Every finding on record at Totally Kids Specialty Healthcare - Sun Valley

Based on observation, interview and record review, the facility failed to provide care in a manner that promoted and maintained residents' rights for two of four sampled residents (Resident 2 and Resident 3) by failing to ensure Physical Therapy Assistant 1 (PTA 1) knocked on Resident 2 and Resident 3's door prior to entering Resident 2 and Resident 3's room. This deficient practice had the potential to compromise Resident 2 and Resident 3's dignity, privacy, autonomy (resident's right to make their own choices), self-esteem and sense of self-worth. a. During a review of Resident 2's admission Record, the admission Record indicated the facility originally admitted Resident 2 on 5/29/2018 with diagnoses including arthrogryposis multiplex congenita (a group of conditions where a baby is born with multiple stiff, rigid joints), encounter for attention to tracheostomy (a surgically created hole in the front of the neck that leads directly into the windpipe), and dependence of respirator (individual's body is unable to breathe adequately on its own). During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool) dated 6/1/2026, the MDS indicated Resident 2's cognitive (the mental process involved in knowing, learning, and understanding things) skills for daily decision making was severely impaired. The MDS further indicated Resident 2 was dependent on staff for oral hygiene, toileting hygiene, showering or bathing, dressing, personal hygiene and mobility (movement). b. During a review of Resident 3's admission Record, the admission Record indicated the facility originally admitted Resident 3 on 4/14/2026 with diagnoses including shaken infant syndrome (a serious brain injury that results from forcefully shaking an infant or a toddler). During a review of Resident 3's MDS dated [DATE], the MDS indicated Resident 3's cognitive skills for daily decision making was severely impaired. The MDS further indicated Resident 3 was dependent on staff for oral hygiene, toileting hygiene, showering or bathing, dressing, personal hygiene and mobility. During an observation on 6/30/2026 at 3:45 p.m., in Resident 2 and Resident 3's room, observed PTA 1 entering Resident 2 and Resident 3's room without knocking or announcing herself prior to entry. During an interview on 6/30/2026 at 3:46 p.m., with PTA 1, PTA 1 stated that she did not knock or introduce herself prior to entering Resident 2 and Resident 3's room. PTA 1 stated that she entered the room to see whether Resident 2 was in the room. PTA 1 continued to state that she (PTA 1) should have knocked and introduced herself prior to entering Resident 2 and Resident 3's room out of respect for residents and to uphold residents' rights. During an interview on 7/1/2026 at 3:56 p.m., with the Director of Nursing (DON), the DON stated that all staff should knock on residents' doors and announce themselves before entering. The DON stated that knocking on residents' doors allows residents to know who is entering their room. The DON continued to state that knocking before entering is important to maintain residents' dignity and demonstrate respect for their (residents) rights. During a review of the facility's policy and procedure (P&P) titled Resident Rights Under California Regulations, reviewed on 12/3/2025, the P&P indicated residents are to be treated with consideration, respect and full recognition of their dignity and individuality, including privacy in treatment and in care of personal needs.

Based on observation, interview, and record review, the facility failed to ensure one of three sampled staff (Certified Nursing Assistant 1 [CNA 1]) donned (put on) personal protective equipment (PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) in the appropriate order prior to entering the room of a resident who was placed on droplet precautions (infection control measure used to prevent transmission of infectious agents spread through respiratory droplets [tiny, moisture-filled particles of mucus and saliva expelled from the nose and mouth] which are generated by coughing, sneezing, or talking) and contact precautions (infection-control measure used to prevent the spread of germs transmitted through direct or indirect contact). This deficient practice had the potential to spread infection and cause cross contamination (the physical movement or transfer of harmful bacteria [germs] from one person, object, or place to another) among staff and other residents.During a review of Resident 4's admission Record, the admission Record indicated the facility admitted Resident 4 on 3/4/2026 with diagnoses that included carrier or suspected carrier of methicillin resistant staphylococcus aureus (MRSA - a bacteria that does not respond to antibiotics [medicines that fight infections]). During a review of Resident 4's Minimum Data Set (MDS - a resident assessment tool) dated 7/2/2026, the MDS indicated Resident 4's cognitive (the mental process involved in knowing, learning, and understanding things) skills for daily decision making was severely impaired. The MDS further indicated Resident 4 was dependent on staff for oral hygiene, toileting hygiene, showering or bathing, and personal hygiene. During a review of Resident 4's Order Summary Report dated 6/26/2026, the Order Summary Report indicated a physician's order for contact and droplet isolation precautions (measures used to prevent the spread of germs).During a review of Resident 4's Care Plan (CP- a written document that summarizes a resident's conditions, specific care needs, and current treatments), initiated on 6/26/2026, the CP indicated Resident 4 had a medical history of MRSA in the sputum (a mixture of saliva and mucus that is coughed up from the respiratory tract, often following an infection or irritation of the mucosa). The CP indicated an intervention to ensure all staff strictly adhered to hygienic (conditions, practices, or environments that are clean, sanitary, and actively promote good health) measures. During an observation on 7/1/2026 at 9:39 a.m., outside Resident 4's room, observed droplet precautions and contact precautions signages posted on the wall adjacent to the right side of the room entrance (next to Resident 4's room door). Observed CNA 1 wearing a surgical mask (a loose-fitting, disposable, medical device worn by healthcare professionals to prevent the spread of germs, bacteria and respiratory droplets). CNA 1 was then observed donning gloves first, followed by a yellow disposable gown, prior to entering Resident 4's room. During an interview on 7/1/2026 at 9:40 a.m., outside Resident 4's room, CNA 1 stated that Resident 4 is on droplet and contact precautions. CNA 1 stated that when donning PPEs, CNA 1 should first perform hand hygiene (the simple practice of cleaning your hands to remove germs, dirt, and bacteria), don a yellow gown, then put on gloves last. CNA 1 stated that she should have donned the yellow gown first before the gloves in accordance with infection control practices. During a concurrent interview and record review on 7/1/2026 at 11:06 p.m., with the Infection Preventionist (IP), the IP stated the proper sequence for donning PPE is to perform hand hygiene first, followed by the gown, mask, eye protection, and gloves last. The IP stated gloves should be donned last to minimize contamination and help keep the gloves as clean as possible before providing resident care. The IP further stated that failing to follow the proper sequence for donning PPE has the potential to increase the risk of infection transmission. During a review of the facility's policy and procedure (P&P) titled Infection Control: Isolation Precautions, reviewed on 12/3/2025, the P&P indicated that transmission based isolation precautions (a set of extra infection-control measures used in healthcare settings) to be used in addition to standard precautions (the minimum infection prevention practices applied to all patient care, regardless of suspected or confirmed infection status), when necessary. During a review of the facility document titled [NAME] and Doff (Remove) PPE: Competency, undated, the facility document indicated to: 1. Perform hand hygiene; 2. [NAME] gown; 3. [NAME] any respiratory equipment; 4. Eye protection; 5. [NAME] gloves.

Based on observation, interview, and record review, the facility failed to follow the facility menu by failing to serve the resident's hamburger bun, lettuce leaf, tomato slices, sweet potato fries, pea and cheese salad, and 1 percent (% - one part of every 100) milk as indicated on the facility menu to be served for lunch on 3/23/2026 for one of three sampled residents (Resident 2). This deficiency had the potential for Resident 2 to not receive the nutrition needed.Findings:During a review of Resident 2's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included of septo-otic dysplasia of brain (a disorder that affects early brain development), multiple congenital malformation (a structural defect or abnormality present at birth, resulting from improper development during pregnancy), and encounter for attention to tracheostomy (a surgical procedure that creates an opening through the neck into the windpipe to provide an alternative airway for breathing).During a review of Resident 2's Minimum Data Set (MDS-a resident assessment tool), dated 2/25/2026, the MDS indicated Resident 2's cognition (a mental process of acquiring knowledge and understanding through thought, experience and senses) was moderately impaired. The MDS indicated Resident 2 required supervision or touching assistance from staff with eating and oral hygiene and required partial/moderate assistance from staff with toileting hygiene and personal hygiene.During a review of Resident 2's Order Summary Report, the Order Summary Report indicated regular diet and pureed texture.During a Record review of the facility menu for the week of 3/23/2026, the menu indicated: Monday, Lunch: Turkey Burger, Hamburger Bun, Lettuce Leaf, Tomato Slices, Sweet Potato Fries, Pea & Cheese Salad, Chilled Peaches, 1% milk.During a Review of Resident 2's meal card, dated 3/23/2026, the meal card indicated turkey burger, peas, peaches, and water. During an observation on 2/23/2026 at 11:35 a.m. in the kitchen, observed the Dietary Supervisor (DS) cooked a turkey patty.During an observation on 2/23/2026 at 11:37 a.m. in the kitchen, observed DS cooked frozen peas.During an observation on 2/23/2026 at 11:48 a.m. in the kitchen, observed DS placed peaches from fruit cup in blender and pureed peaches.During an observation on 2/23/2026 at 11:58 a.m., in the kitchen, observed DS chopped and placed turkey patty in blender and pureed turkey patty.During an observation on 2/23/2026 at 12:12 p.m. in the kitchen, observed DS placed cooked peas in blender and pureed peas.During an observation on 2/23/2026 at 12:15 p.m. in the kitchen, observed the DS prepared Resident 2's lunch tray. Observed the DS placed pureed turkey patty, pureed peas, and pureed peaches on Resident 2's lunch tray.During an observation on 2/23/2026 at 1:34 p.m. in Resident 2's room, observed Resident 2's tray. Observed pureed turkey, pureed peas, and pureed peaches. Resident 2's lunch tray was observed without lettuce leaf, tomato slices, and sweet potatoes.During a concurrent interview and record review on 2/23/2026 at 1:52 p.m. with the DS. The DS reviewed the facility's menu for the week of 3/23/2026. The DS stated that that for lunch the menu indicated turkey burger, hamburger bun, lettuce leaf, tomato slices, sweet potato fries, pea & cheese salad, chilled peaches, and 1 % milk. The DS stated that she did not serve Resident 2 the hamburger bun because Resident 2's does not like bread. The DS reviewed Resident 2's Nutritional assessment dated [DATE] times at 8:46 a.m. and stated that there was no documentation that Resident 2 does not like bread. The DS stated that she should have served Resident 2 bread because it was on the menu. The DS continued to state that the DS did not serve Resident 2 lettuce leaf, tomatoes slices, sweet potato fries, and did not add cheese to the peas because the DS did not check the menu and was in a rush to serve lunch.During a follow up interview on 2/23/2026 at 3:53 p.m. with the DS, the DS stated that it is important to follow the menu to make sure residents are provided with correct nutritional intake according to the dietician recommendations. The DS stated that by not following the facility's menu residents have the possibility of not receiving the needed nutrition. During a review of the facility's policy and procedure (P&P) titled, Menu Guidelines, reviewed date 12/3/2025, the P&P indicated to prepare foods a [NAME] to the menu. The P&P indicated menu planning Plays an important part in the residence nutritional care. The DFNS is responsible for supervising meal preparation and service to assure the menu is followed and served as planned and resident diet orders are implemented.

Based on interview and record review, the facility failed to Inform the resident and/or the responsible party in advance regarding the risks and benefits of administration of a vaccine (a substance that helps the body learn how to fight a specific disease without causing the illness itself) for one of five sampled residents (Resident 3) reviewed during the Infection Control task. This deficient practice resulted in Resident 3 receiving the COVID-19 (a vaccine designed to induce immunity against SARS-CoV-2 [the virus responsible for coronavirus disease 2019]) vaccine without Resident 3's responsible party knowing the risks and benefits of the vaccine prior to administration. Findings: During a review of Resident 3's admission Record, the admission Record indicated the facility admitted Resident 3 on 7/24/2024 with diagnoses that included cerebral palsy (a group of lifelong disorders affecting body movement, muscle tone, and posture caused by abnormal brain development or damage, usually before birth), tracheostomy (a surgical procedure that creates an opening in the neck leading directly into the windpipe [the main cartilaginous tube in the body that carries air between the voice box and the lungs]) status and persistent vegetative (a condition where, following severe brain damage, a person is awake but shows no signs of awareness, thought, or purposeful reaction to their environment). During a review of Resident 3's Minimum Data Set (MDS- a resident assessment tool) dated 12/18/2025, the MDS indicated Resident 3's cognition (a mental process of acquiring knowledge and understanding through thought, experience and the senses) was severely impaired. The MDS indicated Resident 3 was dependent on staff with oral hygiene, toileting hygiene, and personal hygiene. During a review of Resident 3's Immunization History Report, the Immunization History Report indicated that Resident 3 received the COVID-19 vaccine on 10/16/2025. During an interview on 2/22/2026 at 4:09 p.m. with Family Member 1 (FM 1), FM 1 stated that Resident 3 received the COVID-19 vaccine without FM 1's knowledge. FM 1 stated that FM 1 was informed that Resident 3 received the COVID-19 vaccine only after the vaccine was administered. During a concurrent interview and record review on 2/22/2026 at 5:14 p.m., with the Director of Staff Development (DSD) the DSD reviewed Resident 3's progress notes from 8/1/2025-10/31/2025. The DSD stated that there was no documented evidence that FM 1 was informed in advance, nor was there documentation that informed consent was obtained prior to the administration of the COVID-19 vaccine. The DSD stated that it is FM 1's right as Resident 3's responsible party to be informed in advance of the vaccine administration so they may provide informed consent and have the opportunity to ask questions. During a review of the facility's policy and procedure (P&P) titled, Resident's Rights, with review date of 12/3/2025, the P&P indicated it is the resident's right to be fully informed, to be fully informed by the physician of his or her total health status and to be afforded the opportunity to participate on an immediate and ongoing basis in the total care plan of care including the identification of medical, nursing and psychosocial needs and the planning related services. During a review of the facility's P&P titled, Informed Consent, with review date of 12/5/2025, the P&P indicated the facility will be responsible for assuring the resident's record contains documentation that the resident has given informed consent prior to the implementation of the proposed treatment procedure.

Based on observation, interview, and record review, the facility failed to develop and implement comprehensive person-centered care plans (a plan for an individual's specific health needs and desired health outcomes) for six of 15 Resident 1, 10, 35, 2, 5, and 3) residents reviewed under care planning by failing to: 1. Develop a care plan addressing Resident 1's critically high (a test result that is so far outside the normal range that it indicates a potentially life-threatening situation) Depakote (brand name to valproic acid - medication used to treat epileptic seizures [sudden surge of abnormal electrical activity in the brain, causing jerking and stiffness]) laboratory value obtained on 10/10/2025. 2. Develop a care plan addressing a Resident 10`s oral care needs. 3. Develop a care plan addressing Resident 35's bowel and bladder program. 4. Develop a care plan addressing Resident 2's diagnosis of diabetes insipidus (a rare disorder causing the body to produce excessive amounts of diluted urine [up to 20 quarts daily] and extreme thirst). 5. Develop a care plan addressing immunizations (the process of making a person resistant to an infectious disease) for Resident 5, Resident 35, and Resident 3). These deficient practices had the potential to result in failure to deliver the necessary care and services for the residents. Findings: 1.During a review of Resident 1's Admission Record, the admission Record indicated the facility admitted Resident 1 on 7/17/2024 with diagnoses including spastic quadriplegic cerebral palsy (the most severe form of cerebral palsy [brain disorder that appears in infancy and permanently affects body movement], caused by brain damage that results in extreme stiffness [spasticity]), tracheostomy (a surgical procedure that creates an opening in the neck leading directly into the trachea [windpipe]) and epilepsy During a review of Resident 1's Minimum Data Set (MDS – an assessment and care screening tool) dated 1/26/2026, the MDS indicated the resident was nonverbal and rarely/never understood others and rarely/never made themselves understood. The MDS further indicated Resident 1 was completely dependent (helper does all the effort) on facility staff for all activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 1's lab results report dated 10/10/2025, the report indicated the lab value for Depakote was > (greater than)150 micrograms per milliliter (mcg/ml-unit of measurement). The lab results indicated the therapeutic reference range in the blood stream was 50-100 mcg/ml. The lab result was flagged with red colored HH, indicating the report contained critical results. During a concurrent interview and record review on 2/21/2026 at 11:45 a.m. with the Director of Staff Development (DSD), reviewed Resident 1's lab results report dated 10/10/2025, care plans, and progress notes from 10/10/2025 to 2/21/2026. The DSD stated the lab results report for Depakote indicated a value >150 mcg/ml was flagged in red as HH, indicating a dangerously and critically high level. During a concurrent interview and record review on 2/21/2026 at 3:15 p.m. with the DSD, the DSD provided an email dated 10/14/2025 between the Neurology Nurse Practitioner (NP) and facility Case Manager (CM 1) which indicated the NP wrote 50-150 mcg/ml was considered within the therapeutic range (the desired beneficial amount in the blood) for Depakote. The DSD stated there was no care plan created to address Resident 1's Depakote lab value of >150 mcg/ml. The DSD further stated that licensed nurses should have created a care plan to address the resident's Depakote level being out of therapeutic range to ensure licensed nurses were informed of the resident's change in condition. During a review of the facility provided Policy and Procedure (P&P) titled, Resident Care Planning last reviewed on 12/3/2025, the P&P indicated that A comprehensive plan of care will be developed to meet each resident`s medical, developmental and psychosocial needs. This care plan will include the problems/needs identified in the Resident Assessment Instrument as well as other problems/needs as identified by the staff,. 2. During a review of Resident 10's admission Record, the admission Record indicated that the facility admitted the resident on 3/07/2024, with diagnoses including encephalopathy (a disturbance of brain function) and encounter for attention to gastrostomy (a G tube to provide nutrition or medication because the patient can't swallow liquids or food normally). During a review of Resident 10's Minimum Data Set (MDS - a resident assessment tool) dated 12/15/2025, the MDS indicated that the resident`s cognitive skills (the brain's ability to think, read, learn, remember, reason, express thoughts, and make decisions) for daily decision making was severely impaired. The MDS indicated that Resident 10 was totally dependent on staff for self-care. During a review of Resident 10`s care plan titled, Activities of Daily Living (ADL-activities such as bathing, dressing and toileting a person performs daily), self-care performance deficit related to debility (general weakness or reduced strength in the body) post traumatic brain injury (disruption in the normal function of the brain that can be cause by a bump, blow, or jolt to the head), initiated on 3/24/2025, the CP did not include interventions to address Resident 10's oral care needs. During a concurrent interview and record on 02/21/2026 11:59 a.m., with Registered Nurse 2 (RN 2), reviewed Resident 10`s CP for ADLs. RN 2 stated that the CP for ADLs did not include interventions for oral care. RN 2 stated that the CP for ADLs should be resident-centered and specific and should have included interventions addressing oral care to prevent the resident from developing oral infections and tooth decay. During a review of the facility`s policy and procedure (PP) titled Resident Care Planning, last reviewed on 12/3/2025, the PP indicated that A comprehensive plan of care will be developed to meet each resident`s medical, developmental and psychosocial needs. This care plan will include the problems/needs identified in the Resident Assessment Instrument as well as other problems/needs as identified by the staff,. 3. During a review of Resident 35's admission Record, the admission Record indicated the facility admitted the resident to the facility on [DATE] with diagnoses that included congenital malformation (an abnormal, faulty, or imperfectly formed structure of a body part or organ, often present at birth) syndrome, paralysis of vocal cords and larynx (a condition where one or both vocal folds [cords] in the larynx [voice box] cannot move due to damaged nerves), and stenosis of larynx (abnormal narrowing of the voice box which disrupts the flow of air to the lungs and can impair speech and breathing). During a review of Resident 35's MDS dated [DATE], the MDS indicated Resident 35's cognition was severely impaired. The MDS indicated Resident 35 required supervision or touching assistance with eating, oral hygiene, toileting hygiene, and independent with personal hygiene. The MDS indicated Resident 35 is currently on a toileting program (an individualized, resident-centered plan designed to manage, decrease, or prevent urinary or bowel incontinence). During a concurrent interview and record review on 2/21/2026 at 5:19 p.m. with the Director of Staff Development (DSD), the DSD stated that Resident 35 is participating in a bowel and bladder training program. The DSD reviewed Resident 35's care plans and stated that there was no care plan created addressing Resident 35's bowel and bladder training program. The DSD stated that Resident 35, who has a developmental delay should have a specific care plan for bowel and bladder training to encourage the resident to participate in his activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves), to prevent further decline in functional abilities. During a review of the facility's policy and procedure (P&P) titled Bowel & Bladder Evaluation- Incontinence, review date 12/5/2025, the P&P indicated an individual care plan will be developed for each resident selected for training. This will be included in the resident long-term care plan. 4. During a review of Resident 2's admission Record, the admission Record indicated the facility originally admitted Resident 2 on 6/8/2022 and readmitted Resident 2 on 9/17/2025 with diagnoses that included diabetes insipidus (a rare disorder causing the body to produce excessive amounts of diluted urine [up to 20 quarts daily] and extreme thirst). During a review of Resident 2's MDS dated 12/27/2025, the MDS indicated Resident 2's cognitive skills (cognition refers to conscious mental activities, and includes thinking, reasoning, understanding, learning, and remembering) for daily decision making were severely impaired. The MDS indicated that Resident 2 was dependent on staff with oral hygiene, toileting hygiene, and personal hygiene. The MDS indicated diabetes insipidus was one of Resident 2's active diagnoses. During a concurrent interview and record review on 2/21/2026 at 2:26 p.m. with the Director of Staff Development (DSD), the DSD reviewed Resident 2's care plans and stated that there was no care plan created addressing Resident 2's diagnosis of diabetes insipidus. The DSD stated that Resident 2 should have a specific care plan for Resident 2's diagnosis of diabetes insipidus to guide each discipline in providing appropriate care to the resident. The DSD further stated that all departments are responsible for initiating and contributing to the development of the resident's care plans. 5. a. During a review of Resident 5's admission Record, the admission Record indicated the facility admitted Resident 5 on 3/17/2022 with diagnoses that included osteochondrodysplasic (a group of rare, typically genetic, disorders that cause abnormal development of bone and cartilage, resulting in stunted growth, short stature, and skeletal deformities), other congenital (a trait, disorder, or condition that is present at or before birth) deformities of skull, face, and jaw, and hydronephrosis (the swelling of one or both kidneys caused by a buildup of urine that cannot drain properly into the bladder). During a review of Resident 5's Minimum Data Set (MDS-a resident assessment tool) dated 12/18/2025, the MDS indicated Resident 5's cognition (a mental process of acquiring knowledge and understanding through thought, experience and senses) was severely impaired. The MDS indicated Resident 5 required setup or clean-up assistance with eating and substantial/maximal (helper does more than half the effort) assistance with oral hygiene, toileting hygiene, and required partial/moderate (helper does less than half the effort) assistance with personal hygiene. During a review of Resident 5's Immunization History Record, the Immunization History Record indicated that Resident 5 was administered the influenza (contagious respiratory infection) vaccine (shots, liquids, pills, or nasal sprays that you take to teach your body's immune system to recognize and defend against harmful germs) and coronavirus disease (COVID-19, an infectious disease caused by the SRAS-CoV-2 virus) vaccine on 10/16/2025. During a concurrent interview and record review on 2/22/2026 at 5:21 p.m. with the Director of Staff Development (DSD), the DSD reviewed Resident 5's Immunization History Record and stated that Resident 5 was administered the Influenza Vaccine and COVID-19 vaccine on 10/16/2025. The DSD reviewed Resident 5's care plans and stated that Resident 5 did not have a care plan specific to the administration of the influenza and COVID-19 vaccines. b. During a review of Resident 35's admission Record, the admission Record indicated the facility admitted the resident on 10/28/2010 with diagnoses that included congenital malformation (an abnormal, faulty, or imperfectly formed structure of a body part or organ, often present at birth) syndrome, paralysis of vocal cords and larynx (a condition where one or both vocal folds [cords] in the larynx [voice box] cannot move due to damaged nerves), and stenosis of larynx (abnormal narrowing of the voice box which disrupts the flow of air to the lungs and can impair speech and breathing). During a review of Resident 35's MDS dated [DATE], the MDS indicated Resident 35's cognition was severely impaired. The MDS indicated Resident 35 required supervision or touching assistance with eating, oral hygiene, toileting hygiene, and independent with personal hygiene. During a review of Resident 35's Immunization History Record, the Immunization History Record indicated that Resident 35 was administered the influenza vaccine and COVID-19 vaccine on 10/16/2025. During a concurrent interview and record review on 2/22/2026 at 5:24 p.m. with the DSD, the DSD reviewed Resident 35's Immunization History Record and stated that Resident 35 was administered the influenza vaccine and COVID-19 vaccine on 10/16/2025. The DSD reviewed Resident 35's care plans and stated that Resident 35 did not have a care plan specific to the administration of the influenza and COVID-19 vaccines. c. During a review of Resident 3's admission Record, the admission Record indicated the facility admitted Resident 3 on 7/24/2024 with diagnoses that included cerebral palsy (a group of lifelong disorders affecting body movement, muscle tone, and posture caused by abnormal brain development or damage, usually before birth), tracheostomy (a surgical procedure that creates an opening in the neck leading directly into the windpipe [the main cartilaginous tube in the body that carries air between the voice box and the lungs]) status, persistent vegetative (a condition where, following severe brain damage, a person is awake but shows no signs of awareness, thought, or purposeful reaction to their environment), dependence on respirator (ventilator- a medical machine that helps a patient breathe or completely takes over their breathing when they cannot do so on their own) status. During a review of Resident 3's Minimum Data Set (MDS- a resident assessment tool) dated 12/18/2025, the MDS indicated Resident 3's cognition (a mental process of acquiring knowledge and understanding through thought, experience and the senses) was severely impaired. The MDS indicated Resident 3 was dependent on staff with oral hygiene, toileting hygiene, and personal hygiene. During a review of Resident 3's Immunization History Record, the Immunization History Record indicated that Resident 3 was administered the influenza vaccine and COVID-19 vaccine on 10/16/2025. During a concurrent interview and record review on 2/22/2026 at 5:27 p.m. with the DSD, the DSD reviewed Resident 3's Immunization History Record and stated that Resident 3 was administered the influenza vaccine and COVID-19 vaccine on 10/16/2025. The DSD reviewed Resident 3's care plans and stated that Resident 3 did not have a care plan specific to the administration of the influenza and COVID-19 vaccines. The DSD continued to state that it important for care plans to be developed specifically addressing the administration of the influenza and COVID-19 vaccines because it guides the nursing staff on how to appropriately care for the residents who were administered vaccines.

Based on observation, interview, and record review, the facility failed to provide an environment that was free from accidents and hazards to three of three residents (Resident 1, 18, and 5) reviewed under the accidents care area by failing to: a. and b. Provide bilateral bed rail padding for Resident 1 and Resident 18, who have a history of seizures (a sudden surge of abnormal electrical activity in the brain, leading to a range of symptoms like muscle spasms, loss of consciousness). c. Implement the facility's policy on resident safety and care plans addressing use of a helmet when Resident 5 was observed wearing a soft helmet without a chin strap.Findings: a. During a review of Resident 1's Admission Record, the admission Record indicated the facility admitted Resident 1 on 7/17/2024 with diagnoses including spastic quadriplegic cerebral palsy (the most severe form of cerebral palsy [brain disorder that appears in infancy and permanently affects body movement], caused by brain damage that results in extreme stiffness [spasticity]), tracheostomy (a surgical procedure that creates an opening in the neck leading directly into the trachea [windpipe]) and epilepsy (a chronic brain disorder characterized by a tendency to have recurrent, unprovoked seizures). During a review of Resident 1's Minimum Data Set (MDS – an assessment and care screening tool) dated 1/26/2026, the MDS indicated the resident was nonverbal and rarely/never understood others and rarely/never made themselves understood. The MDS further indicated Resident 1 was completely dependent (helper does all the effort) on facility staff for all activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 1's care plan (CP) addressing risk for injury related to seizures, initiated on 12/19/2024, the CP indicated an intervention to ensure the resident's safety at all times and to have padded side rails. During an observation on 2/19/2026 at 8:06 p.m. in Resident 1's room, Resident 1 was lying in bed with his eyes closed and attached to a ventilator (a medical machine that helps a patient breathe or completely takes over their breathing when they cannot do so on their own). The bed rails on Resident 1's bed were made of metal, and only the left side bed rail had padding in place. During a concurrent observation and interview on 2/19/2026 at 8:13 p.m. in Resident 1's room with Licensed Vocational Nurse (LVN 3), LVN 3 stated Resident 1's bed did not have the necessary padding on the right bedrail to keep him safe during a seizure. LVN 1 stated the padding is to protect the resident's head and body from the uncontrolled shaking during a seizure. During an interview on 2/21/2026 at 4:45 p.m. with the Director of Staff Development (DSD), the DSD stated the facility staff did not follow their facility policy to apply padding to both sides of Resident 1's side rails and without the padding, Resident 1 could sustain injuries during a seizure. During a review of the facility provided policy and procedure (P&P) titled, Seizure Management last reviewed on 12/3/2025, the P&P indicated all residents with seizure precaution, will have safety side rail padding in place at all times on both right and left sides. b. During a review of Resident 18's admission Record, the admission Record indicated the facility admitted Resident 18 on 8/21/2014 with diagnoses including anoxic brain damage (damage cause by lack of oxygen), tracheostomy and unspecified convulsions (sudden and violent shaking or stiffening of the body's muscles caused by abnormal brain electrical activity) During a review of Resident 18's MDS dated [DATE], the MDS indicated the resident was in a persistent vegetative state (when patients are awake but have no awareness of themselves or of their surroundings). The MDS further indicated Resident 1 was completely dependent (helper does all the effort) on facility staff for all activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 18's CP on seizure disorder related to brain damage status post (after) drowning, initiated on 8/20/2024, the CP indicated an intervention to protect the resident from injury at all times. During an observation on 2/19/2026 at 7:04 p.m. in Resident 18's room, Resident 18 was lying in bed with her eyes open and attached to a ventilator. Resident18's bed had two upper and two lower metal side rails and only the bottom left side rail had padding in place. During a concurrent observation and interview on 2/19/2026 at 7:08 p.m. in Resident 18's room with LVN 2, LVN 2 stated she was unsure why Resident 18's bed only had one of four side rails on because Resident 18 had a history of seizures and convulsions. LVN 2 stated Resident 18 especially needed the upper side rails padded to protect her head from injury. During an interview on 2/21/2026 at 4:51 p.m. with the DSD, the DSD stated they did not follow the facility's policy to apply padding to Resident 18's side rails. The DSD stated Resident 18 has convulsions and without the padded side rails Resident 18 could sustain injuries. During a review of the facility's P&P titled, Seizure Management last reviewed on 12/3/2025, the P&P indicated all residents with seizure precaution, will have safety side rail padding in place at all times on both right and left sides. c. During a review of Resident 5's admission Record, the admission Record indicated the facility admitted the resident on 3/17/2022 with diagnoses that included osteochondrodysplasia (a group of rare, typically genetic, disorders that cause abnormal development of bone and cartilage, resulting in stunted growth, short stature, and skeletal deformities), other congenital (a trait, disorder, or condition that is present at or before birth) deformities of skull, face, and jaw, and hydronephrosis (the swelling of one or both kidneys caused by a buildup of urine that cannot drain properly into the bladder). During a review of Resident 5's MDS dated [DATE], the MDS indicated Resident 5's cognition (a mental process of acquiring knowledge and understanding through thought, experience and senses) was severely impaired. The MDS indicated Resident 5 required setup or clean-up assistance with eating and substantial/maximal assistance (helper provides more than half of the effort) with oral hygiene, toileting hygiene, and required partial/moderate assistance with personal hygiene. The MDS indicated that Resident 5 has had a fall since admission/entry or reentry or prior to assessment. During a review of Resident 5's order summary report, the order summary report indicated an order dated 1/9/2025, for Resident 5 to wear soft helmet intermittently and as tolerated while out on crib to prevent injury due to fall risk. During a review of Resident 5's CP for high risk for falls related to unaware of safety needs, revised on 12/29/2025, the CP indicated an intervention for Resident 5 to wear soft helmet intermittently while out of bed as tolerated to prevent injury related to fall risk. During a review of Resident 5 CP for use of a helmet related to fall risk, poor safety awareness, initiated 1/9/2025, the CP indicated an intervention to ensure helmet is in good working condition and to discard and notify the Interdisciplinary Team (IDT-a group of healthcare professionals from different disciplines who work together to plan and provide care for a resident) if new helmet is required. During an observation on 2/20/2026 at 7:56 p.m. in Resident 5's room, observed Resident 5 ambulating independently in the room without wearing the soft helmet. During an observation on 2/21/2026 at 8:55 a.m. in Resident 5's room, observed Resident 5 out of bed having breakfast, wearing the soft helmet without the chin strap. During an observation on 2/21/2026 at 5:05 p.m. in Resident 5's room, observed Resident 5 ambulating independently in the room without wearing the soft helmet. During a concurrent observation and interview on 2/21/2026 at 5:06 p.m., with Certified Nursing Assistant 1 (CNA 1) in Resident 5's room, observed Resident 5 wearing the soft helmet without the chin strap. CNA 1 stated that Resident 5 is wearing the soft helmet, but the helmet did not have a chin strap. CNA 1 stated that there was no chin strap because the resident chews on the chin strap. CNA 1 stated that the Rehabilitation Department had been requested multiple times to provide a replacement soft helmet; however, a replacement had not been provided. CNA 1 further stated that Resident 5 needs to wear a soft helmet for fall prevention and safety because the resident runs around frequently. During a concurrent observation and interview on 2/21/2026 at 5:37 p.m., with the Director of Staff Development (DSD) in Resident 5's room, the DSD observed Resident 5. The DSD stated that Resident 5 is wearing his soft helmet but there is no chin strap on the soft helmet. The DSD stated that Resident 5 has to wear a soft helmet with the chin strap to help prevent injuries. The DSD continued to state that all direct care staff are responsible for making sure Resident 5's soft helmet is in good condition. During an interview on 2/21/2026 at 5:57 p.m. with the DSD, the DSD stated that Resident 5's soft helmet did not have a chin strap, which made Resident 5's soft helmet ineffective in preventing injury. The DSD further stated that direct care staff should have noticed the missing chin strap and requested a replacement soft helmet from the registered nurses to help prevent injuries. During a review of the facility's policies and procedures (P&P) titled Resident Safety, reviewed12/5/2025, the P&P indicated all that employees will use safe techniques and procedures while treating residents to assure resident safety at all times . ensure safety devices are in place as ordered. Safety devices may include, but are not limited to: soft helmet, hard helmet, safety pads and landing pads

Based on interview and record review the facility failed to ensure physician's orders were obtain prior to the administration of the COVID-19 vaccine (a vaccine designed to induce immunity against SARS-CoV-2 [the virus responsible for coronavirus disease 2019]) for three of five sampled residents (Resident 5, Resident 35, and Resident 3). This deficient practice placed Resident 5, Resident 35, and Resident 3 at risk for experiencing adverse effects and for having contraindications or allergies that were assessed by a physician. Findings: a. During a review of Resident 5's admission Record, the admission Record indicated the facility admitted the resident to the facility on 3/17/2022 with diagnoses that included osteochondrodysplasia (a group of rare, typically genetic, disorders that cause abnormal development of bone and cartilage, resulting in stunted growth, short stature, and skeletal deformities), other congenital (a trait, disorder, or condition that is present at or before birth) deformities of skull, face, and jaw, and hydronephrosis (the swelling of one or both kidneys caused by a buildup of urine that cannot drain properly into the bladder). During a review of Resident 5's Minimum Data Set (MDS-a resident assessment tool) dated 12/18/2025, the MDS indicated Resident 5's cognition (a mental process of acquiring knowledge and understanding through thought, experience and senses) was severely impaired. The MDS indicated Resident 5 required setup or clean-up assistance with eating and substantial/maximal (helper does more than half the effort) assistance with oral toileting hygiene and required partial/moderate (helper does less than half the effort) assistance with personal hygiene. During a review of Resident 5's Immunization History Record, the Immunization History Record indicated that Resident 5 was administered the coronavirus disease (COVID-19, an infectious disease caused by the SRAS-CoV-2 virus) vaccine on 10/16/2025. During a concurrent interview and record review on 2/22/2026 at 5:21 p.m. with the Director of Staff Development (DSD), the DSD reviewed Resident 5's Immunization History Record and physician orders. The DSD stated that Resident 5 was administered the COVID-19 vaccine on 10/16/2025, however; there was no physician's order for the administration of the vaccine. During a concurrent interview and record review on 2/23/2026 at 9:27 a.m. with the Medical Records Director (MRD), the MRD reviewed Resident 5's active and discontinued physician's orders and stated that there was no physician's order to administer the COVID-19 vaccine to Resident 5. b. During a review of Resident 35's admission Record, the admission Record indicated the facility admitted the resident to the facility on [DATE] with diagnoses that included congenital malformation (an abnormal, faulty, or imperfectly formed structure of a body part or organ, often present at birth) syndrome, paralysis of vocal cords and larynx (a condition where one or both vocal folds [cords] in the larynx [voice box] cannot move due to damaged nerves), and stenosis of larynx (abnormal narrowing of the voice box which disrupts the flow of air to the lungs and can impair speech and breathing). During a review of Resident 35's MDS dated [DATE], the MDS indicated Resident 35's cognition was severely impaired. The MDS indicated Resident 35 required supervision or touching assistance with eating, oral hygiene, toileting hygiene, and independent with personal hygiene. During a review of Resident 35's Immunization History Record, the Immunization History Record indicated that Resident 35 was administered the COVID-19 vaccine on 10/16/2025. During a concurrent interview and record review on 2/22/2026 at 5:24 p.m. with the Director of Staff Development (DSD), the DSD reviewed Resident 35's Immunization History Record and physician orders. The DSD stated that Resident 35 was administered the COVID-19 vaccine on 10/16/2025, however; there was no physician's order for the administration of the vaccine. During a concurrent interview and record review on 2/23/2026 at 9:32 a.m. with the Medical Records Director (MRD), the MRD reviewed Resident 35's active and discontinued physician's orders and stated that there was no physician's order to administer the COVID-19 vaccine to Resident 35. c. During a review of Resident 3's admission Record, the admission Record indicated the facility admitted Resident 3 on 7/24/2024 with diagnoses that included cerebral palsy (a group of lifelong disorders affecting body movement, muscle tone, and posture caused by abnormal brain development or damage, usually before birth), tracheostomy (a surgical procedure that creates an opening in the neck leading directly into the windpipe [the main cartilaginous tube in the body that carries air between the voice box and the lungs]) status, persistent vegetative (a condition where, following severe brain damage, a person is awake but shows no signs of awareness, thought, or purposeful reaction to their environment), dependence on respirator (ventilator- a medical machine that helps a patient breathe or completely takes over their breathing when they cannot do so on their own) status. During a review of Resident 3's Minimum Data Set (MDS- a resident assessment tool) dated 12/18/2025, the MDS indicated Resident 3's cognition (a mental process of acquiring knowledge and understanding through thought, experience and the senses) was severely impaired. The MDS indicated Resident 3 was dependent on staff with oral hygiene, toileting hygiene, and personal hygiene. During a review of Resident 3's Immunization History Record, the Immunization History Record indicated that Resident 3 was administered the influenza vaccine and COVID-19 vaccine on 10/16/2025. During a concurrent interview and record review on 2/22/2026 at 5:27 p.m. with the Director of Staff Development (DSD), the DSD reviewed Resident 3's Immunization History Record and physician orders. The DSD stated that Resident 3 was administered the COVID-19 vaccine on 10/16/2025, however; there was no physician's order for the administration of the vaccine. During an interview on 2/23/2026 at 8:13 a.m. with the Infection Preventionist (IP), the IP stated that a COVID-19 clinic comes to the facility and the clinic's pharmacist administers the COVID-19 vaccine to the residents and that licensed nurses do not administer the COVID-19 vaccine to the residents in the facility. The IP stated that she was not aware that there were no orders to administer COVID-19 vaccine to Resident 5, Resident 35, and Resident 3. The IP stated that she did not obtain physician orders for the COVID-19 vaccine prior to the administration of the COVID-19 vaccine by the clinic pharmacist. During a follow up interview on 2/23/2026 at 8:45 a.m. with the IP, the IP stated that it is important to obtain a physician's orders for the administration of any vaccine to ensure resident safety. During a concurrent interview and record review on 2/23/2026 at 9:45 a.m. with the MRD, the MRD reviewed Resident 3's active and discontinued physician's orders and stated that there was no order to administer the COVID-19 vaccine to Resident 3. During a review of the facility's policy and procedure (P&P) titled Medication Administration, review date 12/5/2025, the P&P indicated that physician ordered medication to be administered by licensed medical/nursing personnel using the six rights of medication administration: The right resident, dose, amount, time, route, and rationale. All medication to be administered following the proper guidelines and techniques: a. Check order on medication record with label on prescribed medication for proper resident name, medication, dosage, time, route, and rationale.

Based on interview and record review, the facility failed to ensure residents were free of any significant medication errors by failing to ensure a resident was given clonidine (medication used to treat hypertension [high blood pressure - when the force of the blood pushing on the blood vessel walls is too high]) for its indication of use as ordered for one of five sampled residents (Resident 1). This deficient practice had the potential to cause adverse side effects and cause confusion in the delivery of care and services for the resident.Findings: During a review of Resident 1's Admission Record, the admission Record indicated the facility admitted Resident 1 on 7/17/2024 with diagnoses including spastic quadriplegic cerebral palsy (the most severe form of cerebral palsy [brain disorder that appears in infancy and permanently affects body movement], caused by brain damage that results in extreme stiffness [spasticity]), tracheostomy (a surgical procedure that creates an opening in the neck leading directly into the trachea [windpipe]), and epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures [sudden, uncontrolled body movements and changes in behavior that occur because of abnormal electrical activity in the brain]). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 1/26/2026, the MDS indicated the resident was nonverbal and rarely/never understood others and rarely/never made themselves understood. The MDS further indicated Resident 1 was completely dependent (helper does all the effort) on facility staff for all activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 1's Order Summary Report, the Order Summary Report indicated the following orders: - Clonidine oral tablet 0.1 milligram (mg- unit of measurement), give 0.5 tablet via G-Tube (gastrostomy tube - a medical device inserted through the abdomen directly into the stomach to deliver nutrition, fluids, and medication) every 12 hours as needed for tachycardia (increased heart rate) >160 beats per minute (bpm) or hypertension (elevated blood pressure) systolic blood pressure (SBP - the first number in a blood pressure reading, which measures the pressure in the arteries [pathway that carries blood away from the heart] when the heart beats) >150 millimeters of mercury (mmHg- unit of measurement), ordered 4/24/2026. During a review of Resident 1's Electronic Medication Administration Record (EMAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) dated 2/2026, the EMAR indicated clonidine oral tablet 0.1 mg as needed for tachycardia >160 bpm or hypertension SBP >150 mmHg was given but there was no documentation to indicate why clonidine was given to Resident 1 and how high the SBP and heart rate was. Resident 1's EMAR indicated the following:- On 2/2/2026 at 1:59 a.m., clonidine was given, but there is no indication why it was given. - On 2/7/2026 at 4:50 p.m., clonidine was given, but there is no indication why it was given. - On 2/9/2026 at 7:30 p.m., clonidine was given, but there is no indication why it was given. - On 2/11/2026 at 3:59 a.m., clonidine was given, but there is no indication why it was given. - On 2/12/2026 at 7:20 p.m., clonidine was given, but there is no indication why it was given. - On 2/13/2026 at 8:29 a.m., clonidine was given, but there is no indication why it was given. - On 2/15/2026 at 7:31 a.m., clonidine was given, but there is no indication why it was given. - On 2/16/2026 at 8:00 p.m., clonidine was given, but there is no indication why it was given. - On 2/20/2026 at 5:29 a.m., clonidine was given, but there is no indication why it was given. During a concurrent interview and record review on 2/21/2026 at 10:55 a.m., with the Director of Staff Development (DSD), reviewed Resident 1's EMAR dated 2/2026 and Progress Notes dated 2/2026. The DSD stated when Resident 1's clonidine order was transcribed initially, the licensed nurse must have forgotten to add supplemental documentation in order to document the indication/reason why the medicine was given. The DSD stated this could be dangerous, because the oncoming nurse will not know why it was given, nor will there be a quantifiable log for the doctors or pharmacist to review on why the medication was given. During a review of the facility's policy and procedure (P&P) titled, Documentation: Licensed Nursing Staff (LNS), last reviewed on 12/3/2025, the P&P indicated the vital signs must be recorded each shift by LNS (Registered Nurses or Licensed Vocational Nurses - not CNAs) and documented in PCC (computer documenting system). The policy further indicates for PRN (as needed) medications or treatments must include: .reason for administration and vitals.

Based on interview and record review, the facility failed to implement the facility's immunization policy by failing to ensure residents' responsible parties were provided education regarding the influenza vaccine (prevents infection from influenza [a common, sometimes deadly viral infection of the nose, throat, and lungs]) for three of five sampled residents (Resident 5, Resident 35, Resident 3). This deficient practice had the potential for Resident 5, Resident 35, and Resident 3's responsible party to not be aware of the risks and benefits of the influenza vaccine. Findings: a. During a review of Resident 5's admission Record, the admission Record indicated the facility admitted the resident on 3/17/2022 with diagnoses that included osteochondrodysplasia (a group of rare, typically genetic, disorders that cause abnormal development of bone and cartilage, resulting in stunted growth, short stature, and skeletal deformities), other congenital (a trait, disorder, or condition that is present at or before birth) deformities of skull, face, and jaw, and hydronephrosis (the swelling of one or both kidneys caused by a buildup of urine that cannot drain properly into the bladder). During a review of Resident 5's Minimum Data Set (MDS-a resident assessment tool) dated 12/18/2025, the MDS indicated Resident 5's cognition (a mental process of acquiring knowledge and understanding through thought, experience and senses) was severely impaired. The MDS indicated Resident 5 required setup or clean-up assistance with eating and substantial/maximal assistance with oral hygiene, toileting hygiene, and required partial/moderate assistance with personal hygiene. During a review of Resident 5's Immunization History Record, the Immunization History Record indicated that Resident 5 was administered the influenza vaccine on 10/16/2025. During an interview on 2/22/2026 at 2:41 p.m., with the Infection Preventionist (IP), the IP stated that the IP does inform residents' responsible parties to provide education about the influenza vaccine. The IP stated that it is the responsibility of the medical records department to provide influenza vaccine information. During an interview on 2/22/2026 at 3:21 p.m., with the Medical Records Director (MRD), the MRD stated that the MRD sends influenza vaccine information to residents' responsible parties to provide education about the influenza vaccine. The MRD stated that the influenza vaccine information was sent to all residents' responsible parties through regular mail and there is no mail confirmation that residents' responsible parties received the information. The MRD continued to state that the MRD does not have any documentation that residents' responsible parties received influenza vaccine information. During a concurrent interview and record review on 2/22/2026 at 5:21 p.m., with the Director of Staff Development (DSD), reviewed Resident 5's Immunization History Record. The DSD stated that Resident 5 was administered the influenza vaccine on 10/16/2025. The DSD reviewed Resident 5's nursing progress notes and social services progress notes from 8/2025-10/2025 and stated that there was no documented evidence that Resident 5's responsible party received influenza vaccine information prior to the administration of the influenza vaccine. b. During a review of Resident 35's admission Record, the admission Record indicated the facility admitted the resident on 10/28/2010 with diagnoses that included congenital malformation (an abnormal, faulty, or imperfectly formed structure of a body part or organ, often present at birth) syndrome, paralysis of vocal cords and larynx (a condition where one or both vocal folds [cords] in the larynx [voice box] cannot move due to damaged nerves), and stenosis of larynx (abnormal narrowing of the voice box which disrupts the flow of air to the lungs and can impair speech and breathing). During a review of Resident 35's MDS dated [DATE], the MDS indicated Resident 35's cognition was severely impaired. The MDS indicated Resident 35 required supervision or touching assistance with eating, oral hygiene, toileting hygiene, and independent with personal hygiene. During a review of Resident 35's Immunization History Record, the Immunization History Record indicated that Resident 35 was administered the influenza vaccine on 10/16/2025. During an interview on 2/22/2026 at 2:41 p.m., with the IP, the IP stated that the IP does inform residents' responsible parties to provide education about the influenza vaccine. The IP stated that it is the responsibility of the medical records department to provide influenza vaccine information. During an interview on 2/22/2026 at 3:21 p.m., with the MRD, the MRD stated that the MRD sends influenza vaccine information to residents' responsible parties to provide education about the influenza vaccine. The MRD stated that the influenza vaccine information was sent to all residents' responsible parties through regular mail and there is no mail confirmation that residents' responsible parties received the information. The MRD continued to state that the MRD does not have any documentation that residents' responsible parties received influenza vaccine information. During a concurrent interview and record review on 2/22/2026 at 5:24 p.m., with the DSD, reviewed Resident 35's Immunization History Record. The DSD stated that Resident 35 was administered the influenza vaccine on 10/16/2025. The DSD reviewed Resident 35's nursing progress notes and social services progress notes from 8/2025-10/2025 and stated that there was no documented evidence that Resident 35's responsible party received influenza vaccine information prior to the administration of the influenza vaccine. c. During a review of Resident 3's admission Record, the admission Record indicated the facility admitted the resident on 7/24/2024 with diagnoses that included cerebral palsy (a group of lifelong disorders affecting body movement, muscle tone, and posture caused by abnormal brain development or damage, usually before birth), tracheostomy (a surgical procedure that creates an opening in the neck leading directly into the windpipe) status, persistent vegetative (a condition where, following severe brain damage, a person is awake but shows no signs of awareness, thought, or purposeful reaction to their environment), dependence on respirator (ventilator- a medical machine that helps a patient breathe or completely takes over their breathing when they cannot do so on their own) status. During a review of Resident 3's MDS dated [DATE], the MDS indicated Resident 3's cognition was severely impaired. The MDS indicated Resident 3 was dependent on staff with oral hygiene, toileting hygiene, and personal hygiene. During a review of Resident 3's Immunization History Record, the Immunization History Record indicated that Resident 3 was administered the influenza vaccine on 10/16/2025. During an interview on 2/22/2026 at 2:41 p.m., with the IP, the IP stated that the IP does inform residents' responsible parties to provide education about the influenza vaccine. The IP stated that it is the responsibility of the medical records department to provide influenza vaccine information. During an interview on 2/22/2026 at 3:21 p.m., with the MRD, the MRD stated that the MRD sends influenza vaccine information to residents' responsible parties to provide education about the influenza vaccine. The MRD stated that the influenza vaccine information was sent to all residents' responsible parties through regular mail and there is no mail confirmation that residents' responsible parties received the information. The MRD continued to state that the MRD does not have any documentation that residents' responsible parties received influenza vaccine information. During a concurrent interview and record review on 2/22/2026 at 5:27 p.m., with the DSD, reviewed Resident 3's Immunization History Record. The DSD stated that Resident 3 was administered the influenza vaccine on 10/16/2025. The DSD reviewed Resident 3's nursing progress notes and social services progress notes from 8/2025-10/2025 and stated that there was no documented evidence that Resident 3's responsible party received influenza vaccine information prior to the administration of the influenza vaccine. During an interview on 2/23/2026 at 8:13 a.m., with the IP, the IP stated that it important to provide residents' responsible parties with vaccine information so that the residents' responsible parties will know the risk and benefits of the vaccine and they also have the right to be informed. During a review of the facility's policy and procedure (P&P) titled, Immunization, review date 12/5/2025, the P&P indicated Social Service staff and/or IP to provide parent/legal representative with Vaccine Information Sheet(s) when indicated. Document when the Information Sheet(s) were provided. Vaccine information sheet can be given at anytime prior to the vaccine being administered.

Based on interview and record review, the facility failed to implement the facility's immunization policy by failing to ensure residents' responsible parties were provided education regarding the Coronavirus Disease vaccine (prevents infection from Coronavirus Disease [COVID-19, a severe respiratory illness caused by virus and transmitted from person to person]) for three of five sampled residents (Resident 5, Resident 35, Resident 3). This deficient practice had the potential for Resident 5, Resident 35, and Resident 3's responsible party to not be aware of the risks and benefits of the COVID-19 vaccine. Findings: a. During a review of Resident 5's admission Record, the admission Record indicated the facility admitted the resident on 3/17/2022 with diagnoses that included osteochondrodysplasia (a group of rare, typically genetic, disorders that cause abnormal development of bone and cartilage, resulting in stunted growth, short stature, and skeletal deformities), other congenital (a trait, disorder, or condition that is present at or before birth) deformities of skull, face, and jaw, and hydronephrosis (the swelling of one or both kidneys caused by a buildup of urine that cannot drain properly into the bladder). During a review of Resident 5's Minimum Data Set (MDS-a resident assessment tool) dated 12/18/2025, the MDS indicated Resident 5's cognition (a mental process of acquiring knowledge and understanding through thought, experience and senses) was severely impaired. The MDS indicated Resident 5 required setup or clean-up assistance with eating and substantial/maximal assistance with oral hygiene, toileting hygiene, and required partial/moderate assistance with personal hygiene. During a review of Resident 5's Immunization History Record, the Immunization History Record indicated that Resident 5 was administered the COVID-19 vaccine on 10/16/2025. During an interview on 2/22/2026 at 2:41 p.m., with the Infection Preventionist (IP), the IP stated that the IP does inform and provide education to residents' responsible parties about the COVID-19 vaccine. During an interview on 2/22/2026 at 3:21 p.m., with the Medical Records Director (MRD), the MRD stated that the MRD sends COVID-19 vaccine information to residents' responsible parties to provide education about the COVID-19 vaccine. The MRD stated that the COVID-19 vaccine information was sent to all residents' responsible parties through regular mail and there is no mail confirmation that residents' responsible parties received the information. The MRD continued to state that the MRD does not have any documentation that residents' responsible parties received COVID-19 vaccine information. During a concurrent interview and record review on 2/22/2026 at 5:21 p.m., with the Director of Staff Development (DSD), reviewed Resident 5's Immunization History Record. The DSD stated that Resident 5 was administered the COVID-19 vaccine on 10/16/2025. The DSD reviewed Resident 5's nursing progress notes and social services progress notes from 8/2025-10/2025 and stated that there was no documented evidence that Resident 5's responsible party received COVID-19 vaccine information prior to the administration of the COVID-19 vaccine. b. During a review of Resident 35's admission Record, the admission Record indicated the facility admitted the resident on 10/28/2010 with diagnoses that included congenital malformation (an abnormal, faulty, or imperfectly formed structure of a body part or organ, often present at birth) syndrome, paralysis of vocal cords and larynx (a condition where one or both vocal folds [cords] in the larynx [voice box] cannot move due to damaged nerves), and stenosis of larynx (abnormal narrowing of the voice box which disrupts the flow of air to the lungs and can impair speech and breathing). During a review of Resident 35's MDS dated [DATE], the MDS indicated Resident 35's cognition was severely impaired. The MDS indicated Resident 35 required supervision or touching assistance with eating, oral hygiene, toileting hygiene, and independent with personal hygiene. During a review of Resident 35's Immunization History Record, the Immunization History Record indicated that Resident 35 was administered the COVID-19 vaccine on 10/16/2025. During an interview on 2/22/2026 at 2:41 p.m., with the IP, the IP stated that the IP does inform and provide education to residents' responsible parties about the COVID-19 vaccine. During an interview on 2/22/2026 at 3:21 p.m., with the MRD, the MRD stated that the MRD sends COVID-19 vaccine information to residents' responsible parties to provide education about the COVID-19 vaccine. The MRD stated that the COVID-19 vaccine information was sent to all residents' responsible parties through regular mail and there is no mail confirmation that residents' responsible parties received the information. The MRD continued to state that the MRD does not have any documentation that residents' responsible parties received COVID-19 vaccine information. During a concurrent interview and record review on 2/22/2026 at 5:24 p.m., with the DSD, reviewed Resident 35's Immunization History Record. The DSD stated that Resident 35 was administered the COVID-19 vaccine on 10/16/2025. The DSD reviewed Resident 35's nursing progress notes and social services progress notes from 8/2025-10/2025 and stated that there was no documented evidence that Resident 35's responsible party received COVID-19 vaccine information prior to the administration of the COVID-19 vaccine. c. During a review of Resident 3's admission Record, the admission Record indicated the facility admitted the resident on 7/24/2024 with diagnoses that included cerebral palsy (a group of lifelong disorders affecting body movement, muscle tone, and posture caused by abnormal brain development or damage, usually before birth), tracheostomy (a surgical procedure that creates an opening in the neck leading directly into the windpipe) status, persistent vegetative (a condition where, following severe brain damage, a person is awake but shows no signs of awareness, thought, or purposeful reaction to their environment), dependence on respirator (ventilator- a medical machine that helps a patient breathe or completely takes over their breathing when they cannot do so on their own) status. During a review of Resident 3's MDS dated [DATE], the MDS indicated Resident 3's cognition was severely impaired. The MDS indicated Resident 3 was dependent on staff with oral hygiene, toileting hygiene, and personal hygiene. During a review of Resident 3's Immunization History Record, the Immunization History Record indicated that Resident 3 was administered the COVID-19 vaccine on 10/16/2025. During an interview on 2/22/2026 at 2:41 p.m., with the IP, the IP stated that the IP does inform and provide education to residents' responsible parties about the COVID-19 vaccine. During an interview on 2/22/2026 at 3:21 p.m., with the MRD, the MRD stated that the MRD sends COVID-19 vaccine information to residents' responsible parties to provide education about the COVID-19 vaccine. The MRD stated that the COVID-19 vaccine information was sent to all residents' responsible parties through regular mail and there is no mail confirmation that residents' responsible parties received the information. The MRD continued to state that the MRD does not have any documentation that residents' responsible parties received COVID-19 vaccine information. During a concurrent interview and record review on 2/22/2026 at 5:27 p.m., with the DSD, reviewed Resident 3's Immunization History Record. The DSD stated that Resident 3 was administered the COVID-19 vaccine on 10/16/2025. The DSD reviewed Resident 3's nursing progress notes and social services progress notes from 8/2025-10/2025 and stated that there was no documented evidence that Resident 3's responsible party received COVID-19 vaccine information prior to the administration of the COVID-19 vaccine. During an interview on 2/23/2026 at 8:13 a.m. with the IP, the IP stated that it important to provide residents' responsible party with vaccine information so that the residents' responsible party will know the risk and benefits of the vaccine and they also have the right to be informed. During a review of the facility's policy and procedure (P&P) titled, Immunization, review date 12/5/2025, the P&P indicated Social Service staff and/or IP to provide parent/legal representative with Vaccine Information Sheet(s) when indicated. Document when the Information Sheet(s) were provided. Vaccine information sheet can be given at anytime prior to the vaccine being administered.

Based on observation, interview and record review, the facility failed to provide care in a manner that maintained a resident's dignity and promoted respect by failing to ensure Licensed Vocational Nurse (LVN 1) knocked or request permission before entering the room of one of two sampled residents (Resident 37) reviewed under the dignity care area. This deficient practice violated the resident`s rights to be treated with respect and dignity and had the potential to negatively affect the resident's sense of self-worth and self-esteem. Findings: During a review of Resident 37's admission Record, the admission Record indicated the facility initially admitted Resident 37 on 10/18/2018 and readmitted the resident on 11/7/2023, with diagnoses including tracheostomy (a surgical procedure that creates an opening in the neck leading directly into the trachea [windpipe]) and dependence on a ventilator (a medical machine that helps a patient breathe or completely takes over their breathing when they cannot do so on their own). During a review of Resident 37's Minimum Data Set (MDS-a standardized assessment and care screening tool) dated 1/12/2026, the MDS indicated the resident usually makes herself understood and usually understood others. The MDS further indicated Resident 37 required supervision (helper provides verbal cues and some touch assistance) with eating, upper body dressing and putting on shoes. The MDS indicated Resident 37 required partial assistance (helper does less than half the effort) with toileting, bathing, lower body dressing and personal hygiene. During an observation and interview on 2/20/26 at 7:57 p.m., in the hallway near the entrance of Resident 37's room with LVN 1, LVN 1 was observed entering Resident 37`s room through a closed door, without knocking on the door or asking permission to go in. Observed Resident 37 standing on the right side of her bed, nearest to the door. Upon leaving the room, LVN 1 was interviewed and stated that she should have knocked and asked permission prior to entering to ensure Resident 37's privacy and dignity. During an interview on 2/22/26 at 5:26 p.m. with the Director of Staff Development, (DSD), the DSD stated that anyone entering a resident`s room must knock and ask permission prior to entering the resident`s room. The DSD stated residents' privacy and dignity should be respected and promoted at all times. During a review of the facility`s policy and procedure (P&P) titled Resident Rights last reviewed on 12/3/2025, the P&P indicated that the facility shall treat each resident with consideration, respect and full recognition of dignity and individuality, including privacy in treatment and in care of personal needs. During a review of the facility`s policy and procedure (P&P) titled Privacy last reviewed on 12/3/2025 the P&P indicated that the facility would ensure that each resident's right to privacy will be respected.

Based on interview and record review, the facility failed to notify a resident's responsible party (RP-the person designated for all care decisions of a resident) regarding a change of condition for one of five residents (Resident 1) reviewed for unnecessary medications when the facility failed to notify Resident 1's responsible party (RP 1) of a critically high (a test result that is so far outside the normal range that it indicates a potentially life-threatening situation) Depakote (brand name to valproic acid - medication used to treat epileptic seizures [sudden surge of abnormal electrical activity in the brain, causing jerking and stiffness]) laboratory value (reference range was 50-100 micrograms per millimeter [mcg/ml-unit of measurement]) greater than 150 mcg/ml on 10/10/2025. This deficient practice resulted in RP 1 not being informed of the critical lab values and prevented RP 1 from participating in Resident 1's care planning. Findings: During a review of Resident 1's Admission Record, the admission Record indicated the facility admitted Resident 1 on 7/17/2024 with diagnoses including spastic quadriplegic cerebral palsy (the most severe form of cerebral palsy [brain disorder that appears in infancy and permanently affects body movement], caused by brain damage that results in extreme stiffness [spasticity]), tracheostomy (a surgical procedure that creates an opening in the neck leading directly into the trachea [windpipe]) and epilepsy During a review of Resident 1's Minimum Data Set (MDS - an assessment and care screening tool) dated 1/26/2026, the MDS indicated the resident was nonverbal and rarely/never understood others and rarely/never made themselves understood. The MDS further indicated Resident 1 was completely dependent (helper does all the effort) on facility staff for all activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 1's lab results report dated 10/10/2025, the report indicated the lab value for Depakote was > (greater than)150 mcg/ml. The lab results indicated the therapeutic reference range in the blood stream was 50-100 mcg/ml. The lab result was flagged with red colored HH, indicating the report contained critical results. During a review of Resident 1's facility provided audit of the resident's Change of Condition (COC - a record that tracks any new, worsening, or unexpected change in a patient's physical, mental, or functional status) documents, there was no documented COC assessment completed following the lab result of Depakote obtained on 10/10/2025. During a review of Resident 1's progress notes from 10/10/25 to 2/21/2026, there was no documented evidence that RP 1 was notified of Resident 1's critical Depakote lab value results on 10/10/2025. During an attempted telephone interview on 2/21/2026 at 12:33 p.m. with RP 1, the call was not answered and a message was left. An attempt to call RP 1 again on 2/21/2026 at 3:45 p.m. was unanswered and was not returned prior to the survey exit. During a concurrent interview and record review on 2/21/2026 at 11:45 a.m. with the Director of Staff Development (DSD), the DSD reviewed Resident 1's COCs, lab results report dated 10/10/2025 and progress notes from 10/10/2025 to 2/21/2026. The DSD stated the lab results report for Depakote indicated a value >150 mcg/ml and was flagged in red as HH, indicating a dangerously and critically high level. The DSD stated that a COC should have been completed and that RP1 should have been notified, as RP 1 is responsible for overseeing the resident's care. During a review of the facility provided policy and procedure (P&P) titled, Resident Rights last reviewed on 12/3/2025, the P&P indicated the facility must ensure resident rights are not violated. The P&P indicated the resident has the right to be fully informed of their total health status and be afforded the opportunity to participate on an immediate and on-going basis in their total plan of care. During a review of the facility provided P&P titled, Change of Condition - Resident last reviewed on 12/3/2025, the P&P indicated all occurrences resulting in a resident's change in condition must be documented in the medical records and parent/legal representative will be notified as soon as possible.

Based on observation, interview, and record review, the facility failed to ensure confidential personal information of residents were protected by failing to ensure meal tickets containing protected information ([PHI]- any health information that can be used to identify specific individual which must remain confidential to prevent harmful consequences) were shredded prior to disposing in the trash receptable for two of six residents (Resident 5 and Resident 35) who receive food from the kitchen. This failure had the potential to violate the residents' rights to privacy and confidentiality of personal and medical records. Findings: a. During a review of Resident 5's admission Record, the admission Record indicated the facility admitted the resident to the facility on 3/17/2022 with diagnoses that included osteochondrodysplasia (a group of rare, typically genetic, disorders that cause abnormal development of bone and cartilage, resulting in stunted growth, two short stature, and skeletal deformities), other congenital (a trait, disorder, or condition that is present at or before birth) deformities of skull, face, and jaw, and hydronephrosis (the swelling of one or both kidneys caused by a buildup of urine that cannot drain properly into the bladder). During a review of Resident 5's Minimum Data Set (MDS-a resident assessment tool) dated 12/18/2025, the MDS indicated Resident 5's cognition (a mental process of acquiring knowledge and understanding through thought, experience and senses) was severely impaired. The MDS indicated Resident 5 required setup or clean-up assistance with eating and substantial/maximal assistance with oral hygiene, toileting hygiene, and required partial/moderate assistance with personal hygiene. During an observation on 2/21/2026 at 12:45 p.m., in the Activity/Dining room observed Resident 5 eating lunch. Observed Resident 5's lunch meal tray without a meal ticket. b. During a review of Resident 35's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included congenital malformation (an abnormal, faulty, or imperfectly formed structure of a body part or organ, often present at birth) syndrome, paralysis of vocal cords and larynx (a condition where one or both vocal folds [cords] in the larynx [voice box] cannot move due to damaged nerves), and stenosis of larynx (abnormal narrowing of the voice box which disrupts the flow of air to the lungs and can impair speech and breathing). During a review of Resident 35's MDS dated [DATE], the MDS indicated Resident 35's cognition was severely impaired. The MDS indicated Resident 35 required supervision or touching assistance with eating, oral hygiene, toileting hygiene, and independent with personal hygiene. During an observation on 2/21/2026 at 12:46 p.m., in the Activity/Dining room observed Resident 35 eating lunch. Observed Resident 35's lunch meal tray without a meal ticket. During a concurrent observation, interview and record review on 2/21/2026 at 12:47 p.m., with Activities Assistant (AA), the AA was asked where Resident 5 and Resident 35's meal tickets were located. Observed the AA reach in the trash receptacle and pulled out two meal tickets. The AA reviewed the meal tickets and stated that the meal tickets contain resident information and that the facility had been discarding the meal tickets in the trash. The AA further stated that she was not aware that meal tickets containing resident information should not be disposed of in the trash receptacle. During an interview on 2/21/2026 at 12:47 p.m. with Licensed Vocational Nurse 3 (LVN), LVN 3 stated that licensed nurses dispose of the meal tickets in the trash receptacle. During a concurrent interview and record review on 2/21/2026 at 1:46 p.m. with the Dietary Supervisor (DS), the DS stated the meal ticket contain resident information including the resident's name, menu, and room number. The DS reviewed a facility meal ticket and stated that at the bottom of the meal ticket, the meal ticket slip indicated, Please Return to Kitchen. The DS stated it was not appropriate to throw the meal tickets in the trash because of Health Insurance Portability and Accountability Act ([HIPPA], a law that sets national standard to protect sensitive health information, making sure it stays private and secure) law. The DS continued to state that meal tickets should not be disposed of in the trash but should be shredded. During a review of the facility's policy and procedure (P&P) titled Retention and Destruction, with review date of 12/5/2025, the P&P indicated copies of resident's protected health information (PHI), retained temporarily, are no longer needed, shall be properly destroyed to maintain information privacy. During a review of the facility's P&P titled HIPPA Privacy Compliance Statement, with review date of 12/5/2025, the P&P indicated the facility shall train all member of the workforce on the privacy policies and procedures with respect to protect health information (PHI) to carry out their function within the facility.

Based on observation, interview and record review, the facility failed to provide the necessary services to maintain good grooming and personal hygiene for three of three sampled residents (Resident 10 and Resident 5) by failing to: 1.Ensure Resident 10 was provided oral care in accordance with the facility policy and procedure (P&P) titled Oral Hygiene, reviewed 12/3/2025, which indicated Each resident will be provided proper oral hygiene daily, beginning in the morning, after every meal, before bedtime, and as needed to maintain a healthy oral cavity and prevent complications of poor oral hygiene. This deficient practice placed the resident at risk for oral infections and tooth decay.2. Ensure Resident 5 and Resident 35's nails were trimmed.This deficient practice placed the resident at risk for skin injury or scratches, infection, and may cause discomfort and affect the resident's overall being. Findings: 1.During a review of Resident 10's admission Record (AR), the AR indicated that the facility admitted the resident on 3/07/2024, with diagnoses including encephalopathy (a disturbance of brain function) and encounter for attention to gastrostomy (a G tube to provide nutrition or medication because the patient can't swallow liquids or food normally). During a review of Resident 10's Minimum Data Set (MDS - a resident assessment tool) dated 12/15/2025, the MDS indicated that the resident`s cognitive skills (the brain's ability to think, read, learn, remember, reason, express thoughts, and make decisions) for daily decision making was severely impaired. The MDS indicated that Resident 10 was totally dependent on staff for self-care. During an interview on 02/21/2026 at 8:40 a.m., with Resident 10`s Family Member 1 (FM 1), FM 1 stated that she has concerns regarding the resident's oral care because she had observed debris accumulated in the resident's mouth, which may have resulted from the resident's teeth not being brushed. During a concurrent interview and record review on 02/21/2026 11:59 a.m., with Registered Nurse 2 (RN 2), reviewed Resident 10`s Documentation Survey Report on oral care. RN 2 stated that the Documentation Survey Report on oral care did not indicate oral care was provided on 2/2/2026, 2/4/2026, 2/5/2026 and 2/6/2026 during the 7am-7pm shift. RN 2 stated if residents do not receive oral care, the residents are at risk for developing oral infections and tooth decay. During a review of the facility`s policy and procedure (PP) titled Oral Hygiene, last reviewed on 12/3/2025, the PP indicated that Each resident will be provided proper oral hygiene daily, beginning in the morning, after every meal, before bedtime, and as needed to maintain a healthy oral cavity and prevent complications of poor oral hygiene. 2. a. During a review of Resident 5's admission Record, the admission Record indicated the facility admitted Resident 5 on 3/17/2022 with diagnoses that included osteochondrodysplasia (a group of rare, typically genetic, disorders that cause abnormal development of bone and cartilage, resulting in stunted growth, short stature, and skeletal deformities), other congenital (a trait, disorder, or condition that is present at or before birth) deformities of skull, face, and jaw, and hydronephrosis (the swelling of one or both kidneys caused by a buildup of urine that cannot drain properly into the bladder). During a review of Resident 5's Minimum Data Set (MDS-a resident assessment tool) dated 12/18/2025, the MDS indicated Resident 5's cognition (a mental process of acquiring knowledge and understanding through thought, experience and senses) was severely impaired. The MDS indicated Resident 5 required setup or clean-up assistance with eating and substantial/maximal (helper does more than half the effort) assistance with oral hygiene, toileting hygiene, and required partial/moderate (helper does less than half the effort) assistance with personal hygiene. During an observation on 2/21/2026 at 8:55 a.m. in Resident 5's room, observed Resident 5's fingernails to be long and untrimmed. During a concurrent observation and interview on 2/21/2026 at 5:33 p.m. with the Director of Staff Development (DSD), in Resident 5's room, the DSD observed Resident 5's fingernails. The DSD stated that Resident 5's fingernails are long past fingertips, with sharp and uneven edges. The DSD stated that Resident 5's fingernails should be trimmed and filed. b. During a review of Resident 35's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included congenital malformation (an abnormal, faulty, or imperfectly formed structure of a body part or organ, often present at birth) syndrome, paralysis of vocal cords and larynx (a condition where one or both vocal folds [cords] in the larynx [voice box] cannot move due to damaged nerves), and stenosis of larynx (abnormal narrowing of the voice box which disrupts the flow of air to the lungs and can impair speech and breathing). During a review of Resident 35's MDS dated [DATE], the MDS indicated Resident 35's cognition was severely impaired. The MDS indicated Resident 35 required supervision or touching assistance with eating, oral hygiene, toileting hygiene, and independent with personal hygiene. During an observation on 2/21/2026 at 8:56 a.m. in Resident 35's room, observed Resident 35's fingernails to be long and untrimmed. During a concurrent observation and interview on 2/21/2026 at 5:34 p.m. with the DSD, in Resident 35's room, the DSD observed Resident 35's fingernails. The DSD stated that Resident 35's fingernails are longer than they should be. The DSD stated that resident's' nails extended past the fingertips and that the fingernails should be trimmed and filed to for resident safety. The DSD continued to state that it is the responsibility of all nursing staff to provide nail care to the residents. During a review of the facility's policy and procedure (P&P) titled Nail Care, reviewed 12/5/2025, the P&P indicated nail care for residents should be performed weekly and/or as needed by daily/nightly assigned Licensed Nursing Staff (LNS)/Certified Nursing Assistants (CNA). Fingernails of residents are to be cut as needed. Length of nail is not to extend past tip of digits. Nails to be clipped/filed straight across. Use nail file to gently and carefully clip or file sharp jagged edges. The designated staff to document time, date, how procedure was tolerated, and condition of hands feet and nails

Based on interview and record review, the facility failed to ensure Registered Nurse (RN 1) maintained current CPR (cardio-pulmonary resuscitation - an emergency, life-saving technique performed when someone's breathing or heartbeat has stopped) certification for healthcare providers through a CPR provider whose training includes a hands-on session in accordance with accepted national standards for one of five staff members investigated during review of the staffing facility task. This deficient practice had the potential for delayed provisions of emergency care, including CPR to residents who wish to have full treatment in life threatening illnesses or injuries. Findings: During an employee file review on [DATE] at 2:15 p.m. with Human Resources staff 1 (HR 1), HR 1 reviewed RN 1's employee file. HR 1 stated RN 1's CPR certification was all web based without the required in person hands on component. During an interview on [DATE] at 5:15 p.m. with RN 1, RN 1 stated she was sorry and she did not know a hands-on component was required for return demonstration and compliance for CPR certification. RN 1 stated the CPR course was completely web-based. During an interview on [DATE] at 5:34 p.m. with Director of Staff Development (DSD), the DSD stated according to facility policy, all CPR certifications must have a hands-on component to test out what the staff learned and to ensure CPR is performed correctly. During a review of the facility`s policy and procedure (P&P) titled Verification of Licenses and/or Credentials Required Certifications last reviewed on [DATE] the P&P indicated that they would employ only those that have provided proper certifications and shall be maintained and kept current. The policy indicated a current BLS card is required of all clinical personnel, including registered nurses, and must be renewed every two years. The policy further indicated BLS classes were offered in person at the facility.

Based on interview and record review, the facility failed to implement a bowel (tube-shaped organ in the abdomen that completes the process of digestion) and bladder (a hollow organ that stores urine) training program (B&B retraining program - aim to establish or regain control over bowel and bladder function) for one of two sampled residents (Resident 5) by failing to ensure Resident 5 was placed on the toilet every two hours per physician's order. This deficient practice had the potential for Resident 5 to not their highest functional level and not establish or regain control over bowel and bladder function.Findings: During a review of Resident 5's admission Record, the admission Record indicated the facility admitted the resident on 3/17/2022 with diagnoses that included osteochondrodysplasia (a group of rare, typically genetic, disorders that cause abnormal development of bone and cartilage, resulting in stunted growth, short stature, and skeletal deformities), other congenital (a trait, disorder, or condition that is present at or before birth) deformities of skull, face, and jaw, and hydronephrosis (the swelling of one or both kidneys caused by a buildup of urine that cannot drain properly into the bladder). During a review of Resident 5's Minimum Data Set (MDS- a resident assessment tool) dated 12/18/2025, the MDS indicated Resident 5's cognition (a mental process of acquiring knowledge and understanding through thought, experience and senses) was severely impaired. The MDS indicated Resident 5 required setup or clean-up assistance with eating and substantial/maximal assistance with oral hygiene, toileting hygiene, and required partial/moderate assistance with personal hygiene. The MDS indicated that Resident 5 is currently in a toileting program (a structured, planned routine designed to help a person [child or adult] gain or regain control over bladder and bowel habits). During a review of Resident 5's Order Summary Report, the Order Summary Report indicated for bowel and blader training: Place resident on toilet every two (2) hours while awake for 2 minutes. Certified Nursing Assistants (CNAs) to document method used result. Order date: 7/7/2025. During a review of Resident 5's care plan (a document that summarizes a resident's needs, goals, and care/treatment) initiated on 9/3/2025, the care plan indicated Resident 5 is participating in a Bowel & Bladder training program. Interventions indicated nursing staff to assist resident to the toilet/commode (a portable, chair-like toilet with a removable basin for people with limited mobility) /toddler potty chair every 2 hours while awake and as needed. Document method used. During a concurrent interview and record review on 2/21/2026 at 7:00 p.m., with the Director of Staff Development (DSD), reviewed Resident 5's medical records, nursing progress notes and CNA tasks for the month of 1/2026 to present. The DSD stated that Resident 5 is in a bowel and bladder training program. The DSD stated that Resident 5 is to be placed on the toilet every two (2) hours to help train Resident 5 to use the toilet. The DSD stated when staff place Resident 5 on the toilet, staff are to document in Resident 5's medical record. The DSD stated that there was no documented evidence that Resident 5 was placed on the toilet on the following days: 1/6/2026; 1/10/2026; 1/18/2026; 1/19/2026; 1/20/2026; 1/25/2026; 2/14/2026; 2/15/2026; 2/19/2026; and 2/21/2026. The DSD continued to state that based on the documentation, staff did not place Resident 5 on the toilet as ordered. The DSD stated staff should have placed Resident 5 on the toilet every two (2) hours and document their efforts. The DSD further stated it is important to toilet train Resident 5 because of his age and for his health and well-being. During a review of the facility's policy and procedure (P&P) titled, Bowel and Bladder Evaluations - Incontinence, reviewed 12/5/2025, the P&P indicated nursing measures will be employed to prevent and reduce incontinence (a problem holding in urine or stool) for each resident. Licensed Nurse Staff (LNS) to evaluate the residents' performance in the bowel and bladder management program on the weekly summary. Daily recording of intake and output of all residents unless fully trained. Review and report at each IDT (Interdisciplinary Team- a group of professionals from different fields who work together closely, sharing knowledge to provide comprehensive care) care plan for appropriate input and output.

Based on observation, interview, and record review, the facility failed to: 1.Obtain and document the weight of two of five residents (Resident 4 and Resident 32) reviewed under the nutrition care area in accordance with the physician's order. This deficient practice had the potential to prevent staff from identifying significant weight changes and addressing potential nutritional concerns. 2. Ensure the total volume of water to be infused via gastrostomy tube (G-tube, a feeding tube inserted through the abdomen to provide nutrition, fluids, and medications) was documented on the water bag label for one of three residents (Resident 22) reviewed under the hydration care area, in accordance with the physician's order. This deficient practice had the potential for staff to be unaware of the amount of water to be infused per the physician's order, placing the resident at risk for fluid imbalance (a condition that occurs when the body has too much or too little fluid, disrupting the normal balance needed for the body to function properly). Findings: 1.During a review of Resident 4's admission Record, the admission Record indicated the facility admitted Resident 4 the facility on 1/22/2019 and readmitted on [DATE] with diagnoses including tracheostomy (a surgical procedure that creates an opening in the neck leading directly into the trachea [windpipe]) dependence on a ventilator (a medical machine that helps a patient breathe or completely takes over their breathing when they cannot do so on their own) and seizures (a sudden surge of abnormal electrical activity in the brain, leading to a range of symptoms like muscle spasms, loss of consciousness). During a review of Resident 4's Minimum Data Set (MDS-a standardized assessment and care screening tool) dated 1/25/2026, the MDS indicated Resident 4 is in a persistent vegetative state (when patients are awake but have no awareness of themselves or of their surroundings). The MDS further indicated Resident 4 was completely dependent (helper does all the effort) on facility staff for all activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily) During a review of Resident 4's Order Summary Report printed on 2/21/2026, the Order Summary Report indicated the following orders dated 12/30/2025: – weigh weekly x4 (four) weeks on admission/readmission then weigh monthly thereafter. – weigh before the 12:00 p.m. feeding (tube feeding) every day shift every Mon (Monday) for weight management. During a review of Resident 4's weights during the month of January 2026 there was not a weight recorded on Monday, 1/19/2026 or the week of 1/19/2026 in accordance with the physician's order. During a concurrent interview and record review on 2/21/26 at 4:26 p.m. with the Director of Staff Development, (DSD), the DSD reviewed Resident 4's physician's orders and weekly weights. The DSD stated that the physician's order to obtain weekly weights was not followed because the resident's weight was not taken on 1/19/2026. The DSD stated that accurate weights are extremely important in pediatric residents because the amount of medication and food given to pediatric residents is based on their weight. During a review of the facility`s policy and procedure (P&P) titled Physician Orders last reviewed on 12/3/2025 the P&P indicated that the physician would give orders for medication, treatment., All orders must be carried out completely. During a review of the facility`s P&P titled Monthly Weight Procedure last reviewed on 12/3/2025 the P&P indicated for residents on weekly or more frequent weights, any weight changes may be significant, and the licensed nurse must evaluate and report cumulative weight changes. b. During a review of Resident 32's admission Record, the admission Record indicated the facility admitted Resident 32 to the facility on 10/8/2012 and with diagnoses including tracheostomy, dependence on a ventilator and epilepsy (a chronic brain disorder characterized by a tendency to have recurrent, unprovoked seizures). During a review of Resident 32's Minimum Data Set (MDS-a standardized assessment and care screening tool) dated 1/3/2026, the MDS indicated Resident 32 was in a persistent vegetative state. The MDS further indicated Resident 32 was completely dependent on facility staff for all activities of daily living. During a review of Resident 32's Order Summary Report printed on 2/21/2026, the Order Summary Report indicated an order dated 12/30/2025 to weigh Resident 32 weekly x4 (four) weeks on admission/readmission then weigh monthly thereafter. During a concurrent interview and record review on 2/21/26 at 4:32 p.m. with the DSD, the DSD reviewed Resident 32's physician's orders and monthly weights. The DSD stated that the physician's order to obtain weekly weights was not followed because the resident's weight was not taken for the month of June 2025. The DSD stated that accurate weights are extremely important in pediatric residents because the amount of medication and food given to pediatric residents is based on their weight. During a review of the facility`s P&P titled Monthly Weight Procedure last reviewed on 12/3/2025 the P&P indicated records of weight loss/gain must be maintained monthly. 2. During a review of Resident 22's admission Record, the admission Record indicated that the facility admitted the resident on 8/20/2019, with diagnoses including anoxic brain damage (occurs when the brain is completely deprived of oxygen for more than roughly four minutes, causing rapid cell death and significant, often permanent, injury) and encounter for attention to gastrostomy. During a review of Resident 22's Minimum Data Set (MDS - a resident assessment tool) dated 01/21/2026, the MDS indicated that the resident is comatose (a deep, prolonged state of unconsciousness, unable to wake up or respond to their environment, even to pain or sound, with minimal brain activity). The MDS indicated that Resident 22 was totally dependent on staff for self-care. During a review of Resident 22's Physician Order Summary Report, the Order Summary Report indicated an order dated 04/27/2025, to flush 170 milliliters (ml-measurement of volume) of water via GT pump (machine that delivers liquid nutrition, water or medication through a G-tube) six times a day for hydration. During a concurrent observation and interview on 02/20/2026 8:31 p.m., in Resident 22's room, with Licensed Vocational Nurse 5 (LVN 5), observed an empty water bag hanging on a pole connected to a GT feeding pump next to Resident 22`s bedside. LVN 5 stated that she hung the bag this morning and acknowledged that the sticker attached to the bag, where the date, time, nurse's initials, and the amount of water to be infused were to be documented, was blank. LVN 5 stated the nurses during the day shift should have documented the amount of water infused via the resident's G-tube in the sticker to indicate the total amount of water administered to the resident from 7 a.m. to 7 p.m. LVN 5 stated that it is important to document the amount of fluid on the water bag label to ensure the resident receives the volume of water ordered by the physician. LVN 5 stated that not labeling the bag with the total amount of water administered to the resident had the potential for licensed nurses to be unaware of how much water had already been given. This could result in the resident not receiving the ordered amount of fluid, placing the resident at risk for dehydration (occurs when the body uses or loses more fluids than it takes in) and urinary tract infections (UTI, an infection in any part of the urinary system). During an interview on 02/21/2026 2:24 p.m. with Registered Nurse 2, reviewed Resident 22`s care plan (CP) addressing the risk for dehydration developed on 4/24/2024, the CP included an intervention to provide 170 milliliters (ml) of water via GT pump six times a day for hydration. RN 2 stated that it is important to document the amount of water administered to the resident to ensure nurses are aware of how much water has been given. RN 2 stated that if the resident does not receive enough water, it may increase the resident's risk for dehydration, which could result in urinary tract infection. During a review of the facility`s policy and procedure (PP) titled Resident Care Planning, last reviewed on 12/3/2025, the PP indicated that A comprehensive plan of care will be developed to meet each resident`s medical, developmental and psychosocial needs. This care plan will include the problems/needs identified in the Resident Assessment Instrument as well as other problems/needs as identified by the staff,. During a review of the facility's P&P titled, Enteral Tube Feeding: Gastrostomy ., last reviewed on 12/3/2025, the PP indicated that open system water bags are used when prescribed by the physician.

Based on interview and record review the facility failed to ensure the facility's policy and procedure (P&P) titled, Medication Administration, reviewed 12/3/2025, was followed for one of eight residents (Resident 1) observed during medication administration, when Licensed Vocational Nurse 4 (LVN 4) failed to check placement of Resident 1's gastrostomy tube (G-tube, a tube inserted through the abdomen, to deliver nutrition and medications directly to the stomach) prior to administration of medications. This deficient practice had the potential to place Resident 1 at increased risk for aspiration pneumonia (a type of lung infection that occurs when food, saliva, or other substances are inhaled into the lungs, which occurs when medication is accidentally delivered into the lungs instead of the stomach because an improperly placed tube could be in the esophagus or trachea, allowing medication to enter the airway). Findings: During a review of Resident 1 's admission Record, the admission Record indicated that the facility admitted the resident on 7/17/2024 with diagnoses including epilepsy (a brain condition that causes recurring seizure) and gastrostomy status (the presence of a surgically created opening (stoma) in the stomach used for long-term enteral nutrition or gastric decompression in patients unable to ingest sufficient nutrients orally) During a review of Resident 1's Minimum Data Set ([MDS] - a resident assessment tool,) dated 1/26/2026, the MDS indicated the resident had severely impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) and totally dependent on staff for activities of daily living(ADLs- activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 1`s physician orders, the physician orders indicated an order dated 9/15/2025 for Miralax (laxative) 8.5 grams (Gm-unit of mass and weight) via G-Tube two times a day for constipation (problem with passing stool) and mix with 60 milliliters (ml-unit of volume) of water, hold for loose stools. During a concurrent medication administration observation and interview on 02/21/2026 at 5:04 p.m., with LVN 4, observed LVN 4 prepare Miralax by mixing it (Miralax) with 60 ml of water. LVN 4 donned gloves, gown and mask and proceeded to Resident 1's bedside. LVN 4 turned off Resident 1's enteral feeding pump, flushed the G-tube with five ml of water, administered Miralax, and flushed the G-tube with five ml of water after administration without verifying the placement of the G-tube. When LVN 4 was asked about verifying the placement of Resident 1's G-tube, LVN 4 stated she forgot to check the G-tube placement by aspirating for gastric residual to ensure the G-tube was in the stomach. During an interview on 02/21/2026 at 6:59 p.m., with Registered Nurse 2 (RN 2), RN 2 stated that prior to medication administration via G-tube, the nurse should check the placement by aspirating for gastric contents. RN 2 stated that if the G-tube is not in the stomach, the medications can seep into the abdominal cavity and cause infection and trauma. RN 2 further stated it is important to check G-tube placement to prevent aspiration pneumonia. During a review of the facility`s policy and procedure (PP) titled Medication Administration, last reviewed on 12/3/2025, the PP indicated that Medication Administered Via An Enteral Feeding Tube General Guidelines.Check enteral tube for placement using a syringe to administer an air bolus, while auscultating, then aspirate stomach contents, noting residual and removing previously inserted air.

Based on observation, interview, and record review, the facility failed to ensure seven medium-sized and six large-sized boxes of drinks and food items were not stacked higher than 18 inches from the ceiling in the dry storage area of the facility's kitchen. This failure had the potential to prevent water sprinkler clearance to reach the top of these boxes in the event of a fire and the potential for the boxes to fall and dent resulting in harmful bacteria growth for six of 37 medically compromised and vulnerable residents who received food from the kitchen. Findings: During an initial kitchen observation on 2/20/2026 at 6:15 p.m., observed in the dry storage area, seven medium-sized and six large-sized boxes on two different wire racks that were stacked greater than 18 inches from the ceiling. During a concurrent observation and interview on 2/21/2026 at 11:25 a.m., in the dry food storage area of the kitchen with the Dietary Supervisor (DS), the DS stated it is against the facility's policy to stack items greater than 18 inches from the ceiling and stated there were about 13 boxes total that were stacked greater than 18 inches. The DS stated there must be at least 18 inches for the water sprinkler on the ceilings to reach and put out a fire. The DS stated the boxes could also fall causing dents which could lead to bacteria grow. The DS stated the boxes must be stored correctly as soon as they get delivered. During a review of the facility's policy and procedure (P&P) titled, Food Storage/Preparation, last reviewed on 12/3/2025, the P&P indicated the facility must store and secure food safely.

Based on observation, interview, and record review, the facility failed to dispose garbage and refuse properly by failing to: 1. Ensure two of two black dumpsters (a movable waste container designed to be brought and taken away by a special collection vehicle, or to a bin that a specially designed garbage truck lifts) and one of one blue dumpster were completely closed while not actively being used. 2. Ensure there were no soiled gloves on the floor area and surroundings of the facility's dumpster. This deficient failure had potential to attract birds, flies, insects, pests, and possibly spread infection to 37 of 37 facility residents. Findings: During an observation on 2/21/2026 at 11:32 a.m., of the facility dumpster area with the Dietary Supervisor (DS), observed two black dumpsters and one blue dumpster fully open and a pair of soiled gloves on the ground near the dumpsters. During an interview on 2/21/2026 at 11:34 a.m., with the DS, the DS stated all the trash must be inside the dumpster and dumpster lids should always be closed. The DS stated the lids on the dumpsters must be closed and the area around the dumpsters must be cleaned and free of trash for infection control and to avoid animals and pests from getting into the trash. The DS stated animals and pests could come inside the facility and contaminate the food residents would receive. The DS further stated the dietary department is responsible for keeping the dumpster lid closed. During a review of the facility's policy and procedure (P&P) titled, Disposal of Infectious and Ordinary Waste Products, last reviewed on 12/3/2025, the P&P indicated the facility will ensure all waste products will be disposed of properly and dumpster lids will be closed after every use.

Based on observation, interview, and record review, the facility failed to ensure that a resident with a [MEDICAL CONDITION] (surgical opening in the trachea (windpipe) to place a tube to enable breathing) tube, received care as ordered by the physician to prevent cardiopulmonary arrest (stoppage of the heart-lung function) for one of one sample resident (Resident 1) by failing to: 1. Implement the physician's written order to suction (the flow of a fluid/secretions into a partial vacuum) Resident 1's [MEDICAL CONDITION] every two hours and as needed (PRN) to prevent a mucous (phlegm) plug that clogged the [MEDICAL CONDITION], resulting in the resident's change in condition. 2. Ensure that Resident 1's oxygen saturation (the level of oxygen in the blood), was continuously monitored by means of a pulse oximeter (equipment used to measure the oxygen saturation) as ordered by the physician, and the results documented. Resident 1 developed respiratory difficulties manifested (clearly apparent to the sight or understanding) by cyanosis (a bluish color of the skin and mucous membranes due to insufficient oxygen in the blood), unresponsiveness, and no pulse, and was transferred to the general acute care hospital (GACH) on [DATE], at 7:50 a.m. and readmitted to the facility on [DATE], after 23 days of potentially avoidable hospitalization . Findings: On [DATE], the Department received an Entity Self-Reported incident that alleged on [DATE], at approximately 7:30 a.m. Resident 1 had a cardiopulmonary arrest. The resident was blue in color and without a pulse (heartbeat), with his [MEDICAL CONDITION] in place. According to the report, prior to the event Resident 1 was observed awake, alert and playing in his crib between 7:05 a.m. and 7:20 a.m. that day. The staff called 911 and the resident was transferred to GACH for further evaluation. On [DATE], investigation of the above allegation was initiated. A review of the Resident 1's admission record indicated that the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. According to the Quarterly Minimum Data Set (MDS, a standardized assessment and care screening tool), dated [DATE], the resident was rarely able to make self-understood and understand others. The MDS also indicated that Resident 1 was dependent on the facility staff and required extensive to total care for his activities of daily living. A review of the physician's orders [REDACTED]. 1. Continuous pulse oximetry, change the probe site (the body part or location where the probe/sensor is applied to measure the oxygen) every four hours dated [DATE]. 2. Suction the resident's [MEDICAL CONDITION] every two hours or as needed (PRN) for excessive secretions, dated [DATE]. A review of a Respiratory Care Flow Sheet dated [DATE], at 3:20 a.m., indicated Resident 1 had an oxygen saturation of 98 percent, the sensor site was located on his right foot, the [MEDICAL CONDITION] was secured, and Resident 1 was suctioned. At 5:30 a.m., Resident 1 was on a heated aerosol trachea collar (a tube that provides warm wet air) with a 28 percent FiO2 (the fraction of inspired oxygen, the proportion of the oxygen in the air breathed) without respiratory distress or shortness of breath; suctioned with medium [MEDICATION NAME] (thickness) color pale yellow secretions and the trachea was patent (open/clear) and secure. The pulse oximeter was on and audible (heard), Resident 1 was alert and awake with an oxygen saturation of 99 percent. Oxygen saturation in a range of 96 percent to 100 percent is generally considered normal. Anything below 90 percent could quickly lead to life-threatening complications. The margin between "healthy" saturation levels (,[DATE] percent) and [MEDICAL CONDITION] (usually ,[DATE] percent) is narrow. AJN, American Journal of Nursing: [DATE] - Volume 105 - Issue 5 - Page 72). There was a plan of care related to respiratory care dated [DATE], and updated on [DATE]. The interventions included to monitor pulse oximetry (measures the amount of oxygen in the blood - oxygen saturation) on a regular basis. The care plan did not specify what "regular basis" meant or the frequency to monitor the oxygen saturation. A review of Resident 1's Respiratory Care Flow Sheet from [DATE], 3:20 a.m., to [DATE], 7:20 a.m., indicated there was no documented evidence that the licensed nursing staff or the respiratory therapy staff had monitored and recorded the oxygen saturation reading to ensure that the resident's oxygen saturation was within the acceptable parameters. There was another plan of care for suctioning the [MEDICAL CONDITION] dated [DATE], updated on [DATE], that indicated the resident had an artificial airway as evidenced by a [MEDICAL CONDITION]. The interventions included the resident will be suctioned every two hours and as needed for excessive secretions. Although the physician order [REDACTED]. tube every two hours as per the physician's orders [REDACTED]. For example: A review of Residents 1's Respiratory Care Flow Sheet for the months of May and June, 2014, the resident was not suctioned every two hours as the physician had ordered. According to the Respiratory Care Flow Sheet from [DATE], to [DATE], Resident 1 was suctioned only twice; once on [DATE], at 8 a.m., and once on [DATE], at 2 p.m. The Respiratory Care Flow Sheet dated [DATE], also indicated the resident's oxygen saturation level was monitored and recorded six times in twenty-four hours. The last oxygen saturation level reading of 98 percent was on [DATE], at 3:20 a.m. The resident's oxygen saturation level was not monitored and recorded on the flow sheet from 3:20 a.m. to 7:20 a.m. that day. On [DATE], at 6:10 a.m. the licensed nurse documentation on the Respiratory Care Flow Sheet indicated the resident was asleep and in stable condition, pulse oximeter turned on, no signs of distress noted. However, the corresponding documentation on the Resident Care Flow-sheet dated [DATE] from 7 a.m. through [DATE], at 7 a.m. indicated the oxygen saturation reading via the pulse oximeter was not continuously measured. The corresponding "Suction" column indicated licensed staff did not suction Resident 1 every two hours or PRN as ordered by the physician. A review of Residents 1's Respiratory Care Flow Sheet dated [DATE], at 7:20 a.m. indicated, while doing routine round the resident was observed unresponsive, cyanotic and without a pulse. STAT (Emergency Response Team) was called at 7:20 a.m. and the team performed manual ventilation and chest compressions (CPR-cardiopulmonary resuscitation). Resident 1 was suctioned and trachea was changed and the paramedics were called. The oxygen saturation was 84 percent. On [DATE], at 4:21 p.m., during an interview with licensed vocational nurse 1 (LVN 1), she stated that on [DATE], at 7 a.m., she received report from the night shift nurse that Resident 1 had no respiratory issues. She stated that at 7:15 a.m., the certified nursing assistant (CNA 1) found the resident unresponsive when she tried to awake the resident for breakfast. When asked if Resident 1 had the pulse oximeter in place, LVN 1 said that CNA 1 told her that she forgot to attach the pulse oximeter probe to the resident. According to LVN 1 since the pulse oximeter probe was not attached the oxygen saturation was not continuously monitored as ordered by the physician to prevent a potentially life-threatening complication. On [DATE], at 9:12 a.m., during an interview with Respiratory Therapist 1 (RT 1), he stated that he did not document assessment of Resident 1 on the Respiratory Care Flow Sheet at 6 a.m. or 7 a.m., since the STAT Team started CPR at the beginning of the shift. During an interview with the Director of Nursing (DON), on [DATE], at 5 p.m., he stated Resident 1 did not have a care plan to monitor the oxygen saturation continuously. According to the care plan updated on [DATE], the intervention stated "Monitor pulse oximetry on regular basis" with no specified time line to monitor the resident's oxygen saturation. According to the physician's orders [REDACTED]. The STAT Record dated [DATE], called at 7:20 a.m., indicated Resident 1's color was cyanotic, the respiratory quality was recorded as unresponsive, the suction result was described as a thick mucous plug. The RN (registered nurse) Assessment documentation indicated that the resident was unresponsive, the [MEDICAL CONDITION] was intact with a mucous plug, and the resident had an oxygen saturation of 84 percent; the "trach" tube was changed and CPR was started. The STAT was cleared at 7:50 a.m. when the paramedics arrived and took over, and the police were at the bedside. At 7:50 a.m., the oxygen saturation was 90 percent, and the resident was transferred to GACH emergency department (ER) via a gurney by the paramedics. A review of the GACH Emergency Department Final Report dated [DATE], indicated Resident 1 was admitted to theER on [DATE] in cardiopulmonary arrest. The resident was placed on a mechanical ventilator due to severe metabolic acidosis (too much acid in body fluids) post (after) arrest. On [DATE] at 9:46 a.m., the resident was resuscitated and transferred to the pediatric intensive care unit in a critical condition for post resuscitation care.

Based on observation, interview, and record review, the facility failed to ensure that a four year-old pediatric resident who had a history of [REDACTED]. one sample resident (1) by failing to: 1. Conduct a comprehensive assessment to identify the reason(s) Resident 1 repeatedly removed his [MEDICAL CONDITION] and develop a plan of care with useful and effective interventions to prevent Resident 1 from removing the [MEDICAL CONDITION]. 2. Ensure that Resident 1 was continuously monitored and assessed for his breathing status and to ensure the [MEDICAL CONDITION] is in place, kept clean and unobstructed with mucus and excessive secretions that would force Resident 1 to remove the tube due to air hunger. 3. Ensure that Resident 1's [MEDICAL CONDITION] was securely and snugly tied around the neck to prevent the removal of the tube by the resident and/or during forceful coughing. 4. Ensure that hand mittens were applied as ordered by the physician so that Resident 1 would not be able to remove the [MEDICAL CONDITION]. Findings: On [DATE] the Department received an entity reported incident that alleged a pediatric resident decannulated his [MEDICAL CONDITION] on [DATE] at approximately 1:00 p.m. and became unresponsive. The facility called 911 and the paramedics transferred the resident to an acute care hospital. Resident 1 did not recover from his medical emergency and died of asphyxiation (lack of oxygen) at the emergency room of the acute care hospital. An investigation of the above incident was conducted on [DATE]. A review of Resident 1's admission record indicated Resident 1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS) a standardized assessment, dated [DATE] indicated Resident 1 had no speech, rarely/never understood, and rarely/never understand others, was totally dependent on facility staff for ADL (activities of daily living). The MDS also indicated that Resident 1 was receiving oxygen therapy, suctioning, and [MEDICAL CONDITION] care. There was a plan of care, dated [DATE], that identified a problem related to artificial airway, respiratory distress, [MEDICAL CONDITION], prematurity and developmental delay. The care plan had goals that stated: 1. There would not be episodes of respiratory distress. 2. Would not have stoma irritation. 3. Would not have [MEDICAL CONDITION] dislodgement. The interventions of the care plan included: 1. The Licensed nurses (LNS) and respiratory therapist/care provider (RCP) will assess Resident 1's respiratory status. 2. LNS and RCP will follow STAT (an emergency that compromises ABC airway, breathing, and circulation) Team procedure with [MEDICAL CONDITION]. 3. Replace or [MEDICAL CONDITION] per MD orders. Half-strength hydrogen peroxide every week. 4. [MEDICAL CONDITION] with Resident 1 at all times. 5. If signs or symptoms of respiratory distress are observed, the LNS will do a complete assessment and notify the charge nurse and RCP. 6. Full vital signs every 6 hours and respiratory distress. 7. LNS/RCP will monitor for signs or symptoms of respiratory distress such as dyspnea (difficult or labored breathing; shortness of breath; dyspnea is a sign of serious disease of the airway, lungs), tachypnea (very rapid respiration), [MEDICAL CONDITION](very rapid heart beat), nasal flaring, chest retractions, and apnea (absence of breathing) for more than 20 seconds. 8. LNS/RCP will administer oxygen and medications as ordered. 9. Suction Resident 1 as needed for excessive secretions. 10. Stoma care per MD orders; sterile water every day. The above plan of care was initiated by the multidisciplinary team that included the licensed nursing staff and the respiratory therapist and revised on [DATE]. However, a review of Resident 1's clinical record revealed Resident 1 had recurrent decannulation of the [MEDICAL CONDITION] indicating the interventions mentioned in the plan of care above were not either implemented properly and/or were not effective to achieve the stated goal on the care plan. For example: A review of Resident 1's clinical record indicated Resident 1 had removed his [MEDICAL CONDITION] and that lead to deprivation of air/oxygen on the following dates: 1. A review of a facility STAT (immediate response) team record, dated [DATE] at 7:00 p.m., indicated Resident 1 became agitated and decannulated his [MEDICAL CONDITION]. Resident 1's oxygen saturation dropped to 63% (usual range is 92% ~ 100%), the [MEDICAL CONDITION] was reinserted and Resident 1 recovered. 2. A review of a facility STAT team record, dated [DATE] at 9:20 a.m., indicated that a facility maintenance staff heard Resident 1's ventilator alarming. The report also indicated that the unit desk person checked Resident 1 and she noticed that Resident 1's [MEDICAL CONDITION] was out. The report indicated that a RT unsuccessfully reinserted Resident 1's [MEDICAL CONDITION] on the first attempt. The report also indicated that Resident 1's oxygen saturation dropped to 76% and Resident 1 turned cyanotic (bluish discoloration of the skin due to lack of oxygen in the blood). 3. A review of a facility STAT team record, dated [DATE] at 7:52 p.m., indicated Resident 1 again decannulated his [MEDICAL CONDITION]. Resident 1's oxygen saturation dropped to 52%. By 7:57 p.m., Resident 1 recovered and STAT was called off at 8:00 p.m. While Resident 1 decannulated himself on repeated occasions, there was no documented evidence that indicated the multidisciplinary team assessed Resident 1 to identify the cause(s) of Resident 1's behavior to decannulate himself and remedy the problem accordingly. A review of Resident 1's care plan for [MEDICAL CONDITION] dislodgement, dated [DATE], indicated a plan of action to secure the [MEDICAL CONDITION] with correct size ties to ensure proper tightness. However, there was no documented evidence that indicated the [MEDICAL CONDITION] was secured with correct size ties to ensure proper tightness. A review of the facility nurse's notes, dated [DATE], (time was unreadable) indicated an entry that Resident 1 was able to decannulate his [MEDICAL CONDITION] and was a threat to self decannulate. The entry indicated Resident 1's physician was notified and an order for [REDACTED]. A review of Resident 1's physician's orders [REDACTED]. A review of Resident 1's care plan for "threat to self-decannulation", dated [DATE], indicated a plan of action that included hand mittens to bilateral hands. However, a review of Resident 1's treatment record from [DATE] through [DATE], indicated that the physician's orders [REDACTED]. A review of a facility STAT team record, dated [DATE] at 1:00 p.m., indicated Resident 1 had decannulated the [MEDICAL CONDITION] and was found cyanotic (a bluish or purplish discoloration of the skin due to deficient oxygenation of the blood) and unresponsive. The record did not indicate how long Resident 1 was without a [MEDICAL CONDITION]. However, the record also indicated that a respiratory therapist (RT) reinserted Resident 1's [MEDICAL CONDITION] without difficulty and that Resident 1 was receiving 100% oxygen and CPR (cardiopulmonary resuscitation - chest compressions and artificial breathing) was started. The record indicated at 1:07 p.m. 911 was called. At 1:08 p.m. Resident 1 was still cyanotic, unresponsive and the RT replaced Resident 1's [MEDICAL CONDITION]. The STAT record indicated that facility staff tried to start an IV line twice unsuccessfully. At 1:10 p.m. Resident 1's physician was notified and an order to transfer Resident 1 to the general acute care hospital (GACH) was obtained. A review of the emergency room (ER) report from the acute care hospital indicated the Fire Department Paramedics received a call from the facility at 1:06 p.m. The Paramedics arrived at the scene at 1:11 p.m. The Paramedic report indicated Resident 1 was unresponsive, was in [MEDICAL CONDITION] with no breathing. The Paramedic report indicated CPR with AED (automated external defibrillator) was performed, but Resident 1 remained unresponsive. The Paramedic report indicated Resident 1 was transported to the acute care hospital at 1:22 p.m. The acute care hospital ER report indicated Resident 1 arrived at 1:27 p.m. in full arrest, with no respirations and no pulse. The acute care hospital ER performed advanced CPR but was unsuccessful. CPR was discontinued and Resident 1 was pronounced dead at 1:52 p.m. On [DATE] at 12:50 p.m. during an interview, a certified nursing assistant (CNA 1) stated that she was in Resident 1's room when she heard the apnea alarm beeping, but that the ventilator alarm was not beeping. CNA 1 stated that she called the STAT team immediately. CNA 1 could not recall if Resident 1's [MEDICAL CONDITION] was decannulated when she first saw Resident 1 not breathing and Resident 1's skin turning to a bluish color. On [DATE] at 1:05 p.m., during an interview, RT 1 stated that after the STAT team discovered Resident 1 was decannulated, he (RT 1) reinserted the resident's [MEDICAL CONDITION] and gave artificial breathing to Resident 1 through an oxygen bag, but Resident 1 was not taking in oxygen with the old [MEDICAL CONDITION] in place. RT 1 stated that they had to use an emergency (spare) [MEDICAL CONDITION] while CPR was being performed. RT 1 stated that he doesn't know why the ventilator alarm didn't sound off. On [DATE] at 1:15 p.m. during an interview, the RT supervisor stated that the old [MEDICAL CONDITION] was not plugged with mucous (to interfere with breathing). The RT supervisor also stated that facility RTs set the sensitivity of the ventilator alarms settings. On [DATE] at 2:10 p.m., during an interview, RT 1 stated that changes to the alarm settings may be due to the alarms sounding off too often. RT 1 also stated that he did not make any alarm setting adjustments to Resident 1's ventilator the day of the incident. On [DATE] at 2:55 p.m., during an interview, the RT supervisor stated that facility RTs should document when they make changes to ventilator alarm settings. On [DATE] at 3:05 p.m., during an interview, a vocational nurse (LVN 1) stated that she was assigned to take care of the resident that day. LVN 1 stated that Resident 1 was not wearing hand mittens that day. On [DATE] at 3:15 p.m. the director of nursing (DON) stated that there should be a staff in all residents' rooms at all times to provide continuous monitoring. According to the Certificate of Death dated [DATE], Resident 1's immediate cause of death included asphyxia, dislodgement of [MEDICAL CONDITIONS].

Based on interview and record review the licensed nurses and respiratory therapists failed to ensure that a resident receives proper respiratory care and treatment for one out of one sample resident (2) by failing to have a system in place to prevent self decannulation (the expulsion of the [MEDICAL CONDITION] from the trachea), and failed to closely monitor the resident who had a history of [REDACTED]. She was able to pull the tube out while the certified nursing assistant (CNA) was in the room and died as a result of removing the tube that helped her to breathe. Findings: On [DATE], at 1:05 p.m., an unannounced visit was made to investigate a complaint that a child, who pulled out her [MEDICAL CONDITION] (trach) tube, had a [MEDICAL CONDITION] and died . According to the admission information Resident 2 was three years old, originally admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. According to the American Journal of Nursing, [DATE], Vol. 102, No. 3 a [MEDICAL CONDITION] is the creation of an opening into the trachea through the neck, with insertion of an indwelling tube to facilitate passage of air or evacuation of secretions. The procedure may be an emergency measure or an elective one). The Resident 2 had the following physician orders: 1. [DATE], the resident was to wear bilateral hand mittens as needed to prevent self decannulation (the expulsion of the [MEDICAL CONDITION] from the trachea). Take the mittens off every two hours and check for circulation. 2. [DATE], have on a continuous pulse oximeter. The pulse oximeter measures the oxygen concentration in your arterial blood. The pulse oximeter will display numbers which indicates the concentration of oxygen in your arterial blood. The alarm will sound if the oxygen concentration drops below the set parameters. 3. [DATE], to have a 21% (oxygen concentration in the ambient air) cool aerosol. According to the care plan dated [DATE], Resident 2 was at risk for self-decannulation related to upper extremity mobility, as evidenced by hand grasps. The interventions included applying mittens or arm immobilizers while awake daily. The care plan also indicated all disciplines were to document the use of the mittens/arm immobilizers on the treatment record. The care plan dated [DATE], indicated the problem/concern [MEDICAL CONDITION] dislodgement (decannulation). The plan included to secure [MEDICAL CONDITION] the correct size ties and ensure proper tightness. Resident 2 was transferred to the acute care hospital via paramedics on [DATE], after she pulled out her [MEDICAL CONDITION]. According to the History and Physical report completed by the acute care hospital physician, the resident pulled out her [MEDICAL CONDITION] and was found cyanotic (blue) and pulseless by her care giver at the facility. Cardio-pulmonary resuscitation (CPR) and bagging (forcing air into the lungs manually through a special bag) were necessitated. She recovered with spontaneous respirations and strong pulses after one minute. It is unknown how long she was decannulated prior to being found by facility staff. The resident was transferred to another acute care hospital after she was stabilized. The resident had a second episode of pulling out [MEDICAL CONDITION] on the same day, while at the acute care hospital. CPR was administered again until the resident had spontaneous respirations. The resident was discharged from the acute care hospital and readmitted to the facility on [DATE]. According to the STAT (immediate response)Team Record form dated [DATE], at 7:40 p.m., Resident 2'[MEDICAL CONDITION] was pulled out again and the patient was unresponsive. 911 was called as the respiratory therapist was reinserting [MEDICAL CONDITION]. CPR was initiated. The paramedics arrived and took the resident to an acute care hospital for evaluation and treatment. The Physician Consultation report dated [DATE], recommended more gentle reinsertion of [MEDICAL CONDITION] if it is pulled out again and preventive measures and increased monitoring to prevent self-decannulation. The Nurse's Notes dated [DATE], at 1:08 a.m., written by registered nurse (RN) 1 indicated a STAT was called to the resident's room. When she arrived four respiratory therapists (RT's) were in the room securing the [MEDICAL CONDITION] and started chest compressions. There were also three licensed vocational nurses (LNV's) in the room. Around 1:15 a.m., the paramedics were called. They arrived at 1:20 p.m. and took over. The ordering physician (the paramedics were in contact with via the phone) stopped the CPR. The resident was pronounced dead at 1:32 a.m. at the facility. The Prehospital Care Report Summary completed by the Los Angeles Fire Department Paramedics dated [DATE], indicated the resident had a history of [REDACTED]. According to the report the nurse at the facility told the paramedic she checked on the resident around 1 a.m., and the resident was moving around. The nurse left the room to check on another resident and returned around 1:10 a.m., to find the resident had removed [MEDICAL CONDITION] and was not breathing and pulseless. They called 911 and initiated CPR. The paramedics arrived and took over. The resident was pronounced dead at 1:38 a.m. The Death Certificate dated [DATE], indicated Resident 2's immediate cause of death was asphyxia (death resulting from lack of oxygen) caused by dislodgement of [MEDICAL CONDITIONS] and extreme prematurity. The Death Certificate also indicated the [MEDICAL CONDITION] became dislodged during the night. On [DATE] at 1:47 p.m., during an interview, respiratory therapist (RT) 1 said someone is supposed to be in the Resident 2's room at all times. If the person in the room has to leave they are supposed to get someone else to take their place. On [DATE] at 2:50 p.m., during an interview respiratory therapist (RT) 2 said the night of the incident he was coming back from lunch and heard the STAT call around 1:07 a.m. When he got to the room RT 2 was already in the room with the resident trying to put [MEDICAL CONDITION] back in. CPR was initiated. The paramedics arrived and took over. RT 2 said the resident was successful at pulling out [MEDICAL CONDITION] several times. RT 2 went on to say the RT's do not have any device to keep the resident from pulling out [MEDICAL CONDITION]. The nurses use mittens or a foam board (prevents the resident from bending her arm) and pulling out [MEDICAL CONDITION]. During an interview with certified nursing assistant (CNA) 1 on [DATE] at 3:30 p.m. she said the night of the incident she was in the resident's room at the time the resident pulled out [MEDICAL CONDITION], but she was providing care for the resident in Bed-D. LVN 1 came into the room and noticed Resident 2'[MEDICAL CONDITION] was out. LVN 1 told CNA 1 to call a STAT. The appropriate disciplines responded and CPR was administered. CNA 1 went on to say there is always someone in the rooms at all times, but she was busy with bed D and did not hear Resident 2 moving around. When asked if the resident had any mittens on at the time of the incident, she said LVN 1 had taken them off. When asked why LVN 1 took the mittens off, she said the physician's orders [REDACTED]. CNA 1 said she also takes the mittens off to clean the resident, but immediately puts them back on. On [DATE] at 12:05 p.m. during an interview RN 1 said she was the charge nurse on duty the night of the incident. She heard the STAT call, ran to the resident's room and the STAT Team was already there. The STAT Team secured the Resident 2's airway. According to RN 1 secured meant they put [MEDICAL CONDITION] back in. RN 1 said LVN 1 thought she put it back in but the tube was not in all of the way. Resident 2's neck and face were so swollen (because of the medication she was taking) it was hard to see [MEDICAL CONDITION]. When the RT's arrived they put [MEDICAL CONDITION] in all the way. RN 1 also said there is supposed to be someone in the room at all times. RN 1 went on to say at the time of the incident the resident had on a cool [MEDICAL CONDITION] and had on a pulse-oximeter. According to RN 1, LVN 1 said the pulse oximeter did not display any numbers and the alarm was not sounding. RN 1 said while they were doing CPR the pulse oximeter was displaying numbers and working fine. When the paramedics arrived they took the pulse oximeter off of the resident. The paramedics arrived at 1:14 a.m. and stopped CPR at 1:20 a.m. RN 1 added the resident has pulled [MEDICAL CONDITION] out many times. During an interview with LVN 1 on February 4, 2013 at 10:10 a.m. she said she found Resident 2 decannulated and unresponsive. CNA 1 was in the room at the time the resident decannulated herself. LVN 1 went on to say she told CNA 1 to keep an eye on the resident because she was high risk. The resident pulled [MEDICAL CONDITION] out several times before. She told CNA 1 to sit in front of the resident's crib. LVN 1 left the resident's room and returned 10 minutes later and saw [MEDICAL CONDITION] was out. CNA 1 was providing care for the resident in bed D. LVN 1 put [MEDICAL CONDITION] back in and told CNA 1 to call a STAT. LVN 1 went on to say the resident did not have the mittens on. LVN 1 could not remember if she or CNA 1 took the mittens off.