1 (FM 1) stated the resident came to the facility for rehabilitation (rehab) after a left hip surgery from a fall on the street last year. FM 1 stated while RSR 27 was in the facility, the resident broke the other hip during a fall in January 2016. FM 1 further stated the fall incident was not discovered until FM 1 visited the resident and found him on the floor. FM 1 expressed concerns over potential inadequate assistance provided by the facility to meet the resident' s needs. According to RSR 27's history and physical (H/P) dated October 31 2015, RSR 27 was originally admitted to the facility October 29, 2015, with [DIAGNOSES REDACTED]. A review of RSR 27's Minimum Data Set (MDS- a comprehensive assessment and screening tool) dated November 5, 2015, and May 17, 2016, indicated the resident required extensive assistance with two or more persons in bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture), transfer, dressing, eating, toilet use, and personal hygiene. The MDS also indicated RSR 27 was not steady, only able to stabilize with staff assistance when moving from seated to a standing position and surface-to-surface transfer (transfer between bed and chair or wheelchair). The MDS dated [DATE], failed to indicate any falls since RSR 27's original admission/entry or re-entry. A review of a Fall Risk assessment dated [DATE], indicated RSR 27 had a total score of 18. According to the assessment tool, for a score of 10 or greater, the resident should be considered at high risk for potential falls. According to the care plan for RSR 27's risk for falls related to poor communication/comprehension and gait/balance problems, initiated on November 5, 2015, the staff 's interventions included to anticipate and meet the resident's needs. A review of the SBAR (situation background assessment recommendation) Communication Form and Progress Note dated January 13, 2016, timed at 6:50 a.m., indicated RSR 27 was found on the floor by son and the son alerted a staff who requested assistance from another licensed staff. RSR 27 complained of pain and 2 tablets of Norco (a narcotic to relieve pain) was noted given. RSR 27 told a family member that he was trying to get something from closet. The facility failed to anticipate and meet resident's need as listed on the above mentioned care plan. A review of the Interdisciplinary Post Fall Review, dated January 13, 2016, at 1:41 p.m., indicated RSR 27 was lifted by three persons and transferred back to bed. A review of the progress notes dated January 13, 2016, at 11:50 a.m., indicated RSR 27 was transferred to the emergency department at the GACH. A review of a diagnostic imaging (x-ray) report, dated January 14, 2016, at 9:49 a.m., indicated RSR 27 had an acute intertrochanteric fracture of the right femur (a type of hip fracture that occurs at the proximal or upper part of the thigh bone). A review of the Internal Medicine H/P record from the GACH, dated January 13, 2016, and timed at 4:18 p.m., indicated RSR 27 was admitted to the GACH for a surgical management of an acute right hip fracture sustained from a mechanical fall occurred on the same date. A review of the Discharge Summaries from the GACH, dated January 16, 2016, at 3:08 p.m., indicated RSR 27 successfully underwent an ORIF (open reduction internal fixation-a surgical procedure to repair the fractured femur /a broken long bone done under a general anesthesia) and hospitalized at the GACH from January 13, 2016, to January 16, 2016 and was discharged to the skilled nursing facility. A review of the facility's Nursing Initial Plan of Care for RSR 27 dated January 17, 2016, after readmission from the GACH, indicated the interventions were to continue current interventions for nursing department. According to the facility's incidents record, RSR 27 had five fall incidents since first admission: on November 10, 2015, December 28, 2015, January 13, 2016, March 9, 2016, and April 28, 2016. Therefore, RSR 27 sustained two falls, after the surgical repair of the right hip fracture occurred in January 2016. A review of the care plan care plan for RSR 27's risk for falls, dated on November 5, 2015, indicated there was no revision until April 29, 2016. The interventions were to place Dycem (a multipurpose reel of non-slip material) on wheelchair and educate staff to have Dycem on wheelchair. On May 27, 2016, at approximately 3:45 p.m., during an interview, two licensed vocational nurses, LVN 7 and LVN 8, did not know what Dycem was and used for. During a concurrent interview, the assistant director of nursing (ADON) stated it was a cushion. On May 27, 2016 at 3:50 p.m. during an observation of RSR 27's room and a concurrent interview, the occupational therapist (OT) confirmed that there was nothing on the seat of RSR 27's wheelchair. The OT explained Dycem was like a rubber mat used to create friction between objects to prevent slipping and it should be placed between the wheelchair seat and a cushion. The OT cut out a portion that measures approximately, eight inches by seven inches and then placed it on RSR 27's wheelchair seat followed by a cushion on top. The OT stated that should prevent the cushion from slipping off the wheelchair. A review of the facility's policy and procedure, Fall Management, dated August 2012, indicated the interdisciplinary team (IDT) modifies and implement a care plan and treatment approach to minimize repeat falls. b. On May 23, 2016, at approximately 3:33 p.m., during an initial tour of the facility in the presence of the assistant director of nursing (ADON) a falling star symbol (indicates the resident is at a risk for fall) was located on the left side of the wall next to Resident 22's room entrance). During a an interview with the ADON present during the observation she stated Resident 22 had a fall about a month ago, that resulted in a right hip fracture. The ADON also stated Resident 22 was on the falling star program that indicates the the resident was at risk for falls. According to the admission record, Resident 22 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. It's caused by conditions or changes in the brain), hypertension (high blood pressure), and history of falls. A review of Resident 22's Minimum Data Set (MDS- a comprehensive assessment and screening tool) dated March 29, 2016, indicated the resident had severe cognitive impairment, required extensive one-person assist with transfer, dressing, and personal hygiene. According to the MDS, Resident 22 was totally dependent on staff for moving between locations in her room and the adjacent corridor on the same floor, and if in a wheelchair, self-sufficiency once in the chair. The MDS also indicated the resident was not steady, was only able to stabilize with staff assistance when moving from seated to standing position, moving on and off toilet, walking, and transferring between bed and chair or wheelchair. A review of the Fall Risk assessment dated [DATE], indicated Resident 22 had a score of 16, due to intermittent confusion, decreased muscular coordination, history of falls, and balance problem while standing and walking. According to the assessment tool, for a score of 10 or greater indicates the resident is at a high risk for falls. A review of Resident 22's plan of care initiated on January 28, 2016, for at risk for fall injuries indicated with a goal to minimize falls or injury through interventions daily. Interventions included low bed, bed alarm, and floor mats. The care plan also indicated the falling star program (initiated on March 17, 2016) as an intervention. A review of Resident 22's physician order [REDACTED]. On May 23, 2016, at 3:33 p.m., and on May 26, 2016, at 12:25 p.m., during observation, the facility did not implement the physician's orders [REDACTED]. A review of the facility incidents record indicated Resident 22 had two incidents of falls. The first fall occurred on November 21, 2015. According to SBAR (situation background assessment recommendation) communication and progress note dated November 21, 2015 at 8:56 a.m., the resident was found lying on the floor on his left side by the bed. According to the progress note, the resident stated he fell while he was trying to go to the restroom. Approximately one hour after the fall, the resident had a change in level of consciousness. Resident 22's physician was notified and an order to transfer resident to the GACH was received. Resident 22 was readmitted to the facility and did not have an injury other than the altered level of consciousness observed after the fall. A review of the literature indicates, falls frequently occur when patients get out of bed and go to the bathroom, walk to or from the bathroom, or experience an episode of incontinence. Frequent structured Nursing rounds in which the nursing staff would perform specific tasks at set intervals could help reduce the incidence of falls. Studies have demonstrated the benefits of having structured frequent rounds and performing specific nursing actions, such as asking whether the patient needed anything and assisting with toileting at set intervals was associated with statistically significant reductions in patients' use of call lights and the incidence of falls, and with an increase in patient satisfaction (Stefancyk, Amanda, Safe and Reliable Care, American Journal of Nursing, July 2009, Volume 109 No.7, Pages 70-71). The facility's revised policy dated August 2012, titled fall management indicated the interdisciplinary team (IDT), a group of health care professionals, modifies and implement a care plan and treatment approach to minimize repeat falls. The second fall occurred on March 16, 2016. According to the interdisciplinary post fall review dated March 17, 2016, the treatment nurse heard a noise at the nursing station and Resident 22 was observed lying on the floor on his right side in the hallway. The resident was assisted back in bed. Resident 22 complained of pain on his right knee and hip and Tylenol was administered for pain. Resident 22's physician was notified and an order for [REDACTED]. The x-ray result revealed the resident had fracture of the right hip and an order to transfer Resident 22 to GACH was obtained on March 16, 2016. at 9 p.m. A review of the Internal Medicine history and physical (H/P) record from the GACH, dated March 17, 2016, and timed at 3:09 p.m., indicated Resident 22 was admitted to the GACH for evaluation and treatment of [REDACTED]. An orthopedic (a bone specialist) consultation was requested the same day. A review of a computed tomography scan (CT scan - an imaging method that uses x-rays to create pictures of cross-sections of the body) report from the GACH dated March 17, 2016, and timed 10:35 a.m., indicated Resident 22 sustained an impacted right femoral subcapital and femoral neck fracture (broken hip bone). On March 19, 2016, Resident 22 underwent open reduction internal fixation (ORIF-a type of surgical procedure used to repair broken bones) under general anesthesia and experienced delirium (a serious disturbance in mental abilities that results in confused thinking and reduced awareness of your environment) after the surgical procedure. A review of the literature indicates the risk and complications associated with a surgery under a general anesthesia included bleeding, infection, heart attack, pneumonia, and kidney failure during or after an operation, deep venous thrombosis ((DVT) occurs when blood clots develop in the large veins of the leg. If the blood clots in the veins break apart, they can travel to the lung, where they lodge in the capillaries and cut off the blood supply to a portion of the lung, called a pulmonary embolism) (Savel, Richard H., Postoperative Care. Hospital Medicine. 2nd. Ed. Philadelphia: Lippincott, Williams, & Wilkins, 2005. 261-269). A review of the GACH discharge summary indicated Resident 22 was hospitalized for [REDACTED]. and discharged to the skilled nursing facility on March 22, 2016. c. Resident 2 was transferred into a shower chair, by CNA 6, without the use of the required transfer device, without 2 persons assisting with the transfer and without locking the shower chair brakes for safety. On May 31, 2016 at 8:42 a.m., during a transfer observation, Resident 2 was overheard yelling from her bed to Certified Nursing Assistant 6 (CNA 6), Stop, your hurting me, why do you always have to be so rough. CNA 6 was observed standing on the right side of the head of Resident 2's bed, and was pulling Resident 2, with one hand on the resident's neck and the other hand pulling her out of bed by the resident's upper body, in order to place the resident in a shower chair. Resident 2 continued to whine and plead with CNA 6, saying Stop! Your hurting me, Please, No, your too rough, Why are you doing this to me? No, Help. At the same time, CNA 6 was observed to transfer Resident 2 into the shower chair without assistance, without locking the chair brakes for safety, using a mechanical lift as indicated in the care plan or transfer equipment designated in the transfer evaluation. A review of Resident 2's General Acute Care Hospital (GACH) history and physical dated December 16, 2014, indicated Resident 2 had a compression (a collapse of a backbone), fracture of Lumber 1 with mild pain and history of dementia. The Plan included, patient admitted , for surgical evaluation and pain management. The history or chief complaint was admitted secondary to a slip and fall with intractable low back pain. The CT (computerized tomography) scan and x-ray in the Emergency Department showed evidence of compression fracture of the Lumbar 1. A review of the Admission Record, indicated Resident 2 was originally admitted to the facility on [DATE], and was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 2's Minimum Data Set (MDS),an assessment and care screening tool, dated March 18, 2016, indicated Resident 2 was cognitively impaired and required extensive physical assistance from staff with activities of daily living (ADL's). According to the MDS, Resident 2 required two persons physically assisting with transfers from the bed to chair (including a shower chair). A review of Resident 2's transfer evaluation task score category assessment dated [DATE], indicated the resident had a performance task score of 51% (percent) and the caregiver performed less than 50 % of task with a gait belt and transfer board equipment. Resident 2's Plan of Care dated January 2, 2015, titled L1 compression fracture from a fall , L5 spondylosis, indicated the interventions included: assist with all transfers, two pax (persons) assisting with mechanical lift, assist to move around the unit/facility as needed. On May 31, 2016 at 11:05 a.m., during an interview with CNA 6, she stated she was transferring Resident 2 to the shower chair to give her a shower. CNA 6 stated, I said to the resident, I'm going to do it slow, to move you. Yes, I do everyday, jerk and pull the resident out of bed. I say, I can do it for you. I do not need another person to assist with the transfer, because she can stand up. On May 31, 2016 at 10:46 a.m., during an interview with the Interim Director of Nursing (IDON), she stated the CNA should have stopped the transfer to provide two persons for transferring the resident. The IDON stated the procedure is to let the patient sit at the edge of the bed first, before positioning the chair and lock it. The CNAs have to ask another CNA for assistance in order to hold on to the shower chair before transferring. A review of CNA 6's annual review titled Skills Check-off for Mechanical Lifts, dated November 23, 2010, signed by the facility's designated staff developer, indicated the CNA was correct for patient safety use of mechanical lifts during patient care. However, CNA was not observed using a mechanical lift while transferring Resident 2 between surfaces, from the bed to the shower chair. CNA 6 did not use a mechanical lift or a two person transfer as indicated in the care plan, did not and did not use the wheelchair brakes for safety during the transfer. A review of the facility's policy and procedures titled, Lift, transfer and repositioning policy, dated 2010, indicated each resident-specific protocol will be implemented to ensure that the resident continues to reach his/her highest level of physical functioning. The facility requires two staff members to assist when lifting with mechanical lifting devices. Therefore staff is required to follow this policy and the lift and transfer guide at all times. Failure to follow this policy and the guide will result in disciplinary action, up to and including termination.

Based on interview and record review, the facility failed to identify and evaluate accident risks and hazards, and did not implement and monitor/modify interventions when necessary for one of three sampled residents (1). For Resident 1, who was assessed as a fall risk, the facility failed to: 1. Accurately assess the resident's safety risk factors and hazards. 2. Develop an initial plan of care with interventions to address the resident's identified risk for falls. 3. Place the resident on the Falling Star Program (helps to identify and promote safety for residents with impaired mobility), pending the first interdisciplinary team meeting (IDT), per facility policy. 4. Develop and revise a care plan with interventions to address the resident's identified change in mental status, prior to her fall. These deficient practices resulted in Resident 1 suffering a fall with injuries which included a fractured hip and required surgery. Findings: A review of the closed clinical record indicated Resident 1 was admitted to the facility, on [DATE], and was discharged on [DATE], to a general acute care hospital (GACH). Resident 1's [DIAGNOSES REDACTED]. A care plan developed, on [DATE], for Resident 1's potential safety and fall risk related to her potential for falls, decreased safety awareness, and falls related to her disease process, indicated the resident would be free of falls or fall-related injuries as the goal. The care plan interventions included to initiate safety checks as indicated. There were no individualized / resident-specific interventions documented. A review of the Nursing Daily Skilled Charting assessment form, dated [DATE], indicated Resident 1 was alert and oriented to person only, had short-term memory loss, and had difficulty making herself understood and understanding others. The charting assessment form indicated the resident was incontinent of bowel and bladder, wore pads/briefs, and was not on a facility bowel and bladder program. Resident 1 had full range of motion to both left and right sides. The Charting Assessment form indicated Resident 1 required extensive one-person, weight-bearing physical assistance with bed mobility (moving to/from lying position, turning side to side and positioning body while in bed), transfers (moving between surfaces including to/from bed, chair, wheelchair, and standing position), eating, and toilet use (including transfers on/off toilet, cleaning/hygiene after elimination, and adjusting clothing). The assessment indicated the resident had partial weight-bearing ability and had impaired balance and gait. A review of the Fall Risk Evaluation form, dated [DATE], indicated a score of 9 and placed Resident 1 in the 'low risk' fall category. A total score of 10 or higher indicated the resident was 'at risk' for falls. The fall risk evaluation form indicated two areas, 'balance problem while standing,' and 'balance problem while walking,' were not checked off or counted in the total score. These additional parameters would raise the score to 11, which placed Resident 1 'at risk' for falls. A review of the Physical Therapy (PT) Evaluation and Plan of Treatment form, dated [DATE], indicated Resident 1 previously lived at home with family, and was expected to be discharged home from the facility. The resident was referred to PT due to new onset of pain, decrease in strength, reduced balance, and decreased functional mobility. The evaluation and treatment form indicated Resident 1 had impairments to her right and left hips, knees, and ankles, and indicated the resident felt unsteady when standing and walking. A review of the Occupational Therapy (OT) Evaluation and Plan of Treatment, dated [DATE], indicated Resident 1 was oriented to self only and her safety awareness was impaired. The OT's clinical impression was the resident had decreased bilateral upper extremity strength, decreased balance, decreased functional tolerance, and decreased safety awareness, which limited her ability to perform her activities of daily living (ADLs). A review of the progress notes indicated the following: On [DATE], a 72 hour care conference was held with Resident 1's responsible party. There was no documentation of the Falling Star Program made at this time. On [DATE], at 12:15 p.m., a change of condition summary indicated at 10:40 a.m., Resident 1's family member was present and expressed some concerns about the resident. The family member stated Resident 1 seemed more confused than usual. The resident's physician was notified at 11 a.m. and the family member stated she would visit the resident later. On [DATE], at 12:57 p.m., Resident 1's urine specimen was obtained for urinalysis and culture and sensitivity (to determine presence of a urinary tract infection (UTI) and to determine the most effective antibiotic for treatment. According to WebMD (2015), UTIs are among health problems which can cause confusion or decreased alertness). On [DATE], at 9:18 p.m., the change of condition follow up indicated Resident 1 was alert with confusion. On [DATE], at 10:25 p.m., the certified nurse aide (CNA) called out at 9:30 p.m. that Resident 1 was on the floor. The resident was found in sitting position with both legs folded under her buttocks. Resident 1 was alert, verbally responsive, and pointing toward the bathroom. The resident was assisted to wheelchair then to bed, and pointed to her right shoulder when asked if she had any pain. On [DATE], at 2:56 a.m., Resident 1 was monitored for any adverse changes as a result of her fall, was started on intravenous antibiotics for her UTI, and had an x-ray of the right shoulder. On [DATE], at 6:29 a.m., the change of condition summary indicated Resident 1 was noted with bruising on the left middle of back and left groin area. The resident had severe pain to left hip when moved. Pain medication was given as needed. On [DATE], at 9 a.m., the change of condition follow up indicated a report was received regarding the resident's fall and a new change of condition regarding left hip pain and multiple discolorations to body. There were physician's orders [REDACTED]. A review of the Minimum Data Set (MDS, an assessment and care planning tool), dated [DATE], indicated Resident 1 usually understood others and was usually able to make herself understood (though she was Russian speaking), had moderately impaired cognitive skills for daily decision-making, required extensive two person assistance with bed mobility, and extensive one person assistance with all ADLs. The MDS indicated Resident 1's balance was not steady, she was only able to stabilize with staff assistance, when moving from seated to standing, walking, turning and facing the opposite direction while walking, moving on and off the toilet, and when making surface to surface transfers. A review of the Nursing Daily Skilled Charting, dated [DATE], at 7:45 p.m., indicated Resident 1 was incontinent of bowel and bladder, was not on a facility bowel and bladder program, and did not wear pads/briefs. The charting indicated the resident had strong left and right hand grips and full range of motion on both sides, which contradicted the assessments of the PT and OT. The charting indicated skilled services provided included management and evaluation of plan of care and observation/assessment of resident's condition. A review of a change of condition progress note, dated [DATE], at 10:28 p.m., indicated at 9:30 p.m., Resident 1 was noted sitting on the floor in her room, the call light was not on. The progress note indicated Not Applicable, for inquiry of the resident having experienced mental status changes, such as increased confusion. This contraindicated the clinical record documentation Resident 1 had become more confused than usual, at 10:40 a.m., on the morning before the resident fell . There was no care plan to address Resident 1's mental status/confusion, and there were no interventions to address the resident's increased confusion documented the day of the resident's fall. A review of the Interdisciplinary Post Fall Review, dated [DATE], indicated Resident 1 was seen in sitting position next to her bed by a CNA. Resident 1 stated she wanted to go to the bathroom, but she did not call for help, and did not use her call light before transferring unassisted from her bed. The post fall review indicated Resident 1 had Alzheimer's disease/dementia, change in medications, UTI, cognitive deficits, and had been admitted in the last 30 days. The review failed to indicate Resident 1 had unsteady gait and a room change in the last 7 days. During an interview with the Director of Nurses (DON), on [DATE], at 2 p.m., she read Resident 1's care plan titled, Resident Has Potential Safety and Fall Risk related to: Potential For Falls, Decreased Safety Awareness, Falls Related to Disease Process, initiated and revised on [DATE]. The DON stated the sole care plan intervention indicated to initiate safety checks as indicated, was not individualized for Resident 1 and failed to indicate interventions to provide safety and prevent falls for the resident. The DON stated there was no mention made of the Falling Star Program in the care plan. During an interview with Certified Nurse Aide (CNA 1), on [DATE], at 3 p.m., she stated Resident 1 never used her call light, but just called out when she needed help. The facility's policy and procedure titled, Fall Management, revised [DATE], indicated the facility would take a proactive approach for new residents and would consider new admissions at risk for falls until the resident was reviewed by the IDT (interdisciplinary team). New admissions would be placed on the Falling Star Program until reviewed by the IDT. The policy indicated if determined by the IDT, the resident was at risk, the Falling Star would be continued and interventions in the plan of care would be updated. The facility was responsible for implementing individualized interventions for each resident's fall risks. A review of the facility's policy and procedure titled, Resident Assessment, revised [DATE], indicated during the facility's next scheduled Daily Care Management Meeting, the IDT would review the resident's record, determine additional assessments or care plan items that should be included, and evaluate for immediate needs including risks and interventions. The facility's policy and procedure titled, Care Planning and Care Conference, revised [DATE], indicated the care plan must serve as a guide for care delivery and documentation. Each resident shall have an Initial Plan of Care developed within 24 hours of admission to the facility which addressed identified risk areas and residents' initial individual needs. The policy indicated when developing the individualized care plan for the resident, the nurse must consider all new admissions at risk for falls, therefore a fall care plan would be completed as part of the Initial Plan of Care. In addition, it was vital the direct care staff receive communication of the resident's needs and plan of care. A review of the Physician's Discharge Summary from the acute hospital, signed on [DATE], indicated the following hospital course for Resident 1: The resident underwent [REDACTED]. While recovering, the resident had persistent discharge from the operative wound. A wound vac (vacuum assisted closure, uses a vacuum dressing to promote wound healing) was applied. The resident developed altered mental status and was not able to swallow. A nasogatric tube (carries food and medicine to the stomach through the nose) was placed. The following day the resident was found with high residuals (stomach contents) and the tube was misplaced. The resident aspirated (when food, liquids, saliva, or vomit is breathed into the airways) and gone into respiratory distress. The resident was transferred to the intensive care unit where she had seizure activity and showed signs of cerebral edema (swelling in the brain caused by presence of excessive fluid). The resident was intubated and received multiple blood transfusions. Her condition was discussed and the resident was made DNR (do not resuscitate). Her condition got progressively worse. Palliative care services were provided. The patient ultimately expired on [DATE].

Based on observation, interview, and record review, the facility failed to maintain comfortable and safe temperature levels in three residents' rooms (38, 40 and 42) and provide cooling measures to protect compromised residents against heat stroke (a life-threatening condition with symptoms of high body temperature, rapid pulse, difficulty breathing, and confusion), dehydration (when the body loses water that is not replaced), and possible death, for eight of eight sampled residents (1, 2, 3, 4, 5, 6, 7, 8). In addition, the facility failed to maintain the air conditioning (A/C) unit equipment during disruption of services. Temperatures were measured in the three affected rooms to range from 84 degrees Fahrenheit (F) to 89F. The deficient practice had no actual harm with the potential for serious harm that resulted in Immediate Jeopardy (IJ) to residents' health and safety. An IJ was called at 6:49 p.m., on August 13, 2015, in the presence of the Administrator and Director of Nursing (DON). The IJ was lifted on August 14, 2015, at 6:45 p.m., with the DON and Division District Rehabilitation Manager present. Findings: On August 13, 2015, at 2:53 p.m., the Department received a complaint alleging the facility was hot, without air conditioning, and no air was coming through the vents in rooms [ROOM NUMBER]. On August 13, 2015, at 4:35 p.m., the external temperature was over 100 degrees Fahrenheit (F) according to the weather broadcasts. During the facility tour, accompanied by Registered Nurse 1 (RN 1) and the maintenance supervisor (MS), and during interviews while on tour, the following was observed: 1. There were three residents in room [ROOM NUMBER] (Residents 1, 2, and 3), who were able to communicate and express their needs. The room temperature was between 85 to 88 degrees Fahrenheit (F) when taken by the Maintenance Supervisor (MS) with the facility's temperature gun. The residents needed assistance/supervision in locomotion in and out of the room. There was no air coming out of the A/C vent and a family member, and two residents (1, 2) stated that the room was hot and uncomfortable. 2. room [ROOM NUMBER] had three residents inside the room (Residents 4,5, and 6). Residents 4 and 5 were observed lying in bed sleeping. Resident 4 had an ongoing gastrostomy tube (GT) feeding (feeding via tube into the stomach) and was using an oxygen concentrator at the bedside which gave off heat and made the area hotter. Resident 5 had a low air loss (LAL) mattress, an ongoing GT feeding, and was on oxygen at two liters per minute via nasal cannula. Resident 5 was using an oxygen concentrator at the bedside, which was giving off heat and making the room hotter. Resident 6 was able to communicate but speak a foreign language, and was sitting in bed. The room temperature was measured by the MS to be between 84F to 89F. There was no air coming out of the A/C vent. 3. There were two residents in room [ROOM NUMBER] (Residents 7 and 8) who were alert, awake, and oriented and were able to express their needs and concerns. Resident 8 was observed lying in bed and stated that he felt weak. He had tremors in his right fingers and he was sweating excessively. He stated he had a headache with a pain scale of 5 out of 10, (0 being the lowest and 10 being the most severe pain). There were two friends visiting with Resident 8 at the time. Resident 8 had an oxygen concentrator at the bedside, which was giving off heat, and made the area hotter. His roommate, Resident 7, was observed with a lap top at his bedside and a telephone. The room temperature was measured by the MS to be between 84F to 87F. There was an electric fan in the room to be shared by both residents. There was no air coming out of the vents. Residents 7 and 8, together with visitors of Resident 8, were angry and frustrated at the facility. During the tour, at about 4:40 p.m., the MS stated he discovered the air conditioner (A/C) was not working at about 2 p.m., and called the technicians immediately. The technicians were fixing the air conditioner (A/C) at the time of the interview, and after approximately 10 minutes, they left. According to the MS, the A/C had been fixed. When asked for the facility's policy and procedure regarding the room temperatures, he was not able to provide a policy, and stated that they do not have a policy. During an interview with the Administrator on August 13, 2015, at 4:40 p.m., he stated that he offered Residents 7 and 8 relocation to another room but they did not want to change rooms. It would have been a temporary move. At 5:15 p.m., the temperature of the rooms were measured by the MS as follows: 1. room [ROOM NUMBER] was 86 degrees Fahrenheit; 2. room [ROOM NUMBER] was 88 degrees Fahrenheit; and 3. room [ROOM NUMBER] was 86 degrees Fahrenheit. During an interview on August 13, 2015, at 5:20 p.m. with Resident 8's Durable Power of Attorney 1 (DPOA 1), she stated Resident 8 didn't want to relocate, uses a hydraulic lift to get out of bed and the resident was comfortable with the certified nursing assistants (CNAs) in that station/unit. According to her, there were only few nurses who were trained to use the hydraulic lift with the use of the sling safely and properly. Resident 8 was unable to push his call light, so his roommate, Resident 7 was the one calling for him. These are the reasons why Resident 8 did not want to relocate. The residents were comfortable with each other. During an interview with Resident 7 on August 13, 2015, at 5:25 p.m., he stated that it was also hot last year. According to him, last Sunday (August 9, 2015) he was very sick. He stated they were not giving him ice water. On August 11, 2015, last Tuesday of this week, he stated he complained again. He was complaining about the hot room for about three weeks. He really got hot August 9 and August 12, 2015. He stated the thermostat was set at 70F. He stated that he talked to the MS about the temperature being hot, and there was no air coming out of the vents. He said, I cannot dress less than this. He was wearing a resident's gown. He stated it is cold in the winter and hot in the summer. This is especially being next to the back door and with the heat coming in through the door, it just heats it up more. He state their room is next to the main door entrance for the employees, ambulance, and smoking area, and is open constantly 24 hours a day, seven days a week. I feel extremely hot and sick and have been sweating for weeks. He stated he did not appreciate how the Administrator had treated him. He stated the Administrator told him to suffer when he didn't want to relocate to another room, and he was told the electric company requested everyone to turn the A/C to 78F. Resident 7 stated, We are given a fan for two people and the maintenance person had a portable air conditioner in his office. Why do employees have preference before residents? He said Resident 8 had also complained to different staff members in the facility from licensed nurses to CNAs. He complained to the extent that when he pushed the call button, they do not come since they had stated previously that they cannot do anything with the A/C. Resident 7 stated he did not want to relocate to another room either. To change his Internet service, it would cost him his phone, tablet, and television. He said there was no consideration for residents, and he felt that they were putting the residents' needs second. Resident 7 stated the Administrator was unprofessional and that was unacceptable. On August 13, 2015, at 5:45 p.m., during an interview with Licensed Vocational Nurse 1 (LVN 1), while in room [ROOM NUMBER], he stated that he just arrived at work, and stated the room was hot. According to him, the facility said that they had fixed the A/C. He stated last week the residents (7 and 8) complained that their room was hot. And, about two to three weeks ago, there was also an issue with room [ROOM NUMBER]'s temperature being hot. During this interview, Resident 7 stated the MS told him the A/C was fixed, but it wasn't. On August 13, 2015, at 5:50 p.m., during an individual interview with Resident 8, he stated he did not feel well, felt nauseous, had trouble following on things, had trouble pushing buttons, and he had a headache. He did not want to change his room because Resident 7 helped him a lot. The heat made him feel worse, and stated his headache was a pain level of 5 out of 10. They did not offer me anything except a room change and a fan. He had verbally expressed his frustration to the staff. The staff members did not do anything. He stated that he had an air mattress because of the open sores at the back of his thigh. On August 13, 2015, at 6 p.m., during an interview CNA 1 stated room [ROOM NUMBER] was a little hot. On August 13, 2015, at 6:15 p.m., during an interview with the Administrator, he stated the rooms were warm only this afternoon. He stated he didn't know about the rooms being hot before now. On August 13, 2015, at 7 p.m., during an interview with the DON, she stated she heard that rooms were hot August 12, 2015. It had been brought up by the unit manager for Station 2 during the morning stand-up meeting. She stated the MS was aware because he was present during this meeting. At about 7 p.m., the MS placed a portable A/C unit in room [ROOM NUMBER] and room [ROOM NUMBER]. When asked where the A/C units came from, he stated one was from the laundry and one was from his room. He then went to purchase a third portable A/C unit for room [ROOM NUMBER], which was placed in use at about 7:30 p.m. On August 13, 2015, at 8 p.m., the MS measured the room temperatures to be within acceptable limits as follows: room [ROOM NUMBER] was 73F to 79F; room [ROOM NUMBER] was 81F; and room [ROOM NUMBER] was 75F. On August 13, 2015, at 8:03 p.m., during an interview with Resident 3, using an interpreter, she stated she felt hot in her room (38). She said she thought there was a heater in her room and they could not fix it. On August 13, 2015, at 8:45 p.m., during an interview with the Administrator, he stated according to the MS, it was not part of his job to maintain a temperature/air conditioner log. The Administrator stated the MS did not keep a room temperature log.

Based on interview and record review, the facility failed to prevent severe unplanned weight loss of 18 pounds (8.8%) in approximately twenty-four days or 22 pounds (10.5 %) in approximately 2.5 months for a resident with pressure ulcers and fed by a gastrostomy tube (GT feeding tube is a medical device inserted through the abdomen used to provide nutrition to patients who cannot obtain nutrition by swallowing) feeding (GTF) by not providing the resident with adequate nutrition (calories, protein and free water) and by failing to notify the physician of the Registered Dietitian's (RD) recommendation to increase the GTF from 10 hours per day to 20 hours per day for one out of 24 sample residents (2). Findings: According to the admission record Resident 2 was admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE], indicated the resident was moderately impaired in her cognitive skills for daily decision making, and was independent with eating. The MDS also indicated the resident needed extensive assistance with dressing, personal hygiene, and was totally dependent on staff for bathing. The resident's height was 66 inches and weight was 208 pounds. A review of the History and Physical report obtained from the GACH dated March 20, 2012, and the [MEDICATION NAME] consult dated March 23, 2012, indicated the resident had acute respiratory distress secondary to pneumonia, [MEDICAL CONDITION] and GI (the stomach and the intestine) ulcers. The resident was hospitalized from March 20, 2012, to April 3, 2012. The Nursing Admission assessment dated [DATE], indicated the resident had left upper extremity [MEDICAL CONDITION] at a +3 level. The resident had a physician's orders [REDACTED]. The Speech Therapy Evaluation dated April 5, 2012, indicated the reason for the speech therapy referral was due to a [DIAGNOSES REDACTED]. According to an interview with the Speech Therapist on June 19, 2012, at 10:30 a.m., she stated that based on the Speech Therapy Evaluation of April 5, 2012, the resident had mild difficulty swallowing and was discharged from speech therapy on puree diet, with thin liquids, and with no signs of aspiration. The speech therapist also added that to date the resident's swallow status remained unchanged. The resident had a physician's orders [REDACTED]. [REDACTED]. A plan of care initiated on April 11, 2012, had a goal that stated the resident would have stabilized weight within the range of 200 to 205 pounds. The interventions included to provide diet as ordered, offer preferred foods, meal assistance as needed, weights monthly or as indicated, and interdisciplinary team referral as needed. The Registered Dietitian's (RD) Medical Nutritional Therapy Review dated April 11, 2012, indicated the resident had multiple pressure sores, and her estimated nutritional needs were as follows: Calories 1875-1925, Protein 93-112 grams, and Fluids 2325-2790 cc. The resident's [MEDICATION NAME] level dated March 28, 2012, was 2.3 gram per deciliter (gm/dL reference range 3.5-5g/dL, serum [MEDICATION NAME] test measures the amount of protein in the clear liquid portion of the blood, low [MEDICATION NAME] level indicates poor nutritional status). The Medical Nutritional Therapy Review also indicated the resident's tube feedings were decreased to run nocturnal (during the night) to promote oral intake. The resident was placed on weekly weights times four weeks. The note in addition indicated resident may experience weight fluctuation related to resolving [MEDICAL CONDITION] and possible inadequate caloric intake. A review of the Meal Detail Report indicated there was a total of 103 meals that included breakfast, lunch, and dinner for April 2012. The nutrition consumption were recorded as follows: 38 meals were recorded as GTF's 30 meals were recorded with 25 % oral consumption 26 meals were recorded as refused 12 meals were recorded as nothing to be taken by mouth (NPO) 4 meals were recorded with 50 % oral consumption A review of the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The weight loss could not be attributed to the [MEDICAL CONDITION] because the [MEDICAL CONDITION] was not resolved. The Vital Signs and Weight Flow Sheet indicated the following: 1. On April 5, 2012, the resident weighed 204 pounds (lbs.) on readmission. 2. On April 13, 2012, the resident weighed 202 lbs. lost two lbs. in a week. 3. On April 22, 2012, the resident weighed 192 lbs. Lost 12 lbs. in seventeen days. 4. On April 29, 2012, the resident weighed 186 lbs. The resident lost a cumulative weight of 18 lbs. or 8.8 percent from April 5, 2012, to April 29, 2012. There was no documented evidence that the physician was notified of the above progressive weight loss. The RD's Review/Plan notes dated April 25, 2012, regarding the resident's weight of 192 pounds and a weight loss of 10 pounds in approximately one week indicated that the resident's oral intake remained poor, that tube feedings were unchanged, and they appeared inadequate as evidenced by the recent weight loss, and added that tube feeds were to be adjusted to maintain weight per physician approval. The Interdisciplinary Progress Notes dated April 27, 2012, indicated the RD discussed the resident's weight of 192 pounds with a ten pound weight loss in one week, oral consumption was less than 25 percent (%) of meals, and tube feeds appeared inadequate to meet estimated needs. The tube feeding would be adjusted to maintain the resident's weight. The notes also indicated that the resident still had a Stage III pressure ulcer on sacrococcyx (the base of the tailbone) with decrease in size; and a right buttock pressure ulcer with no change in size noted. Since the resident's base line weight recorded on the MDS assessment dated [DATE], was 208 pounds the resident had a cumulative unplanned weight loss of 208 - 186 = 22 lbs. by April 29, 2012. This was a weight loss of 10.5 % in approximately 2.5 months. According to State Operations Manual (SOM) a weight loss greater than 7.5 percent in in three months is considered severe weight loss (SOM October 2010, Page 306). A Change of Condition form was completed on May 2, 2012, at 10 a.m., which indicated the resident, had a weight loss of six pounds in one week. The form also indicated that the change started on May 2, 2012, to continue to monitor, and there were no new orders from the physician. On May 2, 2012, at 11:45 a.m., the RD wrote a telephone order from the physician indicating to change the tube feeding to Glucerna 1.5 at 50cc/hour times 20 hours to provide 1000cc/1500 calories within 24 hours. The time when this order was actually implemented by the nursing department was not available During an interview with the RD on June 15, 2012, at 1 p.m., she stated she could not recall the reason it took one week to implement her recommendation to adjust the tube feeding by increasing the nutrition provided to the resident. She added that Nursing Department should have notified the physician. On June 15, 2012, at 1:10 p.m., during an interview with Registered Nurse 2 (RN 2) when asked stated the resident was not on diuretic (medications that induces increase urine out put that result in weight loss). RN 2 further stated that the physician should have been notified sooner than May 2, 2012, regarding the resident's weight loss during the month of April 2012.

Based on interview and record review, the facility failed to: 1. Ensure that a resident who received Aspirin (325 milligrams (mg) per day for excessive duration (approximately 33 months), was monitored for the adverse effects of the medication that resulted in gastrointestinal (GI/the stomach and the intestines) bleeding due to stomach ulcer, that resulted in hospitalization and treatment with blood transfusion and placement of [MEDICAL CONDITION] tube (GT) feeding (2). 2. Ensure that [MEDICATION NAME] 5 mg (antipsychotic- psychiatric medication primarily used to manage [MEDICAL CONDITION]) would not be administered for managing resistive care or uncooperative behavior, and failed to ensure that dose reduction attempt was made and/or assessed the need for the continued use of the [MEDICATION NAME] was made in the absence of a behavior manifested by resistive to care (18). 3. Monitor a resident on a long-term administration of [MEDICATION NAME] (iron) to prevent the potential for adverse effects and complications associated with a long-term use of iron (6). 4. Monitor a resident for postural [MEDICAL CONDITION] (a drop in blood pressure due to a change in body position (posture) when a person moves to a more vertical position that may result in falls), while the resident received [MEDICATION NAME] 25 mg (antipsychotic medication) and assessed at high risk for falls (6). 5. Monitor a resident on [MEDICATION NAME] 25 mg based on instruction specified in the manufacturer's instruction (24) for four out of 24 sample residents (2, 6, 18, 24). Findings: a. According to the admission record Resident 2 was initially admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE], indicated the resident was moderately impaired in her cognitive skills for daily decision making, and was independent with eating. The MDS also indicated the resident needed extensive assistance with dressing, limited assistance with personal hygiene, and was totally dependent on staff for bathing. The resident had the following physician's orders [REDACTED]. 1. [MEDICATION NAME] 7 mg by mouth daily dated [DATE], and discontinued on [DATE]. ([MEDICATION NAME] is blood thinner medication used to prevent [MEDICAL CONDITIONS], and blood clots in veins and arteries). 2. Aspirin 325 mg daily dated [DATE]. A review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Aspirin is a non-steroidal anti-[MEDICAL CONDITION] drug (NSAD, medication primarily is used primarily to treat inflammation, mild to moderate pain, and fever); it is also used among other indications as a [MEDICATION NAME] in prevention of blood clots. The potential adverse drug reaction of Aspirin included GI bleeding, dyspepsia (symptoms such as upper abdominal pain, belching, nausea, vomiting, abdominal bloating, abdominal distention) bleeding from gums while brushing teeth, or from small abrasions or contusions, GI distress, occult blood (blood in the feces that is not visibly apparent). Aspirin is contraindicated for residents with a [DIAGNOSES REDACTED]. that carries oxygen to the body), platelets (blood cells that help wounds heal and prevent bleeding by forming blood clots) count and periodic kidney function tests. Aspirin should be taken with food (Geriatric Drug Therapy Handbook, ,[DATE], Pages ,[DATE]). The plan of care dated February 16, 2012, indicated the resident was at risk for increased bleeding, bruising or injury related to use of anticoagulant therapy because the resident was receiving aspirin. The goal of the plan of care stated the resident would be free of excessive bleeding or bruising related to administration of anticoagulant therapy through the next three months. The interventions on the plan of care included to observe for bleeding or increased bruising frequently, monitor labs as ordered, and notify the physician of abnormal labs for further direction and treatment determination. However, the facility did not attain its goal that stated " the resident would be free of excessive bleeding." A review of the resident's laboratory (lab) test results indicated the following: 1. On [DATE], the Hemoglobin was 13.4 g/d/L (reference range 11.5- 15) the Hematocrit was 39.8 (reference range ,[DATE]%) and the Platelets count was 154 (reference range 140 -440. According to the lab report, the physician was notified the results. 2. On February 18, , the hemoglobin was 15.9 g/d/L (reference range 11.5 - 15) the hematocrit was 39.8 percent (reference range ,[DATE]%), and the platelets count was 198 (reference range 140 -440. According to the lab report, the physician was not notified of the results. The spaces on the form designated for physician notification date and time were blank. 3. Laboratory information regarding [MEDICATION NAME] time and international normalized ration were not available. According to the Change of Condition report dated February 19, 2012, that indicated the resident was non-responsive at 9:50 a.m. The vital signs were: blood pressure ,[DATE] millimeters of mercury (mm Hg), pulse was 75 beats per minute, respirations 16 breaths per minute, temperature was 92.7 degrees Fahrenheit and oxygen saturation on room air was 89%. Oxygen saturation range of 96% - 100% is generally considered normal. The margin between "healthy" saturation levels (,[DATE]%) and [MEDICAL CONDITION] (usually 85 - 90%) is narrow. Anything below 90% could quickly lead to life-threatening complications (American Journal of Nursing: [DATE]-Volume 105-issue 5- Page 72). According to the report the problem was thought to be due to a respiratory condition. The resident was started on oxygen with a non-rebreathe mask at 14 liters/minute and the oxygen saturation increased to 94%. The resident was placed on a Trendelenburg position (the body is laid flat on the back with the feet higher than the head by 15 - 30 degrees) due to the low blood pressure. The physician was notified and the resident was transferred via 911 to the general acute care hospital (GACH) at 10:30 a.m. per physician's orders [REDACTED]. A review of the History and Physical report obtained from the GACH dated February 19, 2012, indicated the resident's chest x-ray showed evidence of pneumonia and was admitted for treatment. This report also indicated the resident had septic shock (an extreme immune system response to an infection that has spread throughout the blood and tissues, it often causes extremely low blood pressure, which limits blood flow to the body and can result in organ failure), acute [MEDICAL CONDITIONS] secondary to septic shock, [MEDICAL CONDITION], and was on a ventilator. The medical plan included intravenous fluids (IV) therapy, diagnostic tests, IV antibiotics, blood pressure control, and medical consults. According to a cardiology consult dated February 21, 2012, the resident had evidence of a GI bleed and anticoagulation therapy had been discontinued which according to this report had been used for [MEDICAL CONDITION] (blood clot) [MEDICATION NAME]. A laboratory test result from the GACH dated [DATE], indicated the resident's Hemoglobin was low at 9.7 g/dl (reference range 11.5 - 15) and the Hematocrit was also low at 28.8 % (reference range ,[DATE]%). The resident was hospitalized for [REDACTED]. Another laboratory test report dated [DATE], indicated the resident's hemoglobin was low: 7.9 g/d/L (reference range 11.5 - 15) the resident's hematocrit was low: 22.5 (reference range ,[DATE]%), and the resident's platelets count was low: 92 (reference range 140 -440. According to the lab report, the physician was not notified the results. The spaces on the form designated for physician notification date and time were blank. Low hemoglobin, low hematocrit and low platelets count in a patient on an anticoagulant or blood thinning medication are indicators for bleeding. According to another Change of Condition report dated [DATE], the resident had low blood pressure and a low grade fever. The vital signs were: blood pressure ,[DATE] millimeters of mercury (mm Hg), pulse was 63 beats per minute, respirations 16 breaths per minute, temperature was 100.0 degrees F and oxygen saturation on room air was 97% on 2 liters of oxygen per minute. The physician was notified and the resident was transferred for the second time via 911 to the GACH at 4 p.m. per physician's orders [REDACTED]. A review of the History and Physical report obtained from the GACH dated [DATE], the resident on admission to the emergency room was hypotensive and in respiratory distress. The resident was placed on IV fluids and was transferred to the intensive care unit. This report also indicated the resident had acute respiratory distress secondary to pneumonia, [MEDICAL CONDITION] (low blood pressure), rule out septic shock versus hypovolemia (a state of decreased blood volume), [MEDICAL CONDITION] secondary to blood loss, rule out [MEDICAL CONDITION] ulcer disease, rule out upper versus lower GI bleed, history of diabetes mellitus, history of hypertension and history of dementia. The medical plan included intravenous fluids (IV) therapy, IV antibiotics, and transfused packed cells, among the diagnostic tests was to test the stool for blood. A review of the [MEDICATION NAME] consult dated [DATE], indicated the resident had [MEDICAL CONDITION] and a guaiac-positive stools (test that finds hidden blood in the stool even when the blood is not seen) and the admission hemoglobin was 7.4 g/dl. The resident received blood transfusion with 2 units of packed red blood cells. The hemoglobin was increased to 9.1 g/dl and had subsequently decreased to 8.2 on [DATE]. The resident also received IV fluids, and a [MEDICAL CONDITION] tube inserted that produced suction a coffee ground fluid. In intravenous [MEDICATION NAME] (medication used for the treatment of [REDACTED]. The major complications from blood [MEDICAL CONDITION] include [DIAGNOSES REDACTED], allergic, febrile, and bacterial reactions, circulatory overload, embolism (is an obstruction in a blood vessel due to a blood clot), and the transmission of infectious agents-most notably [MEDICAL CONDITION], more rarely, [DIAGNOSES REDACTED] and syphilis. [MEDICAL CONDITION] is a relatively common complication of transfusion therapy because a number of persons who donate blood have had a mild form of [MEDICAL CONDITION], have experienced no symptoms, and therefore have not been diagnosed as having [MEDICAL CONDITION]. [MEDICAL CONDITION] may develop in the recent three weeks following transfusion (American Journal of Nursing, [DATE], Cullins, Laura C. RN, BSN, Page 935). The resident was hospitalized from [DATE], to [DATE], and readmitted to the facility on [DATE]. When the resident was readmitted to the facility her [DIAGNOSES REDACTED]. During an interview with RN 3 on [DATE], at approximately 12:30 p.m., she stated that a stool occult blood test had never been done for the resident. b. A review of Resident 18's closed record indicated the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident expired on [DATE]. The Minimum Data Set (MDS) assessment dated [DATE], indicated the resident had difficulty communicating and understanding others and her cognitive skills for daily decision making were moderately impaired and had indicators of mood that indicated the resident spoke so slowly that other people could have noticed or that she was being so fidgety or restless that that she had been moving around a lot more than usual. The resident was also assessed to need extensive assistance with dressing, eating, and hygiene and to be totally dependent on staff for transfer, toilet use and bathing. The resident had a physician's orders [REDACTED]. [MEDICATION NAME] is an antipsychotic medication that may be used in the management of major [MEDICAL CONDITION]. Elderly patients with dementia-related [MEDICAL CONDITION] have an increased risk of death if given atypical antipsychotic; the drug is not approved for treating patients with dementia-related [MEDICAL CONDITION] (Lippincott's Nursing Drug Guide, 2010, Pages ,[DATE]). According to the Psychoactive Medication Consent dated [DATE], the specific target behavior for the [MEDICATION NAME] order for the resident is for dementia with agitated behavior manifested by resistive to care. Antipsychotic medications are not indicated in many situations among them uncooperativeness (SOM, [DATE], Page 376). A review of the physician's progress notes dated [DATE], indicated the resident had been on [MEDICATION NAME] for dementia with depression mood. However, a review of the resident's record did not indicate the rationale for not attempting a tapering or gradual dose reduction (GDR) of the [MEDICATION NAME] when the resident received the medication daily for an excessive duration. A review of the Behavior Monitoring Form-Anti-Psychotic Medications for the months of [DATE], [DATE], February 2012, revealed that the resident only had one episode of agitated behavior manifested by resistive to care during the three months reviewed, on [DATE] during the day shift. According to the physician's progress note dated February 17, 2012, the resident's active problems included recurrent [MEDICAL CONDITION] with dementia, the resident was on [MEDICATION NAME], and the behavior was controlled and to continue with current plan of care. However, dose reduction was not attempted. According to State Operations Manual (SOM) within the first year in which a resident is admitted on an antipsychotic medication, the facility must attempt a GDR in two separate quarters with at least one month between the attempts (SOM, [DATE], Page 357). On [DATE], at 5:10 p.m., during an interview with Registered Nurse 2 (RN 2) she stated a GDR for [MEDICATION NAME] had not been done since the resident was admitted . She added that the resident's physician had been asked if [MEDICATION NAME] could be discontinued however, the physician stated to continue with the medication. According to RN 2, there is no evidence in the medical record that indicated the rationale for not attempting a GDR. c.1. According to the admission record, Resident 6 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE], indicated the resident was moderately impaired in cognition, needed limited to extensive assistance in the activities of daily living (ADL) except in eating, and fall was triggered in Care Area Assessment (CAA) summary. The resident had a physician's orders [REDACTED]. A review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. There was no documented evidence that indicated the resident had been monitored for potential iron accumulation in body, and there was no documented justification for the use of [MEDICATION NAME] for more than six months without monitoring the potential iron accumulation in the resident's tissue. On [DATE], at 2: 10 p.m., during an interview with Registered Nurse 3 (RN 3), she was not able to provide the documented evidence the resident had been monitored for the potential iron accumulation, or the justification for administering [MEDICATION NAME] to the resident without monitoring the potential iron accumulation in the resident's tissue. In addition, there was no documentation of the clinical rationale for when [MEDICATION NAME] was ordered for continuous long-term use (greater than two months). According to the State Operational Manual (SOM), clinical rationale should be documented if iron is ordered for a long-term use (greater than two months) or if administered more than once daily (daily for greater than a week), because of side effects and the risk of accumulation of iron in the tissues. Monitoring the baseline serum iron or Ferritin level and periodic complete blood count (CBC) or hematocrit /hemoglobin is needed. Adverse consequences includes constipation, dyspepsia (indigestion, upset stomach) symptoms such as upper abdominal pain, belching, nausea, vomiting, abdominal bloating, abdominal distention), accumulation of iron in tissues that cause multiple complications if given chronically despite normal or high iron stores (SOM, [DATE], Page 390). c.2. A review of Resident 6's clinical record also indicated the resident had the following physician's orders [REDACTED]. 1. [MEDICATION NAME] 25 mg half tablet by mouth before bedtime for [MEDICAL CONDITION] with agitation manifested by anger outburst dated [DATE]. The adverse effects of [MEDICATION NAME] include postural [MEDICAL CONDITION] (a drop in blood pressure ([MEDICAL CONDITION]) due to a change in body position (posture) when a person moves to a more vertical position that may result in a fall). 2. Check the blood pressure at every shift dated [DATE]. There was another order dated [DATE], to check the blood pressure every shift every Monday. There was a plan of care developed on [DATE], for the psychoses and administration of [MEDICATION NAME] and [MEDICATION NAME]. One of the approaches was to observe for the potential side effects of the medication administration and the postural [MEDICAL CONDITION] was one of the side effects of [MEDICATION NAME] and [MEDICATION NAME]. There was another plan of care developed on [DATE], for the risk of falls, and one of the approaches was to observe for potential medication related causes for fall. However, there was no documented evidence that indicated the resident's postural [MEDICAL CONDITION] was monitored as indicated in the plan of care and/or a doctor's ordered obtained to monitor the resident for postural [MEDICAL CONDITION]. A review of the Change of Condition dated [DATE], indicated the resident was found on the floor sitting on a landing pad on side of bed with no injuries. A review of the Fall Risk assessment dated [DATE], indicated the total score was 14 and the total score of 10 or above represents high risk. On [DATE] at 4 p.m. during an interview with Registered Nurse 3, she was not able to provide any documented evidence of the monitoring for the resident's postural [MEDICAL CONDITION], the rationale for not monitoring the postural [MEDICAL CONDITION], and the clarification of the physician's orders [REDACTED]. d. A review of Resident 24's closed record and admission sheet indicated that the resident was admitted on [DATE], with [DIAGNOSES REDACTED]. The resident was discharged on [DATE]. The Minimum Data Set (MDS) assessment [DATE], indicated that the resident had clear speech, had the ability to make self be understood, had the ability to understand others, and had adequate vision and hearing. The MDS also indicated that the resident required extensive assistance from facility staff for ADL. The physician's orders [REDACTED]. [MEDICATION NAME] is a antipsychotic medication (antipsychotic- psychiatric medication primarily used to manage [MEDICAL CONDITION]). A review of the Psychoactive Medication Consent Form (un dated) indicated the potential side effects of the medication and monitoring instructions in accordance with the manufacturer's guidelines included monitor and recording episodes of behavior, common side effects of central nervous system such as nervousness, [MEDICAL CONDITION], dizziness, headache and gastrointestinal such as dry mouth, constipation, anorexia, nausea and abdominal pain. There was no documented evidence that indicated the resident was monitored for the above side effects of the medication including episodes of behaviors as specified in the manufacturer's instruction. During an interview on [DATE], at 4:10 p.m., a facility Registered Nurse 7 (RN 7) acknowledged that Resident 24 should have been monitored for behavior manifestation while on [MEDICATION NAME]. RN 7 further stated behavior monitoring the resident in accordance with the manufacturer's recommendation is expected of the licensed nurse on residents who receive psychoactive medications.

Based on interview and record review, the facility failed to: 1. Ensure that a resident who received Aspirin (325 milligrams (mg) per day for excessive duration (approximately 33 months)) , was monitored for the adverse effects of the medication that resulted in gastrointestinal (GI/the stomach and the intestines) bleeding due to stomach ulcer, that resulted in hospitalization and treatment with blood transfusion and placement of [MEDICAL CONDITION] tube (GT) feeding (2). 2. Ensure that [MEDICATION NAME] 5 mg (antipsychotic- psychiatric medication primarily used to manage [MEDICAL CONDITION]) would not be administered for managing resistive care or uncooperative behavior, and failed to ensure that dose reduction attempt was made and/or assessed the need for the continued use of the [MEDICATION NAME] was made in the absence of a behavior manifested by resistive to care (18). 3. Monitor a resident on a long-term administration of [MEDICATION NAME] (iron) to prevent the potential for adverse effects and complications associated with a long-term use of iron (6). 4. Monitor a resident for postural [MEDICAL CONDITION] (a drop in blood pressure due to a change in body position (posture) when a person moves to a more vertical position that may result in falls), while the resident received [MEDICATION NAME] 25 mg (antipsychotic medication) and assessed at high risk for falls (6). 5. Monitor a resident on [MEDICATION NAME] 25 mg based on instruction specified in the manufacturer's instruction (24), for four out of 24 sample residents (2, 6, 18, 24). Findings: a. According to the admission record Resident 2 was initially admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE], indicated the resident was moderately impaired in her cognitive skills for daily decision making, and was independent with eating. The MDS also indicated the resident needed extensive assistance with dressing, limited assistance with personal hygiene, and was totally dependent on staff for bathing. The resident had the following physician's orders [REDACTED]. 1. [MEDICATION NAME] 7 mg by mouth daily dated [DATE], and discontinued on [DATE]. ([MEDICATION NAME] is blood thinner medication used to prevent [MEDICAL CONDITIONS], and blood clots in veins and arteries). 2. Aspirin 325 mg daily dated [DATE]. A review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Aspirin is a non-steroidal anti-[MEDICAL CONDITION] drug (NSAD, medication primarily is used primarily to treat inflammation, mild to moderate pain, and fever); it is also used among other indications as a [MEDICATION NAME] in prevention of blood clots. The potential adverse drug reaction of Aspirin included GI bleeding, dyspepsia (symptoms such as upper abdominal pain, belching, nausea, vomiting, abdominal bloating, abdominal distention) bleeding from gums while brushing teeth, or from small abrasions or contusions, GI distress, occult blood (blood in the feces that is not visibly apparent). Aspirin is contraindicated for residents with a [DIAGNOSES REDACTED]. that carries oxygen to the body), platelets (blood cells that help wounds heal and prevent bleeding by forming blood clots) count and periodic kidney function tests. Aspirin should be taken with food (Geriatric Drug Therapy Handbook, ,[DATE], Pages ,[DATE]). The plan of care dated February 16, 2012, indicated the resident was at risk for increased bleeding, bruising or injury related to use of anticoagulant therapy because the resident was receiving aspirin. The goal of the plan of care stated the resident would be free of excessive bleeding or bruising related to administration of anticoagulant therapy through the next three months. The interventions on the plan of care included to observe for bleeding or increased bruising frequently, monitor labs as ordered, and notify the physician of abnormal labs for further direction and treatment determination. However, the facility did not attain its goal that stated "the resident would be free of excessive bleeding." A review of the resident's laboratory (lab) test results indicated the following: 1. On [DATE], the Hemoglobin was 13.4 g/d/L (reference range 11.5- 15) the Hematocrit was 39.8 (reference range ,[DATE]%) and the Platelets count was 154 (reference range 140 -440. According to the lab report, the physician was notified of the results. 2. On February 18, 2012, the Hemoglobin was 15.9 g/d/L (reference range 11.5 - 15) the Hematocrit was 39.8 percent (reference range ,[DATE]%), and the Platelets count was 198 (reference range 140 -440. According to the lab report, the physician was not notified of the results. The spaces on the form designated for physician notification date and time were blank. 3. Laboratory information regarding [MEDICATION NAME] time and international normalized ration are not available. According to the Change of Condition report dated February 19, 2012, the resident was non-responsive at 9:50 a.m. The vital signs were: blood pressure ,[DATE] millimeters of mercury (mm Hg), pulse was 75 beats per minute, respirations 16 breaths per minute, temperature was 92.7 degrees Fahrenheit and oxygen saturation on room air was 89%. Oxygen saturation range of 96% - 100% is generally considered normal. The margin between "healthy" saturation levels (,[DATE]%) and [MEDICAL CONDITION] (usually 85 - 90%) is narrow. Anything below 90% could quickly lead to life-threatening complications (American Journal of Nursing: [DATE]-Volume 105-issue 5- Page 72). According to the report the problem was thought to be due to a respiratory condition. The resident was started on oxygen with a non-rebreather mask at 14 liters/minute and the oxygen saturation increased to 94%. The resident was placed on a Trendelenburg position (the body is laid flat on the back with the feet higher than the head by 15 - 30 degrees) due to the low blood pressure. The physician was notified and the resident was transferred via 911 to the general acute care hospital (GACH) at 10:30 a.m. per physician's orders [REDACTED]. A review of the History and Physical report obtained from the GACH dated February 19, 2012, indicated the resident's chest x-ray showed evidence of pneumonia and was admitted for treatment. This report also indicated the resident had septic shock (an extreme immune system response to an infection that has spread throughout the blood and tissues, it often causes extremely low blood pressure, which limits blood flow to the body and can result in organ failure), acute [MEDICAL CONDITIONS] secondary to septic shock, [MEDICAL CONDITION], and was on a ventilator. The medical plan included intravenous fluids (IV) therapy, diagnostic tests, IV antibiotics, blood pressure control, and medical consults. According to a cardiology consult dated February 21, 2012, the resident had evidence of a GI bleed and anticoagulation therapy had been discontinued which according to this report had been used for [MEDICAL CONDITION] (blood clot) [MEDICATION NAME]. A laboratory test result from the GACH dated [DATE], indicated the resident's Hemoglobin was low at 9.7 g/dl (reference range 11.5 - 15) and the Hematocrit was also low at 28.8 % (reference range ,[DATE]%). The resident was hospitalized for [REDACTED]. Another laboratory test report dated [DATE], indicated the resident's Hemoglobin was low: 7.9 g/d/L (reference range 11.5 - 15) the resident's Hematocrit was low: 22.5 (reference range ,[DATE]%), and the resident's Platelets count was low: 92 (reference range 140 -440. According to the lab report, the physician was not notified of the results. The spaces on the form designated for physician notification date and time were blank. Low hemoglobin, low hematocrit and low platelets count in a patient on an anticoagulant or blood thinning medication are indicators for bleeding. According to another Change of Condition report dated [DATE], the resident had low blood pressure and a low grade fever. The vital signs were: blood pressure ,[DATE] millimeters of mercury (mm Hg), pulse was 63 beats per minute, respirations 16 breaths per minute, temperature was 100.0 degrees F and oxygen saturation on room air was 97% on 2 liters of oxygen per minute. The physician was notified and the resident was transferred for the second time via 911 to the GACH at 4 p.m. per physician's orders [REDACTED]. A review of the History and Physical report obtained from the GACH dated [DATE], the resident on admission to the emergency room was hypotensive and in respiratory distress. The resident was placed on IV fluids and was transferred to the intensive care unit. This report also indicated the resident had acute respiratory distress secondary to pneumonia, [MEDICAL CONDITION] (low blood pressure), rule out septic shock versus hypovolemia (a state of decreased blood volume), [MEDICAL CONDITION] secondary to blood loss, rule out [MEDICAL CONDITION] ulcer disease, rule out upper versus lower GI bleed, history of diabetes mellitus, history of hypertension and history of dementia. The medical plan included intravenous fluids (IV) therapy, IV antibiotics, and transfused packed cells, among the diagnostic tests was to test the stool for blood. A review of the [MEDICATION NAME] consult dated [DATE], indicated the resident had [MEDICAL CONDITION] and a guaiac-positive stools (test that finds hidden blood in the stool even when the blood is not seen) and the admission hemoglobin was 7.4 g/dl. The resident received blood transfusion with 2 units of packed red blood cells. The hemoglobin was increased to 9.1 g/dl and had subsequently decreased to 8.2 on [DATE]. The resident also received IV fluids, and a [MEDICAL CONDITION] tube inserted that produced suction a coffee ground fluid. An intravenous [MEDICATION NAME] (medication used for the treatment of [REDACTED]. The major complications from blood [MEDICAL CONDITION] include [DIAGNOSES REDACTED], allergic, febrile, and bacterial reactions, circulatory overload, embolism (is an obstruction in a blood vessel due to a blood clot), and the transmission of infectious agents-most notably [MEDICAL CONDITION], more rarely, [DIAGNOSES REDACTED] and syphilis. [MEDICAL CONDITION] is a relatively common complication of transfusion therapy because a number of persons who donate blood have had a mild form of [MEDICAL CONDITION], have experienced no symptoms, and therefore have not been diagnosed as having [MEDICAL CONDITION]. [MEDICAL CONDITION] may develop in the recent three weeks following transfusion (American Journal of Nursing, [DATE], Cullins, Laura C. RN, BSN, Page 935). The resident was hospitalized from [DATE], to [DATE], and readmitted to the facility on [DATE]. When the resident was readmitted to the facility her [DIAGNOSES REDACTED]. According to the physician's orders [REDACTED]. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. During an interview with RN 3 on [DATE], at approximately 12:30 p.m., she stated that a stool occult blood test had never been done for the resident. b. A review of Resident 18's closed record indicated the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident expired on [DATE]. The Minimum Data Set (MDS) assessment dated [DATE], indicated the resident had difficulty communicating and understanding others and her cognitive skills for daily decision making were moderately impaired and had indicators of mood that indicated the resident spoke so slowly that other people could have noticed or that she was being so fidgety or restless that that she had been moving around a lot more than usual. The resident was also assessed to need extensive assistance with dressing, eating, and hygiene and to be totally dependent on staff for transfer, toilet use and bathing. The resident had a physician's orders [REDACTED]. [MEDICATION NAME] is an antipsychotic medication that may be used in the management of major [MEDICAL CONDITION]. Elderly patients with dementia-related [MEDICAL CONDITION] have an increased risk of death if given atypical antipsychotic; the drug is not approved for treating patients with dementia-related [MEDICAL CONDITION] (Lippincott's Nursing Drug Guide, 2010, Pages ,[DATE]). According to the Psychoactive Medication Consent dated [DATE], the specific target behavior for the [MEDICATION NAME] order for the resident is for dementia with agitated behavior manifested by resistive to care. Antipsychotic medications are not indicated in many situations among them uncooperativeness (SOM, [DATE], Page 376). A review of the physician's progress notes dated [DATE], indicated the resident had been on [MEDICATION NAME] for dementia with depression mood. However, a review of the resident's record did not indicate the rationale for not attempting a tapering or gradual dose reduction (GDR) of the [MEDICATION NAME] when the resident received the medication daily for an excessive duration. A review of the Behavior Monitoring Form-Anti-Psychotic Medications for the months of [DATE], [DATE], February 2012, revealed that the resident only had one episode of agitated behavior manifested by resistive to care during the three months reviewed, on [DATE] during the day shift. According to the physician's progress note dated February 17, 2012, the resident's active problems included recurrent [MEDICAL CONDITION] with dementia, the resident was on [MEDICATION NAME], and the behavior was controlled and to continue with current plan of care. However, dose reduction was not attempted. According to State Operations Manual (SOM) within the first year in which a resident is admitted on an antipsychotic medication, the facility must attempt a GDR in two separate quarters with at least one month between the attempts (SOM, [DATE], Page 357). On [DATE], at 5:10 p.m., during an interview with Registered Nurse 2 (RN 2) she stated a GDR for [MEDICATION NAME] had not been done since the resident was admitted . She added that the resident's physician had been asked if [MEDICATION NAME] could be discontinued however, the physician stated to continue with the medication. According to RN 2, there is no evidence in the medical record that indicated the rationale for not attempting a GDR. c.1. According to the admission record, Resident 6 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE], indicated the resident was moderately impaired in cognition, needed limited to extensive assistance in the activities of daily living (ADL) except in eating, and fall was triggered in Care Area Assessment (CAA) summary. The resident had a physician's orders [REDACTED]. A review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. There was no documented evidence that indicated the resident had been monitored for potential iron accumulation in body, and there was no documented justification for the use of [MEDICATION NAME] for more than six months without monitoring the potential iron accumulation in the resident's tissue. On [DATE], at 2: 10 p.m., during an interview with Registered Nurse 3 (RN 3), she was not able to provide the documented evidence the resident had been monitored for the potential iron accumulation, or the justification for administering [MEDICATION NAME] to the resident without monitoring the potential iron accumulation in the resident's tissue. In addition, there was no documentation of the clinical rationale for when [MEDICATION NAME] was ordered for continuous long-term use (greater than two months). According to the State Operational Manual (SOM), clinical rationale should be documented if iron is ordered for a long-term use (greater than two months) or if administered more than once daily (daily for greater than a week), because of side effects and the risk of accumulation of iron in the tissues. Monitoring the baseline serum iron or Ferritin level and periodic complete blood count (CBC) or hematocrit /hemoglobin is needed. Adverse consequences includes constipation, dyspepsia (indigestion, upset stomach) symptoms such as upper abdominal pain, belching, nausea, vomiting, abdominal bloating, abdominal distention), accumulation of iron in tissues that cause multiple complications if given chronically despite normal or high iron stores (SOM, [DATE], Page 390). c.2. A review of Resident 6's clinical record also indicated the resident had the following physician's orders [REDACTED]. 1. [MEDICATION NAME] 25 mg half tablet by mouth before bedtime for [MEDICAL CONDITION] with agitation manifested by anger outburst dated [DATE]. The adverse effects of [MEDICATION NAME] include postural [MEDICAL CONDITION] (a drop in blood pressure ([MEDICAL CONDITION]) due to a change in body position (posture) when a person moves to a more vertical position that may result in a fall). 2. Check the blood pressure at every shift dated [DATE]. There was another order dated [DATE], to check the blood pressure every shift every Monday. There was a plan of care developed on [DATE], for the psychoses and administration of [MEDICATION NAME] and [MEDICATION NAME]. One of the approaches was to observe for the potential side effects of the medication administration and the postural [MEDICAL CONDITION] was one of the side effects of [MEDICATION NAME] and [MEDICATION NAME]. There was another plan of care developed on [DATE], for the risk of falls, and one of the approaches was to observe for potential medication related causes for fall. However, there was no documented evidence that indicated the resident's postural [MEDICAL CONDITION] was monitored as indicated in the plan of care and/or a doctor's ordered obtained to monitor the resident for postural [MEDICAL CONDITION]. A review of the Change of Condition dated [DATE], indicated the resident was found on the floor sitting on a landing pad on side of bed with no injuries. A review of the Fall Risk assessment dated [DATE], indicated the total score was 14 and the total score of 10 or above represents high risk. On [DATE] at 4 p.m. during an interview with Registered Nurse 3, she was not able to provide any documented evidence of the monitoring for the resident's postural [MEDICAL CONDITION], the rationale for not monitoring the postural [MEDICAL CONDITION], and the clarification of the physician's orders [REDACTED].

Based on interview and record review, the facility failed to provide the necessary care and services to prevent the formation of pressure ulcers in one of one sample residents who had no history of, but was at risk for, developing pressure ulcers (Resident 1). The Licensed Vocational Nurse 1 (LVN1) failed to notify and obtain a physician's orders [REDACTED]. Instead, LVN1 applied a [MEDICATION NAME], (A [MEDICATION NAME] is an adhesive which may make the resident's skin vulnerable to tearing when the dressing is removed (http://findarticles.com/p/articles/mi_qa3977/is_ 3/ai_n 22), did not document the assessment of the reddened buttock area, and failed to inform other licensed staff of the resident's skin condition. The nursing staff also failed to provide physical assistance with repositioning for the resident during the hours of 11 p.m. to 7:30 a.m. for eight days from January 25, 2010 to February 12, 2010, increasing the potential for skin breakdown. The registered dietician's notes failed to address the resident's low pre-[MEDICATION NAME] level. ([MEDICATION NAME] is a test to help diagnose protein-calorie [MEDICAL CONDITION], which can affect the body's ability to heal and fight infection. (Source: labtestsonline.com)). The Interdisciplinary Team notes did not address the evaluation of the pressure ulcer preventative measures/interventions for effectiveness as indicated in the facility's policy. From February 12, through March 22, 2010, the right buttock pressure ulcer progressed from unstageable (full thickness tissue loss in which the base of the ulcer is covered making it unable to be staged) to a Stage IV with odor and undermining. (Undermining is an erosion of tissue beneath or around the affected area). The right heel blister progressed to a Stage III pressure ulcer. On March 23, 2010, the resident was admitted to the acute hospital for fever, and had surgical debridement of the Stage IV right buttock pressure ulcer on March 24, 2010. (Surgical debridement is when the surgeon utilizes a sharp instrument to cut away tissues when they are traumatized or infected, until surrounding healthy tissue is exposed. (Miller-Keane Encyclopedia & Dictionary of Medicine, Nursing, & Allied Health. Sixth Edition.)). The resident was discharged from the acute hospital on March 26, 2010, to a different skilled nursing facility. Definitions according to the Weekly Pressure Ulcer Record were as follows: A Stage II pressure ulcer is a partial thickness loss of skin layers that present as an abrasion, blister, or shallow crater. A Stage III is loss of fullness of the skin, exposing the subcutaneous layer. A Stage IV is a full thickness of skin and subcutaneous tissue loss exposing muscle or bone. An unstageable pressure ulcer is necrotic (dead) tissue that is grayish/yellow slough or soft/hard eschar (dead tissue). Findings: An unannounced complaint visit was initiated April 23, 2010, to investigate a resident's pressure ulcers that developed in the facility and progressed to Stage III and Stage IV pressure ulcers. During an interview on April 23, 2010, at 10:50 a.m., the Director of Nurses (DON) stated the facility's investigation as to the development of Resident 1's right buttock pressure ulcer conducted on February 12, 2010, revealed the following: LVN1 applied a [MEDICATION NAME] to Resident 1's reddened right buttock on February 8, 2010, without obtaining a physician's orders [REDACTED]. When the patch was removed, there was an unstageable pressure ulcer. The DON stated that a [MEDICATION NAME] gel patch is not recommended for use on a Stage I pressure ulcer (an observable, pressure-related alteration of intact skin that usually presents as a localized area of redness or skin discoloration according to the National Pressure Ulcer Advisory Panel). According to the signed undated declaration written by LVN1, on the morning of February 8, 2010, she was asked by a certified nursing assistant (CNA1) to assess the redness on Resident 1's right buttock area. LVN1 applied a "protection patch" (no type given), but failed to notify the physician, did not document in the treatment book, and failed to complete the change of condition form, in accordance with the facility's policy. During the April 23, 2010 interview with the DON, she stated that after LVN1 put a [MEDICATION NAME] on Resident 1's reddened buttocks on February 8, 2010, there was no documented evidence that LVN1 assessed or documented the resident's skin condition prior to applying the [MEDICATION NAME], or that LVN1 or other nursing staff monitored the buttocks area. The DON could not provide evidence that LVN1 notified the physician to receive orders for treatment of [REDACTED]. The Disciplinary Action Record dated and signed by LVN1 on February 12, 2010, indicated that on February 8, 2010, (no time) LVN1 applied a [MEDICATION NAME] dressing to Resident 1's reddened buttock area without obtaining a physician's orders [REDACTED]. The resident developed a Stage III pressure ulcer according to this record. A review of Resident 1's Admission Face Sheet and History and Physical records revealed he was admitted to the facility from an acute care hospital on January 18, 2010, after right total hip replacement revision that occurred on January 15, 2010. He was admitted to this skilled nursing facility for physical and occupational therapy and medical management. The resident's past medical history included diabetes mellitus (elevated blood sugar levels), [MEDICAL CONDITION], (also known as diabetic nerve damage, causes tingling, pain, numbness, or weakness in your feet and hands. It can also lessen the ability to feel pain, with potential inability to feel a foot injury and/or a blister until the skin breaks down and becomes infected (Source:diabetes.org))., peripheral vascular insufficiency (interrupted blood flow through the veins and arteries that can lead to tissue death. (Source: http://www.nmihi.com/p/vascular-disease.htm.)), [MEDICAL CONDITIONS], hypertension (high blood pressure) and osteopenia (thin/weak bones). On January 18, 2010, licensed nursing staff assessed Resident 1 with a Braden score of 15, using a Braden Scale for Predicting Pressure Sore Risk. (The Braden Scale is a clinical tool used to assess the risk of a resident developing a pressure ulcer. To prevent a pressure ulcer, individuals at risk must be identified so that risk factors can be reduced through interventions (Source: tissueviability.com)). The licensed staffs' assessed Braden score value of 15 indicated the resident had a mild risk for the development of pressure ulcers. The physician progress notes [REDACTED]. There was no indication that the resident had any pressure reduction devices, such as heel protectors, in place during this visit, or other visits through February 12, 2010. The Minimum Data Set (MDS) assessment that was initiated upon admission on January 18, 2010, and dated January 28, 2010, indicated the resident was alert and cognitively independent in daily decision making skills. He had no behavioral problems with resisting care, and required extensive assistance in bed mobility, toileting, and bathing. The resident was continent of bowel and bladder, and was free of skin ulcers with no history of resolved ulcers. He was 6 feet 1 inches tall and weighed 227 pounds. A plan of care to address the potential for developing a pressure ulcer secondary to decreased activity and friction and shear problems was developed on January 18, 2010, with a goal of minimizing pressure ulcer risk with reduction interventions. However no pressure reduction interventions were indicated as being initiated. Another plan of care to address the potential for developing a pressure ulcer secondary to impaired bed mobility was developed on February 5, 2010, with a goal that the resident would have no skin breakdown/pressure ulcer formation daily for three months. The approaches included turning and repositioning the resident at least every two hours, observe for any skin breakdown or redness and notify the physician if noted, and for the registered dietitian to assess the dietary needs. There was no documentation that pressure reducing devices were initiated for the resident's less protected bony areas, including the sacral area and heels. The facility's computer printout of the Activities of Daily Living (ADL) Report dated June 17, 2010, revealed the night shift nursing staff failed to provide physical assistance with repositioning Resident 1 the hours of 11 p.m. to 7:30 a.m. on eight days as follows: January 25 and 31, 2010, February 3, 5, 9, 10, 11, and 12, 2010. A review of the Nonpressure Skin Condition Record revealed documentation of treatment to the right hip incision that was 38 cm with 50 staples, from January 18, 2010, to February 10, 2010, when it healed. The daily nursing notes through February 12, 2010 revealed no documented evidence of observation of Resident 1's development of a pressure ulcer, even though the resident was receiving treatment to his right hip suture area daily. A laboratory report dated January 20, 1010, indicated the resident's abnormal low [MEDICATION NAME] level of 10 milligrams per deciliter (mg/dl.; a normal range is 20 to 40 mg/dl). The hemoglobin was 10.0 (normal range is 14.0 to 18.0). On the February 2, 2010, laboratory report, the resident's hemoglobin was 9.5. (Hemoglobin is a protein in the red blood cells that carries oxygen to the body's organs and tissues (mayoclinic.com)). The Registered Dietician's notes from January 21, 2010 through February 12, 2010 failed to address the resident's low pre-[MEDICATION NAME] level. The Interdisciplinary Team (IDT) notes from January 18, 2010 through February 15, 2010, did not address the evaluation of the pressure ulcer preventative measures and/or interventions for effectiveness as indicated in the facility's policy. The abnormal laboratory results were noted, however the intervention was to continue to monitor. The IDT notes dated February 16, 2010, did not address the presence of the actual pressure ulcers. The notes dated February 23, 2010, mentioned the current interventions and that the wounds were healing slowly, but there was no evaluation of the interventions for effectiveness as indicated in the facility's policy. The Resident Assessment Protocol Review Report dated February 4, 2010, indicated the resident was at risk for developing pressure ulcers due to his inability to reposition himself at regular intervals, and his fragile skin. There was no documentation that staff considered the resident's diabetes mellitus with associated [MEDICAL CONDITION] during their preventative skin care assessment. The Report indicated a preventive care program should be initiated, however the interventions section was coded that pressure-reducing devices were not being used. The initial Weekly Pressure Ulcer Record and the Physician's Progress Notes dated February 12, 2010, revealed the resident had an unstageable pressure ulcer on the right buttock measuring 5.5 centimeters (cm) by 5.2 cm, with undetermined depth, a scant amount of serosanguinous and a black wound bed surrounded by pink/red skin. The Nurse Practitioner accompanied the treatment nurse for the skin assessment. The record noted that the resident had pain related to the wound, and indicated Santyl ointment treatment, a low air loss mattress (provided to reduce pressure to the affected area), bilateral heel protectors, and nutritional supplements were to be ordered by the physician. It was also documented on the Weekly Pressure Ulcer Record that the licensed staff assessed the resident's development of three additional pressure ulcers that were discovered on February 12, 2010 as follows: a Stage III pressure ulcer developed on the resident's left heel that measured 1.5 cm by 1.5 cm, and was covered with a dark wound bed; a right heel blister that measured 3.5 cm by 5.0 cm; and an unstageable sacral pressure ulcer measuring 0.5 by 2.0 cm that had a scant amount of serosanguinous drainage with a black wound bed. A Change of Condition form dated February 12, 2010, was completed for the four newly developed pressure ulcers. However, it was not until this time that documentation reflected bilateral heel protectors were to be applied to the resident's heels. It was noted in the Subjective Observation of Clinical change area that the resident stated that he complained of buttock pain "a few days ago" to the treatment nurse. The Nursing Daily Skilled Summary notes dated February 12, 2010 (Friday) during the 7 a.m. to 3 p.m. shift indicated that when the resident was informed of his pressure ulcer on his right buttock area, he stated that he had complained of pain in the buttock area to the treatment nurse on " Sunday ", which would have been February 7, 2010. The resident had physician's orders [REDACTED]. Clean right buttock unstageable pressure ulcer with normal saline and apply Santyl dressing every day. 2. Clean left sacral unstageable pressure ulcer with normal saline and apply Santyl dressing every day. 3. Clean right heel blister/lesion with normal saline and apply [MEDICATION NAME] dressing every day. 4. Clean left heel Stage II pressure ulcer with normal saline and apply Hydrogel dressing every day. 5. Apply bilateral heel protectors. The treatments were completed as ordered, The facility's Skin Management policy and procedure dated June 2007, specific to pressure ulcers, indicated that when a pressure ulcer is identified, the licensed nurse will document in the progress notes and on the Weekly Pressure Ulcer Record the size, stage, location, drainage, odor, pain, obtainment of treatment order, initiation of care plan, and notification of interdisciplinary wound team including the dietician. The licensed nurse will document daily monitoring of all pressure ulcers to include the status of the dressing, surrounding skin, presence of possible complications, and pain. The licensed nurse will communicate all identified pressure ulcers to the attending physician. Residents with newly identified pressure ulcers will be assessed by the Interdisciplinary Team (IDT) upon notification and a care plan will be developed, implemented, evaluated, and re-evaluated to treat actual pressure ulcers and reduce further pressure ulcers. This will include but not be limited to a review of lab results, risk factors, and positioning. The risk factors for pressure ulcers included impaired or decreased mobility and functional ability, [MEDICAL CONDITION], and a hemoglobin less that 14 mg/dl for males. Residents identified as a risk for the development of pressure ulcers will have a plan and interventions included in the care plan to address each risk factor individually. According to the Weekly Pressure Ulcer Records for March, 2010, the right buttock unstageable pressure ulcer was now staged at a Stage IV, measuring 3.5 cm by 3 cm with a depth of 3.5 cm, undermining (no mention of how much), with a moderate amount of serosanguinous drainage with odor present. The left heel Stage II pressure ulcer had progressed to a Stage III with a depth noted as superficial. The right heel pressure ulcer progressed from a blister to a Stage III, measuring 0.6 cm by 0.6 cm, superficial in depth with a scant amount of serosanguinous drainage. On March 23, 2010, the resident was admitted to the acute hospital for fever. The right buttock pressure ulcer was assessed at the acute hospital as a Stage IV measuring 3 cm by 4 cm, with a depth of 3.2 cm, had periwound [DIAGNOSES REDACTED] (reddened area around the wound when it is infected), induration (localized hardening of the soft tissue of the body) maceration (softening and deterioration of skin or tissue of the body), and a palpable wound bed bone (could feel the bone upon assessment). The pressure ulcer had 50 percent wet yellow slough (a layer or mass of dead tissue separated from surrounding tissue, as in a wound, a sore, or an inflammation), was 50 percent dark red in color with brown and tan serosanguinous drainage, and the presence of a foul odor. On March 24, 2010, surgical debridement of the Stage IV right buttock pressure ulcer was done at the acute hospital. During an interview with CNA1 on June 3, 2010, she stated that on February 8, 2010, she called LVN1 to look at the resident's reddened buttock area after she gave Resident 1 a shower. She said that LVN1 put "the patch" on the resident's right buttock at that time. In an interview with Resident 1 on July 19, 2010, at 4 p.m., he stated that during his stay at the facility he was never turned or repositioned (no particular shift was given). He stated that he did not refuse to be repositioned by staff, and that the problem was no one came to help him but left him in bed. He stated that he felt terrible because the sore on the right buttock area was very big. He stated that he refused to be readmitted to the facility when he was discharged from the hospital on March 26, 2010, and chose to go to a different skilled nursing facility for further care.