Every finding on record at Temple Park Convalescent Hospital

Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) was readmitted to the facility following hospital discharge when the resident's needs could be met by the facility.This failure resulted in Resident 1 remaining hospitalized for an additional day after the hospital physician determined the resident was medically stable for discharge, potentially violating Resident 1's rights to return the facility after hospitalization.During a record review of Resident 1's Transfer Record from the facility, dated 6/8/2026, the Transfer Record indicated Resident 1 was sent to a general acute care hospital (GACH 1) on 6/8/2026 due to low hemoglobin (an iron-rich protein found in red blood cells that carries oxygen from the lungs to the rest of the body, and transports carbon dioxide back to the lungs). Resident 1 was stable and required further evaluation as ordered by the facility Nurse Practitioner (NP).During a record review of GACH 1's documentation titled Discharge Summary dated 6/17/2026, the Discharge Summary indicated Resident 1 was transferred to GACH 1 from the facility on 6/8/26 and was treated for acute kidney injury (AKI- a sudden and rapid decline in kidney function that occurs within a few hours or days) and low hemoglobin, and AKI had resolved on 6/16/2026. The Record review also indicated GACH 1 physician cleared Resident 1 for discharge back to the facility on 6/17/26.During a record review of hospital documentation titled Discharge Summary dated 6/17/2026, the Discharge Summary indicated Resident 1had bradycardia (is an abnormally slow heart rate, defined as fewer than 60 beats per minute [bpm] for an adult at rest) and high degree heart block (a condition where the electrical signals that control your heartbeat are delayed or completely blocked as they travel from the heart's upper chambers to the lower chambers. This can cause the heart to beat too slowly or skip beats) and the following heart rate readings had been documented:6/11/2026 4:14 AM 77 bpm6/11/2026 at 8:14 AM 52 bpm6/11/2026 at 11:14 AM 58 bpm6/11/2026 at 3:05 PM 53 bpm6/14/2026 at 8:45 PM 56 bpm6/15/2026 at 5:22 AM 62 bpm6/15/2026 at 6 AM 45 bpm6/17/2026 at 11:31 AM 52 bpmDuring an interview on 6/18/2026 at 9:37 AM with the Admissions Coordinator (AC) of the facility, the AC stated she had last spoken to the Case Manager from GACH 1 on 6/17/2026 at approximately 4 PM and had mentioned to her that the facility would re-admit Resident 1 once his heart rate was stable. The AC stated she had one of the licensed nurses review Resident 1's heart rate readings and paperwork and the licensed nurse determined Resident 1 was not stable for readmission based on a 45 beats per minute heart rate on 6/15/2026. The AC stated Resident 1 had been recommended to have a pacemaker (a small, battery-operated medical device implanted in the chest or abdomen. It treats abnormal heart rhythms by sending mild electrical impulses to the heart, ensuring it beats at a regular rate and pumps enough blood throughout the body), but Resident 1's family member (FM) refused due to Resident 1's age. The FM also refused to place Resident 1 on hospice (specialized medical and support care for people facing a terminal illness) as suggested by GACH 1 physician.During an interview on 6/18/26 at 9:41 AM with the Assistant Director of Nursing (ADON), the ADON stated the facility declined to readmit Resident 1 because Resident 1's heart rate (HR) was below the facility's admission criteria of 60 beats per minute (bpm). The ADON stated, Nursing home has criteria, stable HR at least 60. The ADON further stated the facility had beds available and Resident 1 had a bed hold. The ADON stated that if a current resident's heart rate dropped to 45 bpm, staff would call 911 and transfer the resident to the hospital. The ADON stated Resident 1's bed/room was still available as Resident 1 had his belongings in his assigned room, and the Director of Nursing (DON) made the final decision regarding admissions and readmissions.During an interview on 6/18/26 at 10:04 AM with the DON, the DON stated Resident 1's readmission was declined because the resident had a heart rate of 45 bpm. The DON stated, Criteria used to decline admission was Resident 1's heart rate was 45 bpm on one occasion. The DON stated hospital staff informed her Resident 1's baseline heart rate ranged from 40 to 60 bpm. The DON stated the hospital discussed palliative care (medical care that focuses on providing relief from pain and other symptoms of a serious illness) services and informed the facility Resident 1's family had declined a pacemaker and hospice services. The DON stated, If one of the residents has 40 heart rates, we would call 911. The DON further stated she was awaiting additional directions from the Nurse Practitioner (NP) before approving Resident 1's return to the facility. The DON stated she continued to refuse readmission based on the single heart rate reading of 45 bpm obtained on 6/15/26. The DON stated she was not aware that Resident 1 had additional documented heart rate readings of 52bpm, 56 bpm, and 62 bpm, on 6/14/2026 and 6/15/2026, and stated Resident 1 could be admitted with those readings. The DON stated the last time she had reviewed Resident 1's paperwork was on 6/17/2026. The DON stated she would contact the NP again regarding Resident 1's return to the facility.During an interview on 6/18/26 at 10:25 AM with the ADON, the ADON stated the facility contacted the NP regarding Resident 1 and the NP advised that Resident 1 could be admitted to the facility on [DATE].During an interview on 6/18/26 at 10:37 AM with Licensed Vocational Nurse (LVN) 1, stated that if a resident presented with a heart rate less than 60 bpm, she would reassess the resident, notify the supervisor, review physician orders, contact the physician for further evaluation, continue reassessment, identify signs and symptoms, and transfer the resident to the hospital if the low heart rate persisted or the resident exhibited symptoms.During an interview on 6/18/26 at 1PM with the hospital Case Manager (CM), the CM stated that on 6/16/2026 she spoke to the facility's NP who stated the facility could readmit Resident 1 on 6/16/2026, and to contact the Admissions Coordinator (AC) for processing. The CM stated when she called the facility on 6/16/2026, the AC and DON refused to readmit Resident 1 due to having a low heart rate of 45 on one reading.On 6/18/2026 at 2 PM, a telephone call was placed to the NP to clarify Resident 1's clinical status and readmission decision. A voicemail message was left; however, no return call was received by the conclusion of the investigation.During a review of the facility's policy and procedure (P&P) titled readmission to the Facility dated 1/15/2026, the P&P indicated residents who have been discharged to the hospital or for therapeutic leave may be readmitted to the facility upon the first available bed if the resident requires services provided by the facility, meets the admission criteria as outlined in facility policy, and was not discharged due to health and or safety of individuals in the facility were endangered due to the clinical or behavioral status of the resident, or the resident had failed to pay for a stay at the facility.During a review of the facility's P&P titled admission Criteria dated 1/15/2026, the P&P indicated the facility will admit only those residents whose medical and nursing care needs can be met. The acceptance of residents with certain conditions or needs may require authorization or approval by the Director of Nursing services, and Administrator. Prior to or at the time of admission, the resident's Attending Physician must provide the facility with information needed for the immediate care of the resident, including orders covering type of diet, medication orders, routine care orders to maintain or improve the resident's function until the physician and care planning team can conduct a comprehensive assessment and develop a more detailed interdisciplinary care plan.

Based on interview and record review, the facility failed to ensure that one of three sampled Residents (Resident 1), Resident 1 who was assessed as high risk for falls, received adequate supervision and fall prevention interventions to prevent repeated falls on 5/31/2026 and 6/1/2026 by failing to: 1. Reevaluate the resident's fall risk or determine whether current fall prevention interventions required modification following the fall on 5/31/2026 at approximately 11 PM. 2. Update the resident's care plan or implement additional interventions prior to the second fall occurring on 6/1/2026 at approximately 3 -4 AM. As a result, Resident 1 experienced a second fall and sustained injuries to the right eye and right knee requiring hospital evaluation.During a record review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] with diagnoses of dementia (progressive impaired ability to think, remember or make decisions that interferes with doing everyday activities), repeated falls, and need for assistance with personal care.During a record review of Resident 1's Fall Risk Evaluation dated 3/24/2026, indicated Resident 1 was high risk for falls due to intermittent confusion, history of 1-2 falls in the past three months, poor vision, balance problems, decreased in muscular coordination, taking 1-2 medications in the last seven days that affect coordination, and present predisposing diseases. During a record review of Resident 1's Care Plan (CP) for Risk for falls, dated 4/13/2026, indicated Resident 1 was at risk for falls related to cognitive impairment, history of falls, and poor safety awareness. The goals of CP included that Resident 1 would demonstrate selective prevention measures, would not sustain a fall, and caregivers would implement strategies to increase safety and prevent falls, and Staff would promptly assess the need of the resident to avoid getting up unassisted. During a record review of Resident 1's Minimum Data Set (MDS- resident assessment tool) dated 4/13/2026, the MDS indicated Resident 1 had impaired cognition (ability to think, remember and reason for daily decision making). Resident 1 required maximal assistance (Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) with sitting up, lying to sitting on side of bed, chair/bed to chair transfer, repositioning, oral hygiene, toileting, shower bathe, upper and lower body dressing, putting on/taking off footwear, and personal hygiene. Resident 1 was dependent (Helper does all the effort. Resident 1 does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity) on staff to wheel herself 150 feet once seated in a wheelchair. Resident 1 required supervision (Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) from staff to eat. During a record review of Resident 1's Communication Form, dated 5/31/2026, the Communication Form indicated Resident 1 had a witnessed fall on 5/31/2026 at around 11 PM due to Resident 1 observed to be getting out of her wheelchair multiple times at the nurse's station, and during shift change Resident 1 stood up from her wheelchair and fell and hit her head on a cart at the nurses station. Resident 1 was transferred to the hospital after the accident of the fall. Resident 1 was brought back to the facility on 6/1/2026 at 3 AM. Resident 1 was administered Ativan (Medication used to treat anxiety, insomnia, or sleep difficulty due to anxiety and stress) at 3:10 AM to calm her down since she was agitated, hitting staff, and yelling. Resident 1 was again placed in front of the nurse's station on her wheelchair despite still noted to be restless. Resident 1 was observed by staff stand up from her wheelchair and fall on the floor right side laying causing a skin tear to her right lower eyebrow, mild bleeding, and right knee skin abrasion with mild bleeding. Resident 1 was sent back to the hospital for further evaluation. During a record review of Resident 1's Care Plan (CP), after the initial fall on 5/31/2026, the CP revealed no evidence that the facility implemented new interventions, increased supervision, or reassessed the resident's fall risk upon return from the hospital despite the recent fall event. Following readmission from the hospital on 6/1/2026 after the second fall, Resident 1's CP revealed no evidence the facility implemented new interventions, increased supervision, or reassessed the resident's fall risk upon return from the hospital despite the recent fall event. During a record review of Resident 1's Post Fall Packet, dated 6/1/2026, the Post Fall Packet indicated Resident 1 is at high risk for falls, risk for injury, pain, reoccurrence of fall, and contributing factors included escalating behavior, impaired mobility, decreased safety awareness, and history of recent fall. Resident 1's updated goals included that Resident 1 would demonstrate improved safety awareness during transfers and ambulation to minimize risk of recurrent falls and fall-related injuries. Interventions to update the Care Plan included: assess resident for pain immediately after fall using appropriate pain scale, perform neuro checks and physical assessment, assess for bruising, review fall circumstances, physician to review medications that may increase fall risk and refer to PT/OT evaluation for strengthening, [NAME] training, and transfer safety. During a record review of Resident 1's Progress Notes dated 6/1/2026, The Progress Notes indicated Resident 1 had been witnessed by staff attempting to get up from her wheelchair unassisted when she was observed falling out of the wheelchair and sustaining an injury to her right eye eyebrow. During an interview on 6/8/2026 at 12:15 PM with Licensed Vocational Nurse 1 (LVN1), LVN1 stated Resident 1 was high risk for falls due to her being very unsteady and required closer supervision, including consideration for a sitter, especially after the first fall. LVN 1 stated Resident 1 experienced a witnessed fall from the wheelchair at approximately 11:53 PM and was transferred to the hospital for evaluation. Resident 1 returned to the facility at approximately 3 AM on 6/1/2026. LVN1 stated she was unsure if any new interventions were in place to prevent the second fall from recurring. LVN 1 stated, at approximately 4 AM, Resident 1 experienced a second fall from the wheelchair and sustained a right eye laceration requiring transfer to the hospital for further evaluation and treatment. LVN 1 stated the second fall could have been prevented by ensuring that a staff member was always next to her and ensure she was asleep in her bed. During an interview on 6/8/2026 at 12:21 PM with Certified Nursing Assistant 1 (CNA1), CNA1 stated he had come on his shift on the night of 5/31/2026 and noticed Resident 1 being transferred to the hospital due to a fall at approximately 11 PM. CNA1 reported that Resident 1 returned to the facility on the night of 6/1/2026 at around 3 AM. Resident 1 appeared extremely agitated, screaming and hitting him as well as another staff member. CNA1 stated that he placed Resident 1 in a wheelchair at her request. However, Resident 1 attempted to stand up from the chair and fell, even though she was positioned in front of the nurses' station; staff members were unable to prevent the fall. CNA1 stated given Resident 1's high level of agitation that night, it would have been better if she had a sitter monitoring her. CNA1 stated he had just finished placing Resident 1 on a wheelchair in front of the nurse's station, when he walked away. He was still in front of the nurses' station but not in close proximity to help Resident 1 if she tried to get up, when he suddenly saw Resident 1 try to get up unassisted from her wheelchair and witnessed her falling in front of the nurse's station a second time. During an interview on 6/8/2026 at 12:25 PM with the Director of Nursing (DON), the DON acknowledged by stating Resident 1 fell twice in a five-hour period due to Resident 1 moving suddenly and staff responded after the alarm sounded but did not catch her in time to prevent the second fall. The DON stated upon return from the hospital after the first fall, Resident 1 was found to have a urinary tract infection (UTI- infection that happens when bacteria enter the urethra and infect the urinary tract) that was contributing to her confusion as seen by her yelling and hitting the staff. The DON identified Resident 1's self-transfer behavior as the primary contributing factor to the repeated fall. During a concurrent interview with the DON and a review of Resident 1's fall care plan dated 4/13/2026 on 6/8/2026 at 12:25 PM, the DON stated that the facility was still in the process of revising the fall care plan following the fall on 5/31/2026, at approximately 11 PM, as well as the subsequent fall on 6/1/2026, at 3 AM. The DON did not articulate and identify whether the facility assessed the need for increased supervision, including the possible implementation of a one to one sitter or other enhanced monitoring interventions, after either the initial or subsequent fall. During a record review of Resident 1's Radiology Report from the hospital dated 6/1/2026, the Report indicated Resident 1 had no evidence of fracture or dislocation to Resident 1' head and right knee and was in stable condition. During a review of the facility policy and procedures (P&P) titled Falls, Fall Risk Managing dated 1/15/2026, indicated the staff will monitor resident's response to interventions intended to reduce falling. If underlaying causes cannot be readily identified, staff will try various interventions based on assessment of the nature of falling, until the reason for the continuation of the falling is identified as unavoidable. If resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the attending physician will help the staff reconsider possible causes that may not previously have been identified. In conjunction with the consultant pharmacist and nursing staff, the attending physician will identify and adjust medications that may be associated with an increased risk of falling, or indicate why those medications could not be tapered or stopped, even for a trial period.

Based on interview and record review, the facility failed to ensure medication dispositions (the processes that dictate how a drug moves through) were done by a licensed nurse and another as witness by failing to: -Ensure there was documentation of the witnesses' signatures. This failure had the potential of misuse, or improper storage, of medications.Findings: During a concurrent interview and record review on 5/27/2026 at 2:33 PM with the Director of Nursing (DON), the facility's Medication Disposal binder for non-controlled medications (drugs not classified under the Controlled Substances Act because they carry a low potential for abuse or dependence) was reviewed. The DON reviewed the aforementioned and counted there were three medications listed as disposed on 5/18/2026, 18 medications listed as disposed on 5/24/2026, and stated that did not have documented witness to the disposal. During an interview on 5/27/2026 at 2:35 PM with the DON, the DON stated the instruction on the medication destruction record indicated drugs shall be destroyed in the facility by a licensed nurse and another licensed nurse to witness. During a review of the facility policy and procedures, Discarding and Destroying Medications (dated January 2024), the policy indicated non-controlled substances are disposed of in accordance with state regulations and federal guidelines. The policy indicated the medication disposition record should contain signature of the witnesses.

Based on observation, interview, and record review, the facility failed to ensure to follow sanitary food and water safety practices and food preparation practices by failing to ensure: -The kitchen staff (in general) labeled an opened yogurt container in the reach-in refrigerator with an open date or use by date. - Two of three cutting boards in the dry food preparation area did not have deep knife marks. -To label the facility's emergency portable water (safe to drink for human consumption) reserves for 13 of 13 five-gallon water containers in the kitchen storage. These failures had the potential to result in harmful bacteria 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) for 89 of 97 (unidentified) residents who received food from the kitchen. Findings: During an observation on 5/26/2026 at 8:32 AM of Refrigerator 2 with the Dietary Supervisor (DS), there was an opened container of blueberry yogurt with no open date or use by date. During a concurrent observation on 5/26/2026 at 9:08 AM with the DS in the dry food preparation area, two cutting boards had deep knife marks. The DS stated that even though the yellow cutting board did not have visible cuts like the brown cutting board, the knife marks on the yellow cutting board were easily felt. During an interview on 5/28/2026 at 10:45 AM with Kitchen [NAME] (KC 1), KC 1 stated that cutting boards should be replaced when there were visible cuts or when the cutting boards felt rough to touch. KC 1 stated that small plastic particles from an old cutting board could be transferred onto the food when meal prepping. KC 1 stated that bacteria in deep knife marks could also get on the food. During an interview on 5/28/2026 at 10:52 AM with KC 2, KC 2 stated that opened food items must be labeled with the open date and use by date. KC 2 stated that staff review the use by date to know when food items were expired and when they should be thrown away. KC 2 stated that residents could get food poisoning (an illness caused by eating contaminated food, typically resulting in nausea, vomiting, diarrhea, and abdominal cramps) if they ate expired food. During a concurrent interview and record review on 5/29/2026 at 9:52 AM, the facility's policy and procedure (P&P) titled, Labeling and Dating of Foods, updated January 2026, was reviewed with the DS. The DS reviewed the P&P and stated staff should have labeled the yogurt upon opening with the item name, date opened and referred to storage guidelines to calculate the use by date. The DS stated residents could get sick from eating food past its use by date, when food is at its peak quality and safety. During a review of the facility's P&P titled, Labeling and Dating of Foods, updated January 2026, the P&P indicated newly opened food items need to be closed and labeled with an open date and used by the date that followed the various storage guidelines. During a review of the facility's food storage guideline titled, Refrigerated Storage Guide, updated January 2026, the guideline indicated maximum refrigeration time for yogurt was 7 days after opening. During a concurrent interview and record review on 5/29/2026 at 10:12 AM, the facility's P&P titled, Sanitation, updated January 2026, was reviewed with the DS. The DS reviewed the P&P and stated the brown and yellow cutting board should have be replaced. The DS stated food particles could get stuck in the deep knife marks even after washing. The DS stated bacteria could then grow in the knife marks and transfer to food during meal preparation. During a review of the facility's P&P titled, Sanitation, updated January 2026, the P&P indicated plastic ware that became unsightly, unsanitary, or hazardous because of chips, cracks, or loss of glass should be discarded. During an observation on 5/28/2026 at 9:55 AM at the facility's kitchen storage, 13 five-gallon containers of emergency water were observed. The 13 five-gallon containers were not dated and did not indicate potable for emergency consumption. During a concurrent observation and interview on 5/28 /2026 at 9:58 AM, with the Maintenance Supervisor (MS) inside the facilities' kitchen storage room, 13 five-gallon water containers were in a stackable shelf. The MS stated the 13 emergency water containers were designated as potable water for resident and staff consumption, including drinking food preparation, and cooking during an emergency. The MS Stated that all 13 five-gallon emergency water containers lacked delivery dates and were not labeled to indicate the water supplies were portable and safe for consumption. The MS stated the 13-five-gallon containers should have been labeled and documented on a log with the delivery date expiration date and the name of the supplying company, the MS. stated that the unlabeled emergency water supply could be mistakenly consumed and potentially exposed residents and staff to harmful bacteria. The MS stated the facility failed to properly label and maintain records of the 13 five gallon as emergency potable water supplies. During an interview on 5/29/2026 at 10:39 AM with the DS, the DS stated it was best practice for the emergency water containers to be labeled with the date received to ensure proper tracking. The DS stated it was important that the facility maintained a safe and potable water supplies for consumption during an emergency. During a review of the facility's P&P titled Emergency Water /Fluid Supply last reviewed on 1/15/2026. The P&P indicated to store adequate supply of water/fluid in case of disaster or emergency situation to have adequate supply of water/fluids for the residents use and consumption in case of disaster or emergency situations.

Based on interview and record review, the facility failed to maintain accurate and complete medical records for one of two sampled residents (Resident 84) by failing to:- Ensure the licensed nurses (in general) completed the documentations when Resident 84 returned from hemodialysis (HD-a life-sustaining treatment for kidney failure that acts as an artificial kidney, filtering waste, toxins and excess water from the person's body using a machine) appointments.This failure placed Resident 84 at risk of not receiving appropriate care due to inaccurate medical care information and the potential to result in confusion in the care and services provided to Resident 84. Findings:During a review of Resident 84's admission Record, the admission Record indicated the facility originally admitted Resident 84 on 4/23/2024 and was readmitted on [DATE] with diagnoses including end stage renal disease end stage renal disease (ESRD-a medical condition in which a person's kidney [organ in the body that filters waste and excess fluid from the blood] stop functioning on a permanent basis), and hypertension (HTN - elevated blood pressure). During a review of Order Summary Report (OSR-list of physician orders), dated 3/9/2026, the OSR indicated Resident 84 had a physician order for hemodialysis to be done at outpatient during Tuesday, Thursday, and Saturdays. During a review of Resident 84's Minimum Data Set (MDS- a resident assessment tool) dated 4/1/2026, the MDS indicated Resident 84 had intact cognition (mental action or process of acquiring knowledge and understanding) for daily decision-making and from setting up (helper sets up or cleans up, resident completes activity) to maximal assistance (helper does more than half the effort) from staff for activities of daily living (ADLs-bed mobility, surface transfer, eating, walk in room, dressing, toileting, and personal hygiene). The MDS also indicated Resident 84 was on hemodialysis. During a concurrent interview record review on 5/28/2026 at 10:44 AM with Licensed Vocational Nurse 2 (LVN 2), Resident 84's Progress Notes dated 5/26/2026 were reviewed. The Progress Notes indicated missing documentation when Resident 84 came back to the facility from hemodialysis appointment. LVN 2 stated that he (LVN 2) forgot to document when Resident 84 came back from hemodialysis appointment. LVN 2 stated that he (LVN 2) was supposed to document when the resident comes back from an appointment to be able to show the provided care to the resident since they were supposed to check on the resident and monitor if there were any issues with the resident after hemodialysis.During a concurrent interview and record review on 5/29/2026 at 9:07 AM with Registered Nurse 1 (RN 1), Resident 84's progress notes from 4/30/2026 to 5/26/2026 were reviewed. The progress notes indicated missing documentation when Resident 84 came back to the facility from hemodialysis appointment on the following dates: 4/30/2026, 5/2/2026, 5/5/2026, 5/9/2026, 5/12/2026, 5/14/2026, 5/16/2026, 5/21/2026,5/23/2026. RN 1 stated importance of documenting when Resident 84 came back from hemodialysis appointments. RN 1 also stated documenting when resident came back from an appointment provides an accurate nursing assessment and good communication between the nursing team.During an interview on 5/29/2026 at 11:20 AM with the Director of Nursing (DON), the DON stated that it was best practice to document when a resident (in general) came from an appointment.During a review of the facility's policy and procedure (P&P), titled, End-Stage Renal Disease, Care of a Resident With, reviewed on 1/15/2026, the P&P indicated that Residents with ESRD would be cared for according to currently recognized standards of care.During a review of the facility's P&P, titled, Charting and Documentation, reviewed on 1/15/2026, the P&P indicated that the following information had to be documented in the resident medical record:Objective observations;Medication Administered;Treatments or Services performed;Changes in the resident's condition;Event, incidents or accidents involving the resident; andProgress toward or changes in the care plan goals and objectives.

Based on observation, interview, and record review, the facility failed to revise the care plan for one of two sampled residents (Resident 12) by failing to:-Ensure Resident 12's care plan addressed Resident 12's skin wound treatment. This failure had the potential to affect Resident 12's skin wound care and treatment.Findings:During a review of Resident 12's admission Record, the admission Record indicated the facility admitted Resident 12 on 8/22/2025 with diagnoses of Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), pressure ulcer (injuries to the skin and underlying tissue resulting from prolonged pressure on the skin) of sacral (the large, triangular bone at the base of the spine and back of the pelvis) region, Stage 4 (full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone). During a review of Resident 12's History of Present Illness dated 7/11/2025, the History of Present Illness indicated Resident 12 had a sacral decubitus ulcer Stage 4. During a review of Resident 12's Minimum Data Set (a resident assessment tool) dated 4/10/2026, the MDS indicated Resident 12 had a Stage 4 pressure ulcer and was at risk of developing pressure injury. The MDS indicated Resident 12 was dependent (helper does all the effort, resident does none of the effort to complete the activity or the assistance of two or more helpers is required for the resident to complete the activity) for personal hygiene, shower, toileting, hygiene, and oral hygiene. During a review of Resident 12's physician treatment Order Details dated 4/24/2026, the Order Details indicated to cleanse Resident 12's sacrococcyx pressure injury stage 4 with dakin's (antiseptic used to clean and treat wounds) solution and apply collagen (a thin flexible material made from collagen [protein]) sheet. During a review of Resident 12's Care Plan Report dated 7/18/2025, the Care Plan Report indicated Resident 12 was at risk for skin impairment. The Care Plan Report indicated to turn and reposition Resident 12 every two hours. The Care Plan Report indicated no current wound status and treatment plan. During a concurrent observation and interview on 5/28/2026 at 8:33 AM with Treatment Nurse 1 inside Resident 12's room, Resident 12 had a wound dressing on the sacral area. Treatment Nurse 1 stated the wound physician would examine Resident 12 every two weeks and would provide the wound orders and treatment plan. During an interview on 5/28/2026 at 10:21 AM with the MDS nurse, the MDS nurse stated Resident 12's care plans did not include current wound status and treatment plan which should indicate the wound physician orders and revised to show the resident's current wound condition and treatment. During an interview on 5/29/2026 at 10:26 AM with the Director of Nursing (DON), the DON stated that Resident 12's care plan should have been revised by the treatment nurses and staff nurses (in general) to reflect the current condition of the wound and treatment plan as ordered by the physician. The DON stated that when care plans were not revised and kept current, it resulted in delays in necessary care and treatment, which may lead to deterioration in the resident's wound. During a review of the facility's policy and procedure (P&P) titled, Care plan-comprehensive person-centered, dated 1/2025 the P&P indicated care plans are revised as changes in the resident's condition dictate.

Based on interview and record review, the facility failed to follow professional standards of practice (the everyday rules and behaviors that keep patients safe and ensure high-quality healthcare) for one of five sampled residents (Resident 5) by failing to:-Ensure licensed nurses (in general) rotated the subcutaneous injection (SQ-insertion of medications beneath or under the layers of the skin) sites during medication administration (the process of giving medicine to a resident) of Resident 5's insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) medication.This failure had the potential to cause Resident 5 to have skin breakdown, bruising, lipohypertrophy (lump of fatty tissues under the skin), and/or medication malabsorption (inability to be distributed through the bloodstream to various tissue of the body).Findings:During a review of Resident 5's admission Record, the admission Record indicated the facility originally admitted Resident 5 on 4/23/2024 and was readmitted on [DATE] with diagnoses including diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]), hypertension (HTN - elevated blood pressure) and chronic kidney disease (CKD-a longstanding disease of the kidneys leading to kidney failure).During a review of Resident 5's History and Physical (H&P- a record of a physician's comprehensive medical assessment and plan), dated 1/12/2026, the H&P indicated Resident 5 did not have the capacity to understands and make decisions.During a review of Resident 5's Minimum Data Set (MDS- a resident assessment tool), dated 4/24/2026, the MDS indicated Resident 5 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) for daily decision-making and mostly needing maximal assistance (helper does more than half the effort) from staff for activities of daily living (ADLs-bed mobility, surface transfer, eating, walk in room, dressing, toileting, and personal hygiene). The MDS also indicated Resident 5 was taking high-risk drug class such as hypoglycemic (medication to lower blood glucose) medication. During a concurrent interview and record review on 5/29/2026 at 9:31 AM with Registered Nurse 1 (RN 1), Resident 5's Medication Administration Record (MAR-facility report detailing the drugs administered to a resident by a licensed nurse) and Location of Administration Report (LAR-facility report of when and where injections were administered) were reviewed. The MAR indicated Resident 5 had a physician order for insulin glargine (Lantus-a long-acting man-made-insulin used to control high blood sugar) 20 units SQ every 12 hours and rotate injection site. The MAR also indicated Resident 5 received insulin glargine on the following days:-5/17/2026 at 9 PM-5/18/2026 at 9 AM-5/24/2026 at 9 PM-5/25/2026 at 9AMDuring a concurrent interview and record review on 5/29/2026 at 9:31 AM with RN 1, the MAR indicated the facility did not rotate insulin injections for insulin glargine as follows:-5/17/2026 at 9:00 PM insulin glargine administered SQ in Resident 5's left upper quadrant abdomen (area from umbilicus [belly button]) up to the left rib cage).-5/18/2026 at 9:00 AM insulin glargine administered SQ in Resident 5's left upper quadrant abdomen.-5/24/2026 at 9:00 PM insulin glargine administered SQ in Resident 5's left lower quadrant abdomen (area left of the midline and below umbilicus).-5/25/2026 at 9:00 AM insulin glargine administered SQ in Resident 5's left lower quadrant abdomen.During a concurrent interview and record review on 5/29/2026 at 9:31 AM with RN 1, RN 1 stated it was important to rotate sites when administering medication via SQ due to possible skin issues such as bruising, skin breakdown and malabsorption of the medication. RN 1 stated the licensed nurses (in general) were supposed to follow physician order for safety.During an interview on 5/29/2026 at 11:28 AM with the Director of Nursing (DON), the DON stated nursing staff (in general) were supposed to rotate the insulin sites due to possibility of lipohypertrophy when given at the same site.During a review of the Food and Drug Administration (FDA) labeling package inserts, titled Lantus (Insulin Glargine) injection, for subcutaneous use, revised on 6/2023, FDA labeling package inserts indicated to administer Lantus subcutaneously into the abdominal area, thigh, or deltoid and rotate injection sites.During a review of the facility's policy and procedure (P&P), titled, Administering Medications, reviewed on 1/15/2026, the P&P indicated that facility would administer medications in accordance with the ordersDuring a review of the facility's P&P, titled, Insulin Administration, reviewed on 1/15/2026, the P&P indicated that it was the facility's policy to provide a safe administration of insulin to residents.

Based on observation, interview, and record review, the facility failed to maintain the correct Low Air Loss Mattress (LALM - a pressure-relieving mattress used to prevent and treat pressure ulcers [localized damage to the skin and/or underlying tissue usually over a bony prominence]) settings for one of three sampled residents (Resident 92) who had a stage 3 pressure ulcer (Full thickness loss of skin. Dead and black tissue may be visible) to the left buttock. This failure had the potential to place Resident 92 at risk for further skin breakdown and lead to the worsening of Resident 92's stage 3 pressure ulcer.Findings:During a review of Resident 92's admission Record, the admission Record indicated the facility admitted the resident on 1/28/2026 with diagnoses that included type 2 diabetes (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), hemiparesis (partial weakness or reduced control affecting one entire side of the body), dementia (a progressive state of decline in mental abilities), Alzheimer's disease (a disease characterized by a progressive decline in mental abilities) and contracture (a stiffening/shortening at any joint, that reduces the joint's range of motion) of an unspecified joint.During a review of Resident 92's Minimum Data Set (MDS, a resident assessment tool) dated 1/31/2026, the MDS indicated the resident had severely impaired cognition (a significant loss of intellectual capacity that disrupts a person's ability to communicate, make decisions, and perform basic activities of daily living). The MDS indicated Resident 92 was dependent on help for eating, oral hygiene, upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygiene. The MDS indicated Resident 92 was at risk of developing pressure ulcers.During a review of Resident 92's Order Summary Report, the Order Summary Report indicated the resident had a physician order dated 2/17/2026 to monitor the placement, setting, and functional ability of the LALM every shift for skin management.During a review of Resident 92's Care Plan Report dated 5/10/2026, the Care Plan Report indicated the resident had a stage 3 left buttocks pressure ulcer. The Care Plan Report indicated a goal for Resident 92 to have intact skin that was free of redness, blisters, or discoloration through the review date. The Care Plan Report indicated an intervention for Resident 92 to have a LALM for skin management.During a review of Resident 92's Weight Summary, the Weight Summary indicated the resident weighed 101 pounds (lbs., a unit of weight and mass) on 5/26/2026.During a concurrent observation and interview on 5/29/2026 at 9:10 AM with Treatment Nurse 1 (TN 1), in Resident 92's room, Resident 92 was observed on a Protekt Aire 6000 LALM. TN 1 stated Resident 92's LALM was on the setting of 130 lbs. TN 1 stated Resident 92's LALM setting of 130 lbs. was incorrect. TN 1 stated the LALM should be set to the setting closest to Resident 92's weight. TN 1 stated Resident 92 weighed101 lbs. TN 1 stated Resident 92's LALM should be set at 80 lbs. not 130 lbs. because 80 lbs. was closer to the resident's weight of 101 lbs. TN 1 stated that having the LALM on the wrong setting defeated the purpose of having a LALM. TN 1 stated Resident 92 had LALM as treatment for the resident's Stage 3 pressure ulcer to the resident's left buttock. TN 1 stated there was potential for the resident's pressure ulcer to worsen if the LALM was at the wrong setting.During an interview with the Director of Nursing (DON) on 5/29/2026 at 12:35 PM, the DON stated that Resident 92 had a stage 3 pressure ulcer to the resident's left buttock. The DON stated that Resident 92 had a LALM to prevent the resident's pressure ulcer from worsening. The DON stated the setting of the LALM was based on the manufacturer's guidelines. The DON stated the setting of the LALM was supposed to be set to whichever setting was the closest to Resident 92's weight. The DON stated Resident 92's LALM should be at the correct setting. The DON stated there was potential for Resident 92's pressure ulcer to worsen if the resident's LALM was not at the correct setting.During a review of the facility's Policy and Procedure (P&P) titled Air Mattress reviewed 1/15/2026, the P&P indicated Purpose: To decrease pressure from the resident's weight in bed. To promote the healing of or the prevention of pressure ulcersDuring a review of the undated Operational Manual titled Operational Manual for Protekt Aire 6000/6400/6450/6000AB, the Operational Manual indicated 20-55 mmHg adjustable pressure range selected by patients weight guide listed on panel providing pressure range options.Pressure set up.Users can adjust the pressure level of the air mattress to a desired firmness by themselves or according to the suggestion from a health care professional. It is recommended to press Auto Firm on the panel when the mattress if first inflated. Users can then easily adjust the air mattress to a desired firmness according to the patient's weight and comfort.

Based on observation, interview, and record review, the facility failed to ensure to clarify the physician's order for Meropenem (type of antibiotic, medication used to treat bacterial infections) intravenous IV (administering medication directly into the blood stream through a vein using a needle) for one of one sampled resident (Resident 77).This failure had the potential for Resident 77 to receive an increased amount of Meropenem which could lead to toxicity (a degree to which a substance can injure or poison a person), adverse side effects (any unintended, harmful, or undesirable effect of a medication), and kidney injury (a decline in kidney function). Findings:During a review of Resident 77's admission Record, the admission Record indicated the facility re-admitted the resident from the General Acute Care Hospital (GACH, unspecified) on 5/23/202026 with diagnoses that included metabolic encephalopathy (brain dysfunction caused by chemical imbalances, systemic illnesses, or organ failure), urinary tract infection (UTI, an infection in the bladder/urinary tract), sepsis (a life-threatening blood infection) due to Escherichia Coli (E.coli, a bacteria that can cause infection in the gut and urinary tract), dementia (a progressive state of decline in mental abilities), Extended Spectrum Beta Lactamase (ESBL, a group of enzymes produced by certain bacteria that are highly resistant to many antibiotics) resistance, and hypertension (high blood pressure).During a review of Resident 77's General Acute Care Hospital 1 (GACH 1) Discharge Instructions dated 5/23/2026, the GACH 1 Discharge Instructions indicated for Resident 77 to start taking Meropenem 1000 milligrams (mg, a unit of mass and weight) IV every 12 hours and IV every 8 hours with a stop date of 5/28/2026.During a review of Resident 77's Discontinue Order dated 5/24/2026, the Discontinue Order indicated the resident had a physician order for Meropenem 1 gram (a metric unit of mass, 1 gram is equivalent to 1000 mg) IV every 12 hours for ESBL and E.coli in the blood until 5/28/2026. The Discontinue Order indicated Resident 77's physician order for Meropenem 1 gram IV every 12 hours was discontinued by Registered Nurse 2 (RN 2) because the physician order was updated.During a review of Resident 77's physician order dated 5/24/2026, the physician order indicated the resident was to receive Meropenem 1 gram IV every 8 hours for ESBL and E.coli in the blood until 5/28/2026. The physician order indicated RN 2 confirmed Resident 77's physician order for Meropenem 1 gram IV every 8 hours for ESBL and E.coli in the blood until 5/28/2026.During an observation on 5/26/2026 at 10:32 AM, in Resident 77's room, the resident was observed with an IV to the left hand. Resident 77 stated she (Resident 77) was receiving antibiotics through the IV because she (Resident 77) had a UTI.During a review of Resident 77's IV Administration Record (IAR) dated 5/24/2026 - 5/28/2026, the IAR indicated the resident received a dose of Meropenem 1 gram IV every 8 hours for a total of 14 doses.During a telephone interview on 5/28/2026 at 2:08 PM with Licensed Vocational Nurse 4 (LVN 4), LVN 4 stated she (LVN 4) was working as a desk nurse on 5/23/2026. LVN 4 stated Resident 77 was re-admitted to the facility from GACH 1 on 5/23/2026. LVN 4 stated she (LVN 4) reviewed Resident 77's Discharge Instructions dated 5/23/2026 with the resident's Nurse Practitioner (NP) to clarify the order for Meropenem. LVN 4 stated Resident 77's Discharge Instructions indicated the resident was to start receiving Meropenem every 12 hours and every 8 hours. LVN 4 stated Resident 77's NP stated to continue Meropenem every 12 hours. LVN 4 stated the next day on 5/24/2026 she (LVN 4) saw that Resident 77's orders for Meropenem had been changed from every 12 hours to every 8 hours by RN 2.During a telephone interview on 5/28/2026 at 2:23 PM with RN 2, RN 2 stated that on 5/24/2026 he (RN 2) saw Resident 77's Discharge Instructions from GACH 1 that indicated to start the resident on Meropenem 1 gram IV every 12 hours and every 8 hours. RN 2 stated that he (RN 2) already saw an order was in place for Resident 77 to receive Meropenem 1 gram IV every 12 hours. RN 2 stated he (RN 2) updated Resident 77's order for Meropenem and changed the order from every 12 hours to every 8 hours. RN 2 stated he (RN 2) did not call Resident 77's physician to clarify the order for Meropenem before changing the order from every 12 hours to every 8 hours. RN 2 stated he (RN 2) should have clarified Resident 77's order for Meropenem because the resident's Discharge Instructions were not clear on whether to give Meropenem every 12 hours or every 8 hours. RN 2 stated he (RN 2) did not know why he (RN 2) did not clarify Resident 77's orders for Meropenem with the physician. RN 2 stated there was potential for Resident 77 to receive a higher amount of antibiotics than intended which could lead to toxicity, increased side effects, or kidney injury.During a concurrent interview and record review on 5/29/2026 with the Director of Nursing (DON), Resident 77's Discharge Instructions from GACH 1 dated 5/23/2026, Discontinue Order dated 5/24/2026, and physician order dated 5/24/2026 were reviewed. The DON stated Resident 77's Discharge Instructions from GACH 1 indicated the resident was to start receiving Meropenem 1000 mg IV every 12 hours and every 8 hours with a stop date of 5/28/2026. The DON stated Resident 77's Discharge Instructions were not clear on whether Meropenem was to be given every 12 hours or every 8 hours. The DON stated RN 2 should have clarified Resident 77's Discharge Instructions for Meropenem with the resident's physician to ensure that the physician order was correct. The DON stated there was potential for Resident 77 to not have received an effective dosage of Meropenem if the resident's order for Meropenem was not clarified with the resident's physician.During a review of the facility's Policy and Procedure (P&P) titled Physician Orders reviewed 1/15/2026, the P&P indicated Physician orders are obtained to provide a clear direction in the care of the resident.During a review of the facility's P&P titled General Policies for IV Therapy reviewed 1/15/2026 the P&P indicated When an IV therapy is questioned, a collaborative effort amongst the physician, pharmacy, and facility will determine the safety and appropriateness of the therapy.

Based on observation, interview, and record review, the facility failed to ensure that dental services were provided to one of two sampled residents (Resident 24) reviewed for dental services by failing to: -Ensure to schedule Resident 24's dental consultation and treatment in accordance with the facility's policy and procedure titled Dental, Vision, and Hearing Evaluations. This failure had the potential to negatively affect Resident 24's oral health and ability to chew food.Findings:During review of Resident 24's admission Record , the admission Record indicated the facility originally admitted Resident 24 on 10/5/2024 and readmitted the resident on 3/9/2026 with diagnoses that included major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), type 2 diabetes mellitus (disorder characterized by difficulty in blood sugar control and poor wound healing), anemia (a condition where the body does not have enough healthy red blood cells), and dysphagia (difficulty swallowing). During a review of Resident 24's Onsite Mobile Dental form dated 10/25/2025, the Onsite Mobile Dental form indicated Resident 24 wanted the dental treatment recommendations done. During a review of Resident 24's Order Summary Report dated 3/9/2026, the Order Summary Report indicated dental consultation as needed, with treatment to be completed as indicated by the resident's condition. During a review of Resident 24's Minimum Data Set (a resident assessment tool) dated 3/13/2026, the MDS indicated that Resident 24 had no natural teeth or tooth fragments. The MDS indicated Resident 24 needed partial/moderate assistance for oral hygiene (helper lifts, holds or support trunk or limbs but provides less than half the effort) and required supervision or touching assistance when eating (helper provides verbal cues and /or touching/ steadying as resident completes activity). During a review of Resident 24's Care Plan Report dated 4/10/2026, the Care Plan Report indicated that Resident 24 had dental health problems, missing teeth, and that arrangements for dental care consultations should be coordinated as needed. During a concurrent observation and interview on 5/28/2026 at 2:15 PM with Resident 24, Resident 24 had some missing, broken teeth and was not wearing any dentures (removable false teeth). Resident 24 stated some of her (Resident 24) natural teeth were gone, some are broken, and she has not been seen by a dentist for a long time. Resident 24 stated she (Resident 24) informed the staff (unidentified) about needing a dental consultation but had not received any follow up. During an interview on 5/28/2026 at 2:47 PM with Certified Nursing Assistant 3 (CNA3), CNA 3 stated that Resident 24 had missing and broken teeth and would take additional time to chew food. During an interview on 5/29/2026 at 10:53 AM with the Social Services Director (SSD)and the Discharge Planning Coordinator (DPC), the SSD and the DPC stated that Resident 24 was not provided with dental services. The SSD stated regular dental services should be provided to all residents (in general) to improve their quality of life and health. During an interview on 5/29/2026 at 10:26 AM with the Director of Nursing (DON), the DON stated that Resident 24 should have been seen by the dentist. The DON stated the Social Services should have arranged the dental services for Resident 24. The DON stated that dental consultations were provided as needed, monthly, quarterly (three months), or every six months, as necessary for the overall health of the residents. The DON stated if the residents did not receive any dental consultation and treatment, it could affect their oral health. During a review of the facility's policy and procedure (P&P) titled, Dental, vision, and hearing evaluations, dated 1/2025 the P&P indicated dental, vision and hearing evaluations are done to assure that the residents can function at their highest practical level. The procedure includes assessing the need, obtaining a physician's order, and arranging for the evaluation as soon as possible.

Based on observation, interview, and record review, the facility failed to ensure severe drug-to-drug interaction (occurs when taking two or more medications together causes unexpected, dangerous, or life-threatening reactions) were reviewed and acted upon for one (1) of 3 sampled residents (Resident 82). When on 5/27/2026 Resident 82's Biktarvy (a 3 in 1 antiviral medication used to treat Human Immunodeficiency Virus, HIV, a virus that attacks the body's immune system by destroying white blood cells) 50/200/25 milligrams (mg, unit to measure a dose) was administered with one count of Ferrous Sulfate (an iron supplement) 325 mg, and one count of magnesium oxide (a magnesium supplement) 400 mg, despite having a severe interaction alert documented in the resident's electronic health record. This deficient practice had the potential of reducing the efficacy of antiviral and negatively affects resident's health condition.Findings:During a review of Resident 82's admission record, the admission record indicated Resident 82 was originally admitted to the facility on [DATE] and readmitted on [DATE]. The admitting diagnoses included HIV, polyneuropathy (a condition where multiple peripheral nerves throughout the body malfunction simultaneously), muscle weakness, chronic obstructive pulmonary disease (COPD, a progressive, incurable lung disease that restricts airflow and makes breathing difficult).During a review of Resident 82's Order entry dated 1/20/2026 at 11:19 PM, the order entry indicated an order for Biktarvy Oral Tablet 50/200/25 mg one time a day at 9AM. The order entry had a section titled Additional Information which indicated ALERT! Drug Interaction.During an observation on 5/27/2026 at 9:34 AM, the licensed vocational nurse (LVN 1) was outside Resident 82's room preparing for medications administration. LVN 1 prepared 11 medications for Resident 82, which included one count of Biktarvy 50/200/25 mg, one count of Ferrous Sulfate 325 mg, and one count of magnesium oxide 400 mg.During a medication administration observation on 5/27/2026 at 9:48 AM at Resident 82's bedside, Resident 82 took all 11 medications orally at once.During an interview on 5/27/2026 at 2:10 PM, LVN 1 was sure if there was a drug interaction between Biktarvy and other medications. LVN 1 then reviewed Resident 82's electronic medication orders; there was a link for ALERT! Drug interaction in Resident 82's Biktarvy order. LVN 1 clicked on the link and read the interaction information, then stated magnesium and ferrous sulfate had interactions marked as severe and the concentrations and therapeutic effects could have been decreased by iron and magnesium. LVN stated she would alert the prescribing doctor of the interactions.During an interview on 5/27/2026 at 3:30 PM, the Director of Nursing (DON) reviewed Resident 82's electronic medication orders. The DON referred to the icon of 2 capsules next to the Biktarvy order on the computer screen and stated that icon indicated there was potential drug-to-drug interaction. The DON clicked on the icon and the drug-to-drug interaction details popped up.During an interview on 5/27/2026 at 3:35 PM, the assistant director of nursing (ADON) presented a drug reference sent to the facility by the pharmacy. During a concurrent review of the drug reference, ADON stated the reference indicated Biktarvy concentration could be reduced by 49% if taken in fed state (close to haven eaten a meal). The ADON stated breakfast was served at 7:30 AM daily and the Biktarvy was given around 9 AM, which was during the fed state.During an interview on 5/27/2026 at 3:48 PM, the surveyor asked to review Pharmacy recommendations. ADON stated part of the job duty of the ADON included reviewing the pharmacy consultant's monthly recommendation. ADON stated the pharmacist had never mentioned the drug interaction between Biktarvy and supplements for Resident 82. A concurrent review of a pharmacist's recommendation created between 5/1/2026 and 5/21/2026, the facility consultant pharmacist recommended to routing Resident 82's Biktarvy into antibiotic stewardship. There was no mention of the potential drug-to-drug interactions with concurrent iron and magnesium supplements. During an interview on 5/27/2026 at 4:05 PM, the DON stated the drug-to-drug interaction for Resident 82 could reduce the Biktarvy concentration by half, which could potentially reduce the effectiveness of the antivirals and worsen resident's condition. During a review of the facility policy and procedures, Administering Medications (dated 6/1/2023), the policy indicated if a medication was identified as having potential adverse consequences for the resident or was suspected of being associated with adverse (negative) consequences, the person preparing or administering the medication had to contact the resident's attending physician or the facility's medical director to discuss the concerns.

Based on observation, interview, and record review, the facility failed to ensure that a significant change in condition was promptly reported to licensed nursing staff for one of three residents reviewed (Resident 2), when Certified Nursing Assistant 1 (CNA) did not report a resident's cough on 4/11/2026 for approximately four (4) days.This failure had the potential to delay assessment, diagnosis, and treatment, placing Resident 2 at risk for worsening condition.During a review of Resident 2's admission Record, indicated Resident 2 was admitted to the facility on [DATE] with diagnosis of acute bronchitis (the temporary inflammation of the airways in the lungs, typically caused by viruses), and Chronic Obstructive Pulmonary Disorder (COPD -lung disease causing restricted airflow and breathing problems).During a review of Resident 2's Minimum Data Set (MDS- resident assessment tool), dated 2/5/2026, indicated, Resident 2 had intact cognitive skills for daily decision making. The MDS indicated Resident 2 required partial assistance from staff for oral hygiene, toileting, showering, upper and lower body dressing, personal hygiene, and putting on taking off footwear. Resident 2 required partial assistance from staff to roll left and right, sit to lying, sit to stand, and sitting on side of bed. The MDS indicated Resident 2 required supervision for eating.During a concurrent observation and interview on 4/15/2026 at 10:30 AM with Resident 2, in Resident 2's room, Resident 2 sat up in her bed unassisted and began to cough forcefully, unable to speak. After coughing persistently for about 30 seconds, Resident 2 stated she's had the cough for a few weeks and believed she was secreting green mucus on 4/14/2026. Resident 2 stated she had been hospitalized a few months ago for bronchitis and was not sure if this was related. Resident 2 stated she was not getting any treatment for the cough at the moment.During an interview on 4/15/2026 at 10:45 AM with Certified Nursing Assistant 1 (CNA1), the CNA1 stated she first noticed Resident 2 coughing on Saturday 4/11/2026 after she assisted Resident 2 with her shower. CNA1 was aware Resident 2 had gone to the hospital for a persistent cough in January and had returned to the facility feeling better. CNA1 stated she had not reported to a licensed nurse about the cough Resident 2 was experiencing because she thought the licensed nurses were aware.During a concurrent interview and record review on 4/15/2026 at 11:03 AM with the Charge Nurse (CN), the CN verified that Resident 2 had been sent to the hospital for evaluation of a persistent cough on 1/23/2026. The CN confirmed that the Electronic Medical Record (EMR) was the primary and expected location for reviewing and revising Change of Condition as well as verbal reports by staff. The CN stated no one had reported to her about Resident 2 experiencing a new persistent cough. The CN verified on the EMR that Resident 2's new onset cough had not been reported as a change of condition by staff. Review of the electronic medical record (EMR), identified by staff as the facility's primary source of clinical documentation, revealed no evidence that staff had reported new onset of cough for Resident 2 since her last episode in January 2026.During a review of the facility's policy and procedures titled Changes in Resident Condition dated January 2025, indicated changes in resident condition are communicated from shift to shift through the 24 hour report management system. Changes in the resident status that affect the problem, goals, or approaches on resident's care plan are documented as revisions and communicated to the interdisciplinary caregivers.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 2) had a comprehensive care plan that was timely revised, consistently documented, and readily accessible to staff following a significant change in condition requiring hospitalization on 1/27/2026.This failure resulted in Resident 2 lacking a Care Plan listing goals and interventions to address her diagnosis of acute bronchitis (the temporary inflammation of the airways in the lungs, typically caused by viruses) on 1/27/2026 and had the potential to impact the coordination of care and Resident 2's health outcomes.During a review of Resident 2's admission Record, indicated Resident 2 was admitted to the facility on [DATE] with diagnosis of acute bronchitis (the temporary inflammation of the airways in the lungs, typically caused by viruses).During a review of Resident 2's Minimum Data Set (MDS- resident assessment tool), dated 2/5/2026, indicated, Resident 2 had intact cognitive skills for daily decision making. The MDS indicated Resident 2 required partial assistance from staff for oral hygiene, toileting, showering, upper and lower body dressing, personal hygiene, and putting on taking off footwear. Resident 2 required partial assistance from staff to roll left and right, sit to lying, sit to stand, and sitting on side of bed. The MDS indicated Resident 2 required supervision for eating.During a concurrent observation and interview on 4/15/2026 at 10:30 AM with Resident 2, in Resident 2's room, Resident 2 sat up in her bed unassisted and began to cough forcefully, unable to speak. After coughing persistently for about 30 seconds, Resident 2 stated she's had the cough for a few weeks and believed she was secreting green mucus on 4/14/2026. Resident 2 stated she had been hospitalized a few months ago for bronchitis and was not sure if this was related. Resident 2 stated she was not getting any treatment for the cough at the moment.During an interview on 4/15/2026 at 10:45 AM with Certified Nursing Assistant 1 (CNA1), the CNA1 stated she first noticed Resident 2 coughing on Saturday 4/11/2026 after she assisted Resident 2 with her shower. CNA1 was aware Resident 2 had gone to the hospital for a persistent cough in January and had returned to the facility feeling better. CNA1 stated she had not reported to a licensed nurse about the cough Resident 2 was experiencing because she thought the licensed nurses were aware.During a concurrent interview and record review on 4/15/2026 at 11:03 AM with the Charge Nurse (CN), the CN verified that Resident 2 had been sent to the hospital for a persistent cough on 1/23/2026, and upon her return to the facility from the hospital, Resident 2's Care Plan had not been updated to include new diagnosis of acute bronchitis and respiratory monitoring needs. The CN confirmed that the Electronic Medical Record (EMR) was the primary and expected location for reviewing and revising Care Plans and is the only location she would look to guide her practice when providing care for residents. The CN stated no one had reported to her about Resident 2 experiencing a new persistent cough. The CN verified on the EMR that Resident 2's new onset cough had not been reported as a change of condition by staff. During a concurrent interview and record review on 4/15/2026 at 11:25 AM with the MDS Nurse, the MDS Nurse verified that Resident 2 did not have a Care Plan for acute bronchitis on the EMR after returning from the hospital. The MDS nurse stated Care Plans are revised and updated on the EMR upon arrival from the hospital to list new orders, diagnosis, and treatment. The MDS nurse verified that Resident 2 had a new diagnosis of acute bronchitis upon return to the facility on 1/27/2026 and had new medication orders for an antibiotic (medication to treat infection).Review of the electronic medical record (EMR), identified by staff as the facility's primary source of clinical documentation, revealed no evidence of a revised care plan addressing the new diagnosis of acute bronchitis, respiratory monitoring needs, antibiotic treatment and associated interventions back in January 2026 after Resident 2 returned to the facility from the hospital. The EMR revealed no evidence that staff had reported new onset of cough for Resident 2 since her last episode in January 2026.During an interview on 4/15/2026 at 12:47 PM with the Director of Nursing (DON), the DON stated that Care Plans are important because it helps assess interventions needed for monitoring treatment, medications, side effects of medications, monitor pain and respiratory issues. The DON stated any licensed nurse can update the Care Plan upon admission and or readmission from the hospital. The DON stated a Care Plan addressing the condition for Resident 2 was documented on paper. At the time of the initial request and review, the alleged paper Care Plan was not readily available in Resident 2's chart. Staff present during the review reported they had not seen or accessed such documentation. The paper document was later presented after the state surveyor requested and pointed out it's absence from the EMR.During a review of the facility's policy and procedure titled Care Plan-Comprehensive Person-Centered dated January 2025, indicated an individualized Comprehensive Care Plan includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs. Each resident's Care Plan has been designed to incorporate identified problem areas, risk factors associated with identified problems, reflect treatment goals and objectives in measurable outcomes. Identify the professional services that are responsible for each element of care. Care plans are revised as changes in the resident's condition dictate. Care plans are reviewed at least quarterly.

Based on interview and record review the facility failed to ensure administration of medication was documented for one of three sampled residents (Resident 1). For Resident 1, the facility failed to document when Resident 1 was given Benadryl (medication used to relieve symptoms of allergies) 25 milligrams (mg., metric unit of measurement, used for medication dosage and/or amount) orally on 9/18/25.This deficient practice had the potential for medication error and medication duplication to Resident 1. During a review of the admission Record, indicated the facility admitted Resident 1 on 1/31/25 and re-admitted on [DATE] with diagnoses including generalized muscle weakness, hypertension (high blood pressure) and dementia (a group of thinking and social symptoms that interferes with daily functioning).During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 9/14/25, the MDS indicated Resident 1 had intact cognition (participant has sufficient judgement, planning organization, self-control, and the persistence needed to manage the normal demands of the participant's environment). During a review of the Medication Administration Record (MAR, a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) dated 9/25 indicated an order to give Resident 1 Benadryl 25 mg. one tablet by mouth every four hours as needed for itchiness for 14 days. The box for 9/18/25 was not signed out as given. During a concurrent observation and interview on 9/18/25 at 8:47 a.m. with Registered Nurse Supervisor (RNS 1), in Resident 1's room, RNS 1 stated there is a medication cup with Benadryl on top of Resident 1's table. Resident 1 was observed taking the medication cup from RNS 1 and Resident 1 swallowed the Benadryl. During a follow-up interview on 9/18/25 at 11:49 a.m., RNS 1 stated she did not document when Resident 1 was given the Benadryl. RNS 1 further added documentation of the Benadryl should be done at the time the Benadryl was given and taken by Resident 1. During a review of the facility's policy and procedures (P&P) titled Administering Medications reviewed on 1/30/25 indicated the individual administering the medication must initial the resident's Medication Administration Record (MAR, a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) after giving each medication and before administering the next ones. As required or indicated for a medication, the individual administering the medication will record in the resident's medical record that included: a. the date and time the medication was administered.b. the dosage.c. the route of the administrationd. any complaints or symptoms for which the drug was administerede. the signature and title of the person administering the drug.

Based on observation, interview, and record review, the facility failed to obtain a physician order before administering a medication to one of three sampled residents (Resident 1). For Resident 1 the facility failed to:1. Obtain a physician order prior to the administration of Benadryl tablet (medication used to relieve symptoms of allergies) 25 milligrams (mg., metric unit of measurement, used for medication dosage and/or amount) orally.2. Ensure the Benadryl 25 mg. tablet was not left at Resident 1's bedside table unattended.These deficient practices had the potential to result in harm to Resident 1 and other residents from inappropriate and unsafe medication administration.During a review of the admission Record, indicated the facility admitted Resident 1 on 1/31/25 and re-admitted on [DATE] with diagnoses including generalized muscle weakness, hypertension (high blood pressure) and dementia (a group of thinking and social symptoms that interferes with daily functioning).During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 9/14/25, the MDS indicated Resident 1 had intact cognition (participant has sufficient judgement, planning organization, self-control, and the persistence needed to manage the normal demands of the participant's environment). During a concurrent observation and interview on 9/18/25 at 8:05 a.m. with Resident 1, a medicine cup with one pink pill was observed on Resident 1's bedside table. Resident 1 stated she complained of itching, and she requested licensed vocational nurse (LVN 1) for Benadryl. During a concurrent observation and interview on 9/18/25 at 8:47 a.m. with Registered Nurse Supervisor (RNS 1), in Resident 1's room, RNS 1 stated there is a medication cup with Benadryl on top of Resident 1's table. RNS 1 stated, when LVN 1 brought the Benadryl to Resident 1, LVN 1 should observe Resident 1 take the Benadryl to ensure that Resident 1 had taken the Benadryl. Resident 1 was observed taking the medication cup from RNS 1 and swallowed the Benadryl. During a follow-up interview on 9/18/25 at 11:49 a.m., RNS 1 confirmed there was no physician order for the Benadryl that was given to Resident 1. RNS 1 stated a physician's order for the Benadryl is needed before administering the Benadryl to Resident 1. During an interview on 9/22/2025 at 8:28 a.m., LVN 1 stated Resident 1 complained of itching on 9/19/25. LVN 1 stated she handed the Benadryl to Resident 1 without observing Resident 1 take the Benadryl. LVN 1 stated she did not check for Benadryl order before giving the medication. LVN 1 stated, She had an order, I think. That was my mistake, I did not check the order. LVN 1 stated it is important to check physician orders to prevent medication errors. LVN 1 stated not checking the physician order may result in giving the wrong medication, or wrong dose, or result in giving medication Resident 1 may be allergic to. LVN 1 stated it is important to check Medication Administration Record (MAR, a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) and verify medication orders before giving the Benadryl to Resident 1 for safety. During a review of facility's policies and procedure (P&P) titled Administering Medications, reviewed on 1/30/25, the P&P indicated, Medications shall be administered in a safe and timely manner, and as prescribed. The same Policy indicated medications must be administered in accordance with the orders, including any required time frame.

Based on observation, interview and record review, the facility failed to ensure medications were kept secure in accordance with professional standards of practice for one of four sample residents (Resident 2). During medication pass observation on 7/22/25 at 9 a.m., the facility failed to ensure Resident 2's medications were not left on top of the medication cart while the medication cart was left unattended. This deficient practice had the potential for other residents and other individuals to easily access the medications on top of the cart for their own. use. During a review of the admission Record indicated the facility admitted Resident 2 on 8/2/23 and readmitted on [DATE] with diagnoses including pneumonia (an infection/inflammation in the lungs) and generalized muscle weakness. During a review of the Minimum Data Set (MDS, resident assessment tool) dated 7/10/25 indicated Resident 2 was cognitively intact. Resident 2 needed substantial assistance (helper does more than half the effort) with toileting hygiene, shower/bathe self, lower body dressing, putting on/taking off footwear, moderate assistance (helper does less than the effort) with oral hygiene, upper body dressing and needed supervision with eating. During medication pass observation on 7/22/25 at 9 a.m., licensed vocational nurse (LVN 1) was observed preparing medications for Resident 2. LVN 1 completed preparing the medications and stepped inside Resident 2's room. LVN 1 left the bubble packs (medications arranged in individual compartments with one medication for each dosing period sealed with protective bubbles) on top of the medication cart unattended. During a follow-up interview on 7/22/25 at 10:57 a.m., LVN 1 stated after popping the medications from the bubble pack, place the bubble packs back inside the medication cart and lock the medication cart. LVN 1 further stated when stepping away from the cart, .don't leave any medications on top of the medication cart because of safety reasons because other people might steal the medications. During an interview on 7/22/25 at 11:41 a.m., the assistant director of nursing (ADON) stated when stepping away from the medication cart, no medications should be left on top of the cart for safety reasons. During a review of the facility Policy titled Administering Medications reviewed on 1/30/25 indicated during administration of medications, the medication cart will be kept closed and locked when out of sight of the medication nurse. It may be kept in the doorway of the resident's room, with open drawers facing inward and all other sides closed. No medications are kept on top of the cart. The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or other passing by. During a review of the facility's policy and procedures titled Storage of Medications, reviewed on 1/30/25, the P&P indicated the facility stores all drugs and biologicals in a safe, secure and orderly manner.

Based on interview and record review the facility failed to administer medication as ordered by the physician for one of four sampled residents (Resident 1). For Resident 1, the facility failed to administer the metronidazole (antibiotic that treats infection) 500 milligrams (mg., metric unit of measurement, used for medication dosage and/or amount) as ordered by the physician. This deficient practice resulted in Resident 1 not given one dose of the metronidazole 500 mg. and had the potential for Resident 1's infection to worsen.During a review of the admission Record indicated the facility admitted Resident 1 on 1/30/25 with diagnoses including diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing) and pressure ulcer (wounds that occur from prolonged pressure on the skin) of the sacral region (lower back). During a review of Resident 1's Care Plan initiated on 2/26/25 indicated Resident 1 was on enhanced barrier precautions (an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes) due to gastrostomy tube (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) and pressure injury. The care plan goal indicated to reduce the transmission of the organisms between residents and health care practitioners in the facility. The care plan interventions included administer antibiotic medications as ordered by the physician. During a review of the Minimum Data Set (MDS, resident assessment tool) dated 5/7/25 indicated Resident 1 had severe cognitive impairment. Resident 1 was dependent on toileting hygiene, shower/bathe self, lower body dressing, putting on/taking off footwear and substantial assistance (helper does more than half the effort) with oral hygiene, upper body dressing and personal hygiene. During a review of the Physician Telephone Order dated 7/18/25 at 5:06 p.m., indicated to give Resident 1 metronidazole 500 mg. one tablet by GT every eight hours for pressure sore on the sacral area. During a review of the Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) dated 7/19/25 at 6 a.m. to 7/22/25 at 6 a.m., indicated Resident 1 was given metronidazole 500 mg. every eight hours. The total of the metronidazole given to Resident 1 should be a total of 10 tablets. During a review of Resident 1's metronidazole bubble pack (medication arranged in individual compartments with one medication for each dosing period sealed with protective bubbles) indicated a total of nine tablets were given to Resident 1 instead of a total of 10 tablets. During a concurrent interview and record review on 7/22/25 at 10:35 a.m., Resident 1's MAR, bubble pack and Antibiotic Drug Record for the metronidazole 500 mg. were reviewed with LVN 2 and LVN 3. LVN 2 stated the metronidazole 500 mg. was started on 7/19/25. The bubble pack and the Antibiotic Drug Record indicated a total of nine tablets of metronidazole were given to Resident 1 instead of a total of 10 tablets. LVN 2 and LVN 3 agreed Resident 1 was not given one dose of the metronidazole 500 mg. During an interview on 7/22/25 at 11:41 a.m., the assistant director of nursing (ADON), stated that when Resident 1 was not given a dose of the metronidazole 500 mg., Resident 1's infection may worsen. During a review of the facility's policy and procedures (P&P) titled Administering Medications reviewed on 1/30/25, the P&P indicated medications shall be administered in a safe and timely manner as prescribed. Medications must be administered in accordance with the orders, including any required time frames.

Based on observation, interview and record review, the facility failed to ensure the environment is free of hazard for one of three sampled residents (Resident 3). During observation on 5/13/25, the facility hall was lined with linen carts, dirty linen hampers, trash hampers and showers chairs on both sides of the hall. Residents 3 stated it was difficult for him to self-propel his wheelchair due to the clutter in the hallway. This deficient practice had the potential for accidents to occur for Resident 3 and other residents. Findings: During a review of the Admission Record indicated the facility admitted Resident 3 on 3/21/24 with diagnoses including diabetes mellitus (DM, disorder characterized by difficulty in blood sugar control and poor wound healing), muscle weakness and abnormalities of gait and mobility. During a review of Resident 3 ' s Minimum Data Set (MDS, a resident assessment tool) dated 3/4/25 indicated Resident 3 was cognitively intact. The MDS indicated Resident 3 was independent with activities of daily living (ADLs) and used the walker and wheelchair as mobility devices. During a concurrent observation and interview on 5/13/25 at 9:45 a.m., licensed vocational nurse (LVN 1) stated the hallway is cluttered. LVN 1 stated there are linen carts, dirty linen and trash hampers, shower chairs on both sides of the hallway. LVN 1 stated it could be better. During a concurrent observation and interview on 5/13/25 at 9:48 a.m., the infection preventionist (IP) stated the hallway is a little crowded and stated the linen carts and dirty linen hampers are placed on both sides of the hallway. IP stated this is a hazard and safety issues for residents who are using wheelchairs. During an interview on 5/13/25 at 12:24 p.m., the registered nurse supervisor (RNS 1) stated the linen carts, dirty linen hampers, thrash hampers should be placed on one side of the hallway so there is space for the residents to go through. During an interview on 5/13/25 at 1:26 p.m., the director of nursing (DON) stated the certified nursing assistants were doing morning care. DON stated the linen carts and dirty linen hampers should be placed on one side of the hall for the safety of the residents. During a review of the facility' policy and procedurs (P&P) titled Safety and Supervision of Residents reviewed on 1/30/25, the P&P indicated the facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility- wide priorities. The same Policy indicated safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring and reporting processes: Quality Assurance and Performance Improvement (QAPI) reviews of safety and incident/accident data and a facility -wide commitment to safety at all levels of the organization.

Based on interview and record review the facility failed to implement the care plan for one of three sampled residents (Resident 1). For Resident 1, the facility failed to assess and document weekly Resident 1 ' s moisture associated skin damage (MASD, moisture associated skin damage caused from prolonged exposure to moisture) to the buttocks area as indicated in Resident 1 ' s care plan. This deficient practice resulted in not being able to determine if Resident 1 ' s MASD had healed before Resident 1 was discharged from the facility on 4/11/25. Findings: During a review of the Admission Record indicated the facility admitted Resident 1 on 4/2/25 with diagnoses including diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), difficulty in walking and dementia (a progressive state of decline in mental abilities). During a review of the Minimum Data Set (MDS, a resident assessment tool) dated 4/6/25 indicated Resident 1 had severed cognitive impairment. Resident 1 needed moderate assistance (helper does less than half the effort) with oral hygiene, toileting hygiene, shower/bathe self, upper/lower body dressing, putting on/taking off footwear and supervision with eating). During a review of the Skin Evaluation dated 4/3/25 at 9:03 a.m., Resident 1 indicated MASD on the buttocks area. During a review of Resident 1 ' s Care Plan initiated on 4/8/25, indicated Resident 1 had actual impairment to skin integrity related to fragile skin, and with diagnoses including bilateral buttocks MASD. The care plan goal indicated Resident 1 will maintain or develop clean and intact skin by the review date. The care plan interventions included: 1. Monitor/document location, size and treatment of skin injury. 2. Weekly treatment documentation includes measurement of each area of skin breakdown ' s width, length, depth, type of tissue and exudate and any other notable changes or observations. During a review of Resident 1 ' s Treatment Administration Record (TAR, a daily documentation record used by a licensed nurse to document treatments given to a resident) indicated for the MASD in the bilateral buttocks to wash with soap and water, pat dry, and apply zinc oxide (cream used to treat and prevent skin irritation) to the site and leave open. The TAR indicated the treatment was done from 4/3/25 to 4/11/25. During a concurrent interview and record review on 5/13/25 at 12:24 p.m., Resident 1 ' s skin assessment dated [DATE] was reviewed with the registered nurse supervisor (RNS 1). RNS 1 stated Resident 1 had MASD on the buttocks when Resident 1 was admitted on [DATE]. RNS 1 stated there should be a weekly assessment of the MASD. RNS 1 stated she was unable to find documentation that the MASD was assessed weekly. During an interview on 5/13/25 at 1:26 p.m., the director of nursing (DON) stated there was no documentation of Resident 1 ' s MASD whether the MASD had improved or not. The DON stated when Resident 1 was discharged on [DATE], the transfer out notes indicated no skin issues. During a review of the facility policy and procedures (P&P) titled Non-Pressure Ulcers/Wound Management revised on 1/30/25, the P&P indicated a licensed nurse will document the status of all skin conditions at least weekly or as otherwise indicated in the resident ' s care plan, until the wound, non-pressure ulcer or other skin condition is resolved. The same Policy indicated treatments for skin problems, wounds and non-pressure ulcers will be assessed and documented by a licensed nurse.

Based on interview and record review, the facility failed to ensure one of three sampled Residents (Resident 19) had an advance directive (a legal document indicating resident preference on end-of-life treatment decisions). This failure violated Resident 19 and/or representative's rights to be fully informed of the option to formulate an advanced directive and had the potential not to follow Resident 19's wishes. Findings: During a review of Resident 19's Admission Information, the Admission Information indicated the facility admitted Resident 19 on 9/30/2024 and readmitted Resident 19 on 3/6/2025 with diagnoses including metabolic encephalopathy (brain dysfunction caused by problems with the body's metabolism), cerebral infarction (a condition where brain tissue dies due to a lack of blood flow and oxygen) and moderate intellectual disabilities (observable developmental delays, which may be accompanied by physical impairments). During a review of Resident 19's Resident Care Conference Review dated 10/11/2024, the Resident Care Conference Review indicated Resident 19 was under the Regional Center (RC). The Resident Care Conference Review indicated Resident 19 did not have an advanced directive in place at This time and does not want to formulate one. During a review of Resident 19's History and Physical (H&P), dated 3/7/2025, the H&P indicated Resident 19's had a limited capacity to consent due to moderate intellectual disabilities. During a review of Resident 19's Minimum Data Set (MDS, a resident assessment tool), dated 4/4/2025, the MDS indicated the resident was severely cognitively (anything related to thinking, learning, and understanding) impaired for daily decision making. During an interview on 4/8/2025 at 8:16 AM with the Discharge Planner (DP), the DP stated Resident 19 needed an advance directive. The DP stated Resident 19 came from another Skilled Nursing Facility (SNF) and the DP stated she (DP) contacted the previous facility's Social Worker to check for contacts or responsible party for the resident. The DP stated she did not check to see if the resident had an advance directive. The DP stated she (DP) followed up with the RC regarding the AD but did not document. During an interview on 4/8/2025 at 9:02 AM with the DP, the DP stated Resident 19 did not have the capacity to sign an advance directive. The DP stated there was no documentation on the EMR (Electronic Medical Record) that she (the DP) had notified the doctor of the advance directive status, and it was important to notify the doctor. During an interview on 4/10/2025 at 2:01 PM with the Director of Nursing (DON), the DON stated the advance directive was important to have when deciding Resident 19's well-being and code status (what type of intervention [if any] a healthcare team will conduct should their patient's heart stop beating. The DON stated the advance directive needed to be initiated upon admission or received from the previous facility, however due to its absence the facility would consider Resident 19 as a full code status (all life-saving measures will be taken during a medical emergency). During a concurrent interview and record review on 4/10/2025 at 2:22PM with the DON, the facility's policy and procedure (P&P) titled, Advance Directives, dated June 2023 was reviewed. The DON stated the P&P indicated, Prior to or upon admission of a resident, the Social Services Director or designee will inquire of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives. The DON stated, the policy was not followed.

Based on observation, interview, and record review, the facility failed to ensure one of nine sampled residents (Resident 1), who was identified with wandering episodes, was provided supervision, and maintained a safe and hazard free environment as indicated in Resident1 ' s care plan dated 2/21/2024. The facility failed to ensure a full bottle of hand sanitizer was not within Resident 1 ' s access or reach. As a result, Resident 1 ingested (drank) a toxic substance (hand sanitizer, a liquid or gel, typically one containing alcohol, that is used to clean the hands and kill bacteria, viruses, and other disease-causing agents on the skin) requiring admission to the General Acute Care Hospital (GACH) and was diagnosed with toxic encephalopathy (a neurologic disorder [nervous system problems] caused by consumption or exposure of harmful chemicals/toxins, that cause lead to altered mental status, memory loss, and visual problems). On 7/24/2024 at 3:58 pm., 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 to a resident) was identified and the facility was notified of the IJ in the presence of the Assistant Administrator (AADM) and the Director of Nursing (DON), regarding the facility's failure to provide supervision and an environment free from accident hazards to prevent Resident 1 from ingesting (drinking) a toxic substance (hand sanitizer). The facility was aware Resident 1 had wandering behavior and would pick up items and place the items in her mouth. 1. On 7/7/24, Resident 1 was left unsupervised at the nurses' station and ingested approximately 160 cubic centimeters (cc- unit of measurement) of hand sanitizer. As a result, Resident 1 was admitted to the GACH and diagnosed with toxic encephalopathy and dehydration. 2. On 7/23/2024 at 1:22 pm, the facility's reception area was observed with no staff present and with a half full bottle of hand sanitizer on top of the reception desk. 3. On 7/23/2024 at 4:22 pm, during an observation of the facility's dining room Resident 1 was observed unsupervised with the door closed sitting next to a desk and one opened bottle (approximately 1 liter) of sanitizing wipes within reach of Resident 1. A sanitizing wipe was observed hanging out of the top of the container. 4. On 7/23/24 at 4:44 pm, during an observation of the facility's Maintenance Room, where cleaning solutions/chemicals were stored, the closet door was observed unlocked. There were no staff observed near the Maintenance Room to monitor and ensure no residents were not going inside the closet. Inside the Maintenance Room there was a door to a wired cage where cleaning solutions/chemicals were stored. There were observed stored several cleaning supplies and chemicals such as bleach and aerosols. The wired cage door was observed wide open, making cleaning supply available to residents. 5. On 7/23/24 at 5:57 pm, the facility's maintenance room door was observed opened with no staff present. On 7/26/2024 at 3:35 pm, the IJ was removed in the presence of the AADM, DON, Director of Staff Development (DSD), and Assistant Director of Nursing (ADON) after the onsite verification of the implementation of the IJ removal plan through observation, interview, and record review. The acceptable IJ removal plan included the following: 1. Resident 1 is being monitored by Licensed Vocational Nurse (LVN) for behavior manifested by an episode of ingesting fluids/liquid not suitable for human consumption. On 7/7/2024, Resident 1 was sent to acute hospital as ordered by the Attending Physician for further evaluation and is currently back in the facility with no sign or symptoms of intoxication. On 7/25/2024, IDT met to discuss resident current behavior and IDT recommended for facility to provide 1:1 supervision while awake. 2. On 7/25/2024 at 7:55am, Medical Director (MD), who is also Resident ' s primary physician, was contacted by the AADM and made aware of the facility's current IJ status. 3. On 7/23/2024, the Receptionist and DON removed the bottle of hand sanitizer on top of Facility's reception area. 4. On 7/23/2024, the Assistant Activity Director (AAD) and the DON removed the sanitizing wipes hanging on the top of the container inside of the facility's dining room. 5. On 7/23/2024, the Maintenance Director (MTD) locked the Maintenance Room and the wired cage. On 7/24/2024, MTD replaced the doorknob on the self-closing door located in the maintenance room, the door now self-locks. The MTD and/or Social Services Designee (MOD to check on weekend), will check the maintenance room around 10am, Minimum Data Set Nurse (MDSN) and/or Infection Preventionist (IP), (manager of the day (MOD) to check on weekend) will check around 3 pm and Desk Nurse and/or CART 2 Licensed Vocational Nurse (LVN) will check around 7 pm utilizing the Maintenance Room to ensure door was locked when room was unattended, noncompliance will be reported immediately to Administrator and/or DON. On 7/25/2024, the Registered Nurse (RN) Consultant reeducated the MTD the importance of locking the door where the facility keeps cleaning supply/chemicals to prevent visitors and residents' access. 6. On 7/23/2024 and 7/24/2024, The department heads consisting of the Business office manager, admissions coordinator, MDS Coordinator, Social Services Director (SSD), MTD, DSD, ADON, Dietary Supervisor, Discharge Planner, DON, immediately checked all the facility's common areas and removed all loose bottles of Alcohol-based hand rub (ABHR- is the preferred method for standard hand hygiene, kills the majority of viruses [an infectious agent that can only replicate within a living thing] from hands) to prevent any resident from accidentally ingesting toxic substances. 7. The IP, Activity Director (AD) would conduct daily room rounds before stand-up meeting at 9:30 a.m., utilizing a log Loose bottles hand sanitizer check to ensure that there are no loose bottles, noncompliance will be reported immediately to Administrator (ADM) and/or DON. of hand sanitizer available inside the facility for one month and weekly thereafter. Loose bottles of ABHR were disposed. Beginning 7/24/2024, Central Supply Staff will no longer order loose bottle hand sanitizer and removed current loose bottle hand sanitizer from the facility and disposed accordingly. 8. On 7/24/2024, the seven residents identified by the facility to be at risk of wandering were being observed by the licensed nurses when approaching ABHR dispensers to ensure residents will not accidentally or intentionally ingest ABHR. The monitoring will be documented on the electronic health record (EHR). Licensed Nurses to report immediately if resident safety is compromised to the ADM and/or DON and in the absence of ADM or DON, the incident would be reported to ADON or designee. Licensed Nurses to inform Certified Nursing Assistants by providing a list of residents identified to be at risk of wandering that are being observed by licensed nurses for when approaching ABHR dispensers to ensure residents will not accidentally or intentionally ingest ABHR. List of residents will be updated by Licensed Nurses when there is resident identified during admission to be high risk, when resident is being transferred or discharged or with change of condition. 9. On 7/25/2024, RN Nurse Consultant educated facility department heads which included (DON, ADM, AADM, DSD, IP, MD, AD, Social Services Designee, Dietary supervisor (DS), Business Office Manager (BOM), ADON, Admission Coordinator) regarding the importance Identifying environmental hazards/risks (such as housekeeping chemicals or ABHR and implementing interventions to prevent accidents. The Department Heads that were not able to attend the in-service will be reeducated by DON before they return to work regarding the importance of Identifying environmental hazards/risks. Beginning 7/25/24 and ongoing the DON and ADON provided reeducation to all staff regarding the importance of maintaining toxic substances such as hand sanitizers out of reach of residents and importance of locking the door where facility keeps cleaning supply/chemicals to prevent visitors and residents' access. As of today, the facility has 121 total staff of which 17 are on vacation or out sick. There are 77 staff who completed the in-service, remaining 44 (including the 17 staff) Staff that were not able to attend the in-service will not be allowed to work until in service is completed. The DON and/or ADON and in the absence of both, the DSD and/or Infection Preventionist will review the checklist of facilities who were not in-serviced to ensure staff will be in-serviced before coming back to work. 10. On 7/25/24, the facility begun a Performance Improvement Plan (PIP) titled Toxic substances storage and supervision of residents with following goals and interventions: i. The resident environment remains as free of accident hazards as possible. ii. Each resident receives adequate supervision and assistance devices to prevent accidents by ensuring the MTD, the maintenance department staff and (4) housekeeping/laundry staff understood the importance of locking the door where the facility keeps cleaning supplies/ chemicals to prevent visitors and residents' access. Newly hired Maintenance staff and housekeeping staff will be in-serviced by MTD regarding the importance of locking the door where facility keeps cleaning supply/chemicals to prevent visitors and residents' access before 1st day of work. iii. The Interdisciplinary Team consisting of the BOM, Admissions Coordinator, MDS Coordinator, Social Services Director (SSD), MTD, DSD, ADON, DS, Discharge Planner, IP, AD, would conduct daily room rounds before stand-up meeting at 9:30 a.m., utilizing a log Loose bottles hand sanitizer check to ensure that there are no loose bottles, noncompliance will be reported immediately to ADM and/or DON. iv. Licensed Nurses to inform Certified Nursing Assistants (CNAs) by providing a list of residents identified to be at risk of wandering that are being observed by licensed nurses for when approaching ABHR dispensers to ensure residents will not accidentally or intentionally ingest ABHR. List of residents will be updated by Licensed Nurses when there is resident identified during admission to be high risk, when resident is being transferred or discharged or with change of condition. D v. Department Heads that were not able to attend the in-service will be reeducated by DON before they return to work regarding the importance of Identifying environmental hazards/risks. Department heads which did not attend the training, will not be allowed to work until in service is completed. (such as housekeeping chemicals or ABHR {Alcohol based hand rub) and implement interventions to prevent accidents. vi. The DON and/or ADON and in the absence of both, the DSD and/or Infection Preventionist would review the checklist of facility who were not in-serviced to ensure staff will be in-serviced before coming back to work. The PIP target end date is 8/30/24, the facility would evaluate its effectiveness weekly or as necessary to ensure its approaches/interventions are effective. If approaches are deemed ineffective the team will discuss new approaches/interventions. IF PIP is found ineffective QAPI committee which includes the ADM, the MD, the DON, ADON, MDS Coordinator, Medical Records Director, SSD, MTD, DSD, DS, Discharge Planner, IP, would update or revise interventions. Findings: During a review of Resident 1 ' s admission record, the record indicated the facility initially admitted Resident 1 on 2/17/2024 and was readmitted on ,d+[DATE]//2024 with diagnoses that included toxic encephalopathy, dementia (loss of cognitive functioning-thinking, remembering, and reasoning), chronic obstructive pulmonary disease (COPD-group of lung diseases that block airflow and make it difficult to breathe), and aphasia (loss of ability to understand or express speech, caused by brain damage). During a review of Resident 1 ' s care plan (CP) titled, Resident with wandering episode secondary to: Dementia initiated 2/21/2024, the CP indicated for interventions: Constant monitoring of whereabouts and maintain safe and hazard free environment. During a review of Resident 1 ' s Minimum Data Set (MDS- standardized data collection tool used to assess cognitive and functional status, and care needs) dated 6/23/2024, indicated Resident 1 had severe cognitive impairments (when social and occupational functions are limited where an individual may not be able to recognize people, use language, or execute purposeful movements). The MDS indicated Resident 1 required between partial/moderate to substantial/maximal assistance for Activities of Daily Living (ADLs - eating, oral hygiene, toileting, showers/bathing, dressing, personal hygiene, and toilet transfer. During a review of Resident 1 ' s History and Physical (H & P) dated 6/8/2024, the H & P indicated Resident 1 had fluctuating capacity to understand and make decisions. During a review of Resident 1 ' s nurse progress notes dated 7/7/2024 at 4:30 pm indicated Resident 1 had ingested 165 cc of hand sanitizer, called Medical Doctor (MD) with new orders to transfer out to hospital to monitor for symptoms of intoxication (is the condition of having physical or mental control markedly diminished by the effects of alcohol or drugs). During a review of Resident 1 ' s nurse progress notes dated 7/7/2024 at 6 pm indicated Resident 1 was picked up by two Emergency Medical Technicians (EMTs- a person who is trained to give emergency medical care at the scene of an accident or in an ambulance) in an ambulance going to GACH for further evaluation for ingestion of alcohol hand sanitizer. During a review of Resident 1 ' s physician ' s order dated 7/7/2024 at 4:30 pm, indicated transfer resident to hospital for further evaluation of ingestion of hand sanitizer. During a review of Resident 1 ' s CP initiated on 7/7/2024 for behavioral problems, the care plan indicated, resident ingested almost 165cc of hand sanitizer, resident is more confused. Wandering. During a review of Resident 1 ' s GACH History and Physical (H&P) records dated 7/12/24 under assessment and plan indicated the following: Toxic encephalopathy due to ingestion of hand sanitizer, cognitive impairment (Problems with a person's ability to think, learn, remember, use judgement, and make decisions) and altered mental status upon admission, consistent with toxic encephalopathy. The same H&P indicated, monitor neurological status (consists of a physical examination to identify signs of disorders affecting your brain, spinal cord, and nerves) and mental alertness every 2 hours. Administer intravenous (a way of giving a drug or other substance through a needle or tube inserted into a vein) fluids and electrolytes (minerals in your blood and other body fluids that carry an electric charge) to manage dehydration (a condition that occurs when the body loses too much water and other fluids that it needs to work normally) due to ingestion. Provide activated charcoal (a fine, odorless, black powder often used in emergency room s to treat overdoses) if within ingestion window to reduce systemic absorption (the movement of drug from the site of drug administration to the systemic circulation). Consult Poison Control Center for further management and antidote (a remedy to cancel the effects of poison) recommendations PRN (as needed) for complex cases. During an interview with LVN 3 on 7/23/2024 at 12:21 pm, stated that on 7/7/2024 at 4:30 pm while he (LVN 3) was sitting on the inside of the nurses ' station, LVN 3 observed Resident 1 who was sitting on a wheelchair grab a bottle of hand sanitizer which was full (221 cc) opened it, and started drinking it. LVN 3 stated that Resident 1 drank 165 cc of the hand sanitizer. LVN 3 admitted that Resident 1 was known (no time stated) to place items in her mouth that she could get her hands on, but that the behavior was not care planned. During a concurrent observation of the reception desk and interview with the DSD on 7/23/24 at 1:22 pm, the DSD confirmed and stated that there was no staff present at the reception desk. The DSD stated the sanitizer should be at the receptionist desk but was unable to state how the facility would prevent a confused resident with easy access from consuming the hand sanitizer. The DON stated the hand sanitizer could be toxic if consumed especially that residents are taking medications. During a concurrent observation of a desk in the admission ' s office and interview with the DON 7/23/24 1:27 pm, a loose bottle of hand sanitizer was observed within easy access for residents. The DON admitted the residents had access to the office and that the residents who are confused might consume the easily accessible hand sanitizer. The DON stated the potential effect if consuming hand sanitizer may be toxic and require medical attention. The affected resident may result in resident getting drunk. During a concurrent observation of Resident 1, interview, and record review with the ADON on 7/23/24 at 4:22 pm, Resident 1 ' s admission records dated 7/12/24 was reviewed. Resident 1 was readmitted to the facility on [DATE]. Resident 1 was observed sitting on a chair against the wall in the dining room unsupervised with the door closed. Right behind Resident 1 within easy access was a wall mount containing two boxes of gloves and another one next to the gloves containing about one liter of sanitizing wipes with one wipe hanging over the container. The ADON as well as the activities staff (AS) confirmed the observation. The ADON admitted that Resident 1 had easy access to the sanitizing wipes and could ingest them with her history of ingesting nonedible substances. During a concurrent observation and interview of the maintenance room (just across the hallway from the dining room approximately 30 feet from the dining room where Resident 1 was sitting) on 7/23/24 at 4:48 pm with the DON, the door was tied open using a string connected to the doorknob and a wire behind the door. There were no staff observed near the Maintenance Room to monitor and ensure no residents were not going inside the room. Inside the Maintenance Room there was a door to a wired cage where cleaning solutions/chemicals were stored. There were observed stored several cleaning supplies and chemicals such as bleach and aerosols. The wired cage door was observed wide open, making cleaning supply available to residents. The DON confirmed the observation and admitted that the room was easily accessible to residents. During a concurrent observation and interview with the DON of the Maintenance Room on 7/23/24 at 5:57 pm, The Maintenance Room was unattended, and the doors were open, and the caged door (containing cleaning supplies) was open. The DON confirmed and stated that residents had easy access and may consume the chemicals stored in the room. During an interview with Resident 1 ' s Primary Medical Doctor/Medical Director (PMD/MD) on 7/24/24 at 10 am, PMD/MD stated that Resident 1 required a 1:1 sitter after the incident on 7/7/24 for safety to prevent her from consuming toxic substances. The potential effects of consuming these toxic substances may result in metabolic acidosis (too much acid in the blood and can be life-threatening if not treated appropriately), esophageal strictures (narrowing of your esophagus (swallowing tube), cell injury, and death. During a review of the facility ' s policy and procedures (P&P) title Dementia-Clinical Protocol. Resident Behavior , release date 8/1/2023, the P & P indicated, The physician will order appropriate interventions to address significant behavioral and psychiatric symptoms, based on pertinent clinical guidelines and consistent with regulatory requirements. During a review of the facility ' s P & P titled Alcohol-Based Hand Rub Dispensers, Installation and Use, release date 1/2024, the P & P indicated, Alcohol-based hand rub dispensers shall be installed in areas that facilitate access by healthcare personnel and maintain a safe environment for the residents and staff. The same P&P indicated processes which included: Residents with cognitive or behavioral challenges and will be observed when they are near Alcohol Based Hand Rub (ABHR) dispensers.

Based on observation, interview, and record review, the facility failed to prevent and timely identify a pressure ulcer (Injury to skin and underlying tissue resulting from prolonged pressure on the skin and/or underlying soft tissue usually present over a bony prominence) for one of three sampled residents (Resident 1) by failing to: 1. Reposition and turn Resident 1 every (Q) two hours in accordance with the facility's policy and procedures titled Prevention of Pressure Ulcers/Injuries, revised 7/2017. 2. Perform skin assessments daily, weekly, and quarterly (every three months) for Resident 1. These deficient practices resulted in Resident 1 developing a blister (A small bubble on the skin filled with serum and caused by friction, burning, or other damage], to the left buttock and left flank (The area on the side between the ribs and hip) on 5/15/2023 for Resident 1. A blister is also staged as a Stage II (Partial thickness skin loss involving epidermis [the outermost layer of the skin], dermis [the middle layer of the skin], or both [epidermis and dermis] which presents as an abrasion [the process of scraping or wearing something away] pressure ulcer. Findings: A review of Resident 1's admission record (Facesheet) indicated the facility admitted Resident 1 on 9/26/2022 with diagnoses including cerebral vascular disease (CVA- Stroke, a term for conditions that affect blood flow to your brain either by a clot or by a ruptured blood vessel), diabetes mellitus (elevated blood glucose[sugar] levels), and generalized muscle weakness. A review of Resident 1's document titled assessment of decubitus ulcer (pressure ulcer) potential dated 10/9/2022, indicated Resident 1 scored 23 points (Scores above 16 are considered a risk for developing decubitus ulcer). A review of Resident 1's care plan dated 10/9/2022, for Potential for Skin breakdown/Pressure ulcers related to fragile (delicate) and sensitive skin and total incontinent (inability to voluntarily control passage of stool [feces] and urine). The care plan goals included for Resident 1's skin will remain intact (Not damaged), no skin breakdown or with pressure ulcer. The care plan interventions included: 1. May turn and reposition Q two (2) hours, 2. Assess skin condition upon admission, daily, quarterly, and as needed, 3. Use heel protectors (A medical device usually constructed of foam, air-cushioning, gel, or fiber-filling, and is designed to offload pressure from the heel of a non-ambulatory individual to help prevent decubitus ulcers on the boney heel area of the foot), foot cradles (A frame that is installed at the foot of the bed to keep sheets/blankets off legs/feet) as ordered; and 4. Monitor increase swelling, skin discoloration/breakdown every shift and report to the medical doctor (MD). 5. Body checks as ordered. A review of the facility's nursing re-admission evaluation/data collection dated 10/9/2022, indicated Resident 1's skin condition was dry warm with no pressure ulcers or diabetic ulcers (an open sore or wound that occurs in approximately 15 percent of patients with diabetes, and is commonly located on the bottom of the foot). A review of Resident 1's history and physical (H&P) dated 10/10/2022, indicated Resident 1 did not have capacity to make medical decisions due to chronic (ongoing) encephalopathy (any brain disease that alters brain function or structure) associated with CVA. The H&P indicated Resident 1 did not have, lesions (an abnormal change in structure of an organ or part due to injury or disease) on visible body areas. A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 4/18/2023, indicated Resident 1 had long term and short term memory problem. Resident 1 cognitive (the mental ability to make decisions of daily living) skills was severely impaired (A loss of part or all of a physical or mental ability). The MDS indicated Resident 1 was dependent on staff for bed mobility, surface transfer, locomotion (movement) on and off the unit, dressing, eating, toilet use, and personal hygiene. The MDS further indicated Resident 1 was not able to walk and had impairment on one side to upper extremities (arms) and lower extremities (legs). A review of Resident 1's physician's order dated 5/10/2023 timed at 9:24 am, indicated low air loss mattress (An air mattress covered with tiny holes. These holes are designed to let out air very slowly which helps keep the skin dry and, treat and prevent pressure ulcers) on bed for wound management every shift. for Resident 1. A review of Resident 1's physician's order dated 5/10/2023 at 9:59 am, indicated a wound consult and wound follow up care by an agency until resolved for Resident 1. A review of Resident 1's untitled document, dated 5/10/2023, indicated Resident had a deep tissue pressure injury on the left foot dorsal (refers to the back portion of the body). The approaches included to: 1. Provide pressure relieving mattress for wound management 2. Initial assessment followed by weekly body check. 3. Follow Q two hrs repositioning program 4. Perform daily body check for redness, open areas and report to medical doctor (MD). A review of Resident 1's untitled document, dated 5/10/2023, indicated Resident had a deep tissue pressure injury on the right foot dorsal lateral (side). The approaches included to: 1. Provide pressure relieving mattress for wound management 2. Initial assessment followed by weekly body check. 3. Follow Q two hrs. repositioning program 4. Perform daily body check for redness, open areas and report to MD. A review of Resident 1's untitled document, dated 5/10/2023, indicated Resident had a skin tear on the right buttock. The approaches included to: 1. Provide pressure relieving mattress for wound management 2. Initial assessment followed by weekly body check. 3. Follow Q two hrs. repositioning program 4. Perform daily body check for redness, open areas and report to MD. A review of Resident 1's untitled document, dated 5/10/2023, indicated Resident had a deep tissue pressure injury on the right heel. The approaches included to: 1. Provide pressure relieving mattress for wound management 2. Initial assessment followed by weekly body check. 3. Follow Q two hrs. repositioning program 4. Perform daily body check for redness, open areas and report to medical doctor. A review of Resident 1's untitled document, dated 5/10/2023, indicated Resident had a blister right toe. The approaches included to: 1. Provide pressure relieving mattress for wound management 2. Initial assessment followed by weekly body check. 3. Follow Q two hrs. repositioning program 4. perform daily body check for redness, open areas, and report to MD. A review of Resident 1's physician's order dated 5/18/2023, indicated to cleanse Resident 1's left buttock pressure injury stage II with Normal Saline (NS- wound care solution). A review of Resident 1's physician's order dated 5/19/2023 timed at 11 am, indicated Resident 1 was in pain during Restorative Nurse Assistant (RNA - a trained person to help patients regain their ability to perform daily activities such as bathing, eating, and dressing so they can return to their normal life with minimal assistance)/ Physical Therapy (PT - a medical treatment used to restore functional movements, such as standing, walking, and moving different body parts). The physician's order further indicated to start tramadol (a strong pain medication used to treat moderate to severe pain that is not being relieved by other types of pain medicines) 50 milligram (mg - unit dose measurement) one (1) tablet via Gastrostomy Tube (G-Tube - a tube inserted through the abdomen directly into the stomach for nutrition, hydration, medication) every six hrs. as needed (PRN) for severe pain . A review of Resident 1's care plan initiated on 10/9/2022, and updated on 5/19/2023, indicated, concerns for potential for complains of pain/discomfort. The goals indicated Resident 1's pain/discomfort will be relieved within one hour of intervention. The interventions included to encourage to verbalize and complaints of pain/discomfort, pain location, pain intensity, pain duration and intervene as needed . During an interview with family member 1 (FM 1) on 5/23/2023 at 9 am, FM 1 stated the facility admitted Resident 1 in 10/2022 and that Resident 1 did not have any pressure ulcers. FM 1 further stated that during one family visit with Resident 1, FM 1's family member discovered that Resident 1 had a blister to her left buttock and that the facility was not aware about the blister. FM 1 stated that Certified Nursing Assistant 1 (CNA 1) who was assigned to Resident 1, confirmed that Resident 1 was not frequently turned because Resident 1 was in, so much pain and was pushing them (staff) away most of the time. FM 1 further stated that the facility staff told her that Resident 1 did not request for pain medication when FM 1 when asked if the facility staff had administered any pain medications to Resident 1. During an observation with concurrent interview with Resident 1 on 5/23/2023 at 11:15 am, Resident 1 was observed in her room and lying down in bed. Resident 1 was well kempt (in a neat and clean condition; well cared for). Resident 1 was non-verbal (did not speak) and could only nod with her head mostly for yes and seldom for no. Resident 1's both feet were wrapped with bandages (wound care material) that extended from the toes to the ankles. Resident 1's feet were resting directly onto the mattress and no heel protectors (medical device constructed of foam, air-cushioning, gel, or fiber-filling, used to offload pressure from the heel of a non-ambulatory individual to help prevent pressure ulcers on the boney heel area of the foot) were observed on Resident 1's feet. During an interview with CNA 1 on 5/23/2023 at 12:53 pm, CNA 1 stated that Resident 1 was turned Q two hrs to prevent pressure ulcers. CNA 1 further stated Resident 1 gets guarded (protected), screams, and pushes staff back when moved because pain. CNA 1 further stated there was no documented evidence that indicated Resident 1 was turned every two hrs. CNA 1 further stated that on Monday, 5/15/23, she discovered a blister on Resident 1's left buttock and informed the treatment nurse (Tx). During an interview with the Tx nurse on 5/23/23 at 1:19 pm, the Tx nurse initially stated that Resident 1's family discovered that Resident 1 had pressure ulcer on the left buttock. The Tx nurse then later stated that the staff identified the left buttock pressure ulcer before Resident 1's family arrived at the facility. However, the Tx nurse confirmed and stated there was no documented evidence that the facility was the first to identify the pressure ulcer to left buttock for Resident 1. During an observation and concurrent interview with the wound care specialist Medical Doctor (MD 1) on 5/24/2023 at 1:47 pm, MD 1 stated he assessed Resident 1's left buttock pressure ulcer as a staged II pressure ulcer. MD 1 stated Resident 1's left buttock pressure ulcer wound bed (The base or the floor) was bright pink with no drainage. MD 1 stated the left buttock pressure ulcer measured 0.5 centimeters (cm, unit of measurement) long by (x) 0.9 centimeters wide. MD 1 further stated that the left lower flank wound consisted of two closely spaced intact blisters. MD 1 stated blisters contained serous fluid (a clear to pale yellow watery fluid). MD 1 stated the lower flank wound measured 3 cm long x 2.1 cm wide x 0.1 cm deep. When asked the potential effect for not assessing and identifying pressure ulcers, MD 1 stated Resident 1 was at risk for pressure ulcer and wound infection. During an interview and concurrent record review with the MDS nurse on 5/24/2023 at 2 pm, the MDS nurse stated the desk nurse (LVN), performs a resident's initial skin assessment and that the MDS nurse performs a resident's quarterly skin assessment. The MDS nurse stated that a resident's skin assessment includes checking for redness, wounds, and any other skin abnormalities. However, the MDS nurse did not include turning a resident and assessing the resident's back. A review of the facility's document titled, Job Description Registered Nurse, revised on 10/23/2015, indicated, . the responsibilities/accountabilities of an RN for patient care included assessing and evaluating patient's status. A review of the facility's policy and procedures (P&P) titled Prevention of Pressure Ulcers/Injuries, revised in 7/2017, indicated, the purpose of this procedure is to provide information regarding identification of pressure ulcer/injury risk factors and interventions for specific factors. The P&P indicated that, among other factors for prevention as mobility/Repositioning at least every two hours for residents who are reclining and dependent on staff for repositioning and monitoring by evaluating, reporting, and documenting potential changes in the skin.

Based on observation, interview, and record review, the facility failed to provide supervision and follow their policy and procedures titled, Wandering-Unsafe Residents, to ensure two of three sampled residents (Resident 1 and Resident 2) would not elope (leaving facility without notice or permission) from the facility. The facility failed to: -Develop and implement a person-centered comprehensive elopement care plan for Resident 1 and Resident 2. -Ensure Resident 1 and Resident 2 received care and supervision to prevent accidents and elopement. -Implement elopement care plan interventions to monitor Wander Guard (a device that resident wear and when attempts to wander too close or through the doorway, the door monitor alarm sounds audibly) placement and functioning for Resident 1 and monitoring resident's whereabouts for Resident 2. -Ensure the exit alarms were working properly. As a result, on 3/6/2022, Resident 2 eloped from the facility was found on the street the following day at 2:10 AM. Resident 2 was transferred to the General Acute Care Hospital with abrasions, laceration to left eyebrow, high temperature (fever) and change of Level of Consciousness (ability to relate to self and environment). In addition, Resident 1 eloped from the facility on 12/14/2022 and admitted to GACH 1 on the same day with lacerations (deep cut or tear in skin) and hematoma (a mass of clotted blood) to forehead. Resident 1 eloped again on 12/22/2022. and was admitted to GACH 2 on 12/24/2022 with blunt head trauma (when the head is impacted by a force). On 12/28/2022 at 3:06 PM, an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified in the presence of the Director of Nursing (DON), the Infection Preventionist and the Social Services Director, regarding the facility's failure to properly identify residents who were at risk for elopement and to prevent Resident 1 and Resident 2 from eloping from the facility. On 12/30/2023 at 4:48 p.m., while onsite at the facility, the IJ was lifted after the Administrator (ADM) and DON submitted an acceptable Removal Plan (interventions to correct the deficient practices) which was verified and confirmed through observation, interview and record review. The IJ was removed in the presence of the DON. The acceptable removal plan was as follows: 1. On 12/29/2022, Registered Nurse Supervisor and Licensed Nurse conducted a resident head count. All 87 residents were accounted for every four hours for 24 hours. Licensed Nurse and Certified Nursing Assistant (CNA) or designated staff member shall do a head count at the beginning of each shift and shall complete the log provided thereafter. 2. A designated staff was assigned to monitor the entrance/exit door for 24 hours until the new wander guard system and monitor at the Nursing station is installed. The designated staff shall check each person coming out of the exit door. Procedure as follows: -For staff members they must present their identification badge prior to exiting. -For visitors, upon entering they will be given a visitor's name tag /badge to be worn during their visit and must be surrendered upon exit. All other individual who attempts to exit and is not a staff member nor a visitor must be validated first before they can be let out. (May refer to the binder with resident's pictures). All residents' photos were compiled in a binder and placed by the exit door for reference. On 12/29/2022, maintenance supervisor inspected the wander guard system and wander guards and have identified that the system is no longer at its full function. A new wander guard system order was placed on 12/29/2022. 3. The DON and Minimum Data Set (MDS) coordinator re-assessed all 87 residents for elopement/wandering risk., all residents at risk for elopement will be reviewed further and based on the recommendations of the Interdisciplinary Team (IDT) members will obtain an order for wander guard or 1 to 1 (1:1) sitter until deemed stable/safe; residents who are at risk for elopement may have to be placed closer to the nursing station or farther from the exit doors whichever is appropriate/safer for the resident's needs. IDT to follow up and shall be completed by 12/29/2022. 4 residents were identified to be high risk for elopement; care plans were reviewed and renewed. IDT was conducted on 12/29/2022. 4. The DON provided an In-service training and re-education to all staff on Accidents/Hazards and Supervision with Emphasis on Elopement and Wandering on 12/28-12/29/2022. 5. The DON or designee shall review all the new admissions and re-admissions for elopement risks and validate the accuracy of the initial assessment. In addition, the DON or designee shall review any change of condition that is related to elopement and validate accuracy of assessment and the interventions that was put in place. Any findings shall be corrected immediately and shall be discussed daily during stand-up meeting for follow up. 6. A monitor shall be installed at the Nursing station for nurses to be able to monitor live footage of the exit doors within the next 10 days. The DON placed an order for a new Wander Guard system on 12/29/2022 and shall be installed within 10 days. A review of the facility's policy and procedure on Elopement and wandering shall be done and necessary changes will be made as needed recommended by the Quality Assurance and Assessment (QAA) committee. 7. Director of Staff Development shall conduct a follow up in-service on Accidents/Hazards/Supervision every week for one month then monthly for one month, then quarterly for two months, and as needed thereafter. 8. Administrator shall keep track on the findings, Trends, or any issues related to Accidents/Hazards/Supervision shall be discussed during the monthly Quality Assurance and Assessment (QAA) meeting for recommendations to ensure continued compliance. Findings: a. A review of Resident 1's Face sheet (Admission Record) indicated the facility admitted Resident 1 on 1/20/2022 and readmitted on [DATE], with diagnoses including dementia (loss of memory, thinking and reasoning), psychosis (a mental disorder characterized by a disconnection from reality), depression (a mood disorder with feeling of sadness and loss of interest), and history of falling. A review of Resident 1's Physician's Orders dated 1/20/2022 indicated to place a wander guard alarm on the resident's left arm because of his tendency to wander outside the facility, monitor wander guard alarm for proper placement and functioning every shift, and change Wander Guard alarm every three months. A review of the Care Plan dated 1/20/2022 indicated Resident 1 had a tendency of wandering outside the facility. The goal indicated Resident 1 would remain inside the facility and would not manifest signs of elopement. The care plan approach indicated for staff to observe for signs of elopement such as verbalization of wanting to go outside / home by the resident, searching behavior, looking for exit doors, watching others exit the facility, monitor resident`s whereabouts, apply wander guard alarm on left arm of the resident, and that the Licensed Vocational Nurse / Certified Nursing Assistant (LVN / CNA) assigned to Resident 1 should know the resident`s whereabouts with proper endorsement during breaks. According to a review of Resident 1's Initial Wandering Assessment Guide dated 1/21/2022, the resident was ambulatory, able to walk alone, with a history of wandering. A review of Resident 1`s Physician's History and Physical (H&P) dated 1/22/2022 indicated, the resident had fluctuating (changing) capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care-screening tool) dated 2/1/2022, indicated Resident 1 had intact cognition (able to make decisions consistent). The MDS indicated the resident did not have wandering behavior, required limited assistance with one-person physical assistance for activities of daily living (ADLs, such as transferring, walk in room and corridor, dressing, toilet use, and personal hygiene). A review of Resident 1's Physician's Orders dated 8/8/2022 at 2:30 PM indicated to transfer the resident to hospital for further evaluation and treatment for COVID-19 (Coronavirus disease, a severe respiratory illness caused by virus and transmitted from person to person), and high temperature of 101-degree Fahrenheit (F-normal temperature ranges between 97-degree F to 99-degree F). A review of Resident 1`s GACH 3 Physician`s Noted dated 8/9/2022 indicated the resident was transferred to the hospital for cough and shortness of breath. Resident 1 was positive for COVID-19 and his laboratory tests show acute kidney injury (a condition in which the kidneys suddenly cannot filter waste from the blood), and hypokalemia (lower than normal potassium [a mineral that body needs to work properly] in the blood). A review of Resident 1`s re-admission orders dated 8/11/2022, did not indicate an order for placement and monitoring of a wander guard alarm. A review of Resident 1`s Care Plans dated 8/11/2022 indicated no care plan was updated regarding Resident 1`s tendency to wander outside the facility. The MDS dated [DATE] after resident`s re-admission indicated Resident 1 had moderately impaired cognition (decisions poor, cues/supervision required). A review of Resident 1`s Investigation Report dated 12/14/2022 indicated the resident was missing and had eloped. The report indicated Resident 1 was already missing when the morning shift started at 7 AM. A review of Resident 1`s Investigation Report dated 12/14/2022 indicated Resident 1 was last seen on 12/14/2022 at 6:45 AM. The corrective action and plan of care indicated to apply a Wander Guard alarm to Resident 1's left arm. According to a review of the Facility`s Missing Person Report dated 12/14/2022, Resident 1 was found in GACH 1 on 12/14/2022 at 11 PM confused with multiple bruises on his face. A review of the GACH 1 Physician`s H&P form dated 12/14/2022 at 11:10 PM indicated Resident 1 was found altered and minimally responsive on a park bench. Resident 1 was noted to have a hematoma (an injury causes blood to collect and pool under skin) to the forehead. A review of GACH 1 Discharge Summary Notes dated 12/15/2022 at 7:23 PM indicated, A clinical picture concerning for possible intracerebral brain hemorrhage (ICH- bleeding in brain) and infections. The note indicated possible acute versus chronic laceration to Resident 1`s rectum. Given Resident 1`s unclear history, he will be treated empirically (treatment given based on experience without knowledge of cause) for possible sexual assault (offensive physical contact or bodily harm on a person). A review of Resident 1`s Actual Elopement Care Plan dated 12/14/2022 indicated the goal was for Resident 1 to have no daily episodes of elopement. The care plan approach indicated to observe for signs of elopement such as searching behavior, looking for exit doors and watching others exit the facility, monitor resident`s whereabouts, apply wander guard alarm to resident`s left arm as ordered, monitor wander guard alarm for proper placement and functioning every shift, change Wander Guard alarm every three months and LVN/CNA assigned to him should know the resident`s whereabouts and proper endorsement during breaks. A review of Resident 1`s Physician`s Order dated 12/15/2022 at 4 PM indicated to place a Wander Guard alarm on resident's left arm because of his tendency to wander outside the facility, monitor wander guard alarm for proper placement and functioning every shift, and change Wander Guard alarm every three months. A review of Resident 1`s Wander Guard Alarm Monitoring Log initiated on 12/15 - 12/22/2022, indicated no entries for monitoring. The Monitoring Log instructions indicated: After completing the signaling device test, make your initial in the box. Note special circumstances on the comment list (e.g., wristband replacement or damage to signaling device case). The form was blank and did not have a single entry. A review of the Elopement Risk assessment dated [DATE], indicated Resident 1 was a readmission who exhibited routine or sporadic (occasional) confusion, anxiety or disorientation, exhibits wandering with no purpose, searching or looking for exit doors, and had a history of elopement. The elopement risk assessment indicated Resident 1 was at risk for elopement. According to a review of Resident 1's Medication Administration Record (MAR) dated 12/15 - 12/22/2022, Resident 1 was not monitored for proper placement and functioning of Wander Guard alarm, per the physician's instructions. During an observation on 12/22/2022 at 3 PM, Resident 1 was observed in the hallway, walking around. During a concurrent interview, Resident 1 was asked if he left the facility and he stated yes. Resident 1 was not able to answer further questions and he repeatedly stated that he was okay. A small abrasion above Resident 1`s upper lip and a scratch on his chin were observed. A Wander Guard alarm was observed on the resident's left wrist. A review of Resident 1`s Nurses Notes dated 12/22/2022 documented by LVN3 indicated, at 6:30 PM Resident 1 was observed walking around the facility. The Nurses Notes indicated Resident 1 was always wandering inside the facility. At 7 PM nursing staff noted the resident was not in his room. The search for Resident 1 was initiated and staff searched throughout the facility and nearby neighborhood and was not able to find Resident 1. The note indicated that on 12/22/2022 at 10:30 PM, the police arrived at the facility and filed a missing resident report. A review of the GACH 2 Physician`s H&P dated 12/23/2022 at 1:23 PM indicated Resident 1 was found sitting down in the street with multiple abrasions (superficial injuries of skin). The physician`s notes further indicated Resident 1 appeared anxious, shaky and complained of pain to his left knee. A review of the GACH 2 Emergency Department (ED) Physician`s notes dated 12/23/2022 at 11:20 PM indicated Resident 1 showed possible signs of alcohol withdrawal (symptoms that occur when someone stops using alcohol after a period of heavy drinking) with tongue fasciculations (twitching and involuntary contraction and relaxation of tongue muscle) and bilateral (both sides) hand tremors (shake). The notes indicated Resident 1 was covered in paint and was suspected of possible huffing (a type of substance abuse that involves inhaling fumes from common household substances) versus alcohol withdrawal. The impression and plan indicated blunt head trauma. A review of Resident 1`s Nurses Notes dated 12/24/2022 at 10 AM indicated the facility received a call from GACH 2 informing that Resident 1 was admitted into the hospital. The note indicated Resident 1`s family member, physician and the police were notified. A review of the GACH 2 Physician Progress Note dated 12/27/2022 at 3:05 PM indicated Resident 1 tried to climb out of his bed and attempted to pull out his lines, which required bilateral (both sides) soft wrist restrains (device that limit a patient`s movement). During an interview on 12/28/2022 at 10:42 AM, The DON stated although there were surveillance cameras at the front and the back doors of the facility, according to the facility`s Administrator (ADM), there was no back up footage to be reviewed. The DON stated Resident 1 had a history of removing his Wander Guard alarm, but the facility did not develop any care plans for Resident 1`s repeated behavior to remove his Wander Guard alarm. The DON further stated she was not sure how Resident 1 exited the facility and that It might be from the front door or the back door. During an interview on 12/28/2022 at 12:20 PM, Director of Social Services (DSS) stated Resident 1 eloped from the facility for the first time on 12/14/2022 and he did not have a Wander Guard alarm because he never showed any exit seeking behavior. The DSS stated Upon Resident 1's re-admission back to the facility on [DATE], we placed a Wander Guard alarm. The DSS stated Resident 1, Never told me that he wanted to go home. The DSS stated Resident 1 eloped from the facility on 12/22/2022 with his Wander Guard alarm on his wrist. During an interview on 12/28/2022 at 1:50 PM, CNA 1 stated, Resident 1 was always walking around in the facility. He would enter inside other residents` rooms. He was confused and walking without a walker. CNA1 stated Resident 1 used to remove his Wander Guard alarm from his arm and we would find the Wander Guard alarm in his room. During an interview on 12/28/2022 At 2:35 PM, the DON stated Resident 1 did not have a Wander Guard alarm when he was readmitted to the facility on [DATE] because he was too weak and unable to ambulate but confirmed Resident 1 remained a high risk for elopement on 8/11/2022. The DON stated that after Resident 1 recovered and he was no longer weak, there was no re-assessment done regarding his ability to elope from the facility and consequently Resident 1 remained in the facility without a Wander Guard alarm on his person. The DON stated Resident 1 eloped from the facility on 12/14/2022. The DON stated the facility did not provide enough monitoring for Resident 1 to prevent him from eloping. During an interview and concurrent record review of Resident 1`s care plans on 12/28/2022 at 2:37 PM, the DON stated there was no form indicating how the assigned staff members were monitoring Resident 1's whereabouts and providing proper reports during breaks. The DON confirmed that care plan intervention requirement to check Resident 1`s Wander Guard during every shift was not performed during the month of December 2022. The DON stated Resident 1's care plan did not indicate the frequency of monitoring resident`s whereabouts. The DON also confirmed there was no documentation in Resident 1's medical record indicating that this monitoring was performed by the staff. The DON stated Resident 1's care plans were not updated after his first elopement which occurred on 12/14/2022. The DON stated the facility could have developed a more appropriated person-centered care plan for Resident 1 to prevent elopement. During an interview on 12/28/2023 at 2:40 PM, the DSS stated she was in charge of checking residents Wander Guard alarms. DSS stated, I check their alarms every week. The DSS stated that for Resident 1, she initiated the Wander Guard monitoring log on 12/15/2022 and did not perform the wander guard alarm check for Resident 1 on 12/22/2022. During an observation on 12/29/2022 at 3 PM, the Assistant Maintenance Supervisor (AMS) brought a tester for the facility door's Wander Guard alarm. During the observation the tester did not consistently trigger the alarm when the front door barrier was crossed. During a concurrent interview, the AMS stated the Wander Guard testing device was not setting off its alarm consistently. The AMS stated that when the Wander Guard alarm was in fact triggered, it was deactivated by a code manually entered on to the system platform. During an observation on 12/29/2022 at 3:09 PM, the AMS tested the Wander Guard alarm for the back door and the tester did not trigger the alarm when the back door barrier was crossed. During a concurrent interview with the DON, the DON stated and confirmed that the Wander Guard testing device was not setting off the alarm at the back door. During an interview on 12/30/2022 at 11:16 AM, regarding Resident 1's elopements on both 12/14/2022 and 12/22/2022, the facility Administrator (ADM) stated it was either the Wander Guard alarm system not working properly to recognize a breach, or the alarm engaged, and the staff deactivated the alarm without verifying weather or not a resident had exit the facility. During a telephone interview on 1/3/2023 at 10:43 AM, Family Member 1 stated, I know the facility is not a locked unit (a secured ward in a manner that prevents a resident from leaving the unit at will) and my family had a sensor on his arm. Family Member 1 stated, It is either the facility's alarm system was not working properly, or the staff simply did not pay attention when the alarm went off. Family Member 1 stated, I believe the facility could have done a better job supervising my family to prevent him from exiting the facility two times in one month. Family Member 1 stated, I visited my family in the hospital, he was confused, and he was repeating sentences. He was on restraints because the nurses told me that he was trying to remove his intravenous (IV - a way of giving a drug through a needle or tube inserted into a vein) access. During an interview on 1/3/2023 at 12:26 PM, CNA 2 stated that Resident 1 probably eloped at the back door because the alarm at the back door exit did not sound as loud as the alarm at the front door exit. CNA2 stated on 12/22/2022, he was assigned to Resident 1 during the 3PM-11PM shift, at around 4:30 PM, Resident 1 was agitated and wandering throughout the facility. During an interview on 1/3/2023 at 1:10 PM, LVN2 stated, On 12/14/2022, I was assigned to Resident 1. At 7 AM, we started to pass the breakfast trays. The staff reported to me that Resident 1 did not touch his breakfast tray and nowhere to be found. We initiated a search for Resident 1 which included asking the night shift nurses wether or not they had seen Resident 1. They told us that Resident 1 was last seen at 6:45 AM. LVN2 stated the potential outcome of not providing adequate supervision for residents is elopement and consequent injuries and/or harm. During a telephone interview on 1/3/2023 at 2:21 PM, The ADM stated, The DON and I normally review the facilities policies and procedures and update accordingly in the event there is an issue and requires a revision. The ADM stated he did not know what was the required time period within which the facility must review or revise its policies and procedures. The ADM stated the 'Safety and Supervision of Residents policy currently in place was not dated and the Elopement policy and procedure was revised on December 2007. The ADM stated, for the undated policies, I do not have a way to know when it was actually revised. During a telephone interview on 1/6/2023 at 4:10 PM, Resident 1`s assigned RN Care Team Manager (RN-CTM) for Aids Healthcare Foundation-Positive Healthcare stated that she visited Resident 1 in GACH 2 on 12/27/2022 and she observed Resident 1's wander guard alarm remained on his left arm. During an interview on 1/12/2023 at 10:06 AM, the DON stated, The Initial Wandering Assessment Guide was a form the facility was using previously to perform wandering assessment for residents. The DON stated, The facility is currently using the Elopement Risk Assessment because this form is more accurate. The DON stated there was no Elopement Risk Assessment done on 1/21/2022 (first admission) for Resident 1. b.A review of Resident 2's Face sheet indicated the facility admitted Resident 2 on 2/2/2022 and readmitted on [DATE] with diagnoses including dementia, encephalopathy (any brain disease that altered brain function or structure), and history of falling. A review of Resident 2's Physician's Orders dated 2/2/2022 indicated to place a wander guard alarm on resident `s left arm because of his tendency to wander outside the facility, monitor Wander Guard alarm for proper placement and functioning every shift, and change wander guard alarm every three months. A review of the Care Plan dated 2/2/2022 indicated Resident 2 had a tendency of wandering outside the facility and needed a Wander Guard alarm due to history of elopement from other facility as reported by the discharging hospital, family, and the physician. The care plan goal indicated Resident 2 would remain inside the facility and will not manifest signs of elopement. The care plan approach indicated to observe for signs of elopement such as verbalization of wanting to go outside / home by the resident, searching behavior, looking for exit doors, watching others exit the facility, monitor resident's whereabouts and apply Wander Guard alarm on left arm of the resident. According to a review of Resident 2's Initial Wandering Assessment Guide dated 2/3/2022, the resident had dementia, was ambulatory and able to walk alone, with a history of wandering. A review of Resident 2`s Physician's H&P dated 2/5/2022 indicated the resident had fluctuating capacity to understand and make decisions. A review of Resident 2`s Elopement Care Plan dated 3/6/2022 indicated Resident 2 was nowhere to be found when the RN was making his rounds at 12:30 PM. The nurses searched throughout the facility, and the neighboring blocks. The care plan indicated that on 3/7/2022 at 1:05 AM, a police officer called the facility and reported that they found Resident 2 on the street. On 3/7/2022 at 2:10 AM the police dropped off Resident 2 at the facility. The care plan approach indicated for the staff to observe for signs of elopement such as verbalization of wanting to go outside/home by the resident, searching behavior, looking for exit doors, watching others exit the facility, monitor resident`s whereabouts, apply wander guard alarm on left arm of the resident and LVN/CNA assigned to the resident should know the resident`s whereabouts and proper endorsement during breaks. A review of Resident 2's Physician's Orders dated 8/16/2022 indicated to transfer resident to hospital for COVID-19, generalized weakness, and temperature of 102.9-degree Fahrenheit. A review of the Elopement Risk assessment dated [DATE], indicated Resident 2 was a readmission who exhibited routine or sporadic (occasional) confusion, anxiety or disorientation, exhibits wandering with no purpose, searching, or looking for exit doors, and has a history of elopement. The elopement risk assessment indicated Resident 2 was at risk for elopement. A review of Resident 2's Incident Investigation Report dated 11/1/2022 at 5 PM, indicated the nursing staff noted Resident 2 was not in his room when he was making his rounds. Staff searched throughout the facility, building and nearby neighborhood and was not able to find Resident 2. The note indicated that on 11/2/2022 at 12 PM, the facility received a call from GACH 1 reporting Resident 2 was in the hospital with some abrasions, laceration to left eyebrow and change of Level of Consciousness (ability to relate to self and environment). A review of GACH 1 physician's H&P dated 11/1/2022 at 11:35 PM indicated Resident 2 was brought into the Emergency Department (ED) after a ground level fall. Resident 2 reported that he was walking down the sidewalk and fell on his head. Resident 2 was noted to have a three-centimeter (cm) laceration above the left eyebrow which was sutured (to close a wound with threads) and ecchymosis (bruise) on his left cheek. A review of the MDS dated [DATE], indicated Resident 2 had intact cognition (was able to make decisions) and required limited assistance with one-person physical assistance for ADLs, such as dressing, toilet use, and personal hygiene). The MDS indicated Resident 2 did not exhibit wandering behavior. During an interview on 1/3/2022 At 2 PM, The DON stated there was no form indicating how the assigned staff members are monitoring Resident 2's whereabouts and providing proper reports during breaks. The DON stated Resident 2's care plan does not indicate the frequency of monitoring resident's whereabouts. The DON also confirmed there is no documentation in Resident 2's medical record indicating that this monitoring was performed by the staff. The DON stated that Resident 2's care plans were not updated after his first elopement which occurred on 3/6/2022. The DON stated that the facility could have developed a more appropriated person-centered care plan for Resident 2 to prevent elopement. A review of an undated policy and procedure titled, Wandering-Unsafe Residents, indicated the staff will identify residents who are at risk of harm because of unsafe wandering (including elopement). The staff will assess at-risk individual for potentially correctable risk factors related to unsafe wandering. The policy indicated that the resident`s care plan will indicate the resident is at risk for elopement or other safety issues. Interventions to try to maintain safety will be included in the resident's care plan. Nursing staff will document circumstances related to unsafe actions, including wandering by a resident. Staff will institute a detailed monitoring plan, as indicated for residents who are assessed to have a high risk of elopement or other unsafe behavior. A review of an undated policy and procedure titled, Safety and Supervision of Residents, indicated resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident`s assessed needs and identified hazards in the environment. The type and frequency of resident supervision may vary among residents and over time for the same resident. For example, resident supervision may need to be increased when there is a change of condition. The policy indicated that resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Our individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), who had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility failed to: -administer the [MEDICATION(S)] medication (an antipsychotic medication used to treat certain mental health disorders) to Resident 1, per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -provide psychological counseling to determine the underlying cause for the accusatory behavior (imply that someone has done something wrong) when Resident 1 threw juice at Resident 2 and accused Resident 2 for stealing his cigarette lighter on 5/16/2022. As a result, on 5/23/2022, Resident 1 exhibited aggressive behavior, expressions of distress and anxiety when he punched Resident 3 in the right eye. Resident 3 bled immediately causing a hematoma (a collection of blood under the skin), was transferred to the general acute hospital (GACH 1) where Resident 3 was found to have a closed fracture of the right orbit (break in one of the bones surrounding the eyeball or eye socket, an orbital fracture) with a laceration (deep cut or tear in skin) under the right eye and under the nose, requiring antibiotics. Resident 1 was transferred to GACH 3 for aggressive behavior and other behavioral problems. On 6/1/2022, Resident 2 stated he felt threatened by Resident 1 and on 6/6/2022 Resident 3 stated he was startled and experienced a lot of pain. Findings: A review of Resident 1's Admission Record indicated the facility admitted the resident on 5/11/2022, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Care Plan dated 5/11/2022, indicated non-pharmacological (not based on medication) interventions for [CONDITION(S)], [CONDITION(S)] disorder with medication. The care plan approach indicated Resident 1 was to receive psychological services and treatment which included increased goal-directed behaviors, focus thoughts on reality, redirect, provide reassurance and trust, focus on rapport, maintain calm and empathy, active listening, and environment management. A review of the Care Plan dated 5/11/2022, indicated Resident 1 was on a [CONDITION(S)] medication secondary to [CONDITION(S)] and [CONDITION(S)] disorder manifested by talking to self. The care plan interventions included psychiatrist follow up monthly as ordered, encourage to verbalize thoughts, feelings, concerns, spend time with resident and listen attentively, monitor [CONDITION(S)] medications for possible adverse reaction every shift. According to a review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the History and Physical dated 5/14/2022, indicated Resident 1 was discharged from the acute care hospital, had no aggressive behavior documented and had the capacity for medical decision making. A review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Situation Background, Assessment and Request (SBAR) Communication Form and Progress Notes dated 5/16/2022, indicated Resident 1 threw juice at Resident 2 and was identified as a new behavioral symptom. The SBAR indicated Resident 1 stated Resident 2 stole his cigarette lighter. Resident 1 did not see Resident 2 take his cigarette lighter but stated, Sure that it was him who took it. Resident 1's primary physician was notified. A review of Resident 2's SBAR dated 5/16/2022, indicated Resident 2 was in the rehabilitation department when he verbalized that his roommate Resident 1 threw juice at him but Resident 1 apologized right away. Resident 2 had no injuries or pain. Resident 2 was moved to another room. The SBAR indicated the director of nursing, Resident 2's primary physician and responsible party were notified. A review of the Physician's Telephone Orders dated 5/16/2022 at 9 a.m., indicated to increase [MEDICATION(S)] 200 mg orally twice per day for [CONDITION(S)] and agitation, and to administer [MEDICATION(S)] 200 mg every six hours as needed (PRN) for [CONDITION(S)] and agitation, manifested by throwing things like juice to others and accusatory behavior. A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 5/18/2022 indicated Resident 1 was oriented to year, month, and day, but required supervision with activities of daily living (ADLs). The MDS indicated Resident 1's behavior with hallucinations (perceptual experiences in the absence of real external sensory stimuli) and that the resident was on antipsychotic medications (for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . According to a review of the Daily Skilled Notes dated 5/20/2022, Resident 1 was calm, with no behavioral problems. During an interview on 6/1/2022, at 11:01 a.m., licensed vocational nurse 1 (LVN 1) stated when she interviewed Resident 1, Resident 1 stated he threw juice on Resident 2 (on 5/16/22) because Resident 2 stole his cigarette lighter. LVN 1 stated she informed Resident 1 that nobody stole his cigarette lighter. During an interview on 6/1/2022 at 11:56 a.m., Resident 2 stated he felt threatened by Resident 1's presence. Resident 2 stated he felt better when he was moved to another room. On 6/1/2022 at 12:57 p.m., during an interview, the director of nursing (DON) confirmed Resident 1's [MEDICATION(S)] 200 mg was not signed out as given on 5/15/2022. The DON stated the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . During interview on 6/1/2022 at 1:10 p.m. the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . LVN 1 stated Resident 1's [MEDICATION(S)] 200 mg was not signed out as given on 5/15/2022. LVN 1 stated she was unable to find documentation that the [MEDICATION(S)] 200 mg was given on 5/15/2022. LVN 1 stated if Resident 1 missed a dose of the [MEDICATION(S)], it would trigger accusatory behavior. b. A review of the MDS dated [DATE], indicated Resident 3 was oriented to year, month and day, required one-person physical assistance with ADLs, and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A review of the Nurses Notes dated 5/23/2022, at 8:30 p.m., indicated a loud sound and commotion (noisy disturbance) were coming from Resident 1's room. The Notes indicated Resident 1 was holding down his roommate, Resident 3, who was sitting in his wheelchair. Resident 3 was bleeding from the face and the right eye. Resident 1 was asked to move away from Resident 3. Resident 1 and Resident 3 were separated, and Resident 1 stated, I was very angry because someone stole my beanie (hat), this old guy took it. Resident 1's primary physician was notified and gave an order to transfer Resident 1 to the GACH for aggressive behavior and other behavioral problems. The notes also indicated a cold compress was applied to stop the bleeding from Resident 3's face. The paramedics were called due to open skin that might need stitches and further evaluation. The police and the primary physician were notified. A review of Resident 3's Prehospital Care Report Summary dated 5/23/2022, at 8:34 p.m., indicated Resident 3 had hematoma (bruise, caused by an injury resulting in blood collecting and pooling under the skin) and laceration to the right eye. Resident 3 stated his roommate (Resident 1) accused him of stealing his beanie (hat) and then assaulted him. A review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . According to a review of Resident 3's GACH 1 Emergency Record dated 5/23/2022, at 9:51 p.m., Resident 3 sustained some blows to the head and complained of pain under his right eye and under his nose. The Emergency Record indicated Resident 3's right eye was red, bleeding from the eyelid and nose after being assaulted by his roommate. The GACH 1 Emergency Record indicated Resident 3 had a three-centimeter (cm.) laceration under the right eye and 0.5 cm laceration under the nose. A review of the GACH 1 Doctor Notes dated 5/23/22 indicated Resident 3 had a computed tomography (CT, procedure that used a computer linked to an x-ray machine to make a series of detailed pictures of areas inside the body) that indicated an orbital fracture. The Notes indicated Resident 3 needed antibiotics and specialized care. The Notes indicated GACH 1 did not have the capacity to take care of Resident 3's injuries and needed to be transferred to GACH 2 for higher level of care. A review of the GACH 2 Oral and maxillofacial surgery (medical specialists who diagnose and treat diseases affecting the mouth, jaws, face and neck) Consultation Note dated 5/24/2022 at 10:33 p.m., indicated no surgical intervention but was placed on strict sinus (air-filled cavity in the skull bone) precautions including no nose blowing, no sneezing and coughing with open mouth, no Valsalva maneuver (an effort to exhale without letting air escape through the nose of mouth) and no heavy lifting more than 10 pounds. Resident 3 was discharged back to the facility on [DATE]. During an interview on 6/1/2022, at 12:46 p.m., LVN 2 stated he was at the nurse's station on 5/23/2022 when he heard a loud sound coming from Resident 1's room. When he went to check, Resident 1 had his fist closed, Resident 3 was bleeding from the right side of his face, and pressure was applied to stop the bleeding. The paramedics were notified. LVN 2 stated Resident 1 accused Resident 3 of stealing his beanie (hat) and was very angry. On 6/6/2022, at 1:35 p.m., during an interview Resident 3 stated Resident 1 accused him of taking his beanie (hat) and struck him in the face with a closed fist. Resident 3 stated he bled immediately, and he was startled and experienced a lot of pain. During a telephone interview on 6/22/2022, at 2:47 p.m., the nurse practitioner (NP) stated she gave an order to increase Resident 1's [MEDICATION(S)] to 200 mg two times a day on 5/16/2022, because he was not sleeping well and was combative. The NP stated the facility did not notify her that Resident 1 had accusatory behavior. Stated if she had known, she would have given order for counseling so Resident 1 would comprehend his actions. The NP stated she did not order laboratory tests to determine underlying cause of Resident 1's behavior and stated she told the nurses to tell Resident 1 not to throw juice on other residents. During a telephone interview on 6/28/2022, at 4:35 p.m., the DON stated when Resident 1 threw juice on Resident 2 on 5/16/2022, they called the primary physician and the primary physician stated to call the psychiatrist. LVN 1 called the NP, and she gave the order to increase the [MEDICATION(S)] to 200 mg two times a day on 5/16/2022. The DON stated the NP did not come to the facility to evaluate Resident 1. The DON stated the nurses gave Resident 1 non-pharmacological interventions such as emotional support, encouraged to verbalize thoughts and for the staff to listen to Resident 1 attentively. During a telephone interview on 7/12/2022 at 3:38 p.m., the primary physician stated he gave order for a psychiatrist consult on 5/16/2022, to manage the behavioral/psychiatric issues of Resident 1. Further review of Resident 1's medical record indicated there was no written order from the physician for Resident 1 to receive a psych consult. A review of the facility's policy and procedure titled, Antipsychotic Medication Use, revised on 1/2022, indicated the attending physician and other staff will gather and document information to clarify a resident's behavior, mood, function, medical condition, specific symptoms and risks to the resident and others. The attending physician will identify, evaluate, and document, with input from other disciplines and consultants as needed, symptoms that may warrant the use of antipsychotic medications. A review of the undated facility policy titled, Administering Medications, indicated if a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The policy further indicated the individual administering each medication must initial the resident's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observation, interview, and record review, the facility failed to implement infection control measures in preventing the development and transmission of COVID-19 (Coronavirus disease, a highly contagious respiratory infection that could result in death) for four of four sampled residents (Residents 1, 2, 3 and 4) out of a total of 67 residents in the facility. The facility also failed to promote and control a safe environment for ten of 42 facility staff (Licensed Vocational Nurse (LVN) 2, LVN4, LVN6, LVN8, Housekeeper (HK) 1, HK2, HK3, HK4, Certified Nurse Assistant (CNA8), CNA9), who did not use appropriate Personal Protective Equipment (PPE - protective items or garments worn to protect the body or clothing from hazards that can cause injury and to protect residents from cross-transmission) when required. The facility failed to: a. Ensure the facility had a clear designation of Cohorting units with the use of signage for the Green zone (residents with no Covid-19), Yellow zone (residents under investigation for Covid-19) and Red zone (residents with positive Covid-19), used to help stop the spread of infection from one person to another. Residents 1, 2, 3 and 4 were in the Yellow zone. b. Ensure there were adequate Alcohol-based hand rub (ABHR) in the common areas. There was no ABHR in the kitchen, green and yellow staff break rooms or the nursing stations. c. Ensure wipes used for cleaning were EPA (Environmental Protection Agency, a government agency tasked with environmental protection matters) approved. d. Ensure licensed vocational nurse 2 (LVN2), certified nursing assistant 9 (CNA9) , Housekeeping 2 (HK2), licensed vocational nurse 8 (LVN8), and all staff donned (put on) the proper fit tested (individualized test for proper fitting) NIOSH (National Institute for Occupational Safety and Health is responsible for conducting research and making recommendations for the prevention of work-related injury and illness) approved N95 mask (a particulate-filtering face piece respirator that meets the US National Institute for Occupational Safety and Health (NIOSH) and filters at least 95% of airborne particles). LVN2 wore his own hand made N95 silicone mask. e. Ensure there were PPE carts and trash bins in each resident room (including Resident 1, 2, 3 and Resident 4 yellow zone room), who were persons under investigation (PUI) for 14 days due to a possible exposure to rule out COVID-19 in order to doff (remove) PPE prior to leaving the room. f. Ensure a screening process for staff and for visitors entering and exiting the facility, including checking for signs and symptoms of COVID-19, history of travel, any contact with positive COVID-19 persons and reminder to do hand hygiene upon entering and exiting the facility. g. Ensure CNA8, LVN 6 and LVN 10, HK1, HK3, and HK 4, and all staff properly don and doff required PPE while in the Red Zone (where Covid-19 positive residents are placed). These deficient practices had the potential to result in spread of COVID-19 placing all 67 residents in the facility and staff at risk to be infected with COVID-19 and becoming seriously ill, leading to hospitalization and/or death. On 12/18/2020 at 5:06 p.m., 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 to a resident) was identified in the presence of the Licensed Vocational Nurse Supervisor (LVNS), Social Services Director (SSD) and the Director of Medical Record (MR) for the facility's failure to implement interventions to prevent the transmission of COVID-19 infection that threatened the health and safety of the residents and staff. On 12/23/2020 at 4:56 p.m., after the facility submitted an acceptable Plan of Action (POA, interventions to correct the deficient practices), the survey team verified and confirmed the implementation of the POA while onsite through observations, interviews and record review, and the IJ situation was removed in the presence of the Director of Nursing (DON) and the MR. The accepted POA included the following actions: a. A clear demarcation of the different zones was implemented with designated entrances. b. Housekeeping supervisor installed Alcohol-based hand rub throughout the facility. The facility designated a staff to monitor and ensure that ABHR are available. c. Facility removed and properly disposed Non-EPA approved ABHR. d. One-to-one in-service provided to LVN2, CNA9, LVN8 and HK2 and other staff were in-serviced for appropriate use of approved N95 mask. e. PPE carts were purchased and placed in each resident's room that required isolation. Trash bins were purchased and placed in each resident's room by the exit for PPE disposal (doffing). f. In-services provided to the staff regarding screening process. g. In-services provided to the staff regarding proper donning and doffing PPE. Findings: A review of the facility's census during onsite visits conducted on 12/18- 12/23/2020 indicated the facility had 67, 65, 64, 64, 62 and 61 residents in-house, respectively. a.During an observation on 12/18/2020 at 10:20 a.m., the facility did not have a clear designation of Cohorting zones- green, yellow or red zones. The non- nursing staff such as laundry, housekeeping and dietary were observed walking through the green then to the yellow zone and back again to the green zone, when using the timecard machine. During an observation on 12/18/2020 at 11:28 a.m., there were no signages seen clearly demarcating the different zones. During a concurrent interview, LVNS stated and confirmed there were no signages to notify staff where the green zone and the yellow zone start and end. During an observation on 12/18/2020 at 12:03 p.m., the rooms of Residents 1, 2, 3 and 4 (R1, R2, R3 and R4) did not have the correct signage regarding transmission-based precautions. During a concurrent interview the LVNS stated the facility needed the proper signage to be able to know the specific transmission-based precautions and the appropriate zone of the resident. A review of Resident 1's Admission Record indicated the facility admitted the resident on 10/21/2017 with [DIAGNOSES REDACTED]. A review of facility's line listing indicated Resident 1 received a positive Covid-19 result on 12/19/2020. A review of Resident 2's Admission Record indicated the facility admitted the resident on 10/8/2020 with the [DIAGNOSES REDACTED]. A review of Resident 3's Admission Record indicated the facility admitted the resident on 10/29/2020 with the [DIAGNOSES REDACTED]. A review of facility's line listing indicated Resident 3 received a positive Covid-19 result on 12/19/2020. A review of Resident 4's Admission Record indicated the facility admitted resident on 3/25/2019 with [DIAGNOSES REDACTED]. b. During an observation on 12/18/2020 at 10:30 a.m., there was no alcohol-based hand rub (ABHR) noted in the kitchen. During a concurrent interview the Dietary Supervisor (DS) stated and verified the kitchen did not have any ABHR. During an observation on 12/18/2020 at 11:30 a.m., there was no ABHR in the common areas, the nursing station, green zone and yellow zone break rooms. During a concurrent interview, LVNS stated they were missing the ABHR in the nursing station, yellow and green zone break room. During an observation on 12/18/2020 at 12 p.m., there were facility wide ABHR that did not contain at least 62% alcohol. During a concurrent interview, LVNS verified and stated the facility was using an ABHR that did not contain at least 62% alcohol. A review of facility's handwashing/hand hygiene policy, revised on August 2015, indicated the use of an ABHR should contain at least 62% alcohol. A review of facility's policy titled, Guidance on limiting the transmission of Covid-19, undated, indicated the facility will increase the availability and accessibility of ABHR and to ensure ABHR was accessible in all resident-care areas including inside and outside resident rooms. c.During an observation on 12/18/2020 at 4 p.m., the facility was noted using non-EPA approved wipes throughout the entire facility. During a concurrent interview, the LVNS stated the non-EPA wipes that were noted at the nursing station and throughout the facility were being used for environmental cleaning and disinfecting equipment. During an interview on 12/21/2020 at 2:19 p.m., the Acute Communicable Disease Control program, Infection Preventionist, Registered Nurse ([DIAGNOSES REDACTED], IP) stated that during her observation, non-EPA wipes were seen throughout the facility. A review of California Department of Public Health (CDPH) All Facilities Letter (AFL) 20-14, dated 2/19/2020, indicated products that are EPA-approved are recommended for use against COVID-19 for routine cleaning and disinfection procedures in the healthcare setting. d. During an observation inside the yellow zone break room on 12/18/2020 at 11:40 a.m., licensed vocational nurse (LVN) 2 was seen wearing a blue silicone-like mask hanging on his neck. During a concurrent interview LVN 2 stated, he preferred wearing his own hand made N95 silicone mask, rather than the fit tested N95 mask the facility provided him. LVN 2 stated it irritated his skin and that his makeshift mask was not a NIOSH approved. During an interview on 12/18/2020 at 11:42 a.m., the LVNS stated all staff must wear a NIOSH approved N95 mask and staff should have already been fit tested . A review of facility's N95 mask fit testing master list, undated, indicated LVN2 was fit tested and to use a Makrite 9500 (type of N95 mask and NIOSH approved N95 mask). During an observation, on 12/19/2020, at 12:06 p.m., in the yellow zone (a designated area for person's under investigation for COVID-19), CNA9 was observed wearing a N95 mask upside down with the metal strip on her chin. During a concurrent interview, CNA9 stated she was in-serviced on how to properly wear an N95 mask and stated she was wearing her mask the proper way. During an observation on 12/19/2020 at 12:23 p.m., in yellow zone hallway, CNA9 was observed with N95 mask upside down with metal strip on her chin going in and passing lunch trays to Residents 1, 2, 3 and 4 (R1, R2, R3 and R4). A review of facility document titled N95 Mask Fit Testing Master List undated and signed by the DON, on 12/23/2020 did not include CNA9's name. A review of facility document titled N95 Fit Test dated 12/31/2020 indicated CNA9 was fit tested for Harley 6973 (a type of N95 mask). During an observation on 12/21/2020 at 3:14 p.m., in the red zone hallway, LVN 8 was seen wearing an N95 mask with a valve (allows germs in exhaled air to escape the respirator), 3M 8511 TC-84A1299. LVN8 stated he received the N95 mask from the facility. LVN8 stated he was fit tested . A review of facility's N95 mask fit testing master list, undated, indicated LVN8 was fit tested and to use a N95 1860 (type of N95 mask and NIOSH approved N95 mask). During an observation on 12/21/2020 at 3:23 p.m. HK 2 was seen wearing a green foldable N95 mask with the metal nose ridge missing. During a concurrent interview HK 2 stated he can just change the N95 to any other mask available in the isolation cart, even if it was not the same, he was fit tested for. HK2 stated he was fit tested . A review of facility's N95 mask fit testing master list, undated, indicated HK2 was fit tested and supposed to use a N95 1860 A review of facility document titled Mitigation Plan and the COVID-19 Prevention and Control policy, undated, did not indicate N95 had to be NIOSH approved. A review of facility document titled, Policies and Practices - Infection Control, undated, indicated infection control policies and practices reflect the facility's needs and requirements for preventing transmission of infections and communicable disease as set forth in current OSHA (Occupational Safety and Health Administration) and CDC (Center for Disease Control and Prevention) guidelines and recommendations. e.During an observation on 12/18/2020 at 12:03 p.m., R1, R2, R3 and R4's room did not have the trash bins located near the exit of an isolation room to doff PPE prior to leaving the room. During an observation on 12/18/2020 at 12:04 p.m., R1, R2, R3 and R4's door had a Quarantine yellow paper signage posted in the door. During a concurrent interview on 12/18/2020 at 12:05 p.m., LVN3, stated that R1, R2, R3 and R4's room was a yellow zone isolation room and verified the trash can was in the middle of the room, rather than having a trash bin near the exit door in order to doff and discard the used PPE properly without any contamination. During an observation on 12/18/2020 at 12:40 p.m., there were missing trash bins near the exit of some rooms in the red zone for doffing PPE, but big black plastic bags noted tied up in the hallway railings for trash purposes. Big black plastic bags noted with different trash but mostly PPE wastes. During an observation on 12/18/2020 at 12:45 p.m., the facility had a total of 12 PPE carts out of 31 isolation rooms throughout the facility. Also, the PPE carts were noted with either missing PPE or other things that were not supposed to be there such as blood pressure machine. During an interview on 12/18/2020 at 12:52 p.m., the Infection Preventionist from the sister facility (IP/SNF2) stated the facility should have PPE carts in each and every isolation room in order to doff PPE without contamination. During an observation on 12/19/2020 at 12:30 p.m., the facility was noted with a total of 12 PPE carts for 31 isolation rooms throughout the facility. During a concurrent interview, LVN5 stated it was hard to donn a new gown prior to entering a room since there were only few PPE carts readily available for her to use. During an observation on 12/20/2020 at 1:28 p.m., the facility was noted with a total of 12 PPE carts for 31 isolation rooms throughout the facility. In addition, the PPE carts for seven different rooms had missing isolation gowns. During a concurrent interview, LVN5 stated someone was supposed to re-stock the PPE carts. During an interview, on 12/20/2020 at 4 p.m., the Director of Nursing stated the facility purchased PPE carts and were still in the process of putting them out. A review of the census on 12/18/2020 to 12/20/2020 indicated there was no green zone and all residents were in isolation rooms in the yellow zone or the red zone. During an interview on 12/21/2020 at 2:19 p.m., the [DIAGNOSES REDACTED] IP RN stated PPE carts were observed randomly throughout hallway, but not at the entrance of every isolation room where it should be. [DIAGNOSES REDACTED] IP RN validated with one of the staff that there were no trash bins located inside each room in the red zone area, but seen black trash bags tied to the railings along the walls and weighted, touching the floor due to its contents. A review of facility's policy titled, Trash bins, undated, indicated the facility was to ensure that soiled, contaminated PPE were properly disposed in a receptacle such as trash bins. Staff shall use the trash bins for disposing their PPEs after doffing before exiting the resident room. The trash bins shall be placed by the exit door and shall be emptied at least twice a day and as needed basis to prevent from overflowing of contents. A review of facility's isolation carts policy, undated, indicated an isolation cart shall be placed by the entrance of the resident's room that requires isolation. f.During an observation in the red zone, on 12/18/2020 at 12:30 p.m., there was no screening process for staff / visitors entering and exiting the facility. The facility did not have a Covid-19 surveillance log noted. During an observation on 12/19/2020 at 3:05 p.m., in red zone lobby, Houskeeping (HK1) was observed leaving the facility without self-screening for Covid-19 at the end of his shift. HK1 stated he was leaving for the day and stated he should have self-screened before leaving the facility. During an observation and interview on 12/19/2020 at 3:07 p.m., in red zone lobby, LVN4 was observed leaving facility without self-screening for Covid-19. LVN4 stated they were to self-screen after their shift and it would be easier, and compliance would be better if someone were in the red zone lobby screening people. A review of facility document titled, Mitigation Plan, undated, indicated staff will be subjected to temperature and symptom check near the backdoor entrance prior to start of shift. A review of facility document titled COVID-19 Prevention and Control, undated, indicated staff were supposed to self-assess. During an interview on 12/19/2020 at 12:17 p.m., Dietary Staff 1, stated she observed food supply delivery personnel enter the kitchen through the kitchen back door without being screened to make deliveries. During an interview on 12/19/2020 at 12:26 p.m., the Dietary Supervisor stated she observed food supply delivery personnel enter the kitchen through the kitchen back door without being screened to make deliveries. During a telephone interview on 12/21/2020 at 1:30 p.m., the Public Health Nurse 1 (PHN1) stated when he inspected the facility on 12/18/2020, he observed a delivery person entering the kitchen through the kitchen back door for food supply delivery without being screened. A review of the facility's policy titled, Covid-19, Prevention and Control, undated, indicated all persons entering the facility will be asked if they have traveled outside of the US within the last 14 days, their temperature will be checked and will be asked for any symptoms of a respiratory infection and a fever will be instructed on and encouraged to adhere to respiratory hygiene, cough etiquette and hand hygiene procedures throughout the duration of the stay/visit. g.During an observation on 12/19/2020 at 12:40 p.m., in the red zone, certified nursing assistant 8 (CNA8) was observed exiting a resident room in isolation for COVID-19 while still wearing blue isolation gown and gloves. During an observation on 12/19/2020 at 12:52 p.m., HK1 was seen wearing an orange plastic clear raincoat with plastic white snap on buttons down the front and a hood on the back while in the red zone. HK1 stated he was provided the coat by his supervisor to wear while in the red zone hallway. HK1 stated he wears the orange raincoat in the red zone hallway, and when he enters a resident room he dons on a blue isolation gown. During a concurrent observation and interview on 12/19/2020 at 1:40 p.m., in the red zone hallway, licensed vocational nurse 6 (LVN6) was observed wearing blue isolation gown while in the hallway. LVN6 stated she was instructed to don blue isolation gown before entering the red zone. LVN6 stated staff wear blue isolation gowns while in the hallway. LVN 6 stated gowns were not changed between residents, only gloves were changed. During an observation and interview on 12/22/2020 at 3:25 p.m., Licensed Vocational Nurse 10 (LVN10) was observed entering the red zone through plastic wall without donning face shield, gown, or gloves. LVN 10 stated he received proper training and should have worn all required PPE prior to entering red zone. During an interview on 12/23/2020 at 2:45 p.m., Housekeeper 4 (HK4) was in the red zone and stated he wore a Makrite brand respirator because it fits well for him. HK4 stated he received a mask fit test twice. His supervisor conducted the first fit test on 12/22/2020 and a male nurse conducted the second fit test on 12/23/2020. HK4 stated and revealed his respirator's original box and it was labeled Makrite 9500. A review of the facility's document titled, N95 Mask Fit Testing Master List, undated, indicated HK4 passed the test with N95-1860, not Makrite 9500 During an observation and interview on 12/23/2020 at 2:54 p.m., Certified Nursing Assistant 8 (CNA8) was observed wearing a respirator labeled L-188 TC-84A-6973 in the red zone. CNA8 stated two visitors conducted a mask fit test for her at the patio about two weeks ago. A review of the facility's document titled, N95 Mask Fit Testing Master List, undated, indicated CNA8 passed the test with 3M 1860S mask, not the mask she currently donned. During an interview on 12/29/2020 at 8:59 a.m., Housekeeper 3 (HK3) stated maintenance had been using the raincoats in the hallways of the red zone for a week. HK3 stated the maintenance staff received the raincoats from the facility and used the raincoats because he saw everyone else wearing them, so just followed everyone else. A review of the facility document titled, Mitigation Plan, undated, did not indicate raincoats as PPE. A review of facility document titled, COVID-19 Prevention and Control, undated, indicated staff will don PPE when entering the room of a resident with suspected or confirmed COVID-19 virus and when leaving the resident's room, all PPE will be removed, disposed of in a waste container.