Every finding on record at The Rowland

Based on observation, interview and record review, the facility failed to ensure three of three sampled residents (Resident 1, Resident 2, and Resident 3) with pressure ulcer/injury (PI - localized damage to the skin and/or underlying tissue usually over a bony prominence) used the appropriate support surface (medical device designed to take the weight of a person and spread out [redistribute] the pressure exerted on their skin and tissues) in accordance with the facility's policy and procedure (P&P) titled, Support Surface Guidelines revised 4/2026 by failing to ensure:1. Resident 1 had a physician order for therapeutic mattress.2. Resident 1's, Resident 2's, and Resident 3's care plans (CP) indicated what type of therapeutic mattress was being used.3. Resident 1's, Resident 2's, and Resident 3's therapeutic mattress was monitored and the type of therapeutic mattress used, the mattress' setting and condition was documented on the residents' medical record every shift.These deficient practices had the potential to result in Resident 1, Resident 2, and Resident 3 not receiving the necessary care, treatment and services to promote healing, prevent infection and prevent new PI from developing.a. During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 8/5/2026 with diagnoses which included right hip pressure ulcer, severe protein-calorie malnutrition, and encounter for palliative care (specialized medical care focused on providing relief from the symptoms, pain, and stress of a serious illness).During a review of Resident 1's Order Summary Report (OSR), dated 8/21/2026, the OSR indicated that the resident was admitted to the facility under hospice (compassionate care for people who are near the end of life) for respite care (short-term, temporary relief for primary family caregivers) from 8/5/2026 to 8/10/2026. The OSR indicated Resident 1had a physician order, dated 8/5/2026, to cleanse right hip unstageable pressure injury every day shift and cleanse sacral gluteal unstageable pressure injury every day shift every 2 days. The OSR indicated Resident 1 did not have an order for a therapeutic mattress.During a review of Resident 1's Care Plan (CP), initiated on 8/5/2026, the CP indicated Resident 1 was admitted with unstageable pressure injury (severe skin wound where the true depth and damage cannot be determined because dead tissue blocks a clear view of the wound) to right hip and one of the interventions for this condition is to provide therapeutic mattress as needed. The CP did not indicate the type of therapeutic mattress that was used for Resident 1.During a review of Resident 1's Treatment Administration Record (TAR), dated 8/1/2026 to 8/31/2026, the TAR indicated Resident 1's therapeutic mattress was not monitored and the type of therapeutic mattress used, the mattress' setting and condition was not documented every day.During a review of Resident 1's medical record, there was no evidence that Resident 1's therapeutic mattress was monitored and the type of therapeutic mattress used, the mattress' setting and condition was documented every day.b. During a review of Resident 2's AR, the AR indicated the facility admitted Resident 2 on 7/25/2026 with diagnoses which included sacral region (sacrum- the area at the base of the spine, located in the pelvic area) pressure ulcer/injury (PI) stage 4 (Full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone), vertebra (backbone or spine) osteomyelitis (inflammation of bone or bone marrow, usually due to infection), and Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements).During a review of Resident 2's History and Physical (H&P, physician's clinical evaluation and examination of the resident), dated 8/18/2026, the HP indicated Resident 2 did not have decision making capacity.During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool), dated 8/7/2026, the MDS indicated Resident 2 had severely impaired cognitive skills (ability to make daily decisions). The MDS indicated Resident 2 was dependent (helper does all effort to complete activity) on activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily).During a review of Resident 2's OSR, dated 8/20/2026, the OSR indicated a physician order, dated 7/25/2026, for Resident 2 to use low air loss mattress (LALM, specialized type of medical mattress designed to prevent and treat pressure ulcers while maintaining optimal skin temperature and moisture levels) for PI to sacrococcygeal area (area of the sacrum [triangular bone at the base of the spine] and the coccyx [tailbone]).During a review of Resident 2's CP, initiated on 7/25/2026, the CP indicated Resident 2 was admitted with stage 4 pressure injury to sacrococcygeal area and one of the interventions for this condition is to provide therapeutic mattress as needed. The CP did not indicate the type of therapeutic mattress that was used for Resident 2.During a review of Resident 2's TAR, dated 8/1/2026 to 8/31/2026, the TAR indicated Resident 2's LALM was not monitored and the type of therapeutic mattress used, the mattress' setting and condition was not documented every day.During a review of Resident 2's medical record, there was no evidence that Resident 2's LALM was monitored and the type of therapeutic mattress used, the mattress' setting and condition was documented every day.c. During a review of Resident 3's AR, the AR indicated the facility admitted Resident 3 on 12/18/2020 with diagnoses which included hepatic failure (liver failure- loss of liver function), osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), and encounter for palliative care.During a review of Resident 3's H&P, dated 8/1/2026, the H&P indicated Resident 3 did not have the capacity to understand and make decisions.During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3 had severely impaired cognitive skills. The MDS indicated Resident 3 was dependent on staff for most ADLs.During a review of Resident 3's OSR, dated 8/21/2026, the OSR indicated that Resident 3 had active order to cleanse left and right upper buttock stage 3 PI (full-thickness loss of skin. Dead and black tissue may be visible) every day shift which was ordered on 8/4/2026. The OSR indicated that Resident 3 had an active order to cleanse right lower buttock stage 3 every day shift which was ordered on 8/11/2026. The OSR indicated that Resident 3 had an active order for LALM which was ordered on 8/20/2026.During a review of Resident 3's CP, initiated 8/5/2026, the CP indicated that the resident was admitted with stage 3 PI to right upper and lower buttock and one intervention to treat this condition is to provide therapeutic mattress as needed. The CP did not indicate the type of therapeutic mattress that was used for the resident.During a review of Resident 3's TAR, dated 8/1/2026 to 8/31/2026, the TAR indicated that there is no monitoring or documenting for any therapeutic mattress' condition including LALM.During a review of Resident 3's medical record, there was no evidence that Resident 2's LALM was monitored and the type of therapeutic mattress used, the mattress' setting and condition was documented every day.During a concurrent observation and interview on 8/20/2026 at 1:27 PM with the Director of Staff Development (DSD) in Resident 3's room, Resident 3's LALM did not indicate the resident's weight. The DSD stated that there was no weight indicated on the LALM machine. The DSD stated that Resident 3's LALM should have indicated Resident 3's weight on the machine. The DSD stated that it was important to set the LALM to indicate the correct weight for the residents to prevent pressure ulcers or worsening of the wound.During a concurrent interview and record review on 8/20/2026 at 2:58 PM with Treatment Nurse (TN) 1, Resident 3's TAR, dated 8/1/2026 to 8/31/2026, was reviewed. TN 1 stated that Resident 3's LALM's condition was not monitored and documented in TAR. TN 1 stated that Resident 3's LALM setting should have indicated the proper weight according to Resident 3's weight and the nurse staff should monitor and document the LALM's condition in TAR. TN 1 stated it was important to set the LALM properly according to the resident's weight and monitor and document the LALM's condition in TAR to prevent new pressure ulcer or worsening of the wound.During an interview on 8/21/2026 at 9:35 AM with TN 2, TN 2 stated that a physician order is needed to use the LALM and the LALM's setting should be based on the resident's weight. TN 2 stated that it was important to set the LALM according to the residents' weight and monitor and document the LALM's condition in TAR every shift.During a concurrent interview and record review on 8/21/2026 at 12:40 PM with the Director of Nursing (DON), Resident 1's OSR, Resident 1's TAR, dated 8/1/2026 to 8/31/2026, Resident 1's CP, initiated 8/5/2026, were reviewed. The DON stated that there was no order for Resident 1 to use the LALM and no monitoring and documenting the LALM's condition in TAR. The DON stated that the CP indicated using therapeutic mattress as needed, not the type of therapeutic mattress. The DON stated that there should have been an order for using the LALM and nurse staff should set the LALM according to the residents' weight following the order. The DON stated nurse staff should check, monitor, and document the type of therapeutic mattress, the mattress' setting and condition every day for wound care residents.During a review of the facility's policy and procedure (P&P) titled, Support Surface Guidelines revised 4/2026, the P&P indicated, Support surfaces are used for pressure redistribution, shear reduction, and in some cases temperature/moisture control for the resident at risk of pressure injury. The P&P indicated, Following manufacturer's recommendation for use, ensure the support surface accommodates the weight, height, size and body mass index (BMI) of the resident. The P&P indicated, When an air-inflated device is in use, ensure it remains inflated to a pressure appropriate to the resident's body weight. The P&P indicated that the support surface used and the condition of the support surface should be documented in the resident's medical record.

Based on interview and record review, the facility failed to ensure two of two sampled residents (Resident 123 and 74) received care in accordance with professional standards of practice to attain or maintain the highest practicable physical, mental, and psychosocial well-being, when the facility failed to: a. Ensure staff followed the physician's (MD) order to call/notify the physician if Resident 123's oxygen saturation (measure of how much oxygen the blood is carrying as a percentage of the maximum it could carry) level was below 91%. b. Ensure a change of condition (COC) documentation was completed and Resident 76's physician and family were notified after Resident 76 was found on the floor on [DATE] with a skin tear on the right forearm. These deficient practices had the potential for Residents 123 and 76 not receiving necessary care and services. Findings: a. During a review of Resident 123's admission Record (AR), the AR indicated Resident 123 was admitted to the facility on [DATE] with diagnoses including heart failure (the heart cannot pump enough blood to meet the body's needs), acute respiratory failure (lungs cannot get enough oxygen into the blood) and encounter for palliative care (medical service designed to give supportive care to people in the final phase of a terminal illness and focus on comfort and quality of life). During a review of Resident 123's Order Summary Report (OSR) dated [DATE], the OSR indicated for staff and to call the physician (MD) if Resident 123's oxygen saturation was below 91%. During a review of Resident 123's untitled Care Plan (CP) dated [DATE], the CP indicated Resident 123 had congestive heart failure. The CP interventions included for staff to monitor Resident 123's vital signs and to notify MD of significant abnormalities. During a review of Resident 123's Order Summary Report (OSR) dated [DATE], the OSR indicated, Do Not Resuscitate (DNR- do not try to restart a person's heart or breathing if they stop), selective treatment per signed POLST (Physician Orders for Life-Sustaining Treatment) and to call Resident 123's family for any change in condition (COC). During a review of Resident 123's Minimum Data Set (MDS- a resident assessment tool) dated [DATE], the MDS indicated Resident 123 required partial/moderate assistance (helper does less than half the effort) from staff to shower and lower body dressing. The MDS indicated Resident 123 required supervision (touching assistance) for toileting hygiene, upper body dressing, and personal hygiene. The MDS indicated Resident 123 required set up or clean-up assistance for eating, and oral hygiene. The MDS also indicated Resident 123 was on oxygen therapy. During a review of Resident 123's History and Physical (H&P) dated [DATE], the H&P indicated Resident 123 had the capacity to understand and make decisions. During an interview on [DATE] at 9:10 AM with Registered Nurse 1 (RN1) and record review (RR) of Resident 123's Progress Notes (PN) dated [DATE] at 2:00 AM, RN1 stated Resident 123 was DNR status and the PN indicated Resident 123 was sleeping, was difficult to arouse, breathing slow and shallow and Resident 123's oxygen saturation level was 88%. During the same interview and RR with RN1 on [DATE] at 9:10AM, RN1 stated the order in the OSR dated [DATE] indicated the MD needed to be notified if Resident 123's oxygen saturation level was below 91%. RN1 stated there was no documentation in the PN indicating the MD was notified that Resident 123's oxygen saturation level was 88% on [DATE] at 2:00 AM. During a concurrent interview and RR with RN1 on [DATE] at 9:12AM, RN1 stated the licensed nurse should have followed the MD's order and documented it in the progress notes (PN). RN1 stated even if Resident 123 was on DNR status, the licensed nurse should have documented a COC and called the MD when Resident 123's oxygen saturation level was 88%. RN1 stated there was no documentation in Resident 123's medical record (MR) indicating the MD was notified or that any interventions were done when Resident 123's oxygen saturation level was 88%. During an interview on [DATE] at 12:43PM with the Director of Nursing (DON) and RR of Resident 123's PN dated [DATE], the DON stated Resident 123 was on DNR status and expired on [DATE] at 3:40AM. The DON stated there was no documentation completed by the licensed nurse indicating that the MD was notified that Resident 123's oxygen saturation level was 88% on [DATE] at 2:00AM. The DON stated the licensed nurse did not follow the MD orders and did not document any interventions rendered to Resident 123 when Resident 123 was difficult to arouse and was breathing slow and shallow. During an interview on [DATE] at 8:42AM with License Vocational Nurse (LVN1) and RR of Resident 123's medical records, LVN 1 stated even if Resident 123 was on DNR status, if there was a change of condition, the licensed nurse should have called the MD as ordered. LVN1 stated that the licensed nurse was responsible for documenting the MD's notification and the interventions that were rendered for Resident 123 on [DATE] at 2:00AM. LVN1 stated that the licensed nurse needed to document the MD notification and the interventions in the PN. During a review of the facility's undated Policy and Procedure (P&P) titled, Charting and Documentation, the P&P indicated, All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. During a review of the facility's P&P titled, Change in a Resident's Condition or Status dated 12/2025, the P&P indicated, The facility promptly notifies the resident, resident's attending physician or provider, and the resident representative of changes in the resident's condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. During a review of the facility's undated P&P titled, Doctor Notification, Change of Residents Status, the P&P indicated 'The purpose of the P&P was to define the procedures for notifying a physician or licensed practitioner of changes in a resident's condition, to promote timely medical intervention and compliance with federal and state regulations. b. During a review of Resident 76's admission Record (AR), the AR indicated Resident 76 was admitted to the facility on [DATE] with diagnoses including dementia, heart failure (when the heart muscle is too weak to pump blood effectively) and chronic obstructive pulmonary disease (COPD-a long-term lung condition that makes it hard to breathe). During a review of Resident 76's History and Physical Examination (H&P – a comprehensive assessment of a resident's medical condition) dated [DATE], the H&P indicated Resident 76 did not have the capacity to understand and make decisions. During a review of Resident 76's Minimum Data Set (MDS – a resident assessment tool) dated [DATE], the MDS indicated Resident 76 had moderately impaired cognition (ability to understand). The MDS indicated Resident 76 was dependent (a helper does all of the effort of the activity) for toileting hygiene. The MDS also indicated Resident 76 required maximal assistance (a helper does more than half the effort of the activity) for eating, personal hygiene, and shower/bathe. During an interview on [DATE] at 11:25 AM with the Director of Staff Development (DSD), the DSD stated a COC involves an incident that is not part of a resident's baseline status (normal or typical condition). The DSD stated that when there is a COC, the licensed nursing staff should assess the resident involved and then notify that resident's doctor for any orders. The DSD further stated the licensed nursing staff should also inform the resident's family contact and document the COC per facility policy. During a concurrent interview and record review on [DATE] at 11:48 AM with Registered Nurse 1 (RN 1), Resident 76's electronic record was reviewed. RN 1 stated COC was a change in the resident's baseline status. RN 1 stated resident falls/accidents were considered a COC in which both the doctor and resident's family needed to be informed. RN 1 stated Resident 76's Behavior Note, dated [DATE] indicated that on [DATE] at 5:40 AM, Resident 76 was found on a floor mat (a removable piece of soft material placed on the floor near the bedside for residents who were high risk for falls) crawling and noted with a skin tear to the right forearm. RN 1 stated the Behavior Note dated [DATE], did not indicate Resident 76's physician and family were notified post-fall on [DATE]. RN 1 stated there was no COC documentation completed that comprehensively addressed Resident 76's fall on [DATE]. RN 1 stated COC documentation should have been completed because the physician needed to be updated about the resident's condition. RN 1 stated that a COC documentation ensured that the residents' families were informed and aware of any incident involving the resident while under the care of the facility. During a concurrent interview and record review on [DATE] at 11:31 AM with the Director of Nursing (DON), Resident 76's electronic record was reviewed. The DON stated a COC involved a change in the resident's normal physical and/or mental condition. The DON stated that when a COC occurred, licensed nurses should assess the resident involved and notify both the physician and the resident's family. The DON stated a COC should be documented in the nursing note designated for COC because there were certain categories included in the documentation, such as the notification of the physician and family. The DON stated Resident 76's Behavior Note dated [DATE] was not equivalent to a COC documentation because there was no indication that Resident 76's physician and family were notified post-fall on [DATE]. During a review of the facility's Policy and Procedure (P&P) titled, Change in a Resident's Condition or Status, dated 12/2025, the P&P indicated The facility promptly notifies the resident, resident's attending physician or provider and the resident representative of changes in the resident's condition and or status. The P&P indicated a nurse will notify the resident's attending physician.when there has been an accident or incident involving the resident, and/or a discovery of injuries of an unknown source. The P&P also indicated that unless otherwise instructed by the resident, a nurse will notify the resident's representative when the resident is involved in any accident or incident that results in an injury. The P&P further indicated the nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status.

Based on observation, interview, and record review, the facility failed to implement infection prevention and control practices by failing to:a. Ensure Licensed Vocational Nurse 2 (LVN 2) sanitized the medication tray before giving medications to two of four sampled residents (Residents 63 and 87).b. Label and properly store personal care items that were found inside shared bathrooms for two of three sampled residents (Residents 51 and 118) when:b.1. Resident 51's three unlabeled razors were left on top of the bathroom sink inside a shared bathroom.b.2. Resident 118's unlabeled toothbrush was left on top of the bathroom sink inside a shared bathroom. These failures had the potential to result in cross contamination (the process by which microorganisms are unintentionally transferred from one area/object to another with a harmful effect) and/or the development of infection to Residents 51, 63, 87, and 118. Findings: a. During a review of Resident 63's admission Record (AR), the AR indicated the facility admitted Resident 63 on 6/20/2024 with diagnoses including unilateral (affecting one side) primary osteoarthritis (a condition where the cushioning between the joints wears down over time, causing pain, stiffness, and swelling) of the left knee and hypertension (high blood pressure). During a review of Resident 63's Minimum Data Set (MDS- a resident assessment tool), dated 3/31/2026, the MDS indicated Resident 63's cognitive (the ability to think and process information) skills for daily decision making were moderately impaired. The MDS indicated Resident 63 required setup or clean-up assistance with eating, supervision or touching assistance with oral hygiene, partial/moderate assistance (helper does less than half the effort) with upper body dressing and personal hygiene, and substantial/maximal assistance (helper does more than half the effort) with toileting, showering, and lower body dressing. During a review of Resident 87's AR, the AR indicated the facility admitted Resident 87 on 5/18/2026 with diagnoses including hypertensive urgency (a condition where the blood pressure is extremely high requiring prompt medical attention) and hypertension. During a review of Resident 87's MDS dated [DATE], the MDS indicated Resident 87's cognitive skills for daily decision making were moderately impaired. The MDS indicated Resident 87 required supervision or touching assistance with eating, partial/moderate assistance with oral hygiene and upper body dressing, and substantial/maximal assistance with toileting, showering, and lower body dressing. During a medication pass observation on 7/1/2026 at 8:40 am in the hallway outside Resident 63 and 87's room, LVN 2 prepared medications for Resident 87. LVN 3 placed Resident 87's medication in medication cups and placed the medication cups on the medication tray. The medication tray had dust and dirt on it. LVN 2 took the medication tray into Resident 87's room and handed Resident 87 the medication. LVN 2 then took the medication tray to the medication cart and proceeded to prepare Resident 63's medication. LVN 2 did not sanitize the medication tray. LVN 2 placed Resident 63's medication in medication cups and placed them on the medication tray. LVN 2 took the medication tray into Resident 63's room and handed Resident 63 the medication. During a concurrent observation and interview on 7/1/2026 at 9 am with LVN 2, the medication tray was observed soiled with dust and dirt. LVN 2 stated LVN 2 did not sanitize the medication tray prior to administering medication to Residents 63 and 87. LVN 2 stated it was important to sanitize the medication tray because there might be bacteria on the medication tray which could potentially cause Residents 63 and 87 to get sick. During an interview on 7/2/2026 at 12:21 pm with Infection Prevention Nurse (IPN 1), IPN 1 stated facility staff should ensure the medication tray was sanitized prior to giving medication to residents (in general). IPN 1 stated it was important to sanitize the medication tray to prevent cross contamination and to prevent infections from being spread to other residents. During a review of the facility's undated Policy and Procedure (P&P) titled, Disinfection of Medication Tray, the P&P's policy statement indicated, To maintain infection prevention standards and ensure resident safety, all medication trays that become contaminated shall be immediately removed from service, cleaned, disinfected, and allowed to dry before being returned to use. Staff shall follow standard precautions and facility infection control procedures at all times. The P&P's purpose indicated, To prevent the transmission of infectious organisms through contaminated medication trays and maintain compliance with infection prevention standards. The P&P's definition of contamination indicated, A medication tray is considered contaminated if it: Is visibly soiled with dirt, medication residue, or organic material. The P&P's procedure indicated, Disinfectant wipes [should be used] before and after each use. b.1. During a review of Resident 51's admission Record (AR), the AR indicated Resident 51 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including essential hypertension (having abnormally high blood pressure but with no identifiable cause), anemia (a condition where a person lacks enough healthy red blood cells to carry oxygen throughout the body), and repeated falls. During a review of Resident 51's Minimum Data Set (MDS – a resident assessment tool) dated 11/28/2025, the MDS indicated Resident 51 had intact cognition (ability to understand). The MDS indicated Resident 51 required maximal assistance (a helper does more than half the effort of the activity) from staff for oral hygiene, personal hygiene, and upper body dressing. During a review of Resident 51's History and Physical Examination (H&P – a comprehensive assessment of a resident's medical condition) dated 12/5/2025, the H&P indicated Resident 51 was able to make decisions, but family was involved in care and decision making. During a concurrent observation and interview on 6/30/2026 at 11:31 AM with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated there were three disposable razors left on top of the sink inside Resident 51's shared bathroom. CNA 1 stated the three disposable razors belonged to Resident 51. CNA 1 stated CNA 1 had observed multiple times in the past that Resident 51's multiple disposable razors were not placed in a labeled wash basin (individualized plastic container) and instead left on the sink area inside Resident 51's shared bathroom. CNA 1 stated Resident 51 should use one razor at a time for about a few days and then disposed safely. CNA 1 stated Resident 51 should also keep Resident 51's razor inside a labeled wash basin and stored on Resident 51's nightstand to avoid getting or spreading infection. b.2. During a review of Resident 118's AR, the AR indicated Resident 118 was admitted to the facility on [DATE] with diagnoses including a history of falling, malaise (a general feeling of discomfort, illness, or lack of well-being), and hypertension (abnormally high blood pressure). During a review of Resident 118's MDS dated [DATE], the MDS indicated Resident 118 had intact cognition. The MDS indicated Resident 118 required set up or clean up assistance (a helper sets up or cleans up prior to or after a resident completes the activity) from staff for oral hygiene, personal hygiene, and upper body dressing. During a concurrent observation and interview on 6/30/2026 at 11:31 AM with CNA 1, CNA 1 stated the orange-colored toothbrush that was found inside Resident 118's shared bathroom on top of the sink belonged to Resident 118. CNA 1 stated a resident's personal care item such as toothbrushes and razors should be placed in a labeled wash basin and stored inside or on top of the resident's bedside dresser. CNA 1 stated Resident 118's toothbrush should have been in a labeled container and stored in or on Resident 118's dresser because another resident could accidentally use Resident 118's toothbrush. During an interview on 7/2/2026 at 11:31 AM with the facility's Director of Nursing (DON), the DON stated personal care items such as razors and toothbrushes should be placed in a labeled wash basin stored inside the resident's bedside dresser. The DON stated the wash basin could be brought to a shared bathroom when personal care items were needed and returned to the resident's dresser after each use. The DON stated the purpose of having personal care items labeled and properly stored was to avoid the spread of infection. During a review of the facility's Policy and Procedure (P&P) titled, Infection Prevention and Control Program, revised 8/2016, the P&P indicated the infection prevention and control program is a facility-wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program. The P&P further indicated facets of infection prevention included instituting measures to avoid complications or dissemination of infection.

Based on observation, interview, and record review the facility failed to maintain complete and accurate medical records for three of three sampled residents (Residents 9, 12 and 123) by failing to document:a. Wound treatments for Resident 9.b. A physician's transfer order for Resident 12. c. Accurate oxygen saturation reading of Resident 123 on [DATE] at 6:46 AM. These failures had the potential to negatively impact evaluation of Resident 9's wound progression or regression, affect Resident 9's and 12's care and delivery of services and resulted in an inaccurate assessment of Resident 123's respiratory status after the resident expired.Findings: a. During a review of Resident 9's admission Record (AR), the AR indicated Resident 9 was admitted to the facility on [DATE] with diagnoses including bilateral (both sides) primary osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage) of the knees and encounter for palliative care (medical care that focuses on providing relief from pain and other symptoms of a serious/terminal illness. During a review of Resident 9's Minimum Data Set (MDS, a resident assessment tool), dated [DATE], the MDS indicated Resident 9 had moderately impaired cognition (ability to understand). The MDS indicated Resident 9 had one Stage 4 pressure ulcer (St. 4 PU- Full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) and received pressure ulcer (PU) care. During a review of Resident 9's untitled Care Plan (CP) dated [DATE], the CP indicated Resident 9 was admitted to the facility with a stage 4 PU to the sacrum (large triangular bone at the base of the spine). The CP intervention indicated for licensed staff to provide treatment as ordered by cleansing the sacrum with normal saline (NS), pat dry, apply hydrogel (a gel used for wound care), and cover with dry dressing. During a review of Resident 9's Treatment Administration Record (TAR) for [DATE] – [DATE], the TAR indicated on [DATE] and [DATE] the treatment to clean the sacrum with normal saline (NS), pat dry, apply hydrogel and cover with dry dressing, every day shift for 30 days was left blank During an observation on [DATE] at 10:59 am, Resident 9 was asleep in bed. During an interview on [DATE] at 3:15 pm with Treatment Nurse 1 (TN 1), TN 1 stated the treatment nurses forgot to chart Resident 9's treatment on [DATE] and [DATE]. TN 1 stated, it was important to document in the TAR to validate that the treatment was completed. During an interview on [DATE] at 10:18 am with the Director of Nursing (DON), the DON stated PU treatments should be documented on the TAR by the treatment nurse every time the treatment was completed. The DON stated, if the TAR was left unsigned, the treatment was not done. During a review of the facility's Policy and Procedure (P&P) titled, Charting and Documentation, dated 2001, the P&P indicated, all services provided to the resident, progress toward care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The P&P indicated, treatments or services performed were to be documented in the resident medical record. b. During a review of Resident 12's AR, the AR indicated Resident 12 was admitted to the facility on [DATE] with diagnoses including history of falling, dysphagia (difficulty swallowing), and dementia (a progressive state of decline in mental abilities). During a review of Resident 12's MDS dated [DATE], the MDS indicated Resident 12 had severely impaired cognition. During a review of Resident 12's Transfer to Hospital Summary dated [DATE], the summary indicated Resident 12 was transferred to an acute care hospital after a fall. During a review of Resident 12's Nurses Notes (NN) dated [DATE], the NN indicated Resident 12's the licensed nurse received an order from the on-call physician to send Resident 12 to the emergency room for evaluation and treatment. During a review of Resident 12's re-admission Notes (RAN) dated [DATE], the RAN indicated Resident 12 returned and readmitted back to the facility after the transfer to an acute care hospital on [DATE]. During a concurrent interview and record review on [DATE] at 2:32 pm with Registered Nurse Supervisor 1 (RN 1), Resident 12's Physician Order Summary (OS) was reviewed. The OS did not have an order placed on [DATE] in the medical record of Resident 12 to reflect Resident 12's transfer to an acute care hospital. RN 1 stated there was no order for Resident 12's acute care hospital transfer on [DATE] in Resident 12's medical record. RN 1 stated it was necessary to have the order for Resident 12's acute care hospital transfer on [DATE] in Resident 12's medical record. During an interview on [DATE] at 10:13 am with the Director of Nursing (DON), then DON stated once a transfer order was received by licensed nursing staff, it should be documented in a progress note and input the physician's order. The DON stated, failing to do this documentation made the physician's order incomplete. During a review of the facility's P&P titled, Telephone Orders, dated 2/2014, the P&P indicated, verbal telephone orders may only be received by licensed personnel and must be reduced to writing, by the person receiving the order, and recorded in the resident's medical record. During a review of the facility's P&P titled, Charting and Documentation, dated 2001, the P&P indicated, all services provided to the resident, progress toward care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The P&P indicated, treatments or services performed were to be documented in the resident medical record. c. During a review of Resident 123's admission Record (AR), the AR indicated Resident 123 was admitted to the facility on [DATE] with diagnoses including heart failure (the heart cannot pump enough blood to meet the body's needs), acute respiratory failure (lungs cannot get enough oxygen into the blood) and encounter for palliative care (medical service designed to give supportive care to people in the final phase of a terminal illness and focus on comfort and quality of life). During a review of Resident 123's History and Physical (H&P) dated [DATE], the H&P indicated Resident 123 had the capacity to understand and make decisions. During a review of Resident 123's Minimum Data Set (MDS- a resident assessment tool) dated [DATE], the MDS indicated Resident 123 required partial/moderate assistance (helper does less than half the effort) from staff to shower and lower body dressing. The MDS indicated Resident 123 required supervision (touching assistance) for toileting hygiene, upper body dressing, and personal hygiene. The MDS indicated Resident 123 required set up or clean-up assistance for eating, and oral hygiene. The MDS also indicated Resident 123 was on oxygen therapy. During a review of Resident 123's Progress Notes (PN) dated [DATE] at 3:40AM, the PN indicated the licensed nurse went to check Resident 123 and was unable to obtain vital signs; no blood pressure, no pulse, no respiration; patient appeared to have expired at this time. MD and family were notified and postmortem care (care provided to a person's body after they have died) was rendered to Resident 123. During a review of Resident 123's Weights and Vitals Summary (WVS) dated [DATE] at 6:46AM, the WVS indicated Resident's oxygen saturation was 92%. During an interview and record review (RR) with the DON on [DATE] at 1:04PM, the DON stated the documentation in Resident 123's WVS indicating Resident 123's oxygen saturation level was at 92% on [DATE] at 6:46 AM was inaccurate. The DON stated Resident 123 had expired on [DATE] at 3:40AM and the staff should not have documented that Resident 123's oxygen level was 92% at 6:46AM. During an interview and RR with License Vocational Nurse 1 (LVN1) on [DATE] at 8:42AM, LVN1 stated documentation completed in the resident's chart should be accurate. LVN1 stated documenting that Resident 123's oxygen saturation level was at 92% three (3) hours after the resident had expired was considered an error and it should have been corrected by the staff. During a review of the facility's policy and procedure (P&P) titled, Charting and Documentation, dated 2001, the P&P indicated, all services provided to the resident, progress toward care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The P&P indicated, treatments or services performed were to be documented in the resident medical record.

Based on observation, interview, and record review, the facility failed to properly cover two of three large trash bins as indicated in the facility's Policy and Procedure (P&P) on garbage disposal. This deficient practice had the potential to attract vermin (animals that are harmful and carry diseases) and pests (any living thing that has a negative effect on humans) that could potentially enter the facility, affect the resident care areas, and expose the residents and staff to diseases.Findings:During a facility tour observation on 6/30/26 at 8 AM, two (2) large trash bins were overfilled with trash. The trash bins had open lids, and there was trash on the floor surrounding the trash bin area. During an observation and interview with the Dietary Supervisor (DS) outside in the parking lot area on 6/30/26 at 9:18 AM, the DS stated the two trash bins outside in the parking lot should be closed and there should not be any trash discarded on the floor. The DS stated that when there was trash on the floor and the lids on the trash bins were not closed, it could attract rodents and critters. The DS stated having trash on the floor and open trash bins was an infection control issue and it was not sanitary. During an observation outside the facilities entrance door in the parking lot area on 7/1/26 at 3:15 PM, there was a trash can container not covered and with no lid. The trash can contained left over food containers, food wrappers, and soda cups that had attracted flies. There were multiple pieces of trash throughout the facility's parking lot area such as discarded blue gloves, food wrappers and cigarette buts. During an interview with the Director of Nursing (DON) on 7/1/26 at 3:41 PM, the DON stated the trash bins should always be covered with lids for infection control. The DON stated the trash bin lid should be kept closed at all times because it was unsanitary and to prevent cross contamination (transfer from one substance or object to another, with harmful effect) and rodent infestation. During a review of the facility's P&P titled, Sanitation, revised 11/22, the P&P indicated, Garbage and refuse containers are in good condition, without leaks, and waste is properly contained in dumpsters/compactor with lids (or otherwise covered). Areas used for garbage disposal are free from odors and waste fats and maintained to prevent pests. During a review of the facility's Policies and Procedures titled, Policies and Practices-Infection Control, revised 8/26, the P&P indicated, This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections.

Based on observation, interview, and record review, the facility failed to ensure safe food storage practices for two of two of the residents' refrigerators, by failing to:a. Discard a container of ultra pasteurized milk with a used by date of 6/29/26.b. Discard a gallon of whole milk with no open date.These deficient practices had the potential to result in food-borne illnesses (illness caused by ingesting contaminated food or beverages) for the residents.Findings:During a concurrent observation and interview with the Dietary Supervisor (DS) on 7/30/26 at 9:12 AM, the DS stated there were 2 residents' refrigerators. Inside the refrigerator located in Nurse Station South, there was a container of ultra pasteurized milk with a use by date of 6/29/26. Inside the refrigerator located in Nurse Station North, there was a gallon of whole milk with no open date. The DS stated expired or non-labeled foods should be discarded. The DS stated nursing staff were responsible for checking and cleaning the residents' refrigerators. The DS stated the items inside the residents' refrigerators should have a use by date or expiration date. The DS stated that when food items inside the residents' refrigerators were expired, it should be removed from the refrigerators and not being given to the residents. The DS stated that when the residents eat or drink expired food, the expired food could make the residents sick. During an interview with the Director of Nursing (DON) on 7/1/26 at 3:43 PM, the DON stated expired food should not be placed inside the residents' refrigerators due to the residents could get sick when they ate expired food.During an interview with License Vocational Nurse (LVN) 1 on 7/02/2026 8:45 AM, LVN 1 stated there were residents' refrigerators located at the nurses' stations. LVN 1 stated when the residents' family members brought food to the residents, license nurses (in general) would place the food item inside one of the residents' refrigerators and License nurses also need to label the date when they received the food items from the family member with the residents' name, room number and expiration day. LVN 1 stated the food item was only kept for one (1) day. LVN 1 stated, We don't keep it for longer, if the resident doesn't eat it that same day, then we remove it from the refrigerator and throw the food item away. LVN 1 stated that when the food item inside the refrigerator was not labeled with a received or opened date, then the staff could not know when the food would be expired. LVN 1 stated that when a resident would eat expired food, the residents could get stomach aches, nausea, vomiting and diarrhea. During a review of the facility's undated Policies and Procedures (P&P) titled, Food Receiving and Storage, revised 11/22, the P&P indicated foods shall be received and stored in a manner that complies with safe food handling practices. The P&P indicated all foods belonging to residents are labeled with the resident's name, the item and the use by date.

Based on observation, interview, and record review, the facility failed to ensure safe food storage practices in one of one facility kitchen (Kitchen 1), by failing to:Discard a bag containing three (3) bagels that was not dated.Discard a tray containing 3 bags of ham dated 6/26/26.Discard one a tray containing 5 strawberries and 2 orange ice cream cups dated 6/27/26. These deficient practices had the potential to result in food-borne illnesses (illness caused by ingesting contaminated food or beverages) for the residents.Findings:During a concurrent observation and interview with the Dietary Supervisor (DS) inside the facility kitchen on 6/30/26 at 8:43 AM, there was a bag of bagels inside the freezer that was not labeled. Inside the refrigerator, there was a tray containing 3 bags of ham dated 6/26/26. Inside the walk-in freezer there was a tray containing 5 strawberries and 2 orange ice cream cups dated 6/27/26. The DS stated there was no use by or expiration date on any of these food items. The DS stated that since there was no clear date indicating an expiration date, these items should have been removed from the refrigerator and thrown out. The DS stated food items that do not have a use by or expiration date could be expired. The DS stated it was important to label and date the food items for the residents' safety, since expired food items could make the residents sick by causing the residents to get a stomachache, vomiting, nausea and diarrhea.During an interview with the Director of Nursing (DON) on 7/1/26 at 3:45 PM, the DON stated there should not be any expired food inside the facility's kitchen refrigerator. The DON stated the DS was responsible for ensuring there was no expired food inside the kitchen refrigerator. The DON stated when there was any expired food inside the kitchen refrigerator, the food item should be thrown out in the trash. The DON stated expired food could make the residents sick.During a review of the facility's Policy and Procedure (P&P) titled, Food Receiving and Storage, revised 11/22, the P&P indicated, Foods shall be received and stored in a manner that complies with safe food handling practices. All foods stored in the refrigerator or freezer are covered, labeled and dated ( use by date). Refrigerated foods are labeled, dated and monitored so they are used by their use by date, frozen, or discarded.During a review of the facility's P&P titled, Policies and Practices- Infection Control, revised 11/22, the P&P indicated, This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections.

Based on interview and record review, the facility failed to develop and implement specific, comprehensive, and individualized person-centered care plan (CP) to meet the residents' needs for two of two sampled residents (Residents 53 and 76) by failing to: a. Develop an individualized CP to address Resident 53's diagnosis of dementia (a decline in mental abilities severe enough to interfere with daily life). b. Develop an individualized CP to address Resident 76's fall that occurred on 6/16/2026. These failures resulted in Residents 53 and 76 not receiving individualized care to maintain the residents' highest practicable physical, mental, and psychosocial well-being. Findings: a. During a review of Resident 53's AR, the AR indicated the facility admitted Resident 53 on 1/6/2025 with diagnoses including unspecified psychosis (a mental state where a person loses touch with reality, resulting in disrupted thoughts and perceptions), dementia (a decline in mental abilities severe enough to interfere with daily life) and Alzheimer's Disease ( irreversible, progressive brain disorder that slowly destroys memory and thinking skills, and eventually the ability to carry out the simplest tasks). During a review of Resident 53's MDS dated [DATE] the MDS indicated Resident 53 had moderately impaired cognition. The MDS indicated Resident 53 required partial (helper does less than half the effort) assistance with eating and upper body dressing. The MDS indicated Resident 53 required substantial assistance (helper does more than half the effort) from staff with oral, personal hygiene, showers, putting on/taking off footwear and lower body dressing. The MDS indicated Resident 53 was dependent (helper does all the effort) from staff with toileting hygiene. During a record review and interview with RN 1 on 7/1/2026 at 8:57AM, RN1 stated Resident 53 had a diagnosis of dementia upon admission. Resident 53's care plans (CP) were reviewed. RN 1 stated there was no CP developed and implemented for dementia for Resident 53 since Resident 53's admission to the facility. RN 1 stated there should be a CP in place to address Resident 53's dementia for staff to know specific interventions to address Resident 53's dementia. During a record review and interview with the DON on 7/1/2026 at 12:54PM, the DON stated Resident 53 had a diagnosis of dementia but there was no care plan initiated to address Resident 53's dementia. The DON stated there should be a CP including interventions identified for Resident 53's dementia. The DON stated the licensed nurses were responsible for creating/developing the CPs for the residents. The DON stated that without a CP to address Resident 53's dementia, there were no interventions in place for Resident 53's dementia care. The DON stated the CP identified interventions for specific care concerns. The DON stated the CP needed to be specific, individualized, and resident-centered to address the resident's specific diagnosis, medications, and behavior. During a review of the facility's undated P&P titled, Care Plan-Comprehensive, the P&P indicated an individualized comprehensive care plan includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. b. During a review of Resident 76's admission Record (AR), the AR indicated Resident 76 was admitted to the facility on [DATE] with diagnoses including dementia, heart failure (when the heart muscle is too weak to pump blood effectively) and chronic obstructive pulmonary disease (COPD-a long-term lung condition that makes it hard to breathe). During a review of Resident 76's History and Physical Examination (H&P – a comprehensive assessment of a resident's medical condition) dated 8/17/2025, the H&P indicated Resident 76 did not have the capacity to understand and make decisions. During a review of Resident 76's Minimum Data Set (MDS – a resident assessment tool) dated 6/22/2026, the MDS indicated Resident 76 had moderately impaired cognition (ability to understand). The MDS indicated Resident 76 was dependent (a helper does all of the effort of the activity) for toileting hygiene. The MDS also indicated Resident 76 required maximal assistance (a helper does more than half the effort of the activity) for eating, personal hygiene, and shower/bathe. During a concurrent interview and record review on 7/1/2026 at 11:48 AM with Registered Nurse 1 (RN 1), Resident 76's electronic record was reviewed. RN 1 stated care plans were created and/or updated by licensed nurses. RN 1 stated care plans consisted of a specific resident issue, nursing interventions (actions) that addressed the issue, and a goal that showed an issue had improved or resolved. RN 1 stated Resident 76's Behavior Note, dated 6/16/2026 indicated that on 6/16/2026 at 5:40 AM, Resident 76 was found on a floor mat (a removable piece of soft material placed on the floor near the bedside for residents who were high risk for falls) crawling and noted with a skin tear to the right forearm. RN 1 stated a care plan should be created or updated whenever a resident was discovered to have fallen. RN 1 stated Resident 76 did not have a care plan that specifically addressed the fall incident that occurred on 6/16/2026. During an interview on 7/2/2026 at 11:31 AM with the Director of Nursing (DON), the DON stated care plans consisted of resident specific problems, goals related to the specific problems, and nursing interventions that addressed the problems. The DON stated a care plan should be created whenever there was an incident such as a fall. The DON stated there should have been a care plan created after Resident 76's fall on 6/16/2026. The DON stated care plans were important so that nursing staff know how to provide care to address a resident's specific care concerns. During a review of the facility's undated P&P titled Care Plans, Comprehensive, the P&P indicated the resident's comprehensive care plan is designed to incorporate identified problem areas and to aid in preventing or reducing declines in the resident's functional status and/or functional levels. The P&P further indicated care plans reflect treatment goals, timetables and objectives in measurable outcomes.

Based on interview and record review, the facility failed to ensure two of two sampled residents' (Residents 12 and 116) Minimum Data Set (MDS - a federally mandated resident assessment tool) assessments were accurately documented to reflect: a. Resident 12's fall on 3/11/2026. b. Resident 116's discharge location/destination on 3/3/2026. These failures had the potential to negatively affect Resident 12 and 116's plan of care and delivery of necessary care and services. Findings: a. During a review of Resident 12's admission Record (AR), the AR indicated Resident 12 was admitted to the facility on [DATE] with diagnoses including history of falling, dysphagia (difficulty swallowing), and dementia (a progressive state of decline in mental abilities). During a review of Resident 12's MDS dated [DATE], the MDS indicated Resident 12 had severely impaired cognition (ability to understand) and did not have a fall any time in the last month prior to admission/entry or reentry. During a review of the Accident/Incident Report (AIR) dated 3/11/2026 at 12:13 am, the AIR indicated Resident 12 was found on the floor by the nurse (unidentified) beside the bed, was assessed, and fall precautions were put in place. During a review of Resident 12's Transfer to Hospital Summary dated 3/11/2026 at 2:17 am, the summary indicated Resident 12 was transferred to an acute care hospital after a fall. During an observation on 7/1/2026 at 2:25 pm, Resident 12 was observed sitting upright in a wheelchair across from the nursing station. During a concurrent interview and record review on 7/2/2026 at 9:29 am with the Minimum Data Set Coordinator (MDSC), Resident 12's MDS, dated [DATE], was reviewed. The MDS indicated Resident 12 did not have a fall any time in the last month prior to admission/entry or reentry. The MDSC stated Resident 12 had a fall on 3/11/2026 and the MDS documentation was incorrect. The MDSC stated submitting the MDS to Centers for Medicare and Medicaid Services (CMS) meant giving an accurate assessment of the residents. During an interview on 7/2/2026 at 10:17 am with the Director of Nursing (DON), the DON stated it was important that the MDS submissions were accurate because the facility tracked the resident's conditions that were submitted to CMS. The DON stated the MDS information submitted to CMS needed to be accurate. During a review of the facility's Policy and Procedure (P&P) titled, Charting and Documentation, dated 2001, the P&P indicated documentation in the medical record would be objective (not opinionate or speculative), complete, and accurate. During a review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.20.1, dated October 2025, the manual indicated the RAI process had multiple regulatory requirements. The manual indicated, federal regulations at 42 CFR 483.20 (b)(1)(xviii), (g), and (h) required that the assessment accurately reflect the resident's status. b. During a review of Resident 116's AR, the AR indicated Resident 116 was admitted to the facility on [DATE] with diagnoses including end stage renal disease (irreversible kidney damage), anemia (a condition where the blood lacks enough healthy red blood cells to carry adequate oxygen to the body's tissues) and encounter for palliative care (medical service designed to give supportive care to people in the final phase of a terminal illness and focus on comfort and quality of life). During a review of Resident 116's Discharge Summary Recapitulation of Stay (DSROS) dated 3/3/26 at 10:12 am, the DSROS indicated Resident 116 was discharged home with hospice care (palliative care). During a review of Resident 116's MDS dated [DATE], the MDS indicated Resident 116 had severely impaired cognition. The MDS indicated Resident 116 was dependent (helper does all of the effort) on staff for oral, personal and toileting hygiene, showers putting on or taking off footwear and lower body dressing. The MDS did not indicate Resident 116's discharge location/destination. During a record review and interview with the Director of Nursing (DON) on 7/2/2026 at 10:17AM, the DON stated there was no documentation in Resident 116's MDS dated [DATE] indicating Resident 116's discharge location/destination. The DON stated it was important to submit accurate MDS documentation to keep track of the resident's condition. The DON stated the MDS nurse was responsible for submitting accurate MDS information to CMS. During record review and interview with the Minimum Data Set Coordinator (MDSC) on 7/2/26 at 11:40 AM, the MDSC stated the discharge location of Resident 116 was not completed in the MDS dated [DATE]. The MDSC stated Resident 116 was discharged home on 3/3/26 but the discharge location in the MDS dated [DATE] was not completed. The MDSC stated that the MDSC forgot to complete the discharge destination section of Resident 116's MDS. During a review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.20.1, dated 10/2025, the manual indicated the RAI process had multiple regulatory requirements. The manual indicated, federal regulations at 42 CFR 483.20 (b)(1)(xviii), (g), and (h) required that the assessment accurately reflected the resident's status.

Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 110) received dialysis (a treatment involving the removal of extra fluid and waste products from the blood when the kidneys are unable to function properly) care consistent with professional standards of practice, when the facility failed to take Resident 110's vital signs (measurements of the body's most basic functions such as heart rate and blood pressure) upon arrival to the facility after receiving dialysis on 6/30/2026. This deficient practice had the potential to result in adverse (harmful) consequences on Resident 110. Findings: During a review of Resident 110's admission Record (AR), the AR indicated Resident 110 was admitted to the facility on [DATE] with diagnoses including end stage renal disease (when the kidneys can no longer function on their own to filter blood) and heart failure (when the heart muscle is too weak to pump blood efficiently). During a review of Resident 110's History and Physical Examination (H&P - a comprehensive assessment of a resident's medical condition) dated 9/1/2025, the H&P indicated Resident 110 had the capacity to understand and make decisions. During a review of Resident 110's Order Summary Report (OSR) dated 11/25/2025, the OSR indicated Resident 110 had an order to receive dialysis every Tuesday, Thursday, and Saturday at a dialysis center located outside of the facility.\ During a review of Resident 110's Minimum Data Set (MDS - a resident assessment tool) dated 5/18/2026, the MDS indicated Resident 110 was cognitively (ability to understand) intact. The MDS indicated Resident 110 required moderate assistance (a helper does less than half of the effort) from staff for toileting hygiene and shower/bathe. During a concurrent interview and record review on 7/1/2026 at 1:33 PM with Registered Nurse 2 (RN 2), Resident 110's electronic record was reviewed. RN 2 stated Resident 110's most recent dialysis treatment was on 6/30/2026. RN 2 stated the Progress Note (PN) dated 6/30/2026 indicated Resident 110 left the facility for dialysis on 6/30/2026 at 10:01 AM. RN 2 stated the PN dated 6/30/2026 indicated Resident 110 returned to the facility from dialysis on 6/30/2026 at 2:34 PM. RN 2 stated it was standard nursing practice to check the Resident 110's vital signs before being transported to the dialysis center, immediately after receiving dialysis (at the dialysis center) and when the resident returned back to the facility after dialysis. RN 2 stated the vital signs would be documented on a form called Pre-Dialysis and Post-Dialysis Assessment. RN 2 stated that when a resident returned to the facility after dialysis, vital signs should be checked and documented electronically in the facility's computer system. During a concurrent interview and record review on 7/1/2026 at 1:57 PM with RN 2, Resident 110's medical chart and electronic record were reviewed. RN 2 stated Resident 110's Pre-Dialysis and Post-Dialysis Assessment dated 6/30/2026 indicated Resident 110's vital signs were checked before Resident 110 was transported to the dialysis center on 6/30/2026. RN 2 stated the Pre-Dialysis and Post-Dialysis Assessment also indicated Resident 110's vitals were checked at the dialysis center on 6/30/2026. RN 2 stated Resident 110's electronic record did not show that Resident 110's vitals were checked on 6/30/2026 when Resident 110 returned back to the facility after dialysis. RN 2 stated the purpose of checking vital signs when Resident 110 arrived at the facility after dialysis was to ensure Resident 110 was physically in stable condition. During an interview on 7/2/2026 at 11:31 AM with the Director of Nursing (DON), the DON stated it was standard nursing practice to check the resident's vital signs before transporting the resident to the dialysis center. The DON stated if the resident's blood pressure was low, the assigned licensed nurse would notify the dialysis center for possible cancellation of dialysis treatment. The DON stated the resident's vital signs needed to be documented on the designated dialysis form. The DON stated upon the resident's return to the facility after dialysis, vital signs should be checked because of the possibility that the resident's blood pressure could have dropped as a result of dialysis. During a review of the facility's Policy and Procedure (P&P) titled, Dialysis Procedure, dated 2001, the P&P indicated post-dialysis nursing responsibilities included monitoring and documenting vital signs. The P&P further indicated complications requiring immediate notification of the doctor include severe hypotension (abnormally low blood pressure).

Based on observation, interview, and record review, the facility failed to ensure the nasal cannula oxygen tubing (a flexible tube that administers oxygen through the nose) for one of two sampled residents (Resident 1) was labeled with date and time in accordance with the facility's policy on oxygen administration. This deficient practice had the potential to result in respiratory complications for Resident 1 associated with oxygen therapy. Findings: During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including pneumonitis (the swelling or irritation of tiny air sacs in the lungs), cardiomyopathy (when the heart muscle has become thick, stiff, or enlarged), and anemia (a condition where a person lacks enough healthy red blood cells to carry oxygen throughout the body). During a review of Resident 1's History and Physical Examination (H&P - a comprehensive assessment of a resident's medical condition) dated 2/22/2026, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1's Order Summary Report (OSR) dated 3/27/2026, the OSR indicated an order for licensed staff to change and label oxygen tubing every night shift starting on the 15th and ending on the 15th every month. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 5/18/2026, the MDS indicated Resident 1's cognitive skills (mental ability) for daily decision making was severely impaired. The MDS indicated Resident 1 was dependent (helper does all of the effort of the activity) on staff for eating, toileting hygiene, and shower/bathe. During an observation on 6/30/2026 at 11:04 AM inside Resident 1's room, Resident 1 was lying in bed. Resident 1's nasal cannula oxygen tubing did not have a label indicating when it was last changed/replaced. During a concurrent observation and interview on 6/30/2026 at 11:09 AM with Infection Preventionist Nurse 1 (IPN 1) at Resident 1's bedside, IPN 1 stated Resident 1's nasal cannula oxygen tubing did not have a label indicating when it was last changed/replaced. IPN 1 stated oxygen tubing was supposed to be labeled in accordance with facility policy to prevent infection. During an interview on 7/2/2026 at 11:31 AM with the Director of Nursing (DON), the DON stated oxygen tubing should be labeled with date and time. The DON stated it was the facility's policy to change oxygen tubing on the 15th of the month and at the end of each month. The DON stated the purpose of labeling oxygen tubing was to prevent/control infection. The DON stated labeling oxygen tubing also prevented cross contamination because each oxygen tubing was for a specific resident's personal use. During a review of the facility's Policy and Procedure (P&P) titled, Oxygen Administration / Respiratory Supply, revised 4/1/2026, the P&P indicated all residents on oxygen either continuous or as needed, should be monitored by all nursing staff of the facility. The P&P indicated all oxygen supplies, including tubing, nasal cannula, mask, nebulizer, and nebulizer tubing, should be changed the 15th and end of the month, documenting the date and time.

Based on observation, interview, and record review, the facility failed to revise a care plan for one of one sampled resident (Resident 12), who sustained a fall on 3/11/2026. This failure had the potential to place Resident 12 at risk for recurrent falls. Findings: During a review of Resident 12's admission Record (AR), the AR indicated Resident 12 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including history of falling, dysphagia (difficulty swallowing), and dementia (a progressive state of decline in mental abilities). During a review of Resident 12's Care Plan (CP) dated 3/4/2026, the CP indicated Resident 12 was at risk for falls related to diagnosis of cerebrovascular accident (CVA-stroke, loss of blood flow to a part of the brain). During a review of Resident 12's Minimum Data Set (MDS, a resident assessment tool) dated 3/23/2026, the MDS indicated Resident 12 had severely impaired cognition (ability to understand). During a review of Resident 12's Accident/Incident Report (AIR) dated 3/11/2026 at 12:13 am, the AIR indicated Resident 12 was found on the floor by the nurse (unidentified), beside the bed, was assessed and fall precautions were put in place. During a review of Resident 12's Transfer to Hospital Summary dated 3/11/2026 at 2:17 am, the summary indicated Resident 12 was transferred to an acute care hospital after a fall. During an observation on 7/1/2026 at 2:25 pm, Resident 12 was observed sitting upright in a wheelchair across from the nursing station. During an interview on 7/1/2026 at 2:25 pm with Registered Nurse Supervisor 1 (RN 1), RN 1 stated Resident 12 had an unwitnessed fall on 3/11/2026. RN 1 stated Resident 12's care plan was not updated after Resident 12 fell on 3/11/2026 and should have been. During an interview on 7/2/2026 at 10:14 am with the Director of Nursing (DON), the DON stated if a resident had a change in condition (fall), the care plan should be revised. The DON stated it was important to revise the CP after a fall to prevent further falls. During a review of the facility's undated Policy and Procedure (P&P) titled, Care Plan Revision Policy, the P&P indicated, the facility shall review and revise each resident's comprehensive, person-centered CP to ensure it accurately reflected the resident's current medical, nursing, psychosocial, functional, nutritional, and discharge planning needs. The P&P indicated, CPs would be updated whenever assessments identified changes requiring modification of goals or interventions and the interdisciplinary team would review and revise the comprehensive CP after accidents, falls, pressure injuries, infections, weight changes, behavioral changes, or other clinically significant events.

Based on interview and record review, the facility failed to accurately complete a Preadmission Screening and Resident Review Level I screening (PASRR I-the prescreening process which determines if a resident has a serious mental illness [SMI-diagnosable mental, behavioral, or emotional disorder that significantly impairs a person's ability to function in major life activities], intellectual disability [ID], developmental disabilities [DD], or related condition [RC]) for one of two sampled residents (Resident 3) when Resident 3's PASRR I indicated Resident 3, who was diagnosed with schizophrenia (a mental illness characterized by disturbances in thought), did not have a SMI.This failure resulted in Resident 3 not receiving the PASRR level 2 screening (PASRR II-a required federal assessment that ensures individuals with a SMI or ID are placed in appropriate facilities) and had the potential for Resident 2 to not receive specialized services (the services specified by the State that exceed the services ordinarily provided by the nursing facility) for SMI.Findings:During a review of Resident 3's admission Record (AR), the AR indicated the facility originally admitted Resident 3 on 7/12/2019 with a readmission on [DATE] with diagnoses including generalized osteoarthritis (a condition where the cushioning between the joints wears down over time, causing pain, stiffness, and swelling), anxiety disorder (a mental illness characterized by excessive, persistent, and irrational worry or fear that can interfere with daily life), and schizophrenia. During a review of Resident 3's History and Physical (H&P), dated 3/20/2026, the H&P indicated Resident 3 did not have the capacity to understand and make decisions.During a review of Resident 3's Minimum Data Set (MDS- a resident assessment tool), dated 4/17/2026, the MDS indicated Resident 3's cognitive (the ability to think and process information) skills for daily decision making were severely impaired (never/rarely made decisions). The MDS indicated Resident 3 required substantial/maximal assistance (helper does more than half the effort) with upper body dressing and dependent (helper does all the effort) on eating, oral and personal hygiene, toileting, bathing, and lower body dressing.During a concurrent interview and record review on 7/1/2026 at 12:17 PM with the Assistant Administrator (AADM), Resident 3's PASRR I, dated 1/6/2025, was reviewed. PASRR I indicated Resident 3's was negative for SMI/Negative for ID/DD/RC. The PASRR I's Section III indicated Resident 3 did not have a diagnosed SMI such as schizophrenia disorder. The AADM stated Resident 3 had a diagnosis of schizophrenia which was a SMI. The AADM stated it was important to indicate the SMI on Resident 3's PASRR I since it would ensure Resident 3 was assessed for a PASSR II.During a review of the facility's Policy and Procedure (P&P) titled, PASRR, dated 2001, the P&P's policy statement indicated, PASRR is a federal policy required before admission to a Medicaid-certified nursing facility (nursing home/SNF). Its purpose is to ensure that people with SMI or intellectual/developmental disabilities (ID/DD) are placed in the most appropriate setting and receive the services they need. The P&P's purpose indicated, Ensure specialized mental health or developmental disability services are provided when needed. The P&P's PASRR process indicated, Level 1 Screening screens every applicant for: Serious Mental Illness. The P&P's PASRR process indicated, Level II Evaluation required only if the Level I screen is positive. A comprehensive evaluation determines: Whether nursing facility placement is appropriate. Whether specialized services are needed. Recommendations for the person's care plan.

Based on interview and record review, the facility failed to ensure there was a m/b (manifestation by- refers to the specific, observable signs, symptoms, or behaviors that show a resident needs the antidepressant. It provides concrete, measurable clinical proof [e.g., crying spells, insomnia, weight loss] that justifies the medication and ensures it meets regulatory standards for residents) behavior documented for Sertraline (an antidepressant medication) ordered for one (1) of one (1) sampled resident (Resident 53). This deficient practice had the potential to result in serious health complications for Resident 53.Findings:During a review of Resident 53's admission Record (AR), the AR indicated the facility admitted Resident 53 on 1/06/2025 with diagnoses including psychosis (a mental state where a person loses touch with reality, resulting in disrupted thoughts and perceptions), dementia (a decline in mental abilities severe enough to interfere with daily life), Alzheimer's (a progressive brain disorder and the most common cause of dementia. It slowly destroys memory and cognitive skills by killing brain cells, resulting in impaired thinking, behavioral changes, and an eventual inability to carry out daily tasks) and depression (a serious mood disorder that causes persistent feelings of sadness, emptiness, and a loss of interest in activities). During a review of Resident 53's Minimum Data Set (MDS, a resident assessment tool) dated 5/8/2026, the MDS indicated Resident 53 had moderate cognitive impairment (moderate problems with thinking and memory). The MDS indicated Resident 53 required partial (helper does less than half the effort) assistance with eating and upper body dressing. The MDS indicated Resident 53 required substantial (helper does more than half the effort) from staff with oral, personal hygiene, showers, putting on/taking off footwear and lower body dressing. The MDS indicated Resident 53 was dependent (helper does all the effort) of staff with toileting hygiene. During a record review and interview with the Director of Nursing (DON) on 7/1/26 at 12:54PM, Resident 53's Order Summary Report (OSR) dated 2/11/26 at 1:21PM, indicated, Sertraline HCl (an antidepressant) Oral Tablet 50 MG (Sertraline HCl). Give 0.5 tablet by mouth one time a day for depression m/b. The DON stated the order for Sertraline did not specify m/b reason as to why the resident was taking an antidepression. The DON stated nursing staff were monitoring Resident 53 for depression, but the actual Physician (MD) order did mot have m/b reason. The DON stated the nurses should have clarified the order with the MD. The DON stated there was no documentation indicating that staff contacted the MD to clarify order for the antidepression. The DON stated there was no documentation recorded. The DON stated there was no notification made to the MD or progress notes (PN) from nursing staff indicating they notified the MD. During an interview with License Vocational Nurse (LVN) 1 on 7/02/2026 at 8:48AM, LVN 1 stated that when a resident was taking any kind of antidepression medication, the MD order needed to specify the behaviors that the resident was exhibiting. LVN 1 stated the m/b explained the reason as to why the resident was receiving the medication (antidepressant). LVN 1 stated that in the MD order for Resident 53 for Sertraline dated 2/11/26 at 1:21PM, the m/b behaviors were not included. LVN 1 stated that when there were no m/b behaviors included in the MD order, then staff should have called the doctor to clarify the order and to make sure there really was a m/b behavior for the resident. LVN 1 stated the nurses were responsible for documenting that information in the progress notes. During a review of the facility's undated Policy and Procedures (P&Ps) titled, Physician Medication Orders, the P&P indicated, the orders for medications must include:a. Name and strength of the drug;b. Quantity or specific duration of therapy;c. Dosage and frequency of administration;d. Route of administration if other than oral; ande. Reason or problem for which given. During a review of the facility's P&P titled, Quality of Life-Dignity, dated 10/2009 the P&P indicated, Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. During a review of the facility's undated P&P titled, Quality of Care Policy, the P&P indicated The purpose of this policy is to ensure that high-quality, safe, effective, and person-centered care is consistently provided to all individuals receiving services. The organization is committed to continuous quality improvement and compliance with all applicable laws, regulations, and professional standards.

Based on interview and record review the facility failed to ensure the advance directive (AD-a legal document explaining a resident's health care wishes if he or she cannot speak for themselves) for one of two sampled residents (Resident 3) was accessible to facility staff as indicated in the facility's policy and procedure (P&P) titled, Advance Directives when Resident 3's AD was stored in the medical records office.This failure had the potential to result in conflict regarding Resident 3's choices regarding health care decisions.Findings:During a review of Resident 3's admission Record (AR), the AR indicated the facility originally admitted Resident 3 on 7/12/2019 with a readmission on [DATE] with diagnoses including generalized osteoarthritis (a condition where the cushioning between the joints wears down over time, causing pain, stiffness, and swelling), anxiety disorder (a mental illness characterized by excessive, persistent, and irrational worry or fear that can interfere with daily life), and schizophrenia (a mental illness characterized by disturbances in thought). During a review of Resident 3's History and Physical (H&P), dated 3/20/2026, the H&P indicated Resident 3 did not have the capacity to understand and make decisions.During a review of Resident 3's Minimum Data Set (MDS- a resident assessment tool), dated 4/17/2026, the MDS indicated Resident 3's cognitive (the ability to think and process information) skills for daily decision making were severely impaired (never/rarely made decisions). The MDS indicated Resident 3 required substantial/maximal assistance (helper does more than half the effort) with upper body dressing and dependent (helper does all the effort) on eating, oral and personal hygiene, toileting, bathing, and lower body dressing.During a record review on 6/30/2026 at 2 PM, Resident 3's medical chart was reviewed. Resident 3's medical chart did not contain an AD for Resident 3.During a concurrent interview and record review on 7/2/2026 at 8:40 AM with the Social Services Director (SSD), Resident 3's AD dated 8/15/2019 was reviewed. The SSD stated the SSD obtained Resident 3's AD from the Medical Records (MR) Staff. The SSD stated Resident 3's AD should be kept in Resident 3's medical chart so it could be accessed by the facility staff. During an interview on 7/2/2026 at 8:50 AM with the MR Staff, the MR Staff stated Resident 3's AD was kept in the medical records office and was not easily accessible to facility's staff.During a review of the facility's P&P titled, Advance Directives, dated 2001, the P&P's policy statement indicated, The resident has the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment. Advance directives are honored in accordance with state law and facility policy. The P&P's policy interpretation and implementation indicated, If the resident or the resident's representative has executed one or more advance directive(s), or executes one upon admission, copies of these documents are obtained and maintained in the same section of the resident's medical record and are readily retrievable by any facility staff. The resident's wishes are communicated to the resident's direct care staff and physician by placing the AD documents in a prominent, accessible location in the medical record.

Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 12) was called by the resident's legal (official name recognized by government on documents), proper and preferred name. This failure had the potential for Resident 12 to lose dignity and individuality.Findings: During a review of Resident 12's admission Record (AR), the AR indicated Resident 12 was admitted to the facility on [DATE] with diagnoses including history of falling, dysphagia (difficulty swallowing), and dementia (a progressive state of decline in mental abilities). During a review of Resident 12's Minimum Data Set (MDS, a resident assessment tool) dated 3/23/2026, the MDS indicated Resident 12 had severely impaired cognition (ability to understand) and was dependent (helper did all of the effort, resident did none) on staff to eat. During a review of Resident 12's Quarterly Nutritional Progress Note (NPN) dated 6/23/2026 the NPN indicated Resident 12 remained on the same diet, had a good appetite and was a feeder. During an observation on 7/1/2026 at 2:25 pm, Resident 12 was observed sitting upright in a wheelchair across from the nursing station. During an interview on 7/1/2026 at 2:44 pm with Registered Nurse Supervisor (RN 1), RN 1 stated Resident 12 was a feeder, who needed assistance with feeding during all meals. During an interview on 7/2/2026 at 10:07 am with the Director of Nursing (DON), the DON stated a resident who required feeding assistance was referred as a feeder. The DON stated the facility had a list of feeders for the nursing assistants. The DON stated it was inappropriate to call residents feeders as it was a dignity issue and could cause the resident embarrassment. During a review of the facility's Policy and Procedure (P&P) titled, Dignity, revised 2021, the P&P indicated each resident shall be cared for in a manner that promoted and enhanced his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. The P&P indicated, staff speak respectfully to residents at all times, including addressing the resident by his or her name of choice and not labeling or referring to the resident by his or her room number, diagnosis, or care needs.

Based on observation, interview and record review, the facility failed to provide the correct food texture-modified diet (alters the consistency of food and liquids to make swallowing safer and easier for people with chewing or swallowing difficulties) for two of four sampled residents (Residents 1 and 2) when: 1. The facility did not ensure Resident 1 and Resident 2 received the correct food texture. 2. The facility did not ensure Dietary Supervisor checked for food texture for Resident 1 and Resident 2 before the food leaving the kitchen. These deficient practices had the potential for Residents 1 and 2 to have problems chewing and swallowing and increased the risk of choking for Residents 1 and 2 while eating. Findings: 1. During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included respiratory failure (serious condition that makes it difficult for a person to breathe on their own, lungs can't get enough oxygen into the blood) and heart failure (progressive heart disease that affects pumping action of the heart muscles, causes fatigue and shortness of breath). During a review of Resident 1's History and Physical Examination (H&P, physician's clinical evaluation and examination of the resident), dated 3/14/2026, the H&P indicated Resident 1 had the capacity to understand and make decisions.During a review of Resident 1's Care Plan for nutrition, dated 3/14/2026, the Care Plan indicated Resident 1 required a therapeutic diet (meal plan that modifies a regular diet to manage medical conditions, treat illnesses, or alter nutritional intake). The care plan indicated Resident 1's intervention was to monitor Resident 1 for food pocketing, choking, coughing, drooling, holding food in mouth and several attempts at swallowing. During a review of Resident 1's Nutrition/Dietary Note, dated 4/14/2026, the Nutrition/Dietary note indicated Resident 1 was to receive a mechanical soft texture/easy to chew food texture. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 3/17/2026, the MDS indicated Resident 1's cognitive skills (reasoning, learning, and problem-solving) for daily decision making was intact. The MDS indicated Resident 1 required maximal assistance (helper does more than half the effort) for lower body dressing, shower/bathing, toileting hygiene and putting on/off footwear. The MDS indicated Resident 1 required moderate assistance (helper does less than half the effort) for upper body dressing, oral hygiene and eating. During a review of resident 1's Order Summary Report, dated 4/17/2026, the Order Summary report indicated Resident 1 had an order for mechanical soft easy to chew diet. During an interview on 4/21/2026 at 12:48 p.m. with Resident 1, Resident 1 stated he received meat in one piece and staff cut into smaller pieces. Resident 1 stated the broccoli was hard and was not soft when he chewed it. Resident 1 stated Resident 1 had to chew food longer to be able to swallow the food more easily. During an observation on 4/21/2026 at 12:50 p.m. in Resident 1's room, Resident 1 had a food tray with broccoli and meat. Resident 1's dietary slip indicated mechanical soft diet (nutritionally adequate foods that are physically altered-chopped, ground, mashed, or pureed-to require minimal chewing)/easy to chew. During an observation on 4/22/2026 at 8:11 a.m. in Resident 1's room, Resident 1 had a bowl of grapes, cut in half with skin on and melon cut in rectangle shape. During an interview on 4/22/2026 at 8:15 a.m. with Resident 1, Resident 1 stated grapes and melons looked big in size and would not eat them. During an interview on 4/22/2026 at 2:13 p.m. with the Dietary Supervisor (DS), The DS stated a mechanical soft diet was soft, easy to chew food texture, food in ground meat consistency, and soft vegetables. The DS stated broccoli needed to be chopped up into small pieces and did not know the size of food should be cut into. During a review of facility's P&P titled, Level 7 Regular Easy to Chew, undated, the P&P indicated it was a mechanical altered diet that consist of food that were soft and easy to chew and swallow. The P&P indicated the diet excluded hard, sticky or crunchy food. The P&P indicated meats should be moist and chopped into 1/2 inch or smaller or ground to cottage cheese size. 2. During a review of Resident 2's admission Record (AR), the AR indicated Resident 2 was admitted to the facility on [DATE] with diagnoses that included cerebrovascular disease (a group of conditions affecting the blood vessels that supply the brain, causing temporary or permanent damage due to restricted blood flow, blockage, or rupture) and dysphagia (difficulty or discomfort in swallowing, as a symptom of disease). During a review of Resident 2's History and Physical Examination (H&P, physician's clinical evaluation and examination of the resident), dated 4/25/2025, the H&P indicated Resident 2 had fluctuating capacity to understand and make decisions due to vascular dementia (changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain). During a review of Resident 2's Order Summary Report, dated 11/11/2025, the Order Summary Report indicated Resident 2 had an order for minced and moist diet (consists of soft, cohesive foods finely minced to roughly, designed for individuals with chewing or swallowing difficulties. Foods are moist, hold together without separating into liquid, and are easily mashed with a fork or tongue) three times a day. During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool), dated 2/7/2026, the MDS indicated Resident 2's cognitive skills (reasoning, learning, and problem-solving) for daily decision making was intact. The MDS indicated Resident 2 required supervision for eating. The MDS indicated Resident 2 required moderate assistance (helper does less than half the effort) for upper body dressing, personal hygiene and oral hygiene. The MDs indicated Resident 2 required maximal assistance (helper does more than half the effort) for shower/bathing and lower body dressing. The MDS indicated Resident 2 was dependent on staff for toileting hygiene and putting on/taking off shoes. During a review of Resident 2's Quarterly Nutritional Progress Note, dated 2/6/2026, the Quarterly Nutritional Progress Note indicated Resident 2 had an order for minced and moist diet. During a review of Resident 2's Care Plan for nutrition indicated Resident 2 had a diagnosis for dysphagia. The care plan indicated Resident 1 required a therapeutic diet and required a mechanically altered diet (a therapeutic, texture-modified eating plan designed for individuals with chewing or swallowing difficulties, typically consisting of moist, finely chopped, ground, or mashed foods to ensure safe swallowing). The care plan indicated Resident 2's intervention was to monitor Resident 2 for food pocketing, choking, coughing, drooling, holding food in mouth and several attempts at swallowing. During an observation on 4/21/2026 at 12:43 p.m. in Resident 2's room, Resident 2 had a plate with bread with edges and cheese sandwich. Resident 2's food tray had apple pie with crust and vegetable soups with bacon and carrots. During an interview on 4/21/2026 at 12:45 p.m. with Resident 2, Resident 2 stated Resident 2 received a cheese sandwich and nursing staff cut it into pieces. Resident 2 stated it was not easy to swallow because the pieces were big. Resident 2 stated Resident 2 received food that was not easy to chew and was not cut into little pieces. During an interview on 4/21/2026 at 12:54 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 2's sandwich was supposed to be cut into bite size. CNA 1 stated Resident 2's sandwich arrives from the kitchen in whole and CNA 2 cuts it into bite size. CNA 1 stated the pie served to Resident 2 was too hard for Resident 2 to chew and needed to be cut into smaller pieces to swallow. During an interview on 4/22/2026 at 1:43 p.m. with CNA 2, CNA 2 stated residents received food from the kitchen and CNA 2 had to cut the food into smaller pieces. CNA 2 stated CNA 2 did not know how small to cut food and CNA 2 cut food to the size that was easier to eat. CNA 2 stated residents with an order for mechanical soft diet had problems chewing and swallowing and needed their food to be safe when eating. During an interview on 4/22/2026 at 2:07 p.m. with DS, DS stated a minced/moist diet required food to be wet and chopped into tiny pieces. DS stated food consistency must be ground and moist. DS stated an apple pie had to be minced to avoid residents from choking. DS stated a sandwich cut into bite size was not acceptable for a resident that had an order for a minced/moist diet and it could potentially cause resident to choke. DS stated serving bread with edges was not acceptable because edges were hard to chew and could potentially cause a resident to choke. During an interview on 4/22/2026 at 2:21 p.m. with DS, DS stated dietary staff and DS were responsible to check food served before it left the kitchen. The DS stated it was important to serve the correct food diet and food texture for residents' safety and to make sure residents receive the correct nutrition. During an interview on 4/23/2026 at 1:35 p.m. with the Director of Nursing (DON), the DON stated therapeutic diets were ordered for residents' safety.The DON stated dietary staff were responsible to provide the correct food texture to residents. The DON stated nursing staff was responsible to check al residents' food before delivering it to residents. The DON stated it was important to serve the correct food texture to prevent residents from choking. During a review of facility's P&P titled Level 5 Minced and Moist, undated, the P&P indicated diet consisted of food that were moist, soft textured and easily form into a bolus. The P&P indicated meat must be finely minced or chopped, tender mince (pieces 2-4mm), cottage cheese size; they must be moist with some cohesion.

Based on observation, interview and record review, the facility did not ensure dietary staff followed the dietary menus for two of two meals: 1. Facility did not ensure residents received meals according to dietary menu (a structured, planned selection of food items tailored to meet specific nutritional, health, lifestyle, or cultural needs) on 4/21/2026 and 4/22/2026. 2. Facility did not ensure the Dietary Services Supervisor (DSS) checked food before food left the kitchen. 3. Facility did not notify residents there was a change in food that was served on 4/21/2026 and 4/22/2026. These deficient practices had the potential to impact on resident's nutritional status and placed all (112) residents at risk for unintentional weight loss. Findings: During an observation on 4/21/2026 at 12:20 p.m., residents received meat, a salad, and broccoli for lunch. During a review of facility's lunch menu titled [NAME] Nutrition consulting Spring Menu Week Seven, dated 4/21/2026, the lunch menu indicated residents were scheduled to receive Chicken cacciatore, garlic noodles, sauteed squash, French bread, margarine, and ice cream. During an observation on 4/22/2026 at 12:25 p.m., residents received pizza and a salad for lunch. During a review of facility's lunch menu titled [NAME] Nutrition consulting Spring Menu Week Seven, dated 4/22/2026, the lunch menu indicated residents were scheduled to receive country fried steak with gravy, mashed potatoes, seasoned peas, and cherry cheesecake. During an interview on 4/22/2026 at 2:43 p.m. with the Dietary Services Supervisor (DSS), the DSS stated dietary staff, cooks, and DSS were responsible to check food before it left the kitchen. The DSS stated DSS had provided dietary menus (a structured, planned selection of food items tailored to meet specific nutritional, health, lifestyle, or cultural needs) and food spreadsheets (a tool used by dietary staff to track and manage the specific nutritional needs, dietary restrictions, food allergies, and preferences of each resident) to dietary staff and dietary staff had to follow that for every meal. The DSS stated on 4/22/2026 residents were supposed to receive country fried chicken. The DSS stated the DSS was not aware the [NAME] did not follow the menu until the food was served to the residents. The DSS stated the [NAME] had not informed the DSS about the menu change and the [NAME] was supposed to notify the DSS of any changes. The DSS stated the DSS was in the kitchen when the [NAME] prepared food but the DSS did not check what the [NAME] prepared for lunch and the DSS stated the DSS was not aware of what was on the menu for that day. During an interview on 4/23/2026 at 8:32 a.m. with the Cook, the [NAME] stated the [NAME] reviews the book of menus weekly and gives a list of what needs to be ordered to the DSS. The [NAME] stated the [NAME] served pizza on 4/22/2026 to residents because the chicken that was ordered did not arrive in time. the [NAME] stated on 4/21/2026 the meat company informed the [NAME] the delivery of chicken was delayed. The [NAME] stated the [NAME] decided to cook pizza for lunch and did not notify the DSS. The [NAME] stated the [NAME] was allowed to make changes to the menu and did not have to notify the DSS of menu changes. The [NAME] stated the [NAME] was required to notify the DSS of the menu change because the DSS needed to inform residents of the menu change. The [NAME] stated it was important to follow dietary menus and food spreadsheet to honor residents' diets and nutritional values (providing nutrient-dense, appetizing, and individualized meals that manage chronic conditions, support wound healing, prevent malnutrition, and maintain the physical/cognitive function of aging residents). the [NAME] stated serving pizza did not offer the same nutrition and calories as the scheduled meal did. During an interview on 4/23/2026 at 8:49 a.m. with the Cook, the [NAME] stated on 4/21/2026 he did not serve what was on the dietary menu. the [NAME] stated the [NAME] was supposed to serve chicken on 4/21/2026 but instead the [NAME] looked at what food was in the refrigerator and cooked something else. the [NAME] stated the chicken did not arrive on time and he decided to cook something else and did not inform the DSS that the chicken was not available. The [NAME] stated one month ago the [NAME] received new food menus but did not look over them. The [NAME] stated the [NAME] was supposed to follow the new menus this week but the [NAME] did not. The [NAME] stated the [NAME] did not follow the food menus on 4/21/2026 and 4/22/2026 and the [NAME] should have followed the dietary menus. During an interview on 4/23/2026 at 9:20 a.m. with the DSS, the DSS stated the DSS did not know the food menu was not followed until food had left the kitchen. The DSS stated the DSS was present in the kitchen while the [NAME] was preparing food but the DSS did not notice what the [NAME] served for lunch. The DSS stated residents were not notified of the dietary menu change and residents were supposed to be notified of all menu changes two to three hours ahead of mealtime. the DSS stated the DSS did not know dietary menu was not followed on 4/21/2026 and 4/22/2026. The DSS stated the DSS was supposed to monitor dietary staff, monitor the food that was served and make sure all food plates were served according to doctor's orders but the DSS did not do that. The DSS stated the DSS did not know what food was served to residents on 4/21/2026. During an interview on 4/23/2026 at 1:50 p.m. with Director of Nursing (DON), the DON stated the DSS and the Registered Dieticians were allowed to make menu changes and not the Cook. The DON stated if there was a dietary menu change, nursing staff must be informed to notify residents of the change. The DON stated residents were required to be informed of menu changes because it was their right to be informed of the food that will be served. The DON stated she was not informed that on 4/21/2026 and 4/22/2026 the diet menu was not followed and DON should have been informed. The DON stated on 4/21/2026 and 4/22/2026, the residents did not receive the correct nutritional value because the dietary menu and dietary spreadsheet was not followed. During a review of facility's job description, titled Director of Food and Nutrition Services, undated, the Job description indicated Director of food and nutrition services would effectively manage the operation of the department of food and nutrition services. The job description indicated the Director of Food and Nutrition Services would supervise the preparation of food and food service for resident/patient meals according to established menus and standardized recipes. The job description indicated the Director of Food and Nutrition Services would keep turning, organizing, controlling, coordinating, directing and evaluating all aspects of the food service along with data collection for clinical charting cool. The job description indicated the director of food and nutrition services would ensure food was prepared by methods that conserve nutritional value and is powerful and attractive to residents and patients. The job description indicated the director of food nutrition services would ensure residents/patients received the proper food items to meet the department of food and nutrition services needs and that food was served at the appropriate temperatures for safety and palatability. The job description indicated the Director of Food and Nutrition Services would purchase food and supplies according to the facility menu. During a review of facility's job description, titled Cook, undated, the job description indicated the cook would prepare and serve food including texture modified and therapeutic diets according to the facility menu. The job description indicated the cook would prepare food by methods that conserve nutritive value, flavor, and palatability. The job description indicated the cook would follow instructions from dietary services supervisor in the preparation of meals and would maintain meal schedules. During a review of facility's Policy and Procedure (P&P) titled, Menu Substitutions, undated, the P&P indicated the director of food and nutrition services was responsible for supervising meal preparation and service to assure the menu is followed and served as planned. The P&P indicated menu substitutions must be made from the same food group as the omitted item.

Based on observation, interview and record review, the facility failed to provide safe oxygen administration practices ([oxygen therapy], is the medical practice of delivering oxygen at a concentration greater than ambient air) for three of four sampled residents (Residents 1, 3, 4) by: 1. Not ensuring Resident 1's nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) was dated with an open date and did not ensure nasal cannula was not touching the floor. 2. Not ensuring Resident 3 had a bag at the bedside for oxygen equipment and did not ensure nasal cannula was not touching the floor. 3. Not ensuring Resident 4 received oxygen administration when using motorized wheelchair and did not ensure the nasal cannula was not touching the floor and placed over the restroom doorknob. These deficient practices increased the risk for Resident 1, 3, and 4) to acquire a respiratory infection (infectious disease caused by bacteria, viruses, or fungi that affects the respiratory tract, including the nose, sinuses, throat, airways, and lungs) and placed resident 3 at risk of respiratory distress (difficulty breathing, shortness of breath, rapid breathing, and the use of accessory muscles to breathe). Findings: 1. During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included respiratory failure (serious condition that makes it difficult for a person to breathe on their own, lungs can't get enough oxygen into the blood) and heart failure (progressive heart disease that affects pumping action of the heart muscles, causes fatigue and shortness of breath). During a review of Resident 1's History and Physical Examination (H&P, physician's clinical evaluation and examination of the resident), dated 3/14/2026, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 3/17/2026, the MDS indicated Resident 1's cognitive skills (reasoning, learning, and problem-solving) for daily decision making was intact. The MDS indicated Resident 1 required maximal assistance (helper does more than half the effort) for lower body dressing, shower/bathing, toileting hygiene and putting on/off footwear. The MDS indicated Resident 1 required moderate assistance (helper does less than half the effort) for upper body dressing, oral hygiene and eating. During a review of Resident 1's Order Summery Report dated 3/17/2026, the Order Summary Report indicated Resident 1 had an order for oxygen 2 liters per minute (L/min) to maintain oxygen saturation ([O2 sat], a measurement of how much oxygen the blood is carrying as a percentage) greater than 91 percent (%). During an observation on 4/21/2026 at 1:20 p.m., in Resident 1's room, Resident 1 nasal cannula was not labeled with open date and was touching the floor. During a concurrent observation and interview on 4/22/2026 at 11:43 a.m. with the Infection Preventionist Nurse (IPN) in Resident 1's room, Resident 1's nasal cannula was not labeled with opened date and the nasal cannular was touching the floor. The IPN stated the nasal cannula should be labeled with the date it was opened for infection prevention. The IPN stated there was no way of knowing when or if the nasal cannula had been changed because it was not dated. 2. During a review of Resident 3's AR, the AR indicated Resident 3 was admitted to the facility on [DATE] with diagnoses that included end stage of renal disease (a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life) and peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). During a review of Resident 3's Order Summery Report dated 3/31/2026, the Order Summary Report indicated Resident 3 had an order for oxygen 3 liters per minute (L/min) to maintain oxygen saturation greater than 92%. During a review of Resident 3's Medication Administration Record (MAR), dated 4/1/2026 - 4/30/2026, the MAR indicated to change and label oxygen tubing and plastic bag every night shift starting on the last day of the month and ending on the last day of the month. The MAR indicated from 4/1/2026 to 4/23/2026 oxygen tubing was not changed. During a review of Resident 3's electronic medical record, unable to locate Resident 3's care plan for oxygen administration. During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3's cognitive skills for daily decision making was intact. The MDS indicated Resident 3 required supervision for eating and oral hygiene. The MDS indicated Resident 3 required moderate assistance for upper body dressing and personal hygiene. The MDS indicated Resident 3 required maximal assistance for toileting hygiene, shower/bathing, lower body dressing, and putting on/taking off shoes. During a concurrent observation and interview on 4/22/2026 at 11:47 a.m. with the IPN in Resident 3's room, Resident 3 did not have a bag for oxygen equipment and the nasal cannular was touching the floor. The IPN stated residents required a bag for their oxygen equipment for infection control and was touching the floor. The IPN stated when residents are not using the nasal cannula, the nasal cannula must be placed in the bag to prevent it from getting contaminated with germs. During an interview on 4/23/2026 at 12:46 p.m. with the Director of Nursing (DON), the DON stated Resident 3 should have a care plan for oxygen administration because it was a lifesaving issue. The DON stated an oxygen care plan would outline interventions for nursing staff to follow. The DON stated oxygen administration interventions would be to check residents' pulse, to follow doctor's oxygen order, to place oxygen tubing in a bag when not in use and to change oxygen tubing every two weeks. 3. During a review of Resident 4's AR, the AR indicated Resident 4 was admitted to the facility on [DATE] and was readmitted to the facility on [DATE] with diagnoses that included respiratory failure and dependence on supplement oxygen. During a review of Resident 4's Order Summery Report dated 11/23/2025, the Order Summary Report indicated Resident 4 had an order for oxygen 2 L/min, three times a day for shortness of breath (SOB). During a review of Resident 4's MDS, dated [DATE], the MDS indicated Resident 4's cognitive skills for daily decision making was intact. The MDS indicated Resident 4 was independent when eating. The MDS indicated Resident 4 required set up assistance for oral hygiene. The MDS indicated Resident 4 required supervision for upper body dressing and personal hygiene. The MDS indicated Resident 4 required moderate assistance for toileting hygiene and shower/bathing. The MDS indicated Resident 4 required maximal assistance for lower body dressing and putting on/off footwear. During a review of Resident 4's H&P, dated 2/23/2026, the H&P indicated Resident 4 had the capacity to understand and make decisions. During an observation on 4/21/2026 at 2:32 p.m., Resident 4 was observed on motorized wheelchair without oxygen administration. During an observation on 4/22/2026 at 9:33 a.m., Resident 4 was observed on motorized wheelchair without oxygen administration. During an interview on 4/22/2026 at 11:25 a.m. with the IPN, The IPN stated for infection prevention for resident receiving oxygen administration, nursing staff must label the nasal cannulas with open date, place nasal cannula in a bag when not in use and avoid the nasal cannula tubing to touch the floor. The IPN stated oxygen equipment had to be changed weekly or biweekly for infection prevention. The IPN stated it was important to change oxygen equipment for residents' safety. The IPN stated the risk of not dating oxygen cannulas was nursing staff would not know if oxygen equipment was old and would potentially cause an infection. During a concurrent interview and record review on 4/22/2026 at 11:39 a.m. with the IPN, Resident 4's Order Summary Report, dated 11/23/2025, was reviewed. The Order Summary Report indicated Resident 4 had an order for 2 L/min of oxygen three times day. The IPN stated three times a day meant Resident 4 required continuous oxygen and all three shifts had to monitor when Resident 4 received oxygen continuously. IPN stated Resident 4 required oxygen at all times and should not be without oxygen even when Resident 4 was using motorized wheelchair. The IPN stated it was important for Resident 4 to continuously receive oxygen to prevent Resident 4 from experiencing respiratory distress. During a concurrent observation and interview on 4/22/2026 at 11:53 a.m. with the IPN in Resident 4's room, Resident 4's nasal cannula was hanging off restroom doorknob and touching the floor. The IPN stated that was not acceptable practice because the nasal cannula had to be placed in a bag and not touching the floor. The IPN stated Resident 4 could not reuse that nasal cannula because it was contaminated. The IPN stated Resident 4 continuously removed the nasal cannula when Resident 4 used motorized wheelchair. During an interview on 4/23/2026 at 12:37 p.m. with the DON, the DON stated nursing staff were required to label oxygen equipment with open date, to change oxygen equipment every two weeks, and place unused oxygen equipment in a bag for infection prevention and for resident safety. The DON stated if infection prevention practices were not followed there was a risk for residents to get a respiratory infection. The DON stated residents were not allowed to remove their oxygen because it would potentially cause resident to experience respiratory distress. The DON stated all staff were responsible to make sure all infection prevention practices were followed and to make sure all residents were continuously receiving oxygen. During a review of facility's Policy and Procedure (P&P) titled, Oxygen Administration/Respiratory Supply, dated 4/1/2026, the P&P indicated all residents on oxygen either continuous or as needed, should be monitored by all nursing staff. The P&P indicated all oxygen supplies, including tubing, nasal cannula, mask, nebulizer, and nebulizer tubing should be changed biweekly, documenting the date and time. The P&P indicated all supplies not in use should be placed in a bag for infection prevention control.

Based on interview and record review the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for four resident of four sampled residents (Resident 1, 3, 4 and 5) by: 1. Not ensuring Resident 1 and 3 had floor mats at bedside. 2. Not ensuring Resident 1, 4, and 5 had a fall risk assessment (a comprehensive, non-invasive evaluation conducted to determine an individual's likelihood of falling, typically focusing on older adults or high-risk patients) after experiencing a fall. These deficient practices placed Residents 1, 3, 4 and 5 for recurring falls and increased the risk for the residents to sustain injuries after a fall from their beds. Findings: 1. During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included respiratory failure (serious condition that makes it difficult for a person to breathe on their own, lungs can't get enough oxygen into the blood) and heart failure (progressive heart disease that affects pumping action of the heart muscles, causes fatigue and shortness of breath). During a review of Resident 1's Fall Risk Assessment (a comprehensive, non-invasive evaluation conducted to determine an individual's likelihood of falling, typically focusing on older adults or high-risk patients), dated 3/5/2026, the Fall Risk Assessment indicated Resident 1 had no history of falls and had a score of 16 ([High Risk], 16-20 range, requiring immediate fall alert protocols). During a review of Resident 1's Accident/Incident Report, dated 3/12/2026, the Accident/Incident Report indicated Resident 1 had a fall on 3/12/2026. During a review of Resident 1's Order Summery Report dated 3/12/2026, the Order Summary Report indicated Resident 1 had an order for bilateral floor mats. During a review of Resident 1's History and Physical Examination (H&P, physician's clinical evaluation and examination of the resident), dated 3/14/2026, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 3/17/2026, the MDS indicated Resident 1's cognitive skills (reasoning, learning, and problem-solving) for daily decision making was intact. The MDS indicated Resident 1 required maximal assistance (helper does more than half the effort) for lower body dressing, shower/bathing, toileting hygiene and putting on/off footwear. The MDS indicated Resident 1 required moderate assistance (helper does less than half the effort) for upper body dressing, oral hygiene and eating. During an observation on 4/21/2026 1:20 p.m. in Resident 1's room, Resident 1 did not have bilateral floor mats. During an interview on 4/22/2026 at 9:57 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 1 had an order for bilateral floor mats because Resident 1 had a previous fall. LVN 1 stated Resident 1 should have bilateral mats to prevent fall injuries but did not know if Resident 1 had bilateral floor mats. LVN 1 stated the risk of not having floor mats was a fall with injuries. LVN 1 stated all residents that had an order for floor mats should have floor mats at their bedside. 2. During a review of Resident 3's AR, the AR indicated Resident 3 was admitted to the facility on [DATE] with diagnoses that included end stage of renal disease (a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life) and peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3's cognitive skills for daily decision making was intact. The MDS indicated Resident 3 required supervision for eating and oral hygiene. The MDS indicated Resident 3 required moderate assistance for upper body dressing and personal hygiene. The MDS indicated Resident 3 required maximal assistance for toileting hygiene, shower/bathing, lower body dressing, and putting on/taking off shoes. During a review of Resident 3's Order Summery Report dated 4/10/2026, the Order Summary Report indicated Resident 3 had an order for bilateral floor mats. During an observation on 4/22/2026 11:48 a.m. in Resident 3's room, Resident 3 did not have bilateral floor mats. 3. During a review of Resident 4's AR, the AR indicated Resident 4 was admitted to the facility on [DATE] and was readmitted to the facility on [DATE] with diagnoses that included respiratory failure and dependence on supplement oxygen. During a review of Resident 4's MDS, dated [DATE], the MDS indicated Resident 4's cognitive skills for daily decision making was intact. The MDS indicated Resident 4 was independent when eating. The MDS indicated Resident 4 required set up assistance for oral hygiene. The MDS indicated Resident 4 required supervision for upper body dressing and personal hygiene. The MDS indicated Resident 4 required moderate assistance for toileting hygiene and shower/bathing. The MDS indicated Resident 4 required maximal assistance for lower body dressing and putting on/off footwear. During a review of Resident 4's H&P, dated 2/23/2026, the H&P indicated Resident 4 had the capacity to understand and make decisions. During a review of Resident 4's Accident/Incident Report, dated 3/7/2026, the Accident/Incident Report indicated Resident 4 had a fall on 3/7/2026 and sustained on a forehead laceration. During a review of Resident 4's Fall Risk Assessment, dated 4/16/2026, the Fall Risk Assessment indicated Resident 4 had history of one or two falls and had a score of 14 ([moderate Risk], 12-15 range, requiring standard care with fall risk factors). 4. During a review of Resident 5's AR, the AR indicated Resident 5 was admitted to the facility on [DATE] with diagnoses that included hemiplegia (a condition caused by a brain injury, that results in a varying degree of weakness, stiffness and lack of control in one side of the body) and hemiparesis (neurological condition characterized by weakness, reduced muscle strength, or partial paralysis on one side of the body, affecting the arm, leg, and sometimes the face). During a review of Resident 5's H&P, dated 9/1/2025, the H&P indicated Resident 5 had the capacity to understand and make decisions. During a review of Resident 5's MDS, dated [DATE], the MDS indicated Resident 5's cognitive skills for daily decision making was intact. The MDS indicated Resident 5 was independent for eating. The MDS indicated Resident 5 required set up assistance for oral hygiene and upper body dressing. The MDS indicated Resident 5 required supervision for personal hygiene. The MDS indicated Resident 5 required moderate assistance for toileting hygiene, shower/bathing, lower body dressing and putting on/taking off footwear. During a review of Resident 5's Fall Risk Assessment, dated 2/16/2026, the Fall Risk Assessment indicated Resident 5 had no history of falls and had a score of 13. During a review of Resident 5's Accident/Incident Report, dated 3/1/2026, the Accident/Incident Report indicated Resident 5 had a fall on 3/1/2026. During an interview on 4/23/2026 at 12:58 p.m. with the Director of Nursing (DON), the DON stated a fall risk assessment was a tool used to indicate if a resident was at risk for a fall. The DON stated a fall risk assessment was completed on admission, quarterly, yearly and after a fall. The DON stated residents that were at risk for falls were monitored and nursing staff care planned the risk for fall and developed interventions to keep residents safe. The DON stated a resident must have floor mats if they had order for floor mats. The DON stated it was important to provide floor mats to resident for their safety and to prevent injuries. During a review of facility's Policy and Procedure (P&P) titled, Fall Risk Assessment, undated, the P&P stated upon admission, the nursing staff and the physician will review a resident's record for a history of falls, especially falls in the last 90 days and recurrent or periodic bouts of falling over time. During a review of facility's P&P titled, Assessing Falls and Their Causes, undated, the P&P stated when a resident had a fall, the following information would be recorded in the resident's medical record: Completion of a falls risk assessment an appropriate interventions taken to prevent future falls. During a review of facility's P&P titled, Carrying out Physician's Orders, undated, the P&P indicated the objective of the policy was to ensure all physicians orders were carried out in a safe, timely, and accurate manner.

Based on observation, interview, and record review, the facility failed to maintain safe food handling practices by failing to: A.1. Store one of one ice scoop in a sanitary condition. The ice scoop was stored in the ice scooper container that had approximately 100 milliliters (ml-unit of measurement) of brown liquid substance. The ice scoop was touching the brown liquid substance. Certified Nursing Assistant 1 (CNA 1) and CNA 3 used the contaminated ice scooper to fill up two ice chests (containers) with ice and distributed the ice chests to the North and South Nursing Stations. CNAs 1, 2 and 3 distributed the contaminated ice to 42 of 90 residents (Residents 1, 2, 3, 4, 5, 6, 8, 11, 12, 13, 16, 17, 18, 20, 22, 23, 25, 27, 29, 36, 37, 38, 43, 46, 53, 54, 57, 58, 63, 64, 68, 71, 75, 76, 80, 84, 188, 189, 190, 238, 290 and 291) who received ice in the facility during breakfast and lunch on [DATE]. A.2. Ensure one of one ice scooper container used to store the ice scooper was cleaned and sanitized daily in accordance with the facility's Policy and Procedure (P&P) titled, Cleaning and Sanitizing Ice Scooper and Container for Ice Machine. These deficient practices placed Residents 1, 2, 3, 4, 5, 6, 8,11,12,13,16,17,18, 20, 22, 23, 25, 27, 29, 36, 37, 38, 43, 46, 53, 54, 57, 58, 63, 64, 68, 71, 75, 76, 80, 84, 188, 189, 190, 238, 290 and 291 at risk for consuming contaminated ice and result in serious harm, hospitalization , and death from water-borne illnesses (illnesses caused by contaminated water). B.Ensure safe food storage in accordance with the facility's policy and procedure (P&P) on Sanitation and Infection Control and P&P on Food Receiving and Storage by failing to ensure (1) stored food items were dated when it was received in one of two kitchen freezers, (2) mixed and prepared salad dressings were discarded after its indicated shelf life (the length of time for which an item remains usable and fit for consumption) in the kitchen refrigerated storage, (3) stored food items were dated when it was received in the kitchen's dry and canned storage area and (4) stored food items were labeled with the resident's name and date when it was stored and use by date in one of two unit refrigerators. These deficient practices placed the residents at risk for food-borne illnesses (illness caused by ingesting contaminated food or beverages). On [DATE] at 5:34 pm, while onsite at the facility, the survey team called an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) situation regarding the facility's failure to ensure food safety standards were met by storing the food equipment in a sanitary condition. The ice scoop was stored in the ice scooper container that had approximately 100 ml of brown liquid substance which was used by CNAs 1 and 3 to scoop the ice from the ice machine intended for the residents in the facility. CNAs 1, 2 and 3 distributed the contaminated ice to 42 residents during breakfast and lunch on [DATE]. The facility had no records of cleaning and sanitizing the ice scooper container as indicated in the facility's P&P for Cleaning and Sanitizing Ice Scooper and Container for Ice Machine. The IJ was called in the presence of the facility's Director of Nursing (DON) and Director of Staff Development (DSD). On [DATE] at 3:42 pm, the facility submitted an acceptable IJ Removal Plan ([IJRP] a plan with interventions to correct the deficient practice). While onsite at the facility, the survey team verified and confirmed the facility's implementation of the IJRP through observation, interview, and record review. The survey team determined an IJ situation was no longer present and removed the IJ situation on [DATE] at 4:47pm in the presence of the administrator (ADM) and assistant administrator (AADM). A review of the IJRP included the following immediate actions: 1. On [DATE], the ice scoop and ice scoop container were placed in the kitchen dishwasher to be cleaned and sanitized. 2. On [DATE], the two ice chests in the north and south nursing stations were sanitized. 3. On [DATE], the ice machine located in the facility's dining room was locked and put into temporary out of service. 4. On [DATE], all residents' water pitchers and cups for 90 residents (total census) were replaced with new/uncontaminated water pitchers and cups. 5. On [DATE], The Dietary Supervisor (DS) in-serviced four dietary aides on the cleaning of the ice scooper and ice scooper container. 6. On [DATE], 200 pounds of ice was purchased by the ADM. 7. On [DATE], a new ice scooper and container sanitation log was created for the dietary aides on duty to log in the time of the day when they sanitize the ice scooper and the ice scooper container. The DS would check the log to ensure the ice scooper and the ice scooper container were sanitized daily. 8. On [DATE], a water company service had been contracted and scheduled maintenance of the ice machine and replacement of water filter every six months. 9. On [DATE], the facility's (P&P) titled, Cleaning and Sanitizing the Ice Scooper and Container for Ice Machine, was revised to include daily cleaning of the ice scooper, the ice scooper container and document in the cleaning log. 10. On [DATE], a new clear ice scooper container with lid and new ice scooper was purchased. Findings: A. During a concurrent observation and interview on [DATE] at 8:47 am with the DS inside the facility's dining room, the facility had one ice machine as the source of ice for all 90 residents in the facility. There was one ice scoop used to transfer ice from the ice machine to the two ice chests (ice containers) and one ice scooper container to hold the ice scoop. The ice scooper container was mounted on the wall, five feet (ft, unit of measurement) above the floor and was removable. The ice scooper container was blue in color and was not transparent. The ice scooper container lid was not able to close completely. The DS removed the ice scooper container and refused to show it to the surveyor. The DS stated the ice scooper container was dirty with brown-colored liquid substance at the bottom. The DS stated the brown colored liquid substance was approximately 100 ml. The DS stated the ice scoop was touching the brown liquid substance inside the ice scooper container. During a concurrent observation of the ice scooper container in the dining room and an interview on [DATE] at 10:12 am with the Dishwasher Staff (DWS), the DWS looked at the ice scooper container with brown liquid and stated, Eww (used to express disgust or distaste). When the DS handed the ice scooper container to the DWS, the DWS stated the ice scooper container was nasty and dirty. The DWS stated the liquid substance inside the ice scooper container was brown in color, dirty and was not the normal color of water. During a concurrent interview and record review on [DATE] at 10:15 am with the DS, the Ice Machine Scoop Sanitation Log (IMSSL) for the months of May and [DATE] were reviewed. The DS stated there were no records of the ice scooper container sanitation log. The DS stated she did not know when the ice scooper container was cleaned and sanitized. The DS stated ice from the ice machine were transferred to the ice chests using the contaminated ice scoop. The DS stated each nursing station (North and South Nursing Station) had one ice chest. The DS stated she did not know what was in the brown liquid substance at the bottom of the ice scooper container. The DS stated the DS did not know how long the brown liquid substance had been in the ice scooper container. The DS stated the ice scoop inside the ice scooper container was touching the brown liquid substance and the contaminated ice scooper was used to scoop ice from the ice machine all day ([DATE]). The DS stated the ice were contaminated. The DS stated contaminated ice could cause the residents to get sick with water related illnesses such as diarrhea (loose stools) and or vomiting. During an interview on [DATE] at 10:27 am with the facility's Infection Preventionist Nurse (IPN- a nurse who help prevent and identify the spread of infectious disease in the healthcare environment), the IPN stated the ice scoop and ice scooper container needed to be cleaned and sanitized daily to prevent contamination of the ice which could result in water-borne illnesses. During an interview on [DATE] at 10:40 am with Resident 2, Resident 2 stated Resident 2 drank water with ice during breakfast. During an interview on [DATE] at 10:45 am with Resident 37, Resident 37 stated Resident 37 drank water with ice during breakfast. During an interview on [DATE] at 10:49 am with Resident 36, Resident 36 stated Resident 36 drank water with ice during breakfast. During an interview on [DATE] at 10:54 am with Resident 290, Resident 290 stated Resident 290 always ask water with ice with every meal and drank the iced water during breakfast. During a concurrent review of the facility's list of residents who received ice, dated [DATE] and lunch observation on [DATE] from 12 noon to 12:55 pm, the facility's list of residents indicated 42 of 90 residents (Residents 1, 2, 3, 4, 5, 6, 8, 11, 12, 13, 16, 17, 18, 20, 22, 23, 25, 27, 29, 36, 37, 38, 43, 46, 53, 54, 57, 58, 63, 64, 68, 71, 75, 76, 80, 84, 188, 189, 190, 238, 290 and 291) in the facility received ice from the ice chests. CNAs 1, 2 and 3 distributed contaminated ice from the two ice chests from the North and South Nursing Station to Residents 1, 2, 3, 4, 5, 6, 8, 11, 12, 13, 16, 17, 18, 20, 22, 23, 25, 27, 29, 36, 37, 38, 43, 46, 53, 54, 57, 58, 63, 64, 68, 71, 75, 76, 80, 84, 188, 189, 190, 238, 290 and 291. During an interview on [DATE] at 12:02 pm with Certified Nurse Assistant 1 (CNA 1), CNA 1 stated, CNA 1 got ice from the ice machine in the dining room and used the contaminated ice scoop to fill up the ice chest with ice for the South Nursing Station. During an interview on [DATE] at 12:10 pm with CNA 2, CNA 2 stated, she used the contaminated ice scoop inside the ice scooper container that had brown liquid substance to scoop ice for the residents. During an interview on [DATE] at 12:19 pm with CNA 3, CNA 3 stated, she filled up the ice chest for the North Nursing Station with ice from the ice machine using the contaminated ice scoop inside the ice scooper container. During an interview on [DATE] at 5:34 pm with the Director of Nursing (DON), the DON stated a dirty ice scoop could contaminate the ice. The DON stated contaminated ice could cause the residents to get sick with water-borne illnesses such as abdominal pain or diarrhea and would result to hospitalization . During a review of the facility's undated policy and procedure (P&P) titled, Cleaning and Sanitizing Ice Scooper and Container for Ice Machine, the P&P indicated, Ice scooper and ice scooper container, located next to the ice machine, must be washed and sanitized daily in the dietary department dishwasher. During a review of an article titled, Ice Machines and Food Safety (plus, How to Sanitize), dated [DATE], the article indicated for safe handling, ice scoop should be cleaned and sanitized at least daily. https://foodsafepal.com/ice-machines-food-safety/#:~:text=Like%20a%20spatula%2C%20pair%20of,sanitize%20it%20at%20least%20daily. B.1. During an initial tour of the kitchen on [DATE] at 8:46 am with the Dietary Supervisor (DS), one of two kitchen freezers had two boxes of frozen pies and one bag of frozen strawberry fruits without label of the date when it was received. During an interview on [DATE] at 8:48 am with the DS, DS stated, food should be labeled with the date it was received to ensure the kitchen was serving food safe for the residents. B.2. During an initial tour of the kitchen on [DATE] at 8:51 am with the DS, the refrigerated storage had one gallon of plastic container, halfway filled with mixed and prepared thousand island dressing dated [DATE] and one gallon of plastic container, a quarter filled with mixed and prepared ranch dressing dated [DATE]. During an interview on [DATE] at 8:55 am with the DS, DS stated, mixed salad dressings had a shelf life of two weeks. DS stated mixed salad dressings should be discarded after its shelf life to prevent food-borne illnesses. During an interview on [DATE] at 11:47 am with the Lead [NAME] (LC), LC stated, he prepared the thousand island and ranch dressings. LC stated, thousand island and ranch dressings had a shelf life of two weeks. LC stated mixed and prepared salad dressings should be thrown away after two weeks because they were considered expired. LC stated residents could get sick when expired foods were consumed. During a review of the facility's shelf-life list of food, the shelf-life list indicated mixed salad dressings had a shelf life of two weeks when refrigerated. B.3.During an initial tour of the kitchen on [DATE] at 9:00 am with the Dietary Aide (DA) inside the canned and dry goods storage, one can of mixed fruit jelly and two bottles of grape concord jelly did not have a label with the date when it was received. During an interview on [DATE] at 9:03 am with the DA, DA stated, foods needed to be dated to guarantee older supply/stock would be used first. B. 4. During a concurrent observation and interview on [DATE] at 9:27 am inside the North Station medication room with Licensed Vocational Nurse 3 (LVN 3), a unit/snack refrigerator was located above the medication refrigerator. Inside the unit/snack refrigerator were a 12 ounces (oz, a unit of weight) plastic cup of cream-colored fluid covered with a saran wrap and labeled mocha mix without a date or name of the resident, a 64 fluid ounce (fl. oz) of opened, and unlabeled coffee French vanilla zero sugar, and a half peanut/butter jelly sandwich wrapped in saran wrap inside the freezer section of the unit refrigerator did not have a date or name of the resident. LVN 3 stated food should be labeled with the resident's name and date to determine who owned the food and when the food was opened or prepared. During a review of the facility's undated P&P titled, Sanitation and Infection Control-Freezer Storage, the P&P indicated, Upon receipt, frozen foods should be immediately stored in the freezer. Frozen food should be labeled with the date it was placed in the freezer. During a review of the facility's undated P&P titled, Sanitation and Infection Control-Canned and Dry Storage, the P&P indicated, New stock must be placed behind the old stock so oldest items will be used first. Products should be dated to assure FIFO-First in-First out. During a review of the facility's undated P&P titled, Sanitation and Infection Control-Refrigerated Storage, the P&P indicated, Leftover food or unused portions of package foods should be covered, labeled and dated to assure they will be used first. During a review of the facility's undated P&P titled, Food Receiving and Storage, the P&P indicated. All foods stored in the refrigerator or freezer will be covered, labeled, and dated (use by date). All foods belonging to residents must be labeled with the resident's name, the item, the date stored and the use by date. Stored food will be discarded after 3 days.

Based on observation, interview, and record review, the facility failed to ensure residents had an environment free of accident hazards (risks) for two of four residents (Residents 8 and 36) who were smokers (tobacco users) by failing to: 1. Implement the facility's smoking policy titled, Smoking Policy-Residents, for Residents 8 and 36 who did not have smoking privileges to smoke with staff supervision, and for staff to keep Residents 8 and 36's smoking articles including cigarettes and cigarette lighters for Residents 8 and 36. 2. Implement the facility's smoking policy titled, Smoking Policy-Residents, to evaluate Resident 8's ability to smoke safely with the consultation from the facility's Director of Nursing (DON) and Resident 8's Attending Physician when safety restriction for smoking was needed in accordance with facility's Safe Smoking Evaluation Form. 3. Implement the facility's smoking policy titled, Smoking Policy-Residents, not to allow Resident 36 smoked in an area with an oxygen (gas needed for breathing, when combined with fuel, it released heat and generated combustion/ignition/fire) machine present in Resident 36's room. 4. Implement Resident 36's untitled Care Plan (CP), dated 5/25/2024 indicating not to allow Resident 36 to have cigarettes and lighters on her possession, and for Resident 36 to dispose cigarettes in the proper receptacle (facility's ashtrays). 5. Implement Resident 36's smoking intervention in Resident 36's Smoking Evaluation (SE) form, dated 3/27/2024 indicating Resident 36 had poor vision and required supervision when smoking. These failures had the potential for Resident 8 and Resident 36 to turn on the lighters, cause a fire that could affect the health, safety, and wellbeing of all 90 residents in the facility, facility staff and visitors and result in serious harm, injuries, hospitalization , and death. On 6/4/2024 at 5:15 pm, while onsite at the facility, the survey team called an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) situation regarding the facility's failure to ensure Residents 8 and 36, who were smokers, had an environment that was free of accident hazard by allowing both residents to have cigarettes and cigarette lighters in possession inside their rooms. Resident 8 was on Seroquel (an antipsychotic [medicine to treat mental illness] medication) for hearing voices telling him to hurt himself and others in the facility. Resident 36's roommate had an oxygen machine used whenever necessary (PRN) with a posted Danger sign in red color that indicated, Oxygen, No Smoking, No Open Flames posted outside Resident 36's room. The IJ was called in the presence of the facility's Administrator (ADM) and DON. On 6/6/2024, at 4:06 pm, the facility submitted an acceptable IJ Removal Plan ([IJRP] a plan with interventions to correct the deficient practice). While onsite at the facility, the survey team verified and confirmed the facility's implementation of the IJRP through observation, interview, and record review. The survey team determined an IJ situation was no longer present and removed the IJ situation on 6/6/2024 at 6:19 pm in the presence of the DON. A review of the IJRP included the following immediate actions: 1. On 6/4/2024, cigarettes and cigarette lighters were removed from Resident 8 and Resident 36's rooms and placed under supervision of the charge nurses (Licensed Vocational Nurses [LVNs] and Registered Nurses [RNs]). 2. On 6/4/2024, Resident 8 and Resident 36's CPs were updated by LVNs and the DON. 3. On 6/4/2024, Resident 8 and Resident 36 were educated by the facility's DON on smoking and cigarette lighter safety and why cigarette lighters cannot be in residents' possession. 4. On 6/4/2024, Resident 8 was informed by the ADM for safety and importance of using appropriate and approved ashtrays for cigarette butts (the part of the cigarette that was left after it had been smoked). 5. On 6/4/2024, the Supervised Designated Smoking Area Map for smokers was created which included the following: a. Patio in front of the facility by the front entrance. b. Patio outside the facility by the back entrance/parking lot. c. Patio outside the facility exit located between rooms [ROOM NUMBERS]. 6. On 6/4/2024, the Designated Smoking Time Schedule for residents who required smoking supervision was created which included the following: a. Morning after breakfast from: 8:00 am to 8:30 am, 9:00 am to 9:30 am and 11:30 am to 12:00 pm b. Afternoon after lunch from: 1:00 pm to 1:30 pm, 2:30 pm to 3:00 pm and 4:30 pm to 5:00 pm c. Evening after dinner from: 6:00 pm to 6:30 pm 7. On 6/4/2024, the Director of Staff Development (DSD) provided an in-service to 26 Certified Nursing Assistants (CNAs), nine LVNs, four RNs, one Social Services Designee, one Medical Records Designee, three activity staff, and one housekeeper on the facility's revised smoking policies regarding supervised smoking, designated smoking areas, and designated smoking time schedules. Findings: a. During a review of Resident 8's Admission Record (AR), the AR indicated the facility admitted Resident 8 on 8/6/2019 and readmitted on [DATE] with diagnoses that included diabetes mellitus (a disease in which the body does not control the amount of glucose (a type of sugar) in the blood and the kidneys make a large amount of urine), nicotine (chemical found in tobacco) dependence (an addiction to tobacco product) and paranoid schizophrenia (mental disorder characterized by abnormal social behavior and failure to understand what is real). During a review of Resident 8's Nurses Notes (NN) dated 5/22/2024, timed 7:46 pm, the NN indicated Resident 8 was transferred to General Acute Care Hospital 1 (GACH 1) emergency roiagnom on a 5150 (the number of the section of the Welfare and Institutions Code, which allows an adult who was experiencing a mental health crisis to be involuntarily detained for a 72- hour psychiatric hospitalization when evaluated to be a danger to others, or to himself or herself, or gravely disabled) hold due to confusion, agitation, wanting to commit suicide, threatening to kill the DON and threatening to blow up the hospital. During a review of Resident 8's Order Summary Report (OSR) dated 6/3/2024, the OSR indicated for licensed staff to administer Seroquel (antipsychotic drug) 100 milligram ([mg] unit of measurement) one tablet in the morning, and three tablets at bedtime by mouth, daily for paranoid schizophrenia to Resident 8, as manifested by hearing voices telling Resident 8 to hurt himself and others. During a review of Resident 8's Medication Administration Record (MAR) dated 6/3/2024 through 6/10/2024, the MAR indicated Resident 8 received Seroquel 100 mg one tablet at 9 a.m., and three tablets at 10 p.m. by mouth every day from 6/3/2024 through 6/10/2024. During a concurrent observation and interview on 6/4/2024 at 10:58 am, Resident 8 stated he just came back from a smoke break in the patio. Resident 8 stated he smoked in the patio by himself without staff supervision. Resident 8 had one opened pack of cigarette with 17 cigarettes, three disposable lighters on Resident 8's bedside table, and three unopened packs of cigarettes in Resident 8's cabinet drawer. Resident 8 demonstrated the three cigarette lighters were working (lighting up). Resident 8 stated he was a smoker and consumed 20 cigarettes per day (one pack of cigarette per day). Resident 8 stated staff (unable to recall the name) gave him the cigarettes and lighters (unable to recall the date) so he could smoke anytime without asking for the cigarettes and lighters from staff. Resident 8 stated he had been smoking without staff supervision (did not indicate timeframe). During a concurrent observation and interview with the DON in Resident 8's room on 6/4/2024 at 11:02 am, the DON stated she did not know why Resident 8 had four packs of cigarettes (one opened and three unopened) with three disposables lighters in Resident 8's room. The DON stated Resident 8 had not been evaluated for safe smoking and had no plan of care (CP) to address smoking when she checked Resident 8's medical record at around 10 am this morning (6/4/2024). The DON stated Resident 8 should not be in possession of cigarettes and lighters because it was an accident hazard. The DON stated the lighter could cause burns (damage to the skin caused by fire) to Resident 8 or cause fire in the facility. The DON stated Resident 8 could not smoke without staff supervision due to Resident 8's behavior of hearing voices telling him to hurt himself and others in the facility. During an interview with the Social Services Director (SSD), and concurrent review of Resident 8's SE form, dated 6/4/2024, on 6/4/2024 at 2 pm, Resident 8's SE form indicated Resident 8 was not safe to have cigarette lighter in Resident 8's room and Resident 8 needed to be supervised by staff during smoke break. The SSD stated she was responsible for evaluation for all smokers, including Resident 8 in the facility. The SSD stated Resident 8 should not have cigarettes and lighter in Resident 8's possession and should be supervised by staff when smoking. The SSD stated she has not completed the SE for Resident 8 until this morning (6/4/2024) around 11:43 am after she was informed by the DON that Resident 8 had cigarettes and lighters in his possession in his room 48905 b. During a review of Resident 36's AR, the AR indicated the facility admitted Resident 36 on 3/18/2023 with diagnoses that included nicotine dependence and depression (persistent feelings of sadness and worthlessness and a lack of desire to engage in formerly pleasurable activities). During a review of Resident 36's untitled CP, dated 3/31/2023, the CP indicated Resident 36 had impaired visual function (poor vision) related to aging process. The CP interventions included for staff to alert Resident 36 to changes in the environment. During a review of Resident 36's untitled CP dated 2/27/2024, the CP indicated Resident 36 was at risk for a smoking related injury due to noncompliant behavior with smoking hours and designated areas. The CP goal was for Resident 36 to smoke with staff supervision. The CP interventions included for staff to accompany Resident 36 to smoke in the designated area, observe the resident during smoking hours, set limits with noncompliant behavior, and to monitor Resident 36 in safe handling and disposing of cigarette butts and ashes. During a review of Resident 36's Minimum Data Set (MDS, a standardized assessment and care planning tool) dated 3/25/2024, the MDS indicated Resident 36 had intact cognition (ability to understand). The MDS indicated Resident 36 used a walker and wheelchair for ambulation (walking/moving) and required supervision with walking for 10 feet (ft, unit of measurement). The MDS indicated Resident 36 required partial/moderate assistance (helper does less than half of the effort) for oral hygiene, toileting, and personal hygiene. During a review of Resident 36's SE form, dated 3/27/2024 at 9:27 am, the SE form indicated Resident 36 had poor vision and required supervision when smoking. During a review of Resident 36's History and Physical (H&P, formal document of a medical provider's examination of a patient) dated 4/10/2024, the H&P indicated Resident 36 had the capacity to understand and make decisions. During a review of Resident 36's untitled CP dated 5/25/2024, the CP indicated Resident 36 was a smoker. The CP goal indicated for Resident 36 not to smoke without supervision. The CP interventions included for staff to educate Resident 36 on proper disposal of cigarettes after smoking, explain the purpose of supervision for safety, and instruct Resident 36 that cigarettes and lighters were not allowed in Resident 36's possession. During an interview on 6/4/2024 at 10:46 am with the Assistant Administrator (AADM), the AADM stated there were no designated smoking times because all residents who smoke were alert and oriented. During a concurrent observation and interview on 6/4/2024 at 11:01 am with Resident 36 in the patio, Resident 36 was sitting in a chair, alone and unsupervised, next to a sliding glass door that was connected to Resident 36's room. Resident 36 placed a black cigarette pack into the basket of the front wheeled walker (FWW, an assistive device with four legs and two wheels on the front two legs) that was in front of Resident 36. Resident 36 stated Resident 36 just finished smoking in the patio and stated Resident 36 kept the cigarettes and lighters in Resident 36's possession for over a year. Resident 36 stated staff never supervised Resident 36 when Resident 36 smoked. Resident 36 stated Resident 36 had extra cigarette lighters in Resident 36's room in a tin container. Resident 36 stated Resident 36's roommate had an oxygen machine in Resident 36's room. Resident 36 stated Resident 36 was legally blind (the vision was less than 20 degrees which means if an object was 200 feet away, the resident/patient had to stand 20 feet from it in order to see it clearly). Resident 36 stated Resident 36 had difficulty using the ashtrays in the patio. Resident 36 stated Resident 36 placed cigarette butts inside a plastic bottle and threw the bottle in the trash can in the resident's bedroom when Resident 36 filled the bottle with cigarette butts. During a concurrent observation and interview on 6/4/2024 at 11:15 am with Registered Nurse Supervisor 1 (RN Sup 1) in Resident 36's room, an oxygen machine was next to Resident 36's roommate bed. A sign was posted outside Resident 36's door with red text that indicated Danger, Oxygen, No Smoking, No Open Flame. RN Sup 1 stated there was an oxygen machine in Resident 36's room and a Danger Sign was posted outside Resident 36's room. RN Sup 1 stated Resident 36 would smoke alone, outside in the patio in front of Resident 36's room. RN Sup 1 stated RN Sup 1 was unsure if Resident 36 could keep cigarettes and cigarette lighters at Resident 36's bedside. RN sup 1 stated RN sup 1 was unaware if Resident 36 could smoke unsupervised. During a concurrent interview and record review on 6/4/2024 at 11:16 am with RN Sup 1, Resident 36's untitled CP, dated 5/25/2024 was reviewed. The CP indicated Resident 36 required supervision during smoking and staff to instruct and educate Resident 36 that cigarettes and lighters were not allowed in Resident 36's possession. RN Sup 1 stated it was a fire hazard having a lighter at Resident 36's bedside or in Resident 36's possession because Resident 36's roommate had an oxygen machine in the room. RN Sup 1 stated Resident 36 needed supervision during smoking according to Resident 36's CP. RN Sup 1 stated Resident 36 needed to use the ashtray that was provided in the patio because the plastic bottle could catch fire when the cigarette butt was not extinguished (put out) completely. During a concurrent observation and interview on 6/4/2024 on 11:36 am with CNA 4 in Resident 36's room, there were seven disposable lighters, one unopened cigarette pack (20 cigarettes/pack) and one opened cigarette pack with two and half cigarettes in the box. CNA 4 stated all seven disposable lighters were functional. CNA 4 stated CNA 4 was unsure when Resident 36 got the seven lighters and kept them in Resident 36's room. During an interview on 6/4/2024 at 4:56 pm with the DON, the DON stated cigarette lighters should not be at Resident 36's bedside especially when there was an oxygen machine in Resident 36's room because it could cause an explosion or fire. The DON stated staff needed to remove the lighters immediately from Resident 36 for Resident 36 and other residents' (other residents in the facility) safety. The DON stated Resident 36 needed supervision during smoking according to Resident 36's CP and SE form. The DON stated Resident 36's safety would be at risk when staff did not provide supervision during smoking. The DON stated residents who smoke (smokers in general) needed to use the ashtrays to dispose cigarette butts appropriately. The DON stated cigarette butts should not be placed inside of a used plastic bottle because it could cause fire when cigarette butts were not extinguished completely. During a review of the facility's undated Policy and Procedure (P&P) titled, Smoking Policy-Residents, the P&P indicated Residents without independent smoking privileges may not have or keep any smoking articles, including cigarettes, tobacco, etc. The P&P indicated Ashtrays are emptied into designated receptacles and the use of oxygen is prohibited in smoking areas. The P&P indicated Residents who smoked (smokers) needed to be evaluated on admission to determine if the residents had the ability to smoke safety with or without supervision. The P&P indicated Any resident with restricted smoking privileges requiring monitoring shall have the direct supervision of a staff member, family member, visitor, or volunteer worker at all times while smoking. The P&P further indicated Staff should consult with the attending physician and DON to determine if safety restrictions was needed on the residents' smoking privileges based on Safe Smoking Evaluation.

Based on interview and record review, the facility failed to ensure one of two sample residents (Resident 1) who was assessed at risk for falls, had impaired vision and had a diagnosis of [CONDITION(S)] ([CONDITION(S)]) and history of syncopal episodes (a temporary loss of consciousness [awareness] usually related to insufficient blood flow to the brain) and collapse (to fall) was free from fall accidents and injury and was provided supervision by ensuring: 1. All relevant staff who cared for Resident 1 that included, Certified Nursing Assistants (CNA 1 and 2) were aware the resident was at risk for falls to ensure the resident was supervised during transfers, walking, and toileting to prevent falls. 2. The facility's interdisciplinary team (IDT, group of diverse health care professionals from different fields) discussed interventions to reduce the potential for Resident 1 to sustain further falls with injuries, when Resident 1 presented with a decline in medical condition on [DATE] and was diagnosed with a urinary tract infection on [DATE] (a urinary traction infection [[CONDITION(S)]] is a very common type of infection in your urinary system and can involve any part of your urinary system. Symptoms typically include needing to urinate often, having pain when urinating and feeling pain in your side or lower back). These deficient practices resulted in Resident 1 having an unwitnessed fall on [DATE] at 4:30 am, was found lying on the floor at the right side of the bed, facing down, and unresponsive. Resident 1 was transferred to a General Acute Care Hospital (GACH) via 911 (emergency services), was intubated (tube placed in throat to help breathing), admitted to the Intensive Care unit (ICU, a department of a hospital in which patients who are dangerously ill are kept under constant observation), and was diagnosed with a subdural hematoma (a buildup of blood on the surface of the brain), traumatic injury (physical injury which occurs suddenly) of the head, brain compression (a condition in which something increases the amount of pressure pushing on the brain, which can damage brain tissue). On [DATE], the resident died at the GACH with an immediate cause of death of a [MEDICATION(S)] force head trauma (a severe injury to the head). Findings: A review of Resident 1's Admission Record indicated the facility admitted Resident 1 on [DATE], with diagnoses including unspecified dementia (loss of memory and other mental abilities severe enough to interfere with daily life), [CONDITION(S)] and collapse. A review of Resident 1's History and Physical (H&P), dated [DATE], indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1's Fall Risk assessment dated [DATE], indicated the resident was at risk for falls. A review of Resident 1's Care Plan initiated on [DATE], indicated Resident 1 had a history of syncopal episodes. The care plan indicated a goal for the resident to have no further episode and or no injury from [CONDITION(S)] with a target date of [DATE]. The care plan interventions included to monitor the resident for changes in level of mentation (mental activity), dizziness, and lethargy. A review of Resident 1's Minimum Data Set (MDS, a Resident assessment and care screening tool), dated [DATE], indicated Resident 1 was assessed having moderately impaired vision and required supervision for transfers, bed mobility (how resident moves to and from lying position, turns side to side and positions body while in bed), and walking in the room (how the resident walks between locations in his/her room) with one person to assist. A review of Resident 1's Care Plan initiated on [DATE], indicated Resident 1 was at risk for falls due to unsteady gait. The care plan goal was for Resident 1 not to have episodes of falls. Interventions included to assess and monitor the resident's safety needs and awareness, assess other casual factors of falls such as dizziness, medication side effects, frequent visual checks for needs and safety, and provision of a hazard free environment. A review of Resident 1's Care Plan initiated on [DATE], indicated Resident 1 required assistance with activities of daily living (ADLs). The goal was for Resident 1 to continue with current functional status (not specified on the care plan). Interventions included to encourage the resident to get out of bed and assist her up on the wheelchair as tolerated, monitor the resident for decline in condition and to monitor for safety compliance and provide verbal cues as needed. A review of Resident 1's Care Plan initiated on [DATE], indicated Resident 1 had impaired visual function related to cataract (a medical condition in which the lens of the eye becomes progressively opaque, resulting in blurred vision). The goal was for Resident 1 not to have injuries related to visual impairment. Interventions included to alert the resident to necessary changes in environment and to assess visual function and consult as needed. A review of Resident 1's Care Plan initiated on [DATE], indicated the resident had episodes of refusing care and urinating on the floor. The interventions included for licensed nurses to assess the resident for pain, the need to void (to urinate), acute changes such as acute/[CONDITION(S)]. A review of Resident 1's Progress Notes Change of Condition, dated [DATE], timed at 7:25 am, indicated Licensed Vocational Nurse 2 (LVN 2) found the resident sitting on the floor next to her wheelchair, complete assessment done able to move all extremities without difficulty and no visible injury noted and the physician was notified. A review of Resident 1's Care Plan dated [DATE], indicated Resident 1 was found sitting on the floor next to her wheelchair. The Resident Goals were for Resident 1 not to have falls and no serious complications. The approach plan included to assess and monitor safety needs and teaching, monitor casual factors that could attribute to fall incidence and frequent checks by staff and assessment of her needs. A review of Resident 1's Progress Notes, Change of Condition Note, dated [DATE], timed at 2:37 pm, nine (9) days after the resident was found on the floor, indicated Resident 1 was sitting in her wheelchair feeling sleepy and was assisted back to bed, the resident's physician was notified, and laboratory tests were ordered. A review of Resident 1's Progress Notes dated [DATE], timed at 12:28 pm, indicated the resident's laboratory blood test results were reported to the resident's physician and a new order for [MEDICATION(S)] (antibiotic medication) was given for a diagnosis of [CONDITION(S)]. A review of Resident 1's care plan titled Actual infection: [CONDITION(S)], dated [DATE], indicated the interventions indicated for the licenses nurses to monitor presence of signs and symptoms of [CONDITION(S)], fever, pain in abdomen, change in mentation, strong persistent urge to urinate, strong smell of urine, difficulty urinating and pain during urination. A review of Resident 1's Progress Notes dated [DATE], timed at 2:20 pm, indicated Resident 1 was still very weak, the resident's physician was notified and ordered for [MEDICATION(S)] (antibiotic) 1 gram (g, unit of measurement). A review of Resident 1's untitled ADL sheet, dated [DATE] indicated the resident used the toilet at 1:24 am, 1:26 pm, and at 6:55 pm. The form indicated the resident used the toilet on [DATE], at 12:08 am. A review of Resident 1's Progress Notes, dated [DATE], timed at 4:30am, indicated the resident was found beside her bed, face down with laceration to right forehead. The Notes indicated the resident's blood pressure (is the force of the blood pushing against the walls of the arteries, each time the heart beats, it pumps blood into the arteries), was ,d+[DATE] (elevated, normal blood pressure for most adults is defined as a systolic pressure of less than 120 and a diastolic pressure of less than 80) and was transferred to GACH via 911. A review of Resident 1's Progress Notes dated [DATE] indicated CNA (unidentified) at 4:30 am, found the resident on the floor on the right side of the bed, arousable to pain only without spontaneous eye-opening response. The notes indicated the resident had a laceration to the right side of the forehead, and some bleeding was observed from the laceration sustained from the unwitnessed fall. The notes indicated the paramedics (911 services) picked the resident up from the floor. A review of Resident 1's Prehospital Care Report, dated [DATE], timed at 4:58 am, indicated Resident 1 was found lying on the ground, at the facility and had unequal pupils (black part in the center of the eye), swelling, a laceration (a deep cut), hematoma (pool of clotted blood formed in a tissue caused by a broken blood vessel damaged by injury) to her head, and an obvious deformity to the right side of her temple (the area just behind and to the side of the forehead and the eye). A review of Resident 1's GACH record titled ED Note Physician, dated [DATE], timed at 5:46 am, indicated Resident 1 presented to the Emergency Department (ED) after a traumatic fall at the facility and the resident was intubated (inserting a tube through the patient's mouth and into their airway) due to severe head trauma. The note indicated there was significant trauma to the resident's head especially on the right temporal frontal area with a 2 cm laceration and a low Glasgow Coma Scale (GCS - a 15-point scoring system used to describe the initial level of awareness). The note indicated the resident was admitted to the ICU (An intensive care unit (ICU) provides the critical care and life support for acutely ill and injured patient) with diagnoses of subdural hematoma (a buildup of blood on the surface of the brain) and traumatic injury of the head. A review of Resident 1's GACH records titled Discharge Summary, dated [DATE], timed at 1:47 pm, indicated Resident 1 expired with diagnoses of subdural hematoma, traumatic head injury of head, and brain compression. A review of Resident 1's Certificate of Death, indicated the resident's date of death was [DATE], at 1:47 pm. The resident's immediate cause of death was a [MEDICATION(S)] head trauma from an injury described as a Ground level-fall that occurred on [DATE]. During an interview on [DATE] at 10:59 am, Certified Nursing Assistant 1 (CNA 1) stated she was familiar with Resident 1. CNA 1 stated Resident 1 used the wheelchair as a walker to walk. CNA 1 stated she was not aware Resident 1 was at risk for falls and that Resident 1 was independent with her mobility. During an interview on [DATE] at 12:30 pm, Register Nurse 1 (RN 1) stated she worked the 11 pm shift on [DATE] to 7:30 am [DATE]. RN 1 stated that around 4:30 am, Resident 1's Licensed Vocational Nurse 1 (LVN 1) informed her Resident 1 was on the floor. RN 1 stated she found Resident 1 laying on the right side of the bed and stated Resident 1 had a laceration on her right temple of approximal 2- 2.5 centimeters (cm, a unit of measurement) and the resident was unresponsive. During an interview on [DATE] at 3:56 pm, with the Director of Nursing (DON), the DON stated Resident 1 was at risk for falls. During a telephone interview on [DATE], at 10 am, Certified Nursing Assistant 2 (CNA 2), stated he was working on the night Resident 1 fell and started his shift at 11 pm on [DATE] and ended his shift at 7 am on [DATE]. CNA 2 stated Resident 1 did not have a roommate and her room was located at the end of the hallway from the nurse's station. CNA 2 stated Resident 1 walked to the toilet alone and would not press the call light (device used by a resident to signal his or her need for assistance from a professional staff), for help. CNA 2 stated he was not aware Resident 1 was at risk for falls. CNA 2 stated that during his shift on [DATE], when he was walking down the hallway, he could see the resident sleeping on her bed. CNA 2 stated that he saw the resident at 11 pm, 1:30 am, 2 am, 2:30 am, 3 am, 4 am. CNA 2 stated that during these times, he did not enter the resident's room to ask if she needed assistance with toileting. CNA 2 stated Resident 1 preferred to sleep with the lights on and the curtains and the door open and that made it easier for the staff to see the resident from the hallway. CNA 2 stated the last time he saw Resident 1 in bed was at 3 am on [DATE]. CNA 2 stated that at 4:15 am, he was performing an adult brief (disposable garment) change across Resident 1's room and did not see the resident in bed. CNA 2 stated that as soon as he was done, he went to Resident 1's room and found Resident 1 on the floor at 4:30am, at the right side of her bed, facing down, and unresponsive. CNA 2 worked with Resident 1 on ,d+[DATE] to [DATE], and on [DATE]. During an interview on [DATE], at 6:36 am, LVN 1 (assigned to Resident 1) stated Resident 1 was able to go to the bathroom by herself (in general), using a four-wheel walker (FWW, walking aid device) and the resident could also transfer by herself from a four-wheel walker to the bed. LVN 1 stated she saw Resident 1 in bed on [DATE] between 3:30 am and 4 am. LVN 1 stated when she was preparing for rounds at 4:30 am, CNA 2 called her to Resident 1's room and when she got to Resident 1's room, she found the resident laying, facing down on the floor. LVN 1 stated there was scant to moderate bleeding, the resident was not arousable, non-responsive to verbal or touch. LVN 1 stated she was aware that Resident 1 was being monitored for falls risk and stated they should have implemented safety precautions such as asking the resident if she needed anything (every hour), assist her, and attend to her needs. LVN 1 stated that although she was aware Resident 1 was at risk for falls the staff did not provide assistance to the resident and Resident 1 was not supervised to the bathroom. LVN 1 stated Resident 1 should have been supervised to prevent the resident from falling. LVN 1 stated Resident 1 got up on her own and the resident could have benefited from one-on-one staff supervision because she was weak during her weakness. LVN 1 stated she did not request from Resident 1 an order from the resident's physician for one-on-one supervision, and stated the resident should have been provided floor mats (used to reduce fall?related trauma if a patient gets up from bed, loses balance, and falls to the floor), on each side of her bed, and a bed alarm to alert the staff if the resident got out of bed. LVN 1 stated if these interventions had been provided by the facility, she was confident that this fall could have been prevented. During an interview and concurrent record review of the facility's policy and procedures titled: Safety and Supervision of Residents, with the Director of Nursing (DON) on [DATE]at 9:53 am, the DON stated that according to Resident 1's Progress Notes dated [DATE], Resident 1 was very weak. The DON stated Resident 1's weakness was not specific; the resident was ambulatory (walking around on her own) and then had a change of condition with [CONDITION(S)] (a major decline in a resident's status) and had become very weak. The DON stated the facility did not assess the resident who had weakness and dizziness and a history of falling. The DON stated the facility did not think of assessing the resident because the focus was on the resident's medical condition (urinary tract infection, an infection in any part of the urinary system, the kidneys, bladder, or urethra). The DON stated Resident 1's weakness should have been discussed in the change of shift huddle (stand-up meeting), but it was not. The DON stated Resident 1 had a low bed, but the facility could have put a bed alarm and floor mats in case the resident fell , according to the facility's policy. The DON stated a bed alarm and floor pads were considered nursing interventions and a physician's order was not required. During a telephone interview on [DATE], at 3:55 pm, the DON stated in general, the residents who were at risk for falls, the facility's interventions to prevent falls included, floor mats, and if the residents were confused, the facility would move them closer to the nursing station. The DON stated those interventions were not implemented for Resident 1 because she was alert and oriented. The DON stated some of the symptoms of [CONDITION(S)] include weakness, poor appetite, frequent urination, and going to the restroom more often. The DON stated the staff should check every two hours and physically went inside the residents' room to see if the residents' needed assistance during the rounds. During a telephone interview on [DATE], at 12:17 pm, the DON stated the facility did not have documented evidence of monitoring Resident 1 for prevention falls such checking the resident every two hours. A review of the Facility's Policy and Procedures titled Fall Prevention Program, undated, indicated preventative measures that included, assistance given when necessary to ensure ambulation is safe and placing the resident in a low bed and may apply bed alarm and floor mat. A review of the Facility's current Policy and Procedures titled Safety and Supervision of Residents, revised [DATE], indicated the interdisciplinary team (IDT, group of diverse health care professionals from different fields) shall target interventions to reduce the potential for accidents. Implementing interventions to reduce accident risks and hazards shall include the following: communicating specific interventions to all relevant staff; assigning responsibility for carrying out interventions; providing training as necessary, ensuring interventions are implemented and documenting interventions. The Policy indicated systems approach to safety included Resident supervision is a core component of the system approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment. The type and frequency of resident supervision may vary among residents and over time for the same resident. For example, resident supervision may need to be increased when there are temporary hazards in the environment or if there is a change in the resident's condition. A review of the Facility's current Policy and Procedures titled Falls and Fall Risk, managing, revised [DATE] indicated the staff will monitor and document each resident's response to interventions intended to reduce falling or the risk of falling. A review of the Facility's current Policy and Procedures titled Fall Risk Assessment revised [DATE] indicated that the nursing staff, attending physician, and consultant pharmacist will review for medications or medication combinations that could relate to falls or fall risk, such as those that have side effects of dizziness, ataxia (Ataxia is a [CONDITION(S)] disease of the nervous system. Many symptoms of Ataxia mimic those of being drunk, such as slurred speech, stumbling, falling, and incoordination) or [CONDITION(S)] (low blood pressure). The staff and the attending physician will collaborate and address modifiable fall risk factors and interventions to minimize the consequences of risk factors that are not modifiable. A review of the facility's current Urinary Tract Infections/Bacteriuria-Clinical Protocol revised [DATE], indicated the physician and nursing staff would review the status of individuals whare are being treated for a [CONDITION(S)] and adjust treatment accordingly. Per interview with the DON All the policies the facility provided are currently used at the facility. The nurses failed to anticipate Resident 1's needs, such as, using the bathroom more often due to [CONDITION(S)].

Based on observation, interview, and record review, the facility failed to have an effective pest control program to prevent cockroach (roaches, a small insect that can carry and spread infectious diseases) infestation (the presence of an unusually large number of cockroaches) in the facility's kitchen for 74 of 74 residents (Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, and 74). This deficient practice resulted in the presence of thirty-three live German cockroaches (a small species of cockroach) of various stages of development crawling on the kitchen wall, under the dish washer machine, and near the water fountain on the wall separating the walls from the activity room and the kitchen. 74 residents were placed at risk of serious diseases caused by contaminating human food with germs (small living thing/cell, especially one which causes diseases) from bacteria that the cockroaches pick up from the toilets and garbage dumps. On 11/4/2021 at 6:07 pm, the California Department of Public Health declared an Immediate Jeopardy (IJ, a situation in which the provider's non-compliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death of a resident or residents), and the facility's Administrator (ADM) was notified of the findings that placed 74 residents residing at the facility at risk to experience food infection from ingesting live bacteria, food intoxication from ingesting food containing toxins from bacteria, and disease transmission that could lead to life threatening complications or death. The Environment Health Specialist (EHS) from Environmental Health Department (EHD) closed the facility's kitchen to food preparation. The current resident census in the facility is 74 who received a combination of regular to soft textured foods, a pureed diet (a texture-modified diet that do not need to be chewed), and fluids for residents on gastrostomy tube feeding (A feeding tube is a device that's inserted into your stomach through your abdomen. It's used to supply nutrition when you have trouble eating). As of 11/8/21, the kitchen remains closed (a total of four days). On 11/4/2021 and on 11/5/2021, the facility did not submit an acceptable Plan of Action (POA, action to correct the deficient practices), and the Department did not abate the IJ. Findings: During an observation inside the facility's kitchen on 11/4/2021 at 3:30 pm, the Surveyor and the Registered Environmental Health Specialist (REHS, a health inspector who inspects various facilities and properties to determine conformance with applicable State laws and County Ordinance Code sections), observed 16 live cockroaches throughout the kitchen and 10 dead cockroaches under the dish washing machine. During the concurrent observation, the surveyors also observed nine live cockroaches on the wall under the dish washing machine, five cockroaches under the two-compartment sink (deep sink basin made for washing, rinsing or sanitizing dinnerware) and three live cockroaches observed near the water fountain on the wall separating the walls from the activity room and the kitchen (total of 33 live cockroaches observed). A review of the facility's Resident Roster, dated 11/4/2021, indicated the facility had 74 residents residing in the facility. During an interview on 11/4/2021 at 5:38 pm, the ADM stated the housekeeping staff (unidentified) would spray the kitchen and bathrooms with an ant, roach, and spider spray bottle as needed with no specified day, time, or frequency. In addition, the ADM stated he did not have an ongoing contract with a pest control company to maintain a pest control program. The facility had 35 residents on regular diet, 26 residents on soft Puree, seven residents on G-tube, and six residents nothing by mouth (NPO). During an interview on 11/5/2021 at 7:15 am, the Dietary Supervisor (DS) stated she saw live cockroaches in the kitchen before 11/4/2021 (no specific date and time) and she informed the ADM (unspecified time). During an interview on 11/6/2021 at 7:30 am, the housekeeping (HK) stated he sprayed with an ant, roach, and spider spray bottle before 11/4/2021, in the residents' (no specific dates)bathrooms and rooms as needed (no specific dates). A review of the facility's Pest Control form dated 11/4/2021, timed at 5:47 pm, indicated the pest control company did an initial assessment to the facility and reinstatement of service. The form indicated the pest control technician (unidentified) killed multiple (unidentified number) roaches and vacuumed roaches as they came out. The invoice indicated the technician applied German roach intensive treatment to the facility's kitchen areas and found multiple areas and cracks and crevices that needed to be sealed. A review of the facility's Pest Control policy and procedure with a revised date of August 2008, indicated the facility should maintain an effective pest control program to ensure the building was kept free of insects and rodents. The policy did not indicate the frequency of pest control maintenance. A review of the undated article from the County of Los Angeles, Department of Public Health, Effective Management of Cockroach Infestation, at http://publichealth.lacounty.gov/eh/docs/specialized/vector_management/cockroachmgmt.pdf, indicated that cockroaches may become pests in any structure that has food preparation or storage areas. The article indicated cockroaches contaminate food and kitchen utensils, occasionally damage fabric and paper products, leave stains on surfaces, and produce unpleasant odors when present in high numbers. Cockroaches that live outdoors could come into contact with human excrement (waste matter/feces) in sewers or with animal fecal matter and had the potential to transmit bacteria that cause food poisoning when they entered the facility's kitchen. A review of the Centers for Disease Control and Prevention, Guidelines for Environmental Infection Control in Health Care Facilities, updated July 1, 2019 https://www.cdc.gov/infectioncontrol/guidelines/environmental/index.html, indicated the guidelines were recommendations for the prevention and control of infectious diseases that are associated with healthcare environments. The guidelines indicated pest included cockroaches from inside the health care facilities that can serve as agents for the mechanical transmission of microorganisms (small living thing/cell), or as active participants in the disease transmissions process by serving as a vector (a live carrier that transfers infectious pathogens/germs) to animal and or human. References: According to the World Health organization (WHO), cockroaches have been known to play a role as carriers of intestinal diseases, such as dysentery (infection of the intestines), diarrhea (loose, watery stools), [MEDICATION(S)] (an infectious and often fatal bacterial disease of the small intestine), and [MEDICATION(S)] fever (bacterial disease spread through contaminated food and water or close contact). Cockroaches and their droppings may trigger an asthma attack (airways become swollen and inflamed). The cockroaches' feces, saliva, eggs, and outer covering, or cuticles left behind on surfaces contain substances that are allergenic (an allergen is a substance that can cause an allergic reaction) to humans, especially those with asthma or other respiratory conditions. Within and on the surface of their bodies, cockroaches carry bacteria that can cause salmonella, staphylococcus and streptococcus if deposited in food. Additionally, cockroach feces, skin shedding and saliva can cause asthma and allergies, especially in children. https://www.who.int/water_sanitation_health/resources/vector288to301.pdf

Based on observation, interview and record review, the facility failed to provide skin care treatments and implement intervention to prevent pressure injury, as the physicians ordered, and as the facility's policy and procedure, for 12 of 12 sampled residents (Residents 2, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, and 15) by failing to: 1. Ensure that the charge nurse assigned to the Red Zone (area for residents tested positive for COVID-19 (Coronavirus disease, a severe respiratory illness caused by virus and spread from person to person)) provide skin assessments and skin care treatments to pressure injury development for Residents 2, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, and 15. 2. Ensure Residents 2, 6, 8 and 15 received skin care treatments to prevent development of new pressure injuries (localized damage to the skin and/or underlying soft tissue due to prolonged pressure on the skin). 3. Ensure Residents 5, 7, 9, 10, 11, 12, 13, and 14 received treatments to prevent development of pressure injury and worsening skin condition. As a result, Resident 2 developed a Stage 2 pressure injury (partial thickness skin loss, skin breaks open) on the left buttocks; Resident 6 developed a Stage 2 pressure injury on the sacrococcyx (tailbone area); Resident 8 developed a Stage 3 pressure injury (full thickness skin loss involving damage to tissue under the skin) on the sacrococcyx; Resident 15 developed a Stage 2 pressure injury on the left buttocks. These deficient practices placed Residents 5, 7, 9, 10, 11, 12, 13, 14 who were assessed as high risk for skin breaks down to develop new pressure injuries, and Residents 2, 6, 8, 15 at risk for pressure injuries infection that could lead to health complications including osteo[DIAGNOSES REDACTED] (infection of the bone) and hospitalization . On 9/5/20 at 7:05 p.m., an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified in the presence of the facility's Assistant Administrator (AADM) regarding facility's staff failure to provide skin assessment and skin care to prevent the development of new pressure injuries and worsening of skin condition for Residents 2, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, and 15. On 9/11/20 at 1 p.m., the IJ was lifted after the AADM submitted an acceptable Plan of Action (POA, interventions to correct the deficient practices). The surveyor verified and confirmed the implementations of the POA while onsite by observation, interview and record review. The IJ was removed in the presence of the AADM. The acceptable POA as follows: 1. On 9/6/2020, the facility's AADM posted an ad to hire new full?time treatment nurse. On 9/12/2020, the AADM hired a treatment nurse to work in the Red Zone 2. On 9/5/20, Licensed Vocational Nurse 1 (LVN 1) assessed Residents 2's, 6's. 8's, 15's pressure injuries, notified the residents' Physician (MD 1) of the new pressure injuries, provided wound treatments and completed the care plans for the residents. On 9/7/2020, the facility transferred Resident 8 to another Skilled Nursing Facility (SNF). On 9/10/20, Wound Care Physician 1 (WCMD 1) reassessed Residents 2's, 6's, 8's and 15's pressure injuries and prescribed new wound treatment orders. 3. On 9/10/20, WCMD 1 reassessed Resident 5's, 7's, 9's, 12's, and 14's and prescribed new treatment orders. The facility transferred Resident 10 to another SNF. The facility transferred Residents 11 and 13 to General Acute Care Hospitals (GACHs) for further evaluation due to COVID-19 complications. Findings: 1. During an initial meeting with the California Medical Assistance Team (CAL-MAT, a group of highly trained licensed medical professionals that coordinated by the State Emergency Medical Services Authority (EMSA) for rapid field disaster medical response), and a concurrent interview with CAL-MAT Team Leader 1 (CAL-MAT TL 1) on 9/5/20 at 10:40 a.m., CAL-MAT TL 1 stated he had concerns regarding the residents in the Red Zone (Residents 2, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, and 15) not receiving skin assessments and skin care treatment to prevent the development of pressure injuries. CAL-MAT TL 1 stated the Red Zone did not have wound treatment supplies (scissors, dressings, bandages) for these residents. CAL-MAT TL 1 stated he identified Residents 2, 6, 8 and 15 with new pressure injuries and did not know if there was skin care and order for pressure injury treatments. During a review of the facility's staffing schedule and census, dated 9/5/2020, and a concurrent interview with facility's Registered Nurse 1 (RN 1), on 9/5/20 at 11:09 a.m., the facility's census indicated the Red Zone had 34 positive COVID-19 residents. The facility's staffing schedule indicated two Certified Nurse Assistants (CNA 2 and CNA 5), one Licensed Vocational Nurse (LVN 8), and two Registered Nurses (RN 3 and RN 4) were working in the Red Zone. RN 1 stated these five staff members in the Red Zone were from staffing registry and they were not familiar with the residents' care and needs. During an observation of the Red Zone, on 9/5/2020, at 11:28 a.m., there were no treatment nurse available to perform skin assessments and wound treatment for [REDACTED]. During an interview with Registry's Registered Nurse 4 (RN 4) on 9/5/20 at 1:55 p.m., RN 4 stated she did not receive orientation and did not know that she needed to provide skin care and wound treatment to the residents besides administering medications to them. RN 4 stated she did not receive report from RN 1. RN 4 stated she could not identify and did not provide wound treatments for the residents in the Red Zone. During an interview on 9/5/20 at 4 p.m., RN 1 stated she could not identify and could not provide the list of the residents that had wound treatment orders. RN 1 stated she could not differentiate the residents that had wound treatment orders and was not familiar with the access of the residents' Electronic Treatment Administration Record (ETAR). During an interview with facility's Licensed Vocational Nurse 6 (LVN 6) on 9/6/20 at 1:45 p.m., LVN 6 stated she did not provide skin care and wound treatments to the Residents 2, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, and 15, because she was the only licensed nurse assigned to the Red Zone. LVN 6 stated she did not receive instruction from RN 1 to provide skin care and wound treatments for prevention of pressure injuries for these residents. LVN 6 stated she could not provide skin care and wound treatment for [REDACTED]. LVN 6 stated she had no access to the residents' treatment records. During an interview on 9/6/20 at 2 p.m., RN 1 stated she refused to go to the Red Zone to conduct a skin assessment for Residents 2, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, and 15, and provide skin care as physician ordered, due to concern of being over exposed to positive COVID-19 residents. RN 1 stated the charge nurses assigned in the Red Zone would need to provide skin care to prevent pressure injuries for Residents 2, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, and 15. During an interview on 9/7/20 at 1:20 p.m., facility's Licensed Vocational Nurse 5 (LVN 5) stated she did not provide skin care treatments to Residents 2, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, and 15. LVN 5 stated he was not aware that these residents had skin care treatment orders. During an interview on 9/9/20 at 1:36 p.m., LVN 6 stated she did not implement the turning schedule for Residents 2 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, and 15, who required turning and repositioning. During an interview on 9/9/20 at 1:50 p.m., registry's Licensed Vocational Nurse 7 (LVN 7) stated she was not aware Residents 2, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, and 15 had skin care treatment orders for skin maintenance to prevent pressure injury. 2a. A review of Resident 2's Admission Record indicated the facility admitted Resident 2 on 1/9/19 and readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 2's Physician Order, dated 4/18/20, indicated the resident had orders for [MEDICATION NAME] (ointment helped heals skin irritations), and A & D ointment (medication used as a moisturizer to treat or prevent dry, rough, scaly, itchy skin and minor skin irritations) to the sacrococcyx (tailbone area), daily, for skin maintenance. A review of Resident 2's Minimum Date Set (MDS, an assessment and care planning tool), dated 5/26/20, indicated the resident had impairment in cognition (ability to learn and process information). The MDS indicated Resident 2 required extensive assistance (residents involved in activities, staff provided weight bearing support) on staff for bed mobility, transfer, dressing, and personal hygiene. The MDS indicated Resident 2 was totally dependent on staff assistance for toilet use and at risk for developing pressure injuries. A review of Resident 2's laboratory test result, dated 8/19/20, indicated Resident 2 tested positive for COVID 19. During a review of Resident 2's ETAR for the month of August and September 2020, and a concurrent interview on 9/9/20 at 12:30 p.m., facility's Licensed Vocational Nurse 1 (LVN 1) stated Resident 2's ETAR indicated the resident did not receive wound treatment as ordered by the physician on 8/20, 8/22, and from 8/24/20 to 9/7/20. LVN 1 stated licensed nurses (in general) who assigned to the Red Zone being mostly from staffing registry and were not familiar with the resident's needs. A review of Resident 2's Wound Consultation Notes, dated 9/10/20, indicated the resident had a Stage 2 pressure injury measuring 0.7 centimeter (cm, unit of measurement) by 1.5 cm to left buttocks and a deep tissue injury (DTI, persistent non-blanchable deep red, purple areas of skin or blood-filled blisters caused by damage to the underlying soft tissues) without measurement to the right buttocks. 2b. A review of Resident 6's Admission Record indicated the facility admitted the resident on 2/5/19 and readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 6's MDS, dated [DATE], indicated the resident had severe impairment in cognition. The MDS indicated Resident 6 was totally dependent on staff assistance for bed mobility, transfer, dressing, eating, toilet use, and personal hygiene. The MDS indicated Resident 6 was at risk of developing pressure injuries. A review of Resident 6's Physician Order, dated 7/6/20, indicated the resident had an order for [REDACTED]. A review of Resident 6's laboratory test result, dated 8/27/20, indicated the resident tested positive for COVID-19. During an observation in the Red Zone and interview on 9/5/20 at 1:30 p.m., Resident 6 observed lying in bed with a small skin tear on the left hand and a pressure injury on the back. Resident 6 could not tell what had happened. Registry's Registered Nurse 3 (RN 3) stated he received a report from CAL-MAT 2 that Resident 6 had pressure injury on the back. RN 3 stated he did not conduct skin assessments or provide wound treatment because he did not have access to Resident 6's ETAR or treatment supplies available. RN 3 stated Resident 6 did not receive wound treatment. During a review of Resident 6's ETAR for the month of August 2020 and September 2020, and a concurrent interview on 9/9/20 at 12:30 p.m., LVN 1 stated Resident 6's ETAR indicated the resident did not receive the barrier cream to coccyx from 8/27/20 to 9/9/20 as ordered by the physician. A review of Resident 6's Wound Consultation Notes, dated 9/10/20, indicated Resident 6 had a Stage II pressure injury on the sacrococcyx, measuring 1 cm (length), 0.5 cm (width), and 0.1 cm (depth). 2c. A review of Resident 8's Admission Record indicated the facility admitted the resident on 4/13/14 and readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 8's MDS, dated [DATE], indicated the resident had impairment in cognition. The MDS indicated Resident 8 was totally dependent on staff assistance for bed mobility, transfer, dressing, toilet use, and personal hygiene. The MDS indicated Resident 8 was at-risk for developing pressure injuries. A review of Resident 8's Physician Order, dated 8/10/2020, indicated the resident had an order for [REDACTED]. A review of Resident 8's laboratory test result, dated 8/19/20, indicated Resident 8 tested positive for COVID-19. During the concurrent observation in the Red Zone and interview on 9/5/2020, at 1:15 p.m. Resident 8 was lying in bed and observed had pressure injury on her buttocks. Registry's Registered Nurse 3 (RN 3) stated it was his first day working at the facility. RN 3 stated Resident 8 had multiple open wounds that were consistent with Stage 3 pressure injury on the resident's buttocks. RN 3 stated he was not familiar with Resident 8's wound and he did not have full access to the facility's electronic treatment system. RN 3 stated he did not receive any orientation and did not know what to do. RN 3 stated he was overwhelmed and would not come back to work in the facility. A review of Resident 8's Nursing Progress Notes, dated 9/5/2020, indicated the resident has a Stage III-pressure injury on the sacrococcyx with slight drainage, measuring 5 cm by 8 cm by 0.1 cm. The notes indicated Resident 8 did not have previous pressure injury. During a review of Resident 8's Nurses Progress Notes, dated 9/7/2020 and a concurrent interview, on 9/30/20 at 3:15 PM, LVN 1 stated Resident 8 was transferred to another SNF on 9/7/20 due to the facility inability to provide care for the resident. During a review of Resident 8's ETAR for the month of August 2020 and September 2020 and a concurrent interview on 9/9/20 at 12:30 p.m., LVN 1 stated Resident 8's ETAR indicated the resident did not receive wound treatment from 8/21/20 to 9/5/20 as ordered by the physician. 2d. A review of Resident 15's Admission Record indicated the facility admitted the resident on 10/22/14 and readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 15's MDS, dated [DATE], indicated the resident had intact cognition. The MDS indicated Resident 15 required extensive assistance from staff for bed mobility, dressing, and personal hygiene. The MDS indicated Resident 15 was totally dependent on staff for toilet use. The MDS indicated Resident 15 was at risk for developing pressure injuries. A review of Resident 15's Physician Order, for the month of August and September 2020, indicated there were no physician orders for skin treatment. A review of Resident 15's laboratory test result, dated 9/3/20, indicated Resident 15 tested positive for COVID-19. During an observation in the Red Zone and interview on 9/5/20 at 11:28 a.m., Resident 15 was lying in bed awake. Resident 15 had one open wound on the resident's left buttocks. Resident 15 stated the nurses have forgotten about us. The resident began to cry and expressed the pain she felt was uncomfortable. Resident 15 stated she needed help with repositioning in bed and that she felt numb. RN 3 stated Resident 15 had a Stage 2 pressure injury to her right buttocks, but he could not obtain measurements because there was no treatment nurse or physician order. RN 3 stated he did not know the facility's electronic treatment system and that he was overwhelmed. A review of Resident 15' Nursing Progress Notes, dated 9/5/2020, indicated the resident developed a Stage 2 pressure injury to the upper left buttocks. The notes did not indicate the measurement of the pressure injury. A review of Resident 15' Wound Consultation Notes, dated 9/10/20, indicated the resident developed a Stage II pressure injury on the left buttocks measuring 2.1 cm by 3.5 cm by 0.1 cm. 3a. A review of Resident 5's Admission Record indicated the facility admitted the resident on 5/9/18 and readmitted on [DATE] with current [DIAGNOSES REDACTED]. A review of Resident 5's MDS, dated [DATE], indicated the resident had no impairment in cognition. The MDS indicated Resident 5 required extensive assistance from staff on bed mobility and was totally dependent on staff assistance for transfer, toilet use, and personal hygiene. The MDS indicated Resident 5 was at risk of developing pressure injuries. A review of Resident 5's laboratory test result, dated 8/19/20, indicated Resident 5 tested positive for COVID-19. A review of Resident 5's Physician Order, dated 8/23/20, indicated the resident had an order for [REDACTED]. During a review of Resident 5's ETAR for the month of August 2020 and September 2020 and a concurrent interview on 9/9/20 at 12:30 p.m., LVN 1 stated Resident 5's ETAR indicated, the resident did not receive A & D ointment to the left heel and Zinc Oxide to the whole buttocks as ordered by the physician from 8/23/20 to 8/31/20 and from 9/1/20 to 9/7/20. 3b. A review of Resident 7's Admission Record indicated the facility admitted the resident on 10/29/18 and re-admitted on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 7's MDS, dated [DATE], indicated the resident had severe impairment in cognition. The MDS indicated Resident 7 required extensive assistance from staff for bed mobility, transfer and was totally dependent on staff assistance for dressing, toilet use, and personal hygiene. The MDS indicated Resident 7 was at risk of developing pressure injuries. A review of Resident 7's laboratory test result, dated 8/31/20, indicated Resident 7 tested positive for COVID-19. A review of Resident 7's Physician Order, dated 9/4/20, indicated the resident had an order for [REDACTED]. During a review of Resident 7's ETAR for the month of September and a concurrent interview on 9/9/20 at 12:30 p.m., LVN 1 stated Resident 7's ETAR indicated the resident did not receive skin barrier cream to the whole buttocks area, as ordered by the physician from 9/4/2020 to 9/7/20. A review of Resident 7's Wound Consultation, dated 9/10/20, indicated the resident had developed bilateral buttocks MASD. 3c. A review of Resident 9's Admission Record indicated the facility admitted the resident on 12/18/17 and re-admitted on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 9's MDS, dated [DATE], indicated the resident had severe impairment in cognition. The MDS indicated Resident 9 required limited assistance from staff for transfer, toilet use, and required extensive assistance from staff including dressing and personal hygiene. The MDS indicated Resident 9 was at risk of developing pressure injuries. A review of Resident 9's Physician Order, dated 8/19/20, indicated to clean and apply hydrogel (used for wound treatment that comes in a form of gel or wound dressing) to left heel DTI, and mid back pressure injury. Apply Zinc Oxide to right heel Stage I (skin is not broken but is red or discolored) pressure injury. A review of Resident 9's laboratory test result, dated 8/31/20, indicated Resident 9 tested positive for COVID-19. During a review of Resident 9's ETAR for the month of August 2020 and September 2020, and a concurrent interview on 9/9/20 at 12:30 p.m., LVN 1 stated Resident 9's ETAR indicated the resident did not receive hydrogel to the left heel and Zinc Oxide to right heel Stage 1 as ordered by the physician, for skin maintenance on 8/28/20, 8/29/20, 9/1/20 to 9/7/20, and 9/9/20 to 9/10/20. 3d. A review of Resident 10's Admission Record indicated the facility admitted the resident on 1/6/16 and readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 10's MDS, dated [DATE], indicated the resident had severe cognitive skill impairments. The MDS indicated Resident 10 was totally dependent on staff assistance for bed mobility, transfer, dressing, eating, toilet use, and personal hygiene. The MDS indicated Resident 10 was at risk of developing pressure injuries. A review of Resident 10's Physician Order, dated 2/12/20, indicated for the resident to have barrier cream and A & D on the whole buttocks area, daily, for skin maintenance. A review of Resident 10's laboratory test result, dated 8/31/20, indicated Resident 10 tested positive for COVID-19. During a review of Resident 10's ETAR for the month of August 2020 and September 2020 and a concurrent interview on 9/9/20 at 12:30 p.m., LVN 1 stated Resident 10's ETAR indicated, the resident did not receive barrier cream and A & D to the whole buttocks, as ordered by the physician 8/28/20, 8/29/20, and from 9/1/20 to 9/7/20, as the resident was assessed risk for developing pressure ulcer. During a review of Resident 10's Nurses Progress Note and an interview with the LVN 1 on 9/9/20 at 12:30 PM, LVN 1 stated Resident 10 did not had skin assessment and was transferred to another SNF on 9/9/2020. 3e. A review of Resident 11's Admission Record indicated the facility admitted the resident on 6/28/19 and re-admitted on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 11's MDS, dated [DATE], indicated Resident 11 had no impairment in cognition. The MDS indicated Resident 11 required extensive assistance on staff for bed mobility and was totally dependent on staff assistance for transfer, dressing, toilet use, and personal hygiene. The MDS indicated Resident 11 was at risk of developing pressure injuries. A review of Resident 11's Physician Order, dated 7/9/20, indicated for the day shift licensed nurse (unidentified) to clean the right and left buttocks MASD with soap, water and apply Zinc Oxide. A review of Resident 11's laboratory test result, dated 8/31/20, indicated Resident 11 tested positive for COVID-19. During an observation in the Red Zone and an interview on 9/5/20 at 11:55 a.m., Resident 11 lying in bed complained of burning sensation on the private area. Resident 11 stated that he waited for 30 minutes for the staff to assist and change the disposable brief. Resident 11 stated he could not remember the last time that he received the treatment to his buttocks. During concurrent observation, Registry's Certified Nurse Assistant 5 (CNA 5) assisted Resident 11 to change his disposable brief. Resident 11's disposable brief was full of brown bowel movement covering the entire buttocks, genital area, and groin area. Resident 11 buttocks, genital area, and groin area were bright red in color. Resident 11 did not receive skin/wound treatments. During a review of Resident 11's ETAR for the month of August and September, and a concurrent interview on 9/9/20 at 12:30 p.m., LVN 1 stated Resident 11's ETAR indicated the resident did not receive wound treatment as ordered by the physician on 8/26/20 to 9/5/20. LVN 1 stated Resident 11 was transferred to GACH on 9/5/20 for further evaluation due to COVID-19 complications. 3f. A review of Resident 12's Admission Record indicated the facility admitted the resident on 8/4/14 and readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 12's MDS, dated [DATE], indicated the resident had no impairment in cognitive. The MDS indicated Resident 12 required extensive assistance from staff for bed mobility and was totally dependent on staff assistance for transfer, dressing, toilet use, and personal hygiene. A review of Resident 12's Physician Order, dated 7/9/20, indicated for day shift licensed nurses (in general) to clean the resident's right and left buttocks MASD with soap, water and apply Zinc Oxide, daily. A review of Resident 12's laboratory result, dated 9/3/20, indicated the resident tested positive for COVID-19. A review of Resident 12's Nurses Progress Notes, dated 9/8/20, indicated the facility's transferred the resident to another SNF. During a review of Resident 12's ETAR for the month of August 2020 and September 2020, and a concurrent interview on 9/9/20 at 12:30 p.m., LVN 1 stated Resident 12's ETAR indicated the resident did not receive Zinc Oxide to left and right buttocks as ordered by the physician on 8/28/20, 8/29/20, 9/5/20 to 9/7/20. 3g. A review of Resident 13's Admission Record indicated the facility admitted the resident on 5/28/14 and readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 13's Physician Order, dated 5/25/20, indicated for day shift licensed nurse (unidentified) to clean the resident's right and left buttocks with soap, water, and apply Zinc Oxide, daily. A review of Resident 13's MDS, dated [DATE], indicated the resident had impairment in cognition. The MDS indicated Resident 13 was totally dependent on staff assistance for bed mobility, transfer, dressing, eating, toilet use, and personal hygiene. The MDS indicated Resident 13 was at risk of developing pressure injuries. A review of Resident 13's laboratory test result, dated 9/3/20, indicated Resident 13 tested positive for COVID-19. A review of Resident 13's Nurses Progress Notes, dated 9/7/20, indicated the resident had excoriation on sacral area. The notes indicated the facility transferred Resident 13 to GACH for further evaluation due to COVID-19 complications. During a review of Resident 13's ETAR for the month of August 2020 and September 2020, and a concurrent interview on 9/9/20 at 12:30 p.m., LVN 1 stated Resident 13's ETAR indicated the resident did not receive wound treatment as ordered by the physician on 8/28/20, 8/29/20, 9/5/20 to 9/7/20. 3h. A review of Resident 14's Admission Record indicated the facility admitted the resident on 8/10/18 and readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 14's MDS, dated [DATE], indicated Resident 14 had intact cognition. The MDS indicated Resident 14 required limited assistance from staff on bed mobility and required extensive assistance from staff for transfer, dressing, and personal hygiene. Resident 14 was totally dependent on staff assistance for toilet use. The MDS indicated Resident 14 was at risk of developing pressure injuries. A review of Resident 14's Physician Order, dated 8/25/20, indicated for the day shift licensed nurses (unidentified) to apply zinc oxide to right and left buttocks for redness and to the coccyx area, daily. A review of Resident 14's laboratory test result, dated 9/3/20, indicated Resident 14 tested positive for COVID-19. During a review of Resident 14's ETAR for the month of August and September and a concurrent interview on 9/9/20 at 12:30 p.m., LVN 1 stated Resident 14's ETAR indicated the resident did not receive wound treatment as ordered by the Physician on 8/28/20, 8/29/20, and from 9/1/20 to 9/10/20. During an interview on 9/21/20 at 3:45 PM, DON stated she acknowledged that Residents 2, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, and 15 were not provided wound treatments as ordered by the physicians. The DON stated the skin check and body assessments were not done for these residents. The DON stated it was important for the residents to receive wound treatments as ordered by the physicians because pressure injuries can develop and progress within an hour. A review of the facility's policy and procedure, titled Prevention of Pressure Ulcers, dated 10/2010 indicated for staff to provide information regarding identification of pressure ulcer risk and interventions for specific risk factors. Routinely assess and document the condition of the resident's skin per facility wound and skin care program for any signs and symptoms of irritation or breakdown. Immediately report any signs of developing pressure ulcer to the supervisor. Change position at least every two hours and more frequently as needed. The following information should be recorded in the resident's medical record which includes any changes in the resident's condition and the condition of the resident's skin (i.e., the size and location of the red or tender areas).

Based on observation, interview, and record review, the facility failed to ensure that three of three sampled residents (Residents 1, 2, and 3) in the facility received pharmaceutical services to meet the needs of each resident in a consistent manner in accordance with physician orders [REDACTED]. 1. Ensure the licensed nurses administered 105 doses of [MEDICATION NAME] sodium (generic for [MEDICATION NAME], a routine anti-[MEDICAL CONDITION] medication) to Resident 1 from 8/1/2020 to 9/4/2020 (35 days), for the [DIAGNOSES REDACTED]. As a result, licensed nurses omitted 85 of 105 doses of Resident 1's [MEDICATION NAME] sodium from 8/1/2020 to 9/4/2020. Ensure Licensed Vocational Nurse (LVN) 5 administer two doses of [MEDICATION NAME] (routine medication for [MEDICAL CONDITION]) by mouth on 9/4/2020 at 9 a.m. and at 5 p.m. Resident 1's clinical record did not have documented evidence of subsequent physician notifications of the missed anti-[MEDICAL CONDITION] medications. Ensure licensed nurses administered 40 doses of Resident 1's other scheduled medications and supplements from 9/1/2020 to 9/4/2020 (4 days). As a result, licensed nurses omitted 24 of 40 doses of Resident 1's other scheduled medications. This failure resulted to two [MEDICAL CONDITION] episodes on 9/4/2020 and led to Resident 1's transfer to the general acute care hospital (GACH) for evaluation of recurrent [MEDICAL CONDITION] and fever. 2. Ensure LVN 2, LVN 3, and LVN 5 administered the prescribed PRN (as needed) narcotic (a drug derived from [MEDICATION NAME] that relieves pain and induces sleep) pain medication to Resident 2, when Resident 2 complained of severe back pain, on 9/4/2020. Ensure LVN 5 administered 15 doses of Resident 2's other scheduled medications and supplements which included blood pressure medications, medication for constipation (difficulty passing stool), and treatments for enlarged prostate (a small gland that is a part of the male reproductive system) on 9/4/2020. As a result, licensed nurses omitted 11 of 15 doses of Resident 1's other scheduled medications. This failure resulted to Resident 2's unrelieved pain and placed the resident at risk for high blood pressure, and kidney complications. 3. Ensure LVN 6 administered Resident 3's scheduled afternoon medications on 9/4/2020, as prescribed by the physician which included [MEDICATION NAME] tablet (muscle relaxant), blood pressure medication, medication for blood sugar, nasal spray, two eye drops for [MEDICAL CONDITION] (group of eye conditions that damage the optic nerve (serve as the communication cable between the eye and the brain)), and one eye drop for eye allergies [REDACTED]. An immediate jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was called on 9/4/2020, at 10:28 p.m. with the facility's Assistant Administrator (AADM). The facility Administrator were informed of the facility's failure to have systems in place to ensure Residents 1, 2, and 3's scheduled and as needed (PRN) medications and supplements were administered as prescribed. This deficient practice resulted serious actual harm to Resident 1 and potential serious harm to Residents 2 and 3, that threatened the health and safety of all 65 residents in the facility with prescribed scheduled and as needed medications and supplements. On 9/11/2020 at 1 p.m., the facility submitted an acceptable plan of action (POA), and the survey team verified the implementation of the POA by observation and record review and confirmed the removal of the immediate jeopardy on 9/11/2020, at 4:24 p.m. in the presence of the AADM. The AADM provided an acceptable plan of action as follows: A. Resident 1 was transferred to an acute general hospital (GACH) on 9/4/2020 due to [MEDICAL CONDITION]. The facility notified Resident 1's primary physician and responsible party. B. All other residents on [MEDICAL CONDITION] medications were screened on 9/9/2020. All medications for [MEDICAL CONDITION] were available, and no further medication issues reported. In?service will be conducted for Licensed Nurses regarding medication administration until 9/18/2020. C. System change: All Licensed Nurses will complete a medication and treatment administration self?audit every shift. Registry Nurses will be given an orientation to include Medication Pass expectations prior to working the shift. Medication Review will be completed by Nurse Manager/Medical Records Director or designee every month and report any issues identified to the Director of Nurses (DON) for further actions as needed. In?service will be done by the Nurse Consultant to the Nurse Manager and Licensed Nurses by 9/18/2020. The facility's contracted pharmacy recommended: o Assist Administration in forming Plan of Correction for Medication related issues. o Reviewed IJ documents 9/7/2020. o Discussed preliminary findings with AADM 9/7/2020. o Reviewed pharmacy Medication profiles for (3) patients per request on 9/7/2020. o Reviewed consultant pharmacist's reports for June, July, August and 9/7/2020. o Reviewed facility inspection reports by pharmacist for June, July and 9/7/2020. o Meet with Health Department Inspectors. o Discuss recommendations for immediate improvement. o Communicate willingness to comply with all recommendations. o PLAN FOR IMPROVEMENT (I=IMMEDIATE, O=ONGOING, P=POSSIBLE). o Mandatory medication pass education/training for all licensed staff (I,O). o Regular follow?up to evaluate effectiveness of med?pass education (O). o Pharmacist review of medication error documentation and reporting (I,O). o Pharmacist involvement in cycle card changes and medication destruction (I,O). o Pharmacist access to electronic medical records and medication pass dashboard (P). o FOLLOW?UP/REPORTING. o Pharmacist to do an immediate review of medication administration Documentation. o Pharmacist to do an immediate inspection of current medications in the facility as compared to patient MAR's. o Pharmacy to remove discontinued medications and supply missing medications. o Pharmacy to document discrepancies noted during inspection. o Pharmacy to report discrepancies to facility administration. D. The Director of Staff Development (DSD) and DON will randomly check medication pass and medication carts weekly times two weeks, then monthly for two months until 100% compliance is achieved. Medication pass skills validation and in?service will be implemented on orientation and yearly thereafter for all employees. Report provided to DON for trending and analysis. This topic will additionally be discussed in the facility's monthly Quality Assurance and Performance Improvement (QAPI) meeting and findings and data will be reviewed and addressed for a period of 3 months until substantial compliance is achieved. Negative trends will require revision of the QAPI action plan. Findings will also be shared and discussed in the Patient Safety Committee and Patient Care Committee meetings monthly (Cross reference to F760). Findings: a. During the facility's initial tour and concurrent interview with the AADM, on 9/4/2020 at 4:06 p.m., the AADM stated the facility's Red Zone (an area where residents who test positive for Coronavirus-19 (COVID-19, a respiratory illness that can spread from person to person) are confined) have 35 residents. During an observation inside Resident 1's room, on 9/4/2020 at 4:55 p.m., Resident 1 was yelling for help and asking for his medications in Spanish. Resident 1 stated he needed his [MEDICAL CONDITION] medications because he felt as if he was going to experience a convulsion ([MEDICAL CONDITION]). During the concurrent observation and interview inside Resident 1's room, on 9/4/2020 at 4:55 p.m., Certified Nursing Assistant 1 (CNA 1) stated Resident 1 asked the facility nurses for his medications since the morning of 9/4/2020. Resident 1 stated he notified LVN 5 that he did not receive his [MEDICAL CONDITION] medications. During an interview, on 9/4/2020 at 5:15 p.m., LVN 2 stated she works for the Nursing Registry and assigned in the facility's Red Zone, stated she had not received facility orientation since the start of her shift in the morning, and had no access to the facility's Electronic Medication Administration Record [REDACTED] During an interview, on 9/4/2020 at 5:16 p.m., LVN 5 stated he was the only nurse passing medications for the facility's Red Zone and did not administer any medications to Resident 1 because Resident 1 was not in the facility's eMAR system. During the concurrent interview and review of Resident 1's eMAR, on 9/4/2020 at 5:16 p.m., LVN 5 stated Resident 1 had missed several doses (unidentified amount) of [MEDICATION NAME] sodium for the months of August and September 2020. A review of Resident 1's undated Face Sheet (admission record) indicated the facility admitted the resident on 10/9/14 and readmitted on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set ((MDS), a resident assessment and care-screening tool) dated 10/19/2020, indicated Resident 1 was severely impaired in cognitive skills (the ability to make decisions) and required limited assistance with transfers and extensive assistance for personal hygiene. A review of Resident 1's Initial History and Physical dated 6/9/2020, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 1's Physician order [REDACTED]. A review of Resident 1's Physician order [REDACTED]. A review of Resident 1's eMAR for the month of August 2020, indicated that from 8/1/2020 to 8/31/2020 (31 days), 73 out of 93 doses of Resident 1's [MEDICATION NAME] sodium was marked as not administered (NA). A review of Resident 1's eMAR from 9/1/2020 to 9/4/2020 (four days), indicated 9 out of 12 doses of [MEDICATION NAME] sodium were marked as Not administered (NA), the remaining 3 out of 12 doses were marked as Not recorded as administered (NR). The eMAR indicated 2 out of 8 doses of [MEDICATION NAME] were marked as Not recorded as administered (NR). During a concurrent observation inside Resident 1's room, on 9/4/2020 at 7 p.m., in the presence of LVN 5, Resident 1's entire body was shaking in bed with eyes rolling. LVN 5 stated Resident 1 was having [MEDICAL CONDITION]. During a subsequent observation, on 9/4/2020 at 7:13 p.m., in the presence of Registered Nurse 2 (RN 2), Resident 1's entire body shook in bed with eyes rolling. RN 2 stated Resident 1 needed his [MEDICAL CONDITION] medications. RN 2 stated Resident 1 was having another [MEDICAL CONDITION] and Resident 1 required emergency services. During an inspection of the facility's medication cart in the Red Zone, on 9/4/2020 at 10 p.m., in the presence of LVN 3, Resident 1's [MEDICATION NAME] sodium bubble packs indicated that the 9 a.m. medication for 9/4/2020, was not punched out, the 1 p.m. and 5 p.m. medication for 9/4/2020 was punched out but not signed as administered in the eMAR. A review of Resident 1's clinical record, titled Progress Notes by Resident dated 9/4/2020, indicated Resident 1 had [MEDICAL CONDITION] activities twice for one minute, that evening, around 7 p.m. The record indicated the physician ordered to transfer Resident 1 to a GACH. During an interview, on 9/4/2020 at 9:40 p.m., LVN 3 stated she works for the Nursing Registry and assigned in the facility's Red Zone. LVN 3 stated she had not received facility orientation since the start of her shift. During an interview, on 9/5/2020 at 11:45 a.m., LVN 1 stated that the NA and NR documented in Resident 1's eMAR indicated the corresponding medication doses were not administered. During an interview and concurrent review of Resident 1's eMAR, on 9/5/2020 at 12:15 p.m., the AADM stated there was a significant amount of Resident 1's [MEDICATION NAME] sodium not administered in the past 35 days. AADM stated he understood the high risk of recurrent [MEDICAL CONDITION] as a result of missed doses. The AADM stated the facility should have intervene before Resident 1 had missed so many doses. During an interview, on 9/5/2020 at 12:30 p.m., LVN 1 presented a copy of the most recent pharmacy delivery receipt of Resident 1's [MEDICATION NAME] sodium dated 8/6/2020. The delivery receipt indicated the facility's pharmacy delivered 84 tablets of [MEDICATION NAME] sodium on 8/6/2020 for Resident 1. On 9/5/2020 at 12:30 p.m., in the presence of LVN 1, a review of Resident 1's eMAR from 9/1/2020 to 9/4/2020, indicated multiple scheduled medication doses were marked as NA and NR such as [MEDICATION NAME] (lowers cholesterol in blood) tablet 10 mg, multivitamins with minerals, [MEDICATION NAME] (treatment for [REDACTED]. During the record review, a total of 24 doses of Resident 1's other scheduled medications were not administered or not recorded as administered in the eMAR. On 9/7/2020, at 10:45 a.m., during an interview, the facility pharmacist consultant stated the licensed nurses should notify the physician when medications are not administered and assessed for any changes in condition. A review of Resident 1's Physician order [REDACTED]. A review of Resident 1's GACH Emergency Department (ED) General notes dated 9/5/2020, indicated Resident 1 was admitted to the GACH for evaluation of recurrent [MEDICAL CONDITION] and fever. A review of Resident 1's GACH History and Physical dated 9/6/20 and timed at 11:10 a.m., indicated the GACH admitted the resident on 9/5/20 with [DIAGNOSES REDACTED]. On 9/7/2020 at 10:46 a.m., an interview was attempted with the facility's Medical Director 1 (MD 1) and the AADM stated MD 1 was unavailable for interview. On 9/21/2020 at 10:37 a.m., MD 1 was again unavailable for interview. During a telephone interview on 9/21/2020 at 3:33 p.m., the facility's Director of Nursing (DON) stated there was no documentation to indicate if Resident 1 refused medications and no documentation of physician notification. During a telephone interview, on 9/21/2020 at 3:40 p.m., the facility's Director of Nursing (DON) stated the medications for [MEDICAL CONDITION] are significant in the control of [MEDICAL CONDITION]. b. During an interview, on 9/4/2020 at 5:16 p.m., LVN 5 stated he was the only nurse passing medications for the facility's Red Zone and did not administer any medications to Resident 2 because Resident 2 was not in the facility's eMAR system. During an observation and interview, on 9/4/2020 at 6:27 p.m., Resident 2 was sitting on a wheelchair outside of her room screaming and crying. Resident 2 stated she would call 9-1-1 because she needed her [MEDICATION NAME] (narcotic pain medication). Resident 2 stated she had a back-pain of 8/10 pain level (7 to 10 for severe pain, 4 to 6 for moderate pain, and 1 to 3 for the lowest pain level). Resident 2 stated she had been asking the facility's nurses for the whole day to administer [MEDICATION NAME] and the nurses ignored her. During an interview, on 9/4/2020 at 6:27 p.m., LVN 5 stated Resident 2 called 9-1-1 paramedics earlier in the day, because she was in pain. LVN 5 stated he did not administer pain medications to Resident 2. A review of Resident 2's undated Face Sheet indicated the facility admitted the resident on 3/10/2020 with [DIAGNOSES REDACTED]. A review of Resident 2's Physician order [REDACTED]. A review of Resident 2's Initial History and Physical, dated 3/16/2020 indicated Resident 2 had the capacity to understand and make decisions. A review of Resident 2's MDS dated [DATE], indicated Resident 2 was intact in cognitive skills for daily decision making and required extensive assistance for bed mobility and transfers. A review of Resident 2's eMAR dated 9/4/2020, indicated Resident 2 did not receive PRN (as needed) [MEDICATION NAME]-[MEDICATION NAME] 10-325 mg for the whole day. A review of Resident 2's eMAR for 9/4/2020, indicated multiple scheduled medication doses were marked as Not recorded (NR) such as [MEDICATION NAME] (drug used to treat high levels of potassium (electrolyte found in blood) in the body) 30 grams (gm; unit of measurement), [MEDICATION NAME] (blood pressure medication) 100 mg, aspirin (used to treat or prevent [MEDICAL CONDITION]) 81 mg, [MEDICATION NAME] Sodium (stool softener) 250 mg, folic acid (supplement) 1 mg, [MEDICATION NAME] (blood pressure medication) 60 mg, Rena-vite tablet (vitamin supplement), [MEDICATION NAME] (prescription drug that controls phosphorus (mineral/electrolyte found in the blood) level in individuals with kidney disease) 2,400 mg, and Vitamin D-3 (vitamin supplement) 2,000 units. During the record review, a total of 24 doses of Resident 2's other scheduled medications and supplements were not administered or not recorded as administered in the eMAR. During an observation of Resident 2 inside his room, and a concurrent interview with LVN 2, on 9/4/2020 at 8:35 p.m., LVN 2 stated Resident 2 was crying and complaining of pain. LVN 2 stated she did not assess Resident 2's pain level because she was not the resident's medication nurse. During an interview, on 9/4/2020 at 9:35 p.m., LVN 3 stated she could not locate Resident 2's pain medication from the medication cart. LVN 3 stated she did not receive report from LVN 5 that Resident 2 had been complaining of pain. LVN 3 stated the eMAR indicated Resident 2 did not receive as needed pain medication ([MEDICATION NAME]) as ordered by the physician. LVN 3 stated she could not give Resident 2's pain medication because the medication was not available in the medication cart. LVN 3 stated she would call the pharmacy to deliver the pain medication. During an interview and record review, on 9/4/2020 at 9:40 p.m., LVN 3 stated Resident 2's pain management form indicated Resident 2's last pain medication was administered on 9/3/2020 at 6:15 a.m. c. During an interview, on 9/4/2020 at 5:16 p.m., LVN 5 stated he was the only nurse passing medications for the facility's Red Zone and did not administer any medications to Resident 3 because Resident 3 was not in the facility's eMAR system. During an interview, on 9/4/2020 at 5:20 p.m., Resident 3 was sitting on his bed and stated he did not receive his 5 p.m. medications. Resident 3 stated he felt stressed out. A review of Resident 3's Face Sheet indicated the facility admitted the resident on 4/26/19, with [DIAGNOSES REDACTED]. A review of Resident 3's Physicians Order Sheet dated 4/26/19, indicated to administer [MEDICATION NAME] (a prescription eye drop that lowers high pressure inside the eye that helps to prevent [MEDICAL CONDITION]) eye drops 0.25% 1 drop to both eyes two times a day at 9 a.m., and 5 p.m., for [MEDICAL CONDITION]. A review of Resident 3's Physicians Order Sheet dated 4/26/19, indicated to administer simbrinza (a prescription eye drop that decreases eye pressure) eye drops 1-0.2 %1 drop to both eyes two times a day at 9 a.m., and 5 p.m., for [MEDICAL CONDITION]. A review of Resident 3's Physicians Order Sheet dated 5/20/19, indicated to administer [MEDICATION NAME] 0.05% (a prescription eye drop for tear production) one drop to both eyes two times a day at 9 a.m., and at 5 p.m., for eye allergies [REDACTED].>A review of Resident 3's MDS dated [DATE], indicated Resident 3 had intact cognitive skills for daily decision making and required supervision for bed mobility and limited assistance for personal hygiene. A review of Resident 3's Physicians Order Sheet dated 11/7/19 indicated to administer [MEDICATION NAME] 10 mg one tablet by mouth three times per day at 9 a.m., 1 p.m., and at 5 p.m., for pain. A review of Resident 3's Initial History and Physical dated 12/5/19, indicated the resident had the capacity to understand and make decisions. During an observation and interview on 9/4/2020 at 8:30 p.m., Resident 3 was awake in his room and stated he had not received his 5 p.m. medications. During a consequent interview and review of Resident 3's eMAR dated 9/4/2020 at 8:30 p.m., LVN 6 stated he did not administer Resident 3's medications on 9/4/2020 at 5 p.m., which included [MEDICATION NAME] 10 mg (pain medication), [MEDICATION NAME] (medication spray that treats nasal congestion), losartan 50 mg (high blood pressure medication), [MEDICATION NAME] 1,000 mg (medication that regulates blood sugar), [MEDICATION NAME] 0.05, simbrinza 1-02, [MEDICATION NAME] 0.25%. LVN 6 stated he marked Resident 3's eMAR as administered at 5 p.m. on 9/4/2020, accidentally. A review of the facility's policy and procedure, titled Administering Medications, revised on December 2012, indicated medications should be administered in a safe and timely manner and as prescribed. The policy indicated medications must be administered in accordance with the orders, including any required time frame. The policy indicated medications must be administered within one hour of their prescribed time, unless otherwise specified. According to the U.S. Food and Drug Administration (FDA) dated October 2011, Anti-[MEDICAL CONDITION] drugs should not be abruptly discontinued in patients whom the drug is administered to prevent major [MEDICAL CONDITION] because of the strong possibility of precipitating (an event or situation, usually a bad one, it causes it to happen suddenly or sooner than normal) [DIAGNOSES REDACTED] (a [MEDICAL CONDITION] that lasts longer than 5 minutes, or having more than 1 [MEDICAL CONDITION] within a 5 minutes period, without returning to a normal level of consciousness between episodes) with attendant [MEDICAL CONDITION] (deficiency in the amount of oxygen reaching the tissues) and threat to life. https://www.accessdata.fda.gov/drugsatfda_docs/label/2011/ 3s037lbl.pdf

Based on observation, interview, and record review, the facility failed to ensure that three of three sampled residents (Residents 1, 2, and 3) medication regimen were free from significant medication errors (causes the resident discomfort) by failing to: 1. Ensure the licensed nurses administered 105 doses of [MEDICATION NAME] sodium (generic for [MEDICATION NAME], a routine anti-[MEDICAL CONDITION] medication) to Resident 1 from 8/1/2020 to 9/4/2020 (35 days), for the [DIAGNOSES REDACTED]. As a result, licensed nurses omitted 85 of 105 doses of Resident 1's [MEDICATION NAME] sodium from 8/1/2020 to 9/4/2020. Ensure Licensed Vocational Nurse (LVN) 5 administer two doses of [MEDICATION NAME] (routine medication for [MEDICAL CONDITION]) by mouth on 9/4/2020 at 9 a.m. and at 5 p.m. Resident 1's clinical record did not have documented evidence of subsequent physician notifications of the missed anti-[MEDICAL CONDITION] medications. These failures resulted to two [MEDICAL CONDITION] episodes as witnessed on 9/4/2020 during the surveyor's onsite visit and led to Resident 1's transfer to the general acute care hospital (GACH) for evaluation of recurrent [MEDICAL CONDITION] and fever. 2. Ensure LVN 2, LVN 3, and LVN 5 administered the prescribed narcotic (a drug derived from [MEDICATION NAME] that relieves pain and induces sleep) pain medication to Resident 2, when Resident 2 complained of severe back pain, on 9/4/2020. This failure resulted to Resident 2's unrelieved pain. 3. Ensure LVN 6 administered Resident 3's scheduled afternoon medications as prescribed by the physician which included [MEDICATION NAME] (muscle relaxant) for pain, two eye drops for [MEDICAL CONDITION] (group of eye conditions that damage the optic nerve (serve as the communication cable between the eye and the brain)), and one eye drop for eye allergies [REDACTED]. Because of this deficient practice and the identified serious actual harm to Resident 1 and potential serious harm to Residents 2 and 3, that threatened the health and safety of all 65 residents in the facility with prescribed medications, an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) situation was called on 9/4/2020 at 10:28 p.m., in the presence of the facility's Assistant Administrator (AADM). On 9/11/2020 at 1:00 p.m., the facility submitted an acceptable plan of action (POA), and the survey team verified the implementation of the POA by observation and record review and confirmed the removal of the immediate jeopardy on 9/11/2020, at 4:24 p.m. in the presence of the AADM. The AADM provided an acceptable plan of action as follows: A. Resident 1 was transferred to an acute general hospital (GACH) on 9/4/2020 due to [MEDICAL CONDITION]. The facility notified Resident 1's primary doctor and responsible party. B. All other residents on [MEDICAL CONDITION] medications were screened on 9/9/2020. All medications for [MEDICAL CONDITION] were available, and no further medication issues reported. In?service will be conducted for License Nurses regarding medication pass until 9/18/2020. C. System change: All License Nurses will complete a medication and treatment administration self?audit every shift. Registry Nurse will be given an orientation to include Med Pass expectations prior to working the shift. Medication Recap will be done by Nurse Manager/Medical Records Director or designee every month and report any issues identified to the DON for further actions as needed. In?service will be done by the Nurse Consultant to the Nurse Manager and License Nurses by 9/18/2020. The facility's contracted pharmacy recommended: o Assist Administration in forming Plan of Correction for Medication related issues o Reviewed IJ documents 9/7/2020 o Discussed preliminary findings with AADM 9/7/2020 o Reviewed pharmacy Medication profiles for (3) patients per request 9/7/2020 o Reviewed consultant pharmacist's reports for June, July and August 9/7/2020 o Reviewed facility inspection reports by pharmacist for June and July 9/7/2020 o Meet with Health Department Inspectors o Discuss recommendations for immediate improvement o Communicate willingness to comply with all recommendations o PLAN FOR IMPROVEMENT (I=IMMEDIATE, O=ONGOING, P=POSSIBLE) o Mandatory med?pass education/training for all licensed staff (I,O) o Regular follow?up to evaluate effectiveness of med?pass education (O) o Pharmacist review of medication error documentation and reporting (I,O) o Pharmacist involvement in cycle card changes and medication destruction (I,O) o Pharmacist access to electronic medical records and med?pass dashboard. (P) o FOLLOW?UP/REPORTING o Pharmacist to do an immediate review of medication administration documentation o Pharmacist to do an immediate inspection of current medications in the facility as compared to patient MAR's o Pharmacy to remove discontinued medications and supply missing medications o Pharmacy to document discrepancies noted during inspection o Pharmacy to report discrepancies to admin. D. Director of Staff Development (DSD) and Director of Nursing (DON) will randomly check medication pass and medication carts weekly times two weeks, then monthly for two months until 100% compliance is achieved. Medication pass skills validation and in?service will be implemented on orientation and yearly thereafter for all employees. Report provided to DON for trending and analysis. This topic will additionally be discussed in the monthly Quality Assurance and Performance Improvement (QAPI) meeting and findings and data will be reviewed and addressed for a period of 3 months until substantial compliance is achieved. Negative trends will require revision of the QAPI action plan. Findings will also be shared and discussed in the Patient Safety Committee and Patient Care Committee meetings monthly (Cross reference to F755). Findings: a. During an observation inside Resident 1's room, on 9/4/2020 at 4:55 p.m., Resident 1 was yelling for help and asking for his medications in Spanish. Resident 1 stated he needed his [MEDICAL CONDITION] medications because he felt as if he was going to experience a convulsion ([MEDICAL CONDITION]). During the concurrent observation and interview inside Resident 1's room, on 9/4/2020 at 4:55 p.m., Certified Nursing Assistant 1 (CNA 1) stated Resident 1 asked the facility nurses for his medications since the morning of 9/4/2020. Resident 1 stated he notified LVN 5 that he did not receive his [MEDICAL CONDITION] medications. During an interview, on 9/4/20 at 5:16 p.m., LVN 5 stated he was the only nurse passing medications for the facility's Red Zone (an area where residents who test positive for Coronavirus-19 (COVID-19, a respiratory illness that can spread from person to person) are confined) and did not administer any medications to Resident 1. During the concurrent interview and review of Resident 1's electronic Medication Administration Record [REDACTED]. A review of Resident 1's undated Face Sheet (admission record) indicated the facility admitted the resident on 10/9/14 and readmitted on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set ((MDS), a resident assessment and care-screening tool) dated 10/19/2020, indicated Resident 1 was severely impaired in cognitive skills (the ability to make decisions) and required limited assistance with transfers and extensive assistance for personal hygiene. A review of Resident 1's Initial History and Physical dated 6/9/2020, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 1's Physician order [REDACTED]. A review of Resident 1's Physician order [REDACTED]. A review of Resident 1's eMAR for the month of August 2020, indicated that from 8/1/2020 to 8/31/2020 (31 days), 73 out of 93 doses of Resident 1's [MEDICATION NAME] sodium were marked as not administered (NA). A review of Resident 1's eMAR for the month of September 2020 indicated that from 9/1/2020 to 9/4/2020 (four days), 9 out of 12 doses of [MEDICATION NAME] sodium were marked as Not administered (NA), the remaining 3 out of 12 doses were marked as Not recorded as administered (NR). A review of Resident 1's eMAR for the month of September 2020, indicated that on 9/4/2020, two out of eight doses of [MEDICATION NAME] were marked as Not recorded as administered (NR). During a concurrent observation, on 9/4/2020 at 7 p.m., in the presence of LVN 5, Resident 1's entire body was shaking in bed with eyes rolling. LVN 5 stated Resident 1 was having [MEDICAL CONDITION]. During a subsequent observation, on 9/4/2020 at 7:13 p.m., in the presence of Registered Nurse 2 (RN 2), Resident 1's entire body shook in bed with eyes rolling. RN 2 stated Resident 1 needed his [MEDICAL CONDITION] medications. RN 2 stated Resident 1 was having another [MEDICAL CONDITION] and Resident 1 required emergency services. During an inspection of the facility's medication cart in the Red Zone, on 9/4/2020 at 10 p.m., in the presence of LVN 3, Resident 1's [MEDICATION NAME] sodium bubble packs indicated that the 9 a.m. medication for 9/4/2020, was not punched out, the 1 p.m. and 5 p.m. medication for 9/4/2020 was punched out but not signed as administered in the eMAR. A review of Resident 1's clinical record, titled Progress Notes by Resident dated 9/4/2020, indicated Resident 1 had [MEDICAL CONDITION] activities twice for one minute, that evening, around 7 p.m. The record indicated the physician ordered to transfer Resident 1 to a GACH. During an interview, on 9/5/2020 at 11:45 a.m., LVN 1 stated that the NA and NR documented in Resident 1's eMAR indicated the corresponding medication doses were not administered. During an interview and concurrent review of Resident 1's eMAR, on 9/5/2020 at 12:15 p.m., the AADM stated there was a significant amount of Resident 1's [MEDICATION NAME] sodium not administered in the past 35 days. AADM stated he understood the high risk of recurrent [MEDICAL CONDITION] as a result of missed doses. The AADM stated the facility should have intervene before Resident 1 had missed so many doses. During an interview, on 9/5/2020 at 12:30 p.m., LVN 1 presented a copy of the most recent pharmacy delivery receipt of Resident 1's [MEDICATION NAME] sodium dated 8/6/2020. The delivery receipt indicated the facility's pharmacy delivered 84 tablets of [MEDICATION NAME] sodium on 8/6/2020 for Resident 1. A review of Resident 1's Physician order [REDACTED]. A review of Resident 1's GACH Emergency Department (ED) General notes dated 9/5/2020, indicated Resident 1 was admitted to the GACH for evaluation of recurrent [MEDICAL CONDITION] and fever. A review of Resident 1's GACH History and Physical dated 9/6/20 and timed at 11:10 a.m., indicated the GACH admitted the resident on 9/5/20 with [DIAGNOSES REDACTED]. On 9/7/2020 at 10:46 a.m., an interview was attempted with the facility's Medical Director 1 (MD 1) and the AADM stated MD 1 was unavailable for interview. On 9/21/2020 at 10:37 a.m., MD 1 was again unavailable for interview. During a telephone interview on 9/21/2020 at 3:33 p.m., the facility's Director of Nursing (DON) stated there was no documentation to indicate if Resident 1 refused medications and no documentation of physician notification. During a telephone interview, on 9/21/2020 at 3:40 p.m., the facility's Director of Nursing (DON) stated the medications for [MEDICAL CONDITION] are significant in the control of [MEDICAL CONDITION]. Resident 2 b. During an observation and interview, on 9/4/20 at 6:27 p.m., Resident 2 was sitting on a wheelchair outside of her room screaming and crying. Resident 2 stated she would call 9-1-1 because she needed her [MEDICATION NAME] (narcotic pain medication). Resident 2 stated she had a back pain of 8/10 (10 being the worst pain and 1 the lowest pain level). Resident 2 stated she had been asking the facility's nurses for the whole day to administer [MEDICATION NAME] and the nurses ignored her. During an interview, on 9/4/2020 at 6:27 p.m., LVN 5 stated Resident 2 called 9-1-1 paramedics because she was in pain. LVN 5 stated he did not administer pain medications to Resident 2. A review of Resident 2's undated Face Sheet indicated the facility admitted the resident on 3/10/2020 with [DIAGNOSES REDACTED]. A review of Resident 2's Physician order [REDACTED]. A review of Resident 2's Initial History and Physical, dated 3/16/2020 indicated Resident 2 had the capacity to understand and make decisions. A review of Resident 2's MDS dated [DATE], indicated Resident 2 was intact in cognitive skills for daily decision making and required extensive assistance for bed mobility and transfers. A review of Resident 2's eMAR dated 9/4/2020, indicated Resident 2 did not receive [MEDICATION NAME]-[MEDICATION NAME] 10-325 mg for the whole day. During an observation of Resident 2 inside his room, and a concurrent interview with LVN 2, on 9/4/2020 at 8:35 p.m., LVN 2 stated Resident 2 was crying and complaining of pain. LVN 2 stated she did not assess Resident 2's pain level because she was not the resident's medication nurse. During an observation and interview, on 9/4/2020 at 9:35 p.m., LVN 3 stated she could not locate Resident 2's pain medication from the medication cart. LVN 3 stated she did not receive report from LVN 5 that Resident 2 had been complaining of pain. LVN 3 stated the eMAR indicated Resident 2 did not receive as needed pain medication ([MEDICATION NAME]) as ordered by the physician. LVN 3 stated she could not give Resident 2's pain medication because the medication was not available in the medication cart. LVN 3 stated she would call the pharmacy to deliver the pain medication. During an interview and record review, on 9/4/2020 at 9:40 p.m., LVN 3 stated Resident 2's pain management form indicated Resident 2's last pain medication was administered on 9/3/2020 at 6:15 a.m. Resident 3 c. During an observation and interview, on 9/4/2020 at 5:20 p.m., Resident 3 was sitting on his bed and stated he did not receive his 5 p.m. medications. Resident 3 stated he felt stressed out. A review of Resident 3's Face Sheet indicated the facility admitted the resident on 4/26/2019, with [DIAGNOSES REDACTED]. A review of Resident 3's Physicians Order Sheet dated 4/26/19, indicated to administer [MEDICATION NAME] eye drops 0.25% 1 drop to both eyes two times a day at 9 a.m., and 5 p.m., for [MEDICAL CONDITION]. A review of Resident 3's Physicians Order Sheet dated 4/26/19, indicated to administer simbrinza eye drops 1-0.2 %1 drop to both eyes two times a day at 9 a.m., and 5 p.m., for [MEDICAL CONDITION]. A review of Resident 3's Physicians Order Sheet dated 5/20/19, indicated to administer [MEDICATION NAME] 0.05% one drop to both eyes two times a day at 9 a.m., and at 5 p.m., for eye allergies [REDACTED].>A review of Resident 3's MDS dated [DATE], indicated Resident 3 had intact cognitive skills for daily decision making and required supervision for bed mobility and limited assistance for personal hygiene. A review of Resident 3's Physicians Order Sheet dated 11/7/19 indicated to administer [MEDICATION NAME] 10 mg one tablet by mouth three times per day at 9 a.m., 1 p.m., and at 5 p.m., for pain. A review of Resident 3's Initial History and Physical dated 12/5/19, indicated the resident had the capacity to understand and make decisions. During a second observation and interview on 9/4/20 at 8:30 p.m., Resident 3 was awake in his room and stated he had not received his 5 p.m. medications. During a consequent interview and review of Resident 3's eMAR dated 9/4/2020 at 8:30 p.m., LVN 6 stated he did not administer Resident 3's medications on 9/4/2020 at 5 p.m., [MEDICATION NAME] 10 mg (pain medication), [MEDICATION NAME] (nose spray), losartan 50 mg (high blood pressure medication), [MEDICATION NAME] 1,000 mg (diabetes medication), [MEDICATION NAME] 0.05 (eye medication), simbrinza 1-02 (eye medication), [MEDICATION NAME] 0.25% (eye medication). LVN 6 stated he marked Resident 3's eMAR as administered at 5 p.m. on 9/4/2020, accidentally. A review of the facility's policy and procedure, titled Administering Medications, revised on December 2012, indicated medications should be administered in a safe and timely manner and as prescribed. The policy indicated medications must be administered in accordance with the orders, including any required time frame. The policy indicated medications must be administered within one hour of their prescribed time, unless otherwise specified. According to the U.S. Food and Drug Administration (FDA) dated October 2011, Anti-[MEDICAL CONDITION] drugs should not be abruptly discontinued in patients whom the drug is administered to prevent major [MEDICAL CONDITION] because of the strong possibility of precipitating [DIAGNOSES REDACTED] ([MEDICAL CONDITION]) with attendant [MEDICAL CONDITION] (deficiency in the amount of oxygen reaching the tissues) and threat to life. https://www.accessdata.fda.gov/drugsatfda_docs/label/2011/ 3s037lbl.pdf

Based on observation, interview and record review, the facility failed to provide adequate (acceptable in quality or quantity) nutrition (food for health and growth) to meet the recommended daily nutritional intake and prevent weight loss for one of three sampled residents (Resident 6) by failing to: 1. Ensure Resident 6 received prescribed diet with correct portion size at 12 pm for lunch, and high protein nourishment (HPN) as the physician ordered. 2. Ensure Resident 6 received ice cream with lunch and protein shake with meals as recommended by the Registered Dietitian (RD, food and nutrition expert). 3. Ensure Resident 6 received [DEVICE] placement (a tube inserted through the belly that brings nutrition directly to the stomach) as ordered and arranged by the physician and agreed by the resident's Family Member 1 (FM 1) to prevent further decline in nutritional status. These deficient practices resulted in Resident 6 lost 31 pounds (lbs, unit of weight), 32 percent (%) of the usual body weight (person's most frequent body weight) within five months (from 3/9/20 to 8/6/20), and placed the resident at risk for delayed in pressure sores (bedsores). Findings: 1a. A review of Resident 6's Admission Record indicated the facility admitted the resident on 2/5/2019 and readmitted the resident on 1/20/2020 with [DIAGNOSES REDACTED]. (either partially or completely), Foley Catheter (FC, sterile tube that is inserted into the bladder to drain urine), Sacrococcyx (the tailbone area) pressure ulcer (injury to skin that covers bony areas of the body, such as the bottom of the spine from prolonged pressure) and COVID-19 (an illness caused by [MEDICAL CONDITION] that can spread from person to person). A review of Resident 6's Care Plan for Nutritional Status, dated 1/21/2020, indicated the resident had alteration in nutritional status related to variable meal intake. The goal was for the resident to have no more than 5% weight loss in three months with goal date of 8/31/2020. The approach interventions were to allow food for substitution within same diet category, fortified regular diet (diet that have nutrients added to improve nutrition and add health benefits), monitor weight and notify the physician of weight loss, offer supplements and monitor compliance. A review of Resident 6's Nutrition Assessment, dated 1/23/2020, indicated the resident's weight was 112 lbs. Resident 6's Ideal Body Weight was 117-143 lbs. Resident 6's estimated caloric needs were 1480-1770 Kcal per day. The assessment indicated the resident was underweight and the goal weight was 112-117 lbs. The assessment indicated the goal was for the resident's intake to meet her estimated daily caloric needs. A review of Resident 6's Care Plan for dehydration, dated 1/27/2020, indicated the resident was at risk for dehydration. The goal was for resident to consume 75% of meals with goal date of 8/31/2020. The approach interventions were to determine likes and dislikes meals, provide supplement as needed, monitor for meals intake, monitor signs and symptoms of dehydration and offer fluids between meals as tolerate. A review of Resident 6's Physician Orders, dated 1/29/20, indicated for the resident to have fortified regular diet with no added salt (NAS) three times per day, and 4 ounce (oz, unit of weight) of high protein nutrition shake (HPN) with lunch and dinner. Prostat liquid (protein supplement), 30 cubic centimeter (cc, unit of measurement in volume) by mouth three times per day for supplement. A review of Resident 6's Nurses Note, dated 3/1/2020, indicated the resident consumed 25% of breakfast. A review of Resident 6's Nurses Notes, dated 3/9/2020, indicated the resident had an actual weight loss with current weight at 102 lbs. The notes indicated Resident 6 had poor oral intake consuming 25% of meals most of the time. The notes indicated Resident 6's Physician (MD 1) ordered for the resident to have dietary consult, calorie count for three days and weekly weights. A review of resident 6's Weekly Weight Record dated from 3/9/20 to 8/6/2020, indicated the resident's weights were as follows: 1. 3/9/2020 = 102 lbs. 2. 3/15/2020 = 99 lbs. 3. 3/23/2020 = 97 lbs. 4. 3/30/2020 = 95 lbs. 5. 4/6/2020 = 93 lbs. 6. 4/15/2020 = 85 lbs. 7. 4/22/2020 = 87 lbs 8. 4/27/2020 = 87 lbs. 9. 5/7/2020 = 86 lbs. 10. 6/8/2020 = 79 lbs. 11. 7/7/2020 = 69 lbs. 12. 8/6/2020 = 70 lbs (32 lbs of weight loss or 31% in five months). A review of Resident 6's Calorie Count, dated from 3/10/2020 to 3/12/2020 indicated the resident consumed 941 calories per day meeting 68% of estimated daily needs. A review of Resident 6's Dietitian Progress Notes and Recommendation, dated 3/12/2020, indicated change the fortified regular NAS diet to fortified regular diet, add one can (240 cc) of [MEDICATION NAME] 1.2 (high protein nutritional supplement provides 285 calories and 13 grams of protein) if oral intake is less than 50%; and add 200 cc every shift. A review of Resident 6's Physician Order, dated 4/30/2020 indicated for the resident to have fortified regular NAS diet three times per day at 7 am, 12 pm and 5 pm. The resident may have 4 oz of prune juice with breakfast and 4 oz of high protein nourishment (HPN) with lunch and dinner. A review of Resident 6's Minimum Data Set (MDS, standardized assessment and care-planning tool), dated 4/30/2020, indicated the resident has severely impaired cognitive skills (ability to think and process information). The MDS indicated Resident 6 was totally dependent with one-person physical assist for bed mobility, transfer, eating, dressing and personal hygiene. During a lunch observation on 9/5/2020, at 1:49 pm, Licensed Vocational Nurse 8 (LVN 8) served lunch tray to residents in the COVID-19 area. LVN 8 did not check the lunch trays to ensure the right diet and portion size is being served to the residents. A concurrent interview was conducted LVN 8 could not explain the reason why the lunch trays were served at 1:49 pm and not at 12 pm. LVN 8 stated all staff from the COVID-19 area are from registry including herself and registry staff did not receive training or orientation before they started their shift. LVN 6 stated facility's staff did not help or guide registry staff. LVN 6 stated she know that residents in the COVID-19 area including Resident 6 received their lunch late, but she is trying to do her best. During a lunch observation on 9/5/2020, at 1:52 pm, Resident 6 was lying in bed awake with dried cracked lips, the water pitcher was not at the resident's bed side. The resident's FC tubing with thick yellow urine. Resident 6 could not answer if staff offer the resident water. A concurrent interview was conducted; Registered Nurse 4 (RN 4) stated she did not know if Resident 6 already ate lunch or if the resident need feeding assistant. During a lunch observation and a concurrent interview on 9/5/2020 2020, at 1:55 pm, LVN 6 served Resident 6 the lunch tray. RN 4 started to feed the resident and stated she will assist Resident 6 with feeding because she thinks the resident needs help. During a concurrent observation of the tray line service in the kitchen for lunch and interview with Chef 1 (CH 1) on 9/8/2020, at 12:15 pm, CH 1 stated he changed the menu due to there was a problem with the refrigerator. CH 1 stated he had to discard the food in the refrigerator and purchase new food. CH 1 stated he did not consult with the facility's RD because it was an emergency situation. CH 1 stated that he did not prepare a spreadsheet (lists the menu with the different diets, consistency and portion sizes to be served) with portion sizes for the cooks to follow. During an observation of on 9/8/2020, at 12:20 pm, Cook 1 (CK 1) was using a slotted spoon (spoon with holes/other openings) to portion food instead of standardized scoops with measurements on the spoon. CK 1 served one spoon of the roasted potato and one spoon of the vegetables on the menu. A concurrent interview was conducted with CK 1 regarding the portion of the residents' meal and how does she know how much to serve; CK 1 stated the menu is similar to the original menu and she serves with the slotted spoon. During a review of the facility's undated original menu and a concurrent interview with CK 1 and CH 1, the menu indicated to use ½ cup of starch and ½ cup of vegetable. CK 1 stated the slotted spoon does not measure ½ cup. CK 1 agreed that the correct size was not served and using the spoon does not provide consistent portions control. CK 1 stated the residents received less food than what the menu indicated. CH 1 stated he will in-service staff on menu serving, portion sizes and to use standardized measurement scoops. During an interview on 9/8/2020 at 12:29 pm, Registered Dietitian 1 (RD 1) stated she was not aware of the changes in the menu. During an interview with CH 1 on 9/8/2020, at 12:40 pm, he stated when he makes changes to the menu, he should consult with the RD to ensure that the menu is adequate and meets the nutritional needs of the residents and to ensure every resident receives the correct portions. A review of the facility's undated policy, titled Menu Adequacy, Policy No. 1.02 indicated facility's menus are to be followed to ensure nutritional adequacy and modified diets are to be adapted from the regular diet and are to approve by the consultant. A review of the facility's undated policy, titled Spreadsheets, Policy No.1.17 indicated spreadsheets are used for purchasing, production, and serving of meal. The policy indicated spread sheets are used to ensure that each resident received the correct diet. A review of the facility's undated policy titled Temporary Menu Changes, policy No. 1.15 indicated temporary menu changes may be made and recorded by the food service supervisor and needed and require subsequent approval of the dietary consultant. 1b. A review of Resident 6's most current Physician Order, dated 4/30/2020 indicated for the resident to have fortified regular NAS diet three times per day at 7 am, 12 pm and 5 pm. The resident may have 4 oz of prune juice with breakfast and 4 oz of high protein nourishment (HPN) with lunch and dinner. During an observation of tray line service for lunch on 9/8/2020, at 12:15 pm, meal trays for residents in COVID-19 area did not include the meal ticket or tray card (basic tray ticket which includes resident's name, room number, diet order, date, adaptive equipment, allergies [REDACTED]. A concurrent interview was conducted with CH 1, he stated since the beginning of August 2020, the facility started using disposable trays and utensils to serve food to the residents in the COVID-19 area. CH 1 stated small stickers are placed on the tray instead of the meal tickets/tray cards are placed on residents' individual trays. CH 1 stated small sticker includes resident name, room number and diet types. CH 1 stated information such as beverages, preferences, residents' likes, and dislikes are not on the stickers. Resident 6's tray included roasted chicken, oven browned potatoes, mixed vegetables, cake, milk and juice. A review of Resident 6's, undated, diet list, titled Red Zone, indicated the resident has high protein nutrition supplement with lunch and dinner. During an interview with Registered Dietitian 1 (RD1) on 9/8/2020, at 12:29 pm, RD 1 stated she could not explain why Resident 6 did not receive the high protein nutrition in the lunch tray. The RD stated that meal card should be on the tray to identify the residents' diet and allows nursing staff (in general) to verify the diet and to make sure the residents would receive the correct diet as ordered. RD1 stated that she will work with facility to develop a meal ticket or tray card that will be placed on each meal trays for staff to identify diet, beverages and residents' preferences. During a lunch observation on 9/8/2020, at 12:35 pm, Resident 6's lunch tray was placed on the resident's bed side table. Resident 6's tray included roasted chicken, oven browned potatoes, mixed vegetables, cake, milk and juice. Resident 6's lunch tray did not have the meal ticket or tray card for nurses (in general) to verify the resident's diet order. Resident 6's lunch tray did not have the high protein nutrition shake. During an interview with CH 1 on 9/8/2020, at 12:40 pm, he stated that Resident 6 did not receive high protein nutrition supplement as ordered with her lunch tray. During a concurrent interview, Cook 2 (CK 2) stated Dietary Staff 1 (DS 1) was the one who was responsible to prepare and add nutrition supplement to the residents' meal trays. During an interview with DS 1 on 9/8/2020, at 12:45 pm, he stated he usually looks at the meal tickets/tray cards and adds the ordered beverage for the residents. DS 1 stated since the beginning of August 2020 with the use of disposable trays and utensils due to COVID 19, facility's staff discontinued using the meal tickets or tray cards and only use the stickers. DS 1 stated the stickers have the residents' name, room number and general diet order but do not have the beverages information for the residents. DS 1 stated he would not know if Resident 6 has high protein nutritional supplement without the tray card. A review of the facility's undated policy, titled Diet Verification Process indicated, all diet orders will be verified through a verification process with nursing and dietary intervention. The policy indicated all residents' diets shall be verified upon delivery to each resident with the use of the medication record by nursing at each meal. 2. A review of Resident 6's Dietitian Progress Notes and Recommendation, dated 3/12/2020, indicated change the fortified regular NAS diet to fortified regular diet, add bolus 1 can (240 cc' s') of [MEDICATION NAME] 1.2 (high protein nutritional supplement provides 285 calories and 13 grams of protein) if oral intake is less than 50%; and add 200 cc of fluids every shift. A review of Resident 6's Nurses Progress Notes from 3/12/2020 to 4/22/2020, indicated there was no documentation that the physician was notified of the RD 1's recommendations. A review of Resident 6's Physician Order, dated from 3/12/2020 to 4/22/2020, indicated there was no order to change diet to fortified regular, to add bolus 1 can [MEDICATION NAME] 1.2 high protein nutrition supplement and to add 200 cc of fluids every shift. A review of Resident 6's Dietitians Progress Notes/Recommendations, dated 4/23/2020, indicated resident had lost significant weight (a loss of >5 percent (%) of the usual body weight in one month) of 9% of body weight in 1 month. RD 1 recommended to add ice cream with lunch and dinner and to increase protein shake to three times a day with meals. A review of Resident 6's Nurses Progress Notes from 4/23/2020 to 4/30/2020, indicated there was no documentation that the physician was notified of the RD 1's recommendations. A review of Resident 6's Physician Order, dated from 4/23/2020 to 4/30/2020, indicated there was no order to increase protein shakes to three times a day with meals instead of twice a day. There was no order to add ice cream for lunch and dinner. A review of Resident 6's Physician Order, dated 4/30/2020 indicated for the resident to have fortified regular NAS diet three times per day at 7 am, 12 pm and 5 pm. The resident may have 4 oz of prune juice with breakfast and 4 oz of high protein nourishment (HPN) with lunch and dinner. During an interview and record review on 9/8/2020 at 4:20 pm with Registered Nurse Supervisor 1 (RN 1), he stated that when dietitian recommends an intervention, the dietitian will write on the medical record and will flag out for Registered Nurses (in general) to see the recommendations. The RN 1 stated he will call the Physician for orders. RN 1 stated physicians are seldom refusing to follow RD's recommendations. RN 1 stated if the physicians refused to follow the RD's recommendations they will document the reasons for refusal in the residents' medical record. A review of the facility's policy, titled Weight Review, Policy No.4.9 (Revised 2005), indicated the Dietitian shall provide further chart recommendations upon his/her consultant visits and nursing shall follow up these recommendations. Nursing staff shall document follow up of these recommendations on the nursing progress notes. The Policy indicated the Dietary Services Supervisor shall follow up to see if recommendations were carried out or addressed. 3. A review of Resident 6's Nurses Notes, dated 3/10/2020, indicated the resident's FM 1 decided for Resident 6 to have a [DEVICE] feeding placement. The notes indicated Physician 1 (MD 1) ordered for Resident 6 to have a gastrointestinal (GI, relating to stomach and the intestines) consult for [DEVICE] placement. A review of Resident 6's Nurses progress notes dated 3/16/2020, indicated the resident's bed sores reports the skin breakdown is getting worse. The notes did not indicate the location of the bed sores or stage of the bed sores. The note indicated that resident's FM 1 agreed to the [DEVICE] placement. A review of Resident 6's Nurses Progress Notes, dated 3/18/2020, indicated resident [DEVICE] placement surgery was cancelled. The note did not indicate why the [DEVICE] placement surgery was cancelled. A review of Resident 6's Nurses Progress Notes, dated 4/15/2020, indicated the resident continues with poor oral intake and consumes only two or three spoonful of meals. The notes indicated the facility is not able to schedule [DEVICE] placement at this time. The notes did not indicate the reason why the [DEVICE] placement was not done at this time. A review of Resident 6's Nurse's Progress Notes, dated 4/16/2020, indicated that due to facility not able to schedule [DEVICE] placement for the resident the family was given option for hospice care. The Progress Notes also indicated the physician was made aware of option provided to family and that physician has stated he will arrange with the acute hospital for [DEVICE] placement. The notes indicated Resident 6 consumed 25% of dinner. A review of Resident 6's Nurses Progress Notes, dated 4/17/2020, indicated [MEDICATION NAME] Physician (Physician that specialized gastrointestinal) had contacted facility and scheduled for a G tube placement on 4/22/2020. A review of Resident 6's Nurses Progress Notes, dated from 4/17/2020 to 4/22/2020, indicated there was no communication with the resident's FM 1 regarding the new scheduled appointment on 4/22/2020 for [DEVICE] placement. A review of Resident 6's physician progress notes [REDACTED]. A review of Resident 6's Nurses Progress Note, dated 5/3/2020, indicated facility received a call from Hospice Company who informed facility that MEDICATION ORDERS FOR [REDACTED]. During an interview and review of Resident 6's Nurses Progress Notes, dated from 3/18/2020 to 5/3/2020, on 9/8/2020 at 4:20 pm RN 1 stated the stated that the [DEVICE] placement surgery in March 2020 was cancelled due to COVID-19 pandemic. RN 1 stated in April, the physician attempted to arrange for the [DEVICE] placement again, but there was no follow up with Resident 6's FM 1. A review of the facility's undated policy, titled Resident Rights Guidelines for All Nursing Procedure, indicated for the residents and their family members to participate in the residents' care. A review of Resident 6's Electronic Treatment Administration Record, dated 9/11/2020 indicated the resident has Stage II (partial-thickness skin loss into but deeper than the dermis) Pressure Sore on the Sacrococcyx area.

Based on observation, interview and record review, the facility failed to assess the skin rash of three of eight sampled residents (Resident 1, 2, and 3) so necessary care and interventions could be given. Resident 1 was started on an anti-itch medicated cream on 1/25/17 and the resident was allowed to self-administer the anti-itch cream from 4/6/17 to 5/15/17 as ordered. The license nurse was not monitoring number of times resident was self-administering cream and not assessing the skin for presence of rash. Resident 1 stated he could not sleep and the nurses had been putting cream on his skin without relief. (Cross refer F425). Resident 3, had self-inflicted wounds from scratching and had an unresolved generalized rash since 10/6/16. The license nurse was not assessing the skin for presence of rash. Resident 3 stated he could not sleep because of the itchiness. Resident 2 was tested positive for scabies by the hospital on the day of the resident's transfer to the hospital. There was no documentation from the facility prior to the transfer to the hospital that the resident had a rash. These deficient findings resulted in the residents experiencing itchiness without relief and had the potential to spread the infectious and itchy rash to other residents. Findings: On 6/30/17 at 1:45 p.m., an unannounced visit was made to the facility to investigate a complaint regarding residents developing rashes. 1. A review of Resident 1's Face Sheet (admission record) indicated Resident 1 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS-clinical assessment tool), dated 3/13/17, indicated Resident 1's cognition was intact and the resident needed limited assistance (resident highly involved in activity; staff provide guided-maneuvering of limbs or other non-weight bearing assistance) with bed mobility, transfer, and room ambulation. A review of Resident 1's record titled, Resident Care Plan, dated 1/25/17 indicated the resident had generalized itchy rash due to contact [MEDICAL CONDITION] (inflamed skin). A review of Resident 1's physician order [REDACTED]. a. [MEDICATION NAME] cream for forty days (an anti-itch cream) for generalized rash, which was started on 1/25/17. b. [MEDICATION NAME] Bethamethasone cream (an antifungal medicine) for generalized rash, which was started on 1/31/17. c. Mometasone ointment (a steroidal medicine that reduces skin inflammation) for itchy rash, which was started on 2/28/17 then renewed on 4/6/17 for 40 days (ending on 5/16/17), may allow the resident to apply Mometasone ointment to generalized rash at night per resident request. There was no Mometasone order from 5/16/17 to 6/30/17. A review of Resident 1's Medication Self Administration evaluation, dated 4/6/17, Resident 1 can self-administer Mometasone. There was no evidence on the ETAR that the licensed nurses were monitoring and documenting the number of times the resident was self-administering the Mometasone. A review of Resident 1's General Nurse's Observation (a weekly assessment), under skin condition, dated 6/17/17 and 6/24/17, indicated Resident 1's skin was clear. During an observation and interview, on 6/30/2017 at 2:40 p.m., Resident 1 was observed sitting in a wheelchair inside his room and scratching his arms. Resident 1 was observed with red bumps on his upper front body, arms and legs. Resident 1 stated he could not recall the onset of his rashes, but it had been awhile. Resident 1 stated his itchiness started when he was in the same room with Resident 3 but Resident 1 was unable to recall the time period he shared a room with Resident 3. Resident 1 stated he could not sleep and the nurses had been putting cream on his skin without relief. During an interview, on 6/30/17 at 3:05 p.m., the Licensed Vocational Nurse (LVN) 1 stated Resident 1 had the rash about six months now. LVN 1 stated Resident 1 had been itching and scratching. During an interview, on 6/30/17 at 2 p.m., the director of nursing (DON) stated a Public Health Nurse (PHN) visited the facility this morning. The DON stated they both toured the facility to check residents who had a rash. The DON stated she was not aware of any residents with rashes. The DON stated after the tour, there were seven residents identified with rashes, which included Resident 1. During an interview, on 6/30/17 at 4:40 p.m., the DON stated the license nurses do not document the presence of skin rash on the weekly assessment form, General Nurse's Observation. The DON stated the presence of rashes is documented on Progress Notes by Resident-by Note Type. The progress notes from 6/17/17 to 6/30/17 was reviewed with the DON and there was no documentation that Resident 1 had rashes. A review of the Resident 1's physician's orders [REDACTED]. The physician also ordered Mometasone ointment as needed and moisturizer for skin maintenance. The physician order [REDACTED]. A review of Resident 1's ETAR, dated 6/30/17 [MEDICATION NAME] was given. During an observation and interview, on 7/3/17 at 3:30 p.m., Resident 1 was observed with red bumps on his upper front body and arms. He stated he had less itching compared to a couple of days ago. Resident 1 verbalized his anger towards his exposure in the past to Resident 3, who had rashes when they were in the same room from 8/17/16 to 1/4/17. 2. A review of Resident 3's Face Sheet indicated Resident 3 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 3's care plan, dated 10/6/16 and 3/31/17, indicated Resident 3 had consistent generalized rash that was not resolved. A review of Resident 3's physician order [REDACTED]. a. [MEDICATION NAME] Cream (an anti-itch medicine) to general rash, which was ordered on [DATE] for [MEDICAL CONDITION] (a skin infection) and discontinued on 10/13/16. b. [MEDICATION NAME] Cream to itchy rash as needed, which was ordered on [DATE] up to 2/13/17 and renewed on 3/31/17 for general rash, to apply daily for 40 days (ending 5/10/17). c. [MEDICATION NAME] 25 milligram (mg) by mouth twice a day for 14 days for itching, which was ordered 10/28/16 (ending 11/10/16). d. [MEDICATION NAME] (an anti-allergy medicine) 10 mg by mouth at bedtime, which was ordered on [DATE]. e. [MEDICATION NAME] Cream (a steroid medicine for skin itchiness) to apply to generalized rash twice per day, which was ordered on [DATE] and discontinued on 2/27/17. f. [MEDICATION NAME] (a medication used to treat anxiety disorders and allergic skin condition) 25 mg by mouth twice a day for 30 days for pruritus (itchiness), which was ordered 5/18/17. The last dose was administered on 6/16/17. A review of Resident 3's MDS, dated [DATE], indicated Resident 3's cognition was moderately impaired. Section C, Skin Condition, of the MDS indicated Resident 3 had no skin issues present. A review of Resident 3's General Nurse Observation, a weekly assessment, dated 6/17/17 and 6/24/17, under Skin Condition, indicated Resident 3's skin was clear. There was no further documentation of the rash on record found. A review of Resident 3's record titled, Multi Wound Chart Detail, an assessment from a wound physician, dated 6/19/17, indicated Resident 3 had chronic [MEDICAL CONDITION], had a self-inflicted wound from scratching, and was on [MEDICATION NAME]. During an observation, on 6/30/17 at 3:25 p.m., Resident 3 was in his bed awake, restless, scratching both arms and body. Resident 3 had red bumps in front and back trunk, head, legs and finger webs. Resident 3 stated he could not sleep because of the itchiness. During an interview, on 6/30/17 at 2 p.m., the director of nursing (DON) stated a Public Health Nurse (PHN) visited the facility this morning. The DON stated they both toured the facility to check residents who had a rash. The DON stated she was not aware of any residents with rashes. The DON stated after the tour, there were seven residents identified with rash, which included Resident 3. During an interview, on 6/30/17 at 4:40 p.m., the director of nursing (DON) stated the license nurses do not document the presence of skin rash on the General Nurse's Observation. The DON stated the presence of rashes is documented on Progress Notes by Resident-by Note Type. Resident 3's progress notes from 6/17/17 to 6/30/17 was reviewed with the DON and there was no documentation that Resident 3 had rashes. A review of Resident 3's physician's orders [REDACTED]. The physician order [REDACTED]. 3. A review of Resident 2's Face Sheet indicated Resident 2 was admitted to the facility on [DATE], transferred to general acute care hospital (GACH) 6/9/17 to 6/14/17 and re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 2's MDS, dated [DATE], indicated the resident was unable to complete brief interview for mental status. Resident 2's functional status indicated the resident needed extensive assist (resident involved in activity; staff provide weight bearing support) on bed mobility and transfer. A review of Resident 2's facility's transfer sheet to GACH, dated 6/9/17, indicated the facility conducted a body check on the resident. There was no documentation of Resident 2 having rashes. A review of Resident 2's GACH record titled, Consultation, dated 6/9/17, an infectious disease doctor indicated the resident having a possible scabies. A review of Resident 2's GACH record titled, Miscellaneous Culture, dated 6/10/17, indicated scabies was present on the resident. During an interview, on 6/30/17 at 2:20 p.m., a licensed nurse/treatment nurse (TN 1) stated Resident 2 was tested positive for scabies while at the acute care hospital and the resident was treated once at the hospital. TN 1 stated the resident's second treatment for [REDACTED]. On 6/30/17 at 2:50 p.m., Resident 2 was observed with rashes on the lower abdomen and left outer side of his hand.

Based on observation, interview and record review the facility failed to prevent the development and progression of avoidable pressure sore (localized injury to the skin and or underlying tissue usually over a bony prominence as a result of pressure or pressure in combination with shear and /or friction) for residents who were at risk for developing pressure sores for four of six residents observed for pressure sores (Residents 5, 13, 19, 20) in a total of 23 sampled residents by failing to: 1. For Resident 5, the facility failed to: (a) Revise the plan of care to address the frequency in which the resident should be turned, as well as positioning the resident while in bed. (b) Ensure the resident was not lying on his back directly on the pressure sore. (c) Accurately assess the skin condition of sacrum (a triangular shaped bone at the bottom of the spine) pressure sore. (d) Monitor and report skin changes to the physician. These failures resulted in Resident 5 developing an avoidable stage III pressure sore (full thickness tissue loss, subcutaneous (under the skin) fat may be visible but bone, tendon or muscle are not exposed) to his sacrum. 2. For Residents 19, the facility failed to follow the physician's orders [REDACTED]. This had the potential to result in development of pressure sore. 3. For Resident 20, the facility failed to follow the physician's orders [REDACTED]. This had the potential to result in development of pressure sore . Findings: a. A review of the admission assessment dated [DATE], indicated Resident 5 was readmitted to the facility without a pressure sore. Resident 5's [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS-a standardized assessment and care planning tool) dated [DATE], indicated Resident 5 was assessed with [REDACTED]. A review of the Braden Scale Assessment (a nursing tool which uses a scoring system to evaluate resident's risk of developing a pressure sore) dated [DATE], indicated Resident 5 scored 13 which indicated Resident 5 was at moderate risk of developing pressure sore. On [DATE] at 8:20 a.m., the medical record of Resident 5 was reviewed with the Director of Nursing (DON) and Treatment Nurse 2. The Skin Condition/Wound progression notes of Treatment Nurse 1 dated [DATE], indicated she assessed Resident 5 with redness (stage 1 pressure ulcer- intact skin with non-blanchable redness of a localized area usually over a bony prominence) on his sacrum. On [DATE], Treatment Nurse 1 assessed the resident's sacrum as stage II pressure sore with minimal yellow colored drainage. The pressure sore measured 4 centimeter (cm) in length (L) by (x) 3 cm in width (W) and 0.1 cm in depth (2.5 cm = 1 inch ). The physician was made aware on [DATE]. Resident 5 had a stage II pressure sore to his sacrum. The treatment order dated [DATE], indicated cleanse the sacral stage II pressure sore with normal saline (salt water solution) pat dry, apply Collagen (use to heal moist wound), apply Hydrogel (help regulate fluid exchange from the wound surface ) and cover the pressure sore with dry dressing every day. Treatment Nurse 1 notes dated [DATE] through [DATE], indicated she continued to assess and categorize the resident's sacrum pressure sore as stage II despite the drainage from the pressure sore which was yellow and tan in color. According to the National Pressure Ulcer Advisory Panel (NPUAP), a pressure ulcer with full thickness tissue loss, visible subcutaneous fat with no bone, tendon or muscle exposure, with slough (yellow, tan, gray, green or brown) that does not obscure the depth of tissue loss, is a stage 3 pressure ulcer. The physician progress notes [REDACTED]. Although the physician had assessed the Resident 5's sacrum as stage III pressure sore on [DATE], Treatment Nurse 1 and Licensed Vocational Nurse (LVN 4) notes dated [DATE] through [DATE] , indicated they both continued to assess and categorize the pressure sore as stage II with yellow and tan colored drainage. On [DATE], Treatment Nurse 2 assessed the Resident 5's sacrum as stage III pressure sore measuring 1 cm in length x 0.5 in width with 0.3 cm in depth. On [DATE] at 8:20 a.m., Resident 5's care plan was reviewed with DON and Treatment Nurse 2. The resident's initial care plan dated [DATE], indicated he was assessed at risk for skin breakdown due to decreased bed mobility. The care plan goal was for Resident 5 not to have a skin breakdown by the next review on [DATE]. The care plan dated [DATE], indicated the resident developed a stage II pressure sore (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (dead tissue) and may present as an intact or open / ruptured blister) to his sacrum. The care plans dated [DATE] and [DATE], indicated turning and repositioning the resident while in bed. However, both care plans did not indicate the frequency and which specific side the resident's body should be turned and repositioned to prevent pressure sore development and to prevent worsening of the existing pressure sore. The care plan dated [DATE], indicated the resident's stage II pressure sore to his sacrum had progressed to stage III pressure sore. The care plan for sacrum stage III pressure sore dated [DATE], did not indicate turning and repositioning Resident 5 while in bed and the care approaches were not revised to promote healing of the pressure sore and to prevent further skin breakdown. According to Medical Surgical Nursing Ninth Edition pages ,[DATE], Prevention remains the best treatment for [REDACTED]. Never position the patient directly on the pressure sore. On [DATE] at 7:35 a.m., an initial tour of the facility was conducted with Registered Nurse (RN 1). Resident 5 was observed lying on his back on a low air loss mattress (a mattress that provides a flow of air to assist in managing the heat and humidity of the skin). He had involuntary movements to both arms and his hands were contracted. The resident was non-communicative. Further observations on [DATE] at 9:35 a.m., 10:37 a.m., 11:30 a.m., 1:20 p.m., 2:40 p.m., 3:38 p.m., and 4:13 p.m., Resident 5 was observed lying on his back in bed. On [DATE], the resident was observed lying on his back while in bed at 7:14 a.m., 9:09 a.m., 9:50 a.m., 10:02 a.m., and 1:40 p.m. During the treatment observation on [DATE] at 10:02 a.m., Resident 5 was observed with stage III pressure sore to his sacrum. Treatment Nurse 2 measured the pressure sore as 1.4 cm in length x 1 cm in width with 0.3 cm in depth. The wound bed had a moderate amount of yellow colored slough (dead tissue). Treatment Nurse 2 cleansed the sacrum pressure sore with normal saline , applied Collagen powder, applied Hydogel gauze and covered the pressure sore with a dry dressing. During an interview on [DATE] at 2:50 p.m., Certified Nursing Assistant (CNA 1) stated LVN 4 (licensed vocational nurse) informed CNA 1 that Resident 5 had stage III pressure sore to his sacrum. He stated the facility had Patient repositioning schedule. The written copy of the Patient repositioning schedule was placed on the back side of CNA 1's identification card. The Patient repositioning schedule indicated to reposition the resident every two hours as follows: 7:00 a.m. - 9:00 a.m. - Back 9:00 p.m. - 11:00 p.m. - Right side 9:00 a.m. - 11:00 a.m. - Right side 11:00 p.m. - 1:00 a.m. - Back 11:00 a.m. - 1:00 p.m. - Back 1:00 a.m. - 3:00 a.m. - Left side 1:00 p.m. - 3:00 p.m. - Left side 3:00 a.m. - 5:00 a.m. - Right side 3:00 p.m. - 5:00 p.m. - Right side 5:00 a.m. - 7:00 a.m. - Left side 5:00 p.m.-7:00 p.m.- Back 7:00 p.m. - 9:00 p.m. - Left side CNA 1 stated he was unable to turn and reposition Resident 5 every two hours because he was busy taking care of another resident. CNA 1 stated he turned and repositioned the resident to his right side, left side and back when in bed. CNA 1 was not informed by any staff member that Resident 5 should not be turned and repositioned on his back while in bed. CNA 1 stated when the resident is lying on the site of pressure sore it will get worse due to pressure. During an interview on [DATE] at 9:18 a.m., DON and Treatment Nurse 2 both stated the Resident 5's pressure sore to his sacrum will get worse due to pressure on the sacrum when the resident was lying on his back in bed. They stated the facility's Patient repositioning schedule to turn and reposition the resident at least every two hours should be followed by the CNA to prevent further skin breakdown and to heal the pressure sore. DON stated RN Supervisor, Charge Nurse and Treatment Nurse were responsible for monitoring the resident every two hours to ensure he was turned and repositioned in bed. DON stated there was no written documentation that Resident 5 was monitored by the staff that he was turned and repositioned in bed every two hours. DON was not aware the resident's pressure sore had yellow drainage since [DATE], and the physician assessed the resident's sacrum as stage III pressure sore on [DATE]. DON stated the Weekly Decubitus Update she received from Treatment Nurse 1 indicated Resident 5 had stage II pressure sore to his sacrum. Treatment Nurse 1 was on medical leave. Treatment Nurse 2 stated he did not inform CNA 1 that Resident 5 should not be turned and repositioned on his back while in bed. During an interview on [DATE] at 9:40 a.m., RN 1 stated she informed CNA 1 that Resident 5 should be turned and repositioned only to his right side and left side while in bed to avoid pressure on the resident's sacrum pressure sore. During an interview on [DATE] at 8:10 a.m., Resident 5's wife stated she visited the resident three times a day to feed him during meal times. She was aware the resident had pressure sore to his sacrum. She always arrived in the facility at 6:30 a.m., and the resident was observed lying on his back most of the time while in bed. b. During the initial tour on [DATE] at 8:40 a.m., Resident 13 was observed flat on her mattress. On [DATE] at 3:30 p.m., and [DATE] at 7:43 a.m., Resident 13 was observed with her back flat against the mattress. According to the admission face sheet Resident 13 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The Minimum Data Set (MDS - a standardized assessment and care planning tool ) indicated Resident 13 ' s decision making was moderately impaired (needs cueing and supervision) as well as completely dependent with two staff physical assist for bed mobility. Upon record review on [DATE], treatment note indicated a stage II pressure sore (partial thickness shim loss) on the sacrum area (triangular bone in at the lower back). The plan of care alteration in skin integrity as evidenced by pressure ulcer sacrum dated [DATE] indicated to assist patient with tuning and repositioning. c. The admission face sheet for Resident 19 indicated that Resident 19 was readmitted on [DATE] with the [DIAGNOSES REDACTED].) The minimum data set (MDS- a standardized assessment and care planning tool) dated [DATE], indicated that Resident 19 never/rarely made decisions and had a memory problem. Resident 19 was completely dependent on staff to physically assist in eating and needed one person physical assist in bed mobility (how resident moves to & from lying position, turns side to side and positions body in bed). The skin condition for Resident 19 indicated resident at risk for developing pressure sore (injury to skin or underlying tissue). Upon record review on [DATE], Resident 19's physician's orders [REDACTED]. During an observation on [DATE] at 9:22 a.m., 3:30 p.m. and on [DATE] at 7:48 a.m., Resident 19 was observed in bed with no heel protectors and both heels directly on the bed mattress. d. The admission face sheet for Resident 20 indicated re-admission on [DATE] with the [DIAGNOSES REDACTED]. The MDS dated Decemeber 21, 2015, indicated Resident 20 needied supervision and cues as well as needing one person physical assist while eating and needed one person physical assist in bed mobility (how resident moves to & from lying position, turns side to side and positions body in bed). The skin condition for Resident 20 indicated resident at risk for developing pressure sores. Upon record review on [DATE] the physician's orders [REDACTED]. During an observation on [DATE], at 7:45 a.m., Resident 20 was observed in bed with both heels flat on mattress in bed.