Every finding on record at The Rehabilitation Center of los Angeles

Based on interview and record review the facility failed to provide clear and concise medical orders for two of three sampled residents (Resident 1 and Resident 3). This deficient practice had the potential to cause confusion among the nursing staff carrying out orders, leading to missed hemodialysis access care, severe infection, and hospitalization. a. During a review of Resident 1's admission Record, the admission Record indicated resident 1 was admitted on [DATE]. With diagnoses including but not limited to displaced intertrochanter fracture of the right femur (a clean break at the top part of the right thigh bone), Bacteremia (bacteria in the bloodstream), and type 2 Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 1's Minimum Data Set (MDS -a resident assessment tool) dated 7/11/2026, Resident 1's cognitive abilities are severely impaired, and her functional abilities are dependent. During a review of Residents 1's Order Summary Report (OSR) dated 7/11/2026, the OSR indicated Right Intrajugular Hemodialysis (R IJ HD - large intravenous tube into a big vein on the right side of the neck to filter blood) Catheter every shift. b. During a review of Resident 3's admission Record, the admission Record indicated resident 3 was admitted on [DATE]. With diagnoses including but not limited to Hypoxia (a medical condition where the body's tissues and organs do not get enough oxygen to work the right way), and toxic encephalopathy (altered brain function caused by harmful chemicals). During a review of Resident 3s Minimum Data Set (MDS - a resident assessment tool) date 7/25/2026, Resident 3's cognitive abilities are severely impaired and functional abilities are dependent. During a review of Resident 3's Order Summary Report (OSR), dated 7/28/2026, the OSR indicated Right chest permacath (soft flexible plastic tube placed in to a large vein in the neck or chest to give to give doctors access to the bloodstream) every shift. During an interview on 7/28/2026 at 11:00am with the Treatment Nurse (TN 1), the TN 1 stated she only talks care of residents and their wounds. TN 1 stated she does not have anything to do with any orders related to hemodialysis (HD - a medical process that filters the blood and gets rid of waste). The person that takes care of hemodialysis orders is the Registered Nurse supervisor (RNS). During an interview on 7/28/2026 at 11:10am with the RNS, the RNS stated there were 10 hemodialysis residents on the floor. The hemodialysis residents that are in the facility are all cared for and charted on by the RNS on shift, per the RNS. The RNS was unable to explain the meaning of the order Right IJ HD Catheter every shift. The RNS stated they had not encountered an order of this type at the facility before and could not identify what the order required or what tasks needed to be carried out as directed. During an interview on 7/28/2026 at 11:50 AM, Provider 1 stated they were the attending provider for Resident 1. Provider 1 reported that nursing staff enter standing admission orders under the provider's name. Provider 1(Primary care physician) stated they were unsure of the meaning of the order Right IJ HD Catheter every shift and further stated it was not a specific order they had issued beyond the standard protocol orders. Provider 1 stated the only interpretation they could infer was that the Right IJ catheter should be flushed every shift. During a review of the facility's policy and procedure (P&P) titled Physicians orders, dated 5/1/2019, indicated the purpose of this P&P is to ensure all physicians orders are complete and accurate. Per the P&P, orders will include a description complete enough to ensure clarity of the physician's plan of care.

Based on interview and record review, the facility failed to develop and implement a comprehensive care plan (a plan of care that summarizes a resident's health conditions, specific care needs, and current treatments) that meets the needs for three of 33 sampled residents (Resident 4, 169 and 190) by failing to: 1. Ensure a pneumonia (PNA-infection that inflames air sacs in one or both lungs which may fill with fluid) care plan was developed on 5/8/2026 when Resident 4 received a physician's order for Ertapenem Sodium (antibiotic medication) one gram (1 gm) via intravenously (IV-administering fluid medication through a needle or tube inserted into a vein) one time a day for PNA for 10 days.2. Ensure a care plan was implemented for diabetes (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing) when a nurse did not provide education on diet management to Resident 169.3. Ensure a care plan was implemented for hemodialysis (HD-filtering the blood of a person whose kidneys are not working normally), when a case manager (CM) 2 failed to schedule transportation at prescribed pick-up time for one of one resident (Resident 190). These deficient practices had the potential to have a negative impact on Resident 4, 169 and 190's health and safety, as well as the quality of care and services received. 2. Findings: During a record review of face sheet of Resident 169, Resident 169 was admitted to the facility on [DATE] with a diagnoses of Essential hypertension (chronic high blood pressure); type 2 diabetes mellitus (DM, chronic disorder of persistent high blood sugar levels); chronic kidney disease, stage 4 (late stage of kidney damage, affecting the body's ability to remove excess water and wastes in urine); peripheral vascular disease (slow, progressive disorder of blood vessels, reducing blood flow and oxygen to the limbs, most often the legs and feet), right 3rd toe ray amputation (a surgical procedure that involves removal of dead tissue/part of extremity). During a record review of Resident 169's Minimum Data Set (MDS, resident assessment tool), dated 3/1/2026, the MDS indicated the resident was cognitively intact, evidenced by had Brief Interview for Mental Status score of 15 (BIMS, an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident). The MDS also indicated that Resident 169's primary language was Spanish, but no need for interpreter services in communications with healthcare staff. The MDS indicated the functional abilities (abilities to perform activities of daily living like eating, dressing, walking, toileting) of Resident 169 required set up/clean up assistance for eating and oral hygiene, partial/moderate assistance (helper does less than half the effort) with upper body dressing, sit to stand, chair/bed transfers, and maximal assistance with lower body dressing, toileting and showering). During an initial observation and interview on 05/11/2026 at 2:13 p.m. with Resident 169, Resident 169 was observed in his room sitting in a wheelchair. Resident 169 stated he was supposed to have food low in sugar, but was served sweet juice, or ice cream, and had too much finger poking and insulin injections. Resident 169 stated she informed the charge nurse last night. During a concurrent interview and record review on 5/13/2026 12:36 p.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated that Resident 169's friend brought him extra food. LVN 2 reviewed the Order Summary for diet, dated 2/26/2026, and LVN 2 stated Resident 169 was on Consistent Carbohydrate diet (CCHO, a diet with controlled amount of sugars in each serving of food). LVN 2 stated the nurse provided education and explained risks and benefits of the diet. During a review of the electronic medical chart for Resident 169, undated, LVN 2 did not find a documentation about Resident 169 being educated on diet or any note of noncompliance with the diet. During a concurrent interview and record review 5/13/2026 at 2:39 p.m. with a Case Manager (CM) 1, Resident 169's care plan for Hypoglycemic medication/Insulin Use (medications to lower blood sugar level), dated 2/26/2026, the care plan indicated an intervention Providing resident education on diabetes management, including meal planning, exercise. CM 1 did not find any documentation in the chart that this care plan was implemented. CM 1 stated It would be important to document education of resident, especially with DM, comorbidities (two or more medical conditions in the same person) and wounds, because not documented means not done. CM 1 stated it would be a challenge to send Resident 169 home. The residents' friend was not aware about diet compliance for the resident. During a record review of Situation, Background, Assessment and Recommendation Change of Condition (SBAR COC, communication tool between a nurse and a doctor), dated 4/20/2026, the SBAR document did not indicate resident 169's noncompliance with or resident 169's education on diet. During a concurrent interview and record review on 5/14/2026 at 10:53 a.m. with Director of Nursing (DON), DON stated, He is on CCHO diet, he is not eating too much sugar, he has half of the carbs (carbohydrates, sugars in the food) compared to normal food for healthy people. DON reviewed dietitian's assessment and did not find documentation about resident diet education or doctor's notification about the resident noncompliance. DON sated It is important to educate the Residents to their benefit to follow recommendations. If it is beneficial to gain weight, especially with elderly, diet is not concerning, mostly medication is the concern to control his blood sugar. During a record review of Resident 169's care plan for hypoglycemic medications /insulin use, dated 2/26/2026, the care plan indicated the following interventions: Providing resident education on diabetes management, including medication administration, monitoring blood glucose levels, meal planning, exercise, and recognizing signs of hyperglycemia or hypoglycemia. 3. Findings: During a review of face sheet of Resident 190, dated 4/29/2026, the face sheet indicated the resident 190 was admitted to the facility on [DATE] with diagnoses of acute respiratory failure with hypoxia (sudden difficulty breathing and oxygen exchange due to damage in lungs), and end stage renal disease (irreversible loss kidney function), renal hemodialysis dependance (HD, a long term treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidneys have failed). During a review of Minimum Data Set (MDS, resident assessment tool) dated 5/5/2026, the MDS indicated the Resident 190's cognitive patterns were intact (able to comprehend complex concepts, memory intact, and verbalize own needs), as evidenced by Brief Interview for Mental Status score of 14 (BIMS score, an assessment tool to screen and identify memory, orientation, and judgement status of the resident). The MDS indicated that Resident 190's functional abilities (abilities to perform activities of daily living, such as eating, dressing, walking, toileting) required supervision/touching assistance for eating, partial/moderate assistance (helper does less than half the effort) with oral hygiene, substantial/maximal assistance with dressing, rolling in bed, dependence with sit to stand, chair/bed transfers, and toileting and showering. During a concurrent observation and interview on 5/12/2026 at 8:08 a.m. with Resident 190, Resident 190 stated there were issues with scheduling of the transportation for HD. Resident 190 stated on 5/11/2026 the ambulance came one hour late to pick him up, and 45 minutes (min.) late to bring me back to the facility. On 5/11/2026 it was most notable, but they were late several times. Resident 190 stated there seems to be a problem in scheduling the HD center staff made me sign some paper about the shorter session. During a concurrent observation and interview 5/13/2026 at 9:07 a.m. with Resident 190, Resident 190 was still in his room waiting for his transportation for HD. Resident 190 stated they were running late again, and no one has told me anything. It is wrong, my dialysis time gets shortened, and other residents' dialysis would be delayed or shortened too. Nurses at the HD clinic get upset too. HD clinic made me sign the paper that my session is cut short. During a concurrent observation and interview on 5/13/2026 at 9:14 a.m. with the emergency medical technician (EMT) 1 stated, the dispatch sends us information about who and where to pick up, and destination, but not exact pick-up time. During an observation on 5/13/2026 at 9:29 am Resident 190 left the facility. During a concurrent phone interview and record review on 5/13/2026 at 9:36 a.m. with a Case Manager (CM ) 2, scheduled the transportation, CM 2 stated Resident 190's HD start time was at 9:30 a.m., pick up time 8:30 a.m. or 9 a.m. CM 2 stated did not know the Physician's order for Resident 190's dated 4/29/2026, the pick-up time was at 8:15 a.m. CM 2 stated Resident 190's was being late and HD time would be shortened. During an interview on 5/13/2026 at 10:20 a.m. with RN 3, RN 3 stated that CM 2 had to follow the order for dialysis arrangement of transportation. During a concurrent interview and record review on 5/14/2026 at 10:11 a.m. with Licensed Vocational Nurse (LVN) 2 dialysis communication record dated 5/11/26 was reviewed, LVN 2 stated the facility usually notifies the dialysis center if transportation was late. LVN 2 stated the dialysis record did not have time indicating when HD treatment started and ended. LVN 2 stated she was not aware Resident 190's dialysis was cut short on 5/11/2026. LVN 2 stated, If we were aware about HD was being cut short, I would notify the physician. During an interview on 5/14/2026 at 10:45 a.m. Director of Nursing (DON), the DON stated the facility communicates with HD center mainly via phone. If dialysis center cut HD session short, they should have communicated with us. During a concurrent interview and record review on 05/14/2026 at 12:50 p.m. with Assistant Director of Nursing (ADON) 1, an Early Termination of Treatment Against Medical Advice form (AMA, a form signed by residents declining recommended medical treatment), dated 5/11/2026 was reviewed. The AMA form indicated the shortened dialysis treatment by 24 minutes (min) (prescribed dialysis treatment time was195 min) due to coming late. During an interview on 5/14/2026 at 5:15 p.m. with DON, DON stated CM 2 did not follow resident's care plan or order for dialysis. The DON stated CM 2 should have followed care plan and orders. DON stated if Resident 190 was running late due to transportation, facility should have communicated to CM 2, and to dialysis center to ask if they can still accommodate so Resident 190 can get the full treatment. The DON stated dialysis facility should have alerted and called the facility that the resident did not receive the full dialysis treatment. The DON stated staff should have alerted the physician that the resident's dialysis was cut short. DON stated there was potential for Resident 190 to have fluid retention, fluid overload, shortness of breath, altered laboratory test results and might require a transfer to the hospital. During a record review of the facility's policy and procedure titled Dialysis Management, dated 3/2023, the P & P indicated: The facility has an agreement with contracted Dialysis Unit(s) which operates in accordance with current standards of practice, including communication and collaboration. The P &P indicated the Dialysis Unit(s) and facility staff coordinate the development and implementation of the dialysis care plan, including the ongoing provision of assessment of the resident and care plan revision, as necessary. The P & P indicated the facility has a qualified social services representative who assists the dialysis resident and their representative with dialysis related transportation needs. During a record review of Nursing Home Dialysis Transfer Agreement, dated 4/28/2025, indicated Transportation of designated resident: facility shall have the responsibility for arranging suitable transportation of the Designated Resident to and from Center. Findings: During a review of Resident 4's admission record, the admission record indicated the facility originally admitted Resident 4 on 3/17/2025 and re-admitted the resident on 1/7/2026 with diagnoses including gastrostomy tube (GT- a flexible tube surgically inserted through the abdomen into the stomach for feeding, fluid, and medication administration), chronic respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide) and dependence on ventilator (a machine or device used medically to support or replace the breathing of a person, unable to breath on their own). During a review of Resident 4's History and Physical (H&P), dated 1/14/2026, the H&P indicated Resident 4 did not have the capacity to understand and/or make decisions. During a review of Resident 4's Minimum Data Set (MDS-standardized assessment tool), dated 3/13/2026, the MDS indicated Resident 4 had impaired cognition (mental action or process of acquiring knowledge and understanding) for daily decision-making and was dependent (helper does all the effort) on staff for activities of daily living (ADLs-bed mobility, surface transfer, eating, walk in room, dressing, toileting, and personal hygiene). During a review of Resident 4's situation background assessment and recommendation (SBAR: a form that is a documentation of a complete assessment in response to a change in condition) Change in Condition dated 5/7/2026, the SBAR: Change in Condition indicated Resident 4 had a fever (high body temperature) and tachycardia (heart rate faster than normal). During a review of Resident 4's Order Summary Report, dated 5/8/2028, the Order Summary Report indicated that Resident 4 had an order for Ertapenem Sodium gm via intravenously one time a day for PNA for 10 days. During a review of Resident 4's complete care plan, the care plan review indicated a care plan for Resident 4's antibiotic (ertapenem) use was not created. During a concurrent interview and record review on 5/14/2026 at 9:54 AM, with Director of Nursing (DON), Resident 4's care plan was reviewed. Resident 4's care plan indicated a missing PNA care plan for antibiotic (ertapenem) use. The DON stated that when a resident started an antibiotic medication, nursing staff had to develop a care plan for the diagnosis of the antibiotic use. The DON stated a care plan for antibiotic use and a care plan for PNA should have been developed when ertapenem on 5/8/2026 was ordered to be able to provide proper care and interventions for Resident 4. During a review of the facility's policy and procedure (P&P), titled, Develop-Implement Comprehensive Care Plans, reviewed on 4/14/2026, the P&P indicated that each resident was to have a person-centered comprehensive care plan that was developed and implemented to meet his or her preferences and goals, and address the resident's medical, physical, mental and psychosocial needs.

Based on interviews and record reviews the facility failed to ensure grievances and recommendations voiced through the Resident Council (an independent group of nursing home residents or family, who meet on a regular basis to discuss concerns and suggestions and to plan activities that are important to them) meetings were acted upon and responded to for two out of five residents (Resident 75 and 147) reviewed for resident council concerns who attended a group meeting with the nurse surveyor (Healthcare official that conducts inspections, investigations, surveys and evaluations of health facilities). By failing to follow through with the steps taken to investigate the grievance, provide the residents a summary of the pertinent findings and/or conclusions regarding the concern and a statement as to whether the grievance was confirmed or not confirmed and corrective actions taken as a result of the grievance as indicated by the facility's Policy and Procedure (P&P), titled, Grievance Policy, last reviewed 4/14/2026. This deficient practice resulted in multiple and unresolved residents' grievances related to delay in answering residents' call light and had the potential to affect residents' ability to receive timely assistance, care, and services.Findings: During a review of Resident 75's admission Record, the admission Record indicated the facility admitted the resident on 11/6/2024 with diagnoses that included dysarthria (difficulty in speaking /slurred speech), cerebral infraction (also called stroke, a result of inadequate blood flow to the brain) and diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]). During a review of Resident 75's Minimum Data Set (MDS: standardized assessment tool) dated 2/6/2026, the MDS indicated Resident 75 had intact cognition (mental action or process of acquiring knowledge and understanding) for daily decision-making and dependent (helper does all the effort) from staff for activities of daily living (ADLs-bed mobility, surface transfer, eating, walk in room, dressing, toileting, and personal hygiene). During a review of Resident 147's admission Record, the admission Record indicated the facility originally admitted the resident on 2/12/2015 and re-admitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD-group of lung diseases that block airflow and make it difficult to breathe), chronic kidney disease (CKD-a longstanding disease of the kidneys leading to kidney failure) and generalized muscle weakness. During a review of Resident 147's History and Physical (H&P) dated 11/3/2025, the H&P indicated Resident 147 had the capacity to understand and make decisions. During a review of Resident 147's MDS, dated [DATE], the MDS indicated Resident 147 had moderately impaired (lacking full function or ability) cognition for daily decision-making and with varying assistance from set up (helper sets up or cleans up; resident completes activity) to maximal assistance (helper does more than half the effort) from staff for ADLs. A review of the Facility's Resident Council Minutes (RCM), dated 8/6/2025, Facility's RCM indicated a resident identified long call light waiting during the 11 AM-7 AM shift (night shift). A review of the Facility's Grievance/Complaint Resolution Report (GCRR), dated 8/7/2025, Facility's GCRR indicated under steps taken to investigate grievance/complaint was grievance and one to one (1:1) in-service started. Facility's GCRR indicated under summary of pertinent findings or conclusion regarding resident's concern was education needed. A review of the Facility's RCM dated 9/9/2025, Facility's RCM indicated a resident identified an extremely long call light waiting during the 3 PM-11 PM (evening shift) and 11 AM-7 AM shifts. A review of the Facility's GCRR, dated 9/10/2025, Facility's GCRR indicated under steps taken to investigate grievance/complaint was grievance and 1:1 in-service started. Facility's GCRR indicated under summary of pertinent findings or conclusion regarding resident's concern was education needed on finding. A review of the Facility's RCM dated 1/13/2026, Facility's RCM indicated a resident identified long call light waiting during the 3 PM-11 PM and 11 AM-7 AM shifts. A review of the Facility's GCRR, dated 1/16/2026, Facility's GCRR indicated under steps taken to investigate grievance/complaint was grievance copy to the Director of Staff Development (DSD) and in-service was completed. Facility's GCRR indicated under summary of pertinent findings or conclusion regarding resident's concern was in-service was needed regarding the concerns. A review of the Facility's RCM dated 3/10/2026, Facility's RCM indicated a resident identified long call light waiting from 11 AM-7 AM shifts. A review of the Facility's GCRR, dated 3/25/2026, Facility's GCRR indicated under steps taken to investigate grievance/complaint was in-service and managers notified. Facility's GCRR indicated under summary of pertinent findings or conclusion regarding resident's concern was education needed regarding concerns. A review of the Facility's RCM dated 4/7/2026, Facility's RCM indicated a resident identified certified nursing assistants (CNAs) not attending call lights in a timely manner for the 3 PM-11 PM shift. A review of the Facility's GCRR, undated, Facility's GCRR indicated under steps taken to investigate grievance/complaint was facility spoke with members from resident council about concerns. Facility's GCRR indicated under summary of pertinent findings or conclusion regarding resident's concern section was blank. During the resident council meeting on 5/11/2026 at 11:30 AM, Resident 75 and 147 stated the facility was made aware regarding call light not being answered promptly and stated that the call light not being answered promptly was still an ongoing issue that was not being resolved by the facility. During a concurrent interview and record review on 5/12/2026 at 12:45 PM with Activity Director (AD), the Facility's GCRR and RCM were reviewed by the AD. The facility's GCRR indicated no other documentation regarding investigation information and/or summary of the pertinent findings regarding the call light issues during the resident council meetings on the following dates: 8/6/2025, 9/9/2025, 1/13/2026, 3/10/2026, and 4/7/2026. The AD stated that when an issues or concern during the resident council meeting was identified, she (AD) would file a grievance to the specific department. The AD stated call light issues were addressed to the Director of Nursing (DON) and DSD. The AD stated there were ongoing issues with call light not being answered promptly during resident council meetings. During a concurrent interview and record review with the Director of Nursing (DON) on 5/13/2026 at 12:13 PM, the facility's GCRR and RCM were reviewed by the DON. The facility's GCRR indicated no other documentation regarding investigation information and/or summary of the pertinent findings regarding the call light issues during the resident council meetings on the following dates: 8/6/2025, 9/9/2025, 1/13/2026, 3/10/2026, and 4/7/2026. The DON stated that when receiving the grievances during the resident council meeting, she (DON) or the DSD would address the issues as soon as possible. The DON stated using the steps according to the GCRR document in which the DON or DSD would have to address the steps taken to investigate the grievance, provide summary of the pertinent findings or conclusion, and if the grievance or complaint was confirmed or not, and lastly the DON or DSD would have to document the corrective action done by the facility as a result of the grievance/complaint. The DON stated that the GCRR documents were incomplete and unacceptable since the facility was supposed to complete the investigation and document the investigation, the result of the investigation, and what the corrective action taken. During a concurrent interview and record review with the Social Service Director (SSD) on 5/14/2026 at 2:06 PM, Facility's GCRR and RCM were reviewed by the SSD. Facility's GCRR indicated no other documentation regarding investigation information and/or summary of the pertinent findings regarding the call light issues during the resident council meetings on the following dates: 8/6/2025, 9/9/2025, 1/13/2026, 3/10/2026, and 4/7/2026. The SSD stated when receiving the grievances during the resident council meeting, grievances were to be filed to the specific department and had to be investigated and addressed immediately by that department. The SSD stated and verified there were multiple issues about the call light not being answered promptly during resident council meetings. The SSD stated there was an incomplete grievance process since the nursing department was supposed to provide the full investigations and summary of the findings or conclusion regarding the call light issues. The SSD stated it was important to complete the grievance process accurately to be able to properly address the issues or concerns. During a review of facility's P&P, titled, Grievance Policy, reviewed on 4/14/2026, the P&P indicated that facility was to ensure all written grievance decision included the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concern(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued. During a review of facility's P&P, titled, Resident Family Group and Response, reviewed on 4/14/2026, the P&P indicated that the facility was to act promptly upon the grievances and recommendations of resident and family groups concerning issues of resident care and life in the facility and had to be able to demonstrate the facility's response and rationale to such grievances and recommendations.

Based on observation, interview, and record review the facility failed to provide reasonable accommodation for resident needs (the facility's efforts to individualize the resident's physical environment) by failing to: 1. Ensure two of five sampled residents (Resident 1 and Resident 185) had a communication board (a visual tool that uses pictures, symbols, or letters to help people with limited speech express their thoughts) at the bedside as indicated in the facility's Policy and Procedures (P&P) titled Communication Barriers, last reviewed 4/14/2026 and the facility's P&P titled ADL (Activities of Daily Living - activities such as bathing, dressing and toileting a person performs daily) Provided for Dependent Residents, last reviewed 4/14/2026. 2. Ensure one of five sampled residents (Resident 93) had a call light (a device used by a resident to signal his or her need for assistance) that was easy for Resident 93 to activate as indicated in the facility's P&P titled Resident Call System last reviewed 4/14/2026. 3. Ensure two of five sampled residents' (Resident 104 and Resident 138's) call light was within reach and accessible as indicated in the facility's P&P titled Resident Call System, last reviewed 4/14/2026. These failures had the potential for Resident 1, Resident 93, Resident 104, Resident 138, and Resident 185 to experience a delay in care and services, including inability to effectively communicate their needs to facility staff.Findings: 1. During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 11/13/2025 with diagnoses that included paralytic syndrome unspecified (loss of ability to move or control certain muscles in the body, but the doctor has not specified the exact cause or the specific name of the condition in the medical record), senile degeneration of the brain (the physical breakdown of brain tissue in older adults, which causes a steady loss of memory, thinking, and daily living skills), Diabetes Mellitus type 2 (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), muscle weakness, dysphagia (difficulty swallowing), suicide attempt, muscle weakness, and schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior). During a review of Resident's History and Physical (H&P), dated 1/6/2025, the H&) indicated Resident 1 had the capacity to make decisions. During a review of Resident 1's Minimum Data Set (MDS – a resident assessment tool) dated 3/15/2026, the MDS indicated Resident 1 usually had the ability to make himself (Resident 1) understood and usually had the ability to understand others. The MDS indicated Resident had unclear speech (slurred or mumbled words). The MDS indicated Resident 1 had moderately impaired cognition (ability to think, read, learn, remember, reason, express thoughts, and make decisions). During a concurrent observation and interview on 5/11/2026 at 10:54 AM with Certified Nursing Assistant 5 (CNA 5) in Resident 1's room, Resident 1 was observed trying to communicate, mumbling words, and was missing a communication board. CNA 5 stated he (CNA 5) could sometimes figure out what Resident 1 was trying to say. CNA 5 stated he would get Resident 1 a communication board. Resident 1 nodded his head yes when he was asked if he wanted a communication board. During a concurrent observation and interview on 5/11/2026 at 11:08 AM with Licensed Vocational Nurse 7 (LVN 7), in Resident 1's room, Resident 1 was observed to nod yes when asked if he wanted a communication board to be able to point to what his needs were. LVN 7 stated it would be better if Resident 1 had a means of communicating directly instead of staff guessing what Resident 1 needed. During a concurrent interview and record review on 5/15/2026 at 5:00 PM with the Director of Nursing (DON), the DON reviewed the facility's policy and procedure (P&P) titled ADL (Activities of Daily Living - activities such as bathing, dressing and toileting a person performs daily) Care Provided for Dependent Residents, last reviewed 4/14/2026, The DON stated the facility should have provided Resident 1 with a communication board. During a review of the facility's P&P titled ADL (Activities of Daily Living - activities such as bathing, dressing and toileting a person performs daily) Care Provided for Dependent Residents, last reviewed 4/14/2026, the P&P indicated ADL (Activities of Daily Living - activities such as bathing, dressing and toileting a person performs daily) Care Provided for Dependent Residents, last reviewed 4/14/2026, The DON stated the P&P indicated Speech, Language or other Functional Communication Systems: The resident's (in general) ability to effectively communicate requests, needs, opinions, and urgent problems; to express emotion, to listen to others and to participate in social conversation whether in speech, writing, gesture, behavior, or a combination of these (e.g., a communication board or electronic augmentative communication device). During a review of the facility's P&P titled, Communication Barriers, last reviewed 4/14/2026, the P&P indicated Facility Staff will inform residents of TTY/TDD availability, as indicated. A. In addition to TTY/TDD devices, the Facility may use other electronic devices, written materials and communication boards to address communication barriers. 2. During a review of Resident 93's admission Record, the admission Record indicated the facility admitted the resident on 1/2/2026, with diagnoses that included rhabdomyolysis (a serious medical condition where damaged muscle tissue rapidly breaks down and dies), transverse myelitis (a rare neurological disorder caused by inflammation across one section of the spinal cord), and hemiplegia (paralysis of the arm, leg, and trunk on the same side of the body) affecting the left side of the body. During a review of Resident 93's MDS dated [DATE], the MDS indicated the resident needed touching assistance (helper provides verbal cues or steadying as resident completed activity) from facility staff to complete activities of daily living ADLs. During a review of Resident 93's Fall Risk Evaluation, dated 1/2/2026, the evaluation indicated the resident was a high risk for falls. During a review of Resident 93's care plan report titled, ADL: Resident requires assistance, revised on 1/5/2026, the care plan indicated an intervention of Call light within reach and answered promptly. During a concurrent observation and interview on 5/11/2026 at 12:20 PM with Resident 93, in Resident 93's room, Resident 93 was observed sitting upright in bed while holding a basin (a plastic open container) on his lap. Yellowish brown fluid was observed on Resident 93's chin, mouth, chest area, and on the resident's bed linens. Resident 93 stated, The call light doesn't work and asked if someone could help clean up the throw up. During a concurrent observation and interview on 5/11/2026 at 12:24 PM with Restorative Nurse Assistant (RNA) 1, in Resident 93's room, RNA 1 pressed the call light but the call light did not alarm. RNA 1 stated there was watery, brown throw up in the basin. During a concurrent observation and interview on 5/11/2026 at 12:26 PM with Maintenance Staff (MS) 1, in Resident 93's room, Resident 93's call light cord was not fully plugged into the wall socket. MS 1 was observed pushing the call light cord completely into the wall socket. MS 1 stated the call light was the only device residents could use to call for help. MS 1 stated that call light cords had to be fully plugged into a working electrical wall socket to work. During a concurrent observation and interview on 5/11/2026 at 12:38 PM with Resident 93, in Resident 93's room, Resident 93 pressed the call light multiple times. The call light did not alarm. Resident 93 stated the call light was still not working. During an interview on 5/11/2026 at 12:39 PM with RNA 1, RNA 1 stated residents could feel scared and frustrated when they were unable activate the call light to call for help. During a concurrent observation and interview on 5/11/2026 at 12:47 PM with LVN 6, in Resident 93's room, LVN 6 pressed Resident 93's call light and activated the alarm. LVN 6 stated Resident 93 could not apply enough pressure on the call light button to activate the alarm. LVN 6 stated without a way to call for help, residents could try to get up unassisted and fall. During a concurrent interview and record review on 5/14/2026 at 5:30 PM with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Resident Call System and Reasonable Accommodation of Needs – Preferences, revised on January 2026, was reviewed by the DON. The DON stated the P&P was not followed because Resident 93 was not able to easily access and activate the call light. The DON stated staff should have assessed residents to determine if they cannot use a standard call light due to limitations in functional extremities. The DON stated care could be delayed and Resident 93 could have aspirated. During a review of the facility's P&P titled, Resident Call System, revised on January 2026, the P&P indicated Some residents may need a specialized call light, such as a call pad to request assistance. During a review of the facility's P&P titled, Reasonable Accommodation of Needs - Preferences, revised on January 2026, the P&P indicated Each resident shall have access to the resident call system within reach and to the ability the resident is able to use it if desired. During a review of Resident 185's Administration Record, the Administration Record indicated the facility admitted the resident on 4/30/2026 with diagnoses that included DM2, hyperlipidemia (high levels of cholesterol in the blood), chronic kidney disease (a condition in which the kidneys are damaged and gradually lose their ability to filter waste and excess fluid from the blood), congestive heart failure (CHF, a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), and hypertension (high blood pressure). During a review of Resident 185's Care Plan Report dated 5/1/2026, the Care Plan Report indicated the resident was a Spanish speaker. The Care Plan Report indicated an intervention to provide Resident 185 with a Spanish communication board at bedside. During a review of Resident 185's MDS dated [DATE], the MDS indicated the resident had severe cognitive impairment (loss of memory and the ability to think, understand, and reason that is severe enough to interfere with daily life). The MDS indicated Resident 185 was dependent on facility staff for help with toileting hygiene and personal hygiene. The MDS indicated Resident 185 required substantial/maximal assistance (helper does more than half the effort) with putting on/taking off footwear. The MDS indicated Resident 185 required partial/moderate assistance (helper does less than half the effort) with showering/bathing self and putting on/taking off footwear. The MDS indicated Resident 185 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with eating, and oral hygiene. During an observation on 5/11/2026 at 10:08 AM in Resident 185's room, the resident was observed lying in bed and watching a Spanish language channel on television (TV). There was no Spanish communication board observed at Resident 185's bedside. During a concurrent observation and interview on 5/11/2026 at 10:14 AM with CNA 4 in Resident 185's room, CNA 4 stated Resident 185 spoke Spanish. CNA 4 stated Resident 185 did not have a communication board at bedside. CNA 4 stated there should have been a communication board at Resident 185's bedside. During an interview on 5/14/2026 at 9:55 AM with Registered Nurse 3 (RN 3), RN 3 stated the facility had communication boards for residents (in general) that did not speak English. RN 3 stated the residents who did not speak English could use the communication board by pointing to pictures when they communicated with staff (in general). RN 3 stated Resident 185 spoke Spanish. RN 3 stated Resident 185 should have had a communication board at bedside. RN 3 stated there was potential for Resident 185 to have not been able to communicate the resident's needs to staff (in general) if the resident did not have a communication board at bedside. During a concurrent interview and record review on 5/14/2026 at 3:14 PM with the Director of Nursing (DON), Resident 185's Care Plan Report dated 5/1/2026 was reviewed. The DON stated Resident 185's Care Plan Report indicated the resident was a Spanish speaker and had an intervention to provide the resident with a Spanish communication board at bedside. The DON stated that if Resident 185's Care Plan Report indicated the resident needed a Spanish communication board at bedside, a Spanish communication board should have been provided. The DON stated a communication board was a way for residents (in general) who did not speak English to communicate with the staff (in general) about the residents' (in general) needs. The DON stated that if Resident 185 did not have a communication board there was potential for the Resident 185 to have not been able to communicate the resident's needs. The DON stated there was potential for Resident 185 to not have the resident's needs met. During a review of the facility's P&P titled Communication Barriers reviewed 4/14/2026, the P&P indicated Facility Staff will inform residents of TTY (Text telephones/TTD (telecommunications devices for the deaf) availability as indicated. In addition to TTY/TTD devices, the facility may use other electronic devices, written materials and communication boards to address communication barriers. During a review of the facility's P&P titled ADL Care Provided for Dependent Residents reviewed 4/14/2026, the P&P indicated The facility provides assistance for residents unable to carry out activities of daily living.Speech, Language or other Functional Communication Systems: The resident's ability to effectively communicate requests, needs, opinions, and urgent problems; to express emotion, to listen to others and to participate in social conversation whether in speech, writing, gesture, behavior, or a combination of these (e.g., a communication board or electronic augmentative communication device).The interdisciplinary team develops and implements interventions in accordance with the resident's assessed needs, goals for care, preferences, and recognized standards of practice that address the identified limitations in ability to perform ADLs. During a review of Resident 138's admission Record (Face Sheet), the admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side (paralysis and weakness on one side of the body following a stroke), functional quadriplegia (complete immobility due to severe physical disability), type 2 diabetes mellitus with hyperglycemia (high blood sugar due to the body not properly using insulin), cognitive communication deficit (difficulty understanding or expressing thoughts), essential hypertension (chronic high blood pressure), acute and chronic respiratory failure with hypoxia (inability to maintain adequate oxygen levels) and muscle weakness (reduced muscle strength affecting mobility and physical function). During a review of Resident 138's Minimum Data Set (MDS), dated [DATE], the MDS indicated Resident 138 had severely impaired cognitive skills for daily decision-making, memory problems with short-term and long-term memory, and required extensive staff assistance for activities of daily living (ADLs), including personal hygiene, toileting hygiene, dressing, bathing, transfers, and mobility.During an observation on 05/13/2026 at 9:08 a.m., Resident 138 was observed receiving morning care from Certified Nursing Assistant 1 (CNA 1). The resident's call light was observed on the floor and not within the resident's reach.During a review of Resident 104's admission Record, the admission Record indicated the Resident 104 was admitted to the facility on [DATE] with diagnoses including hypertension (HTN - elevated blood pressure), diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]), and muscle weakness (reduced muscle strength affecting mobility and physical function). During a review of Resident 104's Minimum Data Set (MDS - a resident assessment tool), dated 5/3/2026, the MDS indicated Resident 104 had intact cognition (mental action or process of acquiring knowledge and understanding) for daily decision-making and with varying assistance from set up (helper sets up or cleans up; resident completes activity) to being dependent (helper does all the effort) from staff for activities of daily living (ADLs-bed mobility, surface transfer, eating, walk in room, dressing, toileting, and personal hygiene). During an observation on 5/13/2026 at 8:26 a.m., inside Resident 104's room, Resident 104's call light was observed on the floor and not within Resident 104's reach. During a concurrent interview on 5/13/2026 at 8:26 a.m., Resident 104 stated, It fell earlier and no one came to help me get it.During a concurrent interview on 05/18/2026 at 2:32 p.m., the Director of Nursing (DON) stated it is important for the resident's call light to remain within reach at all times to ensure the resident has immediate access to call staff for assistance when needed. The DON further stated that failure to keep the call light within reach may place the resident at risk for delayed assistance, unmet needs, and inability to promptly call staff during an emergency. During a record review of the facility's policy and procedure (P&P), titled Reasonable Accommodations of Needs – Preferences, revised January 2026, the policy indicated each resident shall have access to the resident call system within reach and to the ability the resident is able to use it if desired.

Based on observations, interviews, and record reviews, the facility failed to provide skin and pressure ulcer (injuries to the skin and underlying tissue, primarily caused by prolonged pressure on the skin) prevention care consistent with professional standards of practice and per physician's orders for three of five sampled residents (Resident 1, 4, and 9) on Low Air Loss Mattresses (LALM, a specialized medical support surface designed to prevent and treat skin breakdown and pressure ulcers [localized damage to the skin and/or underlying tissue usually over a bony prominence]). By failing to 1. Ensure Resident 1 and Resident 9's LALMs were set to the correct setting as indicated by the facility's Policy and Procedures (P&P) titled Low Air Loss Mattress, last reviewed 4/14/2026 and the product manufacturer guidelines titled Med-Aire Melody Alternating Pressure Low Air Loss Mattress Replacement System Operator's Manual, revised 3/22/2021.2. Ensure Resident 4's LALM was plugged in and working as indicated by the facility's P&P titled Low Air Loss Mattress, last reviewed 4/14/2026 and the product manufacturer guidelines titled, User-Service Manual Roerns(R) Support Surfaces P.R.O. Matt(R) Plus, dated 2024. This failure had the potential for Resident 1, Resident 4, and Resident 9 to develop or worsen existing pressure ulcers/injuries (localized damage to the skin and/or underlying tissue usually over a bony prominence).Findings: During a review of Resident 1'a admission Record, the admission Record indicated the facility admitted Resident 1 on 11/13/2025 with diagnoses that included paralytic syndrome unspecified (a person has lost the ability to move or control certain muscles in their body, but the doctor has not specified the exact cause or the specific name of the condition in the medical record), senile degeneration of the brain (the physical breakdown of brain tissue in older adults, which causes a steady loss of memory, thinking, and daily living skills), Diabetes Mellitus type 2 (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), muscle weakness, dysphagia (difficulty swallowing), suicide attempt, muscle weakness, and schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior). During a review of Resident's History and Physical (H&P), dated 1/6/2025, the H&P) indicated Resident 1 had the capacity (ability) to make decisions. The H&P indicated Resident 1 had an unstageable sacral ulcer (a severe, deep bed sore located directly over the tailbone), bilateral (both) knees with open wound, bilateral toes (toes on both feet), right arm with skin tear, right groin with skin fold wound, and occiput (the back part of the head) pressure sore (localized damage to the skin and/or underlying tissue usually over a bony prominence). During a review of Resident 1's Care Plan Report titled, Resident 1 has high risk/or at risk for delayed wound healing dated 2/13/2026, the Care Plan Report indicated an intervention for LALM for wound management. During a review of Resident 1's Care Plan Report titled Low air loss mattress: the resident (Resident 1) requires the use of a low air loss mattress to relieve pressure and support the maintenance of skin integrity (the overall health, wholeness, and strength of your skin), the Care Plan report indicated an intervention for facility staff to regularly check the mattress's inflation to ensure it is maintaining the correct pressure level and air flow. During a review of Resident 1's Minimum Data Set (MDS – a resident assessment tool) dated 3/15/2026, the MDS indicated Resident 1 usually had the ability to make himself (Resident 1) understood and usually had the ability to understand others. The MDS indicated Resident had unclear speech (slurred or mumbled words). The MDS indicated Resident 1 had a BIMS (Brief Interview for Mental Status-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 12 (a score of 12 is usually a signal for the care team to monitor the person's mental status closely, help them with daily cues if needed). During a review of Resident 1's Order Summary Report dated 5/13/2026, the Order Summary Report indicated Resident 1 had a physician order for LALM for skin and wound management. During a concurrent observation and interview on 5/11/2026 at 11:08 AM with Licensed Vocational Nurse 7 (LVN 7), Resident 1's LALM was observed set for a weight of 120 pounds. LVN 7 stated that the facility's environmental services were responsible for setting up Resident 1's LALM. LVN 7 stated Resident 1 did not have any bed sores. LVN 1 stated she was not sure what the facility's LALM policy was. During a concurrent interview and record review on 5/12/2026 at 2:17 PM with the facility's Infection Preventionist Nurse (IPN) and Registered Nurse 4 (RN 4), Resident 1's electronic medical record (EMR - a digital version of a patient's paper medical chart) was reviewed. The IPN and RN 4 verified Resident 1 weighed 155 lbs. During a concurrent observation and interview at 5/12/2026 at 2:17 PM with the facility's IPN and RN 4, Resident 1's LALM was observed to be set at the same setting, observed on 5/11/2026 at 11:08 AM. The IPN stated the facility's nurses (in general) should have set Resident 1's LALM based on Resident 1's weight. RN 4 stated Resident 1 had a sacrococcyx pressure injury (bed sore located on your lower tailbone and the flat bone connecting to it) and the LALM should have been set to the correct setting based on Resident 1's weight. RN 4 stated Resident 1's sacrococcyx pressure injury could be negatively affected if Resident 1's LALM was not set to the correct weight. During an interview on 5/14/2026 at 5:00 PM with the Director of Nursing (DON), the DON stated the facility should have set Resident 1's LALM based on Resident 1's weight. During a review of the facility's policy and procedure (P&P), titled Low Air Loss Mattress, last reviewed 4/14/2026, the P&P indicated 12. For maintenance, cleaning, settings, and care, the facility shall follow the manufacturer's guidelines. During a review of the manufacturer's guidelines titled Med-Aire Melody Alternating Pressure Low Air Loss Mattress Replacement System Operator's Manual, revised 3/22/2021, the manufacturer's guidelines indicated Step 6 Determine the patient's (resident in general) weight and set the control knob to that weight s setting on the control unit. During a review of Resident 9's admission record, the admission record indicated the facility originally admitted Resident 9 on 12/31/2014 and re-admitted the resident on 4/13/2026 with diagnoses including gastrostomy (GT- a flexible tube surgically inserted through the abdomen into the stomach for feeding, fluid, and medication administration), respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide) and metabolic encephalopathy (a condition in which the functioning of the brain is affected by some agent or condition-such as viral infection or toxins in the blood). During a review of Resident 9's Braden Scale (pressure ulcer risk predictor tool) for predicting pressure ulcer risk (BSPPUR) dated 12/25/2025, the BSPPUR indicated Resident 9 was at risk for pressure ulcer development. During a review of Resident 9's MDS dated [DATE], the MDS indicated Resident 9 had impaired cognition (mental action or process of acquiring knowledge and understanding) for daily decision-making and dependent (helper does all the effort) from staff for activities of daily living (ADLs-bed mobility, surface transfer, eating, walk in room, dressing, toileting, and personal hygiene). The MDS indicated Resident 9 was at risk of developing pressure ulcers/injuries with treatment for pressure reducing devices for bed. During a review of Resident 9's care plan revised on 4/13/2026, the care plan indicated Resident 9 was at risk for developing pressure ulcers and needed specialized pressure-reducing care. Resident 9's care plan indicated under interventions to ensure LALM was in place, plugged in and functioning properly, and maintaining the correct level and air flow. During a review of Resident 9's H&P dated 4/20/2026, the H&P indicated Resident 9 did not have the capacity to understand and make decisions. During a review of Resident 9's order summary report dated 5/12/2026, the order summary report indicated Resident 9 had an order for a LALM for skin management every shift for wound and skin management. During a review of Resident 9's Weights and Vitals Summary Report, on 5/13/2026, Resident 9's weight indicated the following: 5/11/2026 161 pounds (lbs.) 4/27/2026 159 lbs. 3/6/2026 155 lbs. During an observation on 5/11/2026 at 9:59 a.m., inside Resident 9's room, Resident 9's LALM setting was observed set at 280 lbs. During an interview with Treatment Nurse 2 (TX 2) on 5/13/2026 at 12:01 PM, TX 2 stated Resident 9's LALM should have been set at 180 lbs. to prevent pressure ulcer for Resident 9. TX 2 also stated importance of following the manufacturer's manual for the use of LALM. During an interview on 5/13/2026 at 12:13 PM, the DON stated that Resident 9's LALM should have been set according to Resident 9's weight. The DON stated the importance of having LALM set at the right setting to be able to prevent pressure ulcers/injury to high-risk residents of having skin breakdown. During a review of facility's P&P, titled, Treatment Services to Prevent/Heal Pressure Ulcers, reviewed on 4/14/2026, P&P indicated that support surfaces and pressure redistribution devices that are used by the facility are most likely to reduce pressure effectively if they are used in accordance with the manufacturer's instructions. During a review of the LAL Operator's Manual 1 (LAL OM 1), undated, LAL OM 1 indicated the facility needed to determine the patient's weight and set the control knob to the specific weight setting. 2. During a review of Resident 4's admission record, the admission record indicated the facility originally admitted Resident 4 on 3/17/2025 and re-admitted the resident on 1/7/2026 with diagnoses including gastrostomy, chronic respiratory failure and dependence on ventilator (a machine or device used medically to support or replace the breathing of a person, unable to breath on their own). During a review of Resident 4's care plan dated 1/8/2026, care plan indicated Resident 4 was at risk for developing pressure ulcers, requiring specialized care and pressure relief using LALM. Resident 4's care plan indicated under interventions to ensure LALM was in place, plugged in and functioning properly, maintaining the correct level and air flow. During a review of Resident 4's H&P, dated 1/14/2026, the H&P indicated Resident 4 did not have the capacity to understand and make decisions. During a review of Resident 4's MDS dated [DATE], the MDS indicated Resident 4 had impaired cognition for daily decision-making and was dependent on staff for ADLs. The MDS also indicated Resident 4 was at risk of developing pressure ulcers/injuries with treatment for pressure reducing devices for bed. During a review of Resident 4's Braden Scale for predicting pressure ulcer risk (BSPPUR) dated 3/13/2026, the BSPPUR indicated Resident 4 was at risk for pressure ulcer development. During a review of Resident 4's order summary report dated 3/20/2026, the order summary report indicated that Resident 4 had an order for a LALM for skin management every shift. During a concurrent observation and interview on 5/11/2026 at 10:49 AM, with Registered Nurse 2 (RN 2) inside Resident 4's room, Resident 4's LALM machine was observed turned off. RN 2 stated that the LALM machine was unplugged and disconnected from a power wall outlet. RN 2 stated that LALM should have been turned on. RN 2 stated importance of using the LALM to Resident 4 due to Resident 4's high risk of skin breakdown. During an interview with Treatment Nurse 1 (TX 1) on 5/13/2026 at 9:48 AM, TX 1 stated LALM should have been plugged in and turned on to provide the intended use, which was reducing pressure to the skin. During a review of facility's P&P, titled, Treatment Services to Prevent/Heal Pressure Ulcers, reviewed on 4/14/2026, P&P indicated that support surfaces and pressure redistribution devices that are used by the facility are most likely to reduce pressure effectively if they are used in accordance with the manufacturer's instructions. During a review of the LAL Operator's Manual 2 (LAL OM 2), undated, LAL OM 2 indicated to ensure the system is operating correctly, the mattress and control unit should be checked by facility.

Based on observation, interview and record review, the facility failed to provide a fortified diet (diet enhanced to increase caloric content of food) for 18 out of 112 meal trays requiring a fortified diet. This deficient practice had the potential to result in decrease caloric intake and lead to undesirable weight loss.Findings: During an observation of the kitchen tray line (tray line- a system of food preparation, in which trays move along an assembly line) service for lunch on 5/11/2026 at11:56AM, meal trays indicating fortified diet received the same food as the meal trays that did not have fortified diet orders. Dietary Aide (DA2) was observed not communicating to the cooks the fortified diet orders written on the meal tray cards (a printed sheet that includes resident diet order, preferences and dislikes). A review of tray cards on the meal carts indicated orders for fortified diets. However, DA2 did not read out loud the fortified diet and cook (Cook1) did not add any additional food items. During an interview with DA2 on 5/11/2026 at 1:00PM, DA2 stated that fortified diets were to add extra calories to the food. DA2 stated fortified diets were for residents who were losing weight so they can have more calories. DA2 stated I think residents on fortified diets receive special soup. DA2 stated I didn't communicate the fortified diets to the cook, so no one received anything extra. During an interview with cook1 on 5/11/2026 at 1:10PM, cook1 said the cooks would add melted butter to fortified diets. Cook1 confirmed not adding any melted butter to any tray on date of interview (5/11/2026) during lunch service. Cook1 said DA2 would let the cooks know that the trays were for fortified diets so the cooks could add melted butter. Cook1 said DA2 did not read out the fortified diet during the lunch service on 5/11/2026. Cook1 said the fortified diet is for residents who are losing weight. Cook1 stated fortified diets were to get additional butter on the vegetables or starch to add extra calories. During an interview with the Registered Dietitian (RD) on 5/11/2026 at 1:15PM, the RD stated fortified diets were recommended for residents who were at risk of weight loss. [NAME] RD stated fortified diets required an additional 500 calories per day, spread out over three meals. The RD stated residents on fortified diets would receive either melted butter over the vegetables and starches, high protein and calorie mashed potato, or creamy soup. The RD stated regular soups or high calories shakes were separate requests and were not part of the fortified diets. During a review of facility Guideline and procedures Manual titled, Fortified Foods, Supplements, and Snacks (dated 2020) the manual indicated, Residents who cannot consume adequate amounts of regular foods at meals to meet their nutritional needs may be considered for fortified foods, snacks, or supplements to increase nutritional intake. Residents will be evaluated by the Registered Dietitian when additional nutritional intervention is warranted. Fortified foods, house supplements, or snacks will be provided within the specifications of the diet order. During a review of facility's Guideline and procedures Manual titled, Fortified Enhanced power Foods Protocol (FEP) (dated 2020), the manual indicated, A protocol such as the Fortified Foods Protocol (FEP) may be utilized to increase calories and or protein in the foods serves as a part of the meal. The FEP Protocol is based on the regular diet, with foods enhanced, substituted or added to boost the calorie and protein content of meals. FEP foods are designed to provide additional calories and protein. FEP foods are foods that are enhanced in calories and protein. All power foods provide a minimum of 180 to190 calories and 5 to 6 grams of protein per serving. The FEP foods include, but are not limited to : Cheesy eggs, fortified hot chocolate, milk shake, fortified soup, power potatoes, super cereal and pudding.

Based on observations, interviews, and record reviews, the facility failed to maintain infection control practices (the set of everyday habits and rules used to stop germs such as viruses and bacteria from spreading) necessary to prevent the spread of infections for four of nine sampled residents (Resident 7, Resident 9, Resident 175, and Resident 186) by failing to: 1. Ensure Licensed Vocational Nurse (LVN) 5 rinsed Resident 7' medication syringe after administering medications via gastrostomy tube (g-tube - a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) and before putting the syringe away as indicated by the facility's Policy and Procedures (P&P) titled Medication Administration Through Gastrostomy Tube, last reviewed 1/2026, and as indicated in the facility's P&P titled Enteral Feeding [a way of delivering liquid nutrition directly to your stomach] - Restore Eating Skills, last reviewed 4/14/2026.2. Ensure Treatment Nurse (a specialized nurse who focuses on hands-on, procedural care) 2 (TX 2) was wearing a personal protective equipment (PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) gown when providing g-tube dressing care for Resident 9, who was on enhanced barrier precautions (EBP - an infection control strategy used in nursing homes and skilled nursing facilities to prevent the spread of infection) as indicated by the facility's P&P titled Infection and Prevention and Control, last reviewed 4/14/2026.3. Ensure the enteral feeding tubes for Resident 175 and Resident 186 were capped (putting a plug or cover over the opening of the feeding tube when it is not being used to deliver food or medicine) and not open to air as indicated by the facility's P&P titled, Infection and Prevention and Control, last reviewed 4/14/2026 and as indicated by the facility's P&P titled, Enteral Feeding - Safety Precautions, last reviewed 4/14/2026. Cross reference F0693. This failure had the potential to increase the residents' risk of contamination (harmful germs like bacteria or fungus have gotten into the feeding tube or the liquid food) and had the potential to increase the residents' risk of infection. Findings: 1. During a review of Resident 7's admission Record (a document containing demographic and diagnostic information) dated 5/13/2026, the admission record indicated Resident 7 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but not limited to acute transverse myelitis in demyelinating disease of central nervous system (a brief but intense attack of inflammation [swelling] in the spinal cord that damages myelin [protective covering of nerve fibers]), encounter for attention to gastrostomy (g-tube) and gastro-esophageal reflux disease ([GERD] – a condition where stomach acid flows back up into the esophagus and causes heartburn) without esophagitis (swelling and irritation of tissues that line esophagus). During a review of Resident 7's History and Physical (H&P), dated 5/4/2026, the H&P indicated Resident 7 had the capacity to understand and make decisions. During a review of Resident 7's Minimum Data Set ([MDS], a resident assessment tool) dated 3/18/2026, the MDS indicated Resident 7's cognition (mental action or process of acquiring knowledge and understanding through thought and senses) was moderately impaired. The MDS indicated Resident 7 was dependent on facility's staff for performing activities of daily living (ADLs - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) such as oral hygiene, toileting hygiene, showering, upper and lower body dressing, putting on or taking off footwear and personal hygiene. The MDS indicated the function of eating was not attempted due to medical condition or safety reasons. During a medication administration observation on 5/13/2026 at 9:29 a.m. outside Resident 7's room, Licensed Vocational Nurse 5 (LVN 5) was observed preparing eight medications by crushing them individually using a crushing device and dissolving each medication in water separately into small individual medicine cups, to be administered to Resident 7 via g-tube and one injection syringe of enoxaparin (a prescription blood thinner used to prevent and treat harmful blood clots in your veins, legs, or lungs) , for a total of nine medications. LVN 5 entered Resident 7's room and placed the prepared medications on bedside cart without disinfecting the bedside cart. LVN 5 checked for Resident 7's g-tube placement (observing stomach contents, ensuring the measured length matches the recorded baseline, and confirming the skin-to-tube fit) and connected the 60 mL syringe to the g-tube to check for gastric residual volume (the amount of fluid remaining in the stomach of a person being fed through a feeding tube). LVN 5 stated there was very little, less than 1 mL[milliliter] residual in g-tube administration syringe. LVN 5 removed the 60 mL syringe from the g-tube and brought the medicine syringe near the medicine cups. LVN 5 pushed out a couple of droplets of the residual liquid onto the bedside cart with prepared medicines while removing the plunger from the 60 mL syringe. LVN 5 continued with a water flush and then administered the medications administration one by one via g-tube to Resident 7. After administering all medications for Resident 7, LVN 5 disconnected the 60 mL syringe and placed the syringe back in the syringe bag without rinsing and cleaning the syringe. During a follow up interview on 5/13/2026 at 10:04 a.m. with LVN 5, LVN 5 stated there would be a risk of infection because a few drops from residual volume pushed out from syringe onto Resident 7's bedside table before she (LVN 5) started administering medications. LVN 5 stated she should have rinsed out the syringe after g-tube administration before putting it away to keep the syringe clean and patent [intact]. During an interview on 5/14/2026 at 12:39 p.m. with the Director of Nursing (DON), the DON stated were to disinfect areas around the resident. The DON stated the syringe used to administer medications via g-tube should have been cleaned and disinfected to prevent spread of infection. The DON stated the nursing staff should have rinsed the syringe after g-tube administration of medications otherwise the g-tube syringe should have been replaced with a new clean syringe. During a review of the facility's P&P titled, Medication Administration Through Gastrostomy Tube, last reviewed 1/2026, the P&P indicated, Procedure. 25. Rinse the syringe utilized for medication instillation and store in a clean manner. During a review of the facility's P&P titled, Infection and Prevention and Control, last revised 1/2026, the P&P indicated, The facility has an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. 2. During a review of Resident 9's admission record, the admission record indicated the facility originally admitted Resident 9 on 12/31/2014 and re-admitted the resident on 4/13/2026 with diagnoses including gastrostomy tube, respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide) and metabolic encephalopathy (a condition in which the functioning of the brain is affected by some agent or condition-such as viral infection or toxins in the blood). During a review of Resident 9's MDS, dated [DATE], the MDS indicated Resident 9 had impaired cognition for daily decision-making and dependent (helper does all the effort) from staff for activities of daily living (ADLs-bed mobility, surface transfer, eating, walk in room, dressing, toileting, and personal hygiene). The MDS indicated Resident 9 was at risk of developing pressure ulcers/injuries with treatment for pressure reducing devices for bed. During a review of Resident 9's care plan initiated on 4/13/2026, care plan indicated Resident 9 was on EBP related to gastrostomy with intervention to promote importance of EBP including proper hand hygiene and wearing PPE during high contact resident activities. During a review of Resident 9's H&P dated 4/20/2026, the H&P indicated Resident 9 did not have the capacity to understand and make decisions. During a review of Resident 9's order summary report, dated 5/12/2026, the order summary report indicated that Resident 9 had an order for an EBP due to gastrostomy. During a concurrent observation and interview with treatment nurse 2 (TX 2), on 5/13/2026 at 12:01 PM, Resident 9's room was observed with EBP signage indicating that providers and staff (general) had to wear gloves and a gown for high contact resident care activities such as ADLs (dressing, grooming, bathing, changing bed linens), toileting and changing incontinence briefs, caring for devices and giving medical treatments, wound care, mobility assistance and preparing to leave room and cleaning the environment. TX 2 was observed not wearing a gown during the gastrostomy tube site dressing change. TX 2 verbalized having forgotten to wear a gown. TX 2 stated that it was important to wear both the gloves and gown during a gastrostomy tube site dressing change for Resident 9 due to Resident 9 being high risk for infection. During an interview on 5/13/2026 at 12:13 PM, with the Director of Nursing (DON), the DON stated the treatment nurse should have been wearing gloves and gowns when doing any type of wound care dressing to prevent any infections to the residents in EBP. During a review of facility's P&P, titled, Infection and Prevention and Control, reviewed on 4/14/2026, the P&P indicated that facility had an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infections. The P&P indicated facility staff had to ensure EBP were used in conjunction with standard precautions and expanded the use of PPE to donning (putting on) of gowns and gloves during high-contact resident care activities that provide opportunities for transfer of MDRO (multi-drug-resistant organism-bacteria that have become resistant to certain antibiotic medications) to staff hands and clothing. 3a. During a review of Resident 175's admission Record, the admission Record indicated the facility originally admitted Resident 175 on 5/23/2025 and readmitted Resident 175 on 1/16/2026 with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (the person survived a stroke, which left them with weakness or paralysis [the loss of the ability to move or feel in all or part of the body ] on the left side of their body), dysphagia (difficulty swallowing), muscle weakness, type 2 Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), acquired absence of other specified parts of digestive tract (a part of the digestive system was surgically removed), and reduced mobility. During a review of Resident 175's Care Plan Report, titled The Resident (Resident 175) has enteral feeding and must maintain nutritional status via feeding tube r/t (related to) inability to swallow, dated 2/11/2025, the Care Plan Report indicated an intervention to use clean technique when administering tube feedings. During a review of Resident 175's Care Plan Report, titled Gastrostomy tube feeding: Resident (Resident 175) has is on gastrostomy tube (GT - gastrostomy tube -a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) feeding. At risk for aspiration (means food, liquid, or stomach contents go down the wrong pipe and enter your lungs), dehydration (a condition that occurs when the body loses more fluid than it takes in), weight fluctuation, weight gain, weight loss, nausea and vomiting, abdominal distention (stomach is visibly swollen, stretched, or sticking out further than usual), diarrhea, constipation (hard, dry, or difficult to pass stool), intolerance to feeding r/t dysphagia, dated 2/11/2025, the Care Plan Report indicated an intervention to change tubing per policy or as ordered. During a review of Resident 175's Care Plan Report, titled Enhanced Barrier Precautions (EBP - an infection control strategy used in nursing homes and skilled nursing facilities to prevent the spread of multidrug-resistant organisms that requires facility staff to use gown and gloves during high contact resident care activities) related to gastrostomy tube, dated 2/11/2025, the Care Plan Report indicated a goal for the facility to minimize risk and complications of infection. The Care Plan Report indicated an intervention to promote EBP. During a review of Resident 175's H&P dated 3/4/2026, the H&P indicated Resident 175 did not have the capacity (ability) to understand and make decisions. The H&P indicated Resident 175 had an intact GT. The H&P indicated Resident 175 was s/p (status post - condition after) urinary tract infection (UTI- an infection in the bladder/urinary tract) with sepsis (a life-threatening blood infection). The H&P indicated Resident 175's prognosis (a medical prediction about how an illness, disease, or injury will progress over time) was poor. During a review of Resident 175's MDS dated [DATE], the MDS indicated Resident 175 had no speech (absence of spoken word), rarely/never could make himself (Resident 175) understood, and rarely/never had the ability to understand others. During a review of Resident 175's Order Summary Report dated 5/13/2026, the Order Summary Report indicated Resident 175 had a physician order for enteral feeding (the delivery of liquid nutrients directly into the stomach or small intestine through a GT). The Order Summary Report Resident 175 had a physician order for enhanced barrier precautions due to gastrostomy tube. During a concurrent observation and interview on 5/11/2026 at 11:44 AM with LVN 7 in Resident 175's room, Resident 175's enteral feeding tube was observed to be uncapped and open to air. A photo was taken of the uncapped enteral feeding tube. LVN 7 verified Resident 175's enteral feeding tube was uncapped and stated Resident 175 could have been at risk for infection if staff connected the uncapped enteral feeding tube to Resident 175. LVN 7 stated she (LVN 7) would need to change Resident 175's enteral tube feeding system. During an interview on 5/13/2025 at 10:22 AM with Registered Nurse 3 (RN 3), RN 3 stated there could be an infection control issue if Resident 186's enteral feeding tube was uncapped and left open to air. During a concurrent interview and record review on 5/14/2026 at 5:09 PM, with the DON, the DON reviewed the facility's P&P titled Infection and Prevention and Control, last reviewed 4/14/2026. The DON stated the facility should have capped Resident 175's enteral feeding tube if the enteral feeding had been disconnected from Resident 175's gastrostomy tube for infection control. 3b. During a review of Resident 186's admission Record, the admission Record indicated the facility originally admitted Resident 186 on 3/9/2026 and readmitted Resident 186 on 4/27/2026 with diagnoses that included epilepsy (a brain disorder that causes repeated, unprovoked seizures), aphasia (a disorder that makes it difficult to speak), type 2 Diabetes Mellitus, muscle weakness, dysphagia (difficulty swallowing), and essential hypertension (HTN-high blood pressure). During a review of Resident 186's MDS dated [DATE], the MDS indicated Resident 186 had unclear speech (slurred or mumbled words), rarely could make himself (Resident 186) understood, and rarely had the ability to understand others. During a review of Resident 186's Care Plan Report, titled At risk for infection – GT: Resident at risk for infection due to gastrostomy tube site, dated 4/27/2026, the Care Plan Report indicated a goal for the facility to minimize risk for infection at the GT site. The Care Plan Report indicated an intervention for the facility to change tubings per policy or as ordered. During a review of Resident 186's Care Plan Report, titled Enhanced Barrier Precaution: Enhanced Barrier Precaution related to Gtube (GT), dated 4/27/2026, the Care Plan Report indicated a goal to minimize risk and complications of infection. During a review of Resident 186's H&P dated 5/6/2026, the H&P indicated Resident 186 did not have capacity to understand and make decisions. The H&P indicated Resident 186 was s/p fever of unknown etiology (having a high temperature without a clear cause) and s/p c-diff (clostridium difficile - a highly contagious bacteria that causes severe diarrhea) colitis, (swelling or inflammation of the inner lining of your large intestine). During a review of Resident 186's Order Summary Report, dated 5/13/2026, the Order Summary Report indicated Resident 186 had a physician order for enteral feeding. The Order Summary Report indicated Resident 186 had a physician order for EBP. The Order Summary Report indicated Resident 186 had a physician order to monitor the GT site for signs and symptoms of infection. During a concurrent observation and interview on 5/11/2026 11:45 AM with LVN 7 in Resident 186's room, Resident 186's enteral feeding tube was observed to be uncapped and open to air. LVN 7 verified Resident 186's enteral feeding tube was uncapped and stated Resident 186 could be at risk for infection if staff connected the uncapped enteral feeding tube to Resident 186. LVN 7 stated she (LVN 7) would need to change Resident 186's enteral tube feeding system. During an interview on 5/13/2025 at 10:22 AM with RN 3, RN 3 stated there could be an infection control issue if Resident 186's enteral feeding tube was uncapped and left open to air. During a concurrent interview and record review on 5/14/2026 at 5:09 PM, with the DON the facility's P&P titled Infection and Prevention and Control, last reviewed 4/14/2026, the DON stated the facility should have capped Resident 186's enteral feeding tube if the enteral feeding had been disconnected from Resident 186's gastrostomy tube for infection control. During a review of the facility's P&P titled Enteral Feeding – Safety Precautions, last reviewed 4/14/2026, the P&P indicated the following: 1. Personnel responsible for preparing, storing and administering enteral nutrition formulas will be trained, qualified and competent in his or her responsibilities. 3. Staff maintains clean technique when working with enteral nutrition systems and formulas. During a review of the facility's P&P titled Infection and Prevention and Control, last reviewed 4/14/2026, the P&P indicated The facility has an infection prevention and control program designed to provide a safe, sanitary (clean), and comfortable environment and to help prevent the development and transmission of communicable diseases and infections (spread of germs like viruses, bacteria, or fungus). The P&P indicated Standard Precautions: The infection prevention practices that apply to all residents, regardless of suspected or confirmed diagnosis or presumed infection status. Standard precautions are based on the principle that all blood, body fluids, secretions (fluids made and released by your organs, glands, and cells), excretions (the ways your body gets rid of waste and extra fluids ) except sweat, regardless of whether they contain visible blood, non-intact skin (any area where the skin's natural, protective outer barrier is broken, damaged, or missing), and mucous membranes (the moist, inner lining of some organs and body cavities such as the nose, mouth lungs, and stomach) may contain transmissible infectious agents (germs or pathogens, are microscopic organism such as viruses, bacteria, fungi, and parasites that can invade your body, multiply, and cause illness). Furthermore, equipment or items in the resident's environment likely to have been contaminated with infectious body fluids must be handled in a manner to prevent transmission of infectious agents.

Based on interview and record review, the facility failed to maintain accurate and complete medical records for two of five sampled residents (Resident 14 and Resident 190), by failing to accurately document on Resident 14's and Resident 190's Dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) Communication Record (a standardized medical document used to safely transfer critical patient information between a dialysis clinic and another care facility). This failure had the potential for nurses (in general) to misinterpret (to understand or explain something incorrectly) the documented information and lead to Resident 14 and Resident 190 receiving inappropriate care and services.Findings: 1.During a review of Resident 14's admission Record, the admission Record indicated the facility admitted the resident on 5/20/2025 with diagnoses that included End Stage Renal Disease (ESRD, irreversible kidney disease) and dependence on renal (kidney) dialysis. During a review of Resident 14's Care Plan Report dated 1/3/2026, the Care Plan Report indicated that the resident was at risk for complications to the right Internal Jugular (IJ, a major blood vessel in the neck) catheter (a soft hollow tube inserted into the IJ vein in the neck and tunneled under the skin to the chest) related to dialysis. During a review of Resident 14's Minimum Data Set (MDS, a resident assessment tool) dated 2/19/2026, the MDS indicated the resident was cognitively intact (had the ability to think, understand, and reason). The MDS indicated Resident 14 received dialysis. During a review of Resident 14's Dialysis Communication Record dated 5/5/2026 at 11:35 AM, the Dialysis Communication Record indicated the resident had a right upper chest IJ catheter. The Dialysis Communication Record indicated a post-dialysis assessment was completed by Licensed Vocational Nurse 13 (LVN 13). The post-dialysis assessment indicated Resident 14's Arteriovenous (AV, a connection between arteries and veins) shunt (a surgically created connection between an artery and vein to provide high volume blood flow required for dialysis) was checked for bruit (a low-pitched, rushing or whooshing sound of blood flowing rapidly through a dialysis access) and thrill (a gentle, rhythmic buzzing or vibrating sensation felt on the skin over a dialysis access). During a review of Resident 14's Dialysis Communication Record dated 5/7/2026 at 11:31 AM, the Dialysis Communication Record indicated the resident had a right upper chest IJ catheter. The Dialysis Communication Record indicated a post-dialysis assessment was completed by LVN 13. The post-dialysis assessment indicated Resident 14's AV shunt was checked for bruit and thrill. During a review of Resident 14's Dialysis Communication Record dated 5/9/2026 at 10:23 AM, the Dialysis Communication Record indicated the resident had a dialysis catheter. The Dialysis Communication Record indicated a pre-dialysis assessment was conducted by LVN 14. The pre-dialysis assessment indicated Resident 14's AV Shunt was checked for the presence of bruit and thrill. The Dialysis Communication Record indicated a post-dialysis assessment was completed by LVN 13. The post-dialysis assessment indicated Resident 14's AV shunt was checked for bruit and thrill. During an interview on 5/13/2026 at 11:35 AM with Resident 14, Resident 14 stated she had a catheter (a flexible tube inserted into a large vein near the heart to filter blood) to her right upper chest for dialysis. Resident 14 stated she went to dialysis every Tuesday, Thursday, and Saturday. During an interview on 5/14/2026 at 1:54 PM with LVN 13, LVN 13 stated she (LVN 13) mistakenly documented that Resident 14's AV shunt was checked for bruit and thrill on the resident's Dialysis Communication Records dated 5/5/2026, 5/7/2026, 5/9/2026, and 5/9/2026. LVN 13 stated that bruit and thrill could only be checked on an AV fistula (a surgically made connection between an artery and a vein for dialysis) or AV shunt. LVN 13 stated Resident 14 had a catheter to her right chest for dialysis. LVN 13 stated that her (LVN 13) documentation on Resident 14's Dialysis Communication Records was not accurate. LVN 13 stated that documentation should be accurate. LVN 13 stated she (LVN 13) would be more careful with documentation in the future. 2. During a review of Resident 190's admission Record, the admission Record indicated the facility admitted the resident on 4/29/2026 with diagnosis that included ESRD and dependence on renal dialysis. During a review of Resident 190's MDS dated [DATE], the MDS indicated the resident was cognitively intact. The MDS indicated Resident 190 received dialysis. During a review of Resident 190's Dialysis Communication Record dated 5/8/2026 at 7:50 AM, the Dialysis Communication Record indicated the resident had a dialysis catheter. The Dialysis Communication Record indicated a pre-dialysis assessment was conducted by LVN 16. The pre-dialysis assessment indicated Resident 190's AV Shunt was checked for the presence of bruit and thrill. The Dialysis Communication Record indicated a post-dialysis assessment was completed by LVN 2. The post-dialysis assessment indicated Resident 190's AV shunt was checked for bruit and thrill. During a review of Resident 190's Dialysis Communication Record dated 5/11/2026 at 7:46 AM, the Dialysis Communication Record indicated the resident had a dialysis catheter. The Dialysis Communication Record indicated a pre-dialysis assessment was conducted by LVN 15. The pre-dialysis assessment indicated Resident 190's AV Shunt was checked for the presence of bruit and thrill. The Dialysis Communication Record indicated a post-dialysis assessment was completed by LVN 2. The post-dialysis assessment indicated Resident 190's AV shunt was checked for bruit and thrill. During a review of Resident 190's Order Summary Report, the Order Summary Report indicated the resident had a physician order dated 5/12/2026 to monitor the resident's right-side chest permacath (a long-term, specialized catheter inserted into a large blood vessel, typically in the neck or upper chest for dialysis) for redness, swelling, drainage and pain. During a review of Resident 190's Dialysis Communication Record dated 5/13/2026 at 5:42 AM, the Dialysis Communication Record indicated the resident had a dialysis catheter. The Dialysis Communication Record indicated a pre-dialysis assessment was conducted by LVN 15. The pre-dialysis assessment indicated Resident 190's AV Shunt was checked for the presence of bruit and thrill. The Dialysis Communication Record indicated a post-dialysis assessment was completed LVN 2. The post-dialysis assessment indicated Resident 190's AV shunt was checked for bruit and thrill. During a concurrent interview and record review on 5/14/2026 at 1:46 PM with LVN 2, Resident 190's Dialysis Communication Records dated 5/11/2026 and 5/13/2026 were reviewed. LVN 2 stated she mistakenly documented Resident 190's AV shunt was checked for the presence of bruit and thrill. LVN 2 stated that she did not mean to document that bruit and thrill were checked. LVN 2 stated Resident 190's dialysis access was a right upper chest permacath. LVN 2 stated that bruit and thrill were only checked for an AV fistula or an AV shunt. LVN 2 stated that documentation should be accurate and reflect Resident 190's status. LVN 2 stated there was potential for documentation to be misinterpreted if the documentation was not accurate. During a concurrent interview and record review on 5/14/2026 at 3:17 PM with the Director of Nursing (DON), Resident 14's Dialysis Communication Records dated 5/5/2026, 5/7/2026, and 5/9/2026 were reviewed. Resident 190's Dialysis Communication Records dated 5/8/2026, 5/11/2026, and 5/13/2026 were also reviewed with the DON. The DON stated the Dialysis Communication Records indicated that the AV Shunts for Resident 14 and Resident 190 were checked for the presence of bruit and thrill. The DON stated that the documentation that indicated Resident 14's and Resident 190's AV shunts were checked for bruit and thrill was not accurate. The DON stated Resident 14 had a right upper chest IJ catheter and Resident 190 had a right upper chest permacath. The DON stated checking for bruit and thrill was only done with an AV fistula or AV shunt. The DON stated bruit and thrill was not assessed on a resident (in general) with an IJ catheter or permacath for dialysis access. The DON stated documentation had to be accurate. The DON stated documentation had to reflect a proper assessment. The DON stated that inaccurate documentation could mislead the nurses (in general) to perform an assessment or provide an intervention that was not appropriate for Resident 14 or Resident 190. The DON stated the nurses (in general) had to accurately check, assess, and document. During a review of the facility's Policy and Procedure (P&P) titled Documentation Policy reviewed 4/14/2026, the P&P indicated It is the policy of this facility to document relevant findings in the clinical record.

Based on observation, interview and record review the facility failed to ensure safe and sanitary food storage and preparation practices in the kitchen when: 1.Three bags of frozen chicken were stored in the reach in freezer with no date or label. One medium container of expired left over chicken tortilla soup with use by date 5/9/2026 was stored in the walk-in refrigerator; Five bags of thawed raw chicken with use by dates of 5/6/2026; Three logs of ground beef with use by date of 5/10/2026 and two large bags of marinated chunks of beef with use by date of 5/8/2026 were stored in the walk in refrigerator exceeding storage periods for raw beef and poultry. 2. Nutrition shakes labeled store frozen with manufactures instruction to use within 14 days of thawing, were not marked with the date they were thawed to ensure expired shakes were discarded after the 14-day time frame. Two boxes containing 50 single serve cartons of chocolate flavored nutrition shakes and one box containing 50 single serve cartons of strawberry flavored shakes stored in the walk-in refrigerator with no thaw date. 3. One nutrition shake with manufacturers instruction to use within 14 days of thawing; one renal nutrition supplement and a can of soda were stored in the resident refrigerator located on the first floor's utility room with no date or label. These deficient practices had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to food borne illness in 112 out of 166 residents who receive food from the kitchen, including 20 residents who received nutrition shakes and residents who stored food in the resident refrigerator. Findings:1. During a concurrent observation and interview with Assistant Dietary Supervisor (ADS) on 5/11/2026 at 8:30AM, three large bags of chicken were observed stored in the facility's reach in freezer (is an upright, commercial-grade freezer they get their name from the fact that you simply open the front door and reach inside to grab your items, rather than walking into a large storage) with no date or label. The stated the bags of chicken were removed from the original packaging and should have been marked with the date they were opened. The ADS stated kitchen staff should have written the date the food items were delivered or the use by date, so kitchen staff would know when to use the chicken before the chicken reached the discard date. The ADS stated that kitchen staff were not sure how long the chicken had been stored in the freezer because there was no date on the chicken. During an observation in the walk-in refrigerator on 5/11/2026 at 10:00AM, t an open container of chicken tortilla soup was observed with a use by date of 5/9/2026 indicated the soup was expired and remained stored in the walk-in refrigerator. The ADS stated the chicken soup was leftover from the week prior and should have been discarded. The ADS stated expired food could cause residents to get sick. During the same observation in the walk in refrigerator on 5/11/2026 at 10:00AM five bags of thawed raw chicken were observed with a use by dates of 5/6/2026; Three logs of ground beef were observed with a use by date of 5/10/2026 and two large bags of marinated chunks of beef were observed with a use by date of 5/8/2026 stored in the walk in refrigerator exceeding storage periods for raw beef and poultry. During a concurrent interview and record review with the ADS on 5/11/2026 at 10:00AM, the ADS reviewed the menu for the week and stated there was no chicken on the menu for the week and since the chicken was already past the use-by date it would be discarded. The ADS stated the ground beef was a mistake and the cooks thawed more ground beef than needed. The ADS was then observed removing the items from the refrigerator to discard. The ADS stated the marinated chunks of beef did not belong to facility residents and was for staff use. The ADS stated staff belongings, including food, were not to be stored in the facility refrigerator. The ADS stated food brought in from outside could contaminate the refrigerator. The ADS was observed removing the marinated chunks of beef to discard. During an interview with the ADS and the registered dietician (RD) on 5/11/2026 at 10:15AM, the ADS stated raw chicken, and beef was thawed for 2 days and then an additional 2-3 days until preparation for a total of 5 days storage period. The ADS stated the chicken and ground beef were stored for longer than 5 days. During a review of facility provided food storage guidelines titled, US Food and Drug administration's Refrigerator and Freezer storage chart (dated 3/2018) the guidelines indicted to store fresh poultry (chicken or turkey) for 1-2 days in the refrigerator and raw ground meat for 1-2 days in the refrigerator. During a review of facility's policy and procedures (P&P) titled, Food receiving and storage(dated 1/2026) the p&p indicated, When food, food products or beverages are delivered to the nursing home, facility staff must inspect these items for safe transport and quality upon receipt and ensure their proper storage, keeping trach of when to discard perishable foods and covering, labeling, and dating all foods stored in the refrigerator or freezer as indicated. 2. During an observation in the kitchen on 5/11/2026 at 10:00AM there were two boxes of chocolate flavored nutrition shakes (high calorie shakes) and one box of strawberry-flavored nutrition shakes stored in the walk-in refrigerator with no thaw date. Each box contained 50 single serving cartons of nutrition shakes. The ADS stated the single serve cartons of nutrition shakes were frozen when they were delivered and then were stored directly in the refrigerator. The ADS said the expiration dates were already on the individual shakes. A concurrent observation and review of the manufacture's instruction for storage printed on the cartons of the nutrition shakes was done with the ADS. The ADS reviewed the instructions and stated the shakes were stored frozen and once thawed they were good for 14 days. The ADS stated that kitchen staff did not know that the shakes need to be monitored for expiration after thawing. The ADS stated the shakes were dairy based and could go bad and the residents could get sick when they received shakes that were expired. The ADS agreed there should have been a date on the supplements to monitor date of thaw. The ADS did not know when the shakes were thawed because there were no thaw dates on the shakes. 3. During an observation in the resident refrigerator located on the first floor in the utility room on 5/12/2026 at 11:15AM, one nutrition shake, one renal nutrition supplement and one soda were observed stored in the refrigerator with no date. The nutrition shake was thawed with no thaw date. During a concurrent observation and interview with the ADS and the Assistant Director of Nursing (ADON1), the ADS stated the nutrition shake was from the facility and once thawed its only good for 14 days. ADON1 stated that all food and beverages that were stored in the resident refrigerator had to have a date and label indicating to discard within 2 days. During an interview with the director of staff development (DSD) on 5/12/2026 at 11:45AM, the DSD stated everything that was brought from outside was checked in with nurses who would label and date the leftovers before storing them in the resident refrigerator. The DSD stated nursing staff would check dates to discard the food, or beverages once they reach the use by date. The DSD stated the nutritional shake was only good for 2 weeks once thawed, and if there was no date on the shakes facility staff would not know how long the shakes had been there. The DSD said if undated food was given to the residents the residents could get sick. During a review of facility's policy and procedures (p&p) titled Use and storage of food brought ot resident (dated 6/2025) the p&p indicated, The facility strives to support each resident's right to safe food storage, handling, and preparation. To ensure safe food practices and the prevention of foodborne illness, the facility shall provide safe and sanitary storage of food brought to residents by family and visitors for a period not to exceed 48 hours, and in accordance with the following guidelines.Perishable foods must be stored in the refrigerator, in a resealable containers with tightly fitting lids. Containers will be labeled with the resident's name, and the manufacturer use by date as applicable.

Based on observation, interview and record review, the facility failed to ensure 19 pureed diets (foods that do not require chewing and are easily swallowed. All food should be smooth and pureed to the consistency of pudding) meal trays received bread texture in the form that met their needs and in accordance with international Dysphagia Diet Initiative IDDSI (IDDSI-a framework made up of levels and describes food textures and drink thickness) Level Four (pureed foods and extremely thick drinks) when on 5/11/2026 kitchen staff served bread that was lumpy, not smooth and had small pieces of bread grains present that required chewing before swallowing on pureed diet trays. This deficient practice had the potential to result in meal dissatisfaction and increased choking risk for the residents on the pureed diet.Findings:During an observation of the facility's kitchen's tray line (tray line- a system of food preparation, in which trays move along an assembly line) service for lunch on 5/11/2026 at 12:00PM, the pureed bread looked lumpy, and not smooth while in a pan on the steam table (table having openings to hold containers/Pans of cooked food over steam or hot water circulating beneath them). Cook1 stated kitchen staff used the robot coupe (commercial strength food processing machine a kitchen appliance designed for quickly chopping, slicing, shredding, grating, pureeing and mixing foods using interchangeable blades and discs within a close bowl) to make the pureed bread. Cook1 stated kitchen staff added some butter and milk to the bread and pulsed the machine a couple of times until it was mixed. During a concurrent interview and taste test of the pureed bread with the ADS, Cook1 and the RD on 5/11/2026 at 1:15PM, the pureed bread was observed to have a lumpy texture. There were small pieces of bread, and it was not smooth. During a tasting of the pureed bread, the pureed bread was grainy and with some residue remaining in the mouth requiring chewing before swallowing. During the same taste test with the ADS, Cook1 and the RD, Cook1 stated the bread looked minced and it was lumpy. Cook1 said it was because I didn't leave it in food processor until it was smooth. Cook1 stated pureed food had to be smooth and if not prepared correctly, it could cause swallowing problems with residents who were on pureed diets. The ADS agreed that the pureed bread texture was not smooth and said the bread was more like a bread pudding. The RD stated the pureed bread looked lumpy. During a review of the facility recipe titled Pureed Bread or Roll (PU4) (dated 2026) the recipe indicated, place required portions of Soft Bread from regular prepared recipe (remove hard, crispy crusts) into a food processor and pulse until a fine consistency. Gradually add liquid.only use enough liquid needed to achieve a smooth consistency. During a review of the IDDSI guideline website titled IDDSI, dated 7/2019, the IDSSI guideline indicated that Level 4 Pureed is usually eaten with spoon, falls off spoon in a single spoonful when tilted and continues to hold shape on the plate, no lumps, not sticky, and liquid must not separate from solid. Food testing method: Spoon tilt test and Fork drip test. During a review of the facility policy and procedures (P&P) titled, Menus (dated 1/2025) the P&P indicated, Residents receive food in the amount, type, consistency and frequency to maintain normal body weight and acceptable nutritional values.

Based on observation, interviews, and record reviews the facility failed to provide necessary services to maintain good oral care (oral hygiene, the practice of keeping the mouth, teeth, and gums clean and free of disease) for one of one sampled resident (Resident 83) who was dependent on staff for oral hygiene. This failure had potential to affect Resident 83's dignity (providing care that respects a resident's self-esteem, identity, and personal choices) and place the resident at risk for aspiration (accidentally breathing food, liquid, or saliva into the airway and lungs) and tooth decay (damage and destruction of teeth).Findings: During a review of Resident 83's admission Record, the admission Record indicated the facility admitted the resident on 7/25/2013 with diagnoses that included quadriplegia (paralysis from the neck down, including legs and arms, usually due to a spinal cord injury), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), hemiparesis (weakness or the inability to move on one side of the body), gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), bed confinement status (when a resident is unable to safely leave their bed without significant or total assistance), dementia (a progressive state of decline in mental abilities), unspecified intellectual disabilities (a condition characterized by significantly below-average intelligence and limitations in daily living skills), and contracture (a stiffening/shortening at any joint, that reduces the joint's range of motion) of muscle of the right shoulder, left shoulder, right hand, and left hand. During a review of Resident 83's Minimum Data Set (MDS, a resident assessment tool) dated 5/1/2026, the MDS indicated the resident had severely impaired (never/rarely made decisions) cognitive skills (ability to think, understand, and reason) for daily decision making. The MDS indicated Resident 83 was dependent on facility staff for help with oral hygiene, toileting hygiene, showering/bathing self, upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygiene. During a review of Resident 83's Care Plan Report dated 4/9/2026, the Care Plan Report indicated the resident required assistance with bed mobility, transfers, walking in the room/corridor, locomotion (movement) on/off the unit, dressing, eating, toilet use, personal hygiene, and bathing. The Care Plan Report indicated a goal for Resident 83 to have increased Activities of Daily Living (ADLs, activities such as bathing, dressing, and toileting a person performs daily) participation and minimized functional decline by the next review date. The Care Plan Report indicated an intervention that included assisting Resident 83 with maintaining good personal hygiene every shift and as needed. During a concurrent observation and interview on 5/11/2026 at 10:30 AM with the Infection Preventionist Nurse (IPN), Resident 83 was observed lying in bed with white opaque (not transparent or translucent) fluids coming from the resident's mouth and onto the upper part of the resident's gown. Resident 83's mouth and lips were observed covered in the white opaque fluid. The IP stated Resident 83 needed oral care. The IP stated oral care was to be performed for Resident 83 as needed. The IP stated Resident 83 was confused and dependent on staff (in general) for care. The IP stated Resident 83 needed assistance with oral care. The IP stated there was potential for Resident 83 to aspirate (food, drink, saliva, or stomach acid accidentally goes down the wrong pipe into the windpipe and enters the lungs instead of the stomach) or have teeth decay if oral care was not provided. During an interview on 5/14/2026 at 3:06 PM with the Director of Nursing (DON), the DON stated Resident 83 could not verbalize needs and was totally dependent on staff for care. The DON stated Resident 83 needed total assistance from staff for oral care. The DON stated staff (in general) were expected to provide Resident 83 with oral care and ensure the resident was well groomed. The DON stated staff (in general) should have wiped Resident 83's mouth because it was an easy intervention to do. The DON stated it was important to keep Resident 83's mouth clean to maintain the resident's dignity. The DON stated that if oral care was not provided to Resident 83 there was potential for the resident's dignity to be affected. During a review of the facility's Policy and Procedure (P&P) titled ADL Care Provided for Dependent Residents dated 1/2026 the P&P indicated The facility provides assistance for residents unable to carry out activities of daily living. To ensure facility staff provide necessary care and services that are based on the resident's comprehensive assessment, to ensure that a resident who is unable to carry out activities of daily living receive necessary services to maintain good nutrition, grooming, personal and oral hygiene.Oral Care: The maintenance of a health mouth, which includes not only teeth, but the lips, gums, and supporting tissues. This involves not only activities such as brushing teeth or oral appliances, but also maintenance of oral mucosa.Facility staff will assist each resident with bathing, grooming, eating, dressing, transferring and other activities of daily living as necessary.

Based on observation, interview, and record review the facility failed to maintain dignity (providing care that respects a resident's self-esteem, identity, and personal choices) and respect for one of one sampled resident (Resident 83) when the resident's chest was left exposed with the privacy curtain (a fabric partition used to block the line of sight between beds) pulled open. This failure had the potential to violate Resident 83's right to personal dignity, privacy, and respect, and could negatively affect Resident 83's psychosocial well-being and have impact on Resident 83's self-esteem (sense of personal worth and value).Findings: During a review of Resident 83's admission Record, the admission Record indicated the resident was a [AGE] year old woman who was admitted to the facility on [DATE] with diagnoses that included quadriplegia (paralysis from the neck down, including legs and arms, usually due to a spinal cord injury), 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), gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), bed confinement status (when a resident is unable to safely leave their bed without significant or total assistance), dementia (a progressive state of decline in mental abilities), unspecified intellectual disabilities (a condition characterized by significantly below-average intelligence and limitations in daily living skills), and contracture (a stiffening/shortening at any joint, that reduces the joint's range of motion) of muscle of the right shoulder, left shoulder, right hand, and left hand. During a review of Resident 83's Minimum Data Set (MDS, a resident assessment tool) dated 5/1/2026, the MDS indicated the resident had severely impaired (never/rarely made decisions) cognitive skills (ability to think, understand, and reason) for daily decision making. The MDS indicated Resident 83 was dependent on facility staff for help with oral hygiene, toileting hygiene, showering/bathing self, upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygiene. During an observation on 5/11/2026 at 10:21 AM, in Resident 83's room, the resident was observed lying in bed. Resident 83's gown was observed bunched up around the resident's upper chest and neck. Resident 83's abdomen and chest were exposed. Resident 83's privacy curtain was observed pulled open. Staff (in general) were observed passing by Resident 83's room. During a concurrent observation and interview on 5/11/2026 at 10:23 AM with Certified Nursing Assistant 3 (CNA 3), in Resident 83's room, CNA 3 confirmed by stating Resident 83's privacy curtains were pulled open and the resident had her (Resident 83) chest exposed. CNA 3 was observed pulling down Resident 83's gown to cover the resident's chest. CNA 3 stated Resident 83 should have been covered and provided with privacy to maintain Resident 83's dignity. During an interview on 5/14/2026 at 10:30 AM with Registered Nurse 3 (RN 3), RN 3 stated if staff (in general) passed by a resident's (in general) room and noted that the resident (in general) was exposed, the staff should have covered the resident (in general) and provided the resident (in general) with privacy using the privacy curtain. RN 3 stated Resident 83 should have been covered to maintain the resident's (in general) privacy and dignity. During an interview on 5/14/2026 at 3:06 PM with the Director of Nursing (DON), the DON stated Resident 83 could not verbalize the needs and was totally dependent on staff for care. The DON stated staff (in general) should have protected Resident 83's privacy and dignity even though the resident could not call for help or verbalize needs. The DON stated staff (in general) were expected to provide Resident 83 with privacy to maintain the resident's dignity. The DON stated staff should have ensured privacy by drawing Resident 83's curtain, covering the resident with the gown and blanket, and making sure the resident's clothing was secured. The DON stated that if Resident 83 was exposed there was potential for the resident's dignity to be affected. During a review of the facility's Policy and Procedure (P&P) titled Dignity and Respect dated 1/2026, the P&P indicated Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality.Residents shall be treated with dignity and respect at all times. Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth. During a review of the facility's P&P titled Privacy and Confidentiality last reviewed 4/14/2026, the P&P indicated During the delivery of personal care and services, staff prevent exposure of the resident's body parts by pulling privacy curtains or closing doors and providing clothing or draping to prevent public view.

Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 17) who could not self-administer medications did not self-administer Vitamin C (a supplement used to support immune health [body's ability to defend itself against harmful bacteria and viruses], collagen [protein in the body] production, and antioxidant defenses [substances that may prevent or delay some types of cell damage]). This failure had the potential for Resident 17 to self-medicate and result in unsafe medication administration. Findings: During a review of Resident 17's admission Record, the admission Record indicated the facility readmitted the Resident on 9/15/2025, with diagnoses that included pneumonia (an infection/inflammation in the lungs), larynx (commonly called the voice box, a hollow organ in the neck located just about the windpipe) cancer, and gastronomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). During a review of Resident 17's History and Physical (H&P) dated 9/15/2025, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 17's Self Administration of Medication assessment dated [DATE], the Self Administration of Medication Assessment indicated the resident was not a candidate for safe self-administration of medications. The Self Administration of Medication Assessment indicated no physician orders to self-administer medications were obtained nor was a care plan for self-administration of medication implemented. During a review of Resident 17's Speech-Language Pathologist Discharge summary dated [DATE], the Speech-Language Pathologist Discharge Summary indicated oral intake was not safe for Resident 17. The Speech-Language Pathologist Discharge Summary indicated Resident 17 needed to see an ear, nose, and throat (ENT, a physician specializing in medical conditions of the ear, nose, throat, and neck) doctor for further evaluation. During a review of Resident 17's Rehab Dysphagia [difficulty swallowing] Screen dated 11/4/2025, the Rehab Dysphagia Screen indicated Resident 17 had severe dysphagia and to continue nothing by mouth (NPO, a safety measure used to instruct a resident to not eat or drink anything) with current orders of enteral feeding (a feeding tube that delivers liquid nutrition directly to the stomach or small intestine). During a review of Resident 17's Ear, Nose, Throat, and Allergy medical records dated 2/26/2026, the medical records indicated Clearance for oral intake to be determined by speech therapy based on swallow evaluation. During a review of Resident 17's Minimum Data Set (MDS, a resident assessment tool), dated 3/19/2026, the MDS indicated the resident was cognitively intact (able to independently make decisions regarding tasks of daily life). The MDS indicated that the resident needed touching assistance (helper provides verbal cues or steadying as resident completes activity) from facility staff to complete activities of daily living (ADLs, activities a person performs daily such as bathing, dressing, and toileting). During a review of Resident 17's Order Summary Report dated 5/13/2026, the Order Summary Report did not indicate any physician orders to self-administer medications. During a review of Resident 17's Care Plan Report dated 5/13/2026, the Care Plan Report did not indicate any focus, goal, nor interventions for self-administration of medications. During a concurrent observation and interview on 5/11/2026 at 10:19 AM with Resident 17 in Resident 17's room, Resident 17 used a key to unlock his closet to retrieve an unsealed bottle of Vitamin C supplements. The bottle label indicated the following information: Nature Made, [Vitamin] C extra strength 1000 mg [milligram, a metric unit of measurement, used for medication dosage and/or amount], and 100 tablets. Resident 17 stated he (Resident 17) would take one Vitamin C supplement by mouth every other day in the morning. During an interview on 5/13/2026 at 11:46 AM with Certified Nursing Assistant 6 (CNA 6), CNA 6 stated she (CNA6) was unaware if Resident 17 kept medications at bedside. CNA 6 stated licensed nurses (in general) were responsible for medication administration. During an interview on 5/13/2026 at 11:50 AM with Licensed Vocational Nurse 11 (LVN 11), LVN 11 stated residents (in general) were allowed to keep certain medications at bedside if they (residents) passed the Self Administration of Medication Assessment and if there was a physician's order for self-administration of medication. LVN 11 stated that residents who did not pass the Self Administration of Medication Assessment were not allowed to keep any medications at bedside or in their room. LVN 11 stated that vitamins and supplements were considered medication. During an interview on 5/13/2026 at 12:10 PM with Administrative Assistant 1 (AA) 1, AA 1 stated that it was not okay for Resident 17 to keep medications in his closet. AA 1 stated that the medications self-administered by Resident 17 could have interfered with medications the physician ordered. During a concurrent interview and record review on 5/14/2026 at 5:30 PM with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Resident Self Administer Medications, revised on January 2026, was reviewed by the DON. The DON stated the policy was not followed. The DON stated it was unsafe for residents (in general) to self-administer medications without a physician's order and appropriate staff supervision due to potential interactions with prescribed medications. During a review of the facility's P&P titled, Resident Self Administer Medications, revised on January 2026, the P&P indicated, A resident may only self-administer medications, after the IDT [interdisciplinary team, a group of different medical professional who collaborate to coordinate a patient's care] has determined which medications may be self-administered.

Based on interview and record review the facility failed to ensure the Minimum Data Set (MDS, a resident assessment tool) for the use of tobacco was accurately completed for one of two sampled residents (Resident 57).This deficient practice had the potential for Resident 57 to receive inadequate and improper care at the facility.Findings: During a review of Resident 57's admission Record, the admission Record indicated the facility admitted the resident on 3/7/2025 with diagnoses that included spondylosis (age related wear and tear of the spinal disks in the neck), type 2 diabetes (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), diverticulosis (the presence of small, bulging pouches in the lining of the large intestine), muscle weakness, and history of falling. During a review of Resident 57's Care Plan Report dated 9/9/2025, the Care Plan Report indicated the resident was a smoker. The Care Plan Report indicated Resident 57 was at risk for injury, non-compliance (failure or refusal to follow rules), and respiratory illness (any condition that affects the lungs and airways, making it hard to breathe). The Care Plan Report indicated Resident 57 was informed of the facility's smoking guidelines. The Care Plan Report indicated Resident 57 was provided with instructions on safe smoking. During a review of Resident 57's Smoking Risk Assessment (an evaluation used to determine if a resident can safely smoke tobacco) dated 2/23/2026, the Smoking Risk Assessment indicated the resident was a smoker at the time of the assessment. During a review of Resident 57's MDS, dated [DATE], the MDS indicated the resident was cognitively intact (had the ability to think, understand, and reason). The MDS indicated Resident 57 did not currently tobacco at the time of the assessment. During a review of the facility's Resident Smoking List dated 5/11/2026, the Resident Smoking List indicated Resident 57 was a smoker. During a concurrent interview and record review on 5/14/2026 at 10:05 AM with the Minimum Data Set Licensed Vocational Nurse (MDS 1), Resident 57's Smoking Risk assessment dated [DATE], Care Plan Report dated 9/9/2025, and MDS dated [DATE] were reviewed. MDS 1 stated Resident 57's Smoking Risk Assessment and Care Plan Report indicated the resident was a smoker. MDS 1 stated Resident 57's MDS dated [DATE] indicated the resident did not use tobacco. MDS 1 stated Resident 57's MDS was inaccurate and did not reflect the resident's smoking status. MDS 1 stated Resident 57's MDS should have indicated that the resident smoked. MDS 1 stated the MDS assessment should have been accurate. MDS 1 stated the MDS assessment reflected the care that Resident 57 had been receiving at the facility. MDS 1 stated that if the MDS was inaccurate there was potential for Resident 57's care at the facility to be affected. During an interview on 5/14/2026 at 10:25 AM with Resident 57, the resident stated he smoked one cigarettes daily. During a concurrent interview and record review on 5/14/2026 at 3:10 PM with the Director of Nursing (DON), Resident 57's Smoking Risk assessment dated [DATE], Care Plan Report dated 9/9/2025, and MDS dated [DATE] were reviewed. The DON stated Resident 57 was a smoker. The DON stated Resident 57's MDS dated [DATE] indicated the resident was not a smoker and did not use tobacco. The DON stated Resident 57's MDS was inaccurate. The DON stated Resident 57's MDS should have indicated the resident used tobacco. The DON stated the MDS should have captured all of Resident 57's necessary information. The DON stated the MDS should have been documented with accuracy. The DON stated the MDS determined the care that was being provided to Resident 57. The DON stated an inaccurate MDS would potentially mislead Resident 57's care. During a review of the facility's Policy & Procedure (P&P) titled Resident Assessment dated 1/2026, the P&P indicated Initially and periodically, the facility conducts a comprehensive, accurate, standardized, reproducible assessment of each resident's functional capacity.

Based on interview and record review the facility failed to update and revise the End Stage Renal Disease (ESRD, irreversible kidney disease) and dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) care plan (a plan of care that summarizes a resident's health conditions, current treatments, and specific care and services facility staff (in general) need to provide a resident to promote healing and prevent a worsening of a condition) for one out of five sampled residents (Resident 14). By Failing to update Resident 14's care plan on 5/5/2026 when the resident's pick-up time for dialysis was changed. This failure had potential for Resident 14 to miss dialysis and receive care that was not in alignment with the resident's physician orders.Findings:During a review of Resident 14's admission Record, the admission Record indicated the facility admitted the resident on 5/20/2025 with diagnoses that included ESRD and dependence on renal (kidney) dialysis. During a review of Resident 14's Care Plan Report dated 11/14/2025, the Care Plan Report indicated the resident had potential for complications of ESRD and dialysis. The Care Plan Report indicated a goal for Resident 14 to remain free of complications related to renal disease or dialysis through the review date. The Care Plan Report indicated an intervention to assist Resident 14 in the coordination of the dialysis schedule as ordered. The Care Plan Report indicated Resident 14 had physician orders for dialysis every Tuesday, Thursday, and Saturday. The Care Plan Report indicated Resident 14 was to be picked up by transportation for dialysis at 1:15 PM. During a review of Resident 14's Minimum Data Set (MDS, a resident assessment tool) dated 2/19/2026, the MDS indicated the resident was cognitively intact (had the ability to think, understand, and reason). The MDS indicated Resident 14 received dialysis. During a review of Resident 14's Order Summary Report, the Order Summary Report indicated the resident had a physician order dated 5/5/2026, for dialysis three times a week every week on Tuesday, Thursday, and Saturday at 12:15 PM. The physician order indicated Resident 14 was to be picked up by transportation for dialysis at 11:30 AM. During a concurrent interview and record review on 5/14/2026 at 9:50 AM with Registered Nurse 3 (RN 3), Resident 14's Care Plan Report dated 11/14/2025 and physician order dated 5/5/2026 were reviewed. RN 3 stated Resident 14 had physician orders for dialysis every Tuesday, Thursday, and Saturday. RN 3 stated Resident 14 was to be picked up by transportation for dialysis at 11:30 AM. RN 3 stated Resident 14's Care Plan Report did not reflect the resident's active physician orders for dialysis. RN 3 stated it was important that the care plan reflected Resident 14's active plan of care. RN 3 stated the care plan had to match the care Resident 14 was receiving. RN 3 stated Resident 14's care plan was inaccurate because the care plan did not match the resident's physician orders. RN 3 stated Resident 14's care plan needed to be revised to match the resident's physician orders. RN 3 stated there was potential for the staff (in general) to not know what Resident 14's current dialysis schedule was, and the staff (in general) could get confused about resident's dialysis schedule. During a concurrent interview and record review on 5/14/2026 at 10:14 AM with the MDS Licensed Vocational Nurse (MDS 1), Resident 14's Care Plan Report dated 11/14/2025 and physician order dated 5/5/2026 were reviewed. MDS 1 stated Resident 14 had a physician order for dialysis every Tuesday, Thursday, and Saturday at 12:15 PM. MDS 1 stated Resident 14's care plan did not reflect the resident's current physician orders for dialysis. MDS 1 stated Resident 14's care plan should have been revised on 5/5/2026 to include the resident's current physician order for dialysis. MDS 1 stated if Resident 14's care plan was not revised there was potential for the staff to not be aware of the residents' active physician orders for dialysis. During a concurrent interview and record review at 5/14/2026 at 3:17 PM with the Director of Nursing (DON), Resident 14's Care Plan Report dated 11/14/2025 and physician order dated 5/5/2026 were reviewed. The DON stated Resident 14 had physician orders for dialysis that indicated the resident was to have dialysis every Tuesday, Thursday, and Saturday at 12:15 PM. The DON stated the physician order indicated Resident 14 was to be picked up by transportation for dialysis at 11:30 AM. The DON stated Resident 14's care plan indicated to assist the resident in the coordination of dialysis every Tuesday, Thursday, and Saturday. The DON stated Resident 14's care plan indicated the resident was to be picked up by transportation for dialysis at 1:15 PM. The DON stated the dialysis order listed on Resident 14's care plan was from a previous physician order. The DON stated Resident 14's care plan should have reflected the resident's active physician order. The DON stated the care plan was supposed to reflect the care Resident 14 was to receive. The DON stated there was potential for confusion on the care Resident 14 was to receive if the resident's care plan was not revised. During a review of the facility's Policy and Procedure (P&P) titled Develop-Implement Comprehensive Care Plans dated 1/2026, the P&P indicated The comprehensive care plan describes the services that are to be furnished are to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.Care plans shall describe the resident's needs and preferences and how the facility will assist in meeting these needs and preferences.

Based on interview and record review the facility failed to follow professional standards of practice (the everyday rules and behaviors that keep patients safe and ensure high-quality healthcare) for medication administration (the process of giving medicine to a resident) by failing to ensure subcutaneous (fatty tissue under the skin) injection sites were rotated for two of two sampled residents (Resident 80 and Resident 186):Specifically, the facility failed to:1. Ensure two of two sampled residents (Resident 80 and Resident 186's) insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) injection sites were rotated (a method to ensure repeated injections are not administered in the same area).2. Ensure one of two sampled residents (Resident 186's) Enoxaparin (a prescription blood thinner) injections sites were rotated. This failure had the potential to cause skin breakdown, bruising, tissue damage, and/or ineffective medication absorption.Findings: During a review of Resident 80's admission Record, the admission Record indicated the facility originally admitted Resident 80 on 2/16/2026 and readmitted Resident 80 on 5/9/2026 with diagnoses that included type 2 Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing, muscle weakness, local infection of the skin and subcutaneous tissue unspecified (unspecified bacterial infection in the fatty layer of tissue directly underneath your skin), and long-term current use of insulin. During a review of Resident 80's Minimum Data Set (MDS, a resident assessment tool), dated 2/22/2026, the MDS indicated Resident 80 had the ability to understand others and had the ability to make himself (Resident 80) understood. During a review of Resident 80's History and Physical (H&P), dated 4/14/2026, the H&P indicated Resident 80 had the ability to understand and make decisions. During a review of Resident 80's care plan titled Diabetes Mellitus (DM): At risk for hypo (low)/hyperglycemia (high blood sugar) related to diagnosis of DM, dated 4/13/2026, the care plan indicated an intervention (any action a nurse takes to help a patient heal, manage symptoms, or stay comfortable) to give diabetes medication as ordered by doctor. During a concurrent interview and record review on 5/12/2026 at 1:55 PM with the facility's Infection Preventionist Nurse (IPN - implements best practices for halting the spread of viruses and bacteria) and Registered Nurse 4 (RN 4), Resident 80's Location of Administration Report, (report of when and where injections were administered) was reviewed. The Location of Administration Report indicated the facility did not rotate insulin injections for Humalog (a rapid-acting mealtime insulin prescribed to control high blood sugar) insulin as follows:4/17/2026 at 5:30 AM Humalog insulin given subcutaneously in Resident 80's left arm.4/17/2026 at 12:01 PM Humalog insulin given subcutaneously in Resident 80's left arm.4/17/2026 at 11:12 AM Humalog insulin given subcutaneously in Resident 80's left arm.4/18/2026 at 5:22 PM Humalog insulin given subcutaneously in Resident 80's abdomen LLQ (the bottom-left quarter of your belly, located below your belly button). 4/19/2026 at 4:46 PM Humalog insulin given subcutaneously in Resident 80's abdomen LLQ The IPN stated the nurse giving the Humalog insulin injection would be able to see where the previous injection was given because Resident 10's electronic medical record (EMR - a digital version of your paper medical chart) would show where the previous injection was given. During a concurrent interview and record review on 5/12/2026 at 1:55 PM with the IPN and RN 4, Resident 80's Order Summary Report, dated 5/12/2026, was reviewed via Resident 80's EMR. The Order Summary Report indicated a physician order for Humalog, inject subcutaneously (in the fatty layer of tissue directly underneath your skin) per sliding scale (a personalized chart from your doctor that tells you how much rapid-acting insulin to inject right before a meal or at bedtime) before meals and bedtime for DM2 (type 2 Diabetes Mellitus), rotate injection sites. Both the IPN and RN 4 stated the facility nurses (in general) should have rotated Resident 80's insulin sites. Both the IPN and RN 4 stated the nurses (in general) did not follow Resident 80's doctors order when they (facility nurses in general) did not rotate insulin injection sites. During a concurrent interview and record review on 5/14/2026 at 4:48 PM with the Director of Nursing (DON), Resident 80's Location of Administration Report was reviewed. The DON verified the facility did not rotate Resident 80's insulin injection sites as follows: 4/17/2026 at 5:30 AM Humalog insulin given subcutaneously in Resident 80's left arm.4/17/2026 at 12:01 PM Humalog insulin given subcutaneously in Resident 80's left arm.4/17/2026 at 11:12 AM Humalog insulin given subcutaneously in Resident 80's left arm.4/18/2026 at 5:22 PM Humalog insulin given subcutaneously in Resident 80's abdomen LLQ (the bottom-left quarter of your belly, located below your belly button). 4/19/2026 at 4:46 PM Humalog insulin given subcutaneously in Resident 80's abdomen LLQ. During a concurrent interview and record review on 5/14/2026 at 4:48 PM with the DON, the facility's policy and procedure (P&P), titled Insulin Administration, last reviewed 4/14/2026 was reviewed. The P&P indicated 18. Injection sites should be rotated to reduce the risk of damaging the skin tissue. The DON stated the facility nurses (in general) did not follow the facility's P&P and should have rotated Resident 80's injection sites. During a review of Resident 186's admission Record, the admission Record indicated the facility originally admitted Resident 186 on 3/9/2026 and readmitted Resident 186 on 4/27/2026 with diagnoses that included epilepsy (a brain disorder that causes repeated, unprovoked seizures), aphasia (a disorder that makes it difficult to speak), type 2 Diabetes Mellitus, muscle weakness, dysphagia (difficulty swallowing), and essential hypertension (HTN-high blood pressure). During a review of Resident 186's MDS dated [DATE], the MDS indicated Resident 186 had unclear speech, rarely could make himself (Resident 186) understood, and rarely had the ability to understand others. During a review of Resident 186's H&P dated 5/6/2026, the H&P indicated Resident 186 did not have capacity to understand and make decisions.During a concurrent interview and record review on 5/12/2026 at 1:45 PM with the IPN and RN 4, Resident 186's Location of Administration Report was reviewed. The Location of Administration Report indicated the following:5/5/2026 at 8:55 AM Enoxaparin injection given subcutaneously in Resident 186's abdomen LLQ. 5/6/2026 at 8:34 AM Enoxaparin injection given subcutaneously in Resident 186's abdomen LLQ. 5/7/2026 at 6:14 AM NPH insulin (an intermediate-acting insulin to treat DM) given subcutaneously in Resident 186's abdomen LLQ. 5/7/2026 at 1:33 PM NPH insulin given subcutaneously in Resident 186's abdomen LLQ. 5/7/2026 at 6:14 AM Humalog insulin given subcutaneously in Resident 186's abdomen LLQ. 5/7/2026 at 1:33 PM Humalog insulin given subcutaneously in Resident 186's abdomen LLQ.The IPN and RN 4 verified Resident 186's Enoxaparin and insulin injections were not rotated. During a concurrent interview and record review on 5/12/2026 at 1:45 PM with the IPN and RN 4, Resident 186's Order Summary Report was reviewed. The Order Summary Report was reviewed via Resident 186's EMR. The Order Summary Report indicated Resident 186 had the following orders:Enoxaparin inject 40 mg subcutaneously one time a day to prevent blood clotting. Rotate injection site.Humalog insulin inject subcutaneously per sliding scale subcutaneously before meals and at bedtime for type 2 DM. Rotate injection site.NPH Insulin inject 5 units (a small, measured amount of medication used) subcutaneously every 8 hours for type 2 DM. Rotate injection site.The IPN and RN 4 both stated the facility's nurses (in general) should have rotated injection sites for Resident 186's Enoxaparin and insulin injections. Both the IPN and RN stated the facility's nurses (in general) did not follow Resident 186's physician orders for Enoxaparin and Insulin. During a concurrent interview and record review on 5/14/2026 at 4:54 PM with the DON, Resident 80's Location of Administration Report was reviewed. The DON verified the facility did not rotate Resident 80's insulin injection sites as follows:5/5/2026 at 8:55 AM Enoxaparin injection given subcutaneously in Resident 186's abdomen LLQ. 5/6/2026 at 8:34 AM Enoxaparin injection given subcutaneously in Resident 186's abdomen LLQ. 5/7/2026 at 6:14 AM NPH insulin (an intermediate-acting insulin to treat DM) given subcutaneously in Resident 186's abdomen LLQ. 5/7/2026 at 1:33 PM NPH insulin given subcutaneously in Resident 186's abdomen LLQ. 5/7/2026 at 6:14 AM Humalog insulin given subcutaneously in Resident 186's abdomen LLQ. 5/7/2026 at 1:33 PM Humalog insulin given subcutaneously in Resident 186's abdomen LLQ. During a concurrent interview on 5/14/2026 at 4:54 PM with the DON, the facility's policy and procedure (P&P), titled Insulin Administration, last reviewed 4/14/2026 was reviewed. The P&P indicated 18. Injection sites should be rotated to reduce the risk of damaging the skin tissue. The DON stated the facility nurses (in general) did not follow the facility's P&P and should have rotated Resident 186's insulin injection sites. Additionally, the DON stated the facility should have rotated Resident 186's Enoxaparin injection sites.

Based on observation, interview, and record review, the facility failed to provide care and services to prevent aspiration (when food, liquid, or stomach contents accidentally enter the airway or lungs instead of the stomach) for one of three sampled residents (Resident 17) investigated under the accidents care area by failing to: -Ensure to clarify the route of administration of two Boost (nutritional drinks and shakes designed to provide everyday nutritional support) supplement orders for Resident 17. -Ensure to implement a risk for aspiration care plan (a personalized roadmap that guides how facility staff will manage treatments, medication, therapy goals, and safety precautions for residents) for Resident 17. This failure had the potential to increase Resident 17's risk for aspiration.Findings: During a review of Resident 17's admission Record, the admission Record indicated the facility readmitted the Resident on 9/15/2025 with diagnoses that included larynx (commonly called the voice box, a hollow organ in the neck located just above the windpipe) cancer, gastronomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), and dysphagia (difficulty swallowing). During a review of Resident 17's History and Physical (H&P) dated 9/15/2025, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 17's Speech-Language Pathologist Discharge summary dated [DATE], the Speech-Language Pathologist Discharge Summary indicated oral intake was not safe for the resident. The Discharge Summary indicated the resident needed to see an ear, nose, and throat (ENT, a physician specializing in medical conditions of the ear, nose, throat, and neck) doctor for further evaluation. During a review of Resident 17's Order Summary Report order date 10/14/2025, the Order Summary Report indicated, Boost three times a day for [one] Boost for supplement. During a review of Resident 17's Rehab Dysphagia Screen, dated 11/4/2025, the screening indicated the resident had severe dysphagia and to continue nothing by mouth (NPO, a safety measure used to instruct a resident to not eat or drink anything) with current orders of enteral feeding (a feeding tube that delivers liquid nutrition directly to the stomach or small intestine). During a review of Resident 17's Ear, Nose, Throat, and Allergy medical records, dated 2/26/2026, the medical records indicated Clearance for oral intake to be determined by speech therapy based on swallow evaluation. During a review of Resident 17's Minimum Data Set (MDS, a resident assessment tool), dated 3/19/2026, the MDS indicated the resident was cognitively intact (able to independently make decisions regarding tasks of daily life). The MDS indicated that the resident needed touching assistance (helper provides verbal cues or steadying as resident completes activity) from facility staff to complete activities of daily living (ADLs, activities a person performs daily such as bathing, dressing, and toileting). During a review of Resident 17's Order Summary Report, order date 3/20/2026, the Order Summary Report indicated, Acknowledge diet as followed on Boost supplement TID [three times a day] and enteral feeding. During a review of Resident 17's Dietary Screening dated 4/10/2026, the Dietary Screening indicated, Boost supplement. During a review of Resident 17's Care Plan Report dated 5/13/2026, the Care Plan Report did not indicate any focus for risk for aspiration. The Care Plan Report indicated aspiration precautions under special instructions. During an observation on 5/11/2026 at 10:19 AM in Resident 17's room, there was an open bottle of Boost supplement on Resident 17's bedside table. During an observation on 5/13/2026 at 9:20 AM in Resident 17's room, there was a sealed bottle of Boost supplement on Resident 17's bedside table. During a concurrent interview and record review on 5/13/2026 at 11:50 AM with Licensed Vocational Nurse 11 (LVN11), Resident 17's Order Summary Report dated 5/13/2026 was reviewed. The Order Summary Report indicated two separate orders for Boost supplement. LVN 11 stated the Boost supplement orders did not have a route of administration. LVN 11 stated that the order should have been clarified to verify if the Boost supplement was to be given orally or through Resident 17's gastronomy tube (G-tube, a tube inserted through the belly that delivers directly to the stomach). LVN 11 stated Resident 17 could aspirate if he drank the Boost supplement. During an interview on 5/13/2026 with Registered Nurse 3 (RN 3), RN 3 stated Resident 17 would drink the Boost supplement. RN 3 stated Resident 17 was at increased risk of aspiration when consuming the Boost supplement orally. During an interview on 5/14/2026 at 8:31 AM with Resident 17, Resident 17 stated he (Resident 17) received no more than three bottles of Boost supplements every day. Resident 17 stated he (Resident 17) would drink the Boost supplement and that the nurses (unidentified) did not administer it through his (Resident 17's) G-tube. During an interview on 5/14/2026 at 8:50 AM with LVN 12, LVN 12 stated Resident 17 was on aspiration precautions, and that Resident 17 should have a care plan for risk of aspiration. LVN 12 stated care plans outline the interventions for resident care and were implemented to ensure resident safety (in general). During a concurrent interview and record review on 5/14/2026 at 9:07 AM with Minimum Data Set Licensed Vocational Nurse (MDS) 1, Resident 17's Care Plan Report dated 5/14/2026 was reviewed. The Care Plan Report did not indicate any focus for risk for aspiration. MDS 1 stated there was no current plan for risk of aspiration and that there should be one because Resident 17 was diagnosed with dysphagia. During a concurrent interview and record review on 5/14/2026 at 10:12 AM with the Registered Dietitian (RD), Resident 17's Dietary/Nutritional Progress Notes, 10/28/2025 and 9/3/2025 were reviewed. The Dietary/Nutritional Progress Note dated 10/29/2025 indicated Boost supplement TID. The Dietary/Nutritional Progress Note dated 9/3/2025, indicated Boost supplement TID orally. RD stated the difference in the Boost supplement note was due to the Speech Therapist's (ST) assessment of Resident 17 to be unsafe for oral intake. During a concurrent interview and record review on 5/14/2026 at 11:08 AM with the ST, Resident 17's Ear, Nose, Throat, and Allergy medical records, dated 2/26/2026 was reviewed. The medical records indicated for Resident 17 to continue swallow therapy with the ST. The ST stated Resident 17 was high risk for aspiration due to left vocal cord paralysis. The ST stated that Resident 17 could choke or develop aspiration pneumonia (a seriously lung infection caused by inhaling foreign materials into your airways instead of your esophagus) from drinking the Boost supplement. During an interview on 5/14/2026 at 5:36 PM with the Director of Nursing (DON), the DON stated the route for the Boost supplement orders should have been clarified. The DON stated there was no care plan for risk for aspiration. The DON stated that lack of an aspiration risk care plan increased Resident 17's risk for hospitalization due to choking. During a review of the facility's policy and procedure (P&P) titled, Free of Accident Hazards/Supervision/Devices, revised on January 2025, the P&P indicated, A resident-specific modification is revising the care plan to reflect the resident's current condition and risk factors that may have changed since the previous assessment. During a review of the facility's P&P titled, Physician Medication Orders, revised on January 2025, the P&P indicated, orders for medications must include route of administration if other than oral.

Based on observation, interview and record review the facility failed to ensure Resident 138's privacy curtain was completely closed, and private area was exposed during morning care for one of one sampled resident.This deficient practice had the potential to result in compromised resident dignity, embarrassment, emotional distress, and loss of privacy during care.During a review of Resident 138's admission Record (Face Sheet), the admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side (paralysis and weakness on one side of the body following a stroke), functional quadriplegia (complete immobility due to severe physical disability), type 2 diabetes mellitus with hyperglycemia (high blood sugar due to the body not properly using insulin), cognitive communication deficit (difficulty understanding or expressing thoughts), essential hypertension (chronic high blood pressure), acute and chronic respiratory failure with hypoxia (inability to maintain adequate oxygen levels) and muscle weakness (reduced muscle strength affecting mobility and physical function). During a review of Resident 138's Minimum Data Set (MDS- a resident assessment tool), dated 04/12/2026, the MDS indicated Resident 138 had severely impaired cognitive skills for daily decision-making. The MDS indicated has memory problems with short-term and long-term memory and required extensive staff assistance for activities of daily living (ADLs), including personal hygiene, toileting hygiene, dressing, bathing, transfers, and mobility.During an observation on 05/13/2026 at 9:08 a.m. Resident 138 was observed receiving morning care from Certified Nursing Assistant 1 (CNA 1). The privacy curtain was observed halfway open and the lower part of Resident 138's body was exposed. CNA left Resident 138 partially exposed while she went to obtain assistance from another CNA. The resident's call light was also observed on the floor.During a concurrent interview on 05/13/2026 at 10:04 a.m., the Registered Nurse 1 (RN 1) Supervisor stated residents should be provided privacy during care and stated, RN1 stated If I were him, I would be upset.During a concurrent interview on 05/13/2026 at 10:18 a.m., the Director of Nursing (DON) stated that leaving a resident exposed during morning care may place the resident at risk for emotional distress, embarrassment, humiliation, loss of dignity, anxiety, and psychological discomfort. During a record review of the facility's policy and procedure (P&P), titled Privacy and Confidentiality, revised 03/2023, the P & P indicated residents have the right to personal privacy during personal care. The P & P indicated staff shall prevent exposure of the resident's body parts during the delivery of personal care and services by pulling privacy curtains or closing doors and providing clothing or draping to prevent public view.

Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 186) reviewed for unnecessary medications such as psychotropic (any drug that affects the mental function, behavior, and mood) medications had an end date (expiration date of the physician order) for the use of Ativan (help calm the nervous system) as needed (PRN). This failure had the potential for Resident 186 to become over-medicated, restrict mobility, and experience adverse side effects (unexpected or harmful consequences of medication) such as dizziness and sedation (decrease in awareness).Findings: During a review of Resident 186's admission Record, the admission Record indicated the facility originally admitted Resident 186 on 3/9/2026 and readmitted Resident 186 on 4/27/2026 with diagnoses that included epilepsy (a brain disorder that causes repeated, unprovoked seizures), aphasia (a disorder that makes it difficult to speak), type 2 Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), muscle weakness, dysphagia (difficulty swallowing), and essential hypertension (HTN-high blood pressure). During a review of Resident 186's Minimum Data Set (MDS, a resident assessment tool) dated 3/15/2026, the MDS indicated Resident 186 had no speech, rarely could make himself (Resident 186) understood, and rarely had the ability to understand others. During a review of Resident 186's History and Physical (H&P), dated 5/6/2026, the H&P indicated Resident 186 did not have the capacity (ability) to understand and make decisions. During a concurrent interview and record review on 5/14/2026 at 2:38 PM with Licensed Vocational Nurse 9 (LVN 9) and Registered Nurse 3 (RN 3), Resident 186's Order Summary Report dated 5/13/2026 was reviewed. The Order Summary Report indicated Resident 186 had physician order for Ativan 2 milligrams (mg- metric unit of measurement), intramuscularly (giving a medication or vaccine by injecting it directly into a muscle) as needed for seizure with a start date of 4/27/2026. The Order Summary Report indicated Resident 186's order for Ativan 2mg intramuscularly as needed for seizure did not have an end date LVN 9 and RN 3 verified Resident 186's Ativan 2mg intramuscularly as needed for seizure did not have an end date. During a concurrent interview and record review on 5/14/2026 at 2:38 PM with LVN 9 and Registered Nurse 3 RN 3, the facility's policy and procedure (P&P) titled, Dignity and Respect Psychoactive Medications, last reviewed 4/14/2026, the P&P indicated the following: 3. Residents shall not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and PRN orders for psychotropic drugs shall be limited to 14 days. LVN 9 and RN 3 stated the facility did not follow their policy and the physician order for Ativan 2mg intramuscularly as needed for seizure should have been limited to 14 days. During a concurrent interview and record review on 5/14/2026 at 4:46 PM with the Director of Nursing (DON), 2:38 PM with Licensed Vocational Nurse 9 (LVN 9) and Registered Nurse 3 (RN 3), Resident 186's Order Summary Report dated 5/13/2026 was reviewed. The Order Summary Report indicated Resident 186 had physician order for Ativan 2mg intramuscularly as needed for seizure with a start date of 4/27/2026. The Order Summary Report indicated Resident 186's order for Ativan 2mg intramuscularly as needed for seizure did not have an end date. The DON verified Resident 186's Ativan 2mg intramuscularly as needed for seizure did not have an end date. The DON stated Resident 186's order for Ativan 2mg intramuscularly as needed for seizure should have had a 14-day end date.

Based on interview and record review, the facility failed to provide a written notice of transfer or discharge to the Office of the State Long-Term Care Ombudsman (LTC Ombudsman-an independent, neutral official who investigates and resolves complaints) for one of 10 sampled residents (Resident 3) on 5/11/2026, when Resident 3 was transferred to hospital (GACH) on 5/11/2026. This deficient practice had the potential to prevent the LTC Ombudsman from being informed of Resident 3's facility-initiated transfer and from identifying, monitoring, or addressing potential resident rights concerns related to the transfer.Findings: During a review of Resident 3's admission record, the admission record indicated the facility originally admitted Resident 3 on 3/14/2026 and re-admitted the resident on 4/3/2026 with diagnoses including acute and chronic respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide), and encephalopathy (a condition in which the functioning of the brain is affected by some agent or condition-such as viral infection or toxins in the blood). During a review of Resident 3's Minimum Data Set (MDS - a standardized assessment tool) dated 3/18/2026, the MDS indicated Resident 3 had intact cognition (mental action or process of acquiring knowledge and understanding) for daily decision-making and mostly dependent (helper does all the effort) from staff for activities of daily living (ADLs-bed mobility, surface transfer, eating, walk in room, dressing, toileting, and personal hygiene). During a review of Resident 3's History and Physical (H&P) dated 4/6/2026, the H&P indicated Resident 3 had the capacity to understand and make decisions. During a review of Resident 3's Resident Transfer Record (RTR) dated 5/11/2026, Resident 3's RTR indicated Resident 3 was transferred to GACH due to tachycardia (heart rate faster than normal) and having difficulty maintaining adequate oxygen saturation levels. During a review of Resident 3's Notice of Proposed Transfer and Discharge (NPTD-an official, written warning from a nursing home stating an intent to discharge or transfer the resident) dated 5/11/2026, the NPTD indicated that the discharge was necessary for Resident 3 due to the resident's need not being able to be met by the facility. During a concurrent interview and record review on 5/14/2026 at 8:20 AM, with Medical Record Assistant 1 (MRA1), Resident 3's NPTD Facsimile (fax) report was reviewed. Resident 3's NPTD fax report indicated NPTD was faxed on 5/13/2026 at 11:18 AM. MRA 1 stated no fax report was completed and indicated in Resident 3's medical record on 5/11/2026 (date of transfer). MRA 1 stated that she (MRA 1) faxed Resident 3's NPTD on 5/13/2026 since it was requested by the surveyor. During an interview on 5/14/2026 at 9:54 AM, with the Director of Nursing (DON), the DON stated that it was best practice to notify the LTC Ombudsman via fax as soon as possible when a resident was transferred to another facility so LTC Ombudsman could be made aware of resident's status. The DON stated that the NPTD fax report should have been maintained and kept in residents' medical records. During a review of facility's P&P, titled Documentation of Discharge or Transferring Resident reviewed on 4/14/2026, the P&P indicated when a resident was temporarily transferred on an emergency basis to an acute care facility a notice of transfer was to be provided to the resident and resident representative and the facility was to forward a copy of the notices to the Ombudsman. The P&P indicated that facility was to maintain evidence that the notice was sent to the Ombudsman.

Based on interview and record review, the facility failed to provide a safe and accident-free environment for one of three sampled residents (Resident 2), who was assessed as high fall risk, impaired gait (walking pattern different than normal) and mobility, and had diagnosis of dementia (a chronic condition that causes a gradual decline in cognitive abilities, such as thinking, remembering, and reasoning) by failing to: -Provide Resident 2 supervision to prevent falls, per the facility's policy titled, Fall Management Program. -Develop and implement a person-centered care plan which included supervision to prevent falls and injury. As a result, Resident 2 had a fall on 1/19/2025 at 6:30 AM, in his room, and complained of pain rated at 10 out of 10 (the most severe pain). On 1/19/2025 at 6:03 PM, Resident 2 fell again in his room. Resident 2 received a Stat (immediate) X-ray of the right shoulder on 1/20/2025, which resulted in a minimally displaced acute (fresh fracture, bone shifted slightly but not significantly) acromion fracture (a flattened piece of bone that forms the top of the shoulder, meets the collarbone and a key part for wide range of motion) and was transferred to the General Acute Care Hospital (GACH) for further evaluation. Findings: A review of Resident 2's admission record indicated the resident was admitted to the facility on [DATE] with diagnoses including cerebral infarction (a type of stroke that occurs when an area of brain tissue dies due to a lack of blood flow), dementia), and Parkinson's Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity [muscles become stiff and resistant to movement], and slow, imprecise movements). A review of Resident 2's At Risk for Falls care plan related to confusion and incontinence(having no or insufficient voluntary control over urination or defecation), dated 1/4/2025 indicated interventions to place call light within reach, encourage the resident to use the call bell for assistance, and to anticipate and meet the resident's needs. A review of Resident 2's Fall Risk assessment dated [DATE] indicated with a total score of 10 or greater, the resident should be considered a high risk for potential falls, a fall prevention protocol should be initiated immediately, and documented on the resident's care plan. The fall risk assessment indicated Resident 2 was disoriented times three ([NAME], place time), and under gait / balance / ambulation had decreased muscle coordination and jerking movements. The fall risk assessment indicated Resident 2 had no falls in the past three months, scored a 14, and was considered a high risk for potential falls. A review of the Physician's Orders Summary Report dated 1/4/2025 indicated Resident 2 received an indwelling catheter due to benign prostatic hyperplasia (BPH - a common condition in older men where the prostate gland enlarges, putting pressure on the urethra [the tube that carries urine from the bladder to the outside of the body]). According to a review of Resident 2's History and Physical (H&P) dated 1/6/2025 the resident did not have the capacity to understand and make decisions due to dementia, had right sided weakness, and a history of CVA-stroke. The H&P indicated Resident 2 also had a history of Parkinson's Disease, rigidity (being stiff, inflexible, or unable to bend) in both lower extremities. A review of Resident 2's Minimum Data Set (MDS - a resident assessment tool) dated 1/8/2025, indicated the resident's cognitive skills for daily decision-making skills was severely impaired, had problems with short and long-term memory, and the resident was dependent for hygiene, showering/bathing. The MDS indicated Resident 2 had impairment on both sides for upper and lower extremities, was always incontinent of bowel, and had decreased ability to make himself understood (spoke a different language other than English). The MDS indicated Resident 2 did not have a fall in the last 2-6 months, was at high risk for falls/injuries, had impaired gait and mobility, and sit to stand nor transfer was attempted due to the resident's medical condition and safety. A review of the At Risk for Falls and Injuries care plan dated 1/17/2025 indicated Resident 2 had risk factors including a history of falls, poor safety awareness and poor mobility. The care plan goal indicated Resident 2 would have no injuries related to falls. The interventions indicated to encourage Resident 2 to call for assistance in ambulation. A review of the Post Fall Evaluation / Interdisciplinary Team note (IDT, a team of professionals from various fields who work together toward the goals of the resident) dated 1/19/2025 at 7:30 AM, indicated Resident 2 was found on the floor facing the bathroom. The IDT note indicated Resident 2 wanted to go to the bathroom and his bed had no bowel movement noted. The IDT note indicated Resident 2 pointed to his right shoulder when the facility assessed him for pain. A review of the Physician's Order Summary Report dated 1/19/2025 indicated Resident 2 received a stat X-ray of the right shoulder. Further review of the Physician's Orders indicated there was no order for Resident 2 to receive supervision, padded mats, or a bed alarm (a device that monitors a person's movements in bed and alerts caregivers when the person is trying to get up) prior to 1/19/2025. A review of the Progress Note dated 1/19/2025 at 5:03 PM indicted the physician was informed of the fall and gave an order to transfer Resident 2 to the GACH due to abnormal right shoulder X-ray. A review of the Post Fall Evaluation / Interdisciplinary Team note dated 1/19/2025 at 10:24 PM indicated at 6:03 PM Resident 2 had another fall in his room. A visitor of Resident 2's roommate informed the staff that Resident 2 was on the floor. Resident 2 had no complaints of pain and there were no injuries noted. A review of the facility's X ray report dated 1/20/2025 at 9:14 AM indicated Resident 2 had one view of the right shoulder completed. The X-ray report findings indicated Resident 2 had a minimally displaced acute acromion fracture. According to a review of the fax document from the facility to the Department dated 1/20/2025, Resident 2 was found on the floor on his back next to his bed, with his head facing the restroom on 1/19/2025 at 6:30 AM. The fax document indicated Resident 2 complained of pain rated at 10 out of 10 (most severe pain). A review of the facility's fax document dated 1/20/2025, at around 4:20 PM, the facility was notified by the Physician (MD) that Resident 2's x-ray at the GACH was a confirmed fracture of the acromion. According to the MD, Resident 2 was stable, no surgery would be performed, and Resident 2 would return to the facility. A review of the GACH History and Physical (H&P) dated 1/20/25 indicated Resident 2 was brought in by ambulance due to two unwitnessed falls and an x-ray showed an acromion fracture. The H&P indicated Resident 2 had been very restless/agitated a few days prior to hospitalization to the GACH, pulled his catheter out and was noted to have hematuria (blood in your urine) in the catheter. The GACH Emergency Department Note indicated Resident 2 was admitted to the telemetry unit (continuous cardiac monitoring). A review of Resident 2's GACH Progress Notes dated 1/21/2025 indicated the resident continued to complain about his shoulder pain. The progress notes indicated Resident 2 would need a sling for four weeks for the right acromion fracture and could not bear weight (should not put any weight) on the right upper extremity (right arm) for four weeks. A review of Resident 2's GACH Progress Notes dated 1/22/2025 indicated the physician was called by nursing because Resident 2 had become agitated late in the afternoon and was more agitated than he had been earlier in the day. The progress notes indicated the GACH could not transfer Resident 2 to the skilled nursing facility with restraints, therefore mittens were applied, and Ativan (a medication that can make the user feel calm and physically relaxed) was ordered. A review of the facility's Physician's Order Summary Report dated 1/23/2025 indicated Resident 2 received a right upper arm sling for right acromion fracture, may remove for shower. A review of the facility's post fall evaluation dated 1/24/2024 indicated Resident 2 fell on [DATE] at 6:30 AM (first fall) after he wanted to go to the bathroom and the plan was to transfer Resident 2 to the hospital. Another post fall evaluation indicated Resident 2 fell again on 1/19/2025 at 6:03 PM (second fall) which occurred before the transfer to GACH. According to a review of Resident 2's post fall evaluation dated 1/27/2025, the root cause analysis of the resident was a risk for falls and injuries due to history of falls, incontinence bowel and bladder, poor safety awareness, history of CVA, weakness, dementia, toxic encephalopathy (a condition where the brain becomes inflamed and damaged due to exposure to toxins or other harmful substances), Parkinson's disease, and use of psychoactive drugs (a drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior). A review of Resident 2's post fall evaluation dated 2/4/2025 indicated Resident 2 fell on [DATE] (third fall) due to agitation and restlessness and was transferred to the GACH again for further evaluation. During an interview on 2/5/2025 at 8:15 am, the Director of Nursing (DON) stated Resident 2's family member visited the day of the fall, and the resident was calm. The DON stated Resident 2 was later found on the floor and this was most likely when he broke his right acromion. The DON stated Family Member 1 left for the day and Resident 2 had another fall around 7 PM the same day (1/19/2025). The DON stated Resident 2 was transferred to the GACH, returned to the facility on [DATE], then was transferred back again to the GACH on 1/31/2025 (approximately one week later) after a third fall. During an interview on 2/5/2025 at 12:40 PM, Family Member 1 stated, via Spanish language line interpreter, that there were some loose bedding at the bottom of Resident 2's bed and she asked the staff to fix it, but staff fixed and changed the mattress and not the bedding. Family Member 1 stated she received a call from the facility on 1/19/2025 around 8 AM that Resident 2 had a fall, so she asked staff to monitor Resident 2 to prevent falls. Family Member 1 stated that Resident 2 was anxious and confused because he wanted to get out of bed. Family Member 1 stated she did not feel that the facility did a good job protecting Resident 2 from falls. She stated the facility did not do enough to prevent the multiple falls, and that, The facility could have been more careful. Family Member 1 stated she did not get education or information on how the staff would prevent future falls. On 2/5/2025 at 2:47 PM, during an interview, Licensed Vocational Nurse (LVN) 4 stated she worked with Resident 2 and was notified by the Certified Nursing Assistant (CNA) 2 that Resident 2 had a fall on 1/19/2025 in the morning. LVN 4 stated there was no floor mat at the time of the fall, that Resident 2 was confused, and she could not remember if Resident 2 was a high fall risk. LVN 4 stated Resident 2 had a urinary catheter (a thin, flexible tube that a doctor inserts into your bladder to drain urine), was trying to go to the bathroom on his own the day before, and the resident was reminded not to get out of bed. LVN 4 stated Resident 2 continued trying to get out of bed. LVN 4 stated that having a care plan lets staff know how to care for a resident. LVN 4 stated fall precautions were important for safety to prevent injury. During the investigation an attempt to call night Registered Nurse Supervisor 3 (RNS 3) was made on 2/5/2025 at 2:57 PM to discuss Resident 2's fall that occurred on 1/19/2025 at 6:30 AM, but the call was not returned. Another call was attempted for CNA 2 on 2/5/2025 at 2:59 PM, but call was not returned. During a telephone interview on 2/7/2025 at 10:39 AM, Family Member 1 stated, via Spanish language line interpreter, that before his first fall on 1/19/2025, Resident 2 was too confused to be oriented to the call light. Family Member 1 stated Resident 2 did not know how to use the call light. A review of the facility's policy and procedure (P&P) titled, Fall Management Program, dated 3/2023, indicated the facility would provide each resident with adequate supervision and assistance devices to minimize fall risks; and would provide an environment free from accident hazards. The P&P indicated the facility was responsible for resident supervision and would prevent avoidable accidents. The P&P defined an avoidable accident as an accident where the facility failed to implement interventions, including adequate supervision and assistive devises consistent with a resident's needs, goals, care plan and professional standards in reducing fall risk. The P&P indicated the facility would monitor the effectiveness of the interventions and modify the care plan as necessary.

Based on observation, interview, and record review, the facility's staff failed to implement infection control policies and procedures (P &P) for four of five sampled residents (residents 1, 3, 4, and 5), by failing to: 1. Identify and prevent the spread of infestation of scabies (i.e., a highly contagious skin condition caused by the itch mite) when Resident 1 had a skin rash on 11/6/2023. 2. Placed Resident 1 on transmission-based precautions (isolation precautions, actions taken to prevent the or control infections) when she was diagnosed to have scabies on 3/27/2024. 3.Implement control measures to prevent the transmission of scabies among residents in the facility, staff, and visitors. 4. Assess Resident 1's roommates (Residents 3, 4, and 5) for potential exposure to scabies. 5. Perform contact tracing (the action or process of identifying individuals who have been in the proximity of a person diagnosed with an infectious disease, in order to isolate, test, or treat them) for staff and residents to identify potential scabies exposure. These deficient practices resulted in the staff not adhering to its infection control P &P and had a potential of transmitting scabies to 158 inhouse residents, the staff, and community. On 4/1/2024 at 7:40 p.m., an Immediate Jeopardy (IJ - a situation in which the provider's non-compliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident) was identified in the presence of the Administrator (ADM) and the Director of Nursing (DON) due to the facility's lack of a system in providing a timely diagnosis, appropriate treatment, care and services to protect all 158 residents, staff, and residents. On 4/3/2024 at 2:21 p.m., while onsite at the facility, the IJ was removed in the presence of the ADM and the DON, after the ADM submitted an acceptable IJ Removal Plan (interventions and implementation to correct the deficient practices) which was verified and confirmed through observation, interview, and record review. A review of the IJ removal plan included the following: 1. On 4/1/2024, the licensed nurse contacted Resident 1's physician and obtained orders for a skin scraping to identify the presence of scabies mites, the test was completed and sent the specimen to the laboratory for processing. The licensed nurses began immediate cleaning and disinfection of all multi-use resident care equipment to reduce the potential to transmit contagious skin rashes to the extent possible. 2. On 4/1/2024, The Clinical Consultant in serviced the DON, Infection Prevention Nurse (IPN), and the Administrator on the facility's P &P and the guidelines for Prevention and Control of Scabies in California Healthcare settings. 3. On 4/1/2024, The DON and IPN began in servicing licensed nurses working in the facility during the 3-11 shift on the facility's P & P and the guidelines for Prevention and Control of Scabies in California Healthcare settings including weekly assessments of each residents skin, completion of change in condition assessments for all resident rashes identified, notification of the resident's physician and representative and under the direction and guidance of the physician, place the resident on contact precautions, complete a skin scraping to identify the presence of scabies mites, and proper use of PPE. 4. On 4/1/2024, The licensed nurse completed head to toe body assessments of Residents 3, 4, and 5 to identify the presence of a skin rash. Residents 3, 4, 5 do not have evidence of skin rash or complaints of itching. 5. The DON and RN Supervisors reviewed and revised Residents 3 and 4's care plans effective 4/1/24 to address the changes in condition, potential exposure to a resident with possible scabies rash and to ensure continued care and services to maintain their highest practicable outcomes. 6. On 4/2/2024, Physical Plant and Environmental Services Consultants in-serviced housekeeping supervisor and housekeeping staff regarding Housekeeping Disinfection Plan which includes using EPA approved disinfectant for cleaning, wearing gloves and long sleeve gown while conducting disinfection, changing gloves and long-sleeve gown between affected resident rooms, performing handwashing between rooms and tasks, changing water, mop, and rags between resident rooms or between disinfection tasks, and when possible complete cleaning and disinfection of each affected room while the resident is showering. On 4/2/2024, the housekeeping staff deep cleaned Resident l, 3, 4, and 5's room. On 4/2/2024, 3rd and 4th Floor were deep cleaned to reduce potential for transmission of contagious pathogens. 7. On 4/2/2024, the DON and the IPN completed 144 of 158 resident body assessments to identify the presence of rashes on other residents to prevent harm to affected residents. Dermatologist (a medical practitioner specializing in the diagnosis and treatment of skin disorders) also completed an assessment of all 158 residents to identify residents who are likely to suffer, a serious adverse outcome because of the facility's noncompliance. 17 of 158 residents were identified with rashes by the DON and the Dermatologist. 15 of the 17 residents already have on-going treatment orders for identified skin rashes. 2 of the 17 residents are newly identified with diagnosis of unspecified dermatitis (skin disorder). The licensed nurses completed change in condition assessments for the 17 residents identified with skin rashes and their roommates, notified their physicians and resident representatives. Placing the 17 newly identified residents with unspecified dermatitis on isolation, performed scraping (collection of the superficial skin cells and further evaluation of the cells under microscope or cultured environment in the laboratory) for 16 out of 17 residents and completion of Elimite (a medicated skin cream that treats scabies) treatments per physician. 8. On 4/2/2024, Clinical Consultant continued evaluation through interview of available staff to identify any staff with skin conditions. To reduce the potential for transmission of contagious rashes, employee interviews continue in person and via the telephone, prior to staff working with residents during their next assigned shift, to identify any staff members with skin conditions. 149 of 200 staff were interviewed and contacted. Three staff who reported itchiness and identified with rashes were offered Elimite. 9. The IPN revised new employee and annual infection prevention and control training to include education of Scabies prevention in Healthcare Settings and reporting the development of new skin rashes identified to their physician, especially when known to have provided direct care with residents diagnosed with contagious skin rashes effective 4/2/2024. Findings: a. A review of Resident 1's admission record indicated the facility admitted Resident 1, on 2/27/2023 with diagnoses that included hemiplegia (loss of strength in the arm, leg, and sometimes the face on one side of the body) and hemiparesis (loss of use in the arm, leg, and sometimes the face on one side of the body) following cerebral infarction (stroke) affecting tight dominant side, aphasia (difficulty speaking), dysphagia (difficulty swallowing), dependence on supplemental oxygen, and anxiety. A review of Resident 1's Minimum Data Set (MDS- standardized data collection tool used to assess cognitive and functional status, and care needs) dated 1/4/2024, indicated the resident was dependent on facility staff for oral hygiene, toileting, showers/bathing, dressing, and repositioning. A review of Resident 1's care plan (a plan of care that summarizes a resident's health conditions, specific care needs, and current treatments) for The resident has multiple body discoloration dated 8/10/2023, did not indicate the location, size, color, or appearance of the multiple discolorations. The care plan indicated interventions facility staff needed to carry out to address the discolorations included Educate resident/family/caregiver of causative factors and measures to prevent skin injury. The care plan did not indicate what the causative factors were. A review of Resident 1's Assessment Summary dated 11/6/2023 at 1:33 p.m., indicated the resident had a change in condition. The change in condition was documented as: skin dermatitis (rash: redness and inflammation of the skin) to left cheek, right lower chin, and left forearm. Nursing assessment done with no itchiness, pain, or drainage noted to site. A review of Resident 1's situation background assessment and recommendation (SBAR or Change in condition [COC]: a form that is a documentation of a complete assessment in response to a change in condition) form dated 11/6/2023 at 1:33 p.m., indicated the resident had skin dermatitis. The SBAR indicated interventions to improve the condition were Treatment (Tx) as ordered, monitoring, and possible derma (dermatologist) consult. The SBAR indicated a new order was received for Triamcinolone (topical steroid, used to treat certain skin diseases and allergies) 0.5% cream for 14 days until healed and reassess and Claritin (used to treat allergy symptoms) 10 milligrams (mg, unit of measurement) daily for one week. A review of Resident 1's SBAR dated 11/6/2023 at 3 p.m., indicated Around 3 p.m., fell ow Medical Doctor (MD) of [primary MD] seen and examined the resident's skin; noted with new order of Acyclovir (antiviral, medications that help the body fight off harmful viruses) for shingles (a painful rash caused by a virus, that may appear as a stripe of blisters). No pain at this time but noted itchiness; administered treatment cream and Claritin 10 mg times one as ordered at the affected areas; tolerated with no adverse side effect (ASE ). Not in distress. Provided comfort; kept clean and dry. Body assessment done. Will continue to monitor and endorse. A review of Resident 1's care plan for Resident has left forearm unspecified skin dermatitis dated 11/6/2023, did not indicate the location, size, color, or appearance of the dermatitis. The care plan indicated interventions which include facility staff needed to carry out to address the dermatitis by apply treatment as ordered, keep skin clean and dry, monitor effectiveness of treatment, monitor any skin changes, inform MD if treatment not resolved and to monitor for signs and symptoms of infection and adverse changes. A review of Resident 1's SBAR dated 11/12/2023 at 10:46 a.m., indicated noted resident with left thigh skin scratch with 5-centimeter (cm, unit of measurement) x (times) 8 cm. The SBAR indicated interventions to improve the scratch were treatment as ordered, isolation, and antiviral medications. A review of Resident 1's Interdisciplinary Team (IDT, a team of health care professions, which include the facility's medical director, Director of Nursing (DON), social worker, registered nurse, and other staff as needed) who work together to establish plans of care for residents) dated 11/15/2023 at 8:47 p.m., indicated, skin care treatment rendered as ordered The IDT notes did not indicate the IDT discussed skin rash assessment. A review of resident 1's Health Status Note dated 11/16/2023 at 2 p.m., indicated the primary doctor ordered increased Zoloft (medication used to treat depression) to 100 mg via GT (gastrostomy tube, a surgical procedure to insert a tube through the abdomen and into the stomach used for feeding, usually via a feeding tube) daily for depression manifested by (m/b) episode of crying. A review of Resident 1's Health Status Note dated 11/8/2023 at 11:29 p.m., indicated an order was received by the primary doctor to discontinue the Acyclovir and to discontinue the contact isolation (steps that healthcare facility visitors and staff need to follow before going into a patient's room) due to improved skin condition. A review of Resident 1's care plan for Resident has left thigh unspecified skin dermatitis dated 12/4/2023, indicated interventions facility staff needed to carry out to address the dermatitis included cleanse with normal saline (it is an aqueous solution of electrolytes and other hydrophilic molecules) and apply Triamcinolone cream 0.05% Q (every) shift x 14 days, keep clean and dry, and monitor for signs and symptoms of infection and adverse changes. A review of Resident 1's Physician Order Note dated 12/13/2023 at 1:26 p.m., indicated the resident was to continue Zoloft due to episode of crying. A review of Resident1's IDT Progress Note-Behavior Management dated 1/5/2024 at 2:02 p.m., indicated the resident was referred to psychiatry services due to use of Zoloft 50 mg daily for depression m/b crying. Patient's medication was initiated at the facility due to intermittent episodes of crying observed by staff and family. A review of Resident 1's After Visit Summary from the outpatient clinic Neurologist (a medical specialist in the diagnosis and treatment of disorders of the nervous system) dated 3/5/2024 at 1:15 p.m., indicated the reason for the visit was nonspecific paroxysmal spell (alteration in consciousness that look like seizures) and skin rash since October 2023. The after-visit summary indicated the neurologist ordered a referral to dermatology (doctor who specializes in disorders of the skin). A review of Resident 1's Assessment Summary note dated 3/5/2024 at 9:15 p.m., indicated General Skin Conditions: Rash Itching. The note did not indicate the location and size of the rash or if the doctor was notified. A review of Resident 1's care plan for The resident has rash trunk, legs, arms, armpit rash, general body rash with an initiation date of 3/5/2024, indicated interventions which included facility staff needed to carry out to address the rash included avoid scratching, daily shower as tolerated, derma (dermatologist) consult, and monitor skin for signs and symptoms of infection. A review of Resident 1's Assessment Summary Note dated 3/12/2024 at 2:04 p.m., indicated General Skin Conditions: Rash Itching. The note did not indicate the location and size of the rash or if the doctor was notified. A review of Resident 1's Health Status Note dated 3/27/2024 at 1:30 p.m., indicated Resident 1 left the facility to a dermatology appointment. A review of Resident 1's After Visit Summary from the outpatient clinic dated 3/27/2024 at 2 p.m., indicated the reason for the visit was Scabies. The after-visit summary indicated skin scraping was performed and which has a result of diagnosed of scybala (feces) and ovum (eggs). Resident 1 had a diagnosis of Scabies and new medications were ordered to treat the scabies; Permethrin (medication used to treat infestations of small parasites [an organism that lives off a host]) 5% topical cream apply from neck to soles of feet. Wash off after 8 to 14 hours. Repeat in seven days., Ivermectin (medication used to treat diseases caused by parasites) 3 mg oral tablets take 4 tablets at once today by mouth, and Triamcinolone Acetonide 0.1% Topical Ointment apply to affected area(s) 2 times a day. A review of Resident 1's admission record for 2/27/2023, did not indicate the scabies diagnosis was added to the resident's medical record. A review of Resident 1's care plan for The resident has rash (general body) at risk for recurrent skin problems secondary to diagnosis of diabetes, anxiety, anemia (low blood level), quadriplegia, incontinent (unable to control passage of urine and feces), bedbound status, thin and fragile skin dated 3/27/2024, did not indicate the diagnosis of scabies. The care plan indicated interventions facility staff needed to carry out to address the rash which included Deep clean room after Elimite application. A review of Resident 1's care plan for Resident on contact isolation precautions skin treatment prophylaxis [to prevent] dated 3/27/2024, indicated the resident was in isolation for prophylaxis, but did not indicate the resident had scabies. A review of Resident 1's Infection Note dated 3/28/2024 at 2:54 p.m., indicated On 3/27/24, Resident returned from doctor's appointment with orders for Ivermectin and Elimite. Explained to resident's [FM's] that the resident has history of on and off rashes. [Primary Doctor] is aware and was actively treating and addressing resident's skin concerns. During an interview and a concurrent observation of Resident 1 with Licensed Vocational Nurse 1 (LVN 1) on 3/30/2024 at 10:51 a.m., Resident 1 was observed to have a tiny red spot around her (Resident 1) torso (The main part of the body that contains the chest, abdomen, pelvis, and back), arm pits, bilateral legs, arms, web of fingers, and palm of hands with burrow marks on the hands. Resident was observed to be scratching in areas that she was able to reach. LVN 1 stated Resident 1 was isolated due to generalized body rash. LVN 1 confirmed and stated that Resident 1 had a rash. The Treatment Nurse (TN-caring for critically ill or injured patients, providing medications and treatments, monitoring vital signs, and performing diagnostic tests) and the IPN are only ones that are responsible for assessing the resident to determine if the resident had scabies or not. LVN 1 stated that when a resident has generalized rash, they do not require isolation. LVN 1 further confirmed and stated that Resident 1 had all the classic symptoms of scabies. During an interview and a concurrent record review of Resident 1's chart with the TN on 3/30/2024 at 12:11 p.m., the TN stated there was a COC for generalized body rash on 3/28/2024 for Resident 1. TN stated Resident 1 was seen on 3/27/2024 was seen by an outside dermatologist who ordered Ivermectin oral medication and permethrin to be applied on Resident 1. TN stated that the regimen ordered was for scabies. TN stated contact isolation must be placed as soon as suspicions for scabies arise. TN admitted there were neither prophylactic treatments for Resident 1's roommates (Resident 3,4, and 5) nor skin assessments completed. There was no documented evidence of scraping orders for Resident 1. TN stated without proper diagnosis would have increased further spread to other residents not only in Resident 1's roommates and staff. TN stated that she should have assessed the other residents because scabies is highly contagious. During a telephone interview with the IPN on 3/30/2024 at 12:54 p.m., IPN stated that Resident 1 had an ongoing rash on and off but does not recall how long ago it started. IPN stated that she (IPN) had assessed Resident 1 after the 3/27/2024 appointment and noted that she (Resident 1) had scattered rashes under armpits and back. IPN admitted that she (IPN) had not assessed the hands to check in the web of fingers and hands where the burrowing was mostly located. Stated that Resident 1 should have been isolated right away when she was diagnosed to have scabies to prevent further spread to other residents as well as staff. IPN stated that symptoms of scabies included: itching, scattered rashes, crevices, hands, folds, and crusting. IPN admitted that the primary physician should have been notified and scrapings ordered. On the same interview, the IPN confirmed and stated that Resident 1's roommates (Residents 3, 4, and 5) should have been assessed to make sure that they were not exhibiting signs and symptoms (a symptom is something an individual experiences, while a sign is something a doctor, or other person, notices) of scabies, their physicians notified with prophylactic treatments ordered. IPN stated that the Resident 1 roommates' (Residents 3, 4, and 5) families should have been notified. IPN stated that in addition, contact tracing (the process of quickly identifying, assessing, and managing people who have been exposed to a disease to prevent additional transmission of an infectious disease, to isolate, test, or treat them) should have been initiated right away. IPN confirmed and stated that the case was not reported to the local Department of Public Department (DPH). IPN stated that she (IPN) did not report because it was a suspicion and that a scraping should have confirmed the diagnosis. During a telephone interview with FM 1 on 4/1/2024 at 9:45 a.m., FM stated that she (FM 1) had noticed the rash to Resident 1's left upper arm and thought they were bugbites. FM 1stated Resident 1 was scratching very intensely and cried a lot and could not focus the fact that FM 1 was there which she had done before the rash. Before long, the rash had spread to the whole arm. FM 1 was told that in house dermatologist came to see Resident 1. In November, facility staff called her (FM 1) stating that the resident had shingles (also known as herpes zoster, is a viral disease characterized by a painful skin rash with blisters in a localized area). FM 1 stated she received a call by facility staff two days later notifying her that the rash was not shingles. FM 1 stated that staff informed her (FM 1) that they did know what it was, so they would start applying hydrocortisone. On the same interview, FM 1 stated that she believed that she got infected because she (FM 1) provided personal care for Resident 1 daily because she (FM1) developed an itchy rash herself. FM 1 further stated she (FM 1) was diagnosed with scabies herself. FM 1 stated, IPN told her that the facility did not have a dermatologist to see Resident 1. FM 1 stated she was shocked. FM 1 stated that she had brought her sister to her neurologist appointment on 3/5/2024 who then made a dermatology appointment concerning for scabies. FM 1 was scraped and was confirmed to have scabies on 3/27/2024 at the dermatology appointment. b. A review of Resident 3's (roommate of Resident 1) admission record indicated the facility admitted Resident 3 on 9/9/2022 with diagnoses that included hemiplegia and hemiparesis following cerebrovascular accident and aphasia. A review of Resident 3's H&P dated 7/31/2023, indicated the resident did not have the capacity to understand and make decisions. c. A review of Resident 4's (roommate of Resident 1) admission record indicated the facility admitted Resident 4 on 7/22/2023 with diagnoses that included right femur (thigh bone) fracture, high blood pressure, and diabetes. A review of Resident 4's H&P dated 7/31/2023, indicated the resident had the capacity to understand and make decisions. d. A review of Resident 5's (roommate of Resident 1) admission record indicated the facility admitted Resident 5 on 12/14/2023, with diagnoses that included injury of the blood vessels in the head, history of falling, and muscle weakness. A review of Resident 5's H&P dated 12/15/2023, indicated the resident did not appear to have full decision-making capacity. During a concurrent interview and record review of Residents 1, 3, 4, and 5 medical records with IPN on 4/1/2024 at 10:37 a.m., IPN stated that the TN had assessed Residents 3, 4, and 5 per physician recommendation on 3/27/2024 which indicated to assess resident and staff that may have been in close proximity with Resident 1 and with similar rash, but there was no documented evidence of the skin assessment. IPN admitted that the SBAR/COC should have been completed right away on 3/27/2024 for Resident 1. IPN initiating isolation right away may have prevented potential spread to both residents and staff. During a telephone interview with the Medical Director (MD), on 4/1/24 at 5:35 p.m., MD stated the facility had just made him aware about the clinical presentation of scabies about two hours prior to this phone interview. MD stated that the nursing staff should have notified the Primary Care Physician (PCP) as well as the MD about the condition as soon as possible. MD stated that when treatments are not working such as the acyclovir, nystatin that were used for Resident 1, consults for dermatology must be made and followed up within a few hours or days to prevent the patient from suffering. MD stated that Resident 1 should have been isolated immediately she (Resident 1) was diagnosed with scabies. The resident and roommates must be assessed, linens changed including curtains and rooms deep cleaned. MD stated that when as resident is placed on acyclovir, the treatment must be at least for a week for it to be effective. During an interview with the RN Supervisor (RNS), on 4/2/24 at 12:48 p.m., stated that scabies is very infectious and serious diagnosis which needs to be reported to the PCP, and properly assessed. RNS stated the-signs and symptoms includes itchiness, red spots on the back, chest areas, web of fingers (covered areas). RNS stated scabies are diagnosed by scraping. RNS stated that she (RNS) scraped Resident 1 on 4/1/2024 around 4-4:30 p.m. Resident 1 was scraped to the left palm. RNS stated that she had followed the instructions on the kit provided and that the facility did not have a policy and procedure on scraping. RNS admitted that policy and procedures should guide the nursing staff on how to perform procedures. During an interview with the facility Dermatologist (DMT) 1 on 4/2/24 at 2:12 p.m., DMT 1 stated that they had identified 17 residents with possible scabies, eczema (skin dryness), possible reactions, and dry skin. Scrapings, isolations, and prophylaxis treatment was ordered. DMT 1 stated that a negative test does not necessarily mean a negative test, especially in the presence of signs and symptoms. DMT 1 stated that assessments of the residents identified with scabies as well as contact tracing must be initiated right away. A review of the facility's P&P titled Scabies, Infection Control Manual, revised, 7/2015, indicated, To ensure that the Facility takes the precautions needed to prevent, control and manage a scabies outbreak. The same P&P indicated that the facility worked to prevent scabies by strictly adhering to the standards outlined by the Centers for Disease Control and Prevention (CDC- nation's leading science-based, data-driven, service organization that protects the public's health) and State of California Department of Public Health. The procedure of the same P&P indicated, The Administrator and Infection Control Coordinator will make required reports to agencies as outlined in Policy No. - IC - 09 - Communicable Diseases - Outbreak and Policy No. - IC 10 -Reportable Diseases. A review of the facility's P&P titled Infection Prevention and Control Program, undated, indicated, The ensure the Facility establishes and maintains an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection in accordance with Federal and State requirements. The same P&P indicated the reasons the facility must establish the program included: 1. Identifies, investigates, controls, and prevents infections in the Facility. 2. Decides what procedures, such as isolation, should be applied to an individual resident; and 3. Maintains a record of incidents and corrective actions related to infections. The same P&P indicated; the surveillance may include a review of the following information to help identify possible root causes of HAIs (Health Care Associated Infections): i. laboratory records ii. Skin check data iii. Infection control rounds or interviews iv. Verbal reports from staff v. Infection surveillance sheets vi. Temperature logs (e.g., Dietary, laundry, Nursing) vii. Pharmacy records viii. Antibiotic review ix. Transfer log/summaries. A review of the facility's P&P titled Resident Isolation - Categories of Transmission-Based Precautions, undated, indicated, To ensure that transmission-based precautions are used when caring for residents with communicable diseases or transmittable infections. The same P&P indicated, transmission-based precautions are used accordingly when staff are caring for residents who are documented or suspected of having contagious diseases or infections that can be transmitted to others. The P&P indicated under contact precautions a list of examples of infections requiring Contact Precautions included: scabies and shingles. The same P&P indicated The Facility also ensures that the resident's care plan indicates the type of precautions implemented for the resident. A review of the facility's P&P titled Resident Isolation - Initiating Transmission-Based Precautions, undated, indicated, To ensure the use of transmission-based precautions when a resident has a communicable infectious disease. The same P&P indicated, In an emergency or case of outbreak, the Infection Control Coordinator, Administrator and/or Medical Director is responsible to: A. Institute all actions necessary to control or prevent infections within the Facility. B. Notify the health department of reportable diseases, as appropriate. C. Initiate isolation precautions. D. Obtain laboratory specimens. E. Restrict or ban admissions. F. Restrict or ban visitation; and G. Implement other measures as necessary to prevent and control infections within the facility.

Based on observation, interview, and record review, the facility failed to provide care, treatment, and services for five of five sampled residents (Residents 1, 2, 3, 4, and 5) in accordance with professional standards of practice in order to meet the residents' physical, mental, and psychosocial needs, by failing to: 1. Conduct proper assessment to identify what was causing generalized and severely itchy skin rashes despite two separate treatments for Resident 1 and generalized dry crusted skin rashes for Resident 5. Resident 1's rash and itching was first identified by the facility on 11/06/2023. 2. Notify a physician that treatment ordered for skin itchy rashes was ineffective according to the resident's care plan. Residents 1, 2, 3, 4, and 5 had no pre-existing skin conditions/rashes upon admission/readmission to the facility. These deficient practices resulted in: 1. Resident 1 experiencing unrelieved generalized and severely itchy body rashes, itchy skin, discomfort despite two separate treatments since 8/10/2023, and inability to sleep. 2. Zoloft (medication to treat mood disorders) was increased from 50 milligrams (mg- unit of measurement) to 100 mg daily for crying for Resident 1. 3. Resident 1 was referred for psychiatry (is the medical specialty devoted to the diagnosis, prevention, and treatment of deleterious mental conditions) services on 1/5/2024 due to intermittent episodes of crying. 4. Residents 2, 3, 4, and 5 were not assessed for generalized itchy skin rashes, and a physician not notified about the generalized itchy skin rashes. These deficient practices placed Residents 1, 2, 3, 4, and 5 at increased risk for significant decline in the residents' physical, mental, or psychosocial well-being, disfigurement, avoidable excruciating pain, and discomfort. On 4/1/2024 at 7:40 p.m., an Immediate Jeopardy (IJ - a situation in which the provider's non-compliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident) was identified in the presence of the Administrator (ADM) and the Director of Nursing (DON) due to the facility's lack of a system in providing a timely diagnosis, appropriate treatment, care and services to protect all 158 residents, staff, and community. On 4/3/2024 at 2:21 p.m., while onsite at the facility, the IJ was removed in the presence of the ADM and the DON, after the ADM submitted an acceptable IJ Removal Plan (interventions and implementation to correct the deficient practices) which was verified and confirmed through observation, interview, and record review. A review of the IJ removal plan included the following: 1. On 4/1/2024, the licensed nurse contacted Resident 1's physician and obtained orders for a skin scraping (is a bedrock technique in dermatology that is applied in a high proportion of cases. It enables both the full thickness of the epidermis and the contents of the hair follicles to be sampled) to identify the presence of scabies mites (scabies causing parasite), the test was completed and sent the specimen to the laboratory for processing. The licensed nurses began immediate cleaning and disinfection of all multi-use resident care equipment to reduce the potential to transmit contagious skin rashes to the extent possible. 2. On 4/1/2024, The Clinical Consultant inserviced (educated) the DON, Infection Prevention Nurse (IPN), and the Administrator on the facility's policy and procedures (P &P) and the guidelines for Prevention and Control of Scabies in California Healthcare settings. 3. On 4/1/2024, The DON and IPN began in servicing (educating) licensed nurses working in the facility during the 3 pm-11pm shift on the facility's P & P and the guidelines for Prevention and Control of Scabies in California Healthcare settings including weekly assessments of each residents skin, completion of change in condition assessments for all resident rashes identified, notification of the resident's physician and representative and under the direction and guidance of the physician, place the resident on contact precautions (Precautions intended to prevent transmission of infectious agents by use of gloves, gowns, masks), complete a skin scraping to identify the presence of scabies mites, and proper use of PPE (Personal Protective Equipment, protective items or garments worn to protect the body or clothing from hazards that can cause injury and to protect residents from cross-transmission). 4. On 4/1/2024, The licensed nurse completed head to toe body assessments of Residents 2, 3, 4, and 5 to identify the presence of a skin rash. 5. The DON and Registered Nurse (RN) Supervisors reviewed and revised Residents 3 and 4's care plans effective 4/1/24 to address the changes in condition, potential exposure to a resident with possible scabies rash and to ensure continued care and services to maintain their highest practicable outcomes. 6. On 4/2/2024, Physical Plant and Environmental Services Consultants in-serviced housekeeping supervisor and housekeeping staff regarding Housekeeping Disinfection Plan which includes using EPA (Environmental Protection Agency, approved disinfectant for cleaning), wearing gloves and long sleeve gown while conducting disinfection, changing gloves and long-sleeve gown between affected resident rooms, performing handwashing between rooms and tasks, changing water, mop, and rags between resident rooms or between disinfection tasks, and when possible complete cleaning and disinfection of each affected room while the resident is showering. On 4/2/2024, the housekeeping staff deep cleaned Resident l, 2, 3, 4, and 5's room. On 4/2/2024, 3rd and 4th Floor were deep cleaned to reduce potential for transmission of contagious pathogens. 7. On 4/2/2024, the DON and the IPN completed 144 of 158 resident body assessments to identify the presence of rashes on other residents to prevent harm to affected residents. Dermatologist (a medical practitioner specializing in the diagnosis and treatment of skin disorders) also completed an assessment of all 158 residents to identify residents who are likely to suffer, a serious adverse outcome because of the facility's noncompliance. The Don and the dermatologist, identified 17 of 158 residents were identified with rashes. 15 of the 17 residents already had on-going treatment orders for identified skin rashes. Two of the 17 residents are newly identified with diagnosis of unspecified dermatitis (a group of conditions in which the skin becomes inflamed, forms blisters, and becomes crusty, thick, and scaly). The licensed nurses completed change in condition assessments for the 17 residents identified with skin rashes and the roomates for the 17 residents. The residents' physicians and resident representatives were notified.17 residents that were newly identified with unspecified dermatitis, were placed on isolation. Skin scraping was performed on 16 of 17 residents and Elimite (a medicated skin cream that treats scabies) treatments per physician were completed. 8. On 4/2/2024, Clinical Consultant continued evaluation through interview of available staff to identify any staff with skin conditions. To reduce the potential for transmission of contagious rashes, employee interviews were continued in person and via the telephone, prior to staff working with residents during their next assigned shift, to identify any staff members with skin conditions. 149 of 200 staff were contacted and interviewed. Three staff who reported itchiness and identified with rashes were offered Elimite. 9.The IPN revised new employee and annual infection prevention and control training to include education of Scabies prevention in Healthcare Settings and reporting the development of new skin rashes identified to their physician, especially when known to have provided direct care with residents diagnosed with contagious skin rashes effective 4/2/2024. Findings: a. A review of Resident 1's admission record indicated the facility admitted Resident 1 on 2/27/2023, with diagnoses that included hemiplegia (loss of strength in the arm, leg, and sometimes the face on one side of the body) and hemiparesis (loss of use in the arm, leg, and sometimes the face on one side of the body) following cerebral infarction (stroke) affecting right dominant side, aphasia (difficulty speaking), dysphagia (difficulty swallowing), dependence on supplemental oxygen (use of extra oxygen to breathe in), and anxiety. The admission record did not indicate Resident 1 was admitted with any skin rashes and major depression (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life.). A review of Resident 1's Minimum Data Set (MDS- standardized assessment and care screening tool) dated 1/4/2024, indicated the resident's cognition (relating to mental ability to make decisions of daily living) was severely impaired. The MDS indicated Resident 1 was dependent on facility staff for oral hygiene, toileting, showers/bathing, dressing, and repositioning. A review of Resident 1's care plan for The resident has multiple body discolorations (any change in your natural skin tone), dated 8/10/2023, did not indicate the location, size, color, or appearance of the multiple discoloration skin discolorations. The care plan interventions included facility staff to carry out to address the discolorations included Educate resident/family/caregiver of causative factors and measures to prevent skin injury. A review of Resident 1's Wound Weekly Monitoring Assessment-Non-Pressure dated 11/2/2023 at 7:59 AM, indicted the resident did not have any skin concerns other than a bump/lymphoma (tumor) on the left shoulder. A review of Resident 1's Assessment Summary dated 11/6/2023 at 1:33 PM, indicated the resident had a change in condition. The change in condition was documented as: skin dermatitis [rash: redness and inflammation of the skin] to Left cheek, right lower chin, and left forearm. Nursing assessment done with no itchiness, pain, or drainage noted to site. A review of Resident 1's situation background assessment and recommendation (SBAR- is a structured communication tool that helps teams share information about the condition of a patient or team member or about another issue the team needs to address) form dated 11/6/2023 at 1:33 PM, indicated the resident had skin dermatitis [rash: redness and inflammation of the skin] to left cheek, right lower chin, and left forearm. The SBAR interventions to improve the skin condition included, Tx [treatment] as ordered, monitoring, and possible derma consult. The SBAR indicated an order received for Triamcinolone (medication used to treat a variety of skin conditions) 0.5% cream for 14 days until healed and reassess and Claritin (medication to treat allergies) 10 milligrams (mg- unit of measurement) daily for one week. A review of Resident 1's complete Medical Records for 11/6/2023, did not indicate the facility conducted a body assessment on Resident 1. A review of Resident 1's SBAR dated 11/6/2023 at 3 PM, indicated on 11/6/2023 at around 3 PM, Resident 1's physician examined the resident's skin and ordered Acyclovir (medication to treat shingles [(also known as herpes zoster, is a viral disease characterized by a painful skin rash with blisters in a localized area], a painful rash caused by a virus, that may appear as a stripe of blisters). The SBAR indicated Resident 1 had no pain but was noted with itchiness (unspecified). The SBAR indicated treatment cream administered to affected areas, and Claritin 10 mg one time (x 1) administered as ordered and same tolerated with no adverse side effect (ASE). A review of Resident 1's care plan for Resident has Left Forearm unspecified skin dermatitis dated 11/6/2023, did not indicate the size, color, or appearance of the dermatitis. The care plan interventions included facility staff to address the dermatitis included apply treatment as ordered, keep skin clean and dry, monitor effectiveness of tx (treatment), monitor any skin changes, inform MD if tx not resolved . A review of Resident 1's Health Status Note dated 11/8/2023 at 11:29 AM, indicated a physician's order to discontinue the Acyclovir. A review of Resident 1's SBAR dated 11/12/2023 at 10:46 AM, indicated, noted resident with left thigh skin scratch with 5-centimeter (cm, unit of measurement) x 0.8 centimeters (cm - unit of measurement). The SBAR interventions included to administer antiviral medications (medications help the body fight off harmful viruses). A review of Resident 1's Interdisciplinary Team (IDT, a team of health care professions who work together to establish plans of care for residents) dated 11/15/2023 at 8:47 PM, indicated, skin care treatment rendered as ordered. However, the IDT notes did not indicate if IDT discussed conducting assessment about the skin rashes for Resident 1. A review of resident 1's Health Status Note dated 11/16/2024 at 2 PM, indicated a physician's order to increase Zoloft (medication to treat depression) from 50 mg to 100 mg via gastrostomy tube (GT- a surgical procedure to insert a tube through the abdomen and into the stomach used to administer nutrition, hydration, and or medication) daily for depression manifested by (M/B) episode of crying. A review of Resident 1's admission record indicated on 11/16/2023, a diagnosis of Major Depressive Disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life) was added to Resident 1's medical record. A review of Resident 1's care plan for Resident has left thigh unspecified skin dermatitis dated 12/4/2023, indicated interventions facility staff needed to carry out to address the dermatitis included cleanse with normal saline (wound care solution) and apply Triamcinolone cream 0.05% every (Q) shift x 14 days, keep clean and dry, and monitor for signs and symptoms of infection and adverse changes. The care plan did not indicate the facility reviewed and updated the current interventions, after the 14 days of treatment with Triamcinolone cream 0.05%. A review of Resident 1's Physician Order Note dated 12/13/2023 at 1:26 PM, indicated Resident 1 to continue Zoloft due to episode of crying. A review of Resident1's IDT Progress Note-Behavior Management dated 1/5/2024 at 2:02 PM, indicated Resident 1 was referred to psychiatry services due to use of Zoloft 50 mg daily for depression manifested by (m/b) crying. Pt's (patient's -Resident 1) medication was initiated at the facility due to (d/t) intermittent episodes of crying observed by staff and family. A review of Resident 1's MD Progress Notes dated 1/9/2024 at 12:21 PM., indicated Resident 1 was diagnosed with dermatitis, noted with rashes in armpit area, and started on nystatin (medication to treat fungal infection/s) twice a day and hydrocortisone cream (medication used to reduce pain, itching, and swelling (inflammation) twice a day. The MD progress note indicated Resident 1 did not have decision making capacity. A review of Resident 1's After Visit Summary report from the outpatient clinic Neurologist (a medical doctor with specialized training in diagnosing, treating, and managing disorders of the brain and nervous system) dated 3/5/2024 at 1:15 PM, indicated the reason for the visit was nonspecific paroxysmal spell (alteration in consciousness that look like seizures) and rash, and that on 3/5/2024, the neurologist referred Resident 1 to outpatient dermatologist (doctor who specializes in disorders of the skin). A review of Resident 1's Assessment Summary note dated 3/5/2024 at 9:15 PM, indicated General Skin Conditions: Rash Itching. The note did not indicate the location and size of the rash or if a physician was notified. A review of Resident 1's care plan for The resident has rash trunk, legs, arms, armpit rash, general body rash Thin and fragile skin, initiated on 3/5/2024, indicated interventions included the facility will address the rash, avoid scratching, daily shower as tolerated, derma (dermatologist) consult, and monitor skin for signs and symptoms of infection. A review of Resident 1's Assessment Summary Note, dated 3/12/2024 at 2:04 PM, indicated General Skin Conditions: Rash Itching. The note did not indicate the location and size of the rash, or if the facility notified a physician about the itchy skin rash. A review of Resident 1's Health Status Note, dated 3/27/2024 at 1:30 PM, indicated Resident 1 left the facility to a dermatology appointment. A review of Resident 1's After Visit Summary from the outpatient clinic dated 3/27/2024 at 2 PM, indicated the reason for the visit was Scabies (an infestation of the skin where mites (small bugs) dig its way into the top layer of the skin where it will live and lay eggs). A focal skin examination was performed of the face, head, neck, chest, right upper extremity (RUE-arm), left upper extremity (LUE - arm), right lower extremity (RLE-leg), left lower extremity (LLE -leg) . Pertinent findings: -Bilateral (both) palms with erythematous papules (solid elevation of skin with no visible fluid that is reddish (erythematous) in color), single pustule (a bulging patch of skin that's full of a yellowish fluid called pus), scaly -Few linear (resembling a line) burrows in interdigital (in between fingers and toes) areas -Erythematous papules on bilateral upper and lower extremities The same After-Visit Summary further indicated the Assessment and Plan SCABIES Note: Favor scabies given clinical, also notable scybala (feces) and ovum (eggs) on mineral oil prep scraping . The same After-Visit Summary further indicated the plan included: -Start Permethrin (medication used to treat infestations of small parasites) 5 % Topical (TOP-apply to skin) Cream to entire body (include face since involved) at night today and wash off in morning - REPEAT in 7 days . -Start Ivermectin (medication used to treat diseases caused by parasites like head lice and for skin conditions) 3 mg oral (by mouth) TAB (tablet) -4 pills (12 mg) total once today -Start Triamcinolone Acetonide 0.1 % Topical (TOP) Ointment (OINT) tomorrow to affected areas except face and skin folds -Wash all bedding/clothing -Discussed that may remain itchy for 4-6 weeks after treatment. A review of Resident 1's admission record for 3/27/2023, did not indicate the scabies diagnosis was added to the resident's medical record. A review of Resident 1's care plan for The resident has rash (general body) at risk for recurrent skin problems secondary to diagnosis of diabetes, anxiety, anemia (low blood count), quadriplegia (paralysis from the neck the neck to the legs), incontinent, bedbound status, thin and fragile skin dated 3/27/2024, did not indicate the diagnosis of scabies. The care plan interventions included the facility to Deep clean room (volves cleaning objects or surfaces that may not be routinely cleaned, such as walls, ventilation ducts, curtains, carpets) [Resident 1's] after emilite application. The care plan did not have an indication for the emilite. A review of Resident 1's Infection Note dated 3/28/2024 at 2:54 PM, indicated On 3/27/24, Resident returned from doctor's appointment with orders for Ivermectin and Elimite (medication used to treat scabies). The Infection indicated Resident 1's was explained to that Resident 1 has a history of on and off rashes, and that Resident 1's physician was aware and was actively treating and addressing the resident's skin concerns. b. A review of Resident 2's Admission Record indicated the facility readmitted Resident 2 on 9/17/2023 with diagnoses that included hemiplegia and hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles) following cerebrovascular accident (damage to the brain from interruption of its blood supply), aphasia (A language disorder that affects a person's ability to communicate), dysphagia (swallowing difficulties) and type 2 diabetes (is a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel). The admission record did not indicate Resident 2 was readmitted with any skin rashes. A review of Resident 2's History and Physical (H&P) dated 10/16/2023, indicated the resident did not have the capacity to understand or make decisions. A review of Resident 2's MDS dated [DATE], indicated the resident's skin was intact with no abnormalities, rashes, or sores. A review of Resident 2's Weekly Summary: Nursing note dated 3/25/2024 at 9:49 PM, indicated General skin conditions: normal (Assessment not applicable), dermatitis. The note did not indicate where the dermatitis was located. A review of Resident 2's care plan for The resident is at risk for recurrent skin rashes, itching, skin eruption related to: dermatitis dated 12/27/2023, indicated interventions included to observe Resident 2 for skin irritations, signs and symptoms of infection, and trimming fingernails. The care plan indicated a new problem was identified on 3/26/2024 Xerosis [abnormally dry skin] skin generalized body. A review of Resident 2's Weekly Summary: Nursing note dated 3/4/2024 at 10:42 PM, indicated, General Skin Conditions: Skin Normal (Assessment Not Applicable, Dermatitis. A review of Resident 2's Weekly Summary: Nursing note, dated 3/12/2024 at 3:40 PM, indicated, General Skin Conditions: Skin Normal (Assessment Not Applicable, Dermatitis. A review of Resident 2's Weekly Summary: Nursing note dated 3/25/2024 at 9:49 PM, indicated, General Skin Conditions: Skin Normal (Assessment Not Applicable, Dermatitis. A review of Resident 2's Health Status note, dated 3/27/2024 at 12:35 PM, indicated the resident had an unspecified dermatology follow up at bedside on 3/25/2024. The note indicated new orders were received and carried out. However, the health status note did not indicate what the orders were. c. A review of Resident 3's admission record indicated the facility admitted Resident 3, on 9/9/2022 with diagnoses that included hemiplegia and hemiparesis following cerebrovascular accident and aphasia. The admission record did not indicate Resident 3 was admitted with any skin rashes. A review of Resident 3's H&P dated 7/31/2023, indicated the resident did not have the capacity to understand and make decisions. d. A review of Resident 4's admission record indicated the facility admitted Resident 4 on 7/22/2023 with diagnoses that included right femur (thigh bone) fracture (break in a bone), high blood pressure, and diabetes (elevated blood sugar). The admission record did not indicate Resident 4 was readmitted with any skin rashes. A review of Resident 4's H&P dated 7/31/2023, indicated the resident had the capacity to understand and make decisions. e. A review of Resident 5's admission record indicated the facility admitted Resident 5, on 12/14/2023, with diagnoses that included injury of the blood vessels in the head, history of falling, and muscle weakness. A review of Resident 5's H&P dated 12/15/2023, indicated the resident did not appear to have full decision-making capacity. During observation in Resident 1's room and concurrent interview with Licensed Vocational Nurse 1 (LVN 1) on 3/30/2024 10:51 AM, Resident 1 was observed with multiple tiny red spots around Resident 1's torso, arm pits, bilateral legs, arms, web of fingers, and palm of hands with burrow marks on the hands and was observed scratching areas the resident was able to reach. LVN 1 confirmed and stated Resident 1 had generalized itchy rashes and that the Treatment Nurse (TN) and IPN were the only nurses responsible to assess the resident and determine if the resident had scabies or not. LVN 1 confirmed and stated Resident 1 had all the classic symptoms of scabies (Severe itching, especially at night, is the earliest and most common symptom of scabies. A pimple-like itchy scabies rash of the body or be limited to between the fingers). During a concurrent observation In Resident 2's room and interview with Certified Nurse Assistant 3 (CNA 3) on 3/30/2024 at 11:26 AM, CNA 3 stated Resident 2 has had itchy skin rashes for several months. Resident 2 was observed scratching the resident's abdominal area where the resident could reach. Resident 2 had tiny red spots to chest, back, abdominal area, waist thighs, legs, between webs of feet & hands, and arms. Resident 2 also observed with scarring like marks from scratching as well as burrowing (to make a hole or tunnelling) on the resident's hands and feet. During an interview and concurrent record review with TN 3/30/2024 at 12:11 PM, Resident 1's medical chart was reviewed. TN stated there was a Change in Condition (COC) for generalized body rash on 3/28/2024 for Resident 1. TN stated a dermatologist evaluated Resident 1 on 3/27/2024 and ordered Ivermectin oral medication and Permethrin to be applied on Resident 1. The TN stated that the order indicated to administer to Resident 1per physician's request. TN stated that she (TN) would have questioned the order because every order needs to have an indication/diagnosis. TN stated that that the order should have been questioned because the regimen ordered was for scabies. TN stated contact isolation (are steps that healthcare facility visitors and staff need to follow before going into a patient's room) must be placed as soon as suspicions for scabies arise. TN admitted there were neither prophylactic treatments for Resident 1's roommate nor skin assessments completed. There was no documented evidence of scraping orders for Resident 1 of which TN stated would have increased further spread to other residents not only in Resident 1's roommates, but for other residents though staffing working other unaffected residents. TN stated the treatment nurse should have assessed the other residents because scabies is highly contagious. During a telephone interview with the IPN on 3/30/2024 at 12:54, IPN stated that Resident 1 had an ongoing rash on and off but does not recall how long ago it started. IPN stated that she (IPN) had assessed Resident 1 after the 3/27/2024 appointment and noted that she (Resident 1) had scattered rashes under armpits and back. IPN admitted that she (IPN) had not assessed the hands to check in the web of fingers and hands where the burrowing was mostly located. IPN admitted that every medication ordered must have a diagnosis to be a complete order per nursing professional standards. Stated that Resident 1 should have been isolated right away to prevent further spread to other residents as well as staff. IPN stated that symptoms of scabies included: itching, scattered rashes, crevices, hands, folds, crusting. IPN admitted that the primary physician should have been notified and scrapings ordered. During a telephone interview with Family Member 1 (FM 1) on 4/1/2024 at 9:45 AM, FM 1 stated that FM 1 had noticed the rash to Resident 1's left upper arm and thought the rashes were bug bites. FM 1 stated Resident 1 has been scratching intensely and cried a lot. FM 1 stated that before long, the rashes had spread to Resident 1's whole arm, and that the facility's in house dermatologist had evaluated Resident 1. FM 1 stated that in 11/2023, facility staff (unidentified) contacted FM 1 and told FM 1 that Resident 1 had shingles. FM 1 stated two days later, FM 1 received another call by facility staff (unidentified) notifying FM 1 that the rashes on Resident 1 was not shingles. FM 1 stated the facility staff informed FM 1 that the facility did not know what the rashes were and would start applying hydrocortisone. FM 1 stated, IPN told FM 1 that the facility did not have a dermatologist to evaluate Resident 1. FM 1 stated she was shocked. FM 1 stated that on 3/5/2024, FM 1 brought Resident 1 for neurologist appointment. FM 1 stated the neurologist made a dermatology appointment concerning scabies for Resident 1. FM 1 stated that on 3/7/2024, the dermatologist scraped Resident 1's skin and confirmed that Resident 1 had scabies. FM 1 stated that when Resident 1 returned from the dermatologist appointment, FM 1 gave the Social Services Director (SSD) and IPN copies of Resident 1's positive scabies results as well as the physicians notes, and it was then that the IPN included the diagnosis for scabies on Resident 1's medical chart. During a telephone interview with the facility's MD on 4/1/24 at 5:35 PM, MD stated the facility informed the MD two at 3:35 PM, that Resident 1 had scabies. MD stated nursing staff should have notified Resident 1's Primary Care Physician (PCP) as well as the facility's MD as soon as possible, that Resident 1's generalized itchy skin rashes were not responding despite administering acyclovir and nystatin. MD stated dermatology consults must be made and followed up within a few hours or days to prevent Resident 1 from suffering. During an interview with Registered Nurse Supervisor (RNS) on 4/2/24 at 12:48 PM, RNS stated that scabies is very infectious and serious diagnosis which needs to be reported to the PCP, and properly assessed. RNS stated the signs and symptoms of scabies includes itchiness, red spots on the back, chest areas, web of fingers (covered areas). RNS stated scabies are diagnosed by skin scraping. During an interview with DON on 4/2/24 at 1p.m., DON confirmed and stated that the facility did not implement the skin assessment policy, the facility did not routinely conduct assessment of residents' skin. The facility's P&P titled NOTIFICATION OF CHANGES, revised 3/2023 was reviewed with the DON. The P & P indicated: 1. The facility notifies the physician and resident representative of: b. 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). The facility's P&P titled DEVELOP-IMPLEMENT COMPREHENSIVE CARE PLANS, revised, 3/2023, was reviewed with the DON. The P & P, indicated, The facility develops a person-centered comprehensive care plans that are culturally competent and trauma-informed, developed and implemented to meet his or her preferences and goals, and address the resident's medical, physical. mental and psychosocial needs. The guidelines included the following: The facility must establish, document and implement the care and services to be provided to each resident to assist in attaining or maintaining his or her highest practicable quality of life. The facility's P&P titled SKIN ASSESSMENT, revised 3/2023, was reviewed with the DON. The P & P indicated, To provide guidelines for routine assessment of residents' skin to maintain skin integrity and promote healing in accordance with standard of care practice guidelines. The same P&P indicated, skin observations may be documented according to facility preference on a Weekly Summary, narrative documentation or an assessment developed specifically for the skin.

Based on observation, interview, and record review, the facility failed to ensure one of one sampled residents (Resident 6) received appropriate services to prevent further decline in range of motion to both legs and provided services to prevent decline in range of motion to both arms by failing to: 1) Perform a Rehabilitation (Rehab) Joint Mobility Assessment (brief assessment of a resident's range of motion in both arms and both legs) to assess Resident 6's range of motion upon admission to the facility on [DATE]. 2) Accurately assess and monitor Resident 6's range of motion quarterly, since admission to the facility on [DATE], and 3) Provide range of motion services or equipment to ensure Resident 6 did not experience further range of motion decline in both arms and both legs after a Rehab Joint Mobility Screening on 4/23/2021. These deficient practices resulted in Resident 6, who was admitted to the facility on hospice care (specialized care designed to give supportive care to people in the final phase of a terminal illness with a focus on comfort, quality of life rather than cure, and free of pain to live each day as fully as possible), to experience a decline in range of motion, including worsening contractures (deformity and joint stiffness) to both legs and limited range of motion in both arms, resulting in moderate to severe pain in both arms and both legs. Findings: A review of Resident 6's Admission Record indicated Resident 6 was admitted to the facility on [DATE] with hospice services (specialized care designed to give supportive care to people in the final phase of a terminal illness with a focus on comfort, quality of life rather than cure, and free of pain to live each day as fully as possible). Resident 6's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 6's Minimum Data Set (MDS - an assessment and care screening tool), dated 4/22/2020, indicated Resident 6 had no impairments in range of motion in both arms and both legs. A review of Resident 6's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 6's MDS, dated [DATE], indicated Resident 6 had no functional range of motion impairments in both arms, but had impairments in both legs. According to a review of the Rehab Joint Mobility Screening, dated 4/23/2021 (over one year after admission), Resident 6's range of motion in both shoulders, elbows, wrist and fingers were within functional limits (sufficient joint movement to functionally complete daily routines). Resident 6 had severe (more than 50% loss of range of motion in that joint) loss of motion in the left hip, moderate (26-50% loss of range of motion in that joint) loss of motion in the right hip, moderate loss of motion in the left knee, and severe loss of motion in the right knee. The Rehab Screening form indicated there were no recommendations for a Physical Therapy Evaluation (PT, profession aimed in the restoration, maintenance, and promotion of optimal physical function), Occupational Therapy Evaluation (OT, profession aimed to increase or maintain a person's capability of participating in everyday life activities [occupations]) or a Restorative Nursing Assistant (RNA - nursing aide program that helps residents to maintain their function and joint mobility) / Functional Maintenance Program. Resident 6's Rehab Joint Mobility Screening form indicated the resident was In hospice and no skilled services needed at this time. Comfort care only. A review of Resident 6's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation on 7/27/2021, at 9:58 AM, in Resident 6's room, Resident 6 was lying in bed with both hips and knees in a bent position. Resident 6's knees were positioned at chest-level. During an interview on 7/27/2021, at 10:22 AM, Occupational Therapist 1 (OT 1) stated Resident 6 did not have any contractures or limited range of motion in either arm during the Rehab Joint Mobility Screening on 4/23/2021. OT 1 stated Resident 6 was very debilitated but could have benefited from skilled therapy services if Resident 6 was not on hospice services. During a telephone interview on 7/27/2021, at 1:36 PM, Physical Therapist 1 (PT 1) stated Resident 6 was on hospice upon admission to the facility which indicated the resident was not appropriate for skilled therapy services. PT 1 stated a RNA was not recommended after the Rehab Joint Mobility Screening on 4/23/2021 since Resident 6 was comfortable in bed. PT 1 stated range of motion and splints (material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion) were not recommended because the therapist would need to monitor Resident 6 for pain tolerance due to the contractures in both legs. PT 1 stated there were no documented recommendations to ensure Resident 6 did not continue to experience a decline in range of motion in both legs. On 7/27/2021, at 1:50 PM, during an interview, the Interim Director of Rehabilitation (Interim DOR) stated the rehabilitation staff performed a Rehab Joint Mobility Screening upon any resident's admission to the facility, readmission to the facility, and annually if resident remained at the facility. The Interim DOR stated Resident 6 should have received but did not receive a Rehab Joint Mobility Screening upon admission to the facility on [DATE]. The Interim DOR stated Resident 6 did not have a baseline assessment for range of motion in both arms and both legs upon admission to the facility and that nursing would report if Resident 6 had a decline in range of motion, since Physical Therapy and Occupational Therapy did not perform Rehab Joint Mobility Screens quarterly. The Interim DOR then stated nursing was not trained in measuring range of motion for the residents. During an interview and record review on 7/28/2021, at 2:43 PM, in the MDS office, the facility's MDS staff (MDS 1 and MDS 2) stated they did not assess the residents for their range of motion. MDS 1 and MDS 2 stated that they used information from a resident's Joint Mobility Screen, which was performed by the rehabilitation staff, to input the information in the MDS for functional limitation in range of motion. MDS 2 stated Resident 6's MDS assessment, dated 4/22/2020, was inaccurate since Resident 6 had contractures in both legs when admitted to the facility. MDS 2 stated Resident 6's quarterly MDS assessments, dated 7/20/2020 and 10/19/2020, and 1/18/2021, were also inaccurate due to contractures in both legs. During an observation on 7/28/2021, at 9:34 AM, in the resident's room, Resident 6 was observed lying in bed with both hips and knees bent. Resident 6's right knee was at chest-level with an approximately 6-inch space between the resident's chest and knee. OT 1 performed a Rehab Joint Mobility Screen and evaluation with Resident 6. During the observation, OT 1 extended and bent each knee to measure Resident 6's range of motion. Resident 6 verbalized, mucho dolor or severe pain, upon extension of each knee. During the observation, OT 1 also measured the range of motion in both arms. Resident 6 complained of pain in the left shoulder while OT 1 measured the range of motion. During an interview on 7/28/2021, at 9:59 AM, OT 1 stated Resident 6 had contractures in both hips and knees and had limited range of motion in both shoulders and both elbows. OT 1 stated Resident 6 had moderate pain with all motion due to verbalization of pain and resistance with movement but had more pain in the legs than the arms. In a follow-up interview on 7/28/2021, at 10:51 AM, OT 1 stated Resident 6's range of motion had gotten worse in both shoulders and elbows since the Rehab Joint Mobility Screening on 4/23/2021. During an observation on 7/28/2021, at 11:35 AM, in the resident's room, Physical Therapist 2 (PT 2) performed a Rehab Joint Mobility Screen and evaluation with Resident 6. Resident 6 was lying in bed with a small blue pillow in-between the legs. PT 2 measured Resident 6's range of motion in both legs. Resident 6 continued to complain of knee pain with motion and rubbed the left knee when asked if there was any pain. In a follow-up interview on 7/28/2021, at 12:04 PM, PT 2 stated that Resident 6's left knee motion had worsened since the Rehab Joint Mobility Screening on 4/23/2021. PT 2 stated Resident 6 complained of pain upon movement and felt Resident 6 was reluctant to move. On 7/28/2021, at 12:29 PM, during a telephone interview, Family 1 stated Resident 6 had contractures in both knees upon admission to the facility. Family 1 stated the family would not have objected to the facility providing range of motion since Resident 6's knees were positioned up against the resident's body. During an observation and interview on 7/28/2021, at 1:08 PM, in the resident's room, Family 1 stated Resident 6's range of motion in both legs had gotten worse while at the facility. Family 1 stated the facility needed to position a pillow between Resident 6's legs since they tend to seal together, which pushed the knees together at midline. Family 1 stated Resident 6 used to be able to raise her arms but noticed both arms have gotten tighter since being at the facility. A review of the facility's policy titled, Restorative Nursing Program Guidelines, revised 7/1/2015, indicated A resident may be started on a Restorative Nursing Program: A. Upon admission to the Facility with restorative needs, but is not a candidate for formalized rehabilitation therapy; B. When restorative needs arise during the course of a longer-term stay. During an interview and policy review on 7/28/2021, at 3:38 PM, the Director of Nursing (DON) stated contractures were painful due to restrictive movement. The DON stated it was important to address contractures since they can lead to other problems, like circulation, repositioning, and mobility. The DON stated RNA services could maintain functional mobility and prevent contractures with residents and residents with high risk of contractures, including residents who were bed bound, would benefit from RNA services. The DON stated hospice residents were provided the same care as all the other residents in the facility except if there was restriction on care from the family. The DON reviewed the facility's policies titled, Restorative Nursing Program Guidelines, and Range of Motion Exercise Guidelines, revised 7/1/15 and stated the facility policies did not exclude hospice residents from receiving RNA services and/or range of motion. During an interview and record review on 7/28/2021, at 3:58 PM, with the Interim DOR, Regional Rehab Mentor, and DON who agreed that Resident 6 should have been seen for a Rehab Joint Mobility Screen upon admission to the facility, since Resident 6 had contractures to both knees. The Interim DOR, Regional Rehab Mentor, and DON stated if Resident 6 received an initial Rehab Joint Mobility Screen, then Resident 6 could have been provided with splints or range of motion to prevent further contracture. There was no documented evidence that the facility was accurately monitoring Resident 6's range of motion from admission on 4/13/2020 to Rehab Joint Mobility Screen on 4/23/21. The DON reviewed Resident 6's Rehab Joint Mobility Screen, dated 4/23/2021, and stated Resident 6's moderate to severe range of motion limitations to both legs should have been addressed. The DON stated that RNA services should have been recommended, which could have been communicated to the nurse who would then communicate with the hospice company. A review of the Rehab Joint Mobility Screening, dated 7/28/2021, indicated Resident 6 had minimal loss (less than 25% loss) of motion in the both shoulders, minimal loss of motion in both elbows, severe loss of motion in both hips, and severe loss of motion in both knees. Resident 6 had limited range of motion in both arms and worsened range of motion in the right hip and left knee. Recommendations included a PT and OT evaluation and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview and record review on 7/28/2021, at 3:58 PM, the DON reviewed Resident 6's Rehab Joint Mobility Screening, dated 7/28/2021 and stated Resident 6's range of motion loss in both arm and both legs was avoidable because the facility did not implement proper preventative measures. During an interview on 7/29/2021, at 9:19 AM, in the facility's conference room, Physician 1 stated he was aware of Resident 6's contractures in both arms and both legs. Physician 1 stated Resident 6 screamed in pain from the arm contractures when Physician 1 tried to extend the resident's elbows to perform a physical examination of the chest. During a follow-up telephone interview on 7/29/2021, at 1:37 PM, Physician 1 stated being 100% opposed to Resident 6 having any range of motion services since it would cause pain. Physician 1 was unable to provide a standard of practice regarding the risks of providing range of motion to residents under hospice care.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), who was diagnosed with [REDACTED]. (elevated blood sugar) status, and failed to follow facility policy on Blood Glucose Monitoring (amount of sugar in the blood). Resident 1 had an elevated blood glucose level of 410 mg/dl (normal 80 - 100) on [DATE], which was not reported to the physician. The resident was found unconscious, transferred to the General Acute Care Hospital (GACH), where she was diagnosed with [REDACTED]. Findings: On [DATE] an unannounced visit was made to the facility to investigate a complaint regarding quality of care and treatment. A review of the Admission Record indicated Resident 1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 1's Care Plan for [MEDICAL CONDITION] related to diabetes mellitus was initiated on [DATE]. The care plan goal indicated resident was to have no complications related to diabetes through the review date of [DATE]. The interventions indicated to give medication as ordered by doctor, monitor/document side effects and effectiveness and to monitor/document and report to the physician signs and symptoms of [MEDICAL CONDITION] (frequent urination, weight loss, dry skin, poor healing, stupor and coma). The Care Plan did not address notifying the physician when the blood sugar was above 401mg/dl, nor did it address checking the blood sugar prior to transportation. A review of the physician's orders [REDACTED]. According to a review of the Minimum Data Set (MDS - a standardized assessment and care screening tool) dated [DATE], Resident 1 was assessed as having no speech, rarely/never able to understand and rarely/never able to be understood. The MDS indicated Resident 1 received insulin (a hormone made by the pancreas that allows your body to use sugar (glucose) from carbohydrates in the food that you eat for energy or to store glucose for future use) six of the last seven days. A review of the Weights and Vital Summary form indicated on [DATE] at 6:38 a.m., Resident 1's blood sugar was 410 mg/dl. A review of the Progress Note dated [DATE] indicated the physician was not notified of Resident 1's high blood glucose of 410, per physician's orders [REDACTED].>During an interview and concurrent record review with the Director of Nursing (DON) on [DATE] at 3:10 p.m., she stated she could not find in the medical record where the physician was notified regarding Resident 1's 410 mg/dl blood sugar on [DATE]. A review of the Weights and Vital Summary form indicated from [DATE] at 10:56 a.m. - [DATE] at 8:39 p.m., Resident 1's blood sugar ranged from 311 - 374 mg/dl. A review of the Weights and Vital Summary form dated [DATE] indicated Resident 1's blood sugar was 350 mg/dl at 9 p.m. A review of the SBAR - Change of Condition Progress Note dated [DATE] at 10:50 p.m., indicated the respiratory therapist (RT) found Resident 1 unresponsive and immediately checked vital signs (blood pressure, pulse, temperature). The RT noted oxygen saturation (O2 sat, amount of oxygen in the blood) was low at 56% (normal between 80 and 100%), was unable to appreciate vital signs (obtain) at first attempt, as Resident 1 was found with cold, clammy skin. The SBAR form indicated Resident 1 was immediately bagged at 100% oxygen (a hand-held device commonly used to provide positive pressure ventilation to patients who are not breathing or not breathing adequately) which increased to 80%, but later dropped again. The RT was unable to wake Resident 1 who had a pulse rate reading of 0, heart rate reading of 0 and blood pressure reading of 0. The SBAR form indicated Cardiopulmonary Resuscitation (CPR) was started and resident revived, was able to open eyes, gags when suctioned, responds to stimuli, still could not appreciate vital signs, skin cold and clammy, bagged until paramedics arrived. Further review of the SBAR - Change of Condition Progress Note dated [DATE] indicated Instructions / Preparation on the SBAR were to evaluate finger stick glucose if indicated. A review of the Progress Notes indicated on [DATE] at 10:50 p.m., Resident 1 was bagged until paramedics arrived at 11:02 p.m., and took over. The progress note indicated Resident 1 was transferred to the General Acute Care Hospital (GACH) for further evaluation of altered level of consciousness. According to a review of the Emergency Documentation from the GACH, dated [DATE] at 11:29 p.m., Resident 1's chief complaint was altered level of consciousness (ALOC) and respiratory distress. The Subjective Nursing Assessment indicated Resident 1's last known well time (LWKT) was at 9 p.m. The document indicated Resident 1 was bagged (provided oxygen) by trachea (windpipe, allowing passage of air) and was not responsive. Two antibiotics were given for possible infection. No urine obtained on indwelling Foley catheter due to dehydration and found to be in acute [MEDICAL CONDITION] (kidneys unable to filter waste from blood) with [MEDICAL CONDITION] (increased potassium level in blood) for which calcium was given. Intensive Care Unit (ICU) consulted and Resident 1 was accepted into ICU. A review of the Emergency Documentation - MD Critical Care Note, dated [DATE] at 12:42 a.m., indicated Resident 1 had a critical condition, impending deterioration including: airway, cardiovascular (heart system), metabolic and renal with the associated risks factors of [MEDICAL CONDITION] (low blood pressure), metabolic changes, dehydration and acidosis (process causing increased acidity in the blood and other body tissues). The Emergency Documentation - MD Critical Care Note impression indicated Diabetic Ketoacidosis (DKA complication of diabetes the body produces excess blood acids), Acute Kidney Injury, [MEDICAL CONDITION] infarction (a [MEDICAL CONDITIONS] (high potassium in the blood). The Hospital Course indicated no surgery planned related to too unstable, seen by cardiology with no intervention due to too unstable, received blood transfusion, unstable for any other procedures. A review of the GACH Discharge Summary, dated [DATE] at 2:56 p.m., indicated the Discharge [DIAGNOSES REDACTED]. Patient was on ventilator support but [MEDICAL CONDITION] (a potentially life-threatening condition caused by the body's response to an infection) and expired despite maximum supportive measures. During an interview and concurrent record review of the medical record with the Director of Nursing (DON) on [DATE] at 3:12 p.m., she stated the physician should have been notified of Resident 1's elevated the blood glucose of 410 on [DATE]. The DON further stated the nurse may not have had time to take the blood glucose but agreed the blood glucose should have been taken prior to transport to the GACH. During an interview, on [DATE] at 4:20 p.m., the DON stated the SBAR documents were located in a different office, which indicated the physician was notified. These SBAR documents were not kept in Resident 1's medical record. The facility's policy and procedure titled, Diabetic Care, dated [DATE], indicated the purpose was to provide a protocol for the immediate treatment of [REDACTED]. The purpose indicated to improve the quality of care delivered to residents with diabetes. The policy procedure indicated, in any case where the resident's blood sugar was less than 70 mg/dl or greater than 350 mg/dl the Attending Physician must be notified; unless noted on the physician's orders [REDACTED].>The facility's policy and procedure titled, Blood Glucose Monitoring, dated [DATE], indicated the licensed nurse will perform the blood glucose testing as ordered by the physician utilizing the instructions from the testing device. The Attending Physician will be notified of a blood sugar level (BSL) lower than 70 mg/dl or greater than 350 mg/dl, unless otherwise indicated in the plan of care.

Based on observation, interview, and record review, the facility failed to ensure one of five sampled residents (Resident 142) recovering from a stroke (occurs when a blood vessel that carries oxygen and nutrients to the brain is either blocked by a clot or bursts or ruptures) and [DIAGNOSES REDACTED] (a mass or growth of abnormal cells in your brain), with no documented history of [MEDICAL CONDITION] (a mental disorder characterized by a disconnection from reality) was started at the facility on [MEDICAL CONDITION] drugs (any drug capable of affecting the mood, emotions and behavior) had a clinical rationale for initiation or continued use. The facility failed to: 1) Adequately assess Resident 142; 2) Document specific behaviors related to a diagnosed condition; 3) Determine if less restrictive interventions were effective; 4) Monitor and prevent potential adverse reactions (unwanted, uncomfortable, or dangerous effects which may impair the resident's ability to function at their highest possible level of physical, mental, and psychosocial well-being); and 5) Attempt a Gradual Dose Reduction (GDR) or provided clinical justification for the continued use of [MEDICATION NAME] (an atypical antipsychotic used to treat certain mental/mood disorders; with common adverse reactions that included sedation, dizziness, [MEDICAL CONDITION] (low blood pressure; less than 90/60), constipation, nausea, vomiting, abdominal pain, dyspepsia (abdominal pain and a feeling of fullness soon after starting to eat) anxiety, and fatigue) and [MEDICATION NAME] (an antidepressant indicated for the treatment of [REDACTED]. These deficient practices caused Resident 142 to experience adverse reactions while taking [MEDICAL CONDITION] medications ([MEDICATION NAME] and [MEDICATION NAME]). Resident 142 had large amount of coffee ground emesis, [MEDICAL CONDITION] (low blood pressure, normal blood pressure is 120/80) at 82/47, and was transferred to a general acute care hospital (GACH) on 2/23/19, three months after admission to the skilled facility. Findings: A review of Resident 142's admission record indicated the resident was self-responsible and was originally admitted to the facility on [DATE], and readmitted on [DATE], with continued diagnoses that included, but were not limited to, [MEDICAL CONDITION] and [MEDICAL CONDITION] (paralysis and weakness of one side of the body) following cerebral infarction (stroke) affecting left dominant side, [MEDICAL CONDITION] (changes in the brain's electrical activity), morbid (severe) obesity due to excess calories, hypertension (high blood pressure), [MEDICAL CONDITION], and new diagnoses of [MEDICAL CONDITION] (a mental illness that is characterized by disturbances in thought (such as delusions), perception (such as hallucinations), and behavior (such as disorganized speech)), with an onset date of 3/5/19, major [MEDICAL CONDITION] with an onset date of 10/12/19, and [MEDICAL CONDITION] with an onset date of 10/12/19. A review of Resident 142's Minimum Data Set (MDS - a resident assessment and care screening tool), dated 9/30/19, indicated Resident 142's Brief Interview for Mental Status (BIMS) was 14 (BIMS scores between 13-15 indicated resident has intact cognition and was interviewable). The MDS indicated Resident 142 required supervision with one-person physical assistance for eating, extensive assistance with one-person physical assistance for dressing, and was totally dependent upon the facility requiring one to two-person physical assistance for transfer, locomotion on or off the unit in a wheelchair, toilet use and personal hygiene. The MDS indicated, under Behavior, Potential indicators of [MEDICAL CONDITION] was marked as None of the above. On 10/31/19 at 12:23 p.m., during an observation and concurrent interview, Resident 142 was observed awake lying on his back in bed. Resident 142 stated, I am not doing that good. I get confused. I would like to go home, but have not talked to my doctor about my status. I am here because of a stroke I had two weeks before Thanksgiving last year (11/2018) and I have been here ever since. I was a home care worker. I took care of my grandmother, mother, and nephew. I am in limbo right now and do not know what is going on. I have never had a history of [REDACTED]. I was never diagnosed with [REDACTED]. It was just that day I went out and fell . I have put in a request to see the doctor. My doctor is (MD 1). I have not seen my doctor in eight or nine months. I saw the person he sent over here about a month ago and he stayed a few minutes and left. He has not been back since. I have been here a year. I am taking [MEDICATION NAME] for pain and high blood pressure medications. I requested bowel movement medication because I lay in this bed and cannot move or do anything. I cannot go anywhere and in constant pain. It hurts to have a bowel movement. It is like labor pain. I request the laxative from the charge nurse and after they give it to me I am okay. I am in pain right now, but have not seen anyone to ask for the 'poo poo' medicine. That is what I call it. I am between a rock and a hard plate. I can move my right arm, but not my left arm that well. During the interview, Resident 142 was asked if he was able to use his call light to notify the nurse of his discomfort, and the resident stated, Where is my call light? After looking around the resident's bed the call light was observed on the floor and the resident stated, I cannot reach that. The call light was picked up and handed to the resident and he pushed the button. On 10/31/19 at 12:42 p.m., during an observation, a registered nurse (RN 2) and a certified nurse assistant (CNA 2) entered Resident 142's room and the resident stated that he had pain in his behind. RN 2 and CNA 2 repositioned the resident and asked if that helped. Resident 142 stated, No, that the repositioning did not help. On 10/31/19 at 12:44 p.m., during an observation, in the presence of RN 2 and CNA 2, a licensed vocational nurse (LVN 1) entered Resident 142's room and asked if the resident needed to be repositioned. Resident stated, I am constipated. I want the liquid medication. LVN 1 stated, I will give you the [MEDICATION NAME] medication. RN 2 asked the resident if he was having a hard time having a bowel movement and if his stomach was hard. Resident 142 stated yes to both questions. On 10/31/19 at 12:48 p.m., during an observation, in the presence of RN 2, LVN 1 prepared and administered [MEDICATION NAME] to Resident 142. On 10/31/19 at 12:57 p.m., during an observation, LVN 1 prepared and administered Resident 142's laxative medication ([MEDICATION NAME]). On 10/31/19 at 1 p.m., during an interview and concurrent observation, Resident 142's lunch arrived. Resident 142 stated, Breakfast is the best. Lunch and Dinner they give you bread, pasta, and rice. All of those are sticky and makes your stomach tight. I do not move and the food doesn't go anywhere. I eat my vegetables but they do not give enough of it. That cheese and pasta stops you up. I like tuna. They do not give me what I like all the time. See that big bread. Observed on Resident 142's lunch tray included ham, a bread roll, potatoes, broccoli, carrots, a cookie, and milk. On 10/31/19 at 1:06 p.m., during an interview, CNA 2 stated, Every morning he (Resident 142) calls me to give me a banana. It does not bother me when he calls to me. He will say, 'Can you fix my pillow under my head or my leg.' He only calls me when he needs me to assist him with something. A review of Resident 142's GACH History and Physical (H&P)'s Team Report and Goals, dated 11/28/18, timed at 10 a.m., indicated the resident's prior level of function was living with family, ambulating with a cane, retired, independent for ADLs (activities of daily living, eating, dressing, walking, and personal hygiene), and was alert and oriented times 3-4 (forgetful at times with no new neuro deficits noted). Anticipated discharge to skilled nursing facility (facility). A review of Resident 142's GACH discharge orders to the SNF, dated 11/29/18, indicated discharge diagnoses of acute spontaneous hypertensive right basal ganglia hemorrhage (common form of a stroke) craniotomy (surgical removal of part of the bone from the skull to expose the brain) for hematoma evacuation (a surgical procedure to remove a subdural hematoma (SDH) - a pooling of blood on the brain) on 11/13/18, hypertension (stable), and acute [MEDICAL CONDITION]. With past medical history, documented as Diabetes mellitus (high blood sugar levels) and obesity. Hospital course indicated, Will need continued dedicated PT (physical therapy)/OT (occupational therapy)/ST (speech therapy). Stable for discharge to the facility. There was no documentation of [MEDICAL CONDITION] or an order for [REDACTED]. A review of Resident 142's primary care physician at the facility (MD 1) initial H&P, dated 11/30/19, indicated by documentation that the resident was seen and examined by MD 1 and documented, This resident has the capacity to understand and make decisions. MD 1 signed and dated the form. A review of Resident 142's Initial Psychiatric Evaluation, date of visit 12/27/18, chief complaint was documented as, New Evaluation The patient is alert and oriented times two, easily agitated, irritable complaining of seeing some objects on the walls occasionally. Has a history of [MEDICAL CONDITION]. Continues to feel depressed and helpless . Past Psych history: Paranoid [MEDICAL CONDITION] . See H & P New Medication Order: Start [MEDICATION NAME] 1 mg by mouth twice a day. The Initial Psychiatric Evaluation did not include documentation of less restrictive therapy attempted or nonpharmacological (non-drug therapy) interventions attempted prior to initiating antipsychotic drug therapy after Initial (first) Psychiatric Evaluation of Resident 142. The Initial Psychiatric Evaluation was signed and dated 12/27/18, however the provider's name and title were not provided on the evaluation to clearly identify who had evaluated the resident. A review of Resident 142's Nursing Progress Notes, dated 12/27/18, timed at 12:45 p.m., indicated, Resident seen and evaluated by psychiatrist with new orders noted and carried out. Per psyche evaluation 'resident noted with behavior of seeing objects on the walls' will continue to monitor resident. A review of Resident 142's Psychologist behavioral health report, dated 7/10/19, indicated no previous psychotherapy. The report indicated, Patient denied any history of substance abuse and/or psychiatric hospitalization . Patient has history of [MEDICAL CONDITION] but initial [DIAGNOSES REDACTED]. Thought process - Normal, orientation to person, place, and purpose, memory - fair, speech quality - good, speech rate - good, appearance - appropriate. Patient was alert and verbally expressive when prompted. Did not provide any unsolicited responses. Report indicated target symptoms were depression and frustration due to adjustment difficulty to illness, decline, and loss. Report indicated approaches to include providing simple concrete explanations when conducting care and procedures for Resident 142. To provide low-stimulation environment and encourage participation in pleasant activities. Summary of report indicated, Patient has adequate alertness, language skills, and concrete thinking . On 10/31/19 at 3:03 p.m., during a review of Resident 142's clinical records and during a concurrent interview in the presence of the Medical Records Director (MRD) and RN 1, the medical records staff (MR 1) provided the resident's overflow records. After reviewing Resident 142's original history and physical (H & P), dated 11/30/19, MR 1 stated, No [DIAGNOSES REDACTED]. RN 1 stated, I do not see any [MEDICATION NAME] for him on admission. MRD agreed and stated, admission orders [REDACTED]. On 10/31/19 at 3:26 p.m., during an interview with LVN 1, LVN 1 stated, His (Resident 142's) episodes are calling for something. He yells for help. He is not able to ambulate or move for himself. He can only move his right side. Left side is the weakest. Sometimes he wants someone to talk to him. He likes to get up. He stays in his room. He said he is constipated, but he pooped about 6 a.m. Yesterday he had a bowel movement. I offered to reposition him and then give pain medication, [MEDICATION NAME]. It is possible the pain medication contributes to the pain of constipation. On 11/1/19 at 8:17 a.m., during an observation and concurrent interview, Resident 142 was observed sitting up in bed with the breakfast tray. On the tray was partially eaten eggs, sausage, and oatmeal. Resident 142 stated that he felt a little better this morning and would like to have more physical therapy. On 11/1/19 at 9:37 a.m., during an interview with the Director of Rehabilitation Physical Therapist (DOR), the DOR stated, Resident 142's physical therapy (PT) was discontinued on 8/5/19. The DOR stated, He (Resident 142) had a stroke and we wanted to help prevent him from further decline and he was very motivated. When he was sitting up in the wheelchair he was very motivated. His mood was better because he was not in the bed and not as dependent on the nursing staff. He was able to come out and socialize when he was in the wheelchair. I believe it had a good benefit on him psychologically as well and he had a more positive attitude. Then he was discharged to RNA (Restorative Nursing Assistant) and he gets daily ROM (range of motion) exercise for his upper and lower extremities for about 15 minutes a day. RNA is done in bed. The CNA's and nursing staff were in-serviced on getting the resident out of bed. The physician orders are only for ROM and a splint for his left leg. There are no physician orders for him to get out of bed and we know he would benefit. He did not want to get out of bed daily, but three times a week would have been okay. There is no wheelchair designated for him. There is a wheelchair available on the floor for him to use. It was our expectation for the RNAs to continue to assist the resident in getting him up and out of bed with the use of the Hoyer lift. It is important for him to get out of bed at least a few days each week to maintain his ROM, prevent pressure sores, continue his tolerance for sitting in the wheelchair, and have a positive effect on his social interaction, and increase positive attitude. He is happy being in the wheelchair. If he does not get up he is at risk of social isolation and maybe depression. The DOR further stated, Frustration is part of the process when a resident has a stroke and no longer can walk. Yelling, getting angry, refusing care are symptoms that come with patients that are now bound to a wheelchair. We can try to redirect him to positive aspects of what he can still do, like feed himself, change his upper body clothes, and redirect him to positive aspects of recovery or rehabilitation. This is a very common encounter with residents. We cannot change his past, but we can try and work with him to improve his quality of life and what he is still able to do now. On 11/1/19 at 10:34 a.m., during an interview, CNA 3 stated she has had Resident 142 a lot of times and he has never yelled at her. CNA 3 stated, Yesterday he was not feeling okay. He was tired. He was so sleepy that day. Usually he is really sleepy. He sleeps quite a bit during the day . He calls out when he needs help. He does not use the call light. He always calls our name .I have never seen him talking to himself or seeing things not there. He understands and his conversations are clear. He responds appropriately. He calls us when his bed controller falls on the floor and he wants me to get it for him or when he needs a diaper change. He only calls when he needs something. It does not bother me when he calls and ask for help. On 11/1/19 at 12:39 p.m., during an interview and concurrent record review of Resident 142's Initial Psychiatric Evaluation, dated 12/27/18, the Social Services Director (SSD) stated the resident was seen by the Physician Assistant (PA 1) of the Psychiatrist (MD 2). The SSD stated the PA 1 wrote a new order of [MEDICATION NAME] for Resident 142. The SSD stated, I do not have the answer to if the Psychiatrist (MD 2) saw the resident since admission. A review of Resident 142's Physician's Progress Records indicated on: -12/19/18, untimed, Pt sleeping, easily aroused. States he's cold and asking for a blanket. -12/24/18, untimed, Pt lying in bed resting. Doing well. -12/25/18, untimed, Eating 100 % pureed. -12/26/18, untimed, Pt complaint of being cold, No new concerns. Requesting breakfast. -12/27/18, at 9:35 a.m., Complaint, no BM (bowel movement) for two days. No new acute issues per nursing staff. -12/31/18, untimed, Pt eating breakfast. Eating 100 % -1/1/19, untimed, Pt sleeping, easily aroused. No complaints. -3/6/19, untimed, Pt (patient/resident) claims he's upset because he can't go anywhere. States he wants to walk. Denies any pain, SOB (shortness of breath), no other problems. -3/11/19, untimed, Pt sleeping easily aroused. No new concerns. -3/13/19, untimed, Pt states not fully okay, denies pain, but seems tired. -8/14/19, untimed, No acute issues per staff. Stable, [MEDICATION NAME], continue current dose. Dose reduction contraindicated at this time as will likely lead to worsening behavioral symptoms. [MEDICAL CONDITION] stable, continue [MEDICATION NAME] at current dose. Dose reduction not indicated at this time as will likely lead to worsening behavioral symptoms. There were no behavioral symptoms documented on any of the physician, physician assistant's, or nurse practitioner's visits with the resident to provide clinical justification that warranted continued use of either medication. -9/26/19, untimed, No acute issues per staff. [MEDICAL CONDITION] stable, continue [MEDICATION NAME]. No GDR at this time, may result in worsening behavioral symptoms. Major [MEDICAL CONDITION] (MDD), stable, continue [MEDICATION NAME]. No GDR due to may lead to worsening behavioral symptoms. There were no behavioral symptoms documented on any of the physician, physician assistant's, or nurse practitioner's visits with the resident to provide clinical justification that warranted continued use of either medication. A review of Resident 142's Physician Order Summary Report, with active orders as of 2/1/19, included but was not limited to, the following orders: -[MEDICATION NAME] 1 milligrams (mg) by mouth twice a day for [MEDICAL CONDITION] manifested by seeing objects on the walls for 14 days, with a renewed order date of 1/31/19. However, there was no order to monitor the resident for [MEDICAL CONDITION]. -[MEDICATION NAME] 10 mg by mouth one time a day for hypertension (high blood pressure), hold for SBP less than 100 with an order date of 12/31/18. -[MEDICATION NAME] 100 mg by mouth once a day for hypertension, hold for SBP less than 100 with an order date of 13/31/19. -[MEDICATION NAME] 0.3 mg by mouth three times a day for hypertension, no parameter to hold, with an order date of 1/1/19. -[MEDICATION NAME] 25 mg by mouth three times a day for hypertension, hold for SBP less than 100, with an order date of 1/1/19. -[MEDICATION NAME] 40 mg by mouth once a day for hypertension, hold for SBP less than 100, with an order date of 1/1/19. -[MEDICATION NAME] 5/325 ([MEDICATION NAME] (controlled opioid pain medication) 5 mg and [MEDICATION NAME] (non-controlled medication) 325 mg) one tablet by mouth every 4 hours as needed for pain management, with an order date of 1/1/19. A review of the facility's Emergency Transfer Communication, dated 2/23/19, indicated at 12:59 p.m., Resident 142 was seen with large amount of coffee ground emesis, the doctor was informed and ordered resident to be transferred to the GACH. The Transfer Communication form indicated Resident 142's blood pressure was low at 82/47 with a low oxygen saturation of 86 percent. A review of GACH admission records, dated 2/23/19, indicated Resident 142's reason for visit was acute blood loss and [MEDICAL CONDITION]; medical problems included but were not limited to coffee ground emesis, [MEDICAL CONDITION] and abdominal pain. Resident 142's blood pressure on 2/23/19 at 6:18 p.m., was 69/54, at 6:33 p.m., was 79/60, and increased to 90/66 by 7:03 p.m. The GACH Assessment plan indicated to hold antihypertensive medications due to [MEDICAL CONDITION]. Upon discharge four out of five of Resident 142's blood pressure medications were ordered to be discontinued which included, [MEDICATION NAME], and [MEDICATION NAME]; with a new order to decrease the resident's [MEDICATION NAME] from 100 mg to 25 mg a day; and to continue [MEDICATION NAME] 5/325 one tablet every 4 hours as needed (PRN) for moderate pain level of 4 to 6 (with 0 being no pain and 10 being the most severe pain). A review of Resident 142's current Physician Order Summary Report added the following orders: Monitor for Orthostatic [MEDICAL CONDITION]. The physician order indicated, take blood pressure while lying and sitting every week on Saturdays with a start date of 3/9/19; and [MEDICATION NAME] 30 mg by mouth nightly at bedtime for depression manifested by poor oral intake with a start date of 3/21/19. A review of Resident 142's Medication Administration Record [REDACTED]. On 11/1/19 at 1:13 p.m., during an interview and a review of Resident 142 clinical records, the Director of Nursing (DON) after reviewing the resident's MAR monitoring for Orthostatic [MEDICAL CONDITION] stated, Seems like there are no changes for both lying and sitting. The numbers are exactly the same. There is only one measurement documented. I believe the documented reading is the systolic. I cannot be sure. The reading does not indicate systolic or diastolic. This is a discrepancy that should have been brought to my attention. We do not know if they measured the resident lying down and sitting up. We do not know if there was a variance to determine if the resident was experiencing Orthostatic [MEDICAL CONDITION]. If we do not monitor him effectively we would not know if he is having [MEDICAL CONDITION] or not; or if his previous [MEDICAL CONDITION] is an ongoing concern. On 11/1/19 at 2:47 p.m., DON stated, According to my consultant we do not have a policy on Orthostatic [MEDICAL CONDITION]. The DON provided a policy on blood pressure and stated, The policy does not specify how to take Orthostatic [MEDICAL CONDITION]. It would be important to have guidance in checking for Orthostatic [MEDICAL CONDITION]. On 11/1/19 at 3:17 p.m., during a telephone interview, in the presence of the DON, the facility's consultant pharmacist (CP) stated he provided a recommendation for a GDR for Resident 142's [MEDICATION NAME] and [MEDICATION NAME]. CP stated when the doctor writes continue current dose, that is not a clinical justification. The CP stated he reviewed Resident 142's Initial Psychiatric Evaluation, dated 12/27/19, and stated, I do not see the psychiatrist name on the report. The report did not indicate if he had an interview with the resident or what the resident said. The report does not indicate if the nursing staff were interviewed or what information was provided about the resident from the nurses, especially since this would have been an initial or first time the resident would have been seen for a psychiatric evaluation. On 11/1/19 at 3:39 p.m., during a telephone interview in the presence of the facility's Administrator (ADM) and DON the Psychiatrist (MD 2) stated, I cannot give you a specific time I saw the resident. I cannot tell you if I am familiar with the resident. My PA 1 does rounds independently and he documents. The PA 1 can evaluate a patient (resident). At least 10 % (percent) of the cases we should discuss together. Clinical [DIAGNOSES REDACTED]. Confirmed [DIAGNOSES REDACTED]. You could do a gradual dose reduction after six months or a year. This may be a good time to consider a GDR. MD 2 stated, [MEDICAL CONDITION] by itself is not an indication to start a medication. Depends on clinical presentation. You should always justify the reason to continue the medication. Continue current dose is not a clinical justification or clinical rationale. The standard is to talk with the nursing staff. The nursing staff is crucial in getting more clinical information because they are with the resident 24 hours a day. On 11/1/19 at 4:08 p.m., during a telephone interview MD 1 stated, The last time I saw (Resident 142) was a couple of months ago. I also have a Nurse Practitioner (NP 1) to see him. The last time I saw him I did not see him as agitated. At that time, I was not sure if he required [MEDICAL CONDITION] medications. I depend upon the nurses, because I just see a snap shot. I rely heavily on the nurses' report of behavior. I asked for the resident to be seen by a Psychiatrist, but I think he saw a P[NAME] I would expect a supervising Psychiatrist to be involved. Within the first 24 to 48 hours a physician would indicated they agree or disagree with an evaluation or diagnosis. I would expect the Psychiatrist would see the resident at some point. Based on the resident's previous records I would never make the [DIAGNOSES REDACTED]. There should be a Psychiatrist to confirm the [DIAGNOSES REDACTED]. Screaming and yelling is not an indication to start a resident on an antipsychotic medication. I have never used [MEDICATION NAME] for screaming and yelling without finding out the underlying cause. MD 1 stated that it is a concern if only the PA indicated the resident saw objects on the wall. On 11/1/19 at 5:09 p.m., during an interview MRD stated after reviewing Resident 142's clinical records and overflow records that there was no documentation by the staff or licensed nurses indicating or stating the resident was observed or stated seeing anything on the walls. A review of the facility's policy titled, Guidelines for Psychotherapeutic Medications, revised 7/2015, indicated: -Antipsychotic Medications - if the resident has an organic mental syndrome ([MEDICAL CONDITION], dementia, amnesic and other cognitive disorder) with associated psychotic and/ or agitated behaviors, the resident shall be reviewed for preventable reasons i.e. excessive heat, noise, overcrowding, pain, constipation, fever and infection etc. Appropriate non drug interventions shall be attempted prior to prescribing antipsychotic medications. -Antidepressant Medication - Residents receiving antidepressant drugs shall have behaviors and side effects monitored on the Medication Administration Record. Resident care plans shall include non-drug interventions for depression and attempts to decrease isolation and increase socialization for the resident. A review of the facility's policy titled, Bowel and Constipation Management, revised 10/2019, indicated will assist residents in managing bowel habits to increase independence, decrease discomfort and increase sense of well-being. Resident will be provided with interventions for relief of constipation or bowel discomfort related to constipation. Resident environment affects how he/she manages bowel functioning. There are factors to consider including: a. Proper positioning over the toilet/commode versus bedpan b. Encourage fluids as tolerated c. Respect privacy/cultural sensitivity d. Encourage mobility and exercise Non-Pharmacological Interventions (if there is no contraindications); some examples that can be offered: a. Communicate to dietary on needs of such high fiber meals b. Prune juice c. High fiber diet d. Fruits with high fiber e. Re-inforce the importance of fluid intake Monitor effectiveness of initial interventions provided. According to DailyMed, a website operated by the U.S. National Library of Medicine to publish up-to-date and accurate drug labels to health care providers and the general public; manufacturer label for: -[MEDICATION NAME], indicated under warnings and precautions: A dose reduction should be considered if [MEDICAL CONDITION] occurs. [MEDICATION NAME]® should be used with particular caution in patients with known . [MEDICAL CONDITION] disease (stroke), and conditions which would predispose patients to [MEDICAL CONDITION], e.g., dehydration and hypovolemia (decrease in the blood volume resulting from loss of blood). Clinically significant [MEDICAL CONDITION] has been observed with concomitant use of [MEDICATION NAME]® and antihypertensive medication. -[MEDICATION NAME], indicated the most common events associated with discontinuation and considered to be drug related are somnolence and nausea. Particular attention should be paid to any flu-like complaints or other symptoms that might suggest infection. [MEDICATION NAME] may impair judgment, thinking, and particularly, motor skills, because of its prominent sedative effect. -[MEDICATION NAME] Tablets may cause severe [MEDICAL CONDITION] including orthostatic [MEDICAL CONDITION] (a sudden drop in blood pressure caused by a change in posture) and [MEDICAL CONDITION] (temporary loss of consciousness). The most frequently reported adverse reactions are light-headedness, dizziness, constipation, sedation, nausea, vomiting, drowsiness, mental clouding, lethargy (lack of energy and enthusiasm), impairment of mental and physical performance, anxiety, fear, dysphoria (generalized dissatisfaction with life), psychological dependence, mood changes.

Based on observation, interview, and record review, the facility failed to ensure an abuse allegation was thoroughly investigated, and failed to prevent further abuse from occurring as stipulated in the facility's policy for one of one sample residents (Resident 1). In August 2012, Resident 1 and her family had requested that nursing staff remove a certified nursing assistant (CNA 1) from providing care to Resident 1, after they had complained several times that CNA1 was rough when providing care to the resident. The facility continued to assign CNA 1 to provide care for Resident 1 from August 2012 until she was suspended on October 22, 2012, despite her numerous complaints, which also included Resident 1's allegation that CNA 1 threatened to choke her with the call light cord on October 3, 2012. The deficient practice of CNA 1 continuing to provide care to Resident 1 for more than two months after the request to remove CNA 1 from providing care to the resident, and the ongoing contact of Resident 1 by CNA 1 after an allegation that CNA 1 threatened to choke the resident with the call light cord, resulted in Resident 1 experiencing mental anguish, feeling unsafe, fearful, intimidated, and was observed crying. Findings: The Department received an Entity Reported Incident (ERI), dated October 9, 2012, alleging a resident (Resident 1) accused a certified nursing assistant (CNA 1) of threatening to choke her with the call light's cord if she called for assistance again. On October 22, 2012, at 8 a.m., an unannounced complaint investigation was conducted. On October 22, 2012, at 8:10 a.m., the assistant director of nurses (ADON) stated that on October 3, 2012, Resident 1 informed the social services assistant (SSA) that CNA 1 had threatened to choke her with the call light cord if she called for help again. According to the ADON, the SSA reported the allegation to the social service designee (SSD) who reported the incident to the director of nurses (DON) and Administrator 1 (previous administrator during the allegation). On October 22, 2012, a review of Resident 1's clinical records indicated she was a [AGE] year-old female who was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. A review of a Minimum Data Set (MDS), a standardized assessment and care screening tool, dated May 22, 2012, indicated Resident 1 had the ability to understand others and make herself understood at all times. According to the MDS, the resident was able to demonstrate recall (memory) with occasional cueing and had not exhibited any behavioral symptoms. Resident 1 was non-ambulatory, incontinent (inability to control) of both bowel and bladder and required extensive staff assistance with all activities of daily living (ADLs). On October 22, 2012, at 8:30 a.m., during an interview, the SSD stated she had received several grievances from Resident 1 stating the facility's staff were not answering her call light or changing her in a timely manner. The SSD stated Resident 1 appeared to be agitated and very nervous when her family was not able to be at her bedside and she was left alone. At 8:32 a.m., on October 22, 2012, Administrator 1 stated as part of the facility's investigation for the verbal abuse allegation that occurred on October 3, 2012, she and the staff had interviewed other residents CNA 1 had cared for. The administrator stated they had gone into the residents' rooms and pushed the call lights (on day shift, the incident occurred on nightshift) to see how long it was before someone responded. Administrator 1 stated she had questioned Resident 1 if she felt safe while in the presence of the resident's husband. Administrator 1 stated she did not ask Resident 1 any questions regarding the abuse allegation. A review of the facility's investigation, dated October 4, 2012, indicated they interviewed four residents and one staff member (a restorative nursing assistant (RNA)) There was no written evidence of CNA 1 being interviewed by the facility. On October 22, 2012, at 8:38 a.m., the DON stated the resident's allegation of verbal abuse was unsubstantiated because the resident was not able to recall making the statement and the CNA stated she did not do it. When asked if CNA 1 had been suspended during their investigation as stipulated in the facility's policy, the DON stated CNA 1 had not been suspended. According to the facility's Abuse Investigation policy, dated October 1, 2002, if an employee is the suspected perpetrator the employee will be immediately removed from providing care to the resident and may be suspended. The policy also indicated the investigation would be thoroughly investigated. At 9:45 a.m., on October 22, 2012, a telephone call was placed to CNA 1 to interview her regarding the allegation and a voice message was left. The CNA did not return the call. On October 22, 2012 at 10:30 a.m., Resident 1 was observed sitting up in a chair at her bedside with a family member. When an interview was attempted, the resident indicated she could not speak English. After the resident agreed to have an interpreter, the facility's housekeeping staff was asked to interpret. The interpreter stated the resident stated she had told the social worker a CNA (CNA 1) had threatened to choke her with the call light cord. The resident stated her family members had told her CNA 1 was not supposed to take care of her anymore, but CNA 1 continued to care for her when the other CNAs went to lunch. Resident 1 requested the surveyor to call her family members, through the interpreter, and provided the telephone number. During the interview, Resident 1 started crying and stated, "I don't like ---- (CNA 1's name) and I'm scared of ------ (CNA 1's name). A review of CNA 1's employee file with the director of staff development (DSD) indicated on September 10, 2012, CNA 1 was disciplined for refusing to care for Resident 1. The entry indicated CNA 1 stated she could not care for the resident because the resident's family had filed a complaint against her for being too rough. The file indicated CNA 1 was written up in 2008, 2009, and 2010, related to providing poor resident care, residents' complaints, and walking off the job while being counseled by her supervisor. At 11:10 a.m., on October 22, 2012, the DON confirmed that CNA 1 had been disciplined on September 10, 2012, for refusing to care for Resident 1. The DON stated there was no documentation the family had requested CNA 1 not to care for Resident 1, and she had not believed CNA 1, but the DON did not call the family to verify. When asked if the CNA's employee file had been reviewed prior to the allegation of verbal abuse being unsubstantiated the DON stated, "No." On October 22, 2012, at 11:15 a.m., the DSD stated if a family member requested for a specific CNA to not care for a resident, the request should be documented, and the CNA should not be assigned to that resident. The DSD stated he did not know why the family's request to not have CNA 1 care for Resident 1 had not been honored or documented. At 5:45 p.m., on October 22, 2012, during a telephone interview, Resident 1's family member stated in August 2012 she and another family member had reported to one of the charge nurses of Resident 1's complaint of CNA 1 being too rough when cleaning her and that the CNA would not answer the call light when she called for help, and that Resident 1 did not trust CNA 1. The family member stated a charge nurse (name unknown) had told her CNA 1 would not be assigned to take care of Resident 1 anymore. The family stated the facility had not called and informed them of the verbal threat allegation on October 3, 2012, as stipulated in the facility's policy for abuse investigation. A review of CNA 1's assignment sheets for September 2012 through October 2012, indicated CNA 1 was assigned to care for Resident 1 on September 23 and 24, 2012, over a month after the family requested CNA 1 not be assigned to Resident 1. In addition, CNA 1 was assigned to care for the resident on September 7, 9, 12 and 30, 2012. CNA 1 also provided care to the resident on October 6 and 7, 2012, after the resident reported that CNA 1 had threatened to choke her with the call light cord on October 3, 2012. A review of a Licensed Nursing Note, dated September 10, 2012, and timed at 1:37 a.m. (the same day CNA 1 refused to care for Resident 1), Licensed Nurse 1 documented the resident's head was bumped against the head board when two CNAs (names not documented) were pulling the resident up in bed. Another licensed nurse's note, dated September 10, 2012, and timed at 8:09 a.m., indicated the physician was called regarding the resident's head being bumped and ordered neurological checks (assessments made after a head injury to check for changes in level of consciousness). On October 22, 2012, at 11:30 a.m., the DSD stated CNA 1 was one of the CNAs pulling the resident up in bed when the resident's head was bumped against the headboard. At 3:45 p.m., the same day, the DON stated she had heard about the head bumping incident with CNA 1, but she did not feel it was "related." The DON further stated she did not know if the resident's family had been informed who the CNAs were when the incident occurred. On June 24, 2013, at 2 p.m., during a telephone interview, Administrator 2 stated CNA 1 was suspended on October 22, 2012, after the Department's investigation, which was 19 days after the alleged verbal threat. Administrator 2 stated CNA 1 did not return to work.

For Notation purposes only. The deficiency was reflected on the 2nd Revisit [DATE] Event Id RZ7513. See below Based on interview and record review, the facility's nursing staff failed to ensure one of 14 sampled residents (Resident 1) received adequate supervision to prevent accidents in accordance with their policy titled, "Residents Who Require Electronic/Mechanical Lifts For Transfer." The policy indicated that the electric/mechanical lift (lift) is required for any residents who require total assist with transfers, two people for transfers, or have the inability to bear weight on both lower extremities. And, the number of staff required will be based on the manufacturer's guideline, resident's assessment and care plan. Resident 1, who had multiple contractures, could not bear weight on her lower extremities (legs) and required two(+)persons physical assist with transfers, was transferred using a mechanical lift (Invacare) by only one certified nursing assistant (CNA 6). This resulted in the resident falling to the floor, along with the mechanical lift and CNA 6. Resident 1 sustained a gash on the left side of the forehead, had pinpoint pupils (indication of head injury) and vomited, required cardiac pulmonary resuscitation (CPR), and was transferred by paramedics to the general acute care hospital (GACH) where she subsequently expired. Findings: An entity reported incident (ERI), received on [DATE], was investigated during the 2nd revisit survey. The ERI report was regarding a fall incident that occurred when a CNA transferred Resident 1 without assistance of another staff while using a mechanical lift. The resident fell from the mechanical lift and sustained a gash (a long, deep wound or cut)to the left side of the forehead. During an interview and review of the undated Investigative Summary report with the administrator on [DATE], at 2:30 p.m., he stated the facility's risk management and legal team completed the report. He stated CNA 6, the CNA involved in the incident, had been terminated. A review of the clinical record for Resident 1 revealed she was an [AGE] year-old resident who was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Resident Assessment and Care Screening Tool dated [DATE], identified the resident as being severely impaired in cognition, with unclear speech rarely/never understood and rarely/never understands. The MDS [DATE], assessment for daily functions or that placed the resident at risk of injury reflected Resident 1 had functional limitations with impairment in both upper and lower extremities on both sides, required total assistance with transfers and bed mobility requiring a two-person physical assist, and was totally dependent in all activities of daily living (dressing, eating, toilet use, and personal hygiene). The balance assessment indicated the resident was not steady, and was "only able to stabilize with staff assistance" for surface-to-surface transfers. There was a plan of care dated [DATE], with a goal date of [DATE], for the problem of potential for (further) injury related to fall risk factors of: disorientation /confusion, poor safety judgment, impaired sitting balance, and predisposing disease or injury. The goal was the resident will have no major injuries from falls. One of the interventions was to assist with transfers and mobility as needed. The care plan did not include the mode of transfer required (mechanical lift) or the number of persons required to transfer (two(+)persons physical assist) as indicated in the nursing assessment. A review of the Change of Condition assessment dated [DATE], at 8 a.m., indicated Licensed Vocational Nurse (LVN) 9 documented an assessment for neurological ((neuro) nervous system) changes. Resident 1 was transferred to the GACH for altered level of consciousness. The assessment indicated the resident was not alert, was incoherent, with no speech, pupils equal and reactive to light, and upper/lower extremities were rigid (appearing stiff and unyielding), and had vomited a moderate amount of clear/water liquid. Resident 1 was experiencing pain rated at 2 out of 10 (pain scale of 1 to 10, 1 being the least pain, 10 being the most severe pain), had guarded movement and grimacing (facial expression). The Clinical Notes Report dated [DATE], 4:40 p.m., documented by LVN 9, indicated at 7:45 a.m., a CNA asked for immediate assistance with Resident 1. Upon assessment LVN 9 noted a gash on the left side of the resident's forehead. A neuro check indicated the resident's eyes were open and blinking, both pupils were reactive to light, the resident's oxygen saturation level (oxygen in the blood normal 95 to100 percent (%)) was 91%, blood pressure was ,[DATE] (normal ,[DATE]), and pulse 115 beats per minute (normal range is 60 to 100). According to the facility's [DATE], follow-up report, CNA 6 was using the lift to transfer the resident from the bed to the shower chair when the resident tumbled out of the chair, causing the lift and CNA 6 to fall with her. At 7:50 a.m., Registered Nurse 3 (RN 3) provided first aid to the left side of the resident's forehead. At about 8:05 a.m., the resident vomited, and at that time 911 was called. The resident's oxygen saturation was 80%, her pulse was fluctuating "greatly", her eyes were pin-point, and her blood pressure had dropped to ,[DATE]. CPR was started, and Resident 1 was transferred to the GACH where she subsequently expired. During an interview with LVN 9, on [DATE], at 7:45 a.m., regarding the [DATE], incident, she said CNA 6 asked her to come to Resident 1's room, and when she entered the room the resident was in bed. LVN 9 observed a gash on the left side of the resident's forehead and RN 3 was at the bedside. The physician was notified and ordered to transfer the resident to the GACH. Transportation was called, but after the resident vomited a clear color material, 911 was called immediately by LVN 9. During a phone interview with CNA 6 on [DATE], at 1:45 p.m., he stated that Resident 1 was on his regular assignment on [DATE]. He was transferring the resident with the lift, and after placing the resident on the shower chair and was unhooking one side of the sling, the chair tilted over to the left and the resident fell and hit her head on the floor. He stated he called for help, and another CNA came and helped him put the resident back to bed. Resident 1 had blood coming from her head, and vomited before going to the hospital. He stated that he had used the lift by himself "many times" and had no problems. During an interview with the Director of Staff Development 2(DSD 2), on [DATE], at 9:30 a.m., while reviewing CNA 6's employee records, she said CNA 6 was in-serviced via video on the use of the Invacare mechanical lift on [DATE]. DSD 2 was unable to provide the annual skilled proficiency check list for CNA 6, but stated there should have been one. A review of the GACH emergency department notes dated [DATE], indicated Resident 1 arrived at 9:17 p.m., with CPR in progress, via ETT ((endotracheal tube) tube that is inserted through the mouth for the primary purpose of establishing and maintaining an open airway and to ensure the adequate exchange of oxygen and carbon dioxide). According to the notes, the emergency medical services staff stated the resident had gone into cardiac arrest when loading in the ambulance. Resident 1 was unresponsive, and there was no cardiac activity despite all resuscitative efforts, and she was pronounced dead at 9:34 p.m. The facility ' s manual titled "Mechanical Lift Transfer Program" dated [DATE], for transferring of residents, indicated the manufacturer (Invacare) recommends that two (2) assistants be used for all lifting preparation, transferring from and transferring to procedures.

Based on observation and interview, the facility's maintenance staff failed to ensure televisions and other objects were secured; they failed to properly connect a hose to the hand wash sink faucet, which caused the water to over flow to the floor below, placing residents at risk of injury. Findings: a. On February 7, 2013, at 8:30 a.m., during the initial tour of the facility the following was observed: In Rooms 407 Bed B, 408 Bed B and 410 Bed A the televisions were not secured to the surface that they were placed on. In Room 410 Bed A there was a box on top of the television that was not secured. On February 19, 2013 at 9:06 a.m., during an interview, the Maintenance Supervisor, stated he was not aware of the specific televisions mentioned, however, he was in the process of securing the televisions to the residents' beds. b. On February 13, 2013, at 10:10 am, in the activity/dining room on the first floor, there was water observed dripping from the ceiling on to the floor and there were no signs posted to alert residents, visitors or staff that the floor was wet. Further investigation revealed the water was coming from the hand wash sink in Room 220. There was a hose connected to the faucet for a resident that was receiving dialysis. The hose connection was loose and a large amount of water was on the floor leaking to the lower level first floor dining room. At the time of the observation, there were no signs to alert residents, visitors or staff that the floor was wet, to prevent any fall incidents.

Based on interview, record review, and review of facility documents, the facility's nursing staff failed to ensure a resident requiring extensive assistance with transfers was transferred safely for one of 25 sampled residents (Resident 23). The facility determined Resident 23 refused transfer by Hoyer lift, however, there was no care plan developed to address the resident's refusal to use the Hoyer lift and did not address safe transfer. Certified Nurse Assistants 4 and 5 (CNAs 4 and 5) transferred the resident using a gait belt and did not assess environmental hazards according to the care plan by not ensuring all components/parts of the wheelchair footrest were removed or swung outward and sideways prior to lifting and transferring the resident from wheelchair to the bed. During the wheelchair to bed transfer, the resident sustained [REDACTED]. According to the acute hospital record, Resident 23 sustained "jagged, large avulsion (tear) to the left lateral calf" measuring ten centimeter (cm), equivalent to 3.9 inches and went through the subcutaneous fascia (a sheet of fibrous tissue that lies deep into the skin) that required three layers of subcutaneous sutures (sutures below the skin) to close. Resident 23 was subsequently admitted and remained in the acute hospital for seven days. Resident expired on [DATE]. Findings: On [DATE] at 12:52 p.m., the Department received a complaint by telephone from Resident 23's family member alleging the facility nursing staffs transferred the resident from the wheelchair to the bed and the resident sustained [REDACTED]. The family member stated the resident went to the emergency room and stayed in the hospital for one week, was transferred to another skilled nursing facility and never recovered. The family member stated Resident 23 expired on [DATE]. On [DATE], a recertification survey and complaint investigation was conducted to the facility. A review of the admission face sheet indicated Resident 23 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), an assessment tool, dated [DATE], indicated Resident 23 had short and long term memory problems and was moderately impaired in cognitive skills (process of thought) for daily decision making. The resident required extensive assistance (help with weight bearing support or full staff performance) with bed mobility and transfers. A review of the resident's care plan (not dated) for risk for injury indicated the staff members were to assist the resident with transfers and mobility when necessary (PRN) and to keep the environment free from safety hazards. This was not followed for Resident 23. The wheelchair footrest was not removed or swung outward and sideways, placed out of the way and caused the injury to the resident's leg. A review of the nursing notes (not dated) indicated under the physical functioning, the resident required two or more persons for transfer assistance. The resident was non-ambulatory and a wheel chair was used for the resident's mobility. Under the skin assessment, it was documented Resident 23 sustained a laceration to the left lower leg measuring eight centimeters (cm) by two cm. It was also documented the physician was notified on [DATE], and an order was given to transfer the resident to the acute care hospital. On [DATE] at 3:30 p.m., during an interview, Certified Nurse Assistant 4 (CNA 4) stated the morning of the accident ([DATE]), Resident 23 was transferred using a Hoyer lift (a mechanical lift) from the bed to the wheelchair. At 2:45 p.m., CNA 4 stated with the help of CNA 5, they attempted to transfer the resident back to bed using a Hoyer lift but the resident refused. CNA 4 stated with the help of CNA 5, they transferred the resident using a gait belt and the resident's leg was caught on the hook from the wheelchair footrest. On [DATE] at 3:40 p.m., during an interview, CNA 5 stated he assisted CNA 4 with the transfer of Resident 23 on [DATE]. The resident refused to be transferred using the Hoyer lift and pushed the Hoyer lift away. CNA 5 stated the resident was always refusing the Hoyer lift. A gait belt was used to transfer the resident from the wheelchair to the bed. During the process of transferring, the resident's left leg was caught on the hooks (two prongs) from the wheelchair footrest. CNA 5 stated there was a lot of blood and the treatment nurse was called. Further review of Resident 23's care plan revealed there was no care plan developed to address the resident's refusal to be transferred using the Hoyer lift and did not address specifically how the resident would be transferred safely. On [DATE] at 1:30 p.m., during an interview, the Housekeeping Supervisor stated wheelchairs were inspected during the weekly wheelchair washing and if any repairs were needed with the equipment, it would be taken out of circulation and repaired. The Housekeeping Supervisor and the Maintenance Supervisor stated they were not aware what happened to the wheelchair involved in Resident 23's accident. On [DATE] at 3 p.m., during an interview, the Administrator stated when Resident 23 was being transferred from the wheelchair by two CNAs, the sharp hinge from the footrest of the wheelchair cut her calf. He stated when he was notified of the resident's accident, he took the wheelchair off the unit. A review of the facility's report titled "Investigation of Incident/Accident/Injury of Unknown Origin", dated [DATE], indicated Resident 23 hit her leg on the wheelchair footrest, causing a laceration to her left leg measuring eight cm by two cm when two staff members were transferring her using a gait belt. The Interview Record, dated [DATE], (however, the incident happened on [DATE]) Licensed Vocational Nurse 6 (LVN 6) indicated around 2:50 p.m., she was notified by the CNA that during the transfer from the wheel chair to the bed, Resident 23 sustained a left leg laceration which was bleeding and first aid was provided. The Interview Record, dated [DATE], (however, the incident happened on [DATE]) CNA 4 indicated the resident was put back to bed but the resident refused to use the mechanical lift. The resident was transferred by two assistants. During the transfer, the resident hit her left leg on the hook from the wheelchair footrest and the resident sustained [REDACTED]. A review of the emergency department (ED) records, indicated Resident 23 was admitted on [DATE] at 4:34 p.m., came in with a "jagged, deep large avulsion/laceration to the left lateral calf region". The length measured more than eight cm and the depth was through the subcutaneous fascia. The triage assessment indicated Resident 23 had pain of six on a scale of 10 (1 being the lowest) using faces pain scoring. The resident was subsequently admitted to the medical-surgical unit at 8:35 p.m. A review of the acute care hospital records indicated on [DATE] at 9:31 p.m., a laceration repair procedure was done under a local anesthesia. A complex (complicated) repair was done to the left leg laceration/avulsion with a total length of 10 cm, equivalent to 3.9 inches. Three layers of subcutaneous sutures were placed to close the laceration. The photograph, dated [DATE], indicated Resident 23's left leg laceration measured 10 cm. Resident 23 remained in the hospital from [DATE], and was discharged on [DATE], to another skilled facility. According to <http://medicalcenter.osu.edu/PatientEd/Materials/PDFDocs/exer-reh/devices/transfer-non-weight.pdf A transfer is the moving of a person from one surface to another. This transfer is used when the person is not to put weight on their feet or legs. Positioning the Wheelchair C Position the wheelchair parallel, but at an angle, to the middle of the bed. C Lock the wheelchair. C Remove your feet from the footrest and swing the footrest away. C Remove the armrest nearest to the bed. C Move forward to the edge of the chair so you will not hit your bottom on the wheel when you slide across. Returning to the Wheelchair C The process is reversed when returning to the wheelchair. C Position the wheelchair close to the bed with the armrest closest to the bed removed. Swing the footrest out of the way. C Sit up on the side of your bed C Place one hand on the mattress and the other on the chair armrest if you can reach it. C Do a push up to lift your bottom and scoot toward the chair. C Once you are in the chair, replace the armrest on the chair. C Put the footrest back in place and return your feet to the footrests. C Unlock the wheelchair. <http://www.apria.com/manuals/Medline.1.%20Excel%20Wheelchair.pdf> Use and Safety: Wheel Locks-Engage the wheel locks on both wheels before entering the chair, leaving the chair, leaning forward in the chair, or while being transported in an elevator or a wheelchair lift. Check to make sure that the legrests do not unlock the wheel locks when they are swung back.