Every finding on record at The Meadows on Sunset Post Acute

Based on interview and record review, the facility failed to ensure prompt attempts were made to process and resolve the grievances for one of three sampled residents (Resident 1) when the facility failed to investigate the concern reported by Resident 1. This deficient practice had the potential to violate Resident 1's rights.Findings:During a review of Resident 1's admission Record (AR), the AR indicated the facility originally admitted Resident 1 on 3/19/2020, and readmitted on [DATE] with diagnoses including depression (a mental health illness causing a persistent feeling of sadness, loss of interest, and can interfere with daily life), anxiety disorder (feeling of anxiousness that affects daily life), and polyneuropathy (damage to many nerves outside the brain and spine, causing weakness, numbness, tingling, and pain, typically starting in the feet and hands). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 3/17/2026, the MDS indicated Resident 1 had intact cognitive functioning (mental processes that enable people to think, understand, make decisions, and complete tasks). The MDS indicated Resident 1 required maximal assistance (helper does more than half the effort) from facility staff with personal hygiene and upper body dressing. The MDS indicated Resident 1 was dependent (helper does all the effort) on facility staff for toileting hygiene, showers, and lower body dressing. During an interview on 6/22/2026 at 11:50 a.m. with Resident 1, Resident 1 stated that between 5/31/2026 and 6/5/2026 (Resident 1 could not recall the exact date), she (Resident 1) complained to the Certified Nurse Assistant (CNA) 1 and CNA 2 that after Resident 1's personal clothes were washed in the facility's laundry, the clothes were returned damp (slightly wet or moist) and had a moldy (may indicate active fungal spores [mildew] are growing in the fabric fibers). Resident 1 stated that she (Resident 1) informed CNA 1 and CNA 2 that her (Resident 1) personal clothes were not washed properly. Resident 1 stated that the facility staff did not address her (Resident 1) concern. During an interview on 6/22/2026 at 1:09 p.m. with CNA 1, CNA 1 stated that Resident 1 had informed him (CNA 1) that Resident 1's personal clothes, washed in the facility's laundry, smelled stale (something smells old and musty). CNA 1 stated he took Resident 1's clothes back to laundry (CNA 1 could not recall the exact date of the incident). CNA 1 stated that he did not recall discussing Resident 1's concern with other facility staff and was not sure if the issue was resolved. During an interview on 6/22/2026 at 1:35 p.m. with CNA 2, CNA 2 stated Resident 1 had informed her that Resident 1's personal clothes, washed in the facility's laundry, were still wet. CNA 2 stated that Resident 1 wanted to speak with the Charge Nurse (primary nurse for a specific unit during a single shift) to address the issue with clothes. CNA 2 stated she (CNA 2) informed the CN (can't recall the name of the CN and the exact date of the notification) that Resident 1 wanted to speak with the CN. During an interview on 6/22/2026 at 1:50 p.m. with the Social Services Director (SSD), the SSD stated that upon hearing of Resident 1's complaint regarding her (Resident 1) clothes washed in the facility's laundry, CNA 1, CNA 2, should have initiated the grievance report or informed him (SSD) to initiate the grievance process. The SSD stated Resident 1's grievance was not processed and investigation was not completed. The SSD stated Resident 1 had the right to have her concerns heard and addressed. The SSD stated the failure to process Resident 1's grievance had the potential for Resident 1 to not feel satisfied with her care and feel that her concerns are not being addressed.During an interview on 6/22/2026 at 2:09 p.m. with the Director of Nursing (DON), the DON stated that CNA 1 and CNA 2 should have communicated with the SSD to address Resident 1's concerns. The DON stated the failure to process Resident 1's grievance had the potential for Resident 1 to feel that her concerns are not being addressed by the facility. During a review of the facility-provided policy and procedure (P&P) titled, Resident and Family Grievances, last reviewed on 6/17/2026, the P&P indicated:4. A resident or family member may voice grievances with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and other residents, and other concerns regarding their LTC (long term care) facility stay.8. Grievances may be voiced in the following forums:a. Verbal complaint to a staff member or Grievance Official.10. Procedure. b. The staff member receiving the grievance will record the nature and specifics of the grievance on the designated grievance form, or assist the resident or family member to complete the form. c. Forward the grievance form to the Grievance Official as soon as practicable.12. The facility will make prompt efforts to resolve grievances.

Based on observation, interview, and record review, the facility failed to provide care in a manner that maintained a resident's respect and dignity for six (6) of eight (8) sampled residents (Resident 3, 21, 51, 84, 106, 123) when: 1. Certified Nurse Assistant (CNA) 1 and CNA 4 failed to maintain privacy for Residents 21 and 84 while providing Activities of Daily Activities (ADL - basic tasks that must be accomplished every day for an individual to thrive) care. 2. CNA 8 and CNA 3 were standing over Resident 51 and 106 while assisting the residents during mealtime. 3. The staff failed to cover urinary catheter (a hollow tube inserted into the bladder to drain or collect urine) bags with dignity bags (device used to cover the contents of a urinary catheter bag) for Residents 3 and 123. These deficient practices had the potential to cause emotional distress and affect the residents' self-esteem and cause a loss of dignity and decline in psychosocial wellbeing. Findings: Findings: 1. a. During a review of Resident 21's admission Records (the front page of the chart that contains a summary of basic information about the resident), the admission Records indicated that the facility admitted Resident 21 on 12/31/2024, with diagnoses including dysphagia (difficulty swallowing), Diabetes Mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), end stage renal disease (ESRD- a medical condition in which a person's kidneys cease functioning on a permanent basis). During a review of Resident 21's History and Physical (H&P- a document with patient's medical history and physical examination done by a physician) dated 2/1/2026, the H&P indicated that Resident 21 had the capacity to consent. During a review of Resident 21's Minimum Data Set (MDS - a resident assessment tool) dated 12/18/2025, the MDS indicated Resident 21 required substantial/maximal assistance (helper does more than half the effort) with shower, lower body dressing, putting on/off footwear and partial/moderate assistance (helper does less than half the effort) with toileting hygiene, and upper body dressing. During an observation on 4/6/2026 at 9:29 a.m. with CNA 1 in Resident 21's room, observed CNA 1 providing ADL morning care to Resident 21. Observed CNA 1 leaving the privacy curtain partially open when getting wet towels from the bathroom, leaving Resident 21's undressed body exposed and seen from the hallway. During an interview on 4/6/2026 at 9:35 a.m. with CNA 1, CNA 1 stated that she (CNA1) left the curtain partially open while going in and out from Resident 21's bedside to the bathroom wetting towels to perform Resident 21's perineal care. CNA 1 stated leaving the privacy curtain open and residents' naked body exposed to others violates residents' privacy and residents may feel embarrassed. 1.b. During a review of Resident 84's admission Records, the admission Records indicated that the facility admitted Resident 84 on 4/1/2025, with diagnoses including cellulitis (a skin infection that causes swelling and redness) of bilateral lower limbs (BLE), acute thrombosis (the formation of a dangerous blood clot inside a vein or artery that obstructs blood flow) and embolism (an obstacle or blockage in a blood vessel) of BLE, and hypertension (HTN- high blood pressure). During a review of Resident 84's H&P dated 4/2/2026, the H&P indicated that Resident 84 had the capacity to understand and make decisions. During a review of Resident 84's MDS, the MDS indicated that Resident 84 required partial/moderate assistance with shower and lower body dressing, and setup or clean-up assistance with toileting, and personal hygiene. During a concurrent observation and interview on 4/7/2026 at 10:16 a.m. with CNA 4, in Resident 84's room, observed CNA 4 providing ADL morning care to Resident 84. Observed the privacy curtain left open about two feet. CNA 4 stated the privacy curtain was not long enough to completely close the area. CNA 4 stated it was very important to provide the resident privacy before starting morning care, to maintain the resident's dignity and privacy. During an interview on 4/8/2026 at 8:57 a.m. with Registered Nurse (RN) 1, RN 1 stated to maintain residents' privacy and dignity staff need to close privacy curtains before providing care. RN 1 stated not having privacy curtains closed while providing care for residents were violation of residents` dignity and privacy, and this may cause emotional harm, loss of trust, and refusal of care. During an interview on 4/10/2026 at 11:34 a.m. with the Director of Nursing (DON), the DON stated that resident privacy curtains must be kept fully closed when providing ADL/morning care to residents, to ensure resident privacy and dignity. The DON stated that the lack of privacy protection violated residents' rights of dignity, exposed residents to potential loss of dignity, psychological discomfort and emotional distress. 2. a. During a review of Resident 51's admission Record, the admission Record indicated the facility admitted the resident on 3/20/2026, with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (partial paralysis of the arm, leg, and trunk on the same side of the body) following cerebrovascular disease (CVA-stroke, loss of blood flow to a part of the brain) affecting left dominant side, peripheral vascular disease (PVD - a slow progressive narrowing of the blood flow to the arms and legs), and generalized muscle weakness. During a review of Resident 51's H&P, dated 3/22/2026, the H&P indicated that the resident did not have the capacity to understand and make decisions. During a review of Resident 51's MDS, dated [DATE], the MDS indicated Resident 51 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and was usually able to understand and make his needs known. The MDS further indicated Resident 51 required substantial/maximal assistance to total assistance from staff with all ADLs. During a concurrent observation and interview on 4/6/2026 at 1:10 p.m. with CNA 8, inside Resident 51's room, observed Resident 51 lying in bed with the head of the bed elevated to position the resident in upright seated posture. Observed CNA 8 assisting Resident 51 with lunch while standing over the resident. CNA 8 stated staff should be sitting at eye level while assisting residents with eating to respect the dignity of the residents. CNA 8 stated that she (CNA 4) forgot to get a chair and that she (CNA 4) should be sitting at eye level while assisting the resident with eating to respect the dignity of Resident 51 and to make sure the resident was tolerating the food. 2. b. During a review of Resident 106's admission Record, the admission Record indicated the facility admitted the resident on 3/18/2024, with diagnoses including paraplegia (paralysis that affects the legs, making it impossible to stand or walk), schizophrenia (a mental illness that is characterized by disturbances in thought), and generalized muscle weakness. During a review of Resident 106's H&P, dated 3/5/2026, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 106's MDS, dated [DATE], the MDS indicated Resident 106 had an intact cognition and was usually able to understand and make her needs known. The MDS further indicated Resident 106 required supervision or touching assistance with eating and oral hygiene, and substantial/maximal assistance from staff with all other ADLs. During a concurrent observation and interview on 4/6/2026 at 1:14 p.m. with CNA 3, inside Resident 106's room, observed Resident 106 lying in bed with the head of the bed elevated to to position the resident in upright seated posture. Observed CNA 3 assisting Resident 106 with lunch while standing over the resident. CNA 3 stated staff should be sitting at eye level while assisting residents with eating to respect the dignity of the residents. CNA 3 stated that there were no more chairs available and he (CNA 3) should have notified his supervisor. CNA 3 stated that while assisting Resident 106 with eating, he (CNA 3) should be sitting at eye level to respect the dignity of Resident 106 and to make sure the resident was chewing the food properly. During an interview on 4/9/2026 at 2:53 p.m. with RN 1, RN 1 stated that while assisting residents with meals, the staff are supposed to be sitting at eye level to respect the residents' dignity and to ensure that the residents were tolerating the diet and there were no signs and symptoms of choking. RN 1stated that CNA 3 should have been sitting down at eye level while assisting Resident 106 during lunch on 4/6/2026 and CNA 8 should have been sitting down at eye level while assisting Resident 51 during lunch on 4/6/2026 to ensure that the residents did not have any signs and symptoms of choking as well as respecting the residents' right to be treated with respect and dignity and not standing over them. During an interview on 4/10/2026 at 9:30 a.m. with the DON, the DON stated the staff should be assisting the residents with eating at eye level and should be sitting down. The DON stated it was important that the staff be sitting at eye level while assisting the residents with eating to preserve the residents' dignity and to observe if the resident was chewing the food properly and/or if there were signs of choking or aspirations. The DON stated CNA 3 and CNA 8 should have grabbed a chair and sat down while assisting Resident 51 and Resident 106 with eating for safety and dignity. During a review of facility's Policies and Procedures (P&P) titled Promoting/Maintaining Resident Dignity, dated 12/19/2022, the P&P indicated, It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. Maintain residents' privacy. 3. a. During a review of Resident 123's Admission, the admission Records indicated that the facility originally admitted Resident 123 on 1/28/2028, and readmitted on [DATE], with diagnoses including DM, neuromuscular dysfunction of bladder (the nerves that tell your bladder when to squeeze or relax are damaged, causing poor control over storing or emptying urine), HTN. During a review of Resident 123's H&P, dated 4/6/2026, the H&P indicated that Resident 123 had a capacity to understand and make decisions. During a review of Resident 123's MDS dated [DATE], the MDS indicated Resident 123 required substantial/maximal assistance with toileting hygiene, shower self, lower body dressing, and was dependent (helper does all of the effort) to staff for putting on/taking off footwear. During an observation on 4/6/2026 9:48 a.m. inside Resident 123's room, observed Resident 123's indwelling catheter bag was not covered with dignity bag. During a concurrent observation and interview on 4/6/2026 12:27 p.m. with CNA 2 and CNA 4 inside Resident 123's room, CNA 2 stated Resident 123's catheter bag was not covered with a dignity bag. CNA 4 stated that all urinary catheter bags must be covered with dignity bags to provide residents with dignity and privacy. CNA 2 stated that urine might be visible through uncovered catheter bag, which can potentially make resident embarrassed and take away their privacy. 3. b. During a review of Resident 3's admission Records, the admission Records indicated that the facility originally admitted Resident 3 on 7/29/2019, and readmitted on [DATE], with diagnoses including hydronephrosis (the swelling of a kidney caused by a backup of urine (pee) that cannot drain properly into the bladder), neuromuscular dysfunction of bladder (the swelling of a kidney caused by a backup of urine (pee) that cannot drain properly into the bladder), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior). During a review of Resident 3's H&P dated 10/30/2025, the H&P indicated that Resident 3 had the capacity to understand and make decisions. During a review of Resident 3's MDS, the MDS indicated that Resident 3 was cognitively intact. Resident 3 was dependent to staff with all ADLs. During an observation on 4/6/2026 at 11:29 a.m. inside Resident 3's room, observed no dignity bag covering Resident 3's urinary catheter drainage bag. During a Concurrent observation and interview on 4/6/2026 at 12:36 p.m. with CNA 2 in Resident 3's room, CNA 2 stated that Resident 3's urinary catheter bag was not covered with dignity bag. CNA 2 stated not having dignity bag covering the urinary catheter bag may potentially cause the residents to feel embarrassed and uncomfortable. During an interview on 4/10/2026 11:40 a.m. with DON, the DON stated that urinary catheter drainage bag must be covered by dignity bag at all times. The DON stated not covering the drainage bag may potentially result resident embarrassment, emotional distress, decreased self-esteem, and loss of trust in facility staff. During a review of facility's P&P, titled Catheter Care, dated 12/19/2022, the P&P indicated, Privacy bags will be available and catheter drainage bags will be covered at all times while in use.

Based on observation, interview, and record review, the facility failed to ensure that the call light (an alerting device for nurses or other nursing personnel to assist a patient when in need) was within reach of five of nine sampled residents (Resident 45, 15, 103, 102, 96) reviewed under environment task. The deficient practice had the potential to place the resident at risk for delayed assistance, potentially affecting safety and timely care. Findings: 1.During a review of Resident 45's admission Records (the front page of the chart that contains a summary of basic information about the resident), the admission Records indicated that the facility originally admitted Resident 45 on 7/1/2024, and readmitted on [DATE], with diagnoses including end stage renal disease (ESRD- a medical condition in which a person's kidneys cease functioning on a permanent basis), Diabetes Mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing), absence of left leg below knee, heart failure (a condition in which the heart muscle can't pump enough blood to meet the body's needs for blood and oxygen). During a review of Resident 45's History and Physical (H&P- a document with patient's medical history and physical examination done by a physician) dated 4/30/2025, the H&P indicated that Resident 45 had the capacity to understand and make decisions. During a review of Resident 45's Minimum Data Set (MDS - a resident assessment tool) dated 6/16/2025, the MDS indicated Resident 45 required partial/moderate assistance (helper does less than half the effort) with oral hygiene, toileting hygiene, shower/bath, upper body dressing. The MDS indicated Resident 45 required partial/moderate assistance with toilet transfer (the ability to get [NAME] bd off a toilet or commode) and tub/shower transfer (the ability to get in and out of tub/shower). During a concurrent observation and interview on 4/6/2026 at 10:17 a.m. with Certified Nursing Assistant (CNA) 2 inside Resident 45's room, observed Resident 45 sleeping in his bed with no call light within his reach. Observed CNA 2 finding Resident 45's call light on the floor, behind the bedside nightstand. CNA 2 stated that call lights should be within residents' reach at all times. CNA 2 further stated that not having a call light within Resident 45's reach may place the resident at risk for falling when trying to reach for the call light and will result in an injury. During an interview on 4/10/2026 at 8:40 a.m. with the Director of Nursing (DON), the DON stated that the purpose of the call light was for the residents to call for assistance. The DON added that if the call light is out of reach, residents may fall and get injured when trying to access it. 2a. During a review of Resident 15's admission Record (AR), the AR indicated that the facility admitted the resident on 3/3/2025, with diagnoses including Alzheimer's disease, unspecified (a disease characterized by a progressive decline in mental abilities), essential (primary) hypertension (high blood pressure with no known specific cause), and unsteadiness on feet (difficulty keeping balance when standing or walking). During a review of Resident 15's MDS, dated [DATE], the MDS indicated the resident had the ability to make self-understood and understand others. The MDS further indicated that Resident 15 had moderate cognitive impairment (has some trouble with memory and thinking but can still function with support). The MDS indicated that the resident required partial/moderate assistance on mobility and activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 15's Fall Risk Evaluation (FRE), dated 2/18/2026, the FRE indicated that the resident was at risk for falls. During a review of Resident 15's Care Plan (CP) Report, titled Resident 15 was at risk for falls, with impaired cognition (problems with a person's ability to think, learn, remember, use judgement, and make decisions), on antidepressant medication (medications that treat mental health conditions) and required assistance with self-care and mobility, revised on 3/12/2025, the CP indicated a goal of Resident 15 will have no falls with injury for 90 days. The CP intervention was to implement the following safety precautions, call for assistance as needed. During a concurrent observation and interview on 4/6/2026, at 9:45 a.m., with Licensed Vocational Nurse (LVN) 8, inside Resident 15`s room, observed Resident 15's call light on left side of the bed under mattress. LVN 8 stated that Resident 15`s call light was stuck under the mattress, and the resident would not be able to reach the call light. LVN 8 stated call light is used to call for help or in case of an emergency. LVN 8 stated the call light needs to be assessable 24 hours to the resident and if the call light is not accessible then the resident would not be able to call and it could be an emergency. During a concurrent interview and record review on 4/8/2026, at 8:19 a.m., with Registered Nurse (RN) 1, Resident 15's FRE and CP were reviewed. RN 1 stated that Resident 15 is at risk for falls and should always have call light within reach. RN 1 stated that all staff were responsible for making sure call light was within reach of the resident so resident can call for assistance when needed and prevent a potential fall or injury while reaching for the call that is not within reach of the resident. During a concurrent interview and record review on 4/10/2026, at 8:25 a.m., with the Director of Nursing (DON), Resident 15`s FRE was reviewed. The DON stated that Resident 15 is at risk for falls and call light should always be within reach. The DON stated that all staff are responsible for ensuring call light is within residents` reach. The DON stated the staff did not follow the policy and procedure (P&P) titled Call Lights: Accessibility and Timely Response. 2b. During a review of Resident 103's AR, the AR indicated that the facility admitted Resident 103 on 8/5/2025, with diagnoses including unspecified fall, subsequent encounter (a fall but exact cause unknown); Essential Hypertension, and insomnia unspecified (inability to sleep). During a review of Resident 103's H&P dated 8/7/2025, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 103's MDS dated [DATE], the MDS indicated the resident had the ability to make self-understood and understand others. The MDS further indicated Resident 103 had moderate cognitive impairment (has some trouble with memory and thinking but can still function with support). The MDS indicated that the resident required maximal to supervision assistance on mobility and activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 103's Fall Risk Evaluation (FRE), dated 2/7/2026, the FRE indicated that the resident was at risk for falls. During a concurrent observation and interview on 4/6/2026, at 10:04 a.m., with LVN 8 inside Resident 103`s room, observed Resident 103's call light on left side of the bed under mattress. LVN 8 stated that call light was stuck under the mattress, and the resident would not be able to reach the call light and call for assistance. LVN 8 stated that call light is used to call for help or in case of an emergency. LVN 8 stated the call light needs to be assessable 24 hours and if the call light is not accessible then the resident would not be able to call and it could be an emergency. During a concurrent interview and record review on 4/8/2026, at 8:19 a.m., with RN 1, Resident 103's FRE and Care Plans were reviewed. RN 1 stated Resident 15 is at risk for falls and should always have call light within reach. RN 1 stated that all staff were responsible for making sure call light was within reach of the resident so resident can call for assistance when needed and prevent a potential fall or injury while reaching for the call that is not within reach of the resident. During a concurrent interview and record review on 4/10/2026, at 8:25 a.m. with the DON, Resident 103`s FRE and CPs were reviewed. The DON stated that Resident 103 is at risk for falls and call light should always be within reach. The DON stated that all staff are responsible for ensuring call light is within reach. The DON stated the staff did not follow the policy and procedure (P&P) titled Call Lights: Accessibility and Timely Response. 3. During a review of Resident 102's admission Record, the admission Record indicated the facility originally admitted the resident on 4/02/2021, and readmitted on [DATE], with diagnoses including cardiac arrest (a sudden, unexpected stop of the heart's pumping function, not a blockage), gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), history of falling, dysphagia (difficulty swallowing), muscle weakness, and anxiety disorder (a mental health disorder characterized by feelings of worry or fear that are strong enough to interfere with one's daily activities). During a review of Resident 102's H&P dated 4/10/2025, the H&P indicated Resident 102 did not have the capacity to understand and make decisions. During a review of Resident 102's MDS dated [DATE], the MDS indicated that that the resident had severely impaired cognition. The MDS further indicated that Resident 102 required substantial or maximal assistance to personal hygiene, dressing, and repositioning, and was dependent to staff for bathing and all other activities of daily living (ADLs – routine task/activities such as bathing dressing and toileting a person performs daily to care for themselves). During a review of Resident 102's care plan initiated on 12/04/2022, the care plan indicated that Resident 102 is at risk for falls with interventions indicating to place the call light within reach while in bed or close proximity to the bed and remind resident to use call light when attempting to ambulate or transfer to keep resident from falling. During a concurrent observation and interview on 4/6/2026 at 10:20 a.m. inside Resident 102's room, with LVN 3, Resident 102 was observed awake, lying in bed and the call light was placed on the top right part of the bed next to the pillow. LVN 3 stated that the call light was not within reach for Resident 102 to call for assistance. Resident 102 observed attempted to reach for the call light but had limited range of motion to his right arm. LVN 3 stated that it is important for the call light to be within reach so that residents can address their needs. During an interview on 4/6/2026 at 11:45 a.m. with Certified Nursing Assistant (CNA)7, CNA 7 stated that she (CNA 7) did not know why Resident 102's call light was not within reach. CNA 7 stated that Resident 102 is able to tell his needs sometimes depending on his mood. CNA 7 further stated that Resident 102 would engage in conversation but oftentimes remain quiet but when needs are not met, Resident 102 would scream and attempt to throw things around. During a telephone interview on 4/7/2026 at 12:54 a.m. with Resident 102's Responsible Party (RP) 2, RP 2 stated that Resident 102 is not fully able to address all his needs, but when Resident 102 starts getting restless, it might be that his needs are not met. RP 2 stated that Resident 102 can occasionally use the call light, but his roommate mostly is the one telling staff about Resident 102's needs. During a concurrent interview and record review on 4/8/2026 at 8:17 a.m. with RN 1, Resident 102`s fall risk assessments were reviewed. RN 1 stated that Resident 102 was at risk for fall due to history of falls. RN 1 stated that it is important to have the call light within reach for resident's needs to be addressed and prevent injuries. During an interview on 4/10/2026 at 8:20 a.m. with the DON, the DON stated that call light is needed for a resident to ask for assistance. The DON stated that residents could potentially fall if the call light is not within reach. 4. During a review of Resident 96's AR, the AR indicated the facility admitted the resident on 7/30/2021, and readmitted the resident on 1/14/2026, with diagnoses including major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety disorder (a mental health condition characterized by excessive, uncontrollable, and persistent fear or worry that interferes with daily life), and disorders of bone density (a measurement of the amount of minerals—mainly calcium and phosphorus—contained within a certain volume of your bone) and structure. During a review of Resident 96's H&P, dated 9/13/2025, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 96's MDS dated [DATE], the MDS indicated the resident had the ability to make self-understood and understand others and had severe cognitive impairment (a profound loss of mental capacity where a person cannot function independently, manage daily tasks, or comprehend the world around them). The MDS indicated the resident was needing substantial/maximal assistance on mobility and activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 96's Fall Risk Assessment (FR), dated 1/15/2026, the FR indicated the resident was at risk for falls. During a review of Resident 96's Care Plan (CP) Report titled, The resident is at risk for falls related to unaware of safety needs, initiated on 4/7/2026, the CP indicated an intervention to place the resident's call light within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. During a concurrent observation and interview on 4/6/2026, at 9:45 a.m., with CNA 11, inside Resident 96's room, observed Resident 96's call light dangling at the left side of the bed touching the floor. CNA 11 stated the call light should always be within the reach of the resident so they can call for help when needed. During a concurrent interview and record review on 4/8/2026, at 7:50 a.m. with RN 1, Resident 96's FR and CPs were reviewed. RN 1 stated Resident 96's call light should always be within the resident's reach, and all staff were responsible to make sure it is always within reach of the resident so the resident can call for assistance when needed. RN 1 stated the failure of the staff to ensure the call light was within reach had predisposed the resident to have no ability to call for help as needed and had the potential to fall and sustain an injury while reaching for the call light on the floor. During an interview on 4/10/2026, at 8:10 a.m., with the DON, the DON stated that Resident 96's call light should always be within the reach of the resident so they can make their needs known. The DON stated all staff were responsible for ensuring the call light is within reach during their resident's rounds. The DON stated the staff did not follow the policy and procedure (P&P) titled Call Lights: Accessibility and Timely Response. During a review of the facility's recent P&P titled, Call Lights: Accessibility and Timely Response, last reviewed on 3/18/2026, the P&P indicated the purpose of this policy is to assure the facility is adequately equipped with a call light. Policy Explanation and Compliance Guidelines: - Staff will ensure the call light is within reach of resident and secured, as needed. - The call system will be accessible to residents while in their bed or other sleeping accommodations within the resident's room.

Based on observation, interview, and record review, the facility failed to ensure residents were treated with respect and dignity including the right to be free from physical restraints (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the resident's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body) for three of three sampled residents (Residents 71, 102, and 106) reviewed for physical restraints by failing to ensure: 1. Resident 71`s use of a bed placed against the wall was assessed on a quarterly basis. The most recent assessment was completed on 10/2/2025. The deficient practice had the potential to result in the restriction of residents' freedom of movement, a decline in physical functioning, and psychosocial harm (any damage to a person's mental health, emotional well-being, or social functioning caused by their environment, particularly in the workplace). 2. There was a physician's order prior to placement of Resident 102`s bed against the wall. This deficient practice resulted in unnecessary restraint and placed Resident 102 at risk of physical harm from restricting movements freely. 3. Residents 187's wedge pillows on both sides were not tucked under the fitted sheet. This deficient practice had the potential to result in the restriction of residents' freedom of movement, a decline in physical functioning, psychosocial harm, physical harm from entrapment (a state in which a person is trapped by the bed rail in a position that they cannot move from), and death of residents. Findings: a. During a review of Resident 71's admission Record (AR), the AR indicated the facility admitted the resident on 10/2/2023, with diagnoses including repeated falls, morbid obesity (a serious chronic disease defined as being 100 pounds or more over ideal body weight, or having a BMI of 40 or higher), and muscle spasm. During a review of Resident 71's History and Physical (H&P), dated 2/1/2026, the H&P indicated the resident had a capacity to consent. During a review of Resident 71's Minimum Data Set (MDS, a resident assessment tool), dated 9/4/2025, the MDS indicated the resident had the ability to make self-understood and understand others and had intact cognition (having a clear, sharp, and functioning mind that allows a person to think, learn, remember, and make decisions effectively). The MDS indicated the resident independent to needing partial assistance on mobility and activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 71's Order Summary Report (OSR), dated 1/2/2025, the OSR indicated an order for bed against the wall per resident's preference. The OSR further indicated to monitor for change in preference. During a review of Resident 71's Device Evaluation (DE), dated 10/2/2025, the DE indicated a device use of bed against the wall. The DE indicated the resident and/or responsible party verbalized understanding and agreed the use of the device and understands the potential risks of using the device including but not limited to, bruising, skin tear, falls, startling (surprising)/upsetting, feeling isolated, pressure injury (localized damage to the skin and underlying tissue, usually over a bony area), entrapment (a dangerous situation where a person (usually a patient in a hospital or nursing home) gets caught, stuck, or tangled in the gaps around their bed), strangulation (injuries result from external forces applied to the neck), suffocation (the state of being unable to breathe), and death. During a review of Resident 71's Fall Risk Assessment (FR), dated 2/17/2026, the FR indicated the resident was not at risk for falls. During a review of Resident 71's Care Plan (CP) Report titled, Resident has preference for bed to be positioned against the wall for comfort and personal preference, initiated on 12/2/2024, the CP indicated an intervention to regularly assess the patient`s comfort and safety with the bed quarterly and as needed. During a concurrent observation, interview, and record review on 4/7/2026, at 9:58 a.m., with Treatment Nurse (TN) 1, inside Resident 71's room, observed Resident 71's bed was placed against the wall on the right side of the resident's bed with bilateral half (1/2) side rails (or half-length rail- a safety device for hospital-style beds that covers only a portion of the bed's length, typically the area around the torso and hips) on. TN 1 stated every time they apply restraints such as placing the resident`s bed against the wall, they need a physician's order, an informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered), a restraint assessment, and a care plan to ensure its safe use. TN 1 stated she (TN1) cannot find a restraint assessment on the use of Resident 71's bed placed against the wall. TN 1 stated the use of restraints on residents should be reassessed on a quarterly basis to ensure they remain safe use and clinically indicated. During a concurrent interview and record review on 4/7/2026, at 2:41 p.m., with Registered Nurse (RN) 1, Resident 71's OSR, DE, FR, and CPs were reviewed. RN 1 stated that Resident 71`s use of restraint bed placed against the wall was last assessed on 10/2/2025. RN 1 stated restraints use should be assessed quarterly and as needed for resident's safety and to prevent accidents such as bumping of the resident on the wall or entrapment. RN 1 stated the policy and procedure titled Assessment Frequency/Timeliness was not followed by the facility. RN 1 stated their failure to assess the use of Resident 71's restraint bed placed against the wall had predisposed (caused to have a tendency toward) the resident to bed entrapment. During an interview on 4/10/2026, at 8:10 a.m., with the Director of Nursing (DON), the DON stated every time they apply restraints to residents they need a physician's order, an informed consent, a restraint assessment, and a care plan for its safe use. The DON stated the staff should have assessed the use of the restraint bed placed against the wall on Resident 71 quarterly to ensure its safe use and is still needed. The DON stated the failure of the staff to quarterly assess the resident on restraint use had predisposed the resident to accidents such as falls and entrapment. During a review of the facility's recent policy and procedure (P&P) titled, Assessment Frequency/Timeliness, last revised 3/18/2026, the P&P indicated the purpose of this policy is to provide a system to complete standardized assessments in a timely manner, according to the current RAI Manual. Policy Explanation and Compliance Guidelines: 4. A quarterly review assessment will be completed no less than once every three months. It must be completed within 92 days of the ARD of the most recent OBRA assessment During a review of the facility's recent P&P titled, Restraint Free Environment, last reviewed on 3/18/2026, the P&P indicated it is the policy of this facility that each resident shall attain and maintain his/her highest practicable well-being in an environment that prohibits the use of restraints for discipline or convenience and limits restraint use to circumstances in which the resident has medical symptoms that warrant the use of restraints. Definitions: Physical Restraint refers to any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. Physical restraints may include, but are not limited to: -Placing a chair to bed close enough to a wall that the resident is prevented from rising out of the chair of voluntarily getting out of bed. Compliance Guidelines - A physician's order alone is not sufficient to warrant the use of a physical restraint. The facility is responsible for the appropriateness of the determination to use a restraint. - The resident/resident's representative may request the use of a physical restraint; however, the facility is responsible for evaluating the appropriateness of the request. The facility shall explain to the resident/resident representative, the potential risks and benefits of using a restraint, not using a restraint, and alternatives to restraint use. Potential negative outcomes should also be explained including, but not limited to. b. During a review of Resident 102's AR, the AR indicated the facility originally admitted the resident on 4/02/2021, and readmitted on [DATE], with diagnoses including cardiac arrest (a sudden, unexpected stop of the heart's pumping function, not a blockage), gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), acute renal failure (a condition in which the kidneys suddenly cannot filter waste from the blood), history of falling, dysphagia (difficulty swallowing), muscle weakness, and anxiety disorder (a mental health disorder characterized by feelings of worry or fear that are strong enough to interfere with one's daily activities). During a review of Resident 102's H&P dated 4/10/2025, the H&P indicated Resident 102 did not have the capacity to understand and make decisions. During a review of Resident 102's MDS dated [DATE], the MDS indicated that the resident had severely impaired cognition. The MDS further indicated that Resident 102 required substantial or maximal assistance for personal hygiene, dressing, and repositioning, and was dependent on staff for bathing and all other activities of daily living (ADLs – routine task/activities such as bathing dressing and toileting a person performs daily to care for themselves). During a review of Resident 102's care plan (CP) titled Resident prefers to have bed be against the wall initiated on 12/26/2023, the CP indicated to explain risks and complication of having bed be against the wall, offer to have bed be moved in the middle of the room. The CP also indicated that Resident/RP prefers to have bed be against the wall with interventions to monitor for changes in skin related to possibly bumping against the wall, explain risks and complications of preference of resident, encourage to have bed not be against the wall and respect resident's rights. During an observation on 4/06/2026 at 10:06 a.m. inside Resident102's room, Resident 102 was observed awake, lying flat in bed and having the bed against the wall. During a concurrent interview and record review on 4/8/2026 at 8:17 a.m. with Registered Nurse (RN 1), RN 1 stated that Resident 102's bed was positioned against the wall because there was a consent made by Resident 102`s Responsible Party (RP 2) on 12/28/2023. RN 1 stated that licensed staff completed an assessment, obtained a consent, and developed a care plan for placing Resident 102`s bed against the wall, however, licensed staff did not obtain a physician order for placing the resident`s bed against the wall. RN 1 stated that there should have been an order before putting the bed against the wall for safety reasons. RN 1 stated that placing the bed against the wall will impede (block) the movement of residents. During an interview on 4/10/2026 at 8:20 a.m. with the DON, the DON stated that if a bed is placed against the wall and restricts a resident`s movement, it is considered a restraint. The DON stated that before applying for any restraints, there should be an assessment, care plan, consent and physician's order. The DON further stated that if residents' bed is placed against the wall, they could be at risk for entrapment. During a review of the facility's Policy and Procedures (P&P) titled, Restrain Free Environment, revised on 12/19/2022, the P&P indicated that, It is the policy of this facility that each resident shall attain and maintain his/her highest practicable well-being in an environment that prohibits the use of restraints for discipline or convenience and limits restraint use to circumstances in which the resident has medical symptoms that warrant the use of restraints. - Physical Restraint refers to any manual method or physical or mechanical device, material, or equipment attached to adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. Physical restraints may include, but are not limited to: - Placing a chair or bed close enough to a wall that the resident is prevented from rising out of the chair or voluntarily getting out of bed. c. During a review of Resident 106's AR, the AR indicated the facility admitted the resident on 3/18/2024, with diagnoses including paraplegia (paralysis that affects the legs, making it impossible to stand or walk), schizophrenia (a mental illness that is characterized by disturbances in thought), and generalized muscle weakness. During a review of Resident 106's H&P, dated 3/5/2026, the H&P indicated that the resident had the capacity to understand and make decisions. The H&P further indicated that the resident had a diagnosis of schizophrenia. During a review of Resident 106's MDS, dated [DATE], the MDS indicated Resident 106 had an intact cognition and was usually able to understand and make her needs known. The MDS further indicated Resident 106 required supervision or touching assistance with eating and oral hygiene, and substantial/maximal assistance from staff with all other ADLs. During a review of Resident 106's fall risk evaluation dated 2/20/2026, the fall risk evaluation indicated that Resident 106 was not a risk for falls. During an observation on 4/6/2026 at 10:01 a.m. inside Resident 106's room, observed Resident 106 lying asleep in bed. Observed wedge pillows were tucked under Resident 106's fitted sheet on both sides of the bed. During a concurrent observation and interview on 4/6/2026 at 10:08 a.m., inside Resident 106's room with Certified Nursing Assistant (CNA) 3, CNA 3 stated Resident 106 had the wedge pillows tucked under the fitted sheet on both sides of the bed for safety as the resident leans too far towards the left side of the bed and to keep the resident in upright position while in bed. CNA 3 stated that the wedge pillows are for comfort and positioning. CNA 3 stated that Resident 106 was unable to remove the pillows by herself as she had weakness on both arms and is restricting Resident 106's movement. During an interview on 4/6/2026 at 10:23 a.m. with Licensed Vocational Nurse (LVN) 3, LVN 3 stated that she is familiar with Resident 106 and placement of wedge pillows under the fitted sheet is to keep the resident on her side and to prevent the resident from falling. LVN 3 stated that placement if wedge pillows under the fitted sheet is a practice in the facility. LVN 3 stated that Resident 106 had weakness on both upper arms and was unable to remove the wedge pillows if tucked under the fitted sheet. During a concurrent interview and record review on 4/9/2026 at 2:20 p.m., reviewed Resident 106's fall risk evaluation, restraint assessment, physician's order, informed consent, and care plan with RN 1. RN 1 stated that Resident 106 was not a risk for falls, there was no physician's order to place the wedge pillows under the fitted sheet. RN 1 stated that Resident 106 was unable to remove the wedge pillows if tucked under the fitted sheet as she had weakness on both upper arms. RN 1 stated that the wedge pillows under the fitted sheet can be considered a restraint as it was restricting the resident to move freely. RN 1 stated that wedge pillows can be used but should be placed on top of the fitted sheet. RN 1 stated that Resident 106's wedge pillows should have been placed on top of the fitted sheet. RN 1 stated that Resident 106 was not able to remove the wedge pillows under the fitted sheet and it restricted the resident to move freely. During an interview on 4/10/2026 at 8:50 a.m. with the DON, the DON stated that when applying a restraint on a resident, there should be a restraint assessment, physician's order, informed consent, and care plan. The DON stated that wedge pillows are primarily used as positioning devices and are supposed to be placed by staff on top of the fitted sheet where the residents can remove it on their own and be able to move freely. The DON stated that placing the wedge pillows under the fitted sheet restricts a resident movement and the residents are unable to remove the device, hence, considered a restraint. The DON stated that the staff should not have placed the wedge pillows under Resident 106's fitted sheet as the resident was unable to remove the pillows freely and restrict the resident to move freely which can lead to a decline in physical functioning. During a review of the facility's policy and procedure (P&P) titled, Restraint Free Environment, last reviewed on 3/18/2026, the P&P indicated that it is the facility's policy that each resident shall attain and maintain his/her highest practicable well-being in an environment that prohibits the use of restraints for discipline or convenience and limits restraint use to circumstances in which the resident has medical symptoms that warrant the use of restraints. The P&P further indicated: - Physical Restraint refers to any manual method or physical or mechanical device, material, or equipment adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. - Before a resident is restrained, the facility will determine the presence of a specific medical symptom that would require the use of restraints and determine: a. How the use of restraints would treat the medical symptom. b. The length of time the restraint is anticipated to be used to treat the medical symptom, who may apply the restraint, and the time and frequency that the restraint will be released. c. The type of direct monitoring and supervision that will be provided during the use of the restraint. d. How the resident will request staff assistance and how his/her needs will be met. e. How to assist the resident in attaining or maintaining his or her highest practicable level of physical and psychosocial well-being.

Based on observation, interview, and record review, the facility failed to update a resident's comprehensive care plan (a document outlining a detailed approach to care customized to an individual resident's need) for one of five sampled residents (Resident 91) reviewed under the urinary catheter (also known as Foley catheter, is a hollow flexible tube inserted in the bladder through the urethra to drain urine) or UTI (urinary tract infection - an infection in the bladder/urinary tract) care area to include notifying Resident 91's physician when the indwelling urinary catheter becomes dislodged or removed, place a urinary catheter securement device, and follow Resident 91's physician order to change Resident 91's indwelling urinary catheter every 30 days. These deficient practices had the potential to result in inconsistent implementation of the care plan that may lead to catheter acquired urinary tract infection (CAUTI) and not up-to-date implementation of interventions. Cross-reference F690. Findings: During a review of Resident 91's admission Record (AR), the AR indicated that the facility admitted the resident on 6/21/2024, with diagnoses including peripheral vascular disease (PVD - a slow progressive narrowing of the blood flow to the arms and legs), obstructive (a blockage in your body that makes it difficult or impossible to urinate) and reflex uropathy (the backward flow of urine from the bladder up into the ureters and kidneys), and benign prostatic hyperplasia (BPH - a condition in which the prostate gland is larger than normal) with lower urinary tract symptoms. During a review of Resident 91's History and Physical (H&P), dated 3/9/2026, the H&P indicated the resident was alert and oriented x4 (medical abbreviation for Person, Place, Time, and Event/Situation), follows commands, and was verbally responsive. During a review of Resident 91's Minimum Data Set (MDS - a resident assessment tool), dated 2/26/2026, the MDS indicated the resident was cognitively intact (a person's thinking, learning, and memory abilities are functioning normally and are not impaired). The MDS indicated the resident required assistance with toileting hygiene, shower/bathe self, upper and lower body dressing and with mobility. The MDS indicated the resident with an indwelling catheter During a review of Resident 91's physician orders, dated 12/23/2025, the physician orders indicated to maintain indwelling Foley catheter 16 Fr/30 cc (balloon size filled with the amount of sterile water after insertion that keeps the catheter secured inside the bladder, ensuring it does not slip out) balloon to bedside straight drainage, for diagnosis/history of BPH/obstructive uropathy. Routine Foley catheter changes every 30 days. Maintain closed drainage system. During a concurrent observation and interview on 4/9/2026 at 10:16 a.m., inside Resident 91's room, with Registered Nurse (RN) 1, Resident 91 stated that his indwelling urinary catheter came out about a week and a half ago and it was replaced on the same day. Resident 91 stated his urinary drainage bag was replaced two weeks ago. Resident 91 stated that he (Resident 91) did not have the urinary catheter securement device for about a month because he (Resident 91) has a lot of hair and needs to be shaved. Resident 91 stated when they remove the urinary catheter securement device his hair goes with it and it was painful. Resident 91 stated his urinary catheter tubing and urinary drainage bag were not marked with dates ever since a resident of this facility. RN 1 stated Resident 91's urinary catheter tubing did not have a date of when it was placed, and urinary drainage bag did not have a date of when it was last changed. RN 1 stated Resident 91 did not have a urinary catheter securement device to hold the urinary catheter in place and Resident 91's urinary catheter size is 18 Fr / 10 cc balloon. During a concurrent interview and record review on 4/9/2026 at 2:05 p.m., with RN 1, Resident 91's nursing assessments, progress notes, and Care Plans (CP) were reviewed. RN1 stated staff developed a CP titled, Impaired urinary elimination., on 6/22/2024 for Resident 91 and the CP goal indicated that the resident will be free from CAUTI. RN 1 stated she (RN 1) does not see the interventions such as follow physician order for catheter size, replace or change Foley as needed due to dislodgement, call the doctor and get an order to reinsert if there is not already one, change the urinary indwelling catheter per protocol or as ordered, and to place urinary catheter securement device. RN 1 stated there was no note notifying the doctor when the resident's Foley catheter was dislodged. During an interview on 4/10/2026 at 8:10 a.m., with the Director of Nursing (DON), the DON stated that the purpose of the care plan is to develop a plan of care for the resident. The DON stated the care plan is revised on admission and as needed. The DON stated the interventions she would expect for residents with urinary indwelling catheter to monitor urine, monitoring notification if any change, the size of the catheter, any signs of infection, physician orders for leaking or removed, and securement device care planned. The DON stated that when the care plan is not revised to reflect the resident's up-to-date condition and needs, the resident can receive physician orders or interventions such as the insertion of a Foley catheter that have not been explained or about their current condition and the purpose, risks, and benefits of the procedure. The DON stated the resident is at risk for UTI when the care plan is not followed. The DON stated that the purpose of the urinary securement device is to secure the urinary catheter in place. During a review of the facility's policy and procedure (P&P) titled, Appropriate Use of Indwelling Catheter, last reviewed and approved on 3/18/2026, the P&P indicated that 9. Indwelling urinary catheters (urethral or suprapubic) will be utilized in accordance with current standards of practice, with interventions to prevent complications to the extent possible. Possible complications include, but are not limited to: urinary tract infection, blockage of the catheter, expulsion of the catheter, pain, discomfort, and bleeding. 10. The plan of care will address the use of an indwelling urinary catheter, including strategies to prevent complications. During a review of the facility's P&P titled, Comprehensive Care Plans, last reviewed and approved on 3/18/2026, the P&P indicated that it is the facility's policy to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. 5. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. 6. The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented, as needed.

Based on observation, interview, and record review, the facility failed to ensure the resident environment was free of accident hazards for four of eight sampled residents (Residents 13, 109, 138, and 106) reviewed for accidents by failing to ensure residents did not have a furniture or equipment on top of the floor mat (specially designed mats provide cushioning and support to patients who are at risk of falling, helping to prevent serious injuries) and bilateral padded siderails were in place as ordered by the physician. These deficient practices increased the risk of accidents such as falls with injuries. Findings: 1. During a review of Resident 13's admission Record (AR), the AR indicated the facility admitted the resident on 9/12/2024, and readmitted the resident on 2/21/2026, with diagnoses including abnormalities of gait (a person's specific manner or style of walking, running, or moving on foot) and mobility, disorders of bone density (a measure of how much calcium and other minerals are packed into a specific area of your bone) and structure of right shoulder, and lack of coordination. During a review of Resident 13's History and Physical (H&P), dated 8/2/2025, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 13's Minimum Data Set (MDS - a resident assessment tool), dated 9/2/2025, the MDS indicated the resident had the ability to make self-understood and understand others and had intact cognition (having a clear, sharp, and functioning mind that allows a person to think, learn, remember, and make decisions effectively). The MDS indicated the resident required partial to set up assistance on mobility and activities of daily living (ADLs - activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 13's Order Summary Report (OSR), dated 4/8/2026, the OSR did not indicate an order for floor mat. During a review of Resident 13's Fall Risk (FR), dated 2/17/2026, the FR indicated the resident was at risk for falls. During a concurrent observation and interview on 4/7/2026 at 10:25 a.m. with Licensed Vocational Nurse (LVN) 5, inside Resident 13's room, observed Resident 13's floor mat at the left side of the bed, with the wheel of the bed on top of the mat and the mat was halfway under the bed. LVN 5 stated the mat was not placed properly, half of the mat was under the bed and when the resident falls only half of the body will land on the mattress and the resident can sustain injury. During a concurrent interview and record review on 4/7/2026 at 3:01 p.m. with Registered Nurse (RN) 1, Resident 13's OSR, FR, and CP were reviewed. RN 1 stated the floor mats should me checked at least every shift and when they go rounds on their residents. RN 1 stated the purpose of the floor mat was to provide a soft-landing space for resident when they fall. If there is a furniture or equipment on top of them or the mat was halfway under the bed the resident can sustain injury as the resident will hit what is on top of the mat or the resident can land on the floor without the cushion causing injury. RN 1 stated the resident was a fall risk and she was not able to find a physician's order nor a care plan on its use. During an interview on 4/10/2026 at 8:10 a.m. with the Director of Nursing (DON), the DON stated the purpose of the floor mat is for fall intervention. The DON stated the floor mat of Resident 13 should have an order and should be care planned. The DON stated the floor mat minimizes the risk of injury to the resident by providing cushion when they fall. The DON stated the floor mat on Resident 13 was halfway under the bed and will not be able to catch the whole body when the resident falls and the resident may sustain a major injury. The DON stated the policy and procedure (P&P) titled Accidents and Supervision and manufacturer's specification titled Floor Mat (FM) 1 were not followed. 2. During a review of Resident 138's AR, the AR indicated the facility admitted the resident on 4/3/2026, with diagnoses including type 2 diabetes mellitus with diabetic polyneuropathy (high blood sugar has caused nerve damage, usually on the feet, leading to pain or loss of feeling); chronic kidney disease, stage four (4) (a condition that developed over time where kidneys are severely damaged and most of their function is lost being unable to clean waste and extra fluid from the blood); essential (primary) hypertension (high blood pressure with no known specific cause). During a review of Resident 138's H&P, dated 4/6/2026, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 138's MDS, dated [DATE], the MDS indicated the resident had the ability to make self-understood and understand others. The MDS further indicated that Resident 138 had moderate cognitive impairment (has some trouble with memory and thinking but can still function with support). The MDS indicated that the resident needs partial to maximal assistance on mobility and ADLs. During a review of Resident 138's OSR, dated 4/4/2026, the OSR indicated an order for bilateral floor mats. Consent obtained from resident/responsible party. During a review of Resident 138's Fall Risk Evaluation (FRE), dated 4/3/2026, the FRE indicated the resident was at risk for falls. During a review of Resident 138's CP Report, the focus was that Resident 138 is at risk for falls related to (r/t) gait (manner of walking)/balance problems, initiated on 4/3/2026, the CP indicated a goal of resident will be free of falls through the review date. Some interventions are to review information on past falls and attempt to determine cause of falls, record possible root causes, and alter remove any potential causes if possible. During a concurrent observation and interview on 4/6/2026 at 9:36 a.m. with Certified Nursing Assistant (CNA) 12, inside Resident 138's room, observed Resident 138's floor mat on the left side of the bed that had the bedside table on top of the floor mat. CNA 12 stated the floor mat is to prevent the resident from getting injured if the resident were to fall. CNA 12 stated bedside table should not be on top of the floor mat because if Resident 138 were to fall then resident can get injured with the table. During a concurrent interview and record review on 4/8/2026 at 8:20 a.m. with RN 1, Resident 138's OSR, FRE, and CP were reviewed. RN 1 stated Resident 138 is at risk for falls. RN 1 stated the floor mats are for high-risk fall residents and to prevent injury. RN 1 stated there should be no objects on top of the Resident 138's floor mat because it prevents the mat from serving its protective purpose in case residents were to fall. RN 1 stated the purpose of the floor mat was to prevent injury to the resident. RN 1 stated the staff need to ensure that there is nothing on top of the floor mat so it can serve its purpose. During an interview on 4/10/2026 at 8:10 a.m. with the DON, the DON stated the floor mat is used for fall prevention to reduce injury if there is an incidence of fall. The DON stated the purpose of the floor mat is for fall intervention. The floor mat minimizes the risk for injury by providing cushion if they fall. The DON stated the floor mat will not catch the whole body; resident can get major injury if there is an object on top of floor mat. 3. During a review of Resident 109's AR, the AR indicated the facility admitted the resident on 6/2/2023, with diagnoses including legal blindness (cannot see clearly or cannot see much to the sides); essential (primary) hypertension (high blood pressure with no known specific cause); history of falls. During a review of Resident 109's H&P, dated 6/10/2025, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 109's MDS, dated [DATE], the MDS indicated the resident had the ability to make self-understood and understand others. The MDS further indicated that Resident 109 is cognitively intact (thinking and memory are good). The MDS indicated Resident 109 needs maximal assistance on mobility and ADLs. During a review of Resident 109's Care Plan (CP) Report, the focus was that Resident 109 is at risk for falls: weakness, history of blindness with a goal of Resident 109 will have no falls with injury for 90 days. An intervention of assist resident/caregiver to organize belongings for a clutter-free environment in the resident's room and consistent furniture arrangement. During a concurrent observation and interview on 4/6/2026 at 10:45 a.m. with CNA 1, inside Resident 109's room, observed the floor mat on the left side of the bed with the bedside table on top of it. CNA 1 stated the floor mat is for fall protection and the bedside table should not be on top of it, the resident can fall and can get injured with the table. CNA 1 stated the floor mat needs to be removed before placing the table because the mat can also cause the table to tip over since floor mat is not flat. During a concurrent interview and record review on 4/8/2026, at 8:20 a.m., with RN 1, Resident 109's Fall Risk Evaluation and CP were reviewed. RN 1 stated Resident 109 is at risk for falls. RN 1 stated the floor mats are for high-risk fall patients and to prevent injury. RN 1 stated there should be no objects on top of the floor mat of Resident 109 because it prevents the mat from serving its protective purpose in case the resident were to fall. RN 1 stated the purpose of the floor mat was to prevent injury to the resident. RN 1 stated the staff needs to ensure that there is nothing on top of the floor mat so it can serve its purpose. During an interview on 4/10/2026 at 8:10 a.m. with the DON, the DON stated the floor mat is used for fall prevention to reduce injury if there is an incidence of fall. The DON stated the purpose of the floor mat is for fall intervention. The floor mat minimizes the risk of injury by providing cushion if they fall. The DON stated the floor mat will not catch the whole body; resident can get major injury if there is an object on top of floor mat. 4. During a review of Resident 106's AR, the AR indicated the facility admitted the resident on 3/18/2024, with diagnoses including paraplegia (paralysis that affects the legs, making it impossible to stand or walk), schizophrenia (a mental illness that is characterized by disturbances in thought), and generalized muscle weakness. During a review of Resident 106's H&P, dated 3/5/2026, the H&P indicated the resident had the capacity to understand and make decisions. The H&P further indicated that Resident 106 had a history of seizure disorder (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness). During a review of Resident 106's MDS, dated [DATE], the MDS indicated Resident 106 had an intact cognition and was usually able to understand and make her needs known. The MDS further indicated Resident 106 required supervision or touching assistance with eating and oral hygiene, and substantial/maximal assistance from staff with all other ADLs. During a review of Resident 106's FRE, dated 2/20/2026, the FRE indicated that Resident 106 was not a risk for falls. During a review of Resident 106's Order Summary Report dated 4/10/2026, the Order Summary Report indicated the following physician's orders: - 3/19/2024: Seizure precautions every shift. - 10/28/2024: Floor mat (a cushioned floor pad designed to help prevent injury should a person fall) to right side of bed to decrease risk of injury every shift for fall precaution as a landing pad. - 12/19/2025: Monitor padded side rails for seizure precautions every shift. During a review of Resident 106's care plans (CP) indicated the following: - Risk for falls initiated on 10/26/2026 and last revised on 3/5/2026, the CP indicated floor mats as one of the interventions to minimize Resident 106's falls. - Risk for seizure initiated on 3/29/2024 and last revised on 11/25/2025, the CP indicated to maintain a safe environment and monitor the padded side rails as a few of the interventions to keep the resident free of any seizure related injury. During a concurrent observation and interview on 4/6/2026 at 10:23 a.m. with CNA 3, inside Resident 106' s room, CNA 3 stated that the only device for Resident 106 was the use of wedge pillows to keep the resident upright in bed as the resident leans too far to the left side. During a follow up concurrent interview and record review on 4/8/2026 at 12:35 p.m., inside Resident 106's room with CNA 3, CNA 3 stated that he was not aware of any other safety precautions for Resident 106 and the resident did not have any floor mat on the right side of the bed or padded side rails. CNA 3 stated he does not remember that Resident 106 had any seizure events recently. During a concurrent interview and record review on 4/9/2026 at 2:36 p.m. with RN 1, Resident 106's AR, H&P, physician's orders, fall risk evaluations, and CP were reviewed. RN 1 stated that Resident 106's AR and H&P had a history of seizure disorder, the physician's order indicated seizure precautions every shift, floor mat on the right side of the bed, and padded side rails, and the CP indicated floor mat and padded siderails as interventions for Resident 106's safety. RN 1 stated that if there are physician orders and interventions to keep the residents free from any seizure related injury, the interventions and physician orders should be in place and implemented, and the nursing staff are responsible in making sure that these interventions are in place and monitor every shift as indicated in the physician's orders. RN 1 stated that Resident 106's floor mat on the right side of the bed and the padded side rails should have been in place as it placed Resident 106 at risk from accidents and/or any seizure related injury. During an interview on 4/10/2026 at 9:13 a.m. with the DON, the DON stated that the purpose of floor mats is to prevent risk for incurring injury by providing a cushion for the resident during a fall incident and that the padded side rails are used to prevent any injury during a seizure activity. The DON stated that if there is a physician's order to place floor mat and padded side rails and indicated in the CP as well, the nursing staff should ensure that the order and interventions are implemented for the residents' safety and prevent injury. The DON stated that the nursing staff should have ensured that Resident 106's floor mat on the right side of the bed and the padded side rails should have been in place and provide cushion as it placed the resident at risk for accidents and incur injury in the event of a seizure activity. During a review of the facility's recent P&P titled, Accidents and Supervision, last reviewed on 3/18/2026, the P&P indicated the resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes: 1. Identifying hazard(s) and risk(s). 2. Evaluating and analyzing hazard(s) and risk(s). 3. Implementing intervention to reduce hazard(s) and risk(s). 4. Monitoring for effectiveness and modifying interventions when necessary. During a review of the facility-provided Floor Mat (FM) 1 Owner's Manual (OM), printed on 11/2017, the OM indicated the Attendant Protector Foldable Bedside Mat may be placed next to a User's bed to help reduce the impact of a fall should a resident fall from the bed. Directions For Use 4. Place the bedside mat flat on the floor, directly next to the bed, making sure it does NOT go under the bed. Storage 5. Do not place objects on the product during storage.

Based on observation, interview, and record review, the facility failed to ensure residents with a urinary catheter (also known as Foley catheter - a hollow tube inserted into the bladder to drain or collect urine) received appropriate care and services to prevent urinary tract infections (UTI, an infection in the bladder/urinary tract) for seven of seven sampled residents (Resident 91, 135, 137, 51, 123, 3, and 61) reviewed for urinary catheter or UTI by failing to: 1a. Follow the physician order to insert indwelling urinary catheter 16 French (Fr - outer diameter of the catheter size) size when Resident 91 was observed with a gauge 18 Fr size indwelling urinary catheter. 1b. Label with a date when the indwelling urinary catheter was inserted for Resident 91. 1c. Place a urinary catheter securement device (an adhesive patch or strap that anchors a catheter tube to the skin) for Resident 91. 1d. Follow the physician's order to change Foley catheter every 30 days. 2. Ensure Resident 135's urinal bottle (a handheld container designed for collecting urine) was labeled with the name, room number, and the date the bottle was provided. 3. Ensure Resident 137 and 51's urinal bottles were labeled. These deficient practices had the potential for Residents 135, 137, and 51 to develop UTI. 4. Maintain Resident 123's indwelling urinary catheter (a hollow tube inserted into the bladder to drain or collect urine) in a manner that prevents urine backflow. 5. Failing to change urinary catheter every 30 days for Resident 3 and 61, consistent with physician's order. This deficient practice had the potential to result in trauma to Resident 91, 123, 3, and 61's urinary catheter insertion site, dislodgement and/or removal of the urinary catheter, and increased risk for catheter-associated UTI (CAUTI- an infection involving any part of the urinary system). Findings: 1. During a review of Resident 91's admission Record (AR), the AR indicated that the facility originally admitted the resident on 6/21/2024, with diagnoses including peripheral vascular disease (PVD - a slow progressive narrowing of the blood flow to the arms and legs), obstructive (a blockage in your body that makes it difficult or impossible to urinate) and reflex uropathy (the backward flow of urine from the bladder up into the ureters and kidneys), and benign prostatic hyperplasia (BPH – a condition in which the prostate gland is larger than normal) with lower urinary tract symptoms. During a review of Resident 91's History and Physical (H&P), dated 3/9/2026, the H&P indicated the resident was alert and oriented x4 (medical abbreviation for Person, Place, Time, and Event/Situation), followed commands, and was verbally responsive. During a review of Resident 91's Minimum Data Set (MDS – a resident assessment tool), dated 2/26/2026, the MDS indicated the resident was cognitively intact (a person's thinking, learning, and memory abilities are functioning normally and are not impaired). The MDS indicated the resident required assistance with toileting hygiene, shower/bathe self, upper and lower body dressing and with mobility. The MDS indicated the resident with an indwelling catheter During a review of Resident 91's physician orders, dated 12/23/2025, the physician orders indicated to maintain indwelling Foley catheter 16 Fr/30 cc (balloon size filled with the amount of sterile water after insertion that keeps the catheter secured inside the bladder, ensuring it does not slip out) balloon to bedside straight drainage, for diagnosis/history of BPH/obstructive uropathy. Routine Foley catheter changes every 30 days. Maintain closed drainage system. During a concurrent interview and record review on 4/9/2026 at 10:16 a.m., inside Resident 91's room, with Registered Nurse (RN) 1, Resident 91 stated his indwelling urinary catheter came out about a week and a half ago and it was replaced on the same day. Resident 91 stated his urinary drainage bag was replaced two weeks ago. Resident 91 stated he (Resident 91) did not have the urinary catheter securement device for about a month because he (Resident 91) has a lot of hair and the hair needs to be shaved. Resident 91 stated when they remove the urinary catheter securement device his hair goes with it and it was painful. Resident 91 stated his urinary catheter tubing and urinary drainage bag were not marked with dates ever since a resident of this facility. RN 1 stated Resident 91's urinary catheter tubing did not have a date of when it was placed, and urinary drainage bag did not have a date of when it was changed. RN 1 stated Resident 91 did not have a urinary catheter securement device to hold the urinary catheter in place and Resident 91's urinary catheter size is 18 Fr / 10 cc balloon. During a concurrent interview and record review on 4/9/2026 at 10:21 a.m., with RN 1, Resident 91's physician orders, nursing assessment and progress notes were reviewed. RN 1 stated Resident 91`s current indwelling catheter order, dated 12/23/2025, indicated to maintain 16 Fr size urinary catheter, not 18 Fr size. RN 1 stated Resident 91`s physician order was not followed. RN 1 stated the licensed nurse that inserted the urinary catheter should have reviewed the order and clarified with the doctor regarding the urinary catheter size. RN 1 stated the licensed nurse should have documented when Resident 91`s urinary catheter came out and the catheter was changed in the nursing progress notes. RN 1 stated there was no documentation when the urinary catheter was replaced. RN 1 stated the treatment nurses are the ones responsible for placing the urinary securement device. RN1 further stated that urinary securement device is applied to make sure tubing is stabilized and to prevent trauma if resident moves. RN 1 stated when the physician order is not followed it can cause trauma on the site, resident may experience hematuria (blood in urine), pain, discomfort, and dislodgement. RN 1 stated the urinary drainage bag, and urinary indwelling catheter did not have a date of when it was changed. RN 1 stated the date is to ensure that the Foley catheter was changed and prevent infection from long-term use. During a concurrent interview and record review on 4/9/2026 at 10:42 a.m., with Treatment Nurse (TN) 1, Resident 91's Treatment Administration Record (TAR) for the months of 1/2026, 2/2026, and 3/2026 were reviewed. TN 1 stated Resident 91 had an order to change Foley catheter every 30 days, and this is being done towards the end of the month. TN 1 stated once the resident's Foley catheter is changed, they would mark it on the TAR or documented in the progress notes. TN 1 stated the last time she (TN 1) changed Resident 91's urinary catheter was 3/20/2026. TN 1 stated she (TN 1) would also write the date of when it was changed on the white part of the urinary drainage bag. TN 1 stated Resident 91 has told him that someone has changed his urinary catheter tubing because it deflated. TN 1 stated the urinary securement device is changed as needed and regularly no longer than a week. TN 1 stated Resident 91 did not allow them to place the securement device because he (Resident 91) asked his CNA to shave his legs first. TN 1 stated there was no documentation that the Foley catheter was changed every 30 days. TN 1 stated the physician order should have been clarified and scheduled every 30 days then it would notify the licensed nurses that the resident's Foley catheter is due to be changed. During a concurrent interview and record review on 4/9/2026 at 2:05 p.m., with RN 1, Resident 91's nursing assessments, progress notes, and Care Plan (CP) titled, Impaired urinary elimination., dated 6/22/2024 were reviewed. RN 1 stated Resident 91`s CP goal indicated that the resident will be free from CAUTI. RN 1 stated she (RN 1) does not see the interventions such as follow physician order for catheter size, replace or change Foley as needed due to dislodgement, call the doctor and get an order to reinsert if there is not already one, change urinary indwelling catheter per protocol or as ordered, and to place urinary catheter securement device. RN 1 stated there was no note notifying the doctor when the resident's Foley catheter was dislodged. During an interview on 4/10/2026 at 8:26 a.m., with the Director of Nursing (DON), the DON stated that the facility`s protocol for residents with urinary catheter is to have an order for indwelling catheter, monitor the catheter, and assess the residents for the use of indwelling urinary catheter which is done when it was placed and as needed. The DON stated for residents with indwelling urinary catheter reinserting the wrong size, which was done not as ordered, not placing a securement device, the resident could get an infection and catheter associated urinary tract infection. The DON stated the resident's urinary drainage bag should be labeled with a date it was last changed. The DON stated she (DON) can't say it's a policy but it's best practice to label with a date of when the urinary drainage bag was changed. During a review of the facility's policy and procedure (P&P) titled, Appropriate Use of Indwelling Catheter, last reviewed and approved on 3/18/2026, the P&P indicated that it is the facility's policy to ensure that a resident who is continent of bladder on admission receives services and assistance to maintain continence unless his/her clinical condition is or becomes such that continence is not possible to maintain. An indwelling catheter will be utilized only when a resident's clinical condition demonstrates that catheterization was necessary. 4. The use of an indwelling urinary catheter will be in accordance with physician orders, which will include the diagnosis or clinical condition making the use the catheter necessary, size of the catheter, and frequency of change (if applicable). 9. Indwelling urinary catheters (urethral or suprapubic) will be utilized in accordance with current standards of practice, with interventions to prevent complications to the extent possible. Possible complications include, but are not limited to: urinary tract infection, blockage of the catheter, expulsion of the catheter, pain, discomfort, and bleeding. 10. The plan of care will address the use of an indwelling urinary catheter, including strategies to prevent complications. 2. During a review of Resident 135's AR, the AR indicated the facility admitted the resident on 8/6/2025, and readmitted the resident on 3/31/2026, with diagnoses including urinary tract infection, obstructive and reflux uropathy (a blockage in the urinary tract that hinders urine flow, causing backflow (reflux) and kidney injury), and benign prostatic hyperplasia (BPH, a common, non-cancerous enlargement of the prostate gland in older men). During a review of Resident 135's H&P, dated 8/10/2025, the H&P indicated the resident had the capacity to consent. During a review of Resident 135's MDS, dated [DATE], the MDS indicated the resident sometimes had the ability to make self-understood and understand others and had moderately impaired cognition (a noticeable, measurable decline in thinking skills—such as memory, language, or judgment—that is more severe than normal age-related forgetfulness but not severe enough to stop a person from living independently). During a concurrent observation and interview on 4/6/2026, at 10 a.m., with Certified Nursing Assistant (CNA) 10, inside Resident 135's room, observed Resident 135's unlabeled urinal bottle at the side table of the resident. CNA 10 stated the urinal bottle should be labeled with the name of the resident and the date it was provided to ensure the urinal belongs to the resident and for infection control. During an interview on 4/7/2026, at 2:57 p.m., with RN 1, RN 1 stated the urinal bottle of Resident 135 should have been labeled with the resident's name and the date it was provided to ensure the urinal belongs to the resident and they were not using the urinal for more than a week. RN 1 stated the urinal should be changed weekly and if needed (PRN) to prevent UTI on residents. During an interview on 4/10/2026, at 8:10 a.m., with the DON, the DON stated the urinal bottle of Resident 135 should have been labeled with the last name of the resident and the date it was last provided to ensure its safe use. The DON stated labeling the bottle with the resident's last name ensures the bottle is only used for the resident and to avoid switching of urinals among residents and the date it was last provided is affixed to ensure the urinal is changed every week for infection control. The DON stated the failure of the staff to label the urinal with the name of the resident and the date it was provided predisposed the resident to UTI. The DON stated the policy and procedure (P&P) titled Disinfection of Bedpans and Urinals was not followed by the staff. During a review of the facility's recent P&P titled, Disinfection of Bedpans and Urinals, last reviewed on 3/18/2026, the P&P indicated bedpans and urinals are handled in a manner that prevent the spread of infection through personal equipment. Policy Explanation and Compliance Guidelines: 1. Bedpans and urinals are for single resident use only. 3a. During a review of Resident 137's AR, the AR indicated the facility originally admitted the resident on 8/8/2025, and readmitted on [DATE], with diagnoses including absence of left leg below knee, generalized muscle weakness, and unsteadiness on feet. During a review of Resident 137's H&P, dated 3/26/2026, the H&P indicated that Resident 137 had the capacity to understand and make decisions. During a review of Resident 137's MDS, dated [DATE], the MDS indicated Resident 137 had an intact cognition (mental action or process of acquiring knowledge and understanding) and was able to understand others and make his needs known. The MDS further indicated Resident 137 was independent with all activities of daily living (ADLs - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The MDS indicated Resident 137 was always continent of bladder. During a review of Resident 137's care plan (CP) on occasional incontinence of bowel and bladder initiated on 3/25/2026 and last revised on 4/7/2026, the CP indicated to establish voiding patterns and monitor/document/report as needed any possible causes of incontinence such as bladder infection, loss of bladder tone, weakening of control muscles, decreased bladder capacity and medication side effects as a few of the interventions for the resident to be continent at all times. During a review of Resident 137's Bowel and Bladder Assessment form dated 3/25/2026, the Bowel and Bladder Assessment form indicated that resident was continent of bowel and bladder. During a concurrent observation and interview on 4/6/2026, at 9:38 a.m., inside Resident 137's room with CNA 14, CNA 14 stated that the resident's urinal was hanging on the right side of the bed on a urinal holder and did not indicate Resident 137's name. CNA 14 stated that urinals are changed every week on Sundays by the night shift CNA and as needed if soiled and should be labeled with the resident's name and the date it was changed or provided to the resident. CNA 14 stated that Resident 137's urinal should have been labeled with the resident's name and the date it was changed to prevent switching of the urinals which can cause contamination and infection. During an interview on 4/9/2026 at 2:23 p.m. with the Director of Staff Development (DSD), the DSD stated that the facility practice in changing the urinals is every Sunday by the night shift CNAs and should be labeled with the resident's name and the date it was changed to ensure that the urinal belongs to specific resident and prevent switching which can cause cross contamination and infection. The DSD stated the Resident 137's urinal should have been labeled with Resident 137's name and the date it was changed to ensure that the urinal belongs to Resident 137 and that it was changed. The DSD stated that if the urinal did not have Resident 137's name and the date it was changed the staff would not know who it belongs to or if it was new which placed the resident at risk for acquiring UTI due to cross contamination (transfer of bacteria or other contaminants from one surface to another due to unsanitary handling procedures). During an interview on 4/10/2026 at 9:09 a.m. with the DON, the DON stated that urinals are changed weekly on Sundays during the night shift CNAs and should be labeled with the resident name and the date provided to the resident to ensure that the urinal was not old and which resident it belongs to. The DON stated that Resident 137's urinal should have been labeled with Resident 137's name and the date provided to ensure that the urinal belongs to the resident and avoid switching urinal with other residents which placed Resident 137 at risk for acquiring infection or UTI due to cross contamination. During a review of the facility's P&P titled, Disinfection of Bedpans and Urinals, last reviewed on 3/18/2026, the P&P indicated that bedpans and urinals are handled in a manner that prevent the spread of infection through personal equipment. The P&P further indicated that bedpans and urinals are for single resident use only. 3b. During a review of Resident 51's AR, the AR indicated the facility admitted the resident on 3/20/2026, with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (partial paralysis of the arm, leg, and trunk on the same side of the body) following cerebrovascular disease (CVA-stroke, loss of blood flow to a part of the brain) affecting left dominant side, peripheral vascular disease (PVD - a slow progressive narrowing of the blood flow to the arms and legs), and generalized muscle weakness. During a review of Resident 51's H&P, dated 3/22/2026, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 51's MDS, dated [DATE], the MDS indicated Resident 51 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and was usually able to understand and make his needs known. The MDS further indicated Resident 51 required substantial/maximal assistance to total assistance from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive) and that the resident was frequently incontinent of bladder. During a review of Resident 51's care plan (CP) on bowel and bladder incontinence initiated on 3/25/2026, the CP indicated to monitor/document for signs and symptoms of UTI and monitor/document/report as needed any possible causes of incontinence such as bladder infection, loss of bladder tone, weakening of control muscles, decreased bladder capacity and medication side effects as a few of the interventions to minimize the risk for infection via prompt recognition of symptoms of UTI. During a review of Resident 51's Bowel and Bladder Assessment form dated 3/20/2026, the Bowel and Bladder Assessment form indicated that resident was incontinent of bowel and bladder. During a concurrent observation and interview on 4/6/2026 at 9:45 a.m. with CNA 8, inside Resident 51's room, CNA 8 stated that the resident's urinal was hanging on the right side of the bed on a urinal holder and did not indicate Resident 51's name. CNA 8 stated that urinals are changed every week on Sundays by the night shift CNA and as needed if soiled and should be labeled with the resident's name and the date it was changed. CNA 8 stated that Resident 51's urinal should have been labeled with the resident's name and the date it was changed to prevent switching of the urinals which can cause contamination and infection. During an interview on 4/9/2026 at 2:23 p.m. with the DSD, the DSD stated that the facility practice in changing the urinals is every Sunday by the night shift CNAs and should be labeled with the resident's name and the date it was changed to ensure that the urinal belongs to specific resident and prevent switching which can cause cross contamination and infection. The DSD stated the Resident 51's urinal should have been labeled with Resident 51's name and the date it was changed to ensure that the urinal belongs to Resident 51 and that it was changed. The DSD stated that if the urinal did not have Resident 51's name and the date it was changed the staff would not know who it belongs to or if it was new which placed the resident at risk for acquiring UTI due to cross contamination. During an interview on 4/10/2026 at 9:09 a.m. with the DON, the DON stated that urinals are changed weekly on Sundays during the night shift CNAs and should be labeled with the resident name and the date provided to the resident to ensure that the urinal was not old and which resident it belongs to. The DON stated that Resident 51's urinal should have been labeled with Resident 51's name and the date provided to ensure that the urinal belongs to the resident and avoid switching urinal with other residents which placed Resident 51 at risk for acquiring infection or UTI due to cross contamination. During a review of the facility's P&P titled, Disinfection of Bedpans and Urinals, last reviewed on 3/18/2026, the P&P indicated that bedpans and urinals are handled in a manner that prevent the spread of infection through personal equipment. The P&P further indicated that bedpans and urinals are for single resident use only. 4. During a review of Resident 123's AR, the AR indicated that the facility originally admitted the resident on 1/28/2028, and readmitted on [DATE], with diagnoses including Diabetes Mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing), neuromuscular dysfunction of bladder (the nerves that tell your bladder when to squeeze or relax are damaged, causing poor control over storing or emptying urine), hypertension (HTN - high blood pressure). During a review of Resident 123's H&P, dated 4/6/2026, the H&P indicated that Resident 123 had a capacity to make and understand decisions, daily needs. During a review of Resident 123's MDS, dated [DATE], the MDS indicated Resident 123 required substantial/maximal assistance (helper does more than half the effort) with toileting hygiene, shower self, lower body dressing, and dependent (helper does all of the effort) with putting on/taking off footwear. During an observation and interview on 4/6/2026 9:48 a.m. with Resident 123 inside Resident 123's room, observed Resident 123's indwelling catheter drainage tubbing coiled in a loop. During a concurrent observation and interview on 4/6/2026 12:27 p.m. with CNA 2 and CNA 4 inside Resident 123's room, CNA 2 stated when providing catheter care, catheter must be placed above the floor, and below resident's bladder level, the drainage tubbing must be straight, without coils. CNA 2 stated that Resident 123's catheter tubbing was coiled, which may potentially cause urine back flow, and put resident at risk for UTI. During an interview on 4/10/2026 at 11:34 a.m. with the DON, the DON stated the indwelling urinary catheter tubing must be maintained in straight, unobstructed position. The DON stated that coiled tubing may interfere with proper urine drainage and create backflow, which could increase the of urinary retention, discomfort, and potential CAUTI. 5a. During a review of Resident 3's AR, the AR indicated that the facility originally admitted the resident on 7/29/2019, and readmitted to the facility on [DATE], with diagnoses including hydronephrosis (the swelling of a kidney caused by a backup of urine (pee) that cannot drain properly into the bladder), neuromuscular dysfunction of bladder (the swelling of a kidney caused by a backup of urine (pee) that cannot drain properly into the bladder), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior). During a review of Resident 3's H&P, dated 10/30/2025, the H&P indicated that Resident 3 had the capacity to understand and make decisions. During a review of Resident 3's MDS, 11/19/2025, the MDS indicated that Resident 3 was cognitively intact. Resident 3 was dependent to staff with all activities of daily living (ADL). During an observation on 4/6/2026 at 11:29 a.m., inside Resident 3's room, observed Resident 3 urinary catheter draining clear, yellow urine. During a concurrent interview and record review on 4/8/2026 at 9:05 a.m. with RN 1, RN 1 reviewed Resident 3's Order Summary Report. The Order Summary Report indicated a physician's order on 12/5/2025 for routine urinary catheter changes every 30 days. RN 1 reviewed Resident 3's TAR for March 2026. TAR indicated no documentation of Resident 3's catheter consistent with physician's order. RN 1 stated it was important to follow physician orders for catheter care, including timely catheter changes as ordered, to ensure residents safety and prevent UTI. 5b. During a review of Resident 61's AR, the AR indicated that the facility admitted the resident on 4/21/2023, and readmitted on [DATE], with diagnoses including Huntington disease (inherited condition that affects movement, thinking and behavior), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness or the inability to move on one side of the body) of the right side, obstructive uropathy (a blockage in the urinary system that prevents urine from flowing freely, causing it to back up into the kidneys). During a review of Resident 61's H&P, dated 3/4/2026, the H&P indicated that Resident 61 had the capacity to understand and make decisions. During a review of Resident 61's MDS, dated [DATE], the MDS indicated that Resident 61 was dependent (helper does all of the effort) with eating, oral hygiene, toileting hygiene, lower body dressing, putting on/taking off footwear, personal hygiene. During a concurrent interview and record review on 4/8/2026 at 9:15 a.m. with RN 1, RN 1 reviewed Resident 61's Order Summary Report. The Order Summary Report indicated a physician's order on 12/6/2025 for routine urinary catheter change every 30 days. RN 1 reviewed Resident 61's TARs for months of February and March 2026. TARs indicated no documentation of Resident 61's catheter consistent with physician's order. RN 1 stated it was important to follow physician orders for catheter care, including timely catheter changes as ordered, to ensure residents' safety and prevent UTI. During an interview on 4/10/2026 at 9:00 a.m. with the DON, the DON stated that failure to follow physician's order for catheter change schedule may result in prolonged catheter use beyond recommended timeframes, increasing the risk for UTI, catheter blockage, and discomfort. During a review of facility's P&P, titled Incontinence, dated 12/19/2022, the P&P indicated, Residents that are incontinent of bladder or bowel will receive appropriate treatment to prevent infections and to restore continence to the extent possible.

Based on observation, interview, and record review, the facility failed to ensure residents' bed rails (metal or plastic bars or guards attached to the sides of a bed to act as a barrier or support) prior to installation for three of three sampled residents (Residents 96, 85, and 5) reviewed for bed rails by failing to ensure: 1. Resident 96's use of bilateral half (1/2) side/bed rail (or half-length rail) is a safety device for hospital-style beds that covers only a portion of the bed's side, usually the top half near the headboard) had a/an: -Physician's order -Current consent, the resident was readmitted to the facility on [DATE], the consent on the electronic healthcare record was from 9/13/2025 -Correct care plan, the care plan on the electronic healthcare record was for bilateral 1/4 side rail. 2. Resident 85's use of bilateral grab bars (often called a bed assist rail or bed handle) is a sturdy metal handle or railing installed on a bed to provide stability and support) had a/an: -Physician's order; -Informed consent; -Care plan on its use. -The bedrail assessment done on 3/10/2026 was for a 1/4 bilateral side rails not for a grab bar. 3. Resident 5's use of bilateral 1/2 side rail had a/an: -Clarification on the resident's use of side rails with the physician, there were 2 orders one for bilateral 1/2 side rails (which was applied) and one for bilateral 1/4 side rails (not applied). -Indicate what the consent was for. -Asses quarterly the use of the side rails. -Develop and implement a care plan on bilateral 1/2 side rails, the care plan was for bilateral 1/4 side rail. These deficient practices placed the residents at risk for potential accident such as a body part being caught between the rails, falls if a resident attempts to climb over, around, between, or through the rails. Findings: During a review of Resident 96's admission Record (AR), the AR indicated the facility admitted the resident on 7/30/2021, and readmitted the resident on 1/14/2026, with diagnoses of dementia (a progressive state of decline in mental abilities), epilepsy (a brain disorder characterized by recurring, unprovoked seizures caused by sudden, temporary bursts of abnormal electrical activity), and anxiety disorder (a mental health condition characterized by excessive, uncontrollable, and persistent fear or worry that interferes with daily life). During a review of Resident 96's History and Physical (H&P), dated 9/13/2025, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 96's Minimum Data Set (MDS - a resident assessment tool), dated 5/29/2025, the MDS indicated the resident had the ability to make self-understood and understand others and had severe cognitive impairment (a profound loss of mental capacity-such as memory, reasoning, and communication-that prevents a person from living independently). The MDS indicated the resident needed substantial/maximal assistance on mobility and activities of daily living (ADLs - activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 96's Order Summary Report, dated 4/8/2026, the OSR did not indicate any order for bed rails. During a review of Resident 96's Restraint Informed Consent Form (RICF), dated 9/13/2025, the RICF indicated a consent for side rails. During a review of Resident 96's Fall Risk (FR), dated 1/15/2026, the FR indicated the resident was at risk for falls. During a review of Resident 96's Care Plan (CP) Report titled, Side rails management. Risk for entrapment and impairment in skin discoloration related to quarter (1/4) bilateral side rails (a short, roughly 18-inch safety bar attached to the side of a hospital bed, typically near the headboard) as an enabler for mobility and repositioning, last revised on 1/19/2026, the CP indicated an intervention to obtain informed consent. During a concurrent observation and interview on 4/7/2026, at 3:27 p.m., with Licensed Vocational Nurse (LVN) 9, inside Resident 96's room, observed Resident 96 had bilateral 1/2 bed rails up. LVN 9 stated the resident uses the bed rail for mobility. During a concurrent interview and record review on 4/7/2026 at 3:30 p.m. with Registered Nurse (RN) 1, Resident 96's OSR, FR, Consent, and CP were reviewed. RN 1 stated the resident does not have any order for bed rails, and the consent that was on the chart was from 9/13/2025, the resident was readmitted to the facility on [DATE] and they should have obtained a new consent for the bilateral 1/2 bed rail. RN 1 also stated the care plan developed was for a 1/4 bilateral bed rail. RN 1 stated it was important have a physician's order on the use of 1/2 bilateral bed rail to ensure its safe use and to have an updated consent on the use of 1/2 bedrail to ensure the resident/representative are still agreeing with the proposed treatment and to honor their right to informed consent. RN 1 stated it was important to have an accurate care plan on the use of bed rails as it comes in different sizes or lengths. During an interview on 4/10/2026 at 8:10 a.m. with the Director of Nursing (DON), the DON stated Resident 96's use of bilateral 1/2 bed rails should have a physician's order, latest informed consent and correct, accurate care plan to ensure its safe use. The DON stated the bed rails can cause accidents to residents, that is why it should have all the components necessary to ensure its safe use. The DON stated the four components are physician's order, informed consent, bed rail assessment for entrapment (a dangerous, sometimes fatal, situation where a person using a hospital-style bed or a bed with rails becomes caught, stuck, or tangled in the gaps between the mattress and the bed rails, headboard, footboard, or within the rails themselves), and a care plan. During a review of Resident 85's AR, the AR indicated the facility admitted the resident on 3/10/2026, with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness on one entire side of the body), dementia, and muscle weakness. During a review of Resident 85's H&P, dated 3/11/2026, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 85's MDS, dated [DATE], the MDS indicated the resident usually had the ability to make self-understood and sometimes had the ability to understand others and had severe cognitive impairment. The MDS indicated the resident was dependent to needing supervision assistance on mobility and ADLs. During a review of Resident 85' OSR, dated 4/8/2026, the OSR did not indicate an order for bilateral grab bars. During a review of Resident 85's Physician Document Informed Consent (PDIC), dated 3/10/2026, the PDIC indicated a consent for 1/4 bilateral upper side rails. During a review of Resident 85's FR, dated 3/10/2026, the FR indicated the resident was at risk for falls. During a review of Resident 85's Bed Rails (BR), dated 3/10/2026, the BR indicated an assessment for 1/4 bed rails. During a concurrent observation and interview on 4/7/2026, at 3:17 p.m., with Certified Nursing Assistant (CNA) 13, inside Resident 85's room, observed Resident 85 with bilateral upper grab bars on. CNA 13 stated the resident uses the grab bars for mobility. During a concurrent interview and record review on 4/7/2026 at 3:30 p.m. with RN 1, Resident 85's OSR, PDIC, FR, and BR were reviewed. RN 1 stated Resident 85's grab bars should have a physician's order, bed rail assessment, informed consent, and a care plan to ensure its safe use. RN 1 stated she found an assessment but it was intended for 1/4 bed rails not for a grab bar. During an interview on 4/10/2026 at 8:10 a.m. with the DON, the DON stated Resident 85's use of bilateral grab bars should have a physician's order, informed consent, bed rail assessment and a care plan to ensure its safe use. The DON stated the bed rails/grab bars can cause accidents to residents, that is why it should have all the components necessary to ensure its safe use. The DON stated the four components are physician's order, informed consent, bed rail assessment for entrapment, and a care plan. During a review of Resident 5's AR, the AR indicated the facility admitted the resident on 10/4/2025, with diagnoses including abnormalities of gait (a person's specific manner or style of walking, running, or moving on foot) and mobility, weakness, and disorders of bone. During a review of Resident 5's MDS, dated [DATE], the MDs indicated the resident had the ability to make self-understood and understand others and had intact cognition (having a clear, sharp, functioning mind that allows a person to think, learn, remember, and make decisions effectively). The MDS indicated the resident was dependent to needing supervision assistance on mobility and ADLs. During a review of Resident 5's OSR, dated 12/15/2025, the OSR indicated an order for -Bed rails 1/2 as an enabler for turning and repositioning in bed. -Bed rails 1/4 as an enabler for turning and repositioning in bed. During a review of Resident 5's RICF, dated 12/16/2025, the RCIF did not indicate what restraint was consented for. During a review of Resident 5's GHC-Bed Safety Evaluation (BSE), dated 12/15/2025, the BSE indicated that there is no bed rail(s) to be used. During a review of Resident 5's BR, dated 4/7/2026, the BR indicated an assessment for 1/4 bed rails. During a review of Resident 5's CP Report titled Resident/Patient requires assistance/is dependent for mobility related to: Generalized weakness, initiated on 10/7/2025, the CP indicated a goal of resident will utilize bed rail(s) 1/4 side rails with assistance for turning and repositioning while in bed. During a concurrent observation and interview on 4/7/2026 at 4:02 p.m. with LVN 4, inside Resident 5's room, observed Resident 5 had bilateral 1/2 bed rails on. LVN 4 stated the resident uses them for mobility. During a concurrent interview and record review on 4/8/202 at 7:44 a.m., with RN 1, Resident 5's OSR, RICF, BSE, BR and CP were reviewed. RN 1 stated Resident 5's physician orders should have been clarified by the licensed nurses because there were two active orders, one for 1/2 bilateral bed rail which is applied and a 1/4 bilateral bed rail which is not applied to the resident. RN 1 stated the informed consent should specify what bed rails they were consenting for, the consent was not filled out completely, bed rails assessment should be done quarterly as needed. RN 1 stated the bed rail assessment was done for the second quarter of 2026; however, the first quarter bed rail assessment was not done. RN 1 stated the care plan was for 1/4 bilateral bed rail, the resident had 1/2 bilateral bed rail. RN 1 stated it was important to clarify the physician's order because there were multiple sizes of bed rails in the facility in use and each has unique considerations for safe use. RN 1 stated a completed consent helps the residents/representative understand the risks and benefit of the bed rail applied and bed rail assessments should be done quarterly to evaluate its safe use. RN 1 also stated a specific and accurate care plan provides a framework of care to be provided to the resident to achieve its intended goal. During an interview on 4/10/2026 at 8:10 a.m. with the DON, the DON stated Resident 5's use of bilateral 1/2 bed rails should have been clarified with the physician because there were two orders, the informed consent should have been filled out completely specifying what the consent was for, the bed rail assessment should have been done quarterly and an accurate care plan should have been developed and implemented to ensure its safe use. The DON stated the bed rails can cause accidents to residents, that is why it should have all the components necessary to ensure its safe use. The DON stated the four components are physician's order, informed consent, bed rail assessment for entrapment, and a care plan. During a review of the facility's recent policy and procedure (P&P) titled, Proper Use of Bed Rails, last reviewed on 3/18/2026, the P&P indicted it is the policy of this facility to utilize a person-centered approach when determining the use of bed rails. Appropriate alternative approaches are attempted prior to installing or using bed rails. If bed [NAME] are used, the facility ensures correct installation, use, and maintenance of the rails. Definitions: Bed Rails are adjustable metal or rigid plastic bars that attach to the bed. They are available in a variety of types, shapes, and sizes ranging from full to one-half, one-quarter, or one-eight lengths. Also, some bed rails are not designed as part of the bed by the manufacturer and may be installed on or used along the side of a bed. Examples of bed rails include, but are not limited to side rails, bed side rails, safety rails, grab bars and assist bars. Policy Explanation and Compliance Guidelines: Resident Assessment 2. The resident assessment must include an evaluation of the alternatives that were attempted prior to the installation or use of a bed rail and how these alternatives failed to meet the resident's assessed needs. 3. The resident assessment must also assess the resident's risk from using bed rails. Examples of the potential risks with the use of bed risks include: a. Accident hazards (e.g., falls, entrapment, and other injuries sustained from attempts to climb over, around, between, or through the rails, or over the footboard) . Informed Consent Informed consent from the resident or resident representative must be obtained after appropriate alternatives have been attempted prior to installation and use of bed rails. This information should be presented in an understandable manner, and consent given voluntarily, free from coercion. Ongoing Monitoring and Supervision 16. Responsibilities of ongoing monitoring and supervision are specified as follows: a. Direct care staff will be responsible for care and treatment in accordance with the plan of care. b. A nurse assigned to the resident will complete reassessments in accordance with the facility's assessment schedule, but not less than quarterly, upon a significant change in status, or change in the type of bed/mattress/rail. During a review of the facility's recent P&P titled, Assessment Frequency/Timeliness, last revised 3/18/2026, the P&P indicated the purpose of this policy is to provide a system to complete standardized assessments in a timely manner, according to the current Resident Assessment Instrument (RAI) Manual (the official, comprehensive guide for nursing homes on how to assess, care for, and track the health of residents). Policy Explanation and Compliance Guidelines: 4. A quarterly review assessment will be completed no less than once every three months. It must be completed within 92 days of the Assessment Reference Date (ARD, the designated snapshot date or deadline day that defines the end of a 7-day observation period for a resident's clinical assessment) of the most recent Omnibus Budget Reconciliation Act of 1987 (OBRA) assessment (a comprehensive, federally mandated evaluation of a nursing home resident's physical, mental, and functional health).

Based on interview and record review, the facility failed to ensure residents were free of any significant medication errors (means the observed or identified preparation or administration of medications or biologicals which are not in accordance with the prescriber's order, manufacturer's specifications, and accepted professional standards) for two of two sampled residents (Resident 8 and 2) reviewed for insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) use by failing to rotate subcutaneous (sq, beneath the skin) insulin administration sites. This deficient practice had the potential for adverse effect (unwanted, unintended result) of the same site subcutaneous administration of insulin such as excessive bruising, lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (is a condition in which clumps of abnormal proteins called amyloids build up in the skin). Findings: 1. During a review of Resident 8's admission Record (AR), the AR indicated the facility admitted the resident on 4/18/2024, with diagnosis of type 2 diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 8's History and Physical (H&P), dated 8/10/2025, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 8's Minimum Data Set (MDS - a resident assessment tool), dated 7/21/2025, the MDS indicated the resident had the ability to make self-understood and understand others and had intact cognition (having a clear, sharp, and functioning mind that allows a person to think, learn, remember, and make decisions effectively). The MDS indicated the resident was on a high-risk drug class hypoglycemic medication (prescription medicines taken by mouth to lower high blood sugar levels in people with type two diabetes). During a review of Resident 8's Order Summary Report (OSR), dated 2/27/2025, the OSR indicated an order for Insulin Glargine Subcutaneous Solution (Insulin Glargine). Inject 19 unit subcutaneously at bedtime for diabetes mellitus type 2 (DM II) Hold if blood glucose (BG) less than (< )100 milligrams per deciliter (mg/dl., measures the concentration of sugar (glucose) in your blood) During a review of Resident 8's Location of Administration Report (LAR) of Insulin from 1/1/2026 to 1/31/2026, the LAR indicated Insulin Glargine Subcutaneous Solution was administered on: 1/2/2026 at 8:33 p.m. on the Abdomen – Left Upper Quadrant (LUQ) 1/3/2026 at 8:12 p.m. on the Abdomen – LUQ 1/6/2026 at 8:06 p.m. on the Abdomen – Right Lower Quadrant (RLQ) 1/7/2026 at 11:14 p.m. on the Abdomen - RLQ 1/8/2026 at 8:57 p.m. on the Abdomen – RLQ 1/15/2026 at 10:09 p.m. on the Abdomen – Right Upper Quadrant (RUQ) 1/16/2026 at 9 p.m. on the Abdomen - RUQ 1/17/2026 at 9:25 p.m. on the Abdomen - RLQ 1/18/2026 at 9:02 p.m. on the Abdomen - RLQ 1/19/2026 at 10:42 p.m. on the Abdomen – RLQ 1/20/2026 at 9:45 p.m. on the Abdomen – Left Lower Quadrant (LLQ) 1/21/2026 at 8:16 p.m. on the Abdomen – LLQ During a review of Resident 8's Care Plan (CP) Report regarding the resident having a diagnosis of diabetes insulin dependent, last revised on 4/19/2024, the CP indicated the goal of the resident will be free of all signs and symptoms of hypo (low)/hyperglycemia (high blood sugar level). During a concurrent interview and record review on 4/7/2026, at 2:53 p.m., with RN 1, Resident 8's OSR, LAR, and CP were reviewed. RN 1 stated there was an order for Insulin Glargine Subcutaneous Solution (Insulin Glargine). Inject 19 unit subcutaneously at bedtime for DM II Hold if BG < 100 mg/dl. RN 1 stated there were multiple instances on 1/2026 that the insulin administration sites was not rotated. RN 1 stated that insulin was a significant medication. RN 1 stated insulin administration sites should be rotated to prevent Resident 8 from developing skin lumps that can affect the absorption of insulin. RN 1 stated the resident can suffer from hypo/hyperglycemia if the insulin was administered on sites with skin lumps. RN 1 stated not rotating insulin administration sites is a medication error. During an interview on 4/10/2026 at 8:10 a.m. with the Director of Nursing (DON), the DON stated the sites of insulin administration for Resident 8 should have been rotated to prevent lipodystrophy. The DON stated insulin is considered as a significant medication and when administered on sites of lipodystrophy can cause malabsorption of insulin that can cause hypo/hyperglycemia on residents. The DON stated not rotating insulin administration sites as a medication error. The DON stated the licensed staff did not follow the policy and procedure (P&P) titled Timely Administration of Insulin and the facility-provided Highlights of Prescribing Information (HPI) on the use of Lantus. 2. During a review of Resident 2's AR, the admission Record indicated the facility originally admitted the resident on 4/9/2019, and readmitted the resident on 6/3/2025, with diagnoses including DM 2, difficulty in walking, and generalized muscle weakness. During a review of Resident 2's H&P, dated 6/4/2025, the H&P indicated had the capacity to understand and make decisions. During a review of Resident 2's MDS, dated [DATE], the MDS indicated the resident had an intact cognition (mental action or process of acquiring knowledge and understanding) and was able to understand and make his needs known. The MDS further indicated that the resident received insulin. During a review of Resident 2's Order Summary Report, dated 4/10/2026, the Order Summary Report indicated the following physician's orders: 2/3/2026: Insulin lispro injection solution (a short acting insulin) 100 unit per milliliter (unit/ml – a unit of measurement) inject subcutaneously before meals give no longer than 15 minutes before meals inject as per sliding scale: if blood sugar (BS – level of sugar in the blood) is 70 to 150 = seven (7) units; if BS is less than 70 give orange juice and call the physician; if 151 to 200 give eight (8) units; if 201 to 250 give (9) units; if 251 to 300 give ten (10) units; if 301 to 350 give 11 units; if more than 350, give 12 units and call the physician. 2/11/2026: 2/11/2026: Lantus subcutaneous solution (a long-acting insulin) 100 unit/ml (insulin glargine) inject 31 units subcutaneously at bedtime for DM 2. During a review of Resident 2's CP on diabetes, initiated on 4/10/2019, the CP indicated to administered medications as ordered as one of the interventions to keep resident free of all signs and symptoms of hypoglycemia (low level of sugar in the blood) or hyperglycemia (high level of sugar in the blood). During a concurrent interview and record review on 4/9/2026 at 2:22 p.m. reviewed Resident 2's physician's orders, care plan, and location of administration sites for insulin lispro and Lantus for 3/2026 with Registered Nurse (RN) 1. RN 1 stated Resident 2 had a physician's order for Lantus and insulin lispro and were administered as follows: Insulin lispro injection solution 100 unit/ml 3/3/26 12:24 p.m. sq right arm (RA) 3/3/26 4:33 p.m. sq RA 3/15/26 5:18 p.m. sq left arm (LA) 3/16/26 6:19 a.m. sq LA 3/16/26 4:17 p.m. sq RA 3/17/26 5:23 a.m. sq RA 3/17/26 4:45 p.m. sq RA 3/18/26 5:23 a.m. sq left lower quadrant (LLQ) 3/19/26 5:46 a.m. sq LLQ 3/25/26 12:25 p.m. sq left upper quadrant (LUQ) 3/25/26 5:22 p.m. sq LUQ 3/30/26 12:21 p.m. sq LLQ 3/30/26 5:08 p.m. sq LLQ Lantus subcutaneous solution: 3/13/26 8:58 p.m. sq RA 3/14/26 10:07 p.m. sq RA 3/16/26 9:00 p.m. sq RA 3/17/26 11:08 p.m. sq RA RN 1 stated that the licensed nurses did not rotate the insulin administration sites. RN 1 stated that the administration sites for insulin should be rotated per standards of practice, manufacturer's guidelines, and per policy to prevent lumps in the skin which can affect the absorption of insulin. RN 1 stated the location of administration sites for Resident 2's Lantus and insulin aspart were not rotated. RN 1 stated that Resident 2's administration sites should have been rotated to prevent lumps on the resident's skin affecting the absorption of insulin which may lead to hyperglycemia or hypoglycemia. RN 1 stated that not rotating Resident 2's insulin administration sites can be considered a medication error by not following the manufacturer's guidelines and professional standards of care. During a concurrent interview and records review on 4/10/2026 at 8:30 a.m., reviewed Resident 2's physician's orders, and Location of Administration sites for Lantus and insulin lispro with the DON. The DON stated insulin is considered a significant medication. The DON stated that Resident 2's insulin lispro and Lantus administration sites were not rotated for 3/2026. The DON stated that the insulin should be administered on the clean sites and rotated to prevent lipodystrophy. The DON stated that if the insulin was administered on the sites with lipodystrophy, the insulin will not be properly absorbed and not be effective which could lead to hypoglycemia or hyperglycemia. The DON stated that not rotating the insulin administration sites can be considered a significant medication error by not following the manufacturer's guideline and standards of practice. During a review of the facility's recent P&P titled, Timely Administration of Insulin, last reviewed on 3/18/2026, the P&P indicated it is the policy of this facility to provide timely administration of insulin in order to meet the needs of each resident and to prevent adverse effects on a resident's condition. During a review of the facility's recent P&P titled, Medication Errors, last reviewed on 3/18/2026, the P&P indicated it is the policy of this facility to provide protections for the health, welfare, and rights of each resident by ensuring residents receive care and services safely in an environment free of significant medication errors. Medication error means the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order; manufacturer's specifications (not recommendations) regarding the preparation and administration of the medication or biological; or accepted professional standards and principles which apply to professionals providing services. During a review of the facility-provided HPI on the use of Lantus (insulin glargine injection) for subcutaneous injection, with initial U.S. approval in 2000, the HPI indicated to rotate injection sites to reduce the risk of lipodystrophy. During a review of the facility provided HPI on the use of insulin lispro injection, with initial approval of 1996, the HPI indicated that injection sites should be rotated within the same region from one injection to the next to reduce the risk of lipodystrophy.

Based on observation, interview, and record review the facility failed to: 1. Label and date fresh foods held in the kitchen walk-in refrigerator. 2. Discard leftover food held in the kitchen walk-in refrigerator beyond seven days. 3. Record open dates on personal food items held in the resident refrigerator. These deficient practices had the potential to result in harmful bacterial growth that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or toxins) in 125 of 132 medically compromised residents receiving meals from the kitchen and those who had food stored in the patient refrigerator. Findings: 1. During an observation on 4/6/2026 at 8:05 a.m. the walk-in refrigerator contained two 22-quart storage containers of mandarin oranges, two dome lids containing each a plate of lettuce, tomato, deli meat and boiled eggs, and an uncovered plastic food container of whole, raw brussels sprouts with no label identifying the contents, received or preparation date. During an interview with Dietary Supervisor (DS) on 4/7/2026 at 11:45 a.m. DS stated that unlabeled foods may increase the risk of food spoilage, cross-contamination, potentially leading to resident illness and decreased food and nutrient quality, especially lettuce. During a review of the facility's policy and procedure (P&P) titled, Food Safety and Food Storage, dated 11/4/2024, the P&P indicated elements of food safety practices includes the storage of food in a manner that helps prevent deterioration or contamination of the food, including growth of microorganisms, and that facility staff are to practice labeling, dating, and monitoring of refrigerated food, and keeping foods covered or in tight containers. 2. During an observation on 4/6/2026 at 8:05 a.m. the walk-in refrigerator contained a metal pan and lid labeled, Mix Fruit, dated 3/30/2026. The contents of the pan contained chunks of fruit white and golden yellow in color and was suspended in liquid. During a review of the facility's P&P posted in the kitchen titled, Food Storage and Retention Guide, dated 2017, the P&P indicated ready-to-eat foods, including canned fruits, are to be kept refrigerated up to 7 days. Day 1 is the date of preparation. During an observation on 4/7/2026, at 10:28 a.m., the same pan of fruit cocktail was observed in the walk-in refrigerator however was now labeled by 4/7/26. During a concurrent interview with the DS, the DS stated that leftovers are usually consumed within 4-6 days. The DS counted the open days of the leftovers, including the opened date as the first date, resulting in the current held time at the ninth day. The DS stated the labeled date was counted incorrectly and that the fruit cocktail should be discarded as it poses a risk for cross-contamination which could make residents sick. 3. During an observation on 4/6/2026, at 9:48 a.m., the resident refrigerator located in the utility room across from Nurse Station 2 contained six bags of food containers, one plastic container with half of a tuna salad sandwich, one plastic container with a half-eaten frosted cake approximately six inches in diameter with no labeled receive dates. The freezer contained 5 frozen pasta dinners, an opened box of individually wrapped ice cream bars, and a half-eaten quart of ice cream, and a pint of ice cream with no resident name, room number, or receive/open date. During an interview on 4/7/2026, at 10:30 a.m., with the Infection Preventionist (IP), the IP was asked how food quality and freshness is qualified and the IP stated, When it goes bad, it either doesn't smell right or look right. The IP was asked if there is a policy to guide monitoring of food items in the resident refrigerator where IP stated, I'm not sure. During a concurrent review of previous findings, the IP confirms there were missing dates on food items observed in the refrigerator. The IP reviewed the P&P titled, Outside Food Refrigerator, the IP stated that foods with a manufacturer printed expiration or use by date are exempt from the three-day policy, however no such documentation is detailed in the policy. Further review of store-bought items, i.e., tuna sandwich and cake, demonstrated a lack of date printed by the manufacturer. During a concurrent observation, a resealable plastic envelope with chocolates as in the resident refrigerator had no resident name or room number. The IP could not confirm whether this food item belonged to a resident or staff member. During a review of the facility's P&P titled, Outside Food Refrigerator, dated 9/22/2025, the P&P indicated that food items that are already prepared must be approved per Nursing and labeled with content and dated, and will be thrown away if not consumed within three days.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections by, failing to ensure: 1. Three of three sampled linen carts (linen carts 10, 11, and 12) were kept in good condition that were free of holes, tears, and rips. 2. Linens were free of contamination. This deficient practice had the potential to result in contaminated linens, sheets, towels, and gowns being provided to the residents. 3. Employee COVID-19 (an infectious disease caused by the SARS-CoV-2 virus) Vaccination Policy was updated and matched facility's practice. These deficient practices had the potential to lead to staff confusion, noncompliance with infection control practices, increasing the risk for the spread of infection among residents and within the facility. Findings: a. During a concurrent observation and interview on 4/6/2026 at 9:37 a.m., in Station 1 hallway near rooms [ROOM NUMBERS], linen cart #12's cover had rips, tears, and holes, exposing gowns, linens, sheets, and blankets. Certified Nursing Assistant (CNA) 3 stated this cart belongs to him (CNA 3). CNA 3 stated he (CNA 3) does not know what happened to his (CNA 3) linen cart and why its ripped and torn because he (CNA 3) got it like this from the laundry. CNA 3 stated he (CNA 3) did not tell anyone about the condition of his (CNA 3) linen cart because he (CNA 3) does not know who to take it to. CNA 3 stated it should not be like this and should be covered. During a concurrent observation and interview on 4/6/2026 at 9:52 a.m. in Station 1 hallway near room [ROOM NUMBER], linen cart #10's cover had tears, holes, and the top left corner facing the opening of the linen cart was taped. CNA 5 stated this linen cart belongs to her (CNA 5). CNA 5 stated the linen cart has holes, torn, and has been taped on the side. CNA 5 stated she (CNA 5) got it like this from the laundry. During a concurrent observation and interview on 4/6/2026 at 10:33 a.m., in Station 1 hallway near room [ROOM NUMBER], linen cart #11's cover had tears and holes. CNA 6 stated this linen cart belongs to her (CNA 6). CNA 6 stated this linen cart is old and has holes. CNA 6 stated they do not have the same linen carts assigned every time, it changes, but they have had it like this for a long time. CNA 6 stated she (CNA 6) has not told anyone about the tears and holes of linen cart cover. During a concurrent observation and interview on 4/6/2026 at 11:43 a.m. with CNA 3 in facility's hallway, CNA 3 stated two (2) of 2 linen cart covers were partially torn at the top and the linen was not fully covered. CNA 3 stated not having clean linen cart fully covered, may potentially cause clean linen contamination, infection spread among the residents and cause harm. During an interview on 4/9/2026 at 1:52 p.m., with the Laundry Staff (LS) stated she (LS) cleans the linen cart that the CNAs uses. The LS stated some of the linen carts were not in good condition and some of the cart covers were torn and ripped. The LS stated she (LS) has told the Environmental Director (ED) about it and should be able to tell me more. During an interview on 4/9/2026 at 2 p.m. with the ED, the ED stated he (ED) noticed on Monday, 4/6/2026, that some of the linen cart covers had holes and tears. The ED stated he (ED) did not see linen cart #12's cover that was ripped. The ED stated linen cart covers with tears, holes, and ripped are not in good condition and it was not acceptable to go out to the stations. During a follow-up interview on 4/9/2026 at 2:48 p.m., with the ED, the ED stated when the linen carts' covers were not in good condition such as rips, tears, and holes, people can be touching and contaminating it and contamination by the walls and the dust in the air. The ED stated the condition of the linen carts was not brought to his (ED) attention until Monday, 4/6/2026. The ED stated linens not covered are an infection control problem. During an interview on 4/10/2026 at 8:36 a.m., with the Director of Nursing (DON), the DON stated that the linen carts covering is for infection control. The DON stated she (DON) would discuss it with the Administrator, and the CNAs would keep it in a bag and carry it to the resident room. The DON stated that when the linens are exposed the resident could be wearing dirty gowns and lying on dirty linens and sheets and at risk of exposure to microbes that got on it. During a review of the facility's policy and procedure (P&P) titled, Handling Clean Linen, last reviewed and approved on 3/18/2026, the P&P indicated that It is the policy of this facility to handle, store, process, and transport clean linen in a safe and sanitary method to prevent contamination of the linen, which can lead to infection. 2. Linen can become contaminated with pathogens from contact with intact skin or body substances, or from environmental contaminants or contaminated hands. b. During a concurrent observation and interview on 4/9/2026 at 1:06 p.m. with LS, in the laundry area, observed LS folding bedsheets and blankets holding them up in the air, and two bedsheets' corners touching the floor. The LS stated the bedsheets got contaminated when touched the floor and could cause infection spread to residents. During an interview on 4/9/2026 at 1:15 p.m. with the ED, the ED stated that contaminated linens that touched dirty surfaces, torn and ripped linen cart covers, increase the risk for infection spread among residents. During an interview on 4/10/2026 at 8:40 a.m. with the DON, the DON stated all clean linen should be folded and processed on designated clean folding surfaces. The DON stated that using contaminated linens could expose residents to infections and other health problems. During a review of facility's P&P titled Handling Clean Linen, dated 12/19/2022, the P&P indicated, It is the policy of this facility to handle, store, process, and transport clean linen in a safe and sanitary method to prevent contamination of the linen, which can lead to infection. Clean linens must be transported by methods that ensure cleanliness and protect from dust and soil during intra or inter-facility loading, transport and unloading. c. During a concurrent interview and record review on 4/9/2026 at 9:30 a.m. with Infection Preventionist (IP), the facility's P&P titled, Employee COVID-19 Vaccinations, dated 3/13/2023, was reviewed. The IP stated that employees were no longer mandated to receive COVID-19 vaccinations. The IP reviewed the facility's P&P titled, Employee COVID-19 Vaccinations, dated 3/13/2023. The P&P indicated The facility will ensure that all staff (except for staff who have been granted exemptions to the vaccination requirements, or those staff for whom COVID-19 must be temporarily delayed, as recommended by the CDC [Centers for Disease Control and Prevention], due to clinical precautions and considerations) are fully vaccinated or up to date for COVID-19. The IP stated that the facility's written employee COVID-19 vaccination policy had not been updated to reflect the current requirements and practices implemented within the facility. During a concurrent interview and record review on 4/9/2026 at 10:35 a.m. with the DON, the facility's P&P titled, Employee COVID-19 Vaccinations, dated 3/13/2023, was reviewed. The DON stated the facility's current practice did not require employees to receive COVID-19 vaccination. The DON stated the facility's employee COVID-19 vaccination policy had not been updated to reflect current practice. The DON further stated that the written policy not aligning with facility practice may result in unvaccinated staff working without clearly defined infection control precautions, compromising the effectiveness of the Infection Prevention and Control Program ([IPCP] - a mandatory, written safety plan for nursing homes and healthcare facilities designed to stop the spread of infections among residents and staff), and potentially increase the risk of COVID-19 transmission among staff and residents.

Based on interview and record review, the facility failed to ensure visitation restrictions were addressed for one (1) of three (3) sampled residents (Resident 41) when the facility was not aware of Resident 41's responsible party's (RP) request for no visitors without the RP's presence. This deficient practice had the potential for Resident 41 to have unwanted visitors that could cause anxiety or distress to the resident. Findings: During a review of Resident 41's admission Record, the admission Record indicated the resident was admitted on [DATE] with diagnoses including end stage renal disease (ESRD - irreversible kidney failure), unspecified dementia (progressive state of decline in mental abilities), hyperlipidemia (abnormally high levels of fat in the blood), anemia (a condition where the body does not have enough healthy red blood cells), pneumonia (an infection/inflammation of the lungs), and nicotine dependence (a physical and mental addiction to tobacco). During a review of Resident 41's History and Physical (H&P), dated 2/23/2026, the H&P indicated Resident 41 lacks capacity to make and understand decisions. The H&P further indicated that Resident 41 has a designated family representative. During a review of Resident 41's Minimum Data Set (MDS - a resident assessment tool), dated 3/2/2026, the MDS indicated the resident has adequate hearing, clear speech and vision, makes self-understood and understands others. The MDS indicated the resident requires extensive assistance from nursing staff with bed mobility, transferring, toileting and personal hygiene, and partial to moderate assistance with eating. During a review of Resident 41's Advance Healthcare Directive Acknowledgement Form, dated 2/24/2026, the Advance Directive Healthcare Directive Acknowledgement Form indicated Resident 41's resident representative is RP 1. During a concurrent interview and record review on 4/8/2026 at 2:24 p.m. with the Business Office Manager (BOM), an email sent from Resident 41's RP 1, dated 3/1/2026, was reviewed. The BOM stated the email indicated a request for Resident 41 to not have any visitors without RP 1's presence and to specifically to alert all Certified Nursing Assistants (CNAs) and Charge Nurses. The BOM stated that upon receiving the email, she (BOM) immediately informed and forwarded a copy of the email to the Social Services Director (SSD). The BOM stated she (BOM) had no knowledge of what happened thereafter. During an interview on 4/8/2026 at 2:35 p.m. with the SSD, the SSD stated that he (SSD) verbally reported the request to the department head, but was unable to elaborate more of the reporting. During an interview on 4/8/2026 at 3:13 p.m. with the Director of Nursing (DON), the DON stated that she (DON) did not know about the email and stated that it is the first time she (DON) had seen the email. The DON stated that she (DON) does not know any residents who have visiting restrictions. During an interview on 4/8/2026 at 3:46 p.m. with Licensed Vocational Nurse (LVN) 4 , LVN 4 stated that he (LVN 4) started working in the facility for two (2) months. LVN 4 stated that he (LVN 4) does not have any knowledge as to any residents requiring visiting restrictions. LVN 4 stated that any request from a resident or a family representative should be reported to the DON so that every member of staff would be notified to prevent unwanted visitors. During interview on 4/9/2026 at 9:17 a.m. with Registered Nurse (RN) 1 , RN 1 stated that she (RN 1) does not know any residents with visiting restrictions. RN 1 stated that there was no documentation made by the SSD regarding visiting restrictions for Resident 41. RN 1 stated that she (RN 1) does not know what the protocol is regarding visiting restrictions. RN 1 stated unwanted visitors can agitate residents and can cause unnecessary distress. During an interview on 4/9/2026 at 10:30 a.m. with the SSD, the SSD stated that requests for visiting restrictions must be communicated to not just the head departments, but also to the front desk and the staff, to make sure the RP's request is addressed to prevent unwanted visitors. During an interview on 4/10/2026 at 8:20 a.m. with the DON, the DON stated that Resident 41's RP's request should have been communicated to all staff. The DON stated the failure to inform staff could lead to unwanted visitors, which could potentially anger residents. During a review of the facility's policy and procedure (P&P) titled, Resident's Rights, last revised on 12/19/2022, the P&P indicated, The resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. During a review of the facility's P&P titled, Resident Right to Access and Visitation, last revised on 12/19/2022, the P&P indicated, It is the policy of this facility to support and facilitate the resident's right to receive visitors of their choosing, at the time of their choosing, subject to the resident's right to deny visitation when applicable, and in a manner that does not impose on the rights of other residents. Visitation will be person-centered, consider the residents' physical, mental, and psychosocial well-being, and support their quality of life.

Based on observation, interview, and record review, the facility failed to ensure that mail is being delivered to three (3) out of ten (10) sampled residents (Resident 17, Resident 88, and Resident 130) on Saturdays. This deficiency had the potential for residents to feel isolated and worry that their mail might get lost. Findings: During a review of Resident 17's admission Record, the admission Record indicated the facility originally admitted Resident 17 on 6/01/2022 and was readmitted on [DATE] with diagnoses including fusion of spine (a surgical procedure that joins two or more spine bone together into one solid bone to stop painful movement), cellulitis (a skin infection that causes swelling and redness), muscle weakness, asthma (respiratory condition marked by spasms in the bronchi of the lungs causing difficulty in breathing), diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 17's History and Physical (H&P), dated 10/8/2025, the H&P indicated Resident 17 has the capacity to understand and make decisions. During a review of Resident 88's admission Record, the admission Record indicated the facility originally admitted Resident 88 on 11/10/2021 and was readmitted on [DATE] with diagnoses including Bell's palsy (a condition that causes sudden weakness in the muscles on one side of the face), major depressive disorder, muscle weakness, hypertension (high blood pressure) and dysphagia (difficulty swallowing). During a review of Resident 88's H&P, dated 6/27/2025, the H&P indicated Resident 88 has the capacity to understand others and make decisions. During a review of Resident 130's admission Record, the admission Record indicated the Resident 130 was admitted on [DATE] with diagnoses including cerebral infarction (also know as a stroke, when blood flow to part of the brain is blocked or significantly reduced, causing brain tissue to die from lack of oxygen and nutrients), peripheral vascular disease (a slow, progressive circulation disorder involving the narrowing, blockage, or spasms of blood vessels), facial weakness, DM, anxiety disorder (a mental health disorder characterized by feeling worry or fear that are strong enough to interfere with one's daily activity, and hyperlipidemia (abnormally high levels of fats in the blood). During a review of Resident 130's H&P, dated 1/08/2026, the H&P indicated Resident 130 has the capacity to understand others and make decisions. During an interview on 4/7/2026 at 10:45 a.m. with Resident 17, Resident 88, and Resident 130, the residents stated that they receive their mail on weekdays but not on Saturdays. Residents 17, 88, and 130 stated that they never knew that they could also receive mail on Saturdays until it was brought up during the meeting knowing that business office is always closed on weekends. During an interview on 4/8/2026 at 2:59 p.m. with the Business Office Manager (BOM), the BOM stated her (BOM) workdays are Monday through Friday. The BOM stated that upon receiving the mail, she (BOM) only collects mail for monetary items and forwards the rest to the Activity Director, who is responsible for distributing mail to the residents. The BOM stated that mail delivered on Saturdays is placed in the mailbox by the wall outside the facility or to be handed to the receptionist, and those mails are to be distributed on Mondays. The BOM stated that the office is closed on weekends and does not provide mail to residents on Saturdays. The BOM further stated that business office is the only one who has access to the mailbox. During an interview on 4/9/2026 at 9:20 a.m. with Activities Director (AD), the AD stated that he (AD) receives the mail from the business office staff and distributes the mail to residents Monday through Friday. The AD stated that on Saturdays, the receptionist receives the mail because the business office is closed on the weekends. During an interview on 4/9/2026 at 9:33 a.m. with the Receptionist, the Receptionist stated that on Saturdays, the mail carrier delivers the mail to the receptionist. The Receptionist further stated that he (Receptionist) holds the mail until Monday to hand it to BOM because the business office is closed on weekends. The Receptionist further stated mail is not delivered to residents on Saturdays. During an interview on 4/10/2026 at 8:20 a.m. with Director of Nursing (DON), the DON stated the BOM is responsible for the mail and hands it over to the AD which is distributed from Monday through Friday. The DON stated residents do not get their mail on Saturdays because Business Office is closed on the weekends. A review of the facility's policy and procedure (P&P) titled, Resident's Rights, revised on 4/6/2026, the P&P indicated under Information and Communication: The resident has the right to send and receive mail, and to receive letters, packages and other materials delivered to the facility for the resident through a means other than a postal service (.).

Based on interview and record review, the facility failed to inform and provide written information to all adult residents concerning the right to accept and refuse medical and surgical treatment and, at the resident's option, to formulate an advance directive (a legal document indicating resident preference on end-of-life treatment decisions) for two (2) of four (4) sampled residents (Resident 12 and 71) with the Social Services Director (SSD) by failing to ensure the Advanced Healthcare Directive Acknowledgement Form was completed. This deficient practice violated the resident's rights and/or representative's right to be fully informed of the option to formulate their advanced directives. Findings: 1. During a review of Resident 12's admission Record (AR), the AR indicated Resident 12 was originally admitted on [DATE] and re-admitted on [DATE] to the facility with a diagnosis of encounter for orthopedic aftercare following surgical amputation (care and treatment a patient receives after an arm, legs, fingers, etc. has been surgically removed); osteomyelitis, unspecified (inflammation of the bone or bone marrow, usually due to infection); Type 2 diabetes mellitus without complications (a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 12's History and Physical (H&P), dated 2/23/2026, the H&P indicated Resident 12 was alert, oriented x4 (person, place, time, and situation), and has the capacity to consent. During a review of Resident 12's Minimum Data Set (MDS - an assessment and care screening tool), dated 12/8/2025, the MDS indicated Resident 12 had the ability to make self-understood and to understand others. The MDS further indicated that Resident 12 had intact cognitive function (normal thinking). The MDS indicated the resident required partial/ moderate assistance with bed mobility, transfer, dressing, toilet use, and personal hygiene. During a review of Resident 12's Advanced Healthcare Directive (AHCD) Acknowledgment Form, dated 2/18/2026, the AHCD Acknowledgment Form indicated the resident received information regarding the right to make an Advanced Healthcare Directive however, the information if the resident had an advanced healthcare directive, does not have an advanced directive, or if assistance for formulation of advanced directive was offered to the resident was not filled out. During a concurrent interview and record review on 4/8/2026 at 8:33 a.m. with Registered Nurse (RN) 1, Resident 12's AHCD Acknowledgement Form was reviewed. RN 1 stated the advanced directive acknowledgement form was not completed correctly, as it does not indicate whether the resident has or does not have an advance directive. RN 1 stated that by not documenting whether the resident has an advanced directive, the resident's wishes may not be known or followed. RN 1 stated staff should have verified whether the resident wanted to complete an advance directive or not. During a concurrent interview and record review on 4/8/2026 at 11:30 a.m. with the Social Services Director (SSD), Resident 12's AHCD Acknowledgement Form was reviewed. The SSD stated that upon admission the information for Advanced Directive (AD) was collected. The SSD stated that the purpose of AD is to know if they have an advocate to make healthcare decisions for them in case something happens to resident or in an emergency. The SSD stated if the resident does not have an advanced directive and wants to formulate one the SSD will assist with formulating an advanced directive. The SSD stated the AHCD for Resident 12 was not filled out correctly it is missing whether the resident has an advanced directive or not and if assistance for formulation of advanced directive was offered to the resident. The SSD stated that the SSD would not know if the resident had an advanced directive by reviewing the advanced directive acknowledgement form of the resident. During an interview on 4/10/2026 at 8:10 a.m. with the Director of Nursing (DON), Resident 12's AHCD Acknowledgement Form was reviewed. The DON stated that on admission the SSD is responsible for completing the AHCD form with the resident and responsible party. The DON stated Resident 12's AHCD form was not accurately filled out. The DON stated the form is missing whether the resident has an advanced directive or does not have one and if assistance for formulation of advanced directive was offered to the resident. The DON stated it is important for the AHCD form to be filled out correctly to fulfill resident wishes. 2. During a review of Resident 71's AR, the AR indicated the facility admitted the resident on 10/2/2023, with diagnoses including chronic respiratory failure (a long-term condition where the lungs cannot adequately get oxygen into the blood or remove carbon dioxide, lasting longer than a month), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety disorder (a mental health condition characterized by excessive, uncontrollable, and persistent fear or worry that interferes with daily life). During a review of Resident 71's H&P, dated 2/1/2026, the H&P indicated the resident had the capacity to consent. During a review of Resident 71's MDS, dated [DATE], the MDS indicated the resident had the ability to make self-understood and understand others, and had intact cognition (having a clear, sharp, and functioning mind that allows a person to think, learn, remember, and make decisions effectively). During a review of Resident 71's AHCD Acknowledgment Form, dated 10/16/2023, the AHCD indicated the resident received information regarding the right to make an Advanced Healthcare Directive however, the information if the resident had an advanced healthcare directive, does not have an advanced directive, or if assistance for formulation of advanced directive was offered to the resident was not filled out. During a review of Resident 71's Care Plan (CP) Report regarding the resident had an established Physician Orders for Life-Sustaining Treatment (POLST - a form that contains written medical orders for healthcare professionals regarding specific medical treatments that can or cannot be done at the end-of life), (Full Code), last revised on 12/28/2023, the CP indicated an intervention to offer opportunity to complete Advanced Directive. During a concurrent interview and record review on 4/7/2026 at 11:31 a.m. with the SSD, Resident 71's AHCD was reviewed. The SSD stated the AHCD was incomplete and they should have checked the second (2nd) box indicating the resident did not have an advanced directive and would like to receive more information or the third (3rd) box indicating they did not have an advance directive and does not want any information at this time. The SSD stated by checking the 2nd or 3rd box of the form they were able to honor their choice or their right to formulate an advanced directive completely. During an interview and record review on 4/10/2026, at 8:10 a.m., with the DON, Resident 71's AHCD was reviewed. The ADON stated the 2nd or 3rd box should be checked on the AHCD form so they know if they have an advanced healthcare directive and follow their wishes. The DON stated the SSD is responsible for completing the advanced directive form. The DON stated the failure of SSD to complete the form had denied the resident of their right to formulate an advanced healthcare directive. During a review of the facility's recent policy and procedure (P&P) titled, Residents' Rights Regarding Treatment and Advanced Directives, last reviewed on 3/18/2026, the P&P indicated it is the policy of this facility to support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate an advance directive. Policy Explanation and Compliance Guidelines: 1. On admission, the facility will determine if the resident has executed an advanced directive, and if not, determine whether the resident, if cognitively able to, would like to formulate an advance directive. In the event the resident is unable to formulate and AD due to cognitive impairment or deemed by the medical doctor that the resident is incapable of making decisions on his or her own, the facility will provide information and education to the representative. 3. Upon admission, should the resident have an advance directive, copies will be made and placed on the chart as well as communicated to the staff.

Based on observation, interview, and record review, the facility failed to ensure a homelike environment for one of one sampled resident (Resident 54) by not maintaining functional closet drawers. This deficient practice violated Resident 54's rights to a safe, clean, sanitary, and homelike environment. Findings: During a review of Resident 54's admission Record (the front page of the chart that contains a summary of basic information about the resident), the admission Record indicated Resident 54 was admitted to the facility on [DATE], with diagnoses including chronic kidney disease (progressive damage and loss of function in the kidneys), Diabetes Mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing), hypertension (HTN - high blood pressure). During a review of Resident 54's History and Physical (H&P - a document with resident's medical history and physical examination done by a physician), dated 9/27/2024, the H&P indicated that Resident 54 had a Brief Interview for Mental Status (BIMS - an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 15. A BIMS score of 15 indicated Resident 54 had intact cognition. During a review of Resident 54's Minimum Data Set (MDS - a resident assessment tool), dated 9/18/2025, the MDS indicated Resident 54 was independent (resident completed the activity by themselves with no assistance from a helper) with eating, oral, personal and toileting hygiene, upper body dressing. The MDS indicated Resident 54 required setup or clean up assistance with showering and putting on/taking off footwear. During a concurrent observation and interview on 4/6/2026 at 10:04 a.m. with Resident 54 inside Resident 54's room, observed some of Resident 54's personal belongings on Resident 54's bed. Resident 54 stated that the closet drawer provided to him had been broken for two (2) months. Observed the closet drawer had a broken bottom. During a concurrent observation and interview on 4/6/2026 at 10:45 a.m. with the Maintenance Assistant (MA) in Resident 54's room, observed the MA addressing Resident 54's broken drawer in the resident's closet. The MA stated that broken drawers should be addressed promptly to ensure residents maintain a homelike environment, dignity and ability to safely store and access personal belongings. During an interview on 4/10/2026 at 11:29 a.m. with Director of Nursing (DON), the DON stated when broken furniture is identified, staff need to place a work order and address the findings to maintenance department immediately. The DON stated having nonfunctioning furniture can negatively affect resident's mood and psychosocial wellbeing, potentially leading to feeling frustration, decreased independence, and reduced quality of life. During a review of the facility's policy and procedure (P&P) titled, Safe and Homelike Environment, dated 12/19/2022, the P&P indicated, In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment.

Based on interview and record review, the facility failed to ensure residents are screened using the Preadmission Screening and Resident Review (PASRR - a federal requirement to help ensure that individuals are not appropriately placed in nursing homes for long-term care) for a mental disorder (MD - a health condition that significantly affects a person's thinking, emotional regulation, mood, or behavior, making it difficult to cope with daily life) or intellectual disability (ID - a condition that limits intelligence and disrupts abilities necessary for living independently) prior to admission and that individuals identified with serious mental illness (SMI - a health condition that significantly affects how a person thinks, feels, behaves, or interacts with others) and/or ID/developmental disability (DD - a group of conditions due to an impairment in physical, learning, language, or behavior areas)/related conditions (RC) receive the care and services in maintaining his/her highest practicable level in the most appropriate setting for one (1) of 1 sampled resident (Resident 106), by failing to submit a new Level I PASRR for the resident who had a discrepancy in the previous PASRR Level I Screening. This deficient practice had the potential to result in inappropriate placement and unidentified specialized services for the residents. Findings: During a review of Resident 106's admission Record (AR), the AR indicated the facility admitted the resident on 3/18/2024, with diagnoses including paraplegia (paralysis that affects the legs, making it impossible to stand or walk), schizophrenia (a mental illness that is characterized by disturbances in thought), and generalized muscle weakness. During a review of Resident 106's History and Physical (H&P), dated 3/5/2026, the H&P indicated the resident had the capacity to understand and make decisions. The H&P further indicated that the resident had a diagnosis of schizophrenia. During a review of Resident 106's Minimum Data Set (MDS - a resident assessment tool), dated 2/20/2026, the MDS indicated Resident 106 had intact cognition (the mental process of acquiring knowledge and understanding through thought, experience, and the senses) and was usually able to understand and make her needs known. The MDS further indicated Resident 106 required supervision or touching assistance with eating and oral hygiene, and substantial/maximal assistance from staff with all other activities of daily living (ADL - activities such as bathing, dressing and toileting a person performs daily). The MDS further indicated that Resident 106 had a diagnosis of schizophrenia. During a review of Resident 106's PASRR Level I Screening, dated 3/11/2023, the PASRR Level I Screening indicated that the resident had a serious diagnosed mental disorder and that the resident required a Level II Screening. During a review of Resident 106's PASRR Level II Screening, dated 3/17/2023, the PASRR Level II Screening indicated that the Level II Screening was unable to be complete as the resident did not have a SMI. The Level II Screening further indicated that the case is closed and to submit a new Level I Screening to reopen the case. During a concurrent interview and record review on 4/8/2026 at 10:40 a.m., with MDS Coordinator (MDSC) 1, Resident 106's PASRR Level I and Level II Screening, H&P, and AR were reviewed. MDSC 1 stated Resident 106's H&P and AR indicated Resident 106 had a diagnosis of schizophrenia upon admission on [DATE], and the PASRR Level II Screening indicated that the case was closed as the resident did not have a SMI. MDSC 1 stated that the Admissions Director (AdmD) is responsible in ensuring that the residents had a PASRR screening prior to admission and ensure accuracy. MDSC 1 stated she is not sure who is responsible in submitting a new Level I Screening if there was a discrepancy. During an interview on 4/8/2026 at 11:13 a.m. with the Social Services Director (SSD), the SSD stated that he reviews the PASRR Level I Screening with the AdmD and reviews it during the stand-up morning meetings for accuracy. The SSD stated that he is not sure who is directly responsible in ensuring that the PASRR is accurate and matches with the admission diagnosis on the AR and H&P. During a concurrent interview and record review on 4/10/2026 at 8:12 a.m. with the Director of Nursing (DON), Resident 106's PASRR Level I and Level II Screening, H&P, and AR were reviewed. The DON stated the Level I and II Screening indicated that Resident 106 did not have a SMI. The DON stated the H&P and AR indicated the resident had a diagnosis of schizophrenia upon admission to the facility. The DON stated that the AdmD obtains and submits a new Level I Screening for new admissions when the previous facility or hospital did not do a Level I Screening or if there was a discrepancy. The DON further stated that the AdmD should have ensured that Resident 106's Level I Screening matched the diagnosis in the AR and H&P. The DON stated that a Level I Screening should have been submitted by the AdmD indicating that Resident 106 had a SMI as it placed the resident at risk for not receiving or delay in the specialized services and care the resident needed. During a review of the facility's policy and procedure (P&P) titled, Resident Assessment - Coordination with PASARR Program, last reviewed on 3/18/2026, the P&P indicated that the facility coordinates assessments with the PASRR program to ensure that individuals with a MD, ID, or related condition receives care and services int he most integrated setting appropriate to their needs. The P&P further indicated: - Policy Explanation and Compliance Guidance: - All applicants to the facility will be screened for serious mental disorders, or ID, and related conditions in accordance with the state's rules for screening. a. PASRR Level 1 - initial prescreening that is completed prior to admission ii. Positive Level I Screen - necessitates a PASRR Level II Evaluation prior to admission. b. PASRR Level II - a comprehensive evaluation by the appropriate state-designated authority that determines whether the individual had MD, ID, or related condition, determines the appropriate setting for the individual, and recommends any specialized services and/or rehabilitative services the individual needs. - The SSD or designee shall be responsible for keeping track of each resident's PASRR screening status and referring to the appropriate authority. - Recommendations, such as specialized services, for a PASRR Level II determination and/or PASRR evaluation report will be incorporated into the resident's assessment, care planning, and transitions of care.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan (a tool that ensures residents receive personalized, comprehensive, and goal-oriented care in a nursing home setting) for one (1) of 1 sampled resident (Resident 106) reviewed under Preadmission Screening and Resident Review (PASRR - a federal requirement to help ensure that individuals are not appropriately placed in nursing homes for long-term care) care area addressing the resident's diagnoses of schizophrenia (a mental illness that is characterized by disturbances in thought). These deficient practices had the potential for a delay in the delivery of the necessary care and services the resident needs. Findings: During a review of Resident 106's admission Record (AR), the AR indicated the facility admitted the resident on 3/18/2024, with diagnoses including paraplegia (paralysis that affects the legs, making it impossible to stand or walk), schizophrenia, and generalized muscle weakness. During a review of Resident 106's H&P, dated 3/5/2026, the H&P indicated that the resident had the capacity to understand and make decisions. The H&P further indicated that the resident had a diagnosis of schizophrenia. During a review of Resident 106's MDS, dated [DATE], the MDS indicated Resident 106 had an intact cognition and was usually able to understand and make her needs known. The MDS further indicated Resident 106 required supervision or touching assistance with eating and oral hygiene, and substantial/maximal assistance from staff with all other ADLs. The MDS further indicated that Resident 106 had a diagnosis of schizophrenia. During a review of Resident 106's care plans (CP), there was no CP developed and implementing addressing that Resident 106 had schizophrenia. During a concurrent interview and record review on 4/9/2026 at 2:51 p.m. with Registered Nurse (RN) 1, Resident 106's AR, H&P, and CP were reviewed. RN 1 stated that the AR and H&P indicated that Resident 106 had a diagnosis of schizophrenia. RN 1 stated there was no care plan developed and implemented addressing Resident 106's diagnosis of schizophrenia. RN 1 stated that comprehensive CP are developed within 14 days of admission and revised as needed. RN 1 stated the CP are important to ensure that the staff were aware of the plan of care of the residents to be able to provide the care they need. RN 1 stated a comprehensive CP should have been developed and implemented timely to ensure that all the staff involved in Resident 106's care know how to properly care for the resident to meet Resident 106's needs. During an interview on 4/10/2026 at 8:12 a.m. with the Director of Nursing (DON). The DON stated baseline care plans are developed within 48 hours of admission and comprehensive care plans are developed seven (7) days after completion of the admission MDS assessment or 21 days after admission and reviewed quarterly and revised as needed to ensure the appropriate services needed were provided to the residents. The DON stated that Resident 106's care plan should have been developed and implemented timely so the staff involved in her care would be aware of the current plan of care to prevent delay in providing the care and services she needs. During a review of the facility's policy and procedure (P&P) titled, Comprehensive Care Plans, last reviewed on 3/18/2026, the P&P indicated that the facility develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental, and psychosocial needs that are identified in the resident's comprehensive assessment. The P&P further indicated: - Person-centered care means to focus on the resident as the focus of control and support the resident in making their own choices and having control over their daily lives. - The care planning process will include an assessment of the resident's strengths and needs and will incorporate the resident's personal and cultural preferences in developing goals of care. Services provided or arranged by the facility, as outlined by the comprehensive care plan, should be culturally competent and trauma informed. - The comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS assessment. - The comprehensive care plan will describe, at a minimum, the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, any specialized services or specialized rehabilitation services the nursing facility will provide as a result of PASRR recommendation. - The comprehensive care plan will be prepared by an interdisciplinary team (IDT - a group of health care professionals with various areas of expertise who work together toward the goals of the patients), that include, but it not limited to the attending physician or non-physician designee, MDSC, activities staff, SSD or designee, therapists, responsible party, Administration, and mental health professional. - The comprehensive care plan will be reviewed and revised by the IDT after each comprehensive and quarterly MDS assessment. - The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the comprehensive assessment and utilize to monitor the resident's progress.

Based on observation, interview, and record review, the facility failed to ensure effective communication for one of one sampled resident (Resident 61) with hearing impairment, when the facility did not provide communication board (a device that displays symbols, photos, or illustrations to help individuals with limited hearing or language skills to communicate) or other alternative communication tools. This deficient practice had the potential to result in Resident 61's unmet needs, misunderstanding of care and instructions, decreased participation in care, and increased risk for harm due to inability to effectively communicate. Findings: During a review of Resident 61's admission Records (the front page of the chart that contains a summary of basic information about the resident), the admission Records indicated the facility admitted Resident 61 on 4/21/2023, and readmitted on [DATE] with diagnoses including Huntington disease (inherited condition that affects movement, thinking and behavior), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness or the inability to move on one side of the body) of the right side, obstructive uropathy (a blockage in the urinary system that prevents urine from flowing freely, causing it to back up into the kidneys). During a review of Resident 61's History and Physical (H&P- a document with patient's medical history and physical examination done by a physician) dated 3/4/2026, the H&P indicated that Resident 61 had the capacity to understand and make decisions. During a review of Resident 61's Minimum Data Set (MDS - a resident assessment tool) dated 1/22/2026, the MDS indicated Resident 61 had moderate hearing difficulty (speaker has to increase volume and speak distinctly). The MDS indicated that Resident 61 was dependent (helper does all of the effort) to staff with eating, oral hygiene, toileting hygiene, lower body dressing, putting on/taking off footwear, and personal hygiene. During an interview on 4/6/2026 at 10:48 a.m. with Resident 61 in Resident 61's room, Resident 61 stated that he (Resident 61) was unable to hear any questions asked. Attempts were made to communicate with Resident 61 using slower speech, simple words, and increased volume. Resident 61 stated he (Resident 61) continued to have difficulty hearing and was unable to understand what was being asked. No communication board or other alternative communication tools were observed inside Resident 61's room. During a concurrent interview and record review on 4/6/2026 at 2:12 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated that Resident 61 had hearing impairment. LVN 1 was uncertain about the cause of Resident 61's hearing impairment. LVN 1 stated that she (LVN 1) communicated with Resident 61 by talking slowly and with a loud voice. LVN 1 stated residents with hearing impairment are referred to social services for Ear, Nose and Throat (ENT) doctor consult. During a subsequent observation and interview on 4/6/2026 at 2:29 p.m. with LVN 1 in Resident 61's room, observed LVN 1 attempting to communicate with Resident 61 by asking questions. Resident 61 stated he (Resident 61) was unable to hear what LVN 1 was asking. Observed LVN 1 searching for communication board. LVN 1 stated there was no communication board or other communication tools present in Resident 61's room. LVN 1 further stated that the absence of communication board may place Resident 61 at risk for social isolation, depression, and anxiety due to impaired ability to effectively communicate his needs and concerns. During a concurrent interview and record review on 4/8/2026 at 11:38 a.m. with Social Service Director (SSD), the SSD stated that residents with identified hearing impairment were referred to ENT for consultation. The SSD stated that communication boards and visual tools are utilized to help residents understand provided information and express their needs. The SSD further stated that If residents are not provided with appropriate tools, their needs won't be met, putting residents at risk for psychosocial distress. During an interview on 4/10/2026 at 8:40 a.m. with the Director of Nursing (DON), the DON stated that for residents with hearing impairment the facility was responsible for ensuring that communication tools such as communication board, hearing amplifiers, or other interventions as specified in their care plan are provided and utilized. The DON stated that without these tools residents may not be able to communicate their needs, which can result in unmet care needs, misinterpretation of requests and potential negative outcomes affecting resident safety and quality of care. During a review of facility's Policies and Procedures (P&P) titled Effective Communication, updated 7/17/2023, the P&P indicated, It is the policy of this facility to accommodate needs when communicating with residents who have difficulties with communication to promote dignity, understanding, and safety. Staff will communicate with the residents, using techniques identified in their plan of care, and in accordance with his/her established routine for communication, as possible. Adaptive techniques include but are not limited to using communication boards or writing materials.

Based on observation, interview, and record review, the facility failed to provide necessary Activities of Daily Living (ADL - activities such as bathing, dressing and toileting a person performs daily) care, specifically grooming, including nail care, for one of one sampled resident (Resident 43). This failure had the potential to result in poor hygiene, increased risk of infection, skin injury from scratching for Resident 43. Findings: During a review of Resident 43's admission Record (the front page of the chart that contains a summary of basic information about the resident), the admission Record indicated Resident 43 was originally admitted to the facility on [DATE], then readmitted to the facility on [DATE], with diagnoses including Diabetes Mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing), peripheral vascular disease (a common condition in which narrowed arteries reduce blood flow to the arms or legs), atrial fibrillation (an irregular and often very rapid heart rhythm), right foot amputation (the removal of a leg, foot or toes from the body). During a review of Resident 43's History and Physical (H&P - a document with resident's medical history and physical examination done by a physician), dated 7/9/2025, the H&P indicated that Resident 43 has a capacity to understand and make decisions. During a review of Resident 43's Minimum Data Set (MDS - a resident assessment tool), dated 10/1/2025, the MDS indicated Resident 43 requires substantial/maximal assistance (helper does more than half the effort) with toileting hygiene, upper and lower body dressing, putting on/taking off footwear. During a review of Resident 43's care plan (a personalized, written roadmap for managing a person's health and daily needs), revised on 1/2/2026, the care plan indicated that Resident 43 was at risk for decreased ability to perform ADL(s) in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting. The care plan indicated an intervention for staff to provide assistance of one person with personal hygiene, including grooming. During an observation on 4/6/2026 at 10:20 a.m. in Resident 43's room, observed Resident 43 with long fingernails on both hands with visible dark debris underneath nails. During a concurrent observation and interview on 4/6/2026 at 10:30 a.m. with Certified Nurse Assistance (CNA) 2, CNA 2 stated CNAs were responsible to keep residents clean and groomed. CNA 2 stated that Resident 43's fingernails were too long, had black dirt residue under the fingernails. CNA 2 stated that long nails could potentially result in resident scratching himself, causing skin injury, infection and harm. During an interview on 4/8/2026 at 9:31 a.m. with Registered Nurse (RN) 1, RN 1 stated all licensed personnel were responsible for ensuring residents' grooming and hygiene needs are met. RN 1 stated nailcare should be provided during routine care, including showers and morning hygiene. RN 1 stated that poor nail hygiene may lead to accumulation of bacteria under the nails, which can be transferred when residents touch their mouth, eyes or skin, increasing risk for infection. During an interview on 4/10/2026 11:34 a.m. with the Director of Nursing (DON), the DON stated that CNAs are responsible to provide routine ADL care, including nail care. The DON stated not maintaining clean, short nails may allow accumulation of bacteria under the nails and increase the risk of resident scratching themselves causing skin breakdown, introduce infection to skin, wounds and eyes. During a review of facility's Policies and Procedures (P&P) titled, Nail Care, dated 12/19/2022, the P&P indicated, Routine cleaning and inspection of nails will be provided during ADL care on an ongoing basis. Routine nail care, to include trimming and filing, will be provided on a regular schedule. Nail care will be provided between scheduled occasions as the need arises.

Based on observation, interview, and record review, the facility failed to ensure residents with pressure ulcers/injury (a skin and tissue injury caused by prolonged pressure on the skin, often over bony areas) received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for one of four sampled residents (Resident 85) reviewed under pressure ulcer/injury by failing to ensure the low air loss mattress (LALM, a specialized bed mattress that helps prevent and treat pressure ulcers by using a continuous flow of air to regulate temperature and moisture on the skin) of Resident 85 was set according to the resident's weight. The deficient practices had the potential for worsening of Resident 85`s pressure injury. Findings: During a review of Resident 85's admission Record (AR), the AR indicated the facility admitted the resident on 3/10/2026, with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness on one side of the body), muscle weakness, and cerebral infarction (a type of ischemic stroke that occurs when a portion of the brain dies because it is not getting enough blood). During a review of Resident 85's History and Physical (H&P), dated 3/11/2026, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 85's Minimum Data Set (MDS, a resident assessment tool), dated 3/17/2026, the MDS indicated the resident usually makes self-understood and sometimes had the ability to understand others and had severe cognitive impairment (a profound loss of mental capacity-such as memory, reasoning, and language-that makes it impossible for a person to live or function independently). The MDS indicated the resident was dependent to needing supervision assistance on mobility and activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily). The MDS indicated the resident was frequently incontinent of urine and stool (feces). The MDS indicated the resident was at risk for developing pressure injuries. During a review of Resident 85's Order Summary Report (OSR), dated 3/29/2026, the OSR indicated an order for: -Treatment Order: Low Air Loss Mattress for wound management every shift (QS): (Specify Settings) Monitor for Setting accuracy and functionality. every shift for skin Maintenance. -Treatment Order: Abrasion (Coccyx, tailbone) Cleanse with Soap and Water, Pat Dry, apply Zinc, leave open to air, every day shift for Abrasion for 21 Days and if needed (PRN). Every shift for Abrasion for 21 Days AND as needed for Abrasion for 21 Days. During a review of Resident 85's Braden Scale for Predicting Pressure Ulcer Risk Evaluation (BS- an evidence-based clinical tool used to assess a patient's risk of developing pressure ulcers) dated 3/31/2026, the BS indicated that the resident was at risk for developing pressure injuries. During a review of Resident 85's Weights and Vitals Summary (WVS), dated 4/4/2026, the WVS indicated Resident 85's weight was 121 pounds (lbs., a unit of weight) During a review of Resident 85's Care Plan (CP) Report regarding the resident being at risk for impaired skin integrity related to surgical scar and pressure over left lateral spine, last revised on 3/18/2026, the CP indicated an intervention to use pressure-redistributing mattress per facility protocol. During a concurrent observation and interview on 4/6/2026 at 10:11 a.m., with Licensed Vocational Nurse (LVN) 6, observed Resident 85's LALM set at 80 or the softest setting. LVN 6 stated there was a sticker on the LALM machine indicating the setting should be 180, so the setting should be adjusted to 180. LVN 6 stated the purpose of the LALM was to promote good skin circulation and to prevent pressure ulcer on residents. LVN 6 stated the failure of the licensed staff to set the bed according to the resident's weight could lead to worsening of pressure sore. During an interview and record review on 4/7/2026, at 3:16 p.m., with Registered Nurse (RN) 1, reviewed Resident 85's OSR, BS, WVS, and CP. RN 1 stated the LALM should be set according to resident's weight. RN 1 stated the resident's latest weight was 121 lbs., so the LALM setting should be 120 not 180. RN 1 also stated the resident already had a skin abrasion on the coccyx and it could aggravate the problem by not setting the LALM accordingly. RN 1 stated the resident's Braden score was 16 meaning at risk for developing pressure injuries. During an interview on 4/10/2026, at 8:10 a.m., with the Director of Nursing (DON), the DON stated Resident 85's LALM should be set according to the resident's weight. The resident's weight was 121 lbs. so the LALM setting should be 120. The DON stated the failure of the staff to set the LALM according to the resident's weight can promote further development of skin breakdown. The DON stated the Treatment Nurses should be checking the LALM setting every shift to ensure the LALM was on the correct settings. The DON stated the policy and procedure (P&P) titled Pressure Injury Prevention Guidelines and the facility-provided Low Air Loss Mattress 1 User Manual (UM) were not followed. During a review of the facility's recent P&P titled, Pressure Injury Prevention Guidelines, last reviewed on 3/18/2026, the P&P indicated to prevent the formation of avoidable pressure injuries and to promote healing of existing pressure injuries, it is the policy of this facility to implement evidence-based interventions for all residents who are assessed at risk or who have a pressure injury present. Policy Explanation and Compliance Guidelines: 1. Interventions will be implemented in accordance with physician's orders, including the type of prevention devices to be used and, for tasks, the frequency for performing them. Pressure Injury Prevention Guidelines Pressure Relieving Devices: 1. Provide alternative support surfaces as needed. During a review of the facility-provided Low Air Loss Mattress (LALM) 1 Alternating Pressure and Low Air Loss Mattress System Item # 14530 UM, copyright 2018, the UM indicated to turn the pressure knob to set a comfortable pressure level by using the weight scale as a guide.

Based on interview and record review, the facility failed to ensure that one of three sampled residents (Resident 1), who had moderately impaired cognition (a noticeable decline in thinking, memory, and judgment that is more significant than normal aging but does not prevent the resident from performing most daily tasks), bed-bound (unable to leave the bed due to illness or weakness), dependent on staff for activities of daily living (ADLs - activities such as bathing, dressing, and toileting a person performs daily), and was receiving Porcine Heparin injection (a powerful anticoagulant [blood thinner] medication used to prevent and treat blood clots that increases the risk of bleeding), was provided the necessary care and services in accordance with professional standards of practice when on 9/26/2025 at 4:47 a.m., Resident 1 had a change in condition (CIC - a major decline in a resident's status) when Resident 1 had bright red blood of moderate amount in the stool. The facility failed to: 1. Ensure Registered Nurse 1 (RN 1) conducted a comprehensive assessment of Resident 1's respiratory (relating to breathing or the organs of respiration), cardiovascular (relating to the heart and blood vessels), neurological (relating to the brain, spinal cord, and nerves), genitourinary (GU - relating to the genital and urinary organs), and behavioral (relating to or involving observable behavior) status following Resident 1's CIC on 9/26/2025 at 4:47 a.m. RN 1 also failed to assess and document the presence or absence of bowel sounds (the noises made when food, fluids, and gases move through the intestines). 2. Ensure RN 1 followed the facility's policy and procedure (P&P) titled, Change of Condition (COC - when there is a sudden change in a resident's condition): Notification of, indicating, . must immediately . consult with the patient's physician . where there is: . a significant change in the patient's physical . status; A need to alter treatment significantly (that is, a need to discontinue or change an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or A decision to transfer or discharge the patient from the Center. a. RN 1 stated it was his (RN 1) judgment not to immediately notify the physician after Resident 1's CIC on 9/26/2025 at 4:47 a.m. RN 1 stated he (RN 1) had been instructed by Medical Director 2 (MD 2) not to call during the night for non-emergent (medical condition that is not immediately dangerous or serious and does not require immediate action to prevent harmful results ) and stable (medical condition that is not worsening or under control) residents. b. RN 1 stated that if he (RN 1) calls the physician in the middle of the night the physician would get mad, and that 4:47 a.m. was too early to call. RN 1 stated that it was his personal decision to wait until 6 a.m. to notify the physician because 6 a.m. was the acceptable time. c. RN 1 left a voicemail message for Resident 1's physician (Medical Doctor 1 [MD 1]) and sent a text message to Nurse Practitioner 1 (NP 1) on 9/26/2025 at 6 a.m. (1 hour and 13 mins after Resident 1's CIC). d. RN 1 stated he (RN 1) did not follow up with MD 1 and NP 1 to confirm receipt of the voicemail or text message on 9/26/2025 at 6 a.m. e. RN 1 stated that on 9/26/2025 at 8 a.m., he (RN 1) received a text message from NP 1 with an order to obtain STAT (immediately) occult blood test (a screening test to detect small amounts of hidden blood in a stool sample that are not visible to the naked eye and used to screen for medical conditions that may cause bleeding) and a STAT complete blood count (CBC - a laboratory {lab} test [a procedure that analyzes a sample of your blood to provide information about your health] that measures various components of the blood that can help diagnose and monitor conditions such as bleeding). RN 1 then called Registered Nurse 2 (RN 2) to relay the orders (approximately 3 hours and 13 minutes after Resident 1's CIC). 3. Ensure that the STAT occult blood test and STAT CBC ordered on 9/26/2025 at 8 a.m. for Resident 1 were accurately entered and carried out. On 9/26/2025 at 10 a.m., RN 2 entered an order for a routine (not STAT) occult blood test (one time), resulting in a two (2) hour delay from receipt of the STAT order and a three (3) hour and 13 minutes delay from the time of Resident 1's CIC. RN 2 did not enter the STAT CBC order for Resident 1. 4. Ensure there was a clearly documented process for communicating Resident 1's multiple episodes of blood in the stool to MD 1 or NP 1 following Resident 1's initial CIC (first episode of red blood in the stool) on 9/26/2025 at 4:47 a.m. a. RN 2 stated she (RN 2) informed NP 1 by phone on 9/26/2025 (unable to recall specific time) that Resident 1 had a second episode of presence of approximately 30 cubic centimeters (cc - a unit of volume) of blood in the stool on 9/26/2025 at 9:50 a.m. During a telephone interview on 10/8/2025 at 9:11 a.m., with NP 1, NP 1 stated she (NP 1) did not receive any phone call regarding the second episode of blood in the stool on 9/26/2025 at 9:50 a.m. and did not receive any other information that Resident 1 had subsequent episodes of blood in the stool. NP 1 stated that had she (NP 1) known that Resident 1 had a second episode of presence of blood in the stool, she would have ordered to hold heparin administration and transferred Resident 1 to the General Acute Care Hospital 1 (GACH 1). b. Resident 1 had a third episode of presence of blood (amount not indicated) in the stool during the 11 p.m. to 7 a.m. shift on 9/27/2025 at approximately 3 a.m. Licensed Vocational Nurse 2 (LVN 2) stated he (LVN 2) notified RN 1 immediately after observing there was a small amount of red blood in Resident 1's stool but could not recall the exact time. There was no documented evidence of the third episode of blood in the stool, physician notification, or any interventions or necessary care and services provided to Resident 1. c. Resident 1 had a fourth episode of presence of small amount (amount not indicated) of bright red blood in the stool on 9/27/2025 at 9 a.m. There was no documented evidence indicating the fourth episode was relayed to MD 1 or NP 1 and there was no documented evidence of any assessment, interventions, or necessary care and services provided to Resident 1. 5. Ensure that facility staff monitored and documented Resident 1's CIC (presence of blood in the stool) beginning on 9/26/2025 at 4:47 a.m. following the initial report of blood in the stool. These deficient practices resulted in Resident 1 being found unresponsive (a state in which an individual is unconscious and does not respond to stimuli such as voice, touch, or pain), with no pulse (the regular movement of blood through your body that is caused by the beating of your heart and that can be felt by touching certain parts of your body) and no respirations (action of breathing) on 9/27/2025 at 9:14 p.m. On 9/27/2025 at 9:25 p.m., paramedics (a person trained to give emergency medical care to people who are injured or ill, typically in a setting outside of a hospital) arrived at the facility and found Resident 1 with rigor mortis (stiffening of the joints and muscles of a body a few hours after death) in the jaw, arms, and legs. Resident 1's skin was cold and pale. On 9/27/2025 at 9:28 p.m., paramedics pronounced Resident 1 deceased (a person who has died). On 10/8/2025 at 4:49 p.m., while onsite at the facility, the State Survey Agency (SSA) called 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) in the presence of the Administrator (ADM) and the Director of Nursing (DON) due to the facility's failure under S 483.25 Quality of Care by not providing necessary care and services in accordance with professional standards of practice when Resident 1 had a CIC on 9/26/2025 at 4:47 a.m. On 10/10/2025 at 12:36 p.m., the ADM submitted an IJ Removal Plan (a detailed plan that identifies all actions the facility will take to immediately address the noncompliance that has resulted in the IJ situation). On 10/10/2025 at 2:49 p.m., while onsite at the facility, after verifying and confirming the facility's implementation of the IJ Removal Plan through observations, interviews, and record reviews, the SSA accepted the IJ Removal Plan and removed the IJ situation in the presence of the ADM and DON. The acceptable IJ Removal Plan included the following summarized actions: 1. Initiated on 10/7/2025 and ongoing through 10/8/2025 and 10/9/2025, the DON/designee provided an in-service (refers to staff training) and competency evaluations to licensed nurses on the following topics: a. Notification of COC, including comprehensive assessment, physician communication and escalation to the Medical Director. b. Physician availability and escalation process, emphasizing 24/7 (twenty-four hours a day, seven days a week) physician notification using the facility phone system, and escalation to the Medical Director if the attending physician does not respond. Training also included calling 911 (telephone number to call for emergency services) for emergency transfer when clinically indicated and no physician response is received. c. Comprehensive assessment utilizing the Situation Background Assessment, and Recommendation (SBAR - provides a structured, concise, and standardized way for healthcare professionals to communicate important resident information, especially in critical situations such as handoff [the formal process of transferring the responsibility and information for a patient's care from one caregiver to another, such as at the end of a shift] or when escalating a resident's condition) Communication Form. d. Identifying and managing risks associated with anticoagulant (a medication that prevents blood clots from forming in the bloodstream) medications. e. Carrying out STAT laboratory test(s). The on-duty Registered Nurse (RN) Supervisor will audit all STAT labs every shift for accuracy and timeliness using the STAT Lab Audit Form. f. Communication and documentation for reporting COCs to the appropriate healthcare provider. g. Licensed nurses who are off, on leave of absence, or on vacation will receive in-service training prior to returning to their scheduled shifts. h. The DON/designee will conduct posttests to five licensed nurses weekly for four weeks and monthly for three months thereafter to validate continued competency. i. All newly hired licensed nurses will receive COC in-service and competency training as part of their orientation. 2. On 10/8/2025, at 10:57 a.m., the DON conducted an audit of all current in-house residents receiving anticoagulant therapy. 34 residents were identified as receiving anticoagulants. No other residents were found to have adverse outcomes related to the deficient practice. 3. On 10/8/2025 at 1:53 p.m., the DON conducted an audit of all residents who had a COC within the past 30 days (9/1/2025 to 10/8/2025). The audit identified 156 COCs and no other residents were found to have adverse outcomes related to the deficient practice. 4. On 10/8/2025 at 2 p.m., the DON provided a one-on-one (1:1 - a training session where a staff member receives individualized instruction, guidance, and coaching from a supervisor or educator on a specific skill or topic) in-service and competency training to LVN 2 focusing on performing a complete resident evaluation during a COC, immediate physician notification, and clear documentation of all communications and actions taken. 5. On 10/8/25 at 2:05 p.m., the DON conducted an audit of residents that expired within the last 30 days (9/7/2025 to 9/8/2025). No other residents were found to have adverse outcomes associated with the deficient practice. 6. On 10/8/2025 at 4 p.m., the DON provided 1:1 in-service and competency training to Registered Nurse 3 (RN 3) on performing comprehensive assessments, immediate physician notification for any COC, and accurate documentation of communications relaying the COC. 7. On 10/8/2025 at 5 p.m., the DON provided 1:1 in-service training to RN 2 on entering and carrying out orders for STAT laboratory tests. The DON provided 1:1 in-service and competency training to RN 2 on COC procedures including performing a comprehensive assessment, immediately notifying the physician for any change of condition, and clear documentation of communication. 8. On 10/8/2025 at 5:15 p.m., the governing body (a group of people with ultimate legal responsibility for the facility's policies, management, and operation), including the Medical Director, ADM, DON, and Senior [NAME] President of Operations held an ad hoc (when necessary or needed) meeting to review the IJ Removal Plan for further recommendations. The governing body and nursing leadership reviewed the facility's policies including physician/advanced practice provider notification, diagnostic tests (medical procedures or examinations used to identify the presence or absence of a specific disease, condition or injury), notification of COC, and nursing documentation. 9. On 10/8/25 at 5:30 p.m., the DON conducted an audit of residents with STAT laboratory orders over the past 30 days (9/8/2025 to 10/8/2025). 18 residents were identified with STAT laboratory orders and no other residents were found to have adverse outcomes related to the deficient practice. 10. On 10/8/2025 at 10 p.m., the DON provided 1:1 in-service and competency training to RN 1 on COC with a focus on performing a comprehensive assessment and immediately notifying the physician for any COC. 11. On 10/8/2025 at 6:15 p.m., the facility implemented Quality Assurance Performance Improvement (QAPI - a system that combines ensuring service meets set standards with continuously studying and improving processes to prevent problems and enhance outcomes) focused on the COC process. 12. The DON/designee will review daily (including weekends) all residents with COCs to ensure timely physician notification and completion of comprehensive assessments. 13. The DON/designee will conduct an audit of all residents with STAT laboratory test orders during Clinical Meetings on weekdays to confirm that tests that were carried out correctly and completed timely utilizing the STAT Lab Audit Form. Any discrepancies identified will be corrected immediately by the DON/designee. 14. The DON/Designee will report findings from the COC audit and STAT laboratory test audit to the Quality Assessment and Assurance committee (QAA - a committee that oversees a facility's QAPI program) for further recommendations monthly for three months or until substantial compliance is achieved. Findings: During a review of Resident 1's admission Record, undated, the admission Record indicated the facility admitted Resident 1 on 7/22/2025 with diagnoses of metabolic encephalopathy (a condition in which the brain does not function properly due to an imbalance in body chemistry), altered mental status (a state of confusion, change in consciousness or unusual behavior), type 2 diabetes mellitus (DM - a chronic condition characterized by high blood sugar levels that occur when the body does not produce enough insulin [a hormone that turns food into energy and manages your blood sugar level] or does not use insulin effectively), and essential hypertension (abnormally high blood pressure with no identifiable underlying medical cause). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 7/29/2025, the MDS indicated Resident 1 was moderately impaired in thought process (demonstrating noticeable breakdown in thinking that causes significant difficulty with daily tasks, communication, and decision-making). The MDS indicated that Resident 1 required substantial or maximal assistance (a person requires more than half of the effort from a helper to complete a task) from staff with activities of daily living (ADLs - basic tasks of personal care that a resident needs help with to function day-to-day) for toileting hygiene, showering or bathing, upper body dressing, and lower body dressing. During a review of Resident 1's CIC Evaluation form, dated 9/26/2025, timed at 4:47 a.m., the CIC Evaluation indicated that Resident 1 had a first episode of bright red blood in stool, described as moderate amount (exact amount not specified). The CIC Evaluation form indicated that Resident 1 left voicemail and text messages to MD 1 and NP 1 on 9/26/2025 at 6 a.m., reporting the episode. On 9/26/2025 at 7:30 a.m., no response from MD 1 and NP 1 have been received, and the CIC was endorsed to the next RN Supervisor (RN 2) for follow-up. The CIC Evaluation for Resident 1 indicated an Abdominal/GI Status Evaluation indicating blood in stool, described as moderate in amount. The CIC Evaluation indicated that RN 1 did not perform evaluations for Behavioral Status Evaluation, Respiratory Status Evaluation, Cardiovascular Status Evaluation, Genitourinary Status Evaluation, and Neurological Status Evaluation. During a review of Resident 1's Situation, Background, Assessment, and Recommendation (SBAR - a communication tool that provides a consistent framework for sharing critical information, especially in healthcare, by breaking down the message into four parts: Situation [what is happening?], Background [relevant context], Assessment [your analysis and understanding], and Recommendation [what you want done]) Communication Form, dated 9/26/2025, timed at 4:47 a.m., the SBAR indicated that RN 1 did not assess for the presence or absence of bowel sounds (noises produced by movement of food, fluid, and gas through the intestines [the long, winding tubes in the abdomen where food is digested and nutrients are absorbed]). During a review of Resident 1's Care Plan, initiated on 9/26/2025, the Care Plan indicated Resident 1 had an episode of blood in stool. The Care Plan included interventions to Assess for and report signs and symptoms of nausea (an uncomfortable, queasy feeling in the stomach, often accompanied by an urge to vomit)/vomiting, abdominal distention (the physical enlargement or swelling of the abdomen, often accompanied by a feeling of fullness or tightness), abdominal cramping (sudden, tight feeling in the muscles of your belly), constipation (problem with passing stool), decreased bowel movements, decreased bowel sounds and abdominal pain. During a review of Resident 1's Progress Notes, dated 9/26/2025, timed at 9:50 a.m., the Progress Notes indicated that Resident 1 had a second episode of dark red blood in stool (estimated amount 30 cc). During a review of Resident 1's Active Orders as of 9/27/2025, the Active Orders indicated the following: - To administer Porcine Heparin injection solution 5,000 units per milliliter (u/ml - unit of measure). Inject one ml subcutaneously (under the skin) every eight hours for deep vein thrombosis (DVT - blood clot that forms in a deep vein) prophylaxis (preventive care) with an order date of 7/23/2025. - To obtain occult blood test one time only for evaluation of blood in stool for one day with an order date of 9/26/2025 (creation time not indicated). - To obtain occult blood test STAT for blood in stool with an order date of 9/26/2025 (created on 9/26/2025 at 2:04 p.m.). - To obtain CBC STAT one time only for three days with an order date of 9/27/2025 (created on 9/27/2025 at 5:51 a.m.). During a review of Resident 1's Laboratory Result Report, dated 9/27/2025 at 11:48 a.m., the Laboratory Result Report indicated that Resident 1's occult blood test result was positive. A handwritten note on the Laboratory Result Report indicated MD 1 notified on 9/27/2025 but did not include the name of the staff member or the time of notification. During a review of Resident 1's Progress Notes, Type: Lab Result Note, dated 9/27/2025 at 4:20 p.m., the Lab Result Note indicated a late entry (created on 9/28/2025 at 2:25 p.m., a day after Resident 1's death) documenting that Registered Nurse 4 (RN 4) relayed Resident 1's positive occult blood test result to NP 1 and was awaiting for orders. During a review of Resident 1's Medication Administration (Admin) Audit Report, dated 10/1/2025, the Medication Admin Audit report indicated that heparin was administered to Resident 1 after the COC (blood in the stool), first identified on 9/26/2025 at 4:47 a.m. The medication (heparin) was administered on the following dates and times: - 9/26/2025 at 8:52 a.m. by Licensed Vocational Nurse 3 (LVN 3) - second episode of approximately 30 cc of blood in stool occurred on 9/26/2025 at 9:50 a.m.- 9/26/2025 at 5:08 p.m. by Licensed Vocational Nurse 6 (LVN 6)- 9/26/2025 at 11:49 p.m. by LVN 2 - third episode of blood in stool noted on 9/27/2025 at 3 a.m.- 9/27/2025 at 7:11 a.m. by LVN 3 - fourth episode of blood in stool noted on 9/27/2025 at 9 a.m.- 9/27/2025 at 6:02 p.m. by Licensed Vocational Nurse 4 (LVN 4) - Resident 1 was pronounced deceased on 9/27/2025 at 9:28 p.m. During a concurrent interview and record review on 10/1/2025 at 1:55 p.m., with LVN 3, Resident 1's Progress Notes, dated 9/26/2025 timed at 2 p.m. were reviewed. LVN 3 stated that she (LVN 3) assessed Resident 1's stool (second episode of blood in the stool on 9/26/2025 at 9:50 a.m.) and observed a small amount of red blood mixed with urine and stool, which she (LVN 3) immediately reported to RN 2. LVN 3 stated that she (LVN 3) collected a stool specimen, and that RN 2 contacted the laboratory for pickup because the laboratory test was ordered STAT. LVN 3 stated that when she (LVN 3) left the facility around 2 p.m., Resident 1's stool specimen was still in the refrigerator awaiting pickup. LVN 3 stated that the laboratory typically collects STAT specimens within four to six hours. LVN 3 further stated that following a COC, facility staff are required to monitor the resident (Resident 1) every shift for 72 hours. LVN 3 stated that staff should have immediately notified MD 1 of the moderate amount of blood in Resident 1's stool on 9/26/2025 at 4:47 a.m. LVN 3 stated if MD 1 did not respond, staff were to follow up with MD 1 three times within two hours and, if still unsuccessful, notify MD 2. LVN 3 stated that without prompt intervention, Resident 1's condition could have worsened. LVN 3 stated that Resident 1's Progress Notes, dated 9/26/2025 at 9:50 a.m., had no documentation evidence that MD 1 was notified and that it was safe to continue administering heparin. LVN 3 stated that she (LVN 3) administered heparin to Resident 1 because RN 2 told her (LVN 3) to do so and that it was okay to administer the heparin since Resident 1 only had a small amount of blood in the stool. LVN 3 stated that she (LVN 3) documented that Resident 1 had no adverse reaction despite seeing a small amount of blood. LVN 3 stated the documentation that there was no adverse reaction was wrong, and this slipped her mind because she (LVN 3) thought that the blood in Resident 1's stool was only small in amount. During a concurrent interview and record review on 10/1/2025 at 3:21 p.m. with RN 3, Resident 1's Progress Notes (from 9/26/2025 to 9/27/2025) and Laboratory Request Form dated 9/26/2025 and 9/27/2025 were reviewed. RN 3 stated that she (RN 3) could not provide any documented evidence that Resident 1 refused the STAT blood draw. RN 3 stated that on 9/27/2025 at around 8 a.m., LVN 3 reported that Resident 1 had another (fourth) episode of blood in the stool. RN 3 stated that she (RN 3) did not observe the blood in Resident 1's stool because Certified Nurse Assistant 4 (CNA 4) had already cleaned Resident 1. RN 3 stated that she (RN 3) instructed CNA 4 to notify her (RN 3) if Resident 1 had additional bleeding episodes so RN 3 could assess Resident 1. RN 3 stated that later in the afternoon, there was no visible blood in Resident 1's stool and she (RN 3) contacted MD 1, who thought hemorrhoids (though staff had not assessed Resident 1 for hemorrhoids) and constipation. RN 3 stated that MD 1 wanted to wait for the STAT CBC results. RN 3 stated that no CBC STAT order was entered on 9/26/2025. However, a copy of the laboratory request form indicated that Resident 1 refused the laboratory test, and a CBC was ordered on 9/27/2025 but was not drawn. RN 3 was unable to provide documentation of any communication between herself (RN 3) and MD 1. During a concurrent interview and record review on 10/2/2025 at 4:23 p.m., with RN 4, Resident 1's CIC Evaluation form dated 9/26/2025 at 4:47 a.m., and the facility's P&P titled Change of Condition: Notification of were reviewed. RN 4 stated that if Resident 1 had an episode of blood in the stool on 9/26/2025 at 4:47 a.m., facility staff should have notified MD 1 immediately and report that Resident 1 had one episode of moderate amount of blood in the stool. RN 4 stated if MD 1 did not respond within 15 to 30 minutes, staff should escalate the situation by notifying the ADM, DON, Assistant DON, and MD 2, all of whom were available 24 hours a day. RN 4 stated that the facility's P&P indicated to notify the physician immediately following a change of condition. Resident 1's Progress Note, created on 9/28/2025, at 2:25 p.m. and documented as a late entry for 9/27/2025 at 4:20 p.m. was also reviewed. RN 4 stated that RN 4 notified NP 1 through a text message that the occult blood test result was positive. RN 4 stated that NP 1 responded on 9/27/2025 at around 7 p.m. and stated that a prior order for CBC STAT had already been given. RN 4 stated that there was no documented evidence of NP 1's response in Resident 1's medical records. During a concurrent interview and record review on 10/3/2025 at 6:40 a.m., with RN 1, Resident 1's COC dated 9/26/2025 (first episode of blood in the stool) was reviewed. The COC indicated that Resident 1 had signs and symptoms of blood in the stool in a moderate amount. RN 1 stated that LVN 1 notified him (RN 1) that Resident 1 had an episode of bright red blood in the stool, approximately 10 cc in volume. RN 1 stated that on 9/26/2025 at around 6 a.m. he (RN 1) notified MD 1 and NP 1 by calling them (MD 1 and NP 1) using the facility phone and also sending text messages from his (RN 1) personal phone. RN 1 stated physicians get mad if they (physicians) are contacted in the middle of the night and that MD 2 had previously told RN 1 (exact date not specified) that for non-emergency cases, physicians did not need to be called during nighttime hours. RN 1 stated that Resident 1 was stable and that there was no need to notify the physician at 4 a.m. because it was too early. RN 1 stated that it was his (RN 1) personal decision to delay notification until 6 a.m., based on his (RN 1) nursing judgment that Resident 1's condition was not emergent. During a concurrent interview and record review on 10/3/2025 at 6:51 a.m., with RN 1, the facility P&P titled, Change of Condition: Notification of, with effective date of 11/28/2016 and last reviewed on 9/11/2025, Resident 1's progress notes (from 9/26/2025 to 9/27/2025), and physician orders from 9/26/2025 to 9/27/2025 were reviewed. RN 1 stated that based on his (RN 1) nursing judgment, Resident 1's condition was not life-threatening. RN 1 stated that the presence of a moderate amount of blood in the stool could be due to hemorrhoids (swollen veins in the anus or rectum that can cause itching, pain, and bleeding). However, RN 1 was unable to provide documented evidence indicating that he (RN 1) assessed Resident 1 for hemorrhoids and stated that he (RN 1) did not know if Resident 1 had hemorrhoids. RN 1 stated that NP 1 responded to his (RN 1) text message (sent from his personal phone) on 9/26/2025 at around 8 a.m., after his (RN 1) shift had ended, and gave verbal orders for a STAT CBC and STAT occult blood test. RN 1 stated that on 9/262025 at around 8 a.m., he (RN 1) called the facility, spoke to RN 2 and relayed NP 1's orders. RN 1 stated he (RN 1) did not document the exact wording of his (RN1) communication with MD 1 or NP 1 but instead made a generalized entry in Resident 1's medical record. RN 1 further stated that he (RN 1) did not follow up with MD 1 or NP 1 after the initial notification on 9/26/2025 at 6 a.m. RN 1 stated that RN 2 did not carry out the CBC STAT order he (RN 1) had endorsed at 8 a.m. on 9/26/2025. RN 1 stated that the facility failed to carry out the CBC STAT and occult blood test STAT orders promptly as required. During an interview on 10/3/2025 at 10:09 a.m., with RN 2, RN 2 stated that RN 1 informed her (RN 2) between 7:45 a.m. to 8 a.m. that NP 1 had ordered a CBC STAT and Occult Blood Test STAT for Resident 1. RN 2 stated that she (RN 2) entered the orders into the facility's computer system; however, only a routine (non-STAT) occult blood test was entered. RN 2 stated that she (RN 2) also called the laboratory to inform them that the order was STAT. RN 2 stated that Resident 1 had a second episode of blood in the stool at around 10 a.m. and a stool sample was collected. RN 2 stated that she (RN 2) observed a streak of dark red blood in Resident 1's diaper. RN 2 stated that she (RN 2) notified NP 1 of the finding and that NP 1 instructed her (RN 2) to continue to monitor Resident 1 and await the occult blood test results. RN 2 stated she informed NP 1 that Resident 1 was receiving heparin, but NP 1 did not give an order to discontinue the heparin. RN 2 stated she (RN 2) could not recall the exact time she (RN 2) spoke with NP 1 and did not document the conversation with NP 1 in Resident 1's medical records. RN 2 stated that laboratory staff arrived later and attempted to draw the CBC sample from Resident 1, but Resident 1 was refusing and continued to pull away her (Resident 1) arm. RN 2 stated that she (RN 2) and the laboratory staff remained with Resident 1 for more than 10 minutes, attempting to calm Resident 1 and encourage her (Resident 1) three times, but Resident 1 continued to refuse. RN 2 stated that she (RN 2) did not document the attempted blood draws or Resident 1's refusals. RN 2 also stated that she (RN 2) notified NP 1 that Resident 1 was refusing the CBC STAT but did not document. When asked why the CBC STAT order was not entered into the facility's computer system, RN 2 was unable to provide an explanation. RN 2 was also unable to provide documented evidence that she (RN 2) had notified MD 1 and NP 1 of Resident 1's second episode of dark red blood in the stool, which was documented in Resident 1's medical records as approximately 30 cc. RN 2 stated that the 30 cc referred to the amount of stool collected for the occult blood test, not the amount of blood observed. RN 2 stated that according to facility policy, if a COC occurs, staff are required to notify the physician immediately. If there is no callback, the staff must follow up every 15 minutes, up to four times, and if the physician still does not respond, staff must notify the facility's Medical Director but failed to do. During a concurrent interview and record review on 10/3/2025 at 11:42 a.m., with Registered Nurse 5 (RN 5), Resident 1's Laboratory Results Report, dated 9/27/2025, Resident 1's Physician's Order dated 9/26/2025 and Resident 1's Progress Notes (from 9/26/2025 to 9/27/2025) were reviewed. RN 5 stated that the occult blood test result was positive. RN 5 stated that Resident 1's stool sample was collected on 9/26/2025 at 3:00 p.m., received by the laboratory on 9/27/2025 at 8:11 a.m., and the result was reported via the facility's computer system at 11:48 a.m. on 9/27/2025. RN 5 stated that Resident 1's Physician's Order dated 9/26/2025 indicated the occult blood stool test was STAT, meaning the result should have been available within four to six hours of specimen collection. RN 5 stated that the laboratory did not receive Resident 1's stool sample specimen until 9/27/2025 at 8:11 a.m., 17 hours and 11 minutes after collection, and the final result was released on 9/27/2025 at 11:48 a.m., 20 hours and 48 minutes after the stool sample specimen was picked up. RN 5 stated that because the order was STAT, the licensed nurse should have followed up with the laboratory and notified Resident 1's physician (MD 1) when results were delayed. RN 5 also stated that RN 4 entered a late entry on 9/28/2025 at 2:25 p.m. (the day after Resident 1's death) in the Progress Notes for 9/27/2025 at 4:20 p.m., indicating that RN 4 notified NP 1 of the positive

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan (is a form that summarizes a person ' s health conditions and current treatments for their care)for one of six sampled residents (Resident 3), who was dependent (helper does all the effort or the assistance of 2 or more helpers is required for the resident to complete the activity) on staff on personal hygiene and diagnosed with muscle weakness (generalized), morbid (severe) obesity (abnormal or excessive fat accumulation that presents a risk to health) and paraplegia (the inability to voluntarily move the lower parts of the body), by failing to: 1. Develop and implement a care plan (is a form that summarizes a person ' s health conditions and current treatments for their care) consistent with Resident 3 ' s Minimum Data Set (MDS - a standardized assessment and care-screening tool), which indicated Resident 3 was dependent on staff on personal hygiene (includes combing hair, shaving, applying make-up, washing/drying face and hands [excludes baths, showers, and oral hygiene]), toileting hygiene (ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement), and rolling left and right (the ability to roll from lying on back to left and right side, and return to lying on back on the bed). 2. Indicate in Resident 3 ' s care plan to change Resident 3 ' s Med Aire Plus 10 Alternating Pressure and Low Air Loss Bariatric Mattress (LALM, a type of medical mattress designed to reduce pressure on the skin, which helps prevent pressure injuries or bed sores [injuries to skin and underlying tissue resulting from prolonged pressure on the skin]) setting from the physician ' s order of 300 pounds (lbs - unit of measurement for weight) to static mode (the mattress provides a firm surface that makes it easier for the patient to transfer or reposition). As a result, Resident 3 fell while Certified Nursing Assistant (CNA 1), was providing nursing care to Resident 3, without assistance from another staff. Resident 3 sustained a laceration (wound in the skin that occurs when skin and underlying tissues are torn or cut) to the left eyebrow and had approximately 1 liter (L - unit of measurement) of blood next to her head and was pronounced dead by the paramedics (healthcare professionals trained to provide a wide range of emergency services) on [DATE] at 10:21 p.m., in the facility. On [DATE] at 4:31 p.m., while onsite at the facility, the State Survey Agency (SSA) called 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) ) in the presence of the Administrator (ADM) and the Director of Nursing (DON) due to the facility ' s failure to ensure Resident 3 was free from accidents under 42 CFR S S483.21 (b) Comprehensive Care Plans. On [DATE] at 3:33 p.m., the ADM and DON submitted an IJ Removal Plan (a detailed plan to address the IJ findings). While onsite at the facility, the SSA verified the IJ situation was no longer present and confirmed the facility ' s implementation of the IJ Removal Plan through observations, interviews, and record reviews, the SSA accepted the IJ Removal Plan and removed the IJ situation in the presence of the ADM and DON [DATE] at 4:15 p.m. The acceptable IJ Removal Plan included the following summarized actions: 1. On [DATE], the Director of Staff Development (DSD), Minimum Date Set (MDS) Nurse, and charge nurses reassessed all the residents ' turning/repositioning level of assistance by reviewing the MDS to assure appropriate provision of activities of daily living (ADL) care. Five residents (names indicated in the list provided by the facility) were identified to require two-person assistance during ADL care. 2. On [DATE], the DON conducted an order listing report of residents that had an order for LALM (in general) and 23 residents (names indicated in the list provided by the facility) were identified. Five residents (names indicated in the list provided by the facility) with LALM were identified to require two-person assist per MDS. 3. On [DATE], the Resource Nurse and the MDS Nurse reviewed the ADL care plans of the residents with LALM that required two-person assist. Three residents (names indicated in the list provided by the facility) were identified to have discrepancy in the ADL care plan regarding level of assistance during care based on the MDS to assure appropriate provision of ADL care. On [DATE], the Resource Nurse and the MDS Nurse revised the care plans for the three residents that were identified with discrepancy of the ADL care plan. 4. On [DATE], the MDS resource and DON reviewed the ADL care plans for all residents to ensure accuracy in conjunction with the MDS. 5. Revisions for all resident ADL care plans were initiated on [DATE] to ensure proper identification and care planning for resident provision of ADL care including the five residents identified (names indicated in the list provided by the facility) to have orders for LALM and requiring two-person assist. 6. On [DATE], the DON and MDS Resource updated the care plan of 23 residents with LALM to indicate static button is available to discontinue alternation therapy (alleviates pressure points, improves blood circulation, and reduces risk of developing pressure injuries) for resident transfers, caregiving, comfort, or preference. 7. On [DATE], the MDS, Resource Nurse, and MDS Resource staff updated the ADL care plan of the residents identified to require two-person assist based on the provision of care determined through reviewing the MDS. 8. On [DATE], the DON provided an in-service to the MDS RN and Licensed Vocational Nurses (LVNs) on the accuracy of care planning with the emphasis of level of assistance during ADL care. 9. On [DATE], the DON initiated the Special Needs List Form which indicated the level of assistance during ADL care. On [DATE], the DON revised the Special Needs List Form to include a statement that the staff required for ADL care/transfers were minimal requirements, and to ask for additional assistance if needed to ensure patient safety. 10. On [DATE], the DSD initiated a re-education to RNs, LVNs, CNAs, and Rehab Staff emphasizing that the assistance needed on the special needs list are minimum information and emphasized that the staff should ask for additional assistance if needed to ensure patient safety. 11. On [DATE] the DON/Designee initiated an in-service to RNs, LVNs, CNAs and Rehab staff on Med-Aire Plus 10 Alternating Pressure and Low Air Loss Bariatric Mattress Replacement System and other types of LALM the information on the use of static button to discontinue alternation therapy for patient transfers, caregiving, comfort, or preference. 12. On [DATE], the DON/Designee initiated an in-service to RNs, LVNs, CNAs and Rehab staff on other LALM manufacturer's guidelines during patient transfers, caregiving, comfort, or preference. 13. On [DATE], the DSD provided an in-service over the phone to CNA 1 who was assigned to Resident 3 regarding ADL care to a resident with LALM. CNA 1 will be in-serviced in person at the beginning of her next shift. 14. On [DATE], the DON/Designee initiated an in-service to RNs, LVNs, CNAs and rehab staff on the Special Needs List Form which will be located at each nursing station. 15. On [DATE], the DSD provided an in-service over the phone to the assigned Licensed Nurse for Resident 3 addressing the need to set the button to static when ADL is provided. LVN will be in-serviced in person at the beginning of her next shift. 16. On [DATE], the DSD/Designee initiated an in-service to RNs, LVNs, CNAs, and Rehab Staff on providing the correct level of assistance when providing ADL Care. 17. On [DATE], the DON/Designee initiated competencies on providing ADL care for residents on LALM for CNAS, LVNs, RNs and rehab staff. 18. The Director of Nursing and/or Designee will review new admissions daily (Mondays to Fridays). The Director of Nursing and/or Designee will review the ADL care plan based on the information provided from the resident's MDS and the transfer Lift Evaluation assessment. The Director of Nursing and/or Designee will update the Special Needs List Form for accurate provision of ADL care. 19. The DSD/Designee will do random rounds daily (Mondays to Fridays) to ensure that the staff is adhering to the Special Needs List Form for residents that require two-person assist during ADL care using the ADL Audit Form. 20. The DSD/Designee will do random rounds daily (Monday to Friday) during ADL care to check if static mode is turned on during transfers, caregiving, comfort, or preference of the residents for residents on LALM. 21. The MDS and or Designee will review the accuracy of ADL care plan of residents on LALM for three months. 22. The Director of Nursing and/or Designee will review the ADL Audit Form weekly and address any deficient findings. 23. The Director of Nursing and/or Designee will review the Low Air Loss Static Mode Audit weekly and address any deficient findings. 24. The Director of Nursing/Designee and or Administrator /Designee will be responsible for compliance. Findings will be reported to the Administrator and/or Designee who will then present and discuss the findings during Quality Assessment and Assurance (QAA) meetings for three months for any further recommendations and follow-up or until compliance is achieved. Cross Reference with F689. Findings: A review of Resident 3 ' s Admission Record indicated the facility admitted the resident on [DATE] and readmitted on [DATE] with diagnoses including muscle weakness (generalized), morbid obesity, paraplegia, and cognitive communication deficit (difficulty paying attention to a conversation, staying on topic, remembering information, responding accurately, understanding jokes, or following directions). A review of Resident 3 ' s Care plan, developed on [DATE], for the resident ' s risk for skin breakdown with interventions for LALM for wound skin maintenance and history of pressure injury, indicated staff will monitor proper setting and functioning of the LAL, every shift. A review of Resident 3 ' s Care plan, developed on [DATE] and revised on [DATE], for the resident ' s generalized weakness with decline in overall activities of daily living (ADL) performance skill and physical status with impaired cognition and communication skills included interventions for Resident 3 to provide resident with total assist of one person for bed mobility (how resident moves to and from lying position, turns side or side, and. positions body while in bed or alternate sleep furniture). A review of Resident 3 ' s Order Summary Report, dated [DATE], indicated aspirin (medication to prevent blood clot) oral tablet chewable 81 milligrams (mg - a unit of measurement) 1 tablet via gastrostomy tube (g-tube- a tube inserted through the wall of the abdomen directly into the stomach. It allows air and fluid to leave the stomach and can be used for feeding and nutrition administration) one time a day for cerebrovascular accident (CVA, medical condition that occurs when blood flow to the brain is suddenly cut off) prophylaxis (an attempt to prevent disease). A review of Resident 3 ' s History and Physical, dated [DATE], indicated Resident 3 did not have the capacity to understand and make decisions. A review of Resident 3 ' s Order Summary Report, dated [DATE], indicated low air loss mattress to bed every shift for skin maintenance and history of pressure injury with setting at 300 (pounds), and to check settings and functions every shift. A review of Resident 3 ' s MDS, dated [DATE], indicated Resident 3 was able to understand and be understood. The MDS indicated Resident 3 was dependent assist on staff for eating, oral hygiene, toileting, showering, upper and lower body dressing, rolling left and right, and personal hygiene. The MDS indicated Resident 3 weighed 250 pounds. The MDS indicated Resident 3 had impairment on both sides for upper extremity (shoulder, elbow, wrist, and hand) and lower extremity (hip, knee, ankle, and foot). A review of Resident 3 ' s weight, dated [DATE], indicated Resident 3 weighed 252 lbs. A Review of Resident 3 ' s vital signs (measurements of the body's most basic functions), dated [DATE] at 8:40 p.m., indicated a blood pressure (BP - the force of your blood pushing against the walls of your arteries and the normal BP for adults is a systolic pressure [upper number] of less than 120 and a diastolic pressure [lower number] of less than 80 ) of ,d+[DATE] millimeters of mercury (mmHg - unit of measurement), and heart rate (the number of times the heart beats within a minute and the normal resting heart rate for adults ranges from 60 to 100 beats per minute or bpm) of 75 bpm. A review of Resident 3 ' s Situational Background Appearance and Review (SBAR - a written communication tool that helps provide essential, concise information, usually during crucial situations) Communication Form, dated [DATE], indicated that around 9:50 p.m., Licensed Vocational Nurse (LVN 1) called Registered Nurse (RN 1) to assess Resident 3 who had a fall. Resident 3 was noted on the floor head turned to the side. The SBAR indicated Resident 3 was conscious and minimally responsive. The SBAR indicated Code blue (emergency code that indicates a patient is experiencing a life-threatening medical emergency) was called, and code status was verified as Do not attempt Resuscitation (DNR- a legal document that means a person has decided not to have cardiopulmonary resuscitation [CPR- giving strong, rapid pushes to the chest to keep blood moving through the body] attempted on them if their heart or breathing stop). Resident 3 was immobilized and 911 (the telephone number to call for emergency services) was called due to possible head injury. The SBAR indicated when the paramedics arrived, Resident 3 lost consciousness completely. A review of Resident 3 ' s Los Angeles Fire Department (LAFD- an organization that provides fire prevention and fire suppression services as well as other rescue services) Patient Care Report dated [DATE] at 10:04 p.m. indicated the paramedics were notified at 10:04 p.m. and were on scene at 10:10 p.m. The report indicated at 10:13 p.m. Resident 3 was laying supine (a person lying on their back with their face and torso pointing up) on the ground in the room of the nursing home. The report indicated facility ' s staff stated they heard a thud (a loud, dull sound) and Resident 3 was found on the floor with blood next to her head and 911 was called, approximately 20 minutes after Resident 3 was observed on the floor. The report indicated Resident 3 was laying supine (lying on the back with the face and torso pointing up) on ground naked with approximately 3-inch laceration to left eyebrow and approximately 1 liter of blood next to her head. The report indicated Resident 3 ' s head was approximately 18 inches from the wall, and she was laying in the middle of the room. The report indicated Resident 3 ' s bed was pushed out of way and was elevated approximately 24 to 36 inches (2 to 3 feet) off the ground with all side rails down. The report indicated Resident 3 was pulseless and apneic (a temporary and involuntary stop in breathing) and CPR was started. The report indicated a staff stated Resident 3 was DNR, but the paramedics continued while Resident 3 ' s code status was verified. The report indicated staff took approximately 5 minutes to provide documentation of DNR, CPR was discontinued, and Resident 3 was declared dead at 10:21 p.m. A Review of Resident 3 ' s Skin check, dated [DATE] at 10:37p.m., indicated 1.5-inch skin tear to left upper eyebrow. During an interview on [DATE] at 11:15 a.m., Resident 5, who was Resident 3 ' s roommate and who was present when Resident 3 fell , stated on [DATE] at around 10 p.m., one staff (CNA 1) attempted to change Resident 3 ' s incontinent brief. Resident 5 stated the curtain between both beds was closed but she heard Resident 3 fall off the bed. Resident 5 stated the staff (CNA 1) rolled Resident 3 to change her incontinent brief. Resident 5 stated there was only one staff assisting Resident 3. Resident 5 stated Resident 3 ' s bed only had one upper small siderail and (provide cushioned landing surface and reduce the likelihood of injury) next to Resident 3 ' s bed. Resident 5 stated Resident 3 fell on her face, near Resident 5 ' s bed. During an interview on [DATE] at 12:14 p.m. with CNA 1, CNA 1 stated that around 9:30 p.m., on [DATE] she was about to provide care to Resident 3, and while standing on Resident 3 ' s right side, she elevated the resident ' s bed to the level of her waist high. CNA 1 stated she (CNA 1) was six feet tall, and the bed may have been about three feet off the ground. CNA 1 stated Resident 3 was lying on her back, and she rolled Resident 3 onto her left side, placed Resident 3 ' s hand on the handrail with CNA 1 ' s hands on Resident 3 ' s hip. CNA 1 stated she rolled the draw sheet under Resident 3, opened the incontinence brief tab (undergarment designed to absorb urine and it can be fastened at the hip), took the left hand off Resident 3 and Resident 3 let go of the handrail and fell face down. CNA 1 stated she did not request assistance from another staff before performing care and did not change the pressure on Resident 3 ' s LAL. During an interview on [DATE] at 12:32 p.m., LVN 1 stated Resident 3 is bed-bound, alert and oriented to self (able to correctly identify self). LVN 1 stated that on [DATE] around 9:30 to 9:45p.m. she was passing out medications when CNA 1 came out running stating Resident 3 fell on the floor. LVN 1 stated she stopped what she was doing and ran into Resident 3 ' s room. Resident 3 ' s bed was pushed back but the bed was locked. Resident 3 was on the floor with the face down near Resident 5 ' s bed. LVN 1 stated there was no landing mat and Resident 3 was making a noise like she (Resident 3) was trying to breathe. LVN 1 stated she turned Resident 3 and noted Resident 3 with a cut on the left eyebrow with blood. LVN 1 stated Resident 3 ' s bed was too high, possibly three feet off the ground. LVN 1 stated Resident 3 required two staff or 3 staff depending on how small the staff was, for care. During a concurrent interview and record review on [DATE] at 2:47 p.m., with Registered Nurse (RN 2), Resident 3 ' s MDS dated [DATE] and care plan for generalized weakness dated [DATE], were reviewed. RN 2 stated based on the MDS, Resident 3 needed a 2-person assistance when providing care. RN 2 stated the care plan indicated Resident 3 required a one-person assist which was not accurate based on the MDS. RN 2 stated if MDS was not accurate, the plan of care will also not be accurate. RN 2 stated it place the resident at risk of improper care. During an interview on [DATE] at 3:29 p.m., with the DON, the DON stated Resident 3 ' s care plan for generalized weakness did not correlate with the MDS dated [DATE] because the MDS indicated Resident 3 was dependent and/or needed two-person assist. The DON stated Resident 3 would have benefited with a two-person assistance due to Resident 3 ' s diagnosis of left sided weakness. During an interview on [DATE] at 10:08a.m., CNA 1 stated Resident 3 had a LALM, and it was on static mode. CNA 1 stated she was told not to touch the LALM settings because it was set specifically per resident. CNA 1 stated she never called any nurse to change the LALM settings because she was told not to touch it. CNA 1 stated she had never had a nurse change the LALM setting when doing care for Resident 3 since she was hired on [DATE]. During an interview on [DATE] at 10:13 a.m., LVN 1 stated Resident 3 had an LALM which was already set. LVN 1 stated one just needed to keep an eye on it to make sure the setting was correct, the mattress had no holes, and that it was plugged. LVN 1 stated during ADLs, the LALM setting did not need to be changed. During an interview on [DATE] at 10:48 a.m., Treatment Nurse (TN 1) stated Resident 3 had a LALM. TN 1 stated when doing any ADLs care, the LALM setting must be changed into static mode so that it no longer alternates pressure and was firm to do ADLs. TN 1 stated if LALM was not on static mode the LALM would move and inflate on one side and deflate the other. TN 1 stated the LVNs, and RNs were the ones to change the setting from 300 to static mode. During a concurrent interview and record review on [DATE] at 3:14 p.m., Resident 3 ' s LALM 1 was reviewed. The DON stated when a resident was on LALM (in general), the static mode was used when the resident was being cared for. The DON stated for Resident 3, CNA 1 needed to request a LVN or RN to change the setting from 300 lbs to static mode. During an interview on [DATE] at 4:22 p.m. with the DON stated care plans need to be resident-centered comprehensive and with goals that were re-assessed based on each resident ' s condition, and it was an interdisciplinary approach (a way of working where staff with different skills and expertise work together towards a common goal). The DON stated a care plan was used to guide the team that provided care for residents. The DON stated the care plan should include the specific manufacturer ' s guidelines on the resident ' s LALM because each manufacture ' s guideline was different. The DON stated if care plans were not resident centered it could staff would not provide the appropriate care to residents. A review of Med Aire Plus 10 ' Alternating Pressure and Low Air Loss Bariatric Mattress Replacement System User Manual, indicated static button is available to discontinue alternation therapy for patient transfer, caregiving, comfort, or preference. Static mode is pressed to set the system to static therapy mode. The system will revert to the previous set alternation mode after 120 minutes. A review of the current facility-provided policy and procedure titled, Safety of Residents, with last revised date of [DATE] indicated to provide a safe environment for resident and facility staff. A review of the current facility-provided policy and procedure titled, Care Planning Interdisciplinary Team, with last revised date of [DATE] indicated Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident. A comprehensive care plan for each resident is developed within seven (7) days of completion of the comprehensive assessment (MDS).

Based on interview and record review, the facility failed to ensure one of six residents (Resident 3), who was dependent (helper does all the effort or the assistance of 2 or more helpers is required for the resident to complete the activity) on staff on personal hygiene with diagnosis of muscle weakness (generalized), morbid (severe) obesity (abnormal or excessive fat accumulation that presents a risk to health) and paraplegia (the inability to voluntarily move the lower parts of the body), was free from accidents, by failing to: 1. Provide Resident 3 with the needed two-person assistance when Certified Nursing Assistant 1 (CNA 1), with no assistance from another staff, was giving nursing care to Resident 3 on [DATE]. 2. Change the Resident 3 ' s Med Aire Plus 10 Alternating Pressure and Low Air Loss Bariatric Mattress (LALM, a type of medical mattress designed to reduce pressure on the skin, which helps prevent pressure injuries or bed sores [injuries to skin and underlying tissue resulting from prolonged pressure on the skin]) setting from the physician ' s order of 300 pounds (lbs - unit of measurement for weight) to static mode (the mattress provides a firm surface that makes it easier for the patient to transfer or reposition). As a result, Resident 3 fell while Certified Nursing Assistant (CNA 1), was providing nursing care to Resident 3, without assistance from another staff. Resident 3 sustained a laceration to the left eyebrow, had approximately 1 liter (L - unit of measurement) of blood next to Resident 3 ' s head and was pronounced dead by the paramedics (healthcare professionals trained to provide a wide range of emergency services) on [DATE] at 10:21 p.m., in the facility. On [DATE] at 4:31 p.m., while onsite at the facility, the State Survey Agency (SSA) called 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) ) in the presence of the Administrator (ADM) and the Director of Nursing (DON) due to the facility ' s failure to ensure Resident 3 was free from accidents under 42 CFR S S483.25 (d) (1) (2) Accidents. On [DATE] at 3:33 p.m., the ADM and DON submitted an IJ Removal Plan (a detailed plan to address the IJ findings). While onsite at the facility, the SSA verified the IJ situation was no longer present and confirmed the facility ' s implementation of the IJ Removal Plan through observations, interviews, and record reviews, the SSA accepted the IJ Removal Plan and removed the IJ situation in the presence of the ADM and DON [DATE] at 4:15 p.m. The acceptable IJ Removal Plan included the following summarized actions: 1. On [DATE], the Director of Staff Development (DSD), Minimum Date Set (MDS) Nurse, and charge nurses reassessed all the residents ' turning/repositioning level of assistance by reviewing the MDS (a standardized assessment and care screening tool) to assure appropriate provision of activities of daily living (ADL) care. Five residents (names indicated in the list provided by the facility) were identified to require two-person assistance during ADL care. 2. On [DATE], the DON conducted an order listing report of residents that had an order for LAL mattress and 23 residents (names indicated in the list provided by the facility) were identified. Five residents (names indicated in the list provided by the facility) with LAL mattress were identified to require two-person assist per MDS. 3.On [DATE], the Resource Nurse and the MDS Nurse reviewed the ADL care plans of the residents with LAL mattress that required two-person assist. Three residents (names indicated in the list provided by the facility) were identified to have discrepancy in the ADL care plan regarding level of assistance during care based on the MDS to assure appropriate provision of ADL care. On [DATE], the Resource Nurse and the MDS Nurse revised the care plans for the three residents that were identified with discrepancy of the ADL care plan. 4. On [DATE], the MDS resource and DON reviewed the ADL care plans for all residents to ensure accuracy in conjunction with the MDS. 5. Revisions for all resident ADL care plans were initiated on [DATE] to ensure proper identification and care planning for resident provision of ADL care including the five residents identified (names indicated in the list provided by the facility) to have orders for LAL mattresses and requiring two-person assist. 6. On [DATE], the DON and MDS Resource updated the care plan of 23 residents with LALM to indicate static button is available to discontinue alternation therapy (alleviates pressure points, improves blood circulation, and reduces risk of developing pressure injuries) for resident transfers, caregiving, comfort, or preference. 7. On [DATE], the MDS, Resource Nurse, and MDS Resource staff updated the ADL care plan of the residents identified to require two-person assist based on the provision of care determined through reviewing the MDS. 8. On [DATE], the DON provided an in-service to the MDS RN and Licensed Vocational Nurses (LVNs) on the accuracy of care planning with the emphasis of level of assistance during ADL care. 9. On [DATE], the DON initiated the Special Needs List Form which indicated the level of assistance during ADL care. On [DATE], the DON revised the Special Needs List Form to include a statement that the staff required for ADL care/transfers were minimal requirements, and to ask for additional assistance if needed to ensure patient safety. 10. On [DATE], the DSD initiated a re-education to RNs, LVNs, CNAs, and Rehab Staff emphasizing that the assistance needed on the special needs list are minimum information and emphasized that the staff should ask for additional assistance if needed to ensure patient safety. 11. On [DATE] the DON/Designee initiated an in-service to RNs, LVNs, CNAs and Rehab staff on Med-Aire Plus 10 Alternating Pressure and Low Air Loss Bariatric Mattress Replacement System and other types of LALM the information on the use of static button to discontinue alternation therapy for patient transfers, caregiving, comfort, or preference. 12. On [DATE], the DON/Designee initiated an in-service to RNs, LVNs, CNAs and Rehab staff on other LAL mattress manufacturer's guidelines during patient transfers, caregiving, comfort, or preference. 13. On [DATE], the DSD provided an in-service over the phone to CNA 1 who was assigned to Resident 3 regarding ADL care to a resident with LALM. CNA 1 will be in-serviced in person at the beginning of her next shift. 14. On [DATE], the DON/Designee initiated an in-service to RNs, LVNs, CNAs and rehab staff on the Special Needs List Form which will be located at each nursing station. 15. On [DATE], the DSD provided an in-service over the phone to the assigned Licensed Nurse for Resident 3 addressing the need to set the button to static when ADL is provided. LVN will be in-serviced in person at the beginning of her next shift. 16. On [DATE], the DSD/Designee initiated an in-service to RNs, LVNs, CNAs, and Rehab Staff on providing the correct level of assistance when providing ADL Care. 17. On [DATE], the DON/Designee initiated competencies on providing ADL care for residents on LAL for CNAS, LVNs, RNs and rehab staff. 18. The Director of Nursing and/or Designee will review new admissions daily (Mondays to Fridays). The Director of Nursing and/or Designee will review the ADL care plan based on the information provided from the resident's MDS and the transfer Lift Evaluation assessment. The Director of Nursing and/or Designee will update the Special Needs List Form for accurate provision of ADL care. 19. The DSD/Designee will do random rounds daily (Mondays to Fridays) to ensure that the staff is adhering to the Special Needs List Form for residents that require two-person assist during ADL care using the ADL Audit Form. 20.The DSD/Designee will do random rounds daily (Monday to Friday) during ADL care to check if static mode is turned on during transfers, caregiving, comfort, or preference of the residents for residents on LALM. 21. The MDS and or Designee will review the accuracy of ADL care plan of residents on LAL mattress for three months. 22. The Director of Nursing and/or Designee will review the ADL Audit Form weekly and address any deficient findings. 23. The Director of Nursing and/or Designee will review the Low Air Loss Static Mode Audit weekly and address any deficient findings. 24. The Director of Nursing/Designee and or Administrator /Designee will be responsible for compliance. Findings will be reported to the Administrator and/or Designee who will then present and discuss the findings during Quality Assessment and Assurance (QAA) meetings for three months for any further recommendations and follow-up or until compliance is achieved. Cross Reference with F656. Findings: A review of Resident 3 ' s Admission Record indicated the facility admitted the resident on [DATE] and readmitted on [DATE] with diagnoses including muscle weakness (generalized), morbid (severe) obesity (abnormal or excessive fat accumulation that presents a risk to health), paraplegia (the inability to voluntarily move the lower parts of the body), and cognitive communication deficit (difficulty paying attention to a conversation, staying on topic, remembering information, responding accurately, understanding jokes, or following directions). A review of Resident 3 ' s Care plan, developed on [DATE], for the resident ' s risk for skin breakdown with interventions for LAL mattress for wound skin maintenance and history of pressure injury, indicated staff will monitor proper setting and functioning of the LAL, every shift. A review of Resident 3 ' s Order Summary Report, dated [DATE], indicated aspirin (medication to prevent blood clots) oral tablet chewable 81 milligrams (mg - a unit of measurement) 1 tablet via gastrostomy tube (g-tube a tube inserted through the wall of the abdomen directly into the stomach. It allows air and fluid to leave the stomach and can be used to give drugs and liquids, including liquid food, to the patient) one time a day for CVA prophylaxis (an attempt to prevent disease). A review of Resident 3 ' s Order Summary Report, dated [DATE], indicated bilateral one-half side rails as an enabler (facilitates movement while on bed). A review of Resident 3 ' s History and Physical, dated [DATE], indicated Resident 3 did not have the capacity to understand and make decisions. A review of Resident 3 ' s Order Summary Report, dated [DATE], indicated low air loss mattress to bed every shift for skin maintenance and history of pressure injury with setting at 300 (pounds), and to check settings and functions every shift. A review of Resident 3 ' s MDS, dated [DATE], indicated Resident 3 was able to understand and be understood. The MDS indicated Resident 3 was dependent assist on staff for eating, oral hygiene, toileting, showering, upper and lower body dressing, rolling left and right, and personal hygiene. The MDS indicated Resident 3 weighed 250 pounds. The MDS indicated Resident 3 had impairment on both sides for upper extremity (shoulder, elbow, wrist, and hand) and lower extremity (hip, knee, ankle, and foot). A review of Resident 3 ' s weight, dated [DATE], indicated Resident 3 weighed 252 lbs. A Review of Resident 3 ' s vital signs (measurements of the body's most basic functions), dated [DATE] at 8:40 p.m., indicated a blood pressure (BP - the force of your blood pushing against the walls of your arteries and the normal BP for adults is a systolic pressure [upper number] of less than 120 and a diastolic pressure [lower number] of less than 80 ) of ,d+[DATE] millimeters of mercury (mmHg - unit of measurement), and heart rate (the number of times the heart beats within a minute and the normal resting heart rate for adults ranges from 60 to 100 beats per minute or bpm) of 75 bpm. A review of Resident 3 ' s Situational Background Appearance and Review (SBAR - a written communication tool that helps provide essential, concise information, usually during crucial situations) Communication Form, dated [DATE], indicated that around 9:50 p.m., Licensed Vocational Nurse (LVN 1) called Registered Nurse (RN 1) to assess Resident 3 who had a fall. Resident 3 was noted on the floor head turned to the side. The SBAR indicated Resident 3 was conscious and minimally responsive. The SBAR indicated Code blue (emergency code that indicates a patient is experiencing a life-threatening medical emergency) was called, and code status was verified as Do not attempt Resuscitation (DNR- a legal document that means a person has decided not to have cardiopulmonary resuscitation [CPR- giving strong, rapid pushes to the chest to keep blood moving through the body] attempted on them if their heart or breathing stop). Resident 3 was immobilized and 911 (the telephone number to call for emergency services) was called due to possible head injury. The SBAR indicated when the paramedics arrived, Resident 3 lost consciousness completely. A review of Resident 3 ' s Los Angeles Fire Department (LAFD- an organization that provides fire prevention and fire suppression services as well as other rescue services) Patient Care Report dated [DATE] at 10:04 p.m. indicated the paramedics were notified at 10:04 p.m. and were on scene at 10:10 p.m. The report indicated at 10:13 p.m. Resident 3 was laying supine (a person lying on their back with their face and torso pointing up) on the ground in the room of the nursing home. The report indicated facility ' s staff stated they heard a thud and Resident 3 was found on the floor with blood next to his head and 911 was called, approximately 20 minutes after Resident 3 was observed on the floor. The report indicated Resident 3 was laying supine (lying on the back with the face and torso pointing up) on ground naked with approximately 3-inch laceration to left eyebrow and approximately 1 liter of blood next to his head. The report indicated Resident 3 ' s head was approximately 18 inches from the wall and he was laying in the middle of the room. The report indicated Resident 3 ' s bed was pushed out of way and was elevated approximately 24 to 36 inches (2 to 3 feet) off the ground with all side rails down. The report indicated Resident 3 was pulseless and apneic (a temporary and involuntary stop in breathing) and CPR was started. The report indicated a staff stated Resident 3 was DNR, but the paramedics continued while Resident 3 ' s code status was verified. The report indicated staff took approximately five minutes to provide documentation of DNR, CPR was discontinued, and Resident 3 was declared dead at 10:21 p.m. A Review of Resident 3 ' s Skin check, dated [DATE] at 10:37p.m., indicated 1.5-inch skin tear to left upper eyebrow. During an interview on [DATE] at 11:15 a.m., Resident 5, who was Resident 3 ' s roommate and who was present when Resident 3 fell , stated on [DATE] at around 10 p.m., one staff (CNA 1) attempted to change Resident 3 ' s incontinent brief. Resident 5 stated the curtain between both beds was closed but she heard Resident 3 fall off the bed. Resident 5 stated the staff (CNA 1) rolled Resident 3 to change her incontinent brief. Resident 5 stated there was only one staff assisting Resident 3. Resident 5 stated Resident 3 ' s bed only had one upper small siderail and Resident 3 ' s bed was at the highest level. Resident 5 stated there were no landing mats (provide cushioned landing surface and reduce the likelihood of injury) next to Resident 3 ' s bed. Resident 5 stated Resident 3 fell on her face, near Resident 5 ' s bed. During an interview on [DATE] at 12:14 p.m. with CNA 1, CNA 1 stated that around 9:30 p.m., on [DATE] she was about to provide care to Resident 3, and while standing Resident 3 ' s right side, she elevated the resident ' s bed to the level of her waist high. CNA 1 stated she (CNA 1) was six feet tall and the bed may have been about three feet off the ground. CNA 1 stated Resident 3 was lying on her back and she rolled Resident 3 onto her left side, placed Resident 3 ' s hand on the handrail with CNA 1 ' s hands on Resident 3 ' s hip. CNA 1 stated she rolled the draw sheet under Resident 3, opened incontinent brief tab (undergarment designed to absorb urine and it can be fastened at the hip), took left hand off Resident 3 and Resident 3 let go of the handrail and fell face down. CNA 1 stated she did not request assistance from another staff before performing care and did not change the pressure on Resident 3 ' s LAL. CNA 1 stated Resident 3 ' s legs went off the bed causing her to fall to the floor. CNA 1 stated Resident 3 was on the floor, no noise or movement came from Resident 3. CNA 1 stated she ran out of the door and saw Licensed Vocational Nurse 1 (LVN 1) and yelled code blue. CNA 1 stated Resident 3 landed on her face and next to Resident 5 ' s bed. CNA 1 stated LVN 1 came into Resident 3 ' room and CNA 2 came into the room and moved Resident 3 ' s bed towards Resident 5 ' s bed. CNA 1 stated LVNs and RNs came into Resident 3 ' s room to assist and she was told Resident 3 had passed away. During an interview on [DATE] at 12:32 p.m., LVN 1 stated Resident 3 is bed-bound, alert and oriented to self (able to correctly identify self). LVN 1 stated that on [DATE] around 9:30 to 9:45p.m. she was passing out medications when CNA 1 came out running stating Resident 3 fell on the floor. LVN 1 stated she stopped what she was doing and ran into Resident 3 ' s room. Resident 3 ' s bed was pushed back but the bed was locked. Resident 3 was on the floor with the face down near Resident 5 ' s bed. LVN 1 stated there was no landing mat and Resident 3 was making a noise like she (Resident 3) was trying to breathe. LVN 1 stated she turned Resident 3 and noted Resident 3 with a cut on the left eyebrow with blood. LVN 1 stated Resident 3 ' s bed was too high, possibly three feet off the ground. LVN 1 stated Resident 3 was a hospice (a program that provides comprehensive support and care for terminally ill residents and their families) resident. LVN 1 stated no CPR was done and she tried to talk and arouse Resident 3 but nothing worked. LVN 1 stated RN 1 came in and 911 was called, paramedics arrived within 3 minutes and took over. LVN 1 stated Resident 3 required 2 or 3 staff depending on how small the staff was, for care. During an interview on [DATE] at 1:06p.m. with RN 1, RN 1 stated on [DATE] around 9:50 p.m. she was in station 2 and heard a yell from CNA 1 asking for help in Resident 3 ' s room. RN 1 stated he ran to Resident 3 ' s room and observed Resident 3 on the floor face down. RN 1 stated there was blood on the floor and LVN 1 placed pressure on Resident 3 ' s face because Resident 3 had a laceration to the left upper eyebrow. RN 1 stated 911 was called. During a concurrent interview and record review on [DATE] at 2:47 p.m., with Registered Nurse (RN 2), Resident 3 ' s MDS dated [DATE] and care plan for generalized weakness dated [DATE], were reviewed. RN 2 stated based on the MDS, Resident 3 needed 2-person assistance when providing care. RN 2 stated the care plan indicated Resident 3 required a one-person assist which was not accurate based on the MDS. RN 2 stated if MDS was not accurate, the plan of care will also not be accurate. RN 2 stated it placed the resident at risk of improper care. During an interview on [DATE] at 3:29 p.m., with the DON, the DON stated Resident 3 ' s care plan for generalized weakness did not correlate with the MDS dated [DATE] because the MDS indicated Resident 3 was dependent and/or needed two-person assist. The DON stated Resident 3 had left side paraplegic (unable to make voluntarily muscle movements). The DON stated Resident 3 would have benefited with a 2-person assistance due to Resident 3 ' s diagnosis of left side weakness. During an interview on [DATE] at 10:08a.m., CNA 1 stated Resident 3 had a LAL mattress, and it was on static mode. CNA 1 stated she was told not to touch the LAL mattress settings because it was set specifically per resident. CNA 1 stated she never called any nurse to change the LAL mattress settings because she was told not to touch it. CNA 1 stated has never had a nurse change the LAL mattress setting when doing care for Resident 3 since she was hired on [DATE]. During an interview on [DATE] at 10:13 a.m., LVN 1 stated Resident 3 had an LALM which was already set. LVN 1 stated one just needed to keep an eye on it to make sure the setting was correct, the mattress had no holes, and that it was plugged. LVN 1 stated during ADLs, the LALM setting did not need to be changed. During an interview on [DATE] at 10:48 a.m., Treatment Nurse 1 (TN 1) stated Resident 3 had a LAL mattress. TN 1 stated that when doing any ADL care, the LAL mattress setting must be changed into static mode so that it no longer alternates pressure and is firm to do ADL. TN 1 stated if LAL is not on static mode the LAL mattress will move and will inflate one side and deflate the other. TN 1 stated the LVNs and RNs were the ones who can change the setting from 300 lbs to static mode. TN 1 stated they would have to manually change it back to 300 lbs if placed on static mode. During a concurrent interview and record review on [DATE] at 3:14 p.m., Resident 3 ' s LALM 1 was reviewed. The DON stated when a resident was on LALM (in general), the static mode was used when the resident was being cared for. The DON stated for Resident 3, CNA 1 needed to request a LVN or RN to change the setting from 300 lbs to static mode. During a concurrent interview and record review on [DATE] at 3:14 p.m., Resident 3 ' s LALM 1 was reviewed. The DON stated when a resident was on LALM (in general), the static mode was used when the resident was being cared for. The DON stated for Resident 3, CNA 1 needed to request a LVN or RN to change the setting from 300 lbs to static mode. A review of Med Aire Plus 10 ' Alternating Pressure and Low Air Loss Bariatric Mattress Replacement System User Manual, indicated static button is available to discontinue alternation therapy for patient transfer, caregiving, comfort, or preference. Static mode is pressed to set the system to static therapy mode. The system will revert to the previous set alternation mode after 120 minutes. A review of the current facility-provided policy and procedure titled, Safety of Residents, with last revised date of [DATE] indicated to provide a safe environment for resident and facility staff.

Based on interview and record review, the facility to ensure one of three sampled residents (Resident 1), who was newly admitted to the facility, was diabetic (a group of diseases that affect how the body uses blood sugar [glucose]) and needed blood sugar level monitoring for insulin (preparation of the protein hormone insulin that is used to treat high blood glucose) administration, received care and treatment to meet Resident 1's needs. The facility failed to ensure: 1. Registered Nurse 1 (RN 1- admitting nurse) thoroughly reviewed the admission inquiry report and General Acute Care Hospital 1 (GACH 1) for Resident 1, during Resident 1's admission process to the facility. 2. RN 1 verified Resident 1's admitting diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . 3. Licensed nurses followed up with the pharmacy to ensure Resident 1's medications were delivered and administered timely. 4. Physician 1 was notified of the delay to administer Resident 1's medications including insulin. 5. Licensed nurse performed Resident 1's blood sugar check (measure the glucose levels in the blood) after Family Members 1 and 2 (FMs 1 and 2) alerted the licensed nursing that Resident 1's mental status had declined on [DATE]. 6. Notified Physician 1 and called 911 (the telephone number used to reach emergency medical, fire, and police services) that Resident 1's mental status had had declined per FMs 1 and 2. As a result: Resident 1's blood sugar level was not checked, and insulin was not given since her admission on [DATE] to [DATE]. On [DATE] at 11:58 p.m. Resident 1 was found unresponsive, not breathing and without a heartbeat. At 12 midnight, the paramedics (persons trained to give emergency medical care to people who are injured or ill, typically in a setting outside of a hospital) were called. At 12:16 (00:16 of [DATE]) paramedics pronounced Resident 1 dead. Because of the seriousness related to Resident 1 missed insulin, her blood sugar levels not measured, and the admitting physician not aware of Resident 1's admission, the facility staff not having competency to do a complete admission of Resident 1, on [DATE], at 6:20 p.m., the State Survey Agency (SSA) called an Immediate Jeopardy (IJ - a situation in which the facility's non-compliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death of a resident) under the 42 Code of Regulation (CRF) S483.25 Quality of Care (F684) with the scope and severity of J (isolated) in the presence of the facility's Administrator and Director of Nursing 1 (DON (1). On [DATE], at 3:00 p.m., after the facility provided an acceptable IJ Removal Plan (interventions to correct the deficient practice), while onsite, the team confirmed the implementation of the immediate corrective actions through observation, interview, and record review, the SSA removed the IJ situation in the presence of the Administrator and the DON 1. The IJ removal plan included the following: 1. Medical Records Director, Medical Records Assistant, QA (Quality Assurance) RN (registered Nurse), and Clinical Resource RN, initiated and completed an audit on [DATE] related to residents' admission records from the past 60 days for accuracy and complete physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. In-service training was initiated by the DON 1 and designee to all licensed nurses on [DATE] related to admission process including diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . 3.The Senior [NAME] President of Operations provided in-service to DON 1 and Administrator on admission criteria. 4. DON or designee will complete a review of the record of admissions and readmission to ensure orders were complete and verified by the attending physician. 5. The Medical Records Director or designee to conduct a record review on all new admissions and or re-admissions daily Monday thru Friday (M-F) for completion. 6. Interdisciplinary team (IDT- a group of dedicated healthcare professionals who work together to provide you with the care you need, when you need it) members to conduct a baseline conference meeting within 72 hours from admission. 7. The DON or designee to provide orientation training to all newly hired licensed nurses and registry (placement agency) prior to working independently on the floor with emphasis on admission process, pharmacy procedures, and communication with the attending physician. Findings: A review of GACH 1 Discharge Notes - Instructions (sent with the resident) dated [DATE], included a list of medications Resident 1 was receiving. The medications included insulin [MEDICATION(S)] ([MEDICATION(S)], long-acting [slowly absorbed after being administered, and maintains its effects over a long period of time]) insulin injection 20 mg/dL (milligrams per deciliter [unit of measurement] subcutaneously (under the skin) every night and insulin [MEDICATION(S)] ([MEDICATION(S)], short acting insulin) injection ,d+[DATE] mg/dL subcutaneously based on the result of the blood glucose test (using a glucose meter or glucometer, a medical device for determining the approximate concentration of glucose in the blood; a small drop of blood, obtained by pricking the skin with a lancet (a pointed piece of surgical steel encased in plastic, used to puncture the skin on one's finger), is placed on a disposable test strip that the meter reads) to be done before each meal and at hour of sleep (a total of four times a day). The specific dose of insulin based on blood glucose level (sliding scale) was not included in the transfer orders from GACH 1. The discharge instructions also indicated have someone call 911 if you have the following symptoms: Problems breathing or unable to breath, Feeling faint or become unresponsive . A review of Resident's 1 Admission Record (Face Sheet) indicated the facility admitted the resident, a [AGE] year-old female, on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 1 was at GACH 1 from [DATE] to [DATE]. Resident 1 was self-responsible and was admitted under the care of Physician 1. A review of Resident 1's undated Admission Report (report from GACH 1's nurse) indicated the resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 1 was incontinent (unable to control) of bladder and bowel functions, and was alert and oriented to self, place, date, and time. Resident 1's weight was 205 pounds; the last blood sugar level performed at GACH 1 before discharge was 216 milligrams per deciliters (mg/dL) and received four units of insulin (type of insulin was not specified) at GACH 1 (date and time not specified). Resident 1 was Full Code status (if the heart stopped beating and/or stopped breathing, all resuscitation procedures will be provided to keep them alive). Resident 1 was coming to the facility from GACH 1 with an estimated time of arrival was 6:45 p.m. (arrival date not indicated) A review of the Physician's Telephone Orders for Resident 1 dated [DATE] timed at 9:48 p.m. documented by RN 2 (facility's RN), indicated RN 2 verified the admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Progress Notes Post Admission Patient/Family Conference, dated [DATE], timed at 9:35 a.m., indicated the resident was admitted for a short-term stay (between 31 - 100 days) and would return home at previously living arrangement, with husband. The note did not address Resident 1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A review of Resident 1's nursing Progress Notes, dated [DATE], timed at 4:54 a.m. indicated at 11:58 p.m. (of [DATE]) Resident 1 was not breathing, was unresponsive, and did not have pulse (heartbeat). Resident 1 was Full Code (all efforts are attempted to keep a person someone alive if the heart stops beating and/or the person stops breathing) and a Code Blue (generally used to indicate a patient requiring resuscitation or otherwise in need of immediate medical attention). Cardiopulmonary resuscitation (CPR - an emergency procedure that can help save a person's life if their breathing or heart stops) was initiated. At 12 midnight paramedics were called. At 12:16 (00:16 of [DATE]) paramedics pronounced Resident 1 dead. A review of Resident 1's Certificate of Death dated [DATE], indicated Resident 1 died on [DATE] at 00:16 a.m. The immediate cause of death was acute (of sudden onset) on chronic hypercapnic (excessive amount of carbon [MEDICATION(S)] [CO2, a colorless, odorless gas waste product made by the body]) [CONDITION(S)]. Underlying cause were obesity hypoventilation syndrome (causes poor breathing in some people with obesity; it leads to lower oxygen and higher carbon [MEDICATION(S)] levels in the blood) and [CONDITION(S)]. On [DATE], at 12:52 p.m., during a telephone interview, FM 1 stated that on [DATE] morning, FM 2 had tried to call Resident 1 on her cell phone and did not get an answer. FM 1 contacted the facility to talk to Resident 1 and was told by a staff (FM 1 could not identify) they were too busy, and Resident 1 was fine. FM 1 stated FM 2 did not hear back from Resident 1 or the staff by 11:00 a.m. on [DATE], and so they (FMs 1 and 2) went to the facility to visit Resident 1 at around 3:00 p.m. FM 1 stated Resident 1 was slumped over to the side of the bed, was incoherent, was only able to answer questions one word at a time, and was sounding like a baby. FM 1 stated Resident 1 is usually able to converse and use the phone, so she went to the Nurses' Station and got Licensed Vocational Nurse1 (LVN 1) to go to Resident 1's room. FM 1 told LVN 1 that when Resident 1 gets like this sleepy we (FM 1 and FM 2) call 911. FMs 1 and 2 asked LVN 1 to call 911 (to send her to a hospital). LVN 1 took Resident 1's blood pressure and stated would call the physician. Both FMs 1 and 2 left the facility at approximately 4 p.m. FMs 1 and 2 continue to call Resident 1's cellphone with no answer. FM 1 stated after midnight FM 2 received a telephone call from the facility that Resident 1 died . FM 1 stated Resident 1 did not get her medications for two days (from admission and staff let her die. She did not deserve to die FM 1 stated crying very loudly. On [DATE], at 1:30 p.m., during a telephone interview, LVN 1 stated FM 1 went to the facility on [DATE] at 3:00 p.m., towards the end of my shift concerned about Resident 1 sleeping a lot and wanted her (LVN 1) to call 911. LVN 1 stated both her and LVN 4 checked the resident's vital signs (blood pressure, oxygen saturation and breathing rate) and the vital signs were stable. LVN 1 stated Resident 1 was sleeping, but easy to arouse. LVN 1 stated she reported FM 1's concern to RN 1 who went to assess Resident 1. LVN 1 stated she went home at 4 p.m. On [DATE], at 2:28 p.m., during a telephone interview, LVN 4 verified LVN 1's recollection of the events on [DATE]. LVN 4 stated Resident 1 was awake and able to answer yes and no questions. On [DATE], at 2:56 p.m., during a telephone interview, Physician 1 stated he did not receive any communication related to Resident 1's admission or change of condition. Physician 1 stated he did not have Resident 1 under his care. On [DATE], at 8:21 a.m., during a telephone interview, DON 1 stated the admitting nurse should have informed Physician 1 about Resident 1's diabetes diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE], at 1:05 p.m., during a telephone interview, RN 1 stated on [DATE], she texted Physician 1 from her personal cellphone about Resident 1 been admitted at the facility, but she had deleted the text message. On [DATE] at 2:43 p.m., during a telephone interview, RN 1 (who was from a registry [agency that provides temporary staff]) and not the facility's employee) stated she worked double shift (7 a.m. to 3 p.m. and 3 p.m. to 11 p.m.) on [DATE] and [DATE]. RN 1 stated RN 2 (facility's RN) assisted with Resident 1's admission on [DATE] because it was one hour before her (RN 1) shift ended. When RN 1 was asked about Resident 1 diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . RN 1 did not remember if she or RN 2 faxed any documents to Physician 1 or if Resident 1 was diabetic, required accuchecks, and or required insulin. RN 1 stated it was very important to check a resident's blood sugar and or administer insulin because a diabetic resident could develop altered mental status, [CONDITION(S)] (low blood sugar) or [CONDITION(S)] (high blood sugar), and the resident could die. On [DATE] at 3:47 pm, during a telephone interview, the Medical Records Director (MRD) stated he performs resident chart audit the day after admission and provides the audit report to the Quality Assurance (QA) nurse to follow up. The MRD stated he audited Resident 1's medical records on [DATE] and identified the admitting nurse's signature was missing on unidentified consent form and discrepancies with four medications that included [MEDICATION(S)] (medication to treat low blood pressure), [MEDICATION(S)] (medication to treat inflammations [localized swelling, hot, painful, and or red), Methyl solumedrol (medication to treat inflammations), [MEDICATION(S)] (medication to treat high blood pressure)but did not notice any insulin medication or diabetes diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] On [DATE] at 3:57 p.m., during a telephone interview, the QA nurse she was hired on ,d+[DATE] and was probably on orientation when Resident 1 was admitted . A review the facility's policy and procedures titled, Physician/Advanced Practice Provider (APP) Notification. revised on [DATE], indicated upon identification of a patient who has a change of condition a licensed nurse will perform appropriate clinical observations, report to the physician/APP. If unable to contact attending the physician/APP, the medical director will be contacted. A review of the facility's policy and procedures titled, Change in Condition: Notification, dated [DATE], indicated the facility must immediately inform the resident, consult with the resident's physician and/or nurse practitioner (NP), and notify, consistent with his/her authority, the resident's representative when there is a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental or psychosocial status in either life-threatening conditions or clinical complications). A review of the facility's policy and procedures titled, Utilization of Outside Resources During an Emergency, revised on [DATE], indicated the purpose was to ensure competent staff is available to provide safe and adequate care, treatment and services to patients during an emergency. A review of the facility's policy and procedures titled, Physicians Orders, dated [DATE], indicated all physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order is transcribed onto the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), who was newly admitted to the facility and needed a [CONDITION(S)] machine (Bi [two] Level Positive Airway Pressure - also called positive pressure ventilation, a device designed to help push air into the lungs for people who have trouble breathing; a mask or nasal plugs are connected to the machine) due to chronic obstructive respiratory disease ([CONDITION(S)], a group of diseases that cause airflow blockage and breathing-related problems), received the respiratory care needed to meet her needs. The facility failed to: 1. Ensure all licensed nurses were trained and competent to safely operate the [CONDITION(S)] machine before Resident 1 was admitted to the facility on [DATE]. 2. Ensure Resident 1's respiratory status was monitored while on the [CONDITION(S)] machine. 3. Ensure Resident 1's attending Physician (Physician 1) was contacted to verify the [CONDITION(S)] order upon arrival from General Acute Care Hospital 1 (GACH 1) including information about the amount of oxygen, if needed, to be administrated while on the [CONDITION(S)] machine and monitoring of Resident 1's respiratory status while on the machine. As a result, Resident 1 was not provided with appropriate [CONDITION(S)] therapy and on [DATE] at 11:58 p.m. Resident 1 was found unresponsive, not breathing and without heartbeats. At 12 midnight paramedics (persons trained to give emergency medical care to people who are injured or ill, typically in a setting outside of a hospital) were called. At 12:16 (00:16 of [DATE]) paramedics pronounced Resident 1 dead. Because of the seriousness related to Resident 1 needed respiratory care not met, the admitting physician not aware of Resident 1's admission to give orders and direct the care of Resident 1, the facility's licensed nursing staff not limited to Director of Nurses 2 (DON 2), Registered Nurse 1 (RN 1), Vocational Licensed Nurse 1 (LVN 1), LVN 2, LVN 3, not having the skill sets/competency to provide care to Resident 1 on [CONDITION(S)] therapy, on [DATE], at 6:20 p.m., the State Survey Agency (SSA) called an Immediate Jeopardy (IJ - a situation in which the facility's non-compliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death of a resident) under the 42 Code of Regulation (CRF) S483.25 (i) Respiratory Care (F695) with the scope and severity of J (isolated) in the presence of the facility's Administrator and Director of Nursing 1 (DON 1). On [DATE], at 3 p.m., after the facility provided an acceptable IJ Removal Plan (interventions to correct the deficient practice), while onsite, the team confirmed the implementation of the immediate corrective actions through observation, interview, and record review, the SSA removed the IJ situation in the presence of the Administrator and the DON 1. The IJ removal plan included the following: 1. Medical Records Director, Medical Records Assistant, QA (Quality Assurance) RN, and Clinical Resource RN, initiated and completed an audit on [DATE] related to residents' admission records from the past 60 days for accuracy of treatments with special medical equipment such as [CONDITION(S)] and oxygen therapy, medication list from GACH. 2. In-service training was initiated by the DON 1 and designee to all licensed nurses on [DATE] related to admission process. 3.The Senior [NAME] President of Operations provided in-service to DON 1 and Administrator on admission criteria on [DATE]. 4. DON or designee will complete a review of the record of admissions and readmission to ensure orders were complete and verified by the attending physician and competency of staff in special treatment orders. 5. The Medical Records Director or designee will conduct a record review on all new admissions and or re-admissions daily Monday thru Friday (M-F) for completion. 6. Interdisciplinary team (IDT) members to conduct a baseline conference meeting within 72 hours from admission. 7. The DON or designee to provide orientation training to all newly hired licensed nurses and registry (placement agency) prior to working independently on the floor with emphasis on admission process and how to care for a resident on [CONDITION(S)] therapy. Findings: A review of the facility's Quick Check Inquiry Form (the facility uses to obtain information about a prospective resident prior to placement), dated [DATE], with the information from GACH 1, indicated Resident 1 was on a [CONDITION(S)] machine. A review of GACH 1 Discharge Progress Notes (sent with Resident 1 to the facility), dated [DATE], indicated the resident was in stable condition and waiting for the [CONDITION(S)] machine to be sent to the facility (with the resident). A review of GACH 1 Discharge Notes - Instructions included a list of medications Resident 1 needed and the Daily Progress Note, dated [DATE], timed at 11:49 a.m., indicated Resident 1 was on 40% FiO2 (fraction of inspired air; it is the concentration of oxygen in the gas mixture. The gas mixture at room air has a FiO2 of 21%). There were no specific instructions about the use of the [CONDITION(S)] for Resident 1. A review of Resident's 1 Admission Record (Face Sheet) indicated the facility admitted the resident, a [AGE] year-old female, on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 1 was at GACH 1 from [DATE] to [DATE]. Resident 1 was self-responsible and was admitted under the care of Physician 1. A review of Resident 1's Admission Report (report received from GACH 1's nurse) indicated the resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 1 was incontinent (unable to control) of bladder and bowel functions, and was alert and oriented to self, place, date, and time. Resident 1's weight was 205 pounds. Resident 1 was Full Code status (if the heart stopped beating and/or stopped breathing, all resuscitation procedures will be provided to keep them alive), had a [CONDITION(S)] in the room and oxygen (O2) at 4 liters per minute (L/min). Resident 1 was coming to the facility from GACH 1 with an estimated time of arrival was 6:45 p.m. and date not indicated. A review of the Physician's Telephone Orders for Resident 1 dated [DATE] timed at 9:48 p.m. documented by RN 2 indicated RN 2 verified the admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . However, the [CONDITION(S)] orders indicated I (inspiratory - breath in) = ____ (left blank -no number/figure indicated) and E (expiratory - breath out) = ____ (left blank- no number/figure indicated). A review of Resident 1's Progress Notes Post Admission Patient/Family Conference, dated [DATE], timed at 9:35 a.m., indicated the resident was admitted for a short-term stay (between 31 - 100 days) and would return home at previously living arrangement, with husband. A review of Resident 1's nursing Progress Notes dated [DATE], timed at 00:37 a.m., a late entry documented by LVN 3 for [DATE] at 3:00 p.m. to 11:00 p.m. shift, indicated Resident 1 was received in bed at 8 p.m. (on [DATE]) on O2 at 4 L/min via nasal cannula (a lightweight flexible tube which on one end splits into two prongs which are placed in the nostrils to deliver supplemental O2). The [CONDITION(S)] machine was in place at 10 p.m. LVN 3 did not document an evaluation of Resident 1's breathing condition, breathing sounds, O2 saturation, if the [CONDITION(S)] was turned on and connected to the O2, the amount of O2 flowing through the [CONDITION(S)] machine, or the [CONDITION(S)] machine settings. A review of Resident 1's nursing Progress Notes, dated [DATE], timed at 4:54 a.m. indicated at 11:20 p.m. (of [DATE]) Resident 1's [CONDITION(S)] was secured and in place, the O2 saturation was 97% (the normal range is above 92%) with the [CONDITION(S)] machine on. The note did not include if the O2 was connected to the [CONDITION(S)] machine and the [CONDITION(S)] settings. At 11:58 p.m. (of [DATE]) Resident 1 was not breathing, was unresponsive, and did not have pulse (heartbeat). Resident 1 was Full Code and a Code Blue (generally used to indicate a patient requiring resuscitation or otherwise in need of immediate medical attention). Cardiopulmonary resuscitation (CPR - an emergency procedure that can help save a person's life if their breathing or heart stops) was initiated. At 12 midnight paramedics were called. At 12:16 (00:16 of [DATE]) paramedics pronounced Resident 1 dead. A review of Resident 1's Certificate of Death indicated Resident 1 died on [DATE] at 00:16 a.m. The immediate cause of death was acute on chronic hypercapnic (excessive amount of carbon [MEDICATION(S)] [CO2, a colorless, odorless gas waste product made by the body]) respiratory failure. Underlying cause were obesity hypoventilation syndrome (causes poor breathing in some people with obesity; it leads to lower oxygen and higher carbon [MEDICATION(S)] levels in the blood) and [CONDITION(S)]. On [DATE], at 1:19 p.m., during an interview, LVN 1 stated she did not receive any training on how to operate or set up a [CONDITION(S)] machine. LVN 1 stated she could not identify if a [CONDITION(S)] machine was functioning correctly and did not know its indications and when to stop a [CONDITION(S)] therapy. On [DATE], at 2:23 p.m., during an interview, RN 1 (from a nursing agency or registry) stated on [DATE], an outside vendor delivered Resident 1's [CONDITION(S)] machine, set it up, and did not provide instructions on how to operate it. RN 1 stated she had not received any training on the use and settings of a [CONDITION(S)] machine. RN 1 stated the facility did not have a Respiratory Therapist (RT - a certified medical professional who provides relief to those who have difficulty breathing or cannot breathe on their own due to impaired or non-functioning lungs including include oxygen therapy and breathing treatments). On [DATE], at 8:58 a.m., during a telephone interview, LVN 2 stated he did not know how to use and operate a [CONDITION(S)], had never been inserviced on how to operate/use a [CONDITION(S)] machine, and all he had to do is turn in ([CONDITION(S)] machine) on. On [DATE], at 9:15 a.m., during a telephone interview, RN 2 stated on [DATE] a vendor delivered and set up Resident 1's [CONDITION(S)]. RN 2 stated she assisted RN 1 during Resident 1's admission to the facility in the evening of [DATE]. RN 2 stated she did not see an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE], at 9:32 a.m., during a telephone interview, Director of Nursing 1 (DON 1) stated she would not admit a resident who required [CONDITION(S)] therapy without an RT in the facility. DON 1 stated the facility did not have the [CONDITION(S)] manufacturer's manual for the staff to refer to. DON 1 stated the facility did not have a policy on [CONDITION(S)] use. On [DATE], at 10:15 a.m., during an interview, DON 1 stated licensed nurses did not receive [CONDITION(S)] training before ,d+[DATE] and should have been trained before admitting Resident 1. DON 1 stated she was unable to locate any documented evidence that the facility provided [CONDITION(S)] training to staff before, during, or after Resident 1 was admitted . On [DATE], at 10:16 a.m., during an interview, DON 1 stated licensed nurses must obtain a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE], at 11:00 a.m., during an interview, Family Member 2 (FM 2) stated when Resident 1's CO2 (carbon [MEDICATION(S)]) goes up, Resident 1 would become very groggy and sleepy requiring emergency services. On [DATE], at 7:25 a.m., during a telephone interview, RN 3 stated he would trouble shoot the [CONDITION(S)] machine by turning it on and off and reading the manual which should be at Resident 1's bedside. RN 3 stated that approximately 30 minutes into his shift (11 p.m. to 7 a.m.), he heard a nurse scream that Resident 1 was not breathing. RN 3 state he assisted with doing CPR to Resident 1. On [DATE], at 4:02 p.m., during a telephone interview, RN 5 (from a registry) stated the staffing agency did not provide any training to licensed nurses and that it was up to the facility to ensure licensed staff were competent in anticipated tasks. On [DATE], at 4:22 p.m., during a telephone interview, RN 1 (from a registry) stated she worked at the facility as an RN Supervisor. RN 1 stated the former DON did a walk through [CONDITION(S)] orientation upon hire. RN 1 stated on [DATE], a technician delivered the [CONDITION(S)] for Resident 1 and did not give instructions on its use. On [DATE], at 12:49 p.m., during a telephone interview, DON 2 stated she reviewed Resident 1's admission inquiry, accepted for Resident 1 to be admitted , but did not provide training to the licensed nurse on the use of a [CONDITION(S)] machine. On [DATE] at 8:56 a.m., during a telephone interview, RN 3 (facility's RN) stated LVN 3 told him that she had just passed her RN/NCLEX (Registered Nurse/National Council Licensure Examination) (licensing) exam. RN 3 stated that he reported to work on [DATE] at 11:20 p.m. and observed Resident 1 in bed on a [CONDITION(S)]. RN 3 stated the [CONDITION(S)] mask covered Resident 1's face completely and the resident was sleeping and looked weak. introduced himself to Resident 1 who nodded but did not talk. RN 3 stated he recorded Resident 1's vitals (blood pressure, pulse, respirations, O2 saturation, and temperature). RN 3 stated Resident 3 did not talk or move while RN 3 was recording the Resident 1's vitals. RN 3 further stated the [CONDITION(S)] machine was functioning well, was attached to Resident 1, and the lights were on for the [CONDITION(S)] machine. RN 3 did not mention if he assessed Resident 1's lung sounds or if oxygen was connected to the [CONDITION(S)] machine. RN 3 stated the facility seldom got residents on [CONDITION(S)] therapy. RN 3 stated Resident 1 had an oxygen concentrator at the bed. RN 1 stated 30 minutes into his shift he heard a nurse scream that Resident 1 was not breathing. On [DATE] at 9:31 a.m., the Operations Manager (OM - [CONDITION(S)] machine supplier) stated in some cases, oxygen is connected to the [CONDITION(S)] if needed and this will depend on the doctor's order. The facility is responsible to ensure staff competency on the use of the [CONDITION(S)] machine. The OM stated the physician ordering a [CONDITION(S)] machine will include in the order the settings which an RT sets before the [CONDITION(S)] machine is delivered to a facility. On [DATE] at 10:09 a.m., during a telephone interview, LVN 3 stated she passed NCLEX RN exam on ,d+[DATE] LVN 3 stated she applied the [CONDITION(S)] on Resident 1 on [DATE] at 9 p.m. LVN 3 stated, the [CONDITION(S)] mask covered Resident 1's nose and the mouth. LVN 3 stated she checked Resident 1's blood pressure, pulse, O2 saturation, and respirations to make sure she was stable. LVN 3 stated she could not recall if she received [CONDITION(S)] training. LVN 3 stated Resident 1 was on 4 L/min (liters per minute) of oxygen via nasal cannula and she attached the O2 to the [CONDITION(S)] machine and applied it on Resident 1. LVN 3 stated the [CONDITION(S)] machine was delivered to the facility already preset and before Resident 1 arrived in the facility. LVN 3 stated Resident 1 coded (unresponsive) at 11:58 p.m. on [DATE]. On [DATE], at 9:06 a.m., during a telephone interview, MD 2 (pulmonologist [lung doctor] who cared for Resident 1 at GACH 1) stated he did not know the facility's licensed nurses were not trained or competent to provide care to a resident on [CONDITION(S)] therapy. MD 2 further stated the facility should not have accepted the admission of Resident 1. MD 2 stated he did not know the facility's licensed nurses did not communicate with Physician 1 when Resident 1 arrived at the facility. On [DATE] at 2:43 p.m., during a telephone interview, RN 1 (who was from a registry and not the facility's employee) stated she worked double shift (7 a.m. to 3 p.m. and 3 p.m. to 11 p.m.) on [DATE] and [DATE] an that Resident 1 was on the [CONDITION(S)] machine on both evenings ([DATE] and [DATE]). RN 1 stated she did not remember who applied the [CONDITION(S)] machine on Resident 1. A review of the undated facility's in-service training lesson plan titled, '[CONDITION(S)]/[CONDITION(S)] (continuous positive airway pressure)/COC (change of condition). The facility's inservice staff attendance sheet indicated DON 1 provided the inservice on [DATE] and [DATE]. The inservice lesson plan included the following topics: 1. After the in-service, the participants will understand the expectations required. 2. Define what a [CONDITION(S)]/[CONDITION(S)] is for. 3. Monitor resident and how often to document. 4. Name ways to monitor for change of condition 5. What following conditions need to be met to permit [CONDITION(S)]/[CONDITION(S)]. The lesson plan objectives included monitoring airway breathing, LOC (level of consciousness), breathing pattern and rate, pulse oximetry, compliance, and comfort with therapy. A review of the facility's policy and procedures titled, Admission Criteria: Clinical revised on [DATE], indicated in the Practice Standards if the employee handling the referral identifies a patient with clinical conditions not on the Center clinical capabilities list, the employee will discuss the referral with the DON or designee prior to acceptance. A review of the facility's policy and procedures titled, Bi level Positive Airway ([CONDITION(S)])/Continuous Positive Airway Pressure ([CONDITION(S)]) revised [DATE], indicated the machine is set up and monitored by a licensed nurse or respiratory therapist with a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . If being used as a non- invasive device, it may be used in all modes - [CONDITION(S)] . in a non-ventilator setting where staff have received the required training and respiratory health services (RHS) is available. The set up and settings is maintained by a RT but may be monitored by a licensed nurse. A review of the manufacturer's undated [CONDITION(S)] User Guide indicated the following: Adverse Effects: . Unusual chest pain, severe headache, or increased breathless . Caution: 2. Plug the power connector into the rear of the device. Connect one end of the power cord into the power supply unit and the other end into power outlet 6. Connect the free end of the tubing firmly onto assemble mask . Starting Therapy: 2. Press start/stop or breathe normally if SmartStart (therapy starts automatically when a person breathe into the mask) is enabled. You will know that therapy is on when the Sleep Report is displayed .

Based on observation, interview, and record review the facility failed to ensure residents ' safety through effective monitoring, supervision, assessment, and reassessments for three of three sampled residents (Resident 1, Resident 2, and Resident 3), who the facility permitted to go out on pass (OOP) on multiple occasions by failing to: 1. Obtain a Physician ' s Order for residents to go Out on Pass (OOP) under the supervision of a facility staff member. Resident 1 who had moderately impaired cognition (a decline in mental ability to make decisions of daily living), had diagnoses that included psychoactive substance abuse (dependence on substances that, when taken in or administered into one's system, affect mental processes, e.g. perception, consciousness, cognition or mood and emotions), non-pressure chronic ulcer (an open sore caused by poor blood flow) of the left foot and right foot, generalized muscle weakness, and lack of coordination (prevents people from being able to control the position of their arms and legs or their posture), Resident 2 and Resident 3 who had both diagnoses including Type 2 diabetes, muscle weakness, lack of coordination (uncoordinated movement), and unsteadiness on feet were permitted to leave the facility to go OOP on several occasions without a physician order. 2. Ensure the facility ' s designee checked/verified if Residents 1, 2, and 3, had physician ' s order to go OOP prior to the residents signing out and leaving on OOP. 3. Ensure the licensed nurses assessed residents ' physical and mental status prior to the residents leaving on OOP and re-assessed residents ' physical and mental condition, upon return to the facility according to the facility ' s policy and procedures titled Out on Pass. Residents 1, 2, and 3 did not have documented nursing assessment prior to leaving OOP and upon return to the facility. 4. Ensure resident(s) going on OOP, signed out and signed in on the facility ' s Resident Out on Pass Log in accordance with facility ' s policy and procedures. As a result, Resident 1 left the faciity on OOP without a physician ' s order on [DATE] at 3:53 p.m. and was found dead 10.8 miles away from the facility on [DATE] at 6:34 p.m. These deficient practices also had the potential for injuries, accidents, and or death for Residents 2 and 3 and other residents who left the faciity on OOP. On [DATE] at 6:20 p.m., the State Survey Agency (SSA) called an Immediate Jeopardy (IJ-a situation in which the facility's non-compliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death of a resident). The facility failed to not have a system in place to verify physicians ' orders, to ensure residents ' safety through effective monitoring, assessment, and reassessment for Residents 1, 2, and 3 and other residents ' who left the faciity on and returned from OOP according to the facility ' s OOP policy and procedures. Resident 1 exited the facility on [DATE], was found collapsed and lifeless on the street. Resident 1 died on [DATE]. On [DATE] at 5:15 p.m., the IJ was removed after the Administrator (ADM) and the Director of Nursing (DON) submitted an acceptable removal plan (interventions to correct the deficient practices) which was verified and confirmed through observation, interview, and record review. The acceptable removal plan was as follows: 1. An Out on Pass (OOP) audit was completed on [DATE] by the Medical Records Designee who identified six residents with no physician orders for OOP. The six residents identified were re-assessed by a licensed nurse for safety needs specific to cognition (mental ability to make decisions of daily living), clinical diagnosis, functional mobility (capacity of people to move from one place to another, to participate in the activities of daily living), and any devices need on [DATE]. A physician order was obtained that a resident may go out on pass for four hours or as specified by the physician on [DATE]. 2. A re-evaluation for out on pass was completed for Residents 2 and 3 by a licensed nurse on [DATE] specific to cognition, clinical diagnosis, functional mobility, and any devices need. 3. The Regional Resource Nurse completed a facility wide audit review on [DATE] specific to residents out on pass obtaining necessary orders which indicated may go out for four hours from the attending physician and updated plan of care related to the Out on Pass. 4. The Senior Vice President of Clinical Operations provided an in-service training regarding Out on Pass specific to facility ' s policy and procedures to the Department Managers (Administrator, Director of Nursing, Business Office Manager, Maintenance, Activity, Dietary Manager, Social Service Designee, Quality Assurance Nurse, Payroll, Case Manager and Administrator in Training) on [DATE]. 5. The Administrator in Training and Regional Nurse Resource initiated and provided an in-service training regarding Out on Pass procedures and processes to Licensed Nurses and Certified Nursing Assistants (CNA) on [DATE] and [DATE]. 6. The Administrator and or designee reviewed and revised OOP log and leave of Absence Form on [DATE]. 7. Interdisciplinary team (IDT- team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) conducted a review and re-evaluation to residents with out on pass order Independently on [DATE] specific to risk such as accidents/Incidents leading to injuries up to potential death and safety surrounding current conditions, cognitions, medications, devices and or any special needs necessary for resident wellbeing while on Out on Pass. 8. Any residents newly admitted and or readmitted would be reviewed by the IDT team for any potential out on pass order and will collaborate with their respective physicians for an order of may go out on pass for four hours and or as specified by the physician. The physician order will be printed out and attached to the Out on pass log /Leave of Absence form to verify resident clearance upon signing out by the receptionist and or designee. 9. Any residents/ and or family/Responsible party that wish to have an out on pass privilege will be reviewed and discussed by the IDT team to re-evaluate safety risk and needs necessary while out on pass. 10. Licensed Nurse and or designee will inform the attending physician if a resident wishes to go out on pass despite not being allowed to go out on pass per physician ' s order. The physician will attempt to talk to the resident and discuss safety risk of going out on pass and or Leave of Absence. 11. The Social Service Designee, Director of Nursing and or designee will conduct a review on resident Out on pass (OOP) list log, to validate necessary required documentation was in place in the resident clinical record such as physician order of out on pass/Leave of absence, licensed nurse assessment on physical and mental status including care plans, out on pass /Leave of absence form weekly and as needed. The out on pass resident list log will be provided to the nursing stations and communicated during huddle rounds on every shift. 12. The Director of Nursing (DON) and Interdisciplinary team (IDT) will review residents changed of conditions with out on pass order privileges during clinical meeting daily from Monday to Friday to re-evaluate the need of continuous OOP order. Any safety risk identified will be communicated to the resident ' s attending physician by the end of the shift. 13. The Director of Staff development (DSD) and or designee will provide education training to nursing staff and non-nursing staff related to out on pass procedures per policy upon new hire, annually and as needed which includes validation of skills competency through return demonstration or verbalization of the out on pass procedures. Findings: a. A review of Resident 1 ' s Admission Records (Face Sheet), indicated the facility admitted Resident 1 on [DATE] with diagnoses including Type 2 diabetes mellitus (impairment in the way the body regulates and uses sugar as a fuel), psychoactive substance abuse (dependence on substances that, when taken in or administered into one's system, affect mental processes, e.g. perception, consciousness, cognition or mood and emotions), non-pressure chronic ulcer (an open sore caused by poor blood flow) of the left foot and right foot, generalized muscle weakness, and lack of coordination (prevents people from being able to control the position of their arms and legs or their posture). A review of Resident 1 ' s Minimum Data Set (MDS- a standardized assessment and care-screening tool) dated [DATE], indicated Resident 1 had moderately impaired cognition (mental ability to make decisions of daily living). Resident 1 was one person assist for most activities including: bed mobility, transfer, walking in room, walking in corridor, locomotion on/off unit, dressing, toileting, and personal hygiene. Resident 1 normally used wheelchair or walker for assistance with mobility. A review of Resident 1 ' s care plan titled At risk for Decreased ability to perform ADLs (Activities of daily living related to personal care, including bathing, or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating) dated [DATE], indicated Resident 1 was at risk for decreased ability to perform function mobility tasks including: bathing, grooming/personal hygiene, dressing, bed mobility, transfer, locomotion, and toileting related to impaired balance due to resident ' s foot ulcer. A review of Resident 1 ' s care plan titled At risk for Impaired/decline in cognitive function dated [DATE], indicated Resident 1 was at risk for impaired thought processes, and impaired decision making related to Resident 1 ' s substance use disorder. The goal included Resident 1 would make daily decisions/choices when provided with appropriate level cues and supervision, by the next review date. Interventions included to observe and evaluate changes in cognitive status and notify the physician as needed. A review of Resident 1 ' s care plan titled At risk for falls dated [DATE], indicated Resident 1 was at risk for falls due to Resident 1 ' s impaired mobility. The goal included Resident 1 would have no falls with injury times 90 days. Interventions included to provide Resident 1 with opportunities for choice, bed in low position, and provide resident/caregiver education for safe techniques (including when to use call light). On [DATE] at 12:37 p.m., during a concurrent interview and record review, the surveyor and the DON reviewed Resident 1 ' s Physician order Summary Report dated [DATE]. The Director of Nursing (DON) verified and stated Resident 1 did not have a physician ' s order to go OOP. A review of the facility ' s form titled Release of Responsibility for Leave of Absence dated from [DATE] to [DATE], indicated a signing Out date, time, signature of person accepting responsibility, anticipated return date and time, signing In date, time and signature of person accepting responsibility. Resident 1 had three incomplete entries on two separate forms as follows: a. Sign out date, time, anticipated date, and time was blank and Sign In on [DATE] at 7:34 p.m. b. Sign out on [DATE] at 3:07 p.m., anticipated date, time and, signing In date, time and signature was blank c. Sign out on [DATE] at 3:53 pm, anticipated date, time and, signing In date, time and signature was blank On [DATE] at 12:38 p.m., during a concurrent interview and record review, the surveyor and the DON reviewed Resident 1 ' s Medical chart. The DON stated there was no documentation of Resident 1 ' s communication with nursing prior to Resident 1 leaving OOP on [DATE], [DATE], and [DATE]. The DON confirmed and stated, Resident 1 did not have documented nursing assessment prior to leaving on OOP, and reassessment when Resident 1 returned to the facility on : [DATE], [DATE]; and [DATE]. On [DATE] at 12:39 p.m., during concurrent interview and record review, the surveyor and the DON reviewed the facility ' s Policy & Procedures (P&P) titled Out on Pass, dated [DATE]. The DON read and stated, If the resident ' s attending physician or psychiatrist (a medical practitioner specializing in the diagnosis and treatment of mental illness) determine that the resident may participate in activities outside the facility, the Attending Physician will write an order for resident to go out on pass. The DON verified and stated the facility did not comply with its OOP P&P by obtaining a physician ' s order before Resident 1 left the facility OOP. On [DATE] at 1:16 p.m. during a telephone interview, Staff 1 stated Resident 1 frequently went OOP. Staff 1 stated Resident 1 went OOP almost every day for the week of [DATE] through [DATE]: and for the week of [DATE] through [DATE]. Staff 1 stated Resident 1 would go OOP at 3:30 p.m. and return at around 9:00 p.m. Staff 1 stated, Resident 1 signed himself out. Staff 1 stated the Out on Pass Logbook sits there on the front reception desk and residents can just Sign Out and Sign In themselves. Staff 1 stated the physician ' s order for OOP was not checked when Resident 1 signed out for OOP. On [DATE] at 1:33 p.m., during concurrent interview and record review, the surveyor and the DON reviewed Resident 1 ' s OOP form entries dated [DATE] and [DATE]. The DON visually verified, confirmed, and stated there was no ' Anticipated Return information written by Resident 1. The DON further confirmed Resident 1 did not document ' Sign Out ' information on the OOP form on [DATE] and that the OOP forms were incomplete. On [DATE] at 2:17 p.m., during a concurrent interview and record review, the surveyor and the Administrator reviewed Resident 1 ' s physician ' s orders dated [DATE]. The Administrator verified and stated there is no out on pass order for Resident 1. The facility ' s OOP policy and procedures dated [DATE]was also reviewed. The Administrator stated Resident 1 should not have been allowed to leave the facility on OOP. The Administrator stated the facility was not compliant with its OOP policy and procedure by letting Resident went OOP. On [DATE] at 9:15 a.m. during a concurrent interview and internet search, the surveyor and the DON searched Google Maps. The DON calculated the distance from the facility to where Resident 1 was found was 10.8 miles. The DON acknowledged and stated, That is a far distance given the timeframe. A lengthy period for a resident to be unsupervised walking outside. The DON stated the facility noticed Resident 1 was absent from the facility on [DATE] from 3:53 p.m. to 6:26 p.m. On [DATE] at 4:36 p.m. during a concurrent interview and record review, the surveyor, the DON, and Administrator in Training (AIT) reviewed all of Resident 1 ' s care plans. The DON confirmed and stated Resident 1 did not have Care Plan(s) in place (medical records) for OOP or leave of absence (LOA). On [DATE] at 1:35 p.m., during an interview, Resident 1 ' s primary Physician stated licensed nurses should conduct physical and mental sound (thorough) assessment before residents can go OOP. The primary Physician confirmed and stated Resident 1 must have a verbal or written doctor ' s order before going OOP. A review of the facility ' s report incident for Unusual Occurrence dated [DATE], indicated Resident 1 signed a Release of Responsibilities for Leave of Absence form to go OOP on [DATE] at 3:53 p.m. However, Resident did not have a physician ' s order to go OOP. The report further indicated that at around 6:26 p.m. on [DATE], the DON received a telephone call from an unknown caller who stated that a resident had collapsed on the street and was lifeless. The report further indicated coroner's (an official who investigates violent, sudden, or suspicious deaths) office called (contacted) the facility and informed the DON that Resident 1 had passed away (died ) on [DATE] at 6:34 p.m. b. A review of Resident 2 ' s Admission Record indicated the facility admitted Resident 2 on [DATE] from a General Acute Care Hospital (GACH), with diagnoses including Type 2 diabetes, muscle weakness, lack of coordination, unsteadiness on feet, [CONDITION(S)] (PVD- a blood circulation disorder that causes the blood vessels outside of your heart and brain to narrow, block, or spasm), and non-pressure chronic ulcer (an open sore caused by poor blood flow) of the left foot. A review of Resident 2 ' s MDS dated [DATE], indicated Resident 2 was cognitively intact. Resident 2 required one person assist with dressing, toilet use and personal hygiene, and required a walker to ambulate (walk). A review or Resident 2 ' s Physician order Summary Report dated from [DATE] through [DATE], indicated the OOP order was discontinued (stopped) on [DATE]. A review of the facility form titled Release of Responsibility for Leave of Absence for Resident 2 dated from [DATE] through [DATE], indicated Resident 2 signed OOP 19 times on: [DATE] at 8:16 a.m. [DATE] at 9:48 a.m. [DATE] at 9:00 a.m. [DATE] at 9:00 a.m. [DATE] at 7:56 a.m. [DATE] at 8:00 a.m. [DATE] at 11:00 a.m. [DATE] at 1:00 p.m. [DATE] at 10:00 a.m. [DATE] at 9:00 a.m. [DATE] at 1:00 p.m. [DATE] at 1:00 p.m.[DATE] at 1:00 p.m. [DATE] at 8:00 a.m. [DATE] at 11:30 a.m. [DATE] at 9:00 a.m. [DATE] at 8:00 a.m. [DATE] at 8:00 a.m. [DATE] at 8:00 a.m. A review of Resident 2 ' s Active Physician Order, dated [DATE], indicated Resident 2 may go out on pass up to four hours as needed for therapeutic purposes. On [DATE] at 12:38 p.m., during concurrent interview and record review, the surveyor and the DON reviewed Resident 2 ' s Medical Records. The DON stated there were no documented communication with nursing prior to Resident 2 leaving on OOP in Resident 2 ' s Medical Records, no nursing assessment prior to Resident 2 leaving on OOP, and no reassessment of Resident 2 upon return to facility from [DATE] through [DATE]. A review of Resident 2 ' s care plan titled At risk for Decreased ability to perform functional mobility tasks dated [DATE], indicated Resident 2 was a risk for decreased ability to perform function mobility tasks including: bed mobility, transfers, and gait related to recent hospitalization resulting in decreased strength, functional activity tolerance and balance. The goal included Resident 2 would improve current level of function in bed mobility, transfers, and gait . Interventions included . physical therapy evaluation, functional mobility training .safety awareness, gait (a person manner of walking) training and wheelchair mobility for Resident 2. On [DATE] at 10:29 a.m., during an interview and concurrent observation, Resident 2 was in the lobby, seated in a chair, and talking with another resident. Resident 2 stated, when going OOP, I write my sign out on the form by the front when leaving. I come back within three to four hours, then write my Sign in on the form. The receptionist in the front will help to assist with the log during the day and two other employees will assist during the evening. On [DATE] at 1:30 p.m., during an interview, Certified Nursing Attendant 1 (CNA 1) stated Resident 2 would go OOP to the store every two to three days a week. CNA 1 stated, because he (Resident 2) will sign out at the front, that is the job of person at the front, and if they let the resident go then it is ok, when CNA 1 was asked if Resident 2 was allowed to go OOP. CNA 1 stated, No. There ' s nothing else for me to check, not my job. The person at the front will ask, when asked if CNA 1 was required to check for anything else before Resident 2 went OOP. CNA 1 further stated he would sign out and then he (Resident 2) can go. CNA 1 stated, he (Resident 2) does not take long and comes right back, so there is nothing for me to check really, when asked if CNA 1 monitors and or checks on Resident 2 to ensure a safe return to facility. On [DATE] at 1:30 p.m., during a concurrent interview and record review, the surveyor, and Licensed Vocational Nurse 1 (LVN 1), reviewed Resident 2 ' s Physician Order Summary Report dated [DATE] for OOP for Resident 2. Licensed Vocational Nurse 1 (LVN 1) stated she had not seen Resident 2 go OOP on my shift. LVN 1 stated an active physician ' s order for Resident 2, dated [DATE], indicated Resident 2 may go out on pass, and that Resident 2 did not have an active OOP order prior to [DATE]. c. A review of Resident 3 ' s Admission Record dated [DATE], indicated the facility admitted Resident 3 on [DATE] from GACH with diagnoses including Type 2 diabetes, muscle weakness, unsteadiness on feet, lack of coordination, and [CONDITION(S)] (inflammation or swelling that occurs in the bone) of left foot and ankle. A review of Resident 3 ' s MDS dated [DATE], indicated Resident 3 was cognitively intact. Resident 3 required one person assist with bed mobility, transfer, locomotion on/off unit, dressing, toilet use, and personal hygiene. Resident 3 required wheelchair for mobility. A review or Resident 3 ' s Physician Order Summary Report dated from [DATE] to [DATE], indicated Resident 3 did not have a physician ' s order to go OOP. However, a physician ' s order with effect date of [DATE], indicated Resident 3 may go OOP for four hours. A review of the facility ' s form titled Release of Responsibility for Leave of Absence for Resident 3, dated from [DATE] through [DATE], indicated Resident 3 signed out eight times on the OOP log to go OOP on the following dates and time: [DATE] at 10:35 a.m. [DATE] at 8:45 a.m. [DATE] at 5:30 p.m. [DATE] at 2:37 p.m. [DATE] at 8:47 a.m. [DATE] at 11:59 a.m. [DATE] at 8:30 a.m. [DATE] at 12:17 p.m. On [DATE] at 12:38 p.m., during a concurrent interview and record review, the surveyor and th DON, reviewed Resident 3 ' s medical chart. The DON stated there was no documented communication with nursing prior to Resident 3 leaving on OOP, no nursing assessment prior to Resident 3 leaving on OOP, and no reassessment when Resident 3 returned to facility from [DATE] through [DATE]. A review of Resident 3 ' s care plan titled Resident is at risk for falls dated [DATE], indicated Resident 3 was at risk for falls due to left foot [CONDITION(S)]. The goal included Resident 3 would have no falls within injury for 90 days. Interventions included, arrange the patient ' s (Resident 3) environment to enhance vision and maximize independence. On [DATE] at 10:34 a.m., during a concurrent observation and interview, Resident 3 was seen sitting in a wheelchair outside, in front of the facility in the smoking patio area, Resident 3 stated, he Sign Out at the front desk whenever he goes OOP. Resident 3 stated, There is a spot on the paper where you write anticipated return time, and I will take advantage and write five days later. I do not like to follow rules. Then you Sign In when you come back. Resident 3 stated that some staff will question me about writing five days later time in the logbook, but others don ' t and even when they (the staff) question me, staff members will still let me go out. They (the staff) do not like to be confrontational. On [DATE] at 2:14 p.m., during an interview, the DON stated, I have heard that both Residents 1 and 2 do go OOP, but I have not actually seen them do so. The DON stated she would check to see if Residents 1 and 2 had a physician order to go OOP. The DON stated, if a resident is gone for a significant amount of time, I would call them. A review of the facility ' s policy and procedures (P&P) titled, Out On Pass dated [DATE], indicated the facility will make reasonable efforts to ensure the resident safety and uphold resident rights. If the resident ' s attending physician or psychiatrist (if applicable) determine that the resident may participate in activities outside the facility, the attending physician will write an order for resident to go out on pass. Prior to the resident leaving on pass, a licensed nurse will assess the resident ' s physical and mental status. When the resident returns to the facility, a licensed nurse will re-assess the resident to determine the resident ' s condition and account for any medication returned after going out on pass, if applicable. The resident/responsible person will verbally notify a licensed nurse prior to going out on pass and will sign out and back on Resident Out on Pass Log. The resident/responsible person will return to the facility at the agreed-upon time, or else notify the facility of any expected delay in return to the facility.

Based on observation, interview, and record review, the facility failed to ensure two of two residents (Residents 1 and 2) were free from chemical restraint and were not administered antipsychotic medications (used to treat mental illness) imposed for purposes of discipline or convenience as evidenced by: 1. Resident 2, who was nonverbal (not involving or using words or speech) with [CONDITION(S)] (partial or total loss of the ability to move of all four limbs) with intellectual disabilities (term used when there are limits to a person's ability to learn at an expected level and function in daily life) since birth, would raise his hand to his face and/or tap his face, to communicate he was constipated and or had a problem. Resident 2 had no prior history of [CONDITION(S)] diagnosis (a chronic [long [MEDICATION(S)]] and severe mental disorder that affects the way a person thinks, acts, expresses emotions, perceives reality, and relates to others). Resident 2 was started on a [CONDITION(S)] medication (a drug that affects behavior, mood, thoughts, or perception), [MEDICATION(S)] ([[MEDICATION(S)]] an antipsychotic medication used to treat mental illness) from 12/7/2020 through 6/28/2022 after given an inappropriate diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . As a result, Resident 2 was admitted at a General Acute Care Hospital 1 (GACH 1) on 5/14/2022 and 5/30/2022 in GACH 2, for constipation with fecal impaction (a mass of dry, hard stool that cannot pass out of the colon or rectum) and dilation of the bowel (sign of mechanical or functional bowel obstruction), urinary tract infections ([CONDITION(S)]- an infection in any part of the urinary system - the kidneys[organs that remove waste and extra water in the body], ureters [tubes that carry urine from the kidneys to the bladder], bladder [a pouch where urine collects in the body], and urethra [a tube through which urine leaves the body]) and low oxygen levels requiring care and treatments. 2. Resident 1, who was non-verbal, non-mobile (not capable of moving), and communicated via a communication board with no prior history of mental disorder was started on [MEDICATION(S)] and given a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] As a result, Resident 1 received unnecessary drug with an inappropriate diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident received [MEDICATION(S)] from 9/29/2020 to 5/13/2022. Findings: A review of Resident 2's Face Sheet (Admission Record) indicated the facility admitted Resident 2 on 5/28/2020 and was readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of 12 Resident 2's History and Physical Exam (H&Ps) from 11/18/2019 through 4/15/2021, indicated Resident 2 did not have the capacity to understand and make decisions due to profound mental [CONDITION(S)] and intellectual disability and did not include the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 2's care plan titled Exhibits Physical Behaviors, initiated on 9/28/2020 and revised on 1/5/2022, indicated the focus was on Resident 2's physical behaviors of hitting his face. Interventions included to administer [MEDICATION(S)] 5 mg (milligrams - unit of measurement) via G-tube (a flexible tube inserted into the stomach for nutrition, hydration, and or medication) twice a day for [CONDITION(S)] manifested by hitting himself in the head for no reason, staff to evaluate the nature and circumstances (i.e., triggers) of the physical behavior with resident/patient and/or resident representative and discuss findings with resident/patient and family members/caregivers and adjust care delivery appropriately. A review of the Physician's Telephone Order for Resident 2 dated 12/7/2020, indicated Resident 2 to receive [MEDICATION(S)] (medication to treat mental illnesses including [CONDITION(S)] 5 (five) milligram (mg - unit dose measurement) tablet, one tablet by mouth (PO) two times a day for [CONDITION(S)] manifested by (m/b) hitting himself for no reason. A review of Resident 2's care plan titled, Risk for complications related to the use of [CONDITION(S)] drugs on [MEDICATION(S)] ([MEDICATION(S)]) initiated on 3/29/2021 and revised on 6/8/2022, indicated intervention(s) included to monitor for continued need of medication as related to behavior or mood, and to monitor for side effects. However, there was no documented evidence of nonpharmacological (any type of health intervention which is not primarily based on medication) interventions attempted, implemented, and or monitored for the effectiveness and potential triggers for discomfort prior to the use and or while on [MEDICATION(S)] for Resident 2. The care plan interventions did not include to monitor and or assess Resident 2 for side effects of [MEDICATION(S)] including constipation and urinary tract infection ([CONDITION(S)]). A review of Resident 2's Initial Psychiatric Evaluation (PE - relating to mental illness or its treatment), dated 7/19/2021, indicated This patient was requested for psychiatric evaluation per staff due to hitting himself . resident currently taking [MEDICATION(S)] 5 mg via G-tube twice a day. Per staff, he does attempt to hit himself when he appears frustrated, but the 1:1 sitter was able to prevent him from injuring himself . Inpatient psychiatric history: unable to obtain due to communication deficit. Under behavior: involuntary (done other than in accordance with the conscious will of the individual) movement. Under speech: nonverbal. Under thought process: thought content, insight/judgement, and orientation was documented Unable to Assess. Plan to continue [MEDICATION(S)] 5 mg via G-tube twice a day. There was no documented evidence of nonpharmacological interventions attempted or monitoring parameters identified in psychiatric evaluation for Resident 2. A review of Resident 2's Psychiatric Evaluation (PE) notes dated 8/31/2021, indicated The patient is lying down in his bed, nonverbal, and presents as anxious with mild involuntary head and arm movements . the patient is nonverbal and unable to communicate . continue [MEDICATION(S)] 5 mg twice a day via G-tube. A review of Resident 2's PE dated 9/14/2021, indicated The patient seen, chart reviewed, and case discussed with staff. This patient with significant intellectual and developmental delays presenting for follow-up psychiatric encounter . Plan, continue [MEDICATION(S)] 5 mg via G-tube for symptoms of [CONDITION(S)]. Resident 2's psychiatric exam documentation indicated the resident was nonverbal and was unable to assess resident for thought process, thought content, insight/judgement, orientation, recent memory, remote memory, attention/concentration, or knowledge. The psychiatric Nurse Practitioner 1 (NP 1) electronically signed the psychiatric encounter was on 10/18/2021 at 5:06 p.m. A review of Resident 2's PE dated 10/5/2021, 11/2/2021, and 12/9/2021, indicated The patient remains nonverbal and lacks comprehension and is unable to respond to his name or verbal stimulus or unable to track movements. He remains on [MEDICATION(S)] 5 mg via G-tube for [CONDITION(S)] (a mental disorder characterized by a disconnection from reality). A review of Resident 2's PE dated 1/18/2022, indicated Patient with history of [CONDITION(S)] [sic], marked intellectual and developmental delays. The patient is awake to self and is non-verbal. The patient is unable to make needs known. Plan to continue [MEDICATION(S)] 5 mg via G-tube BID (twice a day). A review of Resident 2's PE dated 2/15/2022, 3/17/2022, and 4/15/2022, indicated the patient was unable to assess or make needs known. Plan to continue [MEDICATION(S)] 5 mg via G-tube BID. A review of Resident 2's Admission Minimum Data Set (MDS - a standardized assessment and care- screening tool), dated 3/17/2022, indicated Resident 2 had severe cognitive (mental ability to make decisions of daily living) impairment and was rarely or never understood. The MDS indicated Resident 2 was totally dependent on staff and required one to two person physical assist for activities of daily living (including bathing, dressing, getting in and out of bed or a chair, eating, and toileting). A review of Resident 2's PE 5/4/2022, indicated He (Resident 2) is non-verbal and displays minimal ability for communication. Plan to continue [MEDICATION(S)] 5 mg via G-tube BID. Patient is stable with current medications. Dose reduction is likely to impair functions or cause psychiatric instability. A Review of GACH's Face Sheet for Resident 2 dated 5/14/2022, indicated Resident 2 was transferred from Skilled Nursing Facility (SNF-the facility) to GACH with admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 2 was admitted on the Medical Surgical Unit at GACH. A review of GACH's x-ray results for Resident 2 dated 5/14/2022, indicated Resident 2 had Large stool ball in the rectum with severe dilation of the large bowel and dilatation of multiple small bowel loops in addition to the stomach. Resident's active hospital problem list included, [CONDITION(S)] due to [CONDITION(S)] (5/14/2022) . Plan: admit to hospital, continue [MEDICATION(S)] ([MEDICATION(S)] - an antibiotic to treat infection) . Fecal impaction in rectum (5/14/2022), Chronic constipation . Plan: bowel regimen, soap suds enema given . A review of GACH 1's History and Physical (H&P) for Resident 2, dated from 5/14/2022 to 5/15/2022, indicated Resident 2, who presented from Skilled Nursing Facility (SNF) with shortness of breath, abdominal distention, constipation, and fever for unclear amount of time. Patient started treatment with [MEDICATION(S)] (an antibiotic to treat infection) and aggressive bowel regimen. A review of Resident 2's GACH 1Discharge to SNF Summary and Transfer Orders, dated 5/16/2022, indicated the imaging showed fecal impaction with dilation of the bowel, with [CONDITION(S)] (blood infection) due to a urinary tract infection as well as aspiration (occurs when food or liquid is breathed into the airways or lungs, instead of being swallowed) pneumonitis (inflammation on the lungs) vs pneumonia. He will be discharged with supplemental oxygen (to provide extra oxygen to breathe in) as needed and [MEDICATION(S)] and to start taking the following medications: [MEDICAL RECORD OR PHYSICIAN ORDER] 1. [MEDICATION(S)] (to treat/prevent constipation) 10 milligram (mg - unit of measure of weight), insert one suppository rectally daily as needed (if no BM for 2 [two] days) 2. [MEDICATION(S)] (used to treat occasional constipation) 10 grams per 15 milliliter ([ml] - a unit of measure for volume), take 30 ml by mouth daily to prevent constipation 3. [MEDICATION(S)] (used to treat occasional constipation) 17 grams per dose as needed for constipation. Mix powder with eight (8) ounces ([oz] - a unit of measure for volume) of water or juice daily for five days 4. Senna [MEDICATION(S)] (to treat/prevent constipation) 8.6 mg via g-tube daily at bedtime 5. [MEDICATION(S)] (antibiotic for infection) 750 mg tablet via G-tube daily for five (5) days A review of Resident 2's care plan titled at Risk for respiratory complications, indicated on 5/30/2022, Resident 2 was transferred to GACH 2 via 911 (emergency ambulance) due to actual shortness of breath (SOB), 80% [percentage] oxygen saturation (amount of oxygen carried in the blood) on room air, distended abdomen, cough and [MEDICATION(S)]. A review of Resident 2's GACH 2 Face Sheet indicated the resident was transferred from the SNF and admitted to the GACH 2 through the emergency department on 5/30/2022. The admitting diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 2 GACH 2's H&P, dated 5/31/2022, indicated Resident 2 had profound intellectual disabilities and documented under Psychiatric: Unable to access. The HP indicated the reason for emergency room admission was due to hypoxic respiratory failure with oxygen saturation between 88 percent (%) to 90 % on admission (low if oxygen saturation was less than 95 %). Assessment indicated, Acute Respiratory Failure .Distended Abdomen. A review of Resident 2's GACH 2 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of GACH 2's discharge form titled, Referral for Continuity of Patient Care for Resident 2's dated 6/7/2022, indicated Resident 2 was transferred to the SNF on 6/7/2022 with the following orders: 1. Bowel Softener: [MEDICATION(S)], 2. Enema: Water-based enema, 3. Restraints: Right hand mitten, 4. Inhalation/Oxygen: two (2) Liters (L) nasal cannula (a device used to deliver supplemental oxygen), 5. Sennosides 8.6 mg via feeding tube every day at bedtime, 6. [MEDICATION(S)] (Fleet Enema) 118 ml rectally daily as needed. Medication indication: constipation. Note: every 72 hours for constipation; and 7. [MEDICATION(S)] (Dulcolax Suppository) 10 mg rectally daily as needed. Note: every 72 hours. A review of Resident 2's Order Summary Report with active orders as of 6/15/2022, the report indicated an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/15/2022, at 1:07 p.m., during an observation in Resident 2's room, Resident 2 was lying in bed awake, quietly moving his head side to side with mittens on both hands and tongue movement inside of his mouth. On 6/15/2022, at 3:28 p.m., during an interview, Licensed Vocational Nurse 2 (LVN 2) stated Resident 2 was bedbound, not alert, and hits himself. LVN 2 stated she was not sure if there were orders to monitor Resident 2 or what to monitor Resident 2 for. On 6/16/2022, at 9:48 a.m., during a telephone interview, Resident 2's Conservator/Responsible Parties 2 and 3 (RPs 2 and 3), RP 2 stated Resident 2 was transferred from GACH to the facility because of a wound on Resident 2's back. RP 2 stated Resident 2's mental capacity was that of a child and was nonverbal since birth. RP 2 stated, I don't think he (Resident 2) can be diagnosed with [CONDITION(S)]. He cannot talk and is legally blind. Had no history of [CONDITION(S)]. RP 2 stated for the last [AGE] years, Resident 2 would raise his hand to his face and/or tap his face, to communicate the resident was constipated and or had a problem. RP 2 stated the caregivers at a previous facility, knew this was Resident 2's way to communicate a problem and would check the resident's vitals (including blood pressure, pulse, temperature, and respirations), check if he was constipated, or needed to be repositioned RP 2 stated the facility was aware what Resident 2 means when he (Resident 2) hits himself. RP 2 stated Resident 2 was always fed by mouth until he was admitted to the facility in 2020 where a G-tube was placed in Resident 2 for feeding. RP 2 stated he received a call from the facility that Resident 2 had change in condition (COC) and was transferred to GACH 2 the resident was constipated and that the constipation was putting pressure on resident 2's lungs and had oxygen desaturation (low oxygen to the blood). RP 2 stated Resident 2 had never received [MEDICATION(S)] until the resident was admitted to the facility. RP 2 stated, I do not know how a person with no mental capacity, was diagnosed with [CONDITION(S)] or placed on that type of medication ([MEDICATION(S)]). On 6/16/2022, at 11:15 a.m., during an interview, the facility's Service Coordinator Social Worker (SSC) stated she has worked with Resident 2 for six years. The SSC stated Resident 2 was fed by mouth prior to admission to the facility, had a G-tube inserted and urinary catheter inserted in the facility. The SSC stated Resident 2 was admitted at the facility because of a pressure sore (Damage to an area of the skin caused by constant pressure on the area for a long time) on the resident's back. The SSC stated Resident 2 had rods in his back that caused the recurrent pressure sore. The SSC further stated Resident 2 had occasional behaviors that the facility incorrectly managed by administering antipsychotic ([MEDICATION(S)]) medication. The SSC stated the facility was informed that Resident 2 raises his hand to his head to communicate he was uncomfortable and or had a care need. On 6/16/2022, at 12:26 p.m., during an interview, Resident 2's caregiver/sitter 1 (Caregiver 1) stated the facility never mentioned to her that Resident 2 hits himself to communicate the resident was constipated or uncomfortable and did not know that was how the Resident 2 communicated his needs. Caregiver 1 stated, I was told to stop him from hitting himself. On 6/16/2022, at 1:30 p.m., during an interview, Resident 2's Physician (MD 3) stated Resident 2 has been his patient (resident) for [AGE] years and that Resident 2, has profound intellectual disability and not [CONDITION(S)]. MD 3 stated, I did not diagnose him and would not have put a [CONDITION(S)] diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . MD 3 stated he would have to review the NP 1's notes for Resident and the resident's [CONDITION(S)] diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . MD 3 stated Resident 2 made gestures that his previous caregivers at another facility understood. MD 3 further stated Resident 2's family had mentioned to the facility that Resident 2 self-hitting was a form of communication and that in the past, Resident 2 used self-hitting behavior to indicate he needed something. On 6/16/2022 at 2:58 p.m., during an interview, Resident 2's Psychiatrist (MD 1- a physician who specializes in the prevention, diagnosis, and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . MD 1 stated, We give medications to make patients (residents) more comfortable. This has not been on my radar when we see chronically disabled residents. MD 1 stated he has not seen Resident 2 and will talk with Nurse Practitioner 1 (MD 1's NP) to discuss about Resident 2. MD 1 stated, nonpharmacological interventions should always be attempted to determine if effective or not for the resident. MD 1 stated the facility staff need to work with Resident 2's family that know/familiar with Resident 2 for a longer period for a better understanding about the resident and his care. On 6/16/2022, at 4:57 p.m., during an interview, the Director of Nursing (DON) stated Resident 2's behavior does not demonstrate the classic symptoms of [CONDITION(S)] of seeing things or grabbing for things in the air that are not there that may be observed even when a resident is nonverbal. The DON stated that hitting alone was not considered [CONDITION(S)] behavior. The DON stated side effects of [MEDICATION(S)] include jerking movement, stiffness, constipation, restlessness, and respiratory depression. The DON stated Resident 2 has a care plan on constipation and that the resident was recently hospitalized for constipation. On 6/28/2022 at 1:02 p.m., during an interview, NP 1 stated she thought Resident 2 was previously diagnosed with [CONDITION(S)] and that the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . NP 1 stated she was not aware Resident 2 communicated with his hands and had not spoken with RP 2. NP 1 stated she had not received Resident 2's monthly behavior monitoring report from the facility. NP 1 stated she depends upon the facility's staff to provide information about the resident and if the information was not accurate it can jeopardize the resident's wellbeing. NP 1 stated the facility staff need to be able to provide better care to the resident. NP 1 stated for Resident 2, hitting himself, crying, or screaming does not indicate a person has [CONDITION(S)]. NP 1 stated Resident 2 diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] A review of the facility's policy and procedures (P&P) titled, Restraints: Use of, dated 6/2021, indicated, Patients have the right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms. b. A review of Resident 1's Face Sheet indicated the facility admitted Resident 1 on 3/15/2019 and was readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the facility's Physician Telephone Order for Resident 1 dated 9/29/2020, indicated to administer [MEDICATION(S)] 5 mg tablet one tablet via G-tube two times a day for [CONDITION(S)] m/b paranoid thinking of others trying to hurt her (Resident 1). A review of Resident 1's Care Plan Meeting Progress Notes dated 4/29/2022 timed 11:11 a.m., indicated NP 1, the Social Services Director (SSD), and RP 1 were present. The care plan meeting notes indicated IDT [team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities] held to clarify the services being provided to Resident 1 . RP 1 was requesting clarification on the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . RP 1 reports that she is not in agreement with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . SSD informed RP 1 that IDT is working on a psychiatrist to reassess resident. A review of Resident 1's Social Services Progress Notes dated 5/13/2022, indicated that the facility's SSD spoke with Psychiatrist NP 1, and NP 1 after re-evaluation of Resident 1, has removed the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of GACH 3's Transfer of Care Summary for Resident 1 dated 5/13/2019, indicated there was no documented evidence that Resident 1 received [MEDICATION(S)] and or had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's MDS dated [DATE], indicated Resident 1's cognition was intact. The MDS indicated Resident 1 was totally dependent on staff and required one-to-two-person physical assist for activities of daily living (bathing, dressing, getting in and out of bed or a chair, eating, and toileting). A review of Resident 1's care planning meeting, dated 4/21/2022, indicated under Nursing section: Medication list and regimen has been reviewed . Family and resident (Resident 1) do not agree with the [CONDITION(S)] diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .the resident has requested to be placed in a wheelchair three times per week. A review of Resident 1's Nursing Progress Note dated 5/13/2022 and timed at 3:50 p.m., indicated the Social Service Director (SSD) spoke with the psychiatrist NP 1 after re-evaluating Resident 1 and NP 1 removed the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/14/2022 at 3:10 p.m., during an interview, Resident 1's Family Member 1 (RP 1) stated Resident 1 was nonverbal due to a stroke that occurred in 3/2018. RP 1 stated Resident 1 was unable to walk, speak, or eat independently afterwards and that the resident can still think and communicate through a communication board. RP 1 stated she received a call from another facility earlier this year (2022) and was told they could not accept Resident 1 because the resident had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . RP 1 stated that was the first time she heard of Resident 1's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . RP 1 stated she contacted the current facility and spoke with the facility's SSD about Resident 1 and requested a second opinion. RP 1 stated NP 1 who had initially evaluated resident 1, re-evaluated Resident 1 again on 5/13/2022 and removed the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . RP 1 stated she contacted the facility and was told they could discontinue the medication abruptly and the resident would not have withdrawal or adverse effects after being on the medication for two years. RP 1 stated she was never informed Resident 1 was on [MEDICATION(S)] before the resident received it. On 6/15/2022 at 9:28 a.m., during an interview, Certified Nursing Assistant 1 (CNA 1) stated Resident 1 had never attempted to strike out and/or see or hear things that are not there. CNA 1 stated she has worked with Resident 1 for a long time and knows when the resident needs something. CNA 1 stated Resident 1 can verbalize yes or no and would use the communication board when CNA 1 was not able to understand the resident. CNA 1 stated the resident was alert and will push the call light when she needs assistance. CNA 1 stated Resident 1 understands everything in both English and in the resident's native language. On 6/15/2022 at 9:55 a.m., during an interview with resident 1in the presence of CNA 1, Resident 1 used the communication board to indicate that she (Resident 1) has never been diagnosed with [CONDITION(S)]. Resident 1 indicated that she has anxiety and depression. Resident 1 indicated that no one in the facility talked/discussed with her about [CONDITION(S)] diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 1 indicated she felt tired while on [MEDICATION(S)] and that no one explained to her what to expect after [MEDICATION(S)] was discontinued. Resident 1 indicated she has not seen a psychiatrist since she was admitted to the facility. Resident 1 indicated her primary physician visited once a month but did not recall seeing NP 1. On 6/15/2022 at 11:25 a.m., during a concurrent interview and record review, the DON provided a list of residents including Resident 1 with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The list indicated next to Resident 1 name the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated she did not know the meaning of resolved for [CONDITION(S)] and needed to follow-up. On 6/15/2022 at 2:42 p.m., during an interview, the SSD stated used the communication board to communicate with Resident 1 and that the resident remained calm whenever he interacted with the resident. The SSD stated Resident 1 have made it known she wants to transfer to a facility closer to her family. On 6/16/2022, at 2:40 p.m., during an interview, MD 1 stated if someone (Resident 1) was nonverbal it would be difficult to determine and make a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . MD 1 stated his nurse practitioner (NP 1) diagnosed Resident 1 with [CONDITION(S)] and that MD 1 would have to defer to NP 1 for further assistance and that the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . MD 1 further stated a gradual dose reduction (GDR) should have been attempted within six months and again in a year after Resident 1 was started on [MEDICATION(S)] if a tentative diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . MD 1 stated he did not recall seeing/visiting with Resident 1. MD 1 stated, we should have considered changing or discontinuing the medication ([MEDICATION(S)]) when symptoms does not match, or medication does not seem right for the resident (Resident 1). On 6/28/2022 at 1:02 p.m., during an interview, NP 1 stated she felt Resident 1 was having paranoia. However, NP 1 stated she did not think Resident 1 had the potential to harm herself and was not aware if Resident 1 was diagnosed with [CONDITION(S)] prior to admission to the facility. NP 1 stated she could understand Resident 1, as the resident was clear and oriented times four (4- aware of person, place, time, and event). NP 1 stated she did not ask the resident if she had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . NP 1 stated she had not spoken with RP 1 regarding Resident 1's medical condition. A review of the facility's policy and procedures (P&P) titled, Restraints: Use of, dated 6/2021, indicated, Patients have the right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms. A review of the DailyMed (a database search) that provides the most recent labeling submitted to the Food and Drug Administration (FDA) contains labeling for prescription and nonprescription drugs for [MEDICATION(S)] ([MEDICATION(S)]), dated 11/2021, indicated the common side effects of [MEDICATION(S)] included dizziness, restlessness, unusual behavior, depression, difficulty falling asleep or staying asleep, weakness, constipation, urinary retention, respiratory depression or arrest, postural [CONDITION(S)] (low blood pressure that happens when standing up from sitting or lying down), weight gain, dry mouth, high blood sugar, pain in arms, legs, back, or joints . The symptoms of [CONDITION(S)] include hearing voices, seeing things that are not there, having beliefs that are not true, and being suspicious or withdrawn . To prevent serious side effects, do not stop taking [MEDICATION(S)] tablets USP suddenly .

Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1), who was dependent on staff for activities of daily living (ADLs, such as bed mobility, transfers, dressing, toilet use, bathing, and personal hygiene), was free from neglect (the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress). On 7/2/2022, Resident 1 was left unattended sitting on urine and feces (bowel movements or stools), when a Certified Nursing Assistant [CNA] was not assigned to care the resident on two 8-hour shifts (7 a.m. to 3 p.m. and 3 p.m. to 11 p.m.). As a result, on 7/2/2022 at 6 p.m. (11 hours without a CNA assigned to care for her) Resident 1 became upset, developed an increased heart rate and chest pain requiring emergency transfer to General Acute Care Hospital 1 (GACH 1) where she was found to have a heart rate of 152 beats per minute (bpm, the normal rate is between 60 and 100 bpm). Resident 1, crying, stated she felt treated as an animal, and it was a horrible experience. Findings: According to the complaint, on 7/2/2022, Resident 1 was calling using the call light and was also screaming for assistance the entire day causing the resident chest pain and was transported to GACH 1 via 911 (emergency medical services [paramedics]). A review of Resident 1's Admission Record (Face Sheet) indicated the facility originally admitted Resident 1, a [AGE] year-old female, on 5/26/2022, with a re-admitted d 7/1/2022. Resident 1's diagnoses included heart failure (long-term condition where the heart does not pump blood as well as it should), atrial fibrillation (an irregular and often very rapid heart rhythm [arrhythmia] that can lead to blood clots in the heart), chronic obstructive pulmonary disease (COPD - a group of diseases that cause airflow blockage and breathing-related problems), obesity (a disorder involving excessive body fat that increases the risk of health problems), and hypertension (a condition in which the force of the blood against the artery walls is too high). A review of Resident 1's Care Plan developed on 5/31/2022 for the resident being resistive to care related to difficulty adjusting to the facility, verbal comments of not being satisfied with care provided, included in the interventions providing consistent, trusted caregiver and structured daily routine when possible. A review of Resident 1's Minimum Data Set (MDS - standardized assessment and care-screening tool) dated 6/1/2022, indicated the resident was able to communicate, remember and make decisions. Resident 1 required extensive two-person assist with bed mobility and was totally dependent for bedpan use. Resident 1 was always continent (aware of urge to urinate and able to control bladder) of bladder and bowel functions. A review of Resident 1's Care Plan developed on 6/7/2022 for the resident's activities of daily living (ADLs, such as bed mobility, transfers, dressing, toilet use, bathing, and personal hygiene) included to provide Resident 1 with the required assistance with ADLs. A review of the Daily Nursing Staff Assignment sheet dated 7/2/2022 for the 7 a.m. to 3 p.m. shift, indicated Resident 1's room number was handwritten onto CNA 2's assignment. A review of CNA 2's timecard dated 7/2/2022, indicated CNA 2 did not clock in (did not work). A review of the Daily Nursing Staff Assignment dated 7/2/2022 for the 3 p.m. to 11 p.m. indicated Resident 1's bed number was crossed out under CNA 3's assignment and not assigned to any CNA. A review of Resident 1's Order Summary Report dated 7/2/2022 and timed 6:10 p.m., indicated to transfer Resident 1 to GACH 1 via 911 related to chest pain. A review of Resident 1's Change in Condition (COC) Progress Note dated 7/2/2022 timed 6:32 p.m., indicated Resident 1 had a new onset of irregular heart rate of 110 bpm at 5:33 p.m. A review of GACH 1 Emergency Department (ED) dated 7/2/2022, indicated Resident 1 arrived at the ED at 6:34 p.m. with a heart rate of 152 bpm. Resident 1 was diagnosed with atrial fibrillation with rapid ventricular response in the setting of decompensated heart failure. A review of GACH 1 Social Work Progress Note for Resident 1, dated 7/2/2022 timed 8 p.m., indicated the resident verbalized she was calling (for staff) too long and they should have known that I was not well as I had just gotten out of another hospital. Resident 1 asked not to be sent back to the facility. On 7/6/2022 at 12:37 p.m., during an interview, the Director of Nursing (DON) stated the Director of Staff Development (DSD), who made the CNAs schedules and assignments, had resigned two weeks ago. The DON stated herself (DON), payroll, and the administrator, were responsible to make the staff schedules and staff assignments for the residents and the supervisors could adjust the staff assignment as needed. On 7/7/2022 at 8:11 a.m., during a telephone interview, Resident 1 stated she was treated like an animal at the facility. Resident 1 stated on 7/2/2022, after breakfast (between 7 a.m. and 8 a.m.), she pressed the call light because she was sitting in urine and feces in an incontinent brief and needed to be cleaned and changed. Resident 1 stated after waiting for about an hour with no response from the staff, she started screaming for help. Resident 1 began crying and stated in her [AGE] years on this earth she had never had such a horrible experience. Resident 1 stated CNAs did not show up when she screamed for help. Resident 1 stated she felt as if she was going to have a heart attack when she was screaming for help. On 7/15/2022 at 12:42 p.m., during an interview, LVN 1 stated on the evening of 7/2/2022, she heard Resident 1 screaming nurse. LVN 1 stated she responded to the resident's scream and Resident 1 said the CNA was taking forever to answer the call light and complained of having chest pain. LVN 1 stated she checked Resident 1's vital signs (heart rate, blood pressure, respiration) and noticed Resident 1 had an elevated heart rate and she contacted the attending physician and called 911. On 7/18/2022 at 12:59 p.m., during an interview, CNA 1 confirmed she was on vacation on 7/2/2022. On 7/19/2022 at 1:26 p.m., during an interview, CNA 2 stated she was not assigned Resident 1 on 7/2/2022. On 7/20/2022 at 11:02 a.m., during an interview, Registered Nurse Supervisor (RNS) the DSD did not do the CNAs assignments. Th RNS from the previous shift makes the assignments and the shift supervisor adjust it if someone calls off. On 7/20/2022 at 4:30 p.m., during an interview with the DON and concurrent review of the Daily Nursing Staff Assignments for 7/2/2022 for the 7 a.m. to 3 p.m. and the 3 p.m. to 11 p.m. shifts and CNA 1 and 2's timecards for the same day, the DON was unable to explain why Resident 1 did not have a CNA assigned to care for her from 7 a.m. to 3 p.m. The DON stated CNA 3 was assigned to care for Resident 1 on 7/2/2022 from 3 p.m. to 11 p.m. which could not be corroborated because CNA 3 was on vacation. A review of the facility's policy and procedures titled Abuse Prohibition reviewed 2/23/2021, indicated the following: HealthCare Centers prohibit abuse, mistreatment, neglect, misappropriation of resident property, and exploitation for all residents. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the patient's medical symptoms. Centers also strive to comply with the Elder Justice Act (EJA). Under the EJA, employees are designated as mandated reporters and are obligated to immediately report any suspicion of a crime against a resident. Reporting a suspicion of a crime only to an immediate supervisor does not meet the obligation to report. Retaliation in any form against an employee who reports a suspicion is strictly prohibited. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, injury, or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods and services that are necessary to attain or maintain physical, mental, or psychosocial well-being. Instances of abuse of all patients, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Verbal Abuse is any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to patients or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Examples of verbal abuse include but are not limited to threats of harm; saying things to frighten a patient, such as telling a patient that he/she will never be able to see his/her family again . Mental Abuse includes, but is not limited to humiliation, harassment, and threats of punishment or deprivation. Mental abuse may occur through either verbal or nonverbal conduct which causes or has the potential to cause the patient to experience humiliation, intimidation, fear, shame, agitation, or Degradation. Examples of verbal or nonverbal conduct that can cause mental abuse, include but are not limited to, staff taking photographs or recordings of patients that are demeaning or humiliating using any type of equipment (e.g., cameras, smart phones, and other electronic devices) and keeping or distributing them through multimedia messages or on social media networks. A review of the facility's policy and procedures titled, Activities of Daily Living, revised 6/1/2021 indicated based on comprehensive assessment of a resident and consistent with the patient's needs and choices, the center must provide the necessary care and services to ensure that a patient's ADLs are maintained, or improved and do not diminish . a patient who is unable to carry out ADLs will receive the necessary assistance level of ADLs assistance to maintain good nutrition, grooming, and personal/oral hygiene. A review of the facility's policy and procedures titled, call lights dated 6/1/2021 indicated patients will have a call light or alternative communication device within their reach when unattended. Staff will respond to call lights and communication devices promptly.

Based on observation, interview, and record review, the facility failed to ensure one of 14 sampled residents (Resident 40) who was under hospice care (care designed to give supportive care to people in the final phase of a terminal illness and focus on comfort and quality of life, rather than cure) was free of neglect by: 1. Failing to implement the facility's policy on pain management and the physician's orders [REDACTED]. 2. Failing to provide oral hygiene to Resident 40, who was unable to care for himself. 3. Failing to address Resident 40's inability to eat or drink orally due to swallowing difficulty and lack of alternatives to maintain hydration and prevent discomfort in spite of the resident request for water; complains of pain and discomfort. These deficient practices resulted in Resident 40 had poor oral hygiene, suffered unnecessary pain and discomfort, and thirsty without interventions for seven days instead of receiving comfort care at the end of life. Findings: On (MONTH) 25, (YEAR) at 7:55 a.m. during the initial tour of the facility, accompanied by Registered Nurse Supervisor 1 (RNS 1), Resident 40 was observed lying on a bed, wearing only an incontinent brief, and fidgeting around the bed (restless, not able to keep still in one position for one minute). The call light was hanging on the right side of the bed, not within the reach of the resident. Resident 40 was observed with cracked dry lips, and had a dried flakey white substance covering the left side of the mouth to his left lower jaw area. While Resident 40 was talking, very thick saliva was observed inside his mouth. During an interview at the time of the observation Resident 40 stated he wanted to drink water. RNS 1 stated Resident 40 was under hospice care. RNS 1 stated the resident could verbalize his needs and follow simple commands. RNS 1 stated Resident 40 had an order for [REDACTED]. According to the Admission Record, Resident 40 was admitted to the facility on (MONTH) 19, (YEAR), with [DIAGNOSES REDACTED]. According to the admission nursing assessment dated (MONTH) 19, (YEAR), Resident 40 was confused, had minimal difficulty in hearing, was unable to make significant changes in position independently, and needed extensive assistance from staff with bed mobility and transfer. A review of Physician order [REDACTED]. A review of Resident 40's physician's orders [REDACTED]. A review of Resident 40's physician's orders [REDACTED]. 1. Hospice evaluation. 2. [MEDICATION NAME] (pain medication) Suppository 650 milligrams (mg) every 6 hours as needed for general discomfort. 3. [MEDICATION NAME] (for anxiety or nervousness) 0.5 mg by mouth every 4 hours as needed for restlessness. 4. [MEDICATION NAME] 5 mg sublingually (under the tongue) every 2 hours as needed for pain. A review of the Hospice Interdisciplinary Care Plan dated (MONTH) 20, (YEAR), indicated the goal was for the resident's pain to remain at a comfortable level by the use of [MEDICATION NAME] sulfate every two hours as needed. The plan of care also included promoting the resident's optimal nutrition/hydration as the resident was NPO, but there were no interventions to obtain optimal nutrition/ hydration. There were no interventions to provide fluids for comfort, relieve signs and symptoms of impending dehydration, and hunger pain resulting from the resident's inability to eat or drink due to swallowing problems. A review of Resident 40's Hospice care plan developed by skilled nursing facility staff member initiated on (MONTH) 25, (YEAR), indicated a goal for the resident to experience the highest practical quality of life throughout life journey in the next 90 days. The interventions included to assess for pain, restlessness, agitation, constipation and other symptoms of discomfort, medicate as ordered and evaluate effectiveness, and provide non-pharmacological approaches to aide in decreasing discomfort. On (MONTH) 25, (YEAR), at 2:15 p.m. during an interview, RNS 1 stated Resident 40 was not receiving anything by mouth for six days and did not know why the resident did not have an intravenous fluid therapy (IVF - is the infusion of liquid substances directly into a vein, may be used for fluid administration) for hydration. RNS 1 further stated Resident 40 was receiving antibiotic through IV. RNS 1 stated she had called the resident's physician regarding IV fluid therapy or diet for Resident 40 but was unable to provide documentation of the call and the response from the physician. On (MONTH) 26, (YEAR) at 9:17 a.m., certified nursing assistant 1 (CNA 1) was observed at Residents 40's bed side. CNA 1 stated that resident kept moving and asking for water, but his NPO. Resident 40 was observed in fetal position (a body position in which the body lies curled up on one side with the head bowed and the legs and arms drawn in toward the chest) holding his abdominal area and restless. Resident 40 complained of having abdominal pain and was asking for water. The resident was observed with dried lips and tongue, and had thick saliva. At 10:15 a.m., Resident 40 was still complaining of abdominal pain and upon interview, was unable to quantify the level of pain for zero (no pain) to 10 (worst pain possible). A review of the Medication Administration Record [REDACTED]. There was no documentation Resident 40 received or was administered any pain medication ([MEDICATION NAME] or [MEDICATION NAME]) or [MEDICATION NAME] for the resident's restlessness as ordered by the physician since (MONTH) 20, (YEAR), a total of seven days. On (MONTH) 26, (YEAR) at 9:24 a.m., during an interview, the Medical Social Worker (MSW) stated an IDT meeting was done on (MONTH) 25, (YEAR), in the afternoon and was attended by nursing, social services, business office staff, and RP 1, who participated via telephone. The MSW stated the IDT discussed hospice and insurance coverage but hospice agency staff did not participate. The MSW stated the IDT meeting should have been conducted when the resident was placed on hospice care (April 20, (YEAR)). On (MONTH) 26, (YEAR), at 3:30 p.m., during an interview, the Director of Nursing (DON) stated she expected the licensed nurses to assess the resident for pain and comfort. The DON stated a pain medication should have been given if the resident needed it. The DON stated there was no care plan for oral care and to address the resident's NPO status. A review of facility policy titled Pain Management revision date (MONTH) 28, (YEAR), indicated the purpose of the policy was to maintain the highest possible level of comfort for patients by providing a system to identify, assess, treat, and evaluate pain. Center staff will report any observation or communication of pain to the nurse responsible for that patient. Further record review revealed no documented evidence the nursing staff or the IDT including the hospice staff, addressed the resident's lack of oral intake, the ordered oral medications when there was an order of NPO, the lack of alternative interventions to provide the resident hydrated and comfortable, and the lack of interventions to manage the resident's verbal complaints of pain and requests for water. There was no evidence the policy on Pain Management was implemented. Cross reference F309, F 312, F526

Based on observation, interview, and record review, the facility failed to ensure one of 14 sampled residents (Resident 40) who was under hospice care (care designed to give supportive care to people in the final phase of a terminal illness and focus on comfort and quality of life, rather than cure) was free of neglect by: 1. Failing to implement the facility's policy on pain management and the physician's orders [REDACTED]. 2. Failing to provide oral hygiene to Resident 40, who was unable to care for himself. 3. Failing to address Resident 40's inability to eat or drink orally due to swallowing difficulty and lack of alternatives to maintain hydration and prevent discomfort in spite of the resident request for water; complains of pain and discomfort. These deficient practices resulted in Resident 40 had poor oral hygiene, suffered unnecessary pain and discomfort, and thirsty without interventions for seven days instead of receiving comfort care at the end of life. Findings: On (MONTH) 25, (YEAR) at 7:55 a.m. during the initial tour of the facility, accompanied by Registered Nurse Supervisor 1 (RNS 1), Resident 40 was observed lying on a bed, wearing only an incontinent brief, and fidgeting around the bed (restless, not able to keep still in one position for one minute). The call light was hanging on the right side of the bed, not within the reach of the resident. Resident 40 was observed with cracked dry lips, and had a dried flakey white substance covering the left side of the mouth to his left lower jaw area. While Resident 40 was talking, very thick saliva was observed inside his mouth. During an interview at the time of the observation Resident 40 stated he wanted to drink water. RNS 1 stated Resident 40 was under hospice care. RNS 1 stated the resident could verbalize his needs and follow simple commands. RNS 1 stated Resident 40 had an order for [REDACTED]. According to the Admission Record, Resident 40 was admitted to the facility on (MONTH) 19, (YEAR), with [DIAGNOSES REDACTED]. According to the admission nursing assessment dated (MONTH) 19, (YEAR), Resident 40 was confused, had minimal difficulty in hearing, was unable to make significant changes in position independently, and needed extensive assistance from staff with bed mobility and transfer. A review of Physician order [REDACTED]. A review of Resident 40's physician's orders [REDACTED]. A review of Resident 40's physician's orders [REDACTED]. 1. Hospice evaluation. 2. [MEDICATION NAME] (pain medication) Suppository 650 milligrams (mg) every 6 hours as needed for general discomfort. 3. [MEDICATION NAME] (for anxiety or nervousness) 0.5 mg by mouth every 4 hours as needed for restlessness. 4. [MEDICATION NAME] 5 mg sublingually (under the tongue) every 2 hours as needed for pain. A review of the Hospice Interdisciplinary Care Plan dated (MONTH) 20, (YEAR), indicated the goal was for the resident's pain to remain at a comfortable level by the use of [MEDICATION NAME] sulfate every two hours as needed. The plan of care also included promoting the resident's optimal nutrition/hydration as the resident was NPO, but there were no interventions to obtain optimal nutrition/ hydration. There were no interventions to provide fluids for comfort, relieve signs and symptoms of impending dehydration, and hunger pain resulting from the resident's inability to eat or drink due to swallowing problems. A review of Resident 40's Hospice care plan developed by skilled nursing facility staff member initiated on (MONTH) 25, (YEAR), indicated a goal for the resident to experience the highest practical quality of life throughout life journey in the next 90 days. The interventions included to assess for pain, restlessness, agitation, constipation and other symptoms of discomfort, medicate as ordered and evaluate effectiveness, and provide non-pharmacological approaches to aide in decreasing discomfort. On (MONTH) 25, (YEAR), at 2:15 p.m. during an interview, RNS 1 stated Resident 40 was not receiving anything by mouth for six days and did not know why the resident did not have an intravenous fluid therapy (IVF - is the infusion of liquid substances directly into a vein, may be used for fluid administration) for hydration. RNS 1 further stated Resident 40 was receiving antibiotic through IV. RNS 1 stated she had called the resident's physician regarding IV fluid therapy or diet for Resident 40 but was unable to provide documentation of the call and the response from the physician. On (MONTH) 26, (YEAR) at 9:17 a.m., certified nursing assistant 1 (CNA 1) was observed at Residents 40's bed side. CNA 1 stated that resident kept moving and asking for water, but his NPO. Resident 40 was observed in fetal position (a body position in which the body lies curled up on one side with the head bowed and the legs and arms drawn in toward the chest) holding his abdominal area and restless. Resident 40 complained of having abdominal pain and was asking for water. The resident was observed with dried lips and tongue, and had thick saliva. At 10:15 a.m., Resident 40 was still complaining of abdominal pain and upon interview, was unable to quantify the level of pain for zero (no pain) to 10 (worst pain possible). A review of the Medication Administration Record [REDACTED]. There was no documentation Resident 40 received or was administered any pain medication ([MEDICATION NAME] or [MEDICATION NAME]) or [MEDICATION NAME] for the resident's restlessness as ordered by the physician since (MONTH) 20, (YEAR), a total of seven days. On (MONTH) 26, (YEAR) at 9:24 a.m., during an interview, the Medical Social Worker (MSW) stated an IDT meeting was done on (MONTH) 25, (YEAR), in the afternoon and was attended by nursing, social services, business office staff, and RP 1, who participated via telephone. The MSW stated the IDT discussed hospice and insurance coverage but hospice agency staff did not participate. The MSW stated the IDT meeting should have been conducted when the resident was placed on hospice care (April 20, (YEAR)). On (MONTH) 26, (YEAR), at 3:30 p.m., during an interview, the Director of Nursing (DON) stated she expected the licensed nurses to assess the resident for pain and comfort. The DON stated a pain medication should have been given if the resident needed it. The DON stated there was no care plan for oral care and to address the resident's NPO status. A review of facility policy titled Pain Management revision date (MONTH) 28, (YEAR), indicated the purpose of the policy was to maintain the highest possible level of comfort for patients by providing a system to identify, assess, treat, and evaluate pain. Center staff will report any observation or communication of pain to the nurse responsible for that patient. Further record review revealed no documented evidence the nursing staff or the IDT including the hospice staff, addressed the resident's lack of oral intake, the ordered oral medications when there was an order of NPO, the lack of alternative interventions to provide the resident hydrated and comfortable, and the lack of interventions to manage the resident's verbal complaints of pain and requests for water. There was no evidence the policy on Pain Management was implemented. Cross reference F309, F 312, F526

Based on observation, interview, and record review the facility failed to provide necessary care for a resident's head wound and leg ulcers (Resident 20), for [MEDICAL CONDITION] (Resident 16) and for effective pain assessment and relief (Resident 17) for three of 24 sample residents by failing to: 1. Properly and in a timely manner assess a residents head/scalp scab/lesion and [MEDICAL CONDITION] ulcers (a condition where the flow of blood through the veins is inadequate causing blood to pool in the legs) of the left lower extremity and failed to ensure implementation of the plan of care and coordination of care (Resident 20) and 2. Accurately implement [MEDICAL CONDITION] precaution measures by not monitoring the resident's [MEDICAL CONDITION] activity, and not documenting the characteristics of the [MEDICAL CONDITION] including but not limited to type and duration of [MEDICAL CONDITION] as indicated in the residents care plan and in the facility's policy and procedure (16). 3. Accurately communicate and assess pain, for a resident who was complaining of left hip pain in her native language (Resident 17). These deficient practices resulted in a delay of care for undetected worsening skin conditions and for acquiring an infection of the [MEDICAL CONDITION]/ulcers for Resident 20, the potential to result in aspiration during [MEDICAL CONDITION] activity for Resident 16, and delayed proper communication, pain assessment, and pain management for Resident 17. Findings: a.1. According to the admission record, Resident 20 was admitted to the facility (MONTH) 19, 2009 and readmitted (MONTH) 17, 2012, with [DIAGNOSES REDACTED]. lower leg, contracture (shortening and hardening of muscles) of the knee, abnormal posture, and [MEDICAL CONDITION] arthritis (a disease that causes chronic inflammation of the joints and other areas of the body. A review of a History and Physical (H & P) Examination Report dated (MONTH) 3, (YEAR), indicated Resident 20 had a [DIAGNOSES REDACTED]. The report also indicated the resident had the capacity to understand and make decisions. A review of the Minimum Data Set (MDS - a comprehensive assessment and screening tool) assessment dated (MONTH) 8, (YEAR), indicated Resident 20 was able to make herself understood and had the ability to understand others, her cognitive patterns were intact, needed extensive assistance from staff members for bed mobility, and most activities of daily living (ADL). The MDS also indicated the resident had one venous ulcer present, did not have any problem such as open [MEDICAL CONDITION] other than ulcers, cuts (such [MEDICAL CONDITIONS]) or skin tear(s). A review of Resident 20's care plan goal initiated (MONTH) 4, (YEAR), for actual skin breakdown related to a skin tear on the top of the resident's head indicated the wound would heal as evidenced by decrease in size, absence of [DIAGNOSES REDACTED] (redness) and drainage and presence of granulation (new tissue in the healing surface of a wound) for 14 days. The interventions included to evaluate wound area daily including surrounding tissue and the presence or absence of drainage/infection and/or new wound pain and report to the physician as indicated. Monitor for effectiveness and/or side effects of medication, observe skin condition with ADL care daily and report abnormalities. Obtain dietitian consult as needed/ordered, and weekly wound assessment to include measurements and description of wound status. A review of Resident 20's physician's orders [REDACTED]. 1. Multi-Vitamin/Minerals tablet to be administered once daily for supplement, dated (MONTH) 1, (YEAR). 2. Proheal liquid protein supplement 30 milliliters (ml) to administer daily for supplement, dated (MONTH) 13, (YEAR). 3. House Supplement to be administered once daily for supplement, dated (MONTH) 14, (YEAR). 4. Cleanse top of the head with normal saline, pat dry, apply hydrogel (a dressing put over a cut in the skin to help the skin heal), and cover with dry dressing daily for 14 days, dated (MONTH) 16, (YEAR). This physician's orders [REDACTED]. On (MONTH) 16, (YEAR) at 10 a.m., during a wound care observation for Resident 20 with Licensed Vocational Nurse 3/Treatment Nurse (LVN 3), the top of the head wound was treated first. The dressing was removed and had a small amount of blood stain. The resident had a red scab underneath the dressing which measured approximately 8 centimeters (cm) by 8 cm. (8 cm = 3.14 inches (in) by 3.14 in). The resident did not have any hair around the scab area. The bald area around the scab measured approximately 15 cm by 15 cm. Part of the bald area looked dry with yellowish dry skin lifting off the scalp. LVN 3 applied the treatment as ordered. A review of Resident 20's Change in Condition - Skin report, dated (MONTH) 4, (YEAR), indicated the resident had a top of the head skin tear, medications did not appear to be contributing to change in condition, the resident was assessed with [REDACTED]. The physician was made aware and orders were received to cleanse with normal saline, pat dry, apply hydrogel, cover with dry dressing daily. Orders were noted and carried out and care plan updated. A review of Resident 20's Non-Pressure Ulcer Weekly Skin and Wound Report for a skin tear identified (MONTH) 4, (YEAR), on Resident 20's top of the head indicated preventive measures of hydrogel. The report included weekly progress reports starting (MONTH) 11, (YEAR) to (MONTH) 10, (YEAR). The Size/Extent section of the report indicated the following: 1. (MONTH) 11, (YEAR) to (MONTH) 2, (YEAR) - The skin tear measured 2 X 2 (2 centimeters (cm) = .787 of an inch and 2 inches = 5.08 centimeters), but a unit of measure was not specified in order to determine the actual size of the wound. 2. (MONTH) 9, (YEAR) to (MONTH) 30, (YEAR) - The skin tear measured 1 x 1 (1 centimeter = .393 of an inch and one inch =2.54 centimeters), but a unit of measure was not indicated. 3. (MONTH) 6, (YEAR) to (MONTH) 10, (YEAR) - The Size/Extent section was left blank. The Non-Pressure Ulcer Weekly Skin and Wound Report, Observation Response to Treatment, Healing Process, Change in Treatment Orders section indicated the following: 1. (MONTH) 11, (YEAR) - zero bleeding, zero S/S of infection. 2. (MONTH) 18, (YEAR) - Continue treatment as ordered, zero infection, dry. 3. (MONTH) 25, (YEAR) to (MONTH) 9, (YEAR) - Continue treatment as ordered. 4. (MONTH) 16, (YEAR) - Continue with treatment as ordered, dry, zero S/S of infection. 5. (MONTH) 23, (YEAR) - Continue treatment as ordered. 6. (MONTH) 30, (YEAR) - Dry, healing well. 7. (MONTH) 6, (YEAR) to (MONTH) 13, (YEAR) - Healing well, continue treatment as ordered. 8. (MONTH) 20, (YEAR) to (MONTH) 3, (YEAR) - Bleeding, moist, continue treatment as ordered. Resident 20's Non-Pressure Ulcer Weekly Skin and Wound Reports from (MONTH) 6, (YEAR), to (MONTH) 10, (YEAR), did not include the Size/Extent of the scalp wound in order to determine if the wound status was the same, healing or worsening, as indicated in the care plan. The report did not include the effectiveness of the wound treatment that was provided to Resident 20. The documentation provided on the reports did not reflect the actual condition of the scalp wound. Resident 20's scalp wound did not heal from (MONTH) 4, (YEAR) to (MONTH) 3, (YEAR), (3 months) but there was no documented evidence the facility obtained alternate treatment orders when the scalp wound did not resolve in an attempt to provide more effective treatment. On (MONTH) 16, (YEAR) at 11:05 a.m., during an interview, LVN 3 stated the documentation did not reflect Resident 20's actual condition. The documentation did not include measurements. LVN 3 stated Yes, measurements are important, it will tell if the wound is healing. On (MONTH) 16, (YEAR) at 11:30 a.m., during an interview the DSD stated that Resident 20's weekly wound documentation should show how the wound looks, if any odor, and show if healing is improving. The DSD indicated she was not aware LVN 3 was having difficulty with her wound documentation. On (MONTH) 16, (YEAR) at approximately 12:30 p.m., during an interview the Director of Nursing (DON) stated the Interdisciplinary Team's (IDT - A group of health care professionals from diverse fields working in a coordinated fashion toward a common goal for the resident) last Care Plan conference meeting held for Resident 20 was on (MONTH) 17, (YEAR), and the resident's skin condition had not been discussed. The DON stated Care Plan meetings are to be held every 90 days and as needed. The DON stated no one was supervising wound care and documentation at the time. A review of Resident 20's laboratory (lab) test report dated (MONTH) 7, (YEAR), for Pre-[MEDICATION NAME] (A protein that regulate how the body uses energy), indicated an out of range result of 13 milligrams/deciliter (mg/dL) low, in a reference range of 17 - 34 mg/dL, (low levels may be a sign of malnutrition and key nutrients play specific roles in wound healing). A review of the Nutritional assessment dated (MONTH) 15, (YEAR), indicated Resident 20 weighed 92 pounds as of (MONTH) 1, (YEAR), with an ideal body weight range of 95-105-116 pounds and did not have significant weight gain or loss. The skin problems field of the Assessment was left blank. The Summary field indicated Resident 20 was receiving a protein supplement daily, there was no skin breakdown noted, there were no recent labs to assess and no further assessment was needed. On (MONTH) 16, (YEAR) at 4:40 p.m., during an interview Registered Dietitian 1 (RD 1) stated her assessment of (MONTH) 15, (YEAR), for Resident 20 was based on weekly reports generated by the treatment nurses, electronic charting and review of the hard copy of the chart. RD 1 stated she had not seen or spoken to the resident. RD 1 also indicated she would recommend lab tests be done only if the resident had any weight changes and she had not recommended any labs for the resident. RD 1 stated the resident was receiving a protein supplement as of (MONTH) 13, (YEAR), and did not know who had ordered the supplement, she saw the order but it did not mean anything to her. RD 1 stated the resident did not have a current pre-[MEDICATION NAME] level. RD 1 stated she would continue to monitor the resident's weight because as an RD this was the only monitoring she did for the resident. On (MONTH) 16, (YEAR) at 5:25 p.m., during an interview with both the DON and RD 1, the DON stated that, Unfortunately the facility has issues with poor assessments. As the DON was reading Resident 20's Weekly Skin Progress Notes, she stated, the notes do not say too much. The DON stated the Interdisciplinary Team (IDT - A group of health care professionals from diverse fields working in a coordinated fashion toward a common goal for the resident) should have notified the physician to get him involved to see the resident. RD 1 stated she should have recommended lab tests such as a basic metabolic panel (a blood test that measures blood sugar, electrolyte (body fluids) and fluid balance, and kidney function) and pre-[MEDICATION NAME] which would have provided a current hydration (taking in water) and protein (a nutrient found in food) status of the resident. On (MONTH) 17, (YEAR) at approximately 4:45 p.m., during an interview the DON stated she would call a wound consultant to do a wound assessment for Resident 20. A review of a Surgical Consult dated (MONTH) 18, (YEAR), indicated the reason for the consult was to manage Resident 20's burn tissue to left frontal scalp with a [MEDICAL CONDITION] (wound) on the scalp. According to the Consult the resident reported she had been scratching her (head) with the use of her remote control. The wound consult indicated the resident had a left frontal scalp burn, with purulent (forming pus) drainage, with smooth pink granulated (new formation) tissue present, connected by a bed of [MEDICATION NAME] (one or more layer of cells) tissue to unstable black eschar (a dry scab) beneath a shaven scalp area, with mild purulent drainage, no odor, non[DIAGNOSES REDACTED]tous (no redness of the skin), with 15% granulation 15% eschar, and 70% [MEDICATION NAME] tissue. The wound measured 5.5 cm (2.16 in) length, 9.6 cm (3.77 in) width, 0.1 cm (.039 in) depth, 52.8 cm2 wound area. The scalp condition included seborrheic [MEDICAL CONDITION] (a skin disorder affecting the scalp, face, and torso), crusts, dry, scaly scalp tissue that is non[DIAGNOSES REDACTED]tous. A review of Resident 20's orders from the wound consultant dated (MONTH) 18, (YEAR), included the following: 1. Cleanse left frontal scalp burn with normal saline, pat dry, apply [MEDICATION NAME] cream (antibiotic used to treat or prevent infections on areas of burned skin), 1% cover with dry dressing daily times 14 days. 2. [MEDICATION NAME] (an anti-infective agent, relieves itching and flaking of the scalp) 2.25 % shampoo-wash scalp three times per week times one month. 3. [MEDICATION NAME] tablet 25 milligram to be administered twice daily for 30 days. ([MEDICATION NAME] is an [MEDICATION NAME] medication used to treat itching caused by allergies [REDACTED]. A review of Resident 20's Surgical Consult notes dated (MONTH) 18, (YEAR), also indicated the wounds required topical wound dressing therapy. The goals were wound stabilization, prevention of wound decline, creation of a wound healing bed and reduction of infected tissues. Follow-up in two days. The physician's and designee's Progress Notes from (MONTH) (YEAR), to (MONTH) 11, (YEAR), did not indicate any documented evidence of the resident's skin condition. The last documented Physician's Progress Notes in Resident 20's medical record was dated (MONTH) 6, (YEAR). On (MONTH) 27, (YEAR), at 8:15 a.m., during a telephone interview with Physician 1 (Resident 20's physician), when asked the reason why there are no reference to the resident's skin condition, Physician 1 stated he was being told by the facility licensed staff the resident's skin condition was progressing well. When asked why Resident 20 did not have any physician progress notes [REDACTED]. A review of the facility's Job Description for the position of Dietitian Category III, revised (MONTH) 9, 2012, indicated the dietitian is responsible for utilizing the nutrition care delivery process in providing nutritional care to the residents in the center. He/she advises Administration, Director of Nursing and Food Service Director as needed on all clinical aspects of nutrition care and abides by all standards set forth by applicable regulatory agencies and licensing boards. The dietitian assesses the nutritional status of residents per standards of practice, monitors and evaluates effectiveness of nutritional interventions, ensures appropriate and timely documentation of nutrition assessment tools, recommended interventions and follow-up. addresses appropriate nutrition concerns with all members of the interdisciplinary team. A review of the facility's policy and procedure, reviewed on (MONTH) 1, (YEAR), titled, Nursing Documentation, indicated nursing documentation will follow the guidelines of good communication and be concise, clear, pertinent, and accurate. Narrative charting, as outlined in specific policies and procedures, will be used for initial treatments or procedures. Documentation for subsequent and/or routine care and procedures may be completed by exception or the use of a checklist, flow charts, or other documentation tools. The purpose of the documentation is to communicate patient's status and provide accurate accounting of care and monitoring provided. a. 2. A review of Resident 20's care plan goal initiated on (MONTH) 4, (YEAR), and with a revision date of (MONTH) 22, (YEAR), for actual skin breakdown related to left lower leg lateral venous ulcer indicated the resident's wound would heal as evidenced by decrease in size, absence of [DIAGNOSES REDACTED] and drainage and presence of granulation (the healing surface of a wound) for 90 days. The interventions included to monitor for any clinical changes of condition and notify the physician promptly, obtain dietitian consult as needed/ordered, weekly skin assessment by license nurse, and wound consult with wound consultant weekly. A review of Resident 20's physician's orders [REDACTED]. 1. Multi-Vitamin/Minerals tablet to be administered once daily for supplement, dated (MONTH) 1, (YEAR). 2. Proheal liquid protein supplement 30 milliliters (ml) to administer daily for supplement, dated (MONTH) 13, (YEAR). 3. House Supplement to be administered once daily for supplement, dated (MONTH) 14, (YEAR). 4. Cleanse left lower leg venous ulcer with normal saline, pat dry, apply collagen matrix dressing (helps to promote the growth of new collagen at the wound site), cover with dry dressing and wrap with Kerlix (gauze) daily for 14 days dated (MONTH) 16, (YEAR). A review of the physician's orders [REDACTED]. On (MONTH) 16, (YEAR) at 10 a.m., during a wound care observation for Resident 20 with Licensed Vocational Nurse 3/Treatment Nurse (LVN 3), LVN 3 removed the dressing from the lower part of the left leg with the assistance of LVN 4. The resident had on the outer side of the leg, multiple scattered scabs. It was observed one larger scab had some bleeding. The old dressing adhered to one of the scabs because of the bleeding and was removed by wetting it with normal saline (a sterile solution of sodium chloride (a salt solution) in water used to clean wounds). It was also observed there was a small amount of blood draining on the underside of the leg, unable to visualize this wound because the resident was tired and could not lift her leg. LVN 3 applied the treatment as ordered. A review of Resident 20's Non-Pressure Ulcer Weekly Skin and Wound Report starting (MONTH) 8, (YEAR) to (MONTH) 9, (YEAR), for a venous stasis ulcer, identified on (MONTH) 30, 2014, indicated for left lower leg, preventive measures were to continue, treatment as ordered. The Size/Extent section of the report indicated the following weekly progress report: 1. (MONTH) 8, (YEAR) to (MONTH) 27, (YEAR) - The venous stasis ulcer measured 2 (2 cms =.787 of an inch and 2 in = 5.08 centimeters) X 5 (5 cms =1.96 in and 5 in = 12.7 cm) X SF (superficial) the unit of measure was not indicated. 2. (MONTH) 3, (YEAR) to (MONTH) 9, (YEAR) - The Size/Extent section was left blank. Resident 20's Non-Pressure Ulcer Weekly Skin and Wound Report Observation Response to treatment, Healing Process, Change in treatment orders section indicated the following: 1. (MONTH) 8, (YEAR) to (MONTH) 22, (YEAR) - 100% epi (epithilial tissue on the wound as it begins to heal) with zero signs and symptoms of infection, continue treatment as ordered. 2. (MONTH) 29, (YEAR) - Continue treatment as ordered, without change of condition noted at this time. 3. (MONTH) 6, (YEAR) to (MONTH) 27, (YEAR) - 100 % epi with no S/S (signs and symptoms) of infection noted, physician is aware. 4. (MONTH) 3, (YEAR) - Was left blank. 5. (MONTH) 10, (YEAR) to (MONTH) 25, (YEAR) - Continue treatment without S/S of infection noted. 6. (MONTH) 1, (YEAR) to (MONTH) 22, (YEAR) - Continue treatment as ordered with zero significant change noted. 7. (MONTH) 29, (YEAR) - Continue treatment as ordered with no S/S of infection noted. 8. (MONTH) 6, (YEAR) to (MONTH) 9, (YEAR) - Continue treatment as ordered. The weekly notes entered by the licensed staff for (MONTH) 8, (YEAR) to (MONTH) 9, (YEAR), did not include documentation indicating the effectiveness of the wound treatment that was provided to Resident 20, in order to determine if the wound status was the same, healing or worsening, as indicated in the care plan. The documentation provided on Resident 20's Non-Pressure Ulcer Weekly Skin and Wound Reports for (MONTH) 8, (YEAR) to (MONTH) 9, (YEAR), did not reflect the actual conditions of the venous stasis ulcer. Resident 20's venous stasis ulcer did not show healing from (MONTH) 21, (YEAR), to (MONTH) 9, (YEAR), (1 month and 19 days) but there was no documented evidence the facility obtained alternate treatment orders when the ulcer did not improve in an attempt to provide more effective treatment. On (MONTH) 16, (YEAR) at 11:05 a.m., during an interview, LVN 3 stated the documentation did not reflect Resident 20's actual condition. The documentation did not include measurements. LVN 3 stated Yes, measurements are important, it will tell if the wound is healing. On (MONTH) 16, (YEAR) at 11:30 a.m., during an interview the DSD stated that weekly wound documentation should show how the wound looks, if any odor, and show if healing is improving. The DSD indicated she was not aware LVN 3 was having difficulty with her wound documentation. On (MONTH) 16, (YEAR), at approximately 12:30 p.m., during an interview the Director of Nursing (DON) stated the Interdisciplinary Team's (IDT - A group of health care professionals from diverse fields working in a coordinated fashion toward a common goal for the resident) last care plan conference meeting held for Resident 20 was on (MONTH) 17, (YEAR), and the resident's skin condition had not been discussed. The DON also stated care plan meetings are to be held every 90 days and as needed. The DON indicated that no one was supervising wound care and documentation at the time. A review of the Nutritional assessment dated (MONTH) 15, (YEAR), indicated Resident 20 weighed 92 pounds (lb) as of (MONTH) 1, (YEAR), with an ideal body weight range of 95-105-116 lb and did not have significant weight gain or loss. The skin problems field of the assessment was left blank. The summary field indicated Resident 20 was receiving a protein supplement daily, there was no skin breakdown noted, there were no recent labs to assess and no further assessment was needed. A review of Resident 20's laboratory (lab) test report dated (MONTH) 7, (YEAR), for Pre-[MEDICATION NAME] (a protein that regulate how the body uses energy), indicated an out of range result of 13 milligrams/deciliter (mg/dL) low, in a reference range of 17 - 34 mg/dL, (low levels may be a sign of malnutrition and key nutrients play specific roles in wound healing). On (MONTH) 16, (YEAR) at 4:40 p.m., during an interview Registered Dietitian 1 (RD 1) stated her assessment of (MONTH) 15, (YEAR), for Resident 20 was based on weekly reports generated by the treatment nurses, electronic charting and review of the hard copy of the chart but she had not seen or spoken to the resident. The RD also indicated that she would recommend that lab tests be done only if the resident had any weight changes and she had not recommended any labs for the resident. RD 1 also indicated that supplements would not help [MEDICAL CONDITION] ulcers. RD 1 stated the resident was receiving a protein supplement as of (MONTH) 13, (YEAR), and did not know who had ordered the supplement, and she saw the order but it did not mean anything to her. RD 1 also indicated the resident did not have a current pre-[MEDICATION NAME] level. RD 1 stated she would continue to monitor the resident's weight because as an RD this was the only monitoring she did for the resident. On (MONTH) 16, (YEAR), at 5:25 p.m., during an interview with both the DON and RD 1, the DON stated that, Unfortunately the facility has issues with poor assessments. As she was reading Resident 20's Weekly Skin Progress Notes she stated, the notes do not say too much. The DON also stated the IDT should have notified the physician to get him involved to see the resident. RD 1 stated she should have recommended lab tests such as a basic metabolic panel (a blood test that measures blood sugar, electrolyte (body fluids), fluid balance, and kidney function) and pre-[MEDICATION NAME] which would have provided a current hydration and protein status of the resident. On (MONTH) 17, (YEAR), at approximately 4:45 p.m., during an interview the DON stated she would call a wound consultant to do a wound assessment for Resident 20. A review of a Wound Consult dated (MONTH) 18, (YEAR), indicated the reason for the consult was to manage Resident 20's chronic, reoccurring wounds of the left lateral lower leg. The wound on left lateral lower leg was indicated as a chronic venous ulcers noted of superficial depth and relatively small size along the extreme aspects connected by a large bed of [MEDICATION NAME] (an essential component of wound healing) tissue with a small bed of dry, stable eschar medially (toward the middle) located, with scant (serous watery fluids in the body) drainage, no odor, non[DIAGNOSES REDACTED]tous (no redness) with 25% granulation, 5% eschar (necrotic/dead tissue on the skin after a burn, gangrene, ulcer, fungal infection, and spider bite), 70 % [MEDICATION NAME] tissue. The wound measured 16.5 cm (16.5 cm = 6.46 in) length, 12.0 cm (12 cm = 4.72 in) width, unable to determine depth, 198.0 cm2 wound area. Resident 20 had the following orders from the wound consultant dated (MONTH) 18, (YEAR): 1. Apply ammonium [MEDICATION NAME] (used to treat dry, scaly, itchy skin), lotion 12% on left and right lower extremity skin for dryness daily. 2. Cleanse left lower leg dry, body escar with normal saline, pat dry, paint with [MEDICATION NAME] (a mild antiseptic- prevent the growth of disease-causing microorganisms) solution, cover with dry dressing and wrap with Kerlix daily for 14 days. 3. Cleanse left lower leg venous ulcer with normal saline, pat dry, apply collagen matrix dressing, (helps to promote the growth of new collagen at the wound site), cover with dry dressing and wrap with Kerlix daily times 14 days. According to the Wound Consult notes dated (MONTH) 18, (YEAR), the wounds were stable and require topical wound dressing therapy. (Resident 20) had chronic wounds which may or may not heal and may worsen as a result of restricted mobility, recurring trauma, non-compliance and [MEDICAL CONDITION] resulting in poor tissue perfusion/possible further tissue break down. The goal of the wound were, wound stabilization, prevention of wound decline, creation of a wound healing bed and reduction of infected tissues. Instructions were to continue offloading (taking all pressure off of)and turn per facility protocol. Follow-up in two days. A review of Resident 20's physician H & P report dated (MONTH) 3, (YEAR), did not have any reference to the resident's skin condition. The Skin section of the H & P was left blank. The physician's and designee's Progress Notes from (MONTH) (YEAR), to (MONTH) 11, (YEAR), did not indicate any documented evidence of the resident's skin condition. The last documented physician's Progress Notes in Resident 20's medical record was dated (MONTH) 6, (YEAR). On (MONTH) 27, (YEAR), at 8:15 a.m., during a telephone interview, with Physician 1 (Resident 20's physician), when asked the reason why there are no reference to the resident's skin condition, Physician 1 stated that he was being told by the facility licensed staff that the resident's skin condition was progressing well. When asked why the resident did not have any physician progress notes [REDACTED]. A review of the facility's Job Description for the position of Dietitian Category III, revised (MONTH) 9, 2012, indicated the dietitian is responsible for utilizing the nutrition care delivery process in providing nutritional care to the residents in the center. He/she advises Administration, Director of Nursing and Food Service Director as needed on all clinical aspects of nutrition care and abides by all standards set forth by applicable regulatory agencies and licensing boards. The dietitian assesses the nutritional status of residents per standards of practice, monitors and evaluates effectiveness of nutritional interventions, ensures appropriate and timely documentation of nutrition assessment tools, recommended interventions and follow-up. addresses appropriate nutrition concerns with all members of the interdisciplinary team. A review of the facility's policy and procedure, reviewed on (MONTH) 1, (YEAR), titled, Nursing Documentation, indicated nursing documentation will follow the guidelines of good communication and be concise, clear, pertinent, and accurate. Narrative charting, as outlined in specific policies and procedures, will be used for initial treatments or procedures. Documentation for subsequent and/or routine care and procedures may be completed by exception or the use of a checklist, flow charts, or other documentation tools. The purpose of the documentation is to communicate patient's status and provide accurate accounting of care and monitoring provided. Effective treatments for venous leg ulcer include four layer compression bandaging (a compression bandaging method that achieves better healing rates than traditional compression bandaging), leg elevation, improve mobility, reduce obesity, improve nutrition, skin grafting in selected patients, venous surgery in selected patients, (2004, (MONTH) 5, Management of Venous Leg Ulcers, Academic Department of Surgery, Wythenshawe Hospital, Manchester, M23 9LT.) b. According to the admission records Resident 16 was admitted to the facility on (MONTH) 27, (YEAR), with [DIAGNOSES REDACTED]. A review of Resident 16's Admission Minimum Data Set (MDS- a standardized comprehensive assessment screening tool) dated (MONTH) 8, (YEAR), indicated Resident 16 had moderately impaired cognition, was able to understand and make self understood. Resident 16 required extensive assistance for activities of daily living and required limited assistance for eating. During the survey process resident was declining and requiring total assistance by staff, and was placed under Hospice care on (MONTH) 3, (YEAR), for mediastinal metastatic adenopathy (spread [MEDICAL CONDITION] of the lymph nodes). A review of the residents Medication Administration Record [REDACTED]. A review of Resident 16's MAR for the month of (MONTH) (YEAR), included an order dated (MONTH) 16, (YEAR), for NPO (nothing by mouth) while resident is unconscious except comfort medications. A review of the residents (MAR) for the month of (MONTH) (YEAR), included an order dated (MONTH) 16, (YEAR), to hold the residents [MEDICATION NAME] (medication for anxiety) which can treat anxiety, muscle spasms, and [MEDICAL CONDITION]) and keep resident on her side every shift. On (MONTH) 17, (YEAR) at 11:10 a.m., during an interview the Hospice Nurse stated up until last week, she was visiting the resident three times a week, and since (MONTH) 19, (YEAR), has been visiting daily. The Hospice Nurse stated the resident was having small [MEDICAL CONDITION] and the medication was not effective, therefore was changed. The Hospice Nurse stated the facility staff report when the resident has a [MEDICAL CONDITION] and the resident was currently on comfort measures. A review of Resident 16's care plan dated (MONTH) 20, (YEAR), for [MEDICAL CONDITION], indicated the resident exhibits and /or is at risk for [MEDICAL CONDITION] activity related to history of [MEDICAL CONDITION] disorder. The goals section indicated the resident will be free of any [MEDICAL CONDITION] related injury. The interventions sections of the care plan indicated in the event of seizur (TRUNCATED)

Based on observation, interview, and record review, the facility failed to ensure a resident who wore dentures was provided with well fitting dentures and a diet as ordered to maintained acceptable parameters of body weight for one out of 24 sample residents (Resident 6), by failing to: 1. Continuously assess, monitor, and evaluate Resident 6's weight record, and inform the physician and/or Registered Dietitian (RD) for timely medical interventions when the resident experienced weight loss. 2. Ensure the facility implemented Resident 6's plan of care to prevent weight loss when the resident's intake did not meet the required caloric needs. These deficient practices resulted in Resident 6's unplanned weight loss of 10 pounds (9.0 %) in one month. Findings: On (MONTH) 15, (YEAR), at approximately 9:30 a.m., during the initial tour, Resident 6 was observed in bed, awake, but the resident did not speak the facility's dominant language. However, the resident was able to communicate in her language and she wanted ice water. Resident 6 stated her family visits at times, but does not remember if they visit daily. On (MONTH) 24, (YEAR), at 7:55 a.m., during a general observation, Resident 6 was observed in her bed having breakfast independently. According to the admission record, Resident 6 was admitted to the facility on (MONTH) 2, (YEAR), and readmitted on (MONTH) 11, (YEAR), with [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS - an assessment and care screening tool) dated (MONTH) 6, (YEAR), indicated Resident 6 had the ability to make herself understood and understand others and was cognitively intact skills for daily decision making. The MDS also indicated the resident required extensive assistance with eating, was frequently incontinent of bowel and bladder, and had a height of 64 inches, weight of 93 pounds The MDS indicated the resident had weight loss and not on physician-prescribed weight-loss regimen. A review of Resident 6's care plan created on (MONTH) 8, (YEAR) and updated (MONTH) 7, (YEAR), for nutritional risk of unintentional weight loss (10.8 pounds, (9.8%) times six months). Resident noted to have poor oral intake of most meals, requires assistance with feeding. The goal indicated the resident would consume 75% of at least three meals daily times 90 days. The interventions included to evaluate for proper consistency of diet, encourage resident to chew and swallow each bite, weigh weekly times four weeks and alert the dietitian and physician to any significant loss or gain, monitor for changes in nutritional status, monitor for changes in nutritional status (change in intake, ability to feed self, unplanned weight loss/gain, abnormal labs) and report to food and nutrition/physician as indicated, monitor intake at all meals, offer alternate choices as needed, alert dietitian and physician to any decline in intake. A review of the Registered Dietitian's (RD) Nutritional assessment dated (MONTH) 8, (YEAR), indicated Resident 6 had an order for [REDACTED]. Food preferences were obtained and was communicated to dietary staff. Ideal Body Weight (IBW) range was indicated to be 110 pounds to 120 pounds to 130 pounds. According to the Assessment the resident did not have any swallowing problems and did not have any weight gain or loss. The Assessment also indicated the resident had poor to good oral intake of approximately all meals since admit. According to the Assessment the nutritional needs included calorie needs to be 1327 Kcal, protein needs 64 - 75 grams, and oral intake was meeting 80% of resident's estimated kcal needs and approximately 50 - 60% of protein needs. The Assessment also indicated the resident had nutritional problems with increased nutrient needs. A review of Resident 6's weight log indicated the following: 1. (MONTH) 1, (YEAR) - 111 lbs. 2. (MONTH) 9, (YEAR) - 101 lbs. 3. (MONTH) 1, (YEAR) - 101 lbs. 4. (MONTH) 1, (YEAR) - 99.2 lbs. 5. (MONTH) 1, (YEAR) - 99 lbs. 6. (MONTH) 8, (YEAR) - 93 lbs. 7. (MONTH) 1, (YEAR) - 92 lbs. Resident 6 had a 10 pound weight loss from 111 lbs. on (MONTH) 1, (YEAR) to 101 lbs. on (MONTH) 9, (YEAR), which was equivalent to a 9.0 % severe weight loss within one month. Resident 6 continued to lose an additional seven pounds that resulted in further significant weight loss in (MONTH) 1, (YEAR). Resident 6 had a 19 lbs. weight loss from 111 lbs. on (MONTH) 1, (YEAR) to 92 lbs (MONTH) 1, (YEAR), which is equivalent to a 17 % severe weight loss in the last six months. According to the Centers for Medicare and Medicaid Services (CMS), suggested parameters for evaluating significance of unplanned and undesired weight loss are: Interval Significant Loss Severe Loss 1 month 5 % Greater than 5 % 3 months 7.5 % Greater than 7.5 % 6 months 10 % Greater than 10 % Resident 6 had the following physician's orders [REDACTED].>1. Puree Advanced Dysphagia diet dated (MONTH) 11, (YEAR). 2. Regular/liberalized diet, dysphagia puree texture (diet used with people who have problems with chewing and swallowing. This food is blended or strained to make it the right consistency and requires no chewing) dated (MONTH) 19, (YEAR). As noted above Resident 6 continued to loose weight after (MONTH) 1, (YEAR). A Nutrition Progress Note by Registered Dietitian 1 (RD 1), dated (MONTH) 15, (YEAR), indicated the resident lost 10 pounds (9% (severe loss)) in one month. Oral intake shows improvement 75 - 100% in the past few days, previously 25 - 50 % (intake). According to the note the resident was having issues with dentures, and was receiving dysphagia puree diet and as per the family the resident disliked it. The Note indicated house supplement would be added three times daily with meals. Receives [MEDICATION NAME] ((medication to decrease fluid accumulated in the body through urine) 40 milligram daily for high blood pressure) daily with weight fluctuations expected/potentially unavoidable. Will continue to monitor. The note made no mention how the resident's dislike for puree diet was going to be addressed. A review of Resident 6's Activity of Daily Living Record for the month of (MONTH) (YEAR) and (MONTH) (YEAR) indicated the meal percent consumption by the resident for breakfast, lunch, and dinner. The average percent consumed for each meal was calculated for each month as follows: For the month of (MONTH) (YEAR), average breakfast meal consumed was 76 %, lunch 73 %, and for dinner 60 %. For the month of (MONTH) (YEAR), average breakfast meal consumed was 60 %, lunch 56%, and dinner 60 %. A Nursing Progress Notes dated (MONTH) 15, (YEAR), regarding Weight Change, indicated Resident 6 had a weight loss of 10 lbs. 9 % monthly weight loss, the resident had poor oral intake of 25 - 50 % of regular liberalized puree diet. The physician and Registered Dietitian were aware. Continue with monthly weight monitoring. Continue with plan of care and monitor resident for changes. A Nutrition Progress Note dated (MONTH) 25, (YEAR), by RD 1 indicated Resident 6 had significant weight loss for three months, the resident continued on dysphagia puree diet with house supplement three times daily with meals. RD 1 could not provide documented evidence Resident 6 had been reassessed by Dietary or the Nursing staff when the resident lost 10 pounds from (MONTH) (YEAR) to (MONTH) (YEAR). On (MONTH) 24, (YEAR), at approximately 4:20 p.m., during an interview the Director of Nusing (DON) stated a Change of Condition report had not been completed by the licensed staff regarding Resident 6's ten pound weight loss in one month, from (MONTH) 1, (YEAR), when the resident weighed 111 lbs to (MONTH) 9, (YEAR), when the resident was weighed at 101 lbs. The DON also stated that her nurse's notes of (MONTH) 15, (YEAR) were not clear when and by whom Resident 6's physician was made aware of the weight loss. According to Resident 6's physician's Progress Notes, reviewed with the DON, the physician was in to see the resident approximately every 60 days. According to the DON the physician's review notes do not mention anything about resident's severe weight loss. A review of Nursing Notes dated (MONTH) 12, (YEAR), with the DON, indicated Resident 6's physician was notified of weight change within the last 180 days. No new orders were placed at the time but would continue to monitor the resident and weigh weekly to make sure there were no more (weight) changes. It was approximately four months between (MONTH) 15, (YEAR), and (MONTH) 12, (YEAR), when it was documented the physician was notified of Resident 6's weight loss. Resident 6 had a physician's orders [REDACTED]. According to the Weekly Weights List provided by the DON for (MONTH) (YEAR) and (MONTH) (YEAR), Resident 6 was not on this list. On (MONTH) 24, (YEAR) at 4:55 p.m., during an interview the DON stated there was no evidence in the medical record that weekly weights had been done in (MONTH) (YEAR), for Resident 6 as indicated in the Nursing Notes of (MONTH) 12, (YEAR). The DON stated it was important to weigh the resident weekly to note any weight changes such as improvements or decline. During this interview the DON stated the plan of care of weight loss was not updated on (MONTH) 9, (YEAR) with the resident's current weight status. The focus issue, the goal, and the significant interventions of the plan of care to date had remained the same since the resident was admitted on (MONTH) 2, (YEAR). The DON also stated the care plan interventions should have been updated with information obtained from the resident or her family and interventions should have been more specific to the resident such as to include culture specific foods, and general food preferences. The DON also stated that not only should the plan of care interventions should have been updated but implemented as well. Resident 6 had a physician's orders [REDACTED]. On (MONTH) 27, (YEAR) at 4:20 p.m., during interview the Speech Therapist (ST) stated that Resident 6's family approached ST in (MONTH) (YEAR), because they were concerned the resident was not eating. ST stated Resident 6 did not like the puree diet she was on. The resident stated Definitely would not go back to puree diet. ST stated that on (MONTH) 26, (YEAR), she recommended the resident be placed on dysphagia advanced texture diet. A review of the facility's policy and procedure, revised (MONTH) 28, (YEAR), titled, Nutrition Care Process, indicated Residents are visited and assessed upon admission and routinely thereafter, to assure that each resident receives timely, individualized, and consistent nutritional care. Care plans are evaluated and updated a minimum of quarterly or as scheduled according to established policies.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was provided with the necessary care and services to attain optimal improvement in condition and did not deteriorate outside the limits of normal and recognized processes. For Resident 1, who had a history of [REDACTED]. 1. Administer medications as ordered ([MEDICATION NAME] - a medication that affects the heart and blood flow through arteries and veins to treat high blood pressure). 2. Report vital sign abnormalities to the physician, per the care plan. 3. Recognize and report the change of condition (altered level of concious and possible stroke) to the registered nurse and physician in a timely manner. These deficient practices resulted in Resident 1 not receiving immediate treatment for [REDACTED]. Findings: A review of the admission face sheet indicated Resident 1 was admitted to the facility, on [DATE], with [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS, an assessment and care planning tool), dated [DATE], indicated Resident 1 made consistent / reasonable decisions regarding the tasks of daily life, and required extensive one person physical assistance with ambulation, wheelchair transport, dressing, toileting, and bathing. The resident was continent of bowel and bladder, had impaired range of motion to her upper extremity on one side, and was not steady, only able to stabilize with staff assistance when walking, turning, standing, and transferring surface to surface. A review of the Situation, Background, Assessment and Request (SBAR) Communication Form, dated [DATE], timed at 12 p.m., indicated Licensed Vocational Nurse 1 (LVN 1) reported Resident 1 had a change in condition and the symptoms or signs included altered level of consciousness and possible stroke. The resident's blood pressure was ,[DATE] mmHg (normal range is between ,[DATE] and ,[DATE]) and her pulse was 130 beats per minute (normal range is between 60 to 100). Further review of the SBAR form indicated Resident 1 had decreased consciousness (not arousable but responsive to tactile stimuli), had altered level of consciousness, possible stroke, and LVN 1 requested the resident be transferred to the GACH. A review of the Medication Administration Record [REDACTED]. A review of the Daily and Q Shift Charting narrative notes (incorrectly dated [DATE], as verified by the Director of Nursing) indicated Resident 1 was in bed asleep and snoring at 7 a.m. At 9 a.m., LVN 1 went to the resident's room to administer her medication, but the resident was still asleep and snoring. The narrative notes indicated LVN 1 tried to wake up Resident 1 but there was no verbal response, just moving the right hand and both feet, vital signs were stable, and meds not given. The Daily and Q Shift Charting narrative notes indicated, at 10 a.m., LVN 1 went to Resident 1's room and found the resident still asleep. LVN 1 tried to wake up the resident for her medication, but only responsive to tactile stimuli, just moving the right hand and both feet when her name was called or when she was touched. The narrative notes indicated the vital signs were stable, breathing was even and unlabored. At 11:30 a.m., LVN 1 documented in the narrative notes Resident 1 was asleep snoring, and he called for assistance to wake up the resident. The residents blood pressure was ,[DATE], heart rate was 130. The Daily and Q Shift Charting narrative notes indicated the paramedic was called right away and arrived at 11:37 a.m., paramedic took Resident 1 and left at 12 noon. A review of a Resident 1's care plan, dated [DATE], indicated resident exhibits or was at risk for cardiovascular symptoms or complications related to [DIAGNOSES REDACTED]. The care plan goal indicated the resident's blood pressure would remain within baseline parameters of ,[DATE] mmHg for 90 days. The care plan interventions included to administer medications as ordered, assess for effectiveness, report abnormalities to physician, assess and monitor vital signs as ordered. During an interview and record review, on [DATE], at 2 p.m., the MDS Nurse confirmed there were no care plans addressing Resident 1's [DIAGNOSES REDACTED]. During an interview with the Director of Nursing (DON), on [DATE], at 8:10 a.m., she stated on the day of the incident, LVN 1 came to her around 11 a.m., and told her Resident 1 did not want to get up. The DON stated she would have expected LVN 1 to report to her or the floor supervisor when he first noted the change of condition at 9 a.m. During an interview with Registered Nurse 1 (RN 1, the floor supervisor), on [DATE], at 9:20 a.m., she stated around lunchtime, LVN 1 told her a resident was not awake yet. RN 1 stated she was paged to Resident 1's room and when she arrived, a lot of staff were already there. RN 1 stated the resident's blood pressure was so high, 911 was called. During a phone interview with LVN 1, on [DATE], at 10 a.m., he stated he did not know Resident 1 or what time she usually woke up in the morning. He stated he went to the resident's room at 9 a.m., to medicate her, she was still asleep and he did not wake her up. LVN 1 stated he asked another staff if the resident was like that, but they did not know. LVN 1 stated the resident was moaning, .but like in a deep sleep and hard to wake up. He stated the resident was just transferred from another station and he did not know the resident at all. LVN 1 stated he returned to Resident 1's room at 10 a.m. (one hour later) and called her name and tried to wake her up by holding her shoulders and shaking her. He stated the resident moved her right hand a little, and raised her feet slightly and looked like she tried to open her eyes, but only squinted. He stated he took the resident's blood pressure and vital signs, but did not write them down. He stated he checked the resident's blood sugar level also, but did not write it down. LVN 1 stated he tried tactile stimuli to wake the resident up. He stated he tried to pinch her and tickled her foot. The resident responded the same as earlier, but did not wake up. LVN 1 stated he thought the resident was just sleeping. LVN 1 stated at 11 a.m., he returned to Resident 1's room and found her still sleeping. He stated he then went to the nurse's station to check the resident's chart and to ask about the resident. Staff at the station stated sometimes Resident 1 slept late. LVN 1 stated he then asked for help with the resident. During an interview with Certified Nurse Aide 2 (CNA 2), on [DATE], at 9:45 a.m., she stated she was assigned to Resident 1 for the first time the day of the incident. She stated Resident 1 was in bed around 7 a.m., and she called out to her but she did not wake up, so she took the resident's vital signs, gave them to LVN 1, and went on to her next patients. CNA 2 stated she brought Resident 1's breakfast tray at around 7:,[DATE]:30 a.m. CNA 2 stated she again called out to the resident, raised the head of her bed up a little, but Resident 1 did not wake up. CNA 2 stated she notified LVN 1 of the resident's situation and LVN 1 responded that the resident was just sleeping. CNA 2 stated she returned to the resident's room around 8:20 a.m., and opened the resident's milk carton, but Resident 1 still did not open her eyes. CNA 2 stated she checked and the resident had a pulse. CNA 2 stated she returned to the resident's room at 8:30 a.m., found Resident 1 still sleeping and again informed LVN 1, who stated it was OK, the resident was sleeping. CNA 2 stated she returned to Resident 1's room at 10:30 a.m., and found the resident still sleeping and informed LVN 1, who responded OK. CNA 2 stated she went to lunch at 11:30 a.m., and she always gave report to the LVN before she left the floor. CNA 2 stated she told LVN 1 that Resident 1 was not responding and she did not put her in the wheelchair, and the resident was still in bed. LVN 1 said OK. A review of the facility's Job Description for LVN, revised on [DATE], indicated the LVN was responsible for observing patient conditions and reporting changes in condition to the Registered Nurse (RN). The LVN administered medications per physician's orders [REDACTED]. According to the Job Description, the LVN communicated patient information with unlicensed staff and monitored and followed-up on assigned responsibilities of unlicensed staff. The LVN job skills included a comprehensive knowledge of nursing principles required, including the ability to recognize and identify symptoms and manage emergency situations. During an interview and record review with the Medical Records clerk, on [DATE], at 2:30 p.m., she confirmed there was no discharge summary for Resident 1. The medical records clerk stated she put all the resident's documents in the chart and there was no discharge summary. A review of the acute hospital emergency department admission report indicated Resident 1 was admitted , on [DATE], in critical condition with altered level of consciousness for unknown time since the previous night. Admission [DIAGNOSES REDACTED]. In most cases, causes no symptoms and goes unnoticed. In rare cases, it ruptures, releasing blood into the skull and causing a stroke), and new onset [MEDICAL CONDITION]. A review of the GACH's history and physical form, from the emergency admission, indicated Resident 1 was comatose due to acute hemorrhagic stroke (blood spills into or around the brain and creates swelling and pressure, damaging cells and tissue in the brain). A neurological consult (a visit with a highly-trained physician in the function and malfunction of the brain, nervous system, and muscles) at 4 p.m., on [DATE], indicated Resident 1 had sustained bleeding in the brain and the prognosis was extremely poor for survival or any neurological recovery. A review of Resident 1's Discharge Summary from the GACH indicated hospice placement was discussed with the family and Resident 1 was discharged on [DATE]. A review of the hospice clinical record indicated Resident 1 was admitted to hospice care, on [DATE], and died the following day, [DATE]. A review of the facility's policy and procedure titled, Change in a Resident's Condition or Status, undated, indicated the facility would promptly notify the resident, the physician, and representative of changes in the resident's medical/mental condition. The nurse supervisor/charge nurse would notify the resident's attending physician when there had been a significant change in the resident's physical / emotional / mental condition or a need to transfer the resident to a hospital/treatment center. The policy indicated if a significant change in the resident's physical or mental condition occurred, a comprehensive assessment of the resident's condition would be conducted as required by current OBRA regulations governing resident assessments and as outlined in the MDS 2.0 RAI Instruction Manual. A review of the facility's policy and procedure titled, Medication Administration: General, revised on [DATE], indicated a licensed nurse would administer medications to patients following accepted standards of practice. The facility's policy and procedure titled, Medication Administration Times, revised on [DATE], indicated medications were administered within 60 minutes before or after the facility's medication administration schedule.

Based on observation, interview, and record review, the facility failed to provide supervision for the resident during ambulation and did not implement care plan interventions when necessary (to assist resident during ambulation) for one of three sampled residents (Resident 1). For Resident 1, who had a history of [REDACTED]. This deficient practice resulted in Resident 1 suffering a fall with injuries while ambulating unsupervised from the appointment and sustaining a dislocation of a previously injured left shoulder (fracture). Findings: A review of the clinical record indicated Resident 1 was admitted to the facility, on November 16, 2015, with [DIAGNOSES REDACTED]. A review of Resident 1's Fall Risk Review for admission, dated December 1, 2015, indicated unsteady gait / balance due to lower extremity weakness, a history of falling, [DIAGNOSES REDACTED]. The Fall Risk Review indicated Resident 1 had single or multiple falls in 30 days, fracture secondary to fall and placed the resident at high risk. A review of the Minimum Data Set (MDS - a care planning and assessment screening tool), dated December 10, 2015, indicated Resident 1 was cognitively intact, required limited assistance with one person physical assist for transfer, and walking. The MDS indicated a wheelchair mobility device was normally used. A review of the Care Plan for risk for falls, dated December 14, 2015, indicated the goal was for Resident 1 to have no falls with injury for 90 days and the interventions included to assist Resident 1 with ambulation providing limited assistance using a walker. According to the Physical Therapy Discharge Summary, dated December 31, 2015, Resident 1 was to safely ambulate on level surfaces, with supervision. A review of the Restorative Nursing Referral, dated December 31, 2015, indicated Resident 1 received restorative nursing services for ambulation every day, five times per week, as tolerated, and supervision was the level of assistance required. A review of the Transportation Service Request Form, for CT (computed tomography/X-ray) scan appointment, scheduled January 20, 2016, at 2 p.m., indicated Resident 1 was ambulatory, no devices were indicated, and the resident was able to transfer self safely. A review of the SBAR (Situation Background Assessment Request) Post Fall form, dated January 21, 2016, indicated on January 20, 2016, at 4 p.m., Resident 1 stated she fell , on the concrete outside the appointment building. The resident stated she walked outside the building, missed the two small steps, and fell to the concrete. The SBAR Post Fall form indicated Resident 1 hit the left side of her face and left shoulder, sustained injuries including abrasion of the right knee, bruising of the left eyebrow, and discoloration on left shoulder. The resident complained of pain on the right knee, left side of the face, and left shoulder. The SBAR post fall form indicated to monitor vital signs, neuro checks, and an x-ray was recommended. A review of the Radiology Detail Report, dated January 22, 2016, indicated Resident 1 received an X-ray for post traumatic left shoulder pain. The findings and impression indicated an anterior (frontal) shoulder dislocation (to put out of joint or out of position) and an acute fracture. On January 29, 2016, at 3 p.m., during an interview, the licensed vocational nurse (LVN 1) stated, on January 20, 2016, Resident 1 went out of the facility to an appointment, unaccompanied by transportation. LVN 1 stated upon the resident's return from the appointment she was medicated for complaints of pain in the left shoulder and went to bed. During an observation, on January 29, 2016, at 3:30 p.m., Resident 1 was observed ambulating in the hallway with an unsteady gait, her left arm was noted in a sling, and a light green color was noted above the resident's left eye. During a concurrent interview, Resident 1 stated she was at the imaging center for an appointment, waiting alone for transportation. As the resident walked to go check for transportation, she tripped over two small steps, and fell to the ground, hitting her left shoulder, face, and knee. Resident 1 stated a person passing helped her up from the ground and the pain in her left shoulder and right arm became worse. Resident 1 stated she noticed a scrape over her left eye later, after she returned to the facility. During an interview, on February 4, 2016, at 11:45 a.m., the Physical Therapist (PT 1) stated Resident 1 was able to ambulate around 200 feet on a level surface with supervision. PT 1 stated the resident had stair training with the hand rail and supervision, and that Resident 1 should have been supervised when ambulating. A review of the facility's policy titled, Transportation and Escort: Patient, dated September 1, 2013, indicated the staff may escort patients, if needed, to assure patient safety.

Based on observation, interview, and record review, the facility failed to provide supervision for the resident during ambulation and did not implement care plan interventions when necessary (to assist resident during ambulation) for one of three sampled residents (Resident 1). For Resident 1, who had a history of [REDACTED]. This deficient practice resulted in Resident 1 suffering a fall with injuries while ambulating unsupervised from the appointment and sustaining a dislocation of a previously injured left shoulder (fracture). Findings: A review of the clinical record indicated Resident 1 was admitted to the facility, on November 16, 2015, with [DIAGNOSES REDACTED]. A review of Resident 1's Fall Risk Review for admission, dated December 1, 2015, indicated unsteady gait / balance due to lower extremity weakness, a history of falling, [DIAGNOSES REDACTED]. The Fall Risk Review indicated Resident 1 had single or multiple falls in 30 days, fracture secondary to fall and placed the resident at high risk. A review of the Minimum Data Set (MDS - a care planning and assessment screening tool), dated December 10, 2015, indicated Resident 1 was cognitively intact, required limited assistance with one person physical assist for transfer, and walking. The MDS indicated a wheelchair mobility device was normally used. A review of the Care Plan for risk for falls, dated December 14, 2015, indicated the goal was for Resident 1 to have no falls with injury for 90 days and the interventions included to assist Resident 1 with ambulation providing limited assistance using a walker. According to the Physical Therapy Discharge Summary, dated December 31, 2015, Resident 1 was to safely ambulate on level surfaces, with supervision. A review of the Restorative Nursing Referral, dated December 31, 2015, indicated Resident 1 received restorative nursing services for ambulation every day, five times per week, as tolerated, and supervision was the level of assistance required. A review of the Transportation Service Request Form, for CT (computed tomography/X-ray) scan appointment, scheduled January 20, 2016, at 2 p.m., indicated Resident 1 was ambulatory, no devices were indicated, and the resident was able to transfer self safely. A review of the SBAR (Situation Background Assessment Request) Post Fall form, dated January 21, 2016, indicated on January 20, 2016, at 4 p.m., Resident 1 stated she fell , on the concrete outside the appointment building. The resident stated she walked outside the building, missed the two small steps, and fell to the concrete. The SBAR Post Fall form indicated Resident 1 hit the left side of her face and left shoulder, sustained injuries including abrasion of the right knee, bruising of the left eyebrow, and discoloration on left shoulder. The resident complained of pain on the right knee, left side of the face, and left shoulder. The SBAR post fall form indicated to monitor vital signs, neuro checks, and an x-ray was recommended. A review of the Radiology Detail Report, dated January 22, 2016, indicated Resident 1 received an X-ray for post traumatic left shoulder pain. The findings and impression indicated an anterior (frontal) shoulder dislocation (to put out of joint or out of position) and an acute fracture. On January 29, 2016, at 3 p.m., during an interview, the licensed vocational nurse (LVN 1) stated, on January 20, 2016, Resident 1 went out of the facility to an appointment, unaccompanied by transportation. LVN 1 stated upon the resident's return from the appointment she was medicated for complaints of pain in the left shoulder and went to bed. During an observation, on January 29, 2016, at 3:30 p.m., Resident 1 was observed ambulating in the hallway with an unsteady gait, her left arm was noted in a sling, and a light green color was noted above the resident's left eye. During a concurrent interview, Resident 1 stated she was at the imaging center for an appointment, waiting alone for transportation. As the resident walked to go check for transportation, she tripped over two small steps, and fell to the ground, hitting her left shoulder, face, and knee. Resident 1 stated a person passing helped her up from the ground and the pain in her left shoulder and right arm became worse. Resident 1 stated she noticed a scrape over her left eye later, after she returned to the facility. During an interview, on February 4, 2016, at 11:45 a.m., the Physical Therapist (PT 1) stated Resident 1 was able to ambulate around 200 feet on a level surface with supervision. PT 1 stated the resident had stair training with the hand rail and supervision, and that Resident 1 should have been supervised when ambulating. A review of the facility's policy titled, Transportation and Escort: Patient, dated September 1, 2013, indicated the staff may escort patients, if needed, to assure patient safety.

Based on observation, interview, and record review, the interdisciplinary team failed to ensure that residents assessed at risk for falls and who had experienced recurrent falls would not have injuries for one random sample resident (26) and for three out of 24 sample residents (1, 2,17) by failing to: 1. Provide adequate and continuous supervision to Resident 26, that resulted to sustain an oblique fracture to the right femur that required a surgical repair at the general acute care hospital and hospitalization for nine days. 2. Ensure the safety of the resident by not locking the bed wheels and the resident's wheelchair that was placed near at the foot of the bed that resulted to laceration of the head due to a fall (17), 3. Ensure that a resident who was being wheeled in the wheelchair by a staff member was provided with the appropriate foot rests so as to ensure the resident's feet would not hang and be dragged along the floor that caused the potential for accidents (2), 4. Ensure that a resident was provided with adequate supervision and staff members were able to answer the call light in a timely manner when the resident needed help to go to the bathroom as indicated in the resident's plan of care wherein the resident had an episode of fall that had a potential to sustain injury (1) for three out of 24 sample residents and one randomly selected resident (1, 2, 17, 26). As a result of the facility's failure, Resident 26 was placed at risk for potential complications of surgery that included bleeding, infection, heart attack, pneumonia, and kidney failure during or after an operation, deep venous thrombosis (DVT-occurs when blood clots develop in the large veins of the leg, and Resident 17 sustained a forehead laceration and required surgical intervention, and Resident 1 and 2, were placed at risk for serious injuries related to falls. Findings: a. According to the admission record, Resident 26 was originally admitted to the facility on [DATE] and was readmitted on [DATE], with [DIAGNOSES REDACTED]. dementia without behavioral disturbance, history of falling, contracture of the knee and foot and glaucoma. The quarterly Minimum Data Set (MDS- a comprehensive assessment and screening tool) dated June 15, 2015, indicated the resident's cognitive patterns were intact, no mood and behavioral symptoms, needed limited assistance from staff members for bed mobility, transfer, walking in the room and in the corridor, dressing, toilet use, and personal hygiene. The MDS also indicated Resident 26 was independent, was not steady but able to stabilize without staff assistance when moving from a seated to a standing position. There were two falls with no injury since admission/entry or reentry or prior assessment. There was a plan of care initiated on May 5, 2015, that indicated Resident 26 was found lying on the floor. The care plan had a goal that indicated the resident would not suffer from any injury secondary to fall. The interventions included the use of non-skid footwear at all times, personal alarm device while in wheelchair, and call for assistance when attempting to ambulate. However, the care plan did not include interventions for using personal alarm device while in bed. Although the MDS assessment dated [DATE], indicated the resident had two falls, the plan of care did not include interventions to monitor the resident by means of frequent structured nursing rounds to meet and anticipate the resident's needs. A review of the literature indicates that falls frequently occur when patients get out of bed and go to the bathroom, walk to or from the bathroom, or experience an episode of incontinence. Frequent structured Nursing rounds- in which the nursing staff would perform specific tasks at set intervals could help reduce the incidence of falls. Studies have demonstrated the benefits of having structured frequent rounds and performing specific nursing actions, such as asking whether the patient needed anything and assisting with toileting, at set intervals was associated with statistically significant reductions in patient ' use of call lights and the incidence of falls, and with an increase in patient satisfaction (Stefancyk, Amanda. Safe and Reliable Care, American Journal of Nursing, July 2009, Volume 109 No.7, Pages 70-71. The MDS assessment completed for significant change dated July 26, 2015, indicated Resident 26's cognitive patterns were severely impaired, needed extensive assistance from staff members for bed mobility, transfer, and was totally dependent from staff members for toileting. The resident was assessed to be not steady when performing surface-to-surface transfer (transfer between bed and chair or wheelchair) and was only able to stabilize with staff assistance. The resident used wheelchair as a mobility device. Resident 26's care plan was not updated to include interventions useful to prevent falls and injuries after the facility assessed the resident as severely impaired in cognition on June 26, 2015. The plan of care did not include intervention to adequately and continuously monitor Resident 26. A review of the care plan related to incidents of falls indicated the following: 1. On January 29, 2015, the resident was found seated on the floor next to the wheelchair. The resident was assessed with [REDACTED]. 2. On April 21, 2015, the resident was found seated on the floor next to the wheelchair. The post fall assessment dated [DATE], indicated there was no injury noted. 3. On May 7, 2015, Resident 26 was found on the floor in the hallway. According to the post fall assessment dated [DATE], the resident was to use personal alarm device while in bed and when up in the wheelchair. A review of Resident 26's licensed nurses' note dated May 7, 2015, at 5 p.m., indicated the fall was unwitnessed. There was no injury noted. The physician was notified. an order for [REDACTED]. A personal alarm monitor was then placed on Resident 26 with frequent monitoring interventions (the interval of monitoring was not indicated). The care plan dated May 7, 2015 was updated to include a personal alarm device while in bed. 4. On July 5, 2015, Resident 26 was found on the floor. A review of the nurses' notes dated July 5, 2015, indicated at 7:30 a.m., Resident 26 was found on the floor at the foot of the bed while both side rails were in upward position. The resident's left leg was noted swollen. The physician was made aware and an order was obtained for an x-ray. A review of the licensed nurses' note dated July 5, 2015, at 7:30 a.m., indicated Resident 26 had a fall. The resident was unable to tell what had happened to her. The resident's pain was assessed a five (on a 1-10 pain assessment scale, 10 being the highest pain). At 10:30 a.m., the resident's leg was swollen and the resident was in pain. The order for the x-ray was changed to STAT (now/immediately). The resident was given Tylenol and fell asleep. While Resident 26 was having recurrent falls on April 21, 2015, and May 7, 2015, and July 15, 2015, the IDT did not update the plan of care to included additional interventions useful to reduce falls. A review of the literature also indicates to reduce the patient's risk of falling from bed, use a bed that can be lowered nearer to the floor and place padded mats on the floor at the side of the bed. Remove side rails, unless the patient uses them to reposition himself in bed, in which case a half rail should be used. High-risk patients require close observation and surveillance. Move the person at risk for falls closer to the Nurses' Station; use of bed alarms may be useful. Meade and colleagues found that hourly rounds that are focused on anticipating and meeting patients' needs may help prevent injuries from falls, and nursing assistants are especially critical to its success. (American Journal of Nursing, March 2008, Volume 108 - Issue 3, Pages 40-49). Resident 26 ' s Nurses Note dated July 5, 2015, on the 3 p.m. to 11 p.m. shift indicated the x-ray result was received. According to the x-ray result the resident had an oblique fracture to her right femur. The physician was notified and an order to transfer the resident to the general acute care hospital (GACH) was obtained. Resident 26 was transferred to the GACH at 8 p.m. The resident complained of pain rated at seven out of 10. Two tablets of 325 milligrams (mg) Tylenol was administered. A review of the GACH's history and physical record dated July 11, 2015, indicated upper and lower right leg had some redness, warmth, and swelling. According to the record from the GACH, Resident 26 was admitted to the hospital and had a surgery known as internal fixation (ORIF- a type of surgical procedure to fix a broken bone) under general anesthesia. Resident 26 was at the GACH from July 5, 2015, to July 14, 2015. Resident 26 was readmitted to the skilled nursing facility on July 14, 2015. A review of the literature indicates having a surgery under a general anesthesia places the elderly at risk and potential complications that included bleeding, infection, heart attack, pneumonia, and kidney failure during or after an operation, deep venous thrombosis (DVT-occurs when blood clots develop in the large veins of the leg. If the blood clots in the veins break apart, they can travel to the lung, where they lodge in the capillaries and cut off the blood supply to a portion of the lung, called a pulmonary embolism) and cause infection (Savel, Richard H., Postoperative Care. Hospital Medicine 2nd ed. Ed. Philadelphia: Lippincott, Williams, & Wilkins, 2005. 261-269. b. According to the admission record, Resident 17 was admitted on [DATE], with [DIAGNOSES REDACTED]. A review of the care plan for at risk for falls related to [DIAGNOSES REDACTED]. The interventions included were to assist Resident 17 getting in and out of bed with assistance, provide resident/caregiver education for safe techniques, remind resident to use call light when attempting to ambulate or transfer, and monitor for and assist in toileting needs. The Minimum Data Set (MDS) assessment dated [DATE], indicated the resident's cognitive patterns were intact, no mood and behavior, needed limited assistance from staff members for bed mobility, transfer, walking in the room and corridor, locomotion on and off the unit, toilet use, and personal hygiene. The resident did not have any functional limitation in range of motion, and used walker as a mobility device. For balance during transitions and walking, Resident 17 was not steady and was only stable to stabilize with staff assistance on surface-to-surface transfer (transfer between bed and chair or wheelchair). The Care Area Assessment (CAA) Summary dated October 28, 2015, indicated falls was a triggered area. Under analysis of findings, the resident was at risk for falls and at risk for fall related injury secondary to impaired mobility function, and impaired activities of daily living (ADL) function due to recent hospitalization for laminectomy. The resident had difficulty maintaining sitting balance and had impaired balance during transitions. A review of the Situation Background Assessment Request (SBAR) dated November 2, 2015, indicated at 10 a.m., Resident 17 had an unwitnessed fall when attempted to transfer. There was no pain noted. Prior to the fall, the resident was in the wheelchair in her room. The resident was found on the floor lying on her right side by Licensed Vocational Nurse 8 (LVN 8). Registered Nurse 6 (RN 6) assessed the resident. Resident 17 was noted with laceration to the right side of her forehead. Bleeding was noted and immediately stopped by applying pressure with dressing and ice pack. 911 was called and the resident was transferred to the general acute care hospital (GACH). A review of the Daily and Q (every) Shift Charting dated November 2, 2015, at 5:20 p.m., indicated Resident 17 came back from the hospital secondary status [REDACTED]. Noted right forehead laceration with transparent surgical glue. Swelling with discoloration on the right periorbital and right upper arm swelling, able to move extremities, neck collar in place with dry dressing on surgical site on the cervical area with no dehiscence (a surgical complication in which a wound ruptures along a surgical suture) with staples and stitches intact. A review of the facility's investigation report Risk Management System dated November 2, 2015, at 10:25 a.m., indicated state agency was not notified. Under fall investigation, there was a question that indicated What preventative measures were in place prior to this fall? (Review care plan.). It indicated not applicable. Under the summary of investigation, the root cause/conclusion indicated the resident lost balance and did not use call light for assistance when transferring from bed to wheelchair. On November 23, 2015, at 3 p.m., during an observation and interview with Resident 17 with Restorative Nursing Assistant 1 (RNA 1), the Surveyor checked the resident's call light in her room if it was working since it was observed from the nursing station that it kept on alarming couple of times. The resident was sitting in her bed and the wheelchair was placed at the foot of the bed and was parallel to her bed. The wheelchair and the bed was unlocked. The resident was asked why she did not use call light at the time she fell . She stated she did not use the call light because in the past, when she had always called, and the staff members did not come soon enough for her need to go to the bathroom. She had waited 30 minutes to 45 minutes in her room. She said that her bed and her wheelchair at that time moved and was not locked. When the Surveyor asked her more about it, she demonstrated it and the bed moved because it was not locked. The wheelchair was observed locked on the right side and was unlocked on the left side. She demonstrated that her call light worked. The Surveyor observed that the kind of call light that Resident 17 had, it can be easily and accidentally canceled because the button can easily go up and cancel the call without the staff being present in the room. Her roommate's call light (18 B) can only be canceled by pushing the button located on the wall at the head of the resident's bed. Resident 17's forehead was healing and observed she was wearing a cervical collar. The resident was asked to press the call light in her room while the Surveyor and RNA 1 was present with her. From 3:20 p.m. to 3:40 p.m., (20 minutes) the call light was on with no staff member to ask what she needed. After 20 minutes, Certified Nursing Assistant 6 (CNA 6), went to the room and told the resident that she was busy in the other room. On November 25, 2015, at 11:35 a.m., during an interview with Certified Nursing Assistant 3 (CNA 3), she stated she saw Resident 17 in the bed, sleeping, and went to see another resident. CNA 3 did not see Resident 17 when she fell (on November 2, 2015). The resident told her that she was trying to sit in the wheelchair. CNA 3 stated that usually, the resident calls us. They put pillow under her head. There was blood on the pillow. She was alert, awake, and oriented. The resident was lying on the side of the bed on the floor. Then, they transferred her to the hospital. On November 25, 2015, at 12:21 p.m., during an interview with Registered Nurse 4 (RN 4), he stated Resident 17 was found lying prone (lying flat, face downward) on the floor. A towel was placed under the resident's face. She was able to talk and was conscious. A review of Resident 17's care plan after the fall of November 2, 2015, did not include documented evidence that the issue of the bed and the wheelchair not being locked was addressed as well as the call light. The facility's policy and procedure titled Call Light, indicated all personnel will respond to the resident's requests and needs. Call lights are answered promptly. Defective call lights will be reported immediately to maintenance. A review of another facility's policy and procedure titled Fall Management dated June 30, 2014, indicated the facility will identify and analyze fall risk, implement an investigation, monitor plan for effectiveness and modify interventions as necessary. The licensed nurse will communicate the incident and new interventions through the 24-hour report. A post fall review meeting will be completed by the interdisciplinary team (IDT) by the next business day of the fall and additional care plan interventions implemented as indicated. The Post Fall Review may include by not be limited to medication management review, pain management, environmental review, etc. c. According to the admission record, Resident 2 was admitted on [DATE], with [DIAGNOSES REDACTED]. The history and physical examination [REDACTED]. The resident had a right hip fracture status [REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE], indicated the resident's cognitive patterns were intact, needed extensive assistance from staff members for transfer, dressing, eating, hygiene, and bathing. The resident was incontinent of bowel and bladder. A review of the Resident Care Plan for Activities of Daily Living (ADL) Functional/Rehabilitation Potential dated March 29, 2015, indicated impaired physical mobility that included and as manifested by extensive assistance from staff members when walking in the room and corridor and locomotion on and off the unit. The approaches included ambulate with assistive device and provide assistance as needed, evaluate and provide appropriate devices/aids, teach the correct position and lock wheelchair when able. A review of another care plan dated July 12, 2015, indicated the resident required assistance in ADL's that included locomotion due to cognitive loss, dementia, generalized weakness, history of fracture, and advancing age. The interventions included were to maintain good body alignment. The Physician's Progress Notes dated October 27, 2015, indicated status [REDACTED]. On November 23, 2015, at 9:30 a.m., during an observation, Resident 2 was sitting in the wheelchair being wheeled by Certified Nursing Assistant 8 (CNA 8) while her feet were hanging and dragging along the floor at times. Wheelchair foot rests were not provided. On November 23, 2015, at 9:35 a.m., during an interview with Certified Nursing Assistant 8 (CNA 8), she was not able to provide an answer of why the foot rests were not provided to Resident 2. A review of the physician's orders [REDACTED]. On November 23, 2015, at 10:15 a.m., during an interview with the OT, he stated the resident should have foot/leg rests especially because Resident 2 had a hip fracture. The facility's undated policy and procedure titled Positioning In Chair, indicated the residents are positioned to maintain correct body alignment when seated in a chair. While in the wheelchair, support feet by placing on footplates or adaptive cushions. Devices are placed as described in the resident's plan of care. Document in the resident's plan of care, certified nursing assistant (CNA) notes and licensed nurse's notes. d. According to the admission record, Resident 1 was originally admitted on [DATE] and was readmitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE], indicated the resident's cognitive patterns were intact, needed extensive assistance from staff members for bed mobility, transfer, dressing, toilet use, personal hygiene, and bathing. The resident was frequently incontinent of bladder and bowel. Under the balance during transitions and walking from surface-to-surface transfer (transfer between bed and chair or wheelchair), the resident was not steady and was only able to stabilize with staff assistance. The resident used wheelchair as a mobility device. The Fall Risk Review dated February 10, 2015, indicated the resident had poor decision-making, poor safety awareness/judgment, incontinence, needed ambulatory aid with nurse assistance, low extremity weakness, and on medications (anticonvulsants, anti-Parkinsonians, antipsychotics, [DIAGNOSES REDACTED], laxatives, narcotics, and hypnotics). A review of the Resident Care Plan for falls dated February 11, 2015, indicated at risk for falls related to decrease in range of motion, impaired balance, medications (psychotropics and sedatives/hypnotics) and incontinence with [DIAGNOSES REDACTED]. The goals indicated to experience minimal or no injuries from falls, use call light for assistance, use at least restrictive restraint, decrease restraint use, avoid functional decline related to falls or restraints, and increase balance. The approaches included increase visual checks by staff, have call light within reach, educate resident on use of call light, encourage use of call light, and toileting (change soiled garments timely). The Situation Background Assessment Request (SBAR) dated April 15, 2015, at 7 p.m., indicated Resident 1 was found sitting down next to bed in resident's room. The resident stated he did not ask for help and was trying to get out of bed (OOB) to the wheelchair. When the resident was asked why, he stated I was trying to get my black suitcase. I think my son is under my pillow. Where is my son? The staff member reoriented the resident. There was no black suitcase in the resident's room. Full head to toe body check was done. No injury. No laceration or bruising. The resident was transferred safely back to bed. The resident stated I am not in any pain. I do not need any x-rays. Vital signs were taken and neurocheck was performed. Stable. There was no signs of distress or broken/dislocated bones. The resident stated he wanted to go back to the wheelchair. The resident was safely transferred and was left in front of the nursing station for frequent observation. On November 20, 2015, at 7:30 a.m., during an observation and interview with Resident 1, he was lying in bed in his room, alert, awake, and oriented. When asked what happened on the incident that he fell a few months ago, he stated, when he called for help using his call light, the staff members came to help him after 30 minutes of him waiting. According to him, sometimes he urinated on himself and that was embarrassing because it took the staff members a long time to help him. It usually happens in the morning and afternoon shift. Since it took long for the staff members to respond to the call light, he transferred himself from bed to the wheelchair to go to the bathroom. Then, he fell .

Based on observation and interview, the facility failed to ensure a safe environment was free from avoidable accidental hazards for facility residents, employees and visitors. The facility had stored diesel fuel in 13 five gallon gasoline labeled containers (seven plastic, six galvanized metal totaling 65 gallons and considered hazardous). Six plastic containers full of diesel fuel were stored on the ground, exposed to the weather, next to a full five gallon propane tank and diesel fueled generator (machine for converting mechanical energy into electricity) which had the potential to become an ignition source. Adjacent to the generator space is a visitor parking lot for smoking and non-smoking visitors and a resident identified smoking area 19.5 feet away. This creates an additional increased hazard. This environment has the potential to result in fire and explosion causing serious physical harm and fatalities to residents, employees, and visitors of the facility. Because of the facility's failure to have a system in place to ensure the residents' environment was free from fire hazards associated with the storage of potentially flammable biohazardous materials, Immediate Jeopardy was called on 8/5/14 at 1:20 p.m. with the administrator. An acceptable plan of correction was provided by the administrator on 8/5/14 at 5:42 p.m. The Immediate Jeopardy was abated with the administrator on 8/5/14 at 5:42 p.m. The plan of correction (POC) for the immediate jeopardy included: * Resident smoking area was moved to a location away from any hazardous and flammable materials. * A new container specific for storing diesel fuel, including a storage cabinet, was purchased to contain all flammables. This container will be locked and kept in a secured location which is also locked. * All residents who are smokers have been re-assessed for cognition using a Smoking Safety Assessment. Any resident who scores other than independent on the smoking assessment will be supervised by a staff member while the resident is smoking. During other times a nurse supervisor will observe the smoking area at least every three ours with a sign in log to verify. * A smoking schedule is posted at each nursing station. Smoking materials for those residents who are to be supervised will be kept locked in the in the medication room. * The generator cage is locked and will be checked daily by the assistant administrator or nurse supervisor. * Yellow containers which are designed to store diesel fuel have been ordered with expected date of deliver to be 8/6/14, before the end of the survey. Findings: During an environmental tour of the facility and concurrent interview on 8/5/14 beginning at 7:30 a.m., accompanied by the assistant administrator (AA) and housekeeping supervisor (HS), the designated resident smoking area of the facility was observed to be 19.5 feet away from an area that housed the facility generator. The generator area was fenced in with chain link and is next to the visitor parking lot and an outdoor storage container. Inside the generator space were observed stored diesel fuel in 13 five gallon gasoline labeled containers (seven plastic, six galvanized metal totaling 65 gallons and considered hazardous) on the ground, exposed to the weather, near a full five gallon propane tank and diesel fueled generator. The resident smoking area and the generator area are adjacent to the parking lot where the public walk by to enter the facility. There were observed cigarette butts on the ground next to the diesel fuel and propane tank. There were eight unsupervised residents smoking in the designated smoking area during the time of this observation. The designated smoking area is partially enclosed with a waist high wrought iron fence with an unlocked gate that could access to the outside of the generator area. Directly behind the designated smoking area, a posted "DANGER NO SMOKING" sign was observed nailed on a tree facing the generator area. The no smoking sign was not visible from the designated smoking area nor the parking lot directly adjacent to the designated smoking area. No other no smoking signs were observed within the generator area. The resident smoking area is located on concrete with a concrete path that connects to a dirt area before entering the concrete pad of the enclosed generator area. There was a gray metal cabinet, three feet away from the generator, observed closed but not secured with a lock. There were six red galvanized metal five gallon gasoline containers labeled "gasolina" (gasoline) and one red five gallon plastic container labeled "gasoline." All seven containers were full. There was a cigarette butt observed on the ground near these containers. On the opposite side of the gray metal cabinet, were six red five gallon plastic containers labeled "gasoline." All six red five gallon plastic containers were full and were exposed to the weather and unprotected, creating a fire hazard. During a concurrent interview at 9:49 a.m., the maintenance supervisor (MS) confirmed each of the red containers, both metal and plastic, were filled with diesel fuel and not labeled properly. When asked why six of the diesel fuel containers, next to the metal cabinet, were exposed to the weather, MS stated, "Maybe I need to get a bigger cabinet. This one is too small." When asked why all 13 containers were not marked properly as diesel, MS stated, "They are not labeled as diesel because diesel is the only fuel we use for the generator. That's why it's not labeled. My staff know it's diesel." When asked the question, "If the fire department had to come and extinguish a fire in the generator area, how would the firemen know that the containers contained diesel?" MS was silent for a while then stated," I understand what you mean by putting labels to identify the fuel type." During an interview with the State certified Life Safety Code Inspector (duties to inspect nursing homes for fire and safety hazards) on 8/5/14 at 12:24 p.m., the Inspector indicated the the facility must take caution against flammable vapors associated with the storage of diesel fuel by storing this diesel in identified containers and inside a locked metal cabinet specifically for diesel fuel. This is especially important when there is a close proximity to a generator, individuals smoking, and not shielded against the sun. On 8/7/14, review of the NFPA (National Fire Protection Association) 30, Flammable and Combustible Liquids Code, 1996 Edition, Chapter 4: Container and Portable Tank Storage, 4-8.5 Control of Ignition Sources, "Precautions shall be taken to prevent the ignition of flammable vapors. Sources of ignition include, but are not limited to: open flames; lightning; smoking; static electricity; electrical or mechanical sparks; spontaneous heating, including heat-producing chemical reactions; and radiant heat." Review of the facility policy and procedure titled "Biohazardous Waste Control" dated 12/15/12, indicated "It is the policy of this center to label...materials that are determined to be a health risk in accordance with state and federal regulations." Review of the Material Safety Data Sheet (MSDS - required by Occupational Safety & Health Administration for chemical compliance in nursing homes) identifies diesel fuel to be a "moderate fire hazard when exposed to heat and flame. Diesel fuel vapors are heavier than air and may travel a considerable distance to a source of ignition and flash back...Conditions to avoid: Avoid contact with heat, sparks, flames or other sources of ignition. Vapors may be explosive. Avoid overheating of containers." The MSDS further indicates All Departments (within nursing homes) will maintain labels or create labels in the absence of the original label to identify the contents of "hazardous chemicals." Review of the Hazardous Materials Inventory Reporting Requirements which is a state wide requirement indicated, "Hazardous Material is defined as: Any material that, because of its quantity, concentration, physical or chemical characteristics, poses a significant or potential hazard to human health and safety ot to the environment if released into the workplace or the environment; or any material that is required to have a Material Data Sheet according to Title 8 Section 339 of the California Code of Regulations. A business that handles a hazardous material, a mixture containing a hazardous material, or waste material at any one time during the reporting year shall establish and implement a Hazardous Business Emergency Plan (HMBEP) if the hazardous material is equal to or greater than 55 Gallons of a liquid. Extremely Hazardous Substance (Appendix A): Federal and State law mandates reporting of chemicals listed on the Federal Environment Protection Agency (EPA) list of Extremely Hazardous Substances. You must report any of these chemicals if the amount on hand at any given time exceeds the "Threshold Planning Quantity" (TPQ), or if they exceed the basic quantities listed above 55 gallons), whichever is less. Review of the 2013 California Fire Code indicated, "(A) 105.6.16 Flammable and combustible liquids. An operational permit is required: 3. To store, handle or use Class II or Class IIIA liquids in excess of 25 gallons (95 L) in a building or in excess of 60 gallons (227 L) outside a building..." "(A) 105.6.20 Hazardous materials. An operational permit is required to store, transport on site, dispense, use or handle hazardous materials in excess of the amounts listed in Table 105.6.20. (Class 2 - 5 gallons)." "5703.5 Labeling and signage. The fire code official is authorized to require warning signs for the purpose of identifying the hazards of storing or using flammable liquids. Signage for identification and warning such as for the inherent hazard of flammable liquids or smoking shall be provided..." "5704.3.2.1.2 Labeling. Cabinets shall be provided with a conspiciuous label in red letters on contrasting background which reads: FLAMMABLE - KEEP FIRE AWAY." Review of Occupational Safety and Health Administration (OSHA) Compliance Inside Nursing Homes indicated, "Labeling: All Departments will mantain labels or create labels in absence of the original label to identify the contents within. Labels will be legible and prominently displayed. Persons responsible for ensuring labeling of all hazardous materials will be the manager of each department. Labels will be monitored continiously. When labels become no longer legible, they will be redone to comply with this procedure. Factory labels and labels distributed with product will be the preferred method of labeling. Hand written labels will be implemented as an acceptable substitute when preferred labels are not available."

Based on observation, interview, and record review, the licensed nursing staff failed to manage residents' pain based on a continuous assessment and plan of care that identified the type and intensity of pain, and the pain threshold (the point at which pain begins to be felt); failed to ensure the residents' pain was continuously monitored for the effectiveness of the pain medication(s); failed to schedule pain medications to be given as ordered by the physician; failed to timely administer the pain medication(s) to achieve sustained pain relief and to ensure pain was promptly and effectively managed as long as the pain persists in order to prevent suffering from pain for four of 24 sample residents (1, 4, 6, 7). The facility also failed to monitor the pre- and post- [MEDICAL TREATMENT] status of a resident to prevent the potential for complications for one out of 24 sample residents (12). Findings: a. A review of the Face Sheet indicated Resident 4, an [AGE] year old non-English speaking female, was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Nursing Admission Assessment form, dated January 7, 2012, at 6:45 p.m., indicated the resident was assessed as having generalized pain of 4 (moderate) out of 10, on a 0 to 10 pain rating scale, with 10 being severe/horrible pain. The assessment form also indicated the resident was assessed as having right lateral abdomen and right lower extremity multiple skin discolorations with right lateral foot and facial abrasions. According to the physician's orders [REDACTED]. 1. [MEDICATION NAME] 10/325 mg, one tablet, a one time dose for pain to be given now. 2. [MEDICATION NAME] 650 mg, every 4 hours for mild pain. 3. [MEDICATION NAME] 5/325 mg, one tablet every 4 hours as needed for moderate pain. 4. [MEDICATION NAME] 5/325 mg, two tablets every 4 hours as needed for severe pain. Current reference indicates that [MEDICATION NAME] is a short-acting narcotic [MEDICATION NAME] used to manage moderate to severe pain. The adverse effects of [MEDICATION NAME] include constipation, urinary tract spasm, bladder pain and burning, and [MEDICATION NAME] release ([MEDICATION NAME] causes blood vessels to dilate and become leaky. The leakage of blood into the surrounding tissue causes swelling and pain). Geriatric Drug Therapy Handbook, Pages 684-685. A review of the care plan for Pain Symptom Risk, dated January 7, 2012, indicated the resident had a new onset of acute pain, frequent in nature, moderate in intensity (4 out of 10), general pain which was manifested by disrupted sleep pattern and decreased functional activity/mobility. The care plan had a goal that said the resident will verbalize and/or show decreased physical signs of pain with pain relieving strategies, resident will achieve self-reported pain goal of 0 out of 10 on a pain rating scale, and will sleep through the night. The interventions listed were for staff to assess the level of pain using a pain rating scale, implement non-pharmacological interventions including repositioning, dim lighting/quiet environment, relaxation technique, administer pain medication as ordered, monitor response using pain scale, and evaluate the need to provide medications prior to treatment or therapy (for example, 30 minutes before therapy and established schedules). On January 9, 2012, at 8 a.m., during the initial tour of the facility, accompanied by the facility's Director of Staff Development (DSD), Resident 4 was observed lying in bed on her right side. In an interview with the resident she said she was in pain all over her body and had no "peepee and no poopoo." The DSD stated he would notify the charge nurse to medicate the resident for pain, and he left the room to inform the charge nurse. On January 9, 2012, at 11 a.m., the resident was again observed lying in bed on her right side. She was saying, "No peepee, no poopoo" and stated several times that she was in pain, while rubbing her left leg. A review of the Pain Assessment Medication Sheet, dated January 9, 2012, at 1 p.m., indicated the resident had pain assessed at 8 (severe) out of 10. The form indicated the resident was medicated with 2 [MEDICATION NAME] tablets for pain. At 2 p.m., the post [MEDICATION NAME] pain rating was 0 out of 10. There was approximately 5 hours between the time the resident was observed complaining of pain and the time the [MEDICATION NAME] 2 tablets pain medication was administered. The resident's pain was not promptly and effectively managed from 8 a.m. to 1 p.m. On January 9, 2012, at approximately 2:30 p.m., in an interview with a Licensed Vocational Nurse (LVN 5), who was in charge of Station I, she stated she came on duty approximately after lunch and when she made rounds she noticed the resident was in severe pain, so she medicated the resident with [MEDICATION NAME] 2 tablets. When asked how she assessed the resident for pain, she said the resident was moaning and told her she was in pain. LVN 5 said she thought the pain was severe enough to give the resident two pain pills instead of one. On January 9, 2012, at 2:40 p.m., in an interview with the DSD, he said he notified LVN 6 about Resident 4's pain after the 8 a.m. observation. Upon informing him that the resident had not received any pain medication until 1 p.m., he said he should have followed up on the resident's pain management. On January 9, 2012, at approximately 2:55 p.m., in an interview, the Certified Nursing Assistant (CNA 4) stated she provided care to the resident and assisted the resident to the bathroom in the morning, and at that time the resident complained of pain. When asked how she knew the resident was in pain, CNA 4 stated the resident touched her left leg by rubbing it and moaned like it hurt. According to CNA 4, she notified LVN 6 about the resident's pain. When CNA 4 was asked if she did anything to relieve the resident's pain, she said no, she just left her alone. On January 10, 2012, at approximately 8 a.m., during an interview with LVN 6, who was in charge of Station I on January 9, 2012, on the 7-3 shift, she stated Resident 4's family member was at the bedside around 9 a.m., and at that time the resident complained she did not have a bowel movement for two days. LVN 6 stated she assessed the resident by checking her abdomen which was soft and not distended. LVN 6 stated she only gave the resident her routine [MEDICATION NAME] and [MEDICATION NAME] powder and then endorsed the resident to LVN 5. On January 10, 2012, at approximately 8:50 a.m., during the medication administration observation the resident was observed lying in bed. Prior to the medication administration, LVN 7 asked the resident if she was in pain. The resident groaned with a frowning facial expression, at the same time rubbed her left leg, pointed to her legs, and asked for a pain pill. The resident's roommate commented that the resident had broken bones and was in pain "all the time." LVN 7 administered [MEDICATION NAME] 2 tablets, which was ordered for pain assessed at 8 out of 10 (severe pain). On January 10, 2012, at approximately 9 a.m., the Rehabilitation Director was observed in the resident's room and was asking her by use of a communication board, if she wanted to get up in order to receive therapy. The resident pointed to the communication board indicating she still had pain. Other staff members also entered the room to weigh the resident, however the Rehabilitation Director intervened and told everyone that the resident was still in pain. A review of the PRN Pain Assessment Flow Sheet, dated January 10, 2012, at 9:30 a.m., indicated the resident's pain was assessed at a level 4 (moderate pain) out of 10. On January 10, 2012, at approximately 12:08 p.m., in an interview with the Director of Nursing (DON) she stated that the resident had complained of of abdominal pain on January 9, 2012, and was given an enema which resulted in a small bowel movement. The resident was also catheterized with a Foley catheter (flexible tube passed through the urethra and into the bladder), and according to the DON, 800 milliliters (ml) of urine was drained from the resident's bladder at around 6 p.m. She further said she wanted the resident weighed but she was in too much pain so they could not weigh her. The DON during the interview further stated the facility did not thoroughly manage the resident's pain because the resident continued to verbalize she was in pain. A review of the PPS Licensed Notes form, dated January 9, 2012, at 3:30 p.m., validated the resident was complaining of abdominal pain, cramping and saying "no pee and no poo," There were no bowel sounds present and her abdomen was slightly distended. According to the notes, the resident complained of pain at 3:30 p.m., but was not medicated for pain. At 6 p.m., the physician was called and an order for [REDACTED]. The resident was catheterized and 800 ml of urine was evacuated, and the resident verbalized she felt better afterwards. The normal urinary bladder capacity ranges from 500-530 milliliters, although the urinary bladder may hold as much as 600 ml of urine but it can expand to hold 800 milliliters. When the bladder is not emptied and is filled with excess urine as in case of [MEDICAL CONDITION], it can cause severe pain... (Elert, Glenn, The Volume of a Human Bladder, Volume 860, and Page 1-2, and American Journal of Nursing: August 2000- Volume 100 - Issue 8- Pages 36-44). According to the California Board of Registered Nursing, pain is considered "The Fifth Vital Sign" and the Registered Nurse is responsible for ensuring pain is assessed and treated effectively, promptly, and as long as the pain persists. A review of the facility's policy and procedures titled Pain Management, revised August 31, 2009, indicated residents are to be assessed for pain and a plan of care is developed to manage pain, to provide guidelines for assessment, management, and documentation of resident's pain, in an attempt to provide maximum comfort and enhanced quality of life, provide around the clock dosing, and to obtain orders for as needed (PRN) medication for breakthrough pain. The policy also indicated if the resident cannot verbally indicate the intensity and/or severity of pain using a verbal pain scale, the licensed nurse shall screen/assess the resident utilizing non-verbal cues, such as facial grimacing, moaning, etc., to indicate the severity of pain. The licensed nurse will develop a plan of care for pain management, including the use of non-pharmacological interventions. The plan will be individualized to meet the resident's needs, and the licensed nurse shall administer pain medications as ordered. b. A review of the medical Face Sheet indicated Resident 1, a [AGE] year old non-English speaking female, was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. According to the history and physical examination [REDACTED]. According to the GACH records, the resident was also treated with pain medications during her stay. The physician's admission order, dated January 5, 2012, indicated [MEDICATION NAME] (Sulfate) 4 milligram (mg), was to be administered to the resident through her GT every 4 hours as needed for pain. The Minimum Data Set (MDS) assessment (identifies each resident's functional capabilities and health problems to assist in providing appropriate care) was in progress. A review of the Cognitive Loss/Dementia care plan, dated January 5, 2012, indicated the resident had impaired cognitive skills in daily decision making, altered ability to understand others and make self understood. The Initial Comprehensive Pain Assessment form, dated January 6, 2012, indicated Resident 1 had a history of [REDACTED]. The form indicated currently the pain was rated as 0 on a pain rating scale of 0 to 10, with 10 being the most severe pain level. The assessment form recorded "None" for the location and frequency of the resident's pain. The plan of care titled Pain & Pain Symptom Risk, dated January 6, 2012, indicated the resident had a chronic history of pain, the pain frequency was documented as rare, the pain intensity was severe, the pain sites were the stomach, [DIAGNOSES REDACTED]. The interventions included to assess the level of pain using the pain rating scale, administer pain medication as ordered and monitor response, and evaluate the need to provide medications prior to treatment for [REDACTED]. A review of the Social Work Progress Notes, dated January 6, 2012, indicated at 3 p.m., during an interview, the resident was observed moaning and grimacing, but when asked if she was in pain (through a language translator), the resident did not respond, and there was no facial grimacing and moaning noted. There was no documented assessment to explain the inconsistencies between what was observed by the social worker's notes and the resident's response. A review of the Pain Assessment Flow Sheet, for the month of January 2012, for the 7 a.m. to 3 p.m. shift and 3 p.m. to 11 p.m. shift indicated the resident was not in pain. Further review of the Daily and Q (every) Shift Charting form, dated January 6, 2012, failed to indicate the resident was further re-assessed for pain when the resident moaned and grimaced during the interview with the Social Service Director. On January 9, 2012, between 11:05 a.m. and 11:15 a.m., the resident was heard crying from outside her room. Upon entering her room, the resident was observed with the privacy curtains closed. The Certified Nursing Assistant (CNA 1) was providing personal care to the resident. The resident's private care giver was assisting CNA 1 by holding the resident's wrists. During the care, the resident was crying, pressing her teeth together, groaning and trying to free her wrists by pulling her arms back and forth. The Licensed Vocational Nurse (LVN 2) entered the room and asked CNA 1 if the resident was in pain, and CNA 1 replied no. LVN 2 left the resident's room, even though there was inconsistency between the resident's observed pain behavior of crying, pressing her teeth together, groaning and trying to free her wrists, the resident's denial of the presence of pain, and communication barriers. LVN 2 did not stop the provision of care, assess the resident's vital signs, or report to a registered nurse and/or the physician, in order for the resident to be assessed with [REDACTED]. After LVN 2 left the resident's room, the Evaluator asked CNA 1 to ask the resident if she was in pain. CNA 1 asked the resident (in her native language) if she was in pain. According to CNA 1, the resident stated she had a headache. According to State Operations Manual (SOM), pain significantly affects a person's well-being, therefore it is important that the facility recognize and address pain promptly. It is a challenge to recognize pain in individuals who have cognitive impairment. Some individuals with advance cognitive impairments can accurately report pain and/or respond to questions regarding pain. Those who cannot report pain may present with non-specific signs such as grimacing, increased confusion or restlessness or other distressed behavior. Effective pain management may decrease distressed behaviors that are related to pain; in order to manage pain effectively, it is important to evaluate (for example by touch, look at, move the resident). Other challenges in successfully evaluating and managing pain may include communication difficulties due to illness or language and cultural barriers, stoicism about pain and cognitive impairment. Stoicism about pain is a phenomenon in which patients are indifferent to pleasure or pain, impassiveness or they try to carry their pain alone and keep their discomforts private (SOM October, 2010, page 156). On January 9, 2012, at approximately 11:30 a.m., LVN 2 was observed administering [MEDICATION NAME] 4 mg through the resident's GT. The medication was administered after the resident's morning care had already been provided. There was a delay of approximately thirty minutes from the time the resident was heard crying until the time she received the pain medication. The resident's pain was not addressed promptly, and until the Evaluator intervened. According to the Pain Assessment Flow Sheet, the resident received [MEDICATION NAME] at 11:30 a.m. for headache pain assessed/rated at 8 (on a 0 -10 pain assessment scale, 8 being very severe pain). At 12:30 p.m., the pain flow sheet indicated the resident's pain was reduced to 2 out of 10. On January 11, 2012, at approximately 11:30 a.m., in an interview with the DON after reviewing the medical record with her, she stated the resident's pain was not managed because the staff did not stop the care, assess the resident for pain and administer pain medication as necessary. According to the California Board of Registered Nursing, pain is considered "The Fifth Vital Sign" and the Registered Nurse is responsible for ensuring pain is assessed and treated effectively, promptly, and as long as the pain persists. c. According to the admission record, Resident 7 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS- a standardized comprehensive assessment of the resident's problems and conditions) dated November 14, 2011, indicated the resident was severely impaired in his cognitive skills for daily decision making and was totally dependent on staff for all activities of daily living. The MDS indicated the resident had range of motion limitations on one side for his upper extremities and limitations on both sides for his lower extremities. The resident had the following physician's orders [REDACTED]. 1. Tylenol 650 milligrams (mg) every 4 hours as needed for moderate pain dated December 9, 2011. 2. Tylenol 650 mg every 8 hours for pain management dated December 15, 2011. 3. Occupational therapist (OT) and the physical therapist (PT), to continue with therapeutic exercises, therapeutic activities, neuromuscular reeducation and orthotic management and training five times a week for two weeks dated December 27, 2011, The care plan dated December 15, 2011, indicated the resident had episodes of screaming during care. The care plan also indicated the resident was not able to verbalize pain. The approaches included medicate for pain as ordered, assess the response to the medication and continue care when pain is relieved. The Occupational Therapy Progress Report December 25, 2011, to December 30, 2011, indicated the resident had joint contractures in multiple sites. The report also indicated the resident's right fifth finger had excoriation in the folds of the proximal interphalangeal joints (the joints between the first and second phalanges (finger bone) and the distal interphalangeal joints (the joints between the second and third phalanges), that bleed with opening his hand and stretching his fingers. The report also indicated continued occupational therapy services are necessary in order to decrease the pain in his upper extremities to allow for activities of daily living (ADL) participation and to facilitate the ability to live in an environment with the least amount of supervision and assistance. On January 10, 2012, at 2:10 p.m., during an observation in the resident's room, the Certified Nursing Assistant (CNA 3) and Registered Nurse (RN 4) were asked if the resident's contracted right hand could be opened to check for excoriations and folds as indicated by the OT. CNA 3 and RN 4 could not get the resident's hand open. RN 4 went to get the OT to assist. The resident was making growling and animal sounds as he lay in bed. The OT returned to the resident's room and was able to open the resident's right hand. His palm was red and had indentations from his finger nails digging into his skin. As the OT opened the resident's hand he let out a yell and had facial grimacing. The OT said the resident may be in pain when he yells like that. A review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The MAR indicated [REDACTED]. On January 10, 2012, after the evaluator intervened, the documentation indicated the resident was given Tylenol 650 mg at 2 p.m. During an interview on January 11, 2012, at 9 a.m., the Director of Nursing was asked why the resident did not get his Tylenol 650 mg every 8 hours routinely as ordered. She said the order for the routine Tylenol was erroneously transcribed onto the PRN (as needed) MAR from December 15, 2011 to January 10, 2012, rather than the routine MAR. According to the California Board of Registered Nursing, pain is considered "The Fifth Vital Sign" and the Registered Nurse is responsible for ensuring pain is assessed and treated effectively, promptly, and as long as the pain persists. d. According to the admission information Resident 6 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident had the following physician's orders [REDACTED]. 1. Tylenol 650 milligrams (mg) every 4 hours as needed for mild pain dated December 22, 2010. 2. [MEDICATION NAME] 5/500 mg every 4 hours as needed for moderate to severe pain dated December 13, 2011. According to the Interdisciplinary Progress Notes on January 7, 2012 the resident complained of severe, sharp throbbing pain on her right shoulder. The resident was transferred to an acute care hospital emergency room for evaluation. The Comprehensive Pain Assessment form dated January 7, 2012, indicated the resident had severe continuous, sharp, throbbing pain in her right shoulder rated at 10 on a 1 to 10 pain rating scale with 10 being the most severe pain. The form indicated rest and medication relieved the pain. The x-ray report dated January 7, 2012, indicated the resident had a questionable [MEDICAL CONDITION] (an anatomical feature on the outer upper point of the shoulder blade). The care plan dated January 7, 2012, indicated the resident had potential for pain due to a recent right shoulder fracture. The approaches included pain medication ([MEDICATION NAME]) as ordered, assess the pain level and report to the doctor if the pain persists without relief from medication. The Daily and Q Shift Charting form indicated on January 8, 2012, at 2 a.m. the resident returned from the acute care hospital and was readmitted to the facility. Her right shoulder had an immobilizer with a sling and an ice compress. On January 9, 2012, at 12:05 p.m., the resident was observed in her room from the hallway, and she motioned with her left hand for the evaluator to come inside. The resident said she had severe pain in her right arm, and she had been given medication for pain but it was not working. During an interview with the Licensed Vocational Nurse (LVN 3) on January 9, 2012, at 12:10 p.m., she stated she gave the resident's pain medication at 9 a.m., and she was not due for more pain medication until 1 p.m. According to LVN 3, she was going to call the resident's doctor to obtain an order for [REDACTED]. The Pain Assessment Flow Sheet indicated the resident was given [MEDICATION NAME] 5/500 mg at 9 a.m. for pain assessed at 6 out of 10 (moderate pain). LVN 3 documented at 10 a.m., the resident's pain was assessed as 3 out of 10 (mild pain). LVN 3 did not call the physician for alternative instructions to achieve pain relief of 0 out of 10 (no pain) on the pain scale according to the care plan, until the evaluator brought to her attention that the resident continued to have pain for over two hours. On January 10, 2012, at 7:51 a.m., the resident again complained that she had severe pain in her right arm. The resident said she had been given pain medication, she did not remember the time, and she was still having pain. A review of the Controlled Medications Count Sheet revealed on January 10, 2012, the resident was medicated for pain at 3 a.m. with [MEDICATION NAME]. The resident did not receive pain medication again until 8:30 a.m., which was over five hours. During an interview with the Registered Nurse (RN 3), she said after the medication nurse gives a resident medication for pain they should reassess the resident within at least a half hour to check for relief of pain. However, there was no documented evidence the licensed nurse reassessed the effectiveness of the pain medication and evaluated the need for further intervention to ensure that the resident's pain was managed to the desired level. According to the California Board of Registered Nursing, pain is considered "The Fifth Vital Sign" and the Registered Nurse is responsible for ensuring pain is assessed and treated effectively, promptly, and as long as the pain persists. e. On January 9, 2012 at 8:39 a.m., during the initial tour of the facility, Resident 12 was observed in bed and his left upper arm had an arteriovenous ((AV) connecting the artery and vein) fistula shunt (access site) for [MEDICAL TREATMENT] (type of procedure to remove waste products from the body). According to the admission record, Resident 12 was admitted to the facility March 15, 2006, with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), a comprehensive assessment dated [DATE], indicated Resident 12 had severely impaired cognition, and required extensive assistance from staff for bed mobility. A review of a Physician's [MEDICAL TREATMENT] admission orders [REDACTED]. A review of the December 24, 2011, January 7, 2011, and January 10, 2012, [MEDICAL TREATMENT] communication sheets revealed there was missing documentation that a post-[MEDICAL TREATMENT] assessment had been conducted. concerning the shunt bruit and thrill. During an interview on January 11, 2012, at 3:20 p.m., the Director of Nursing stated the facility's nursing staff should have completed and documented Resident 12's post-[MEDICAL TREATMENT] assessment. A review of the facility's policy and procedure dated October 10, 2007 titled, "Care of The [MEDICAL TREATMENT] Resident," indicated the nursing staff will follow established protocols for all [MEDICAL TREATMENT] residents.