Every finding on record at Valley Healthcare Center

Based on observation, interview, and record review, the facility failed to implement their policy regarding hydration for one of three sampled residents (Resident 1) when Resident 1's fluid intake and output was not monitored and documented every shift for three days, as ordered by the physician.This failure had the potential to result in worsening hydration and serious health complications, including hypovolemic shock (a life-threatening condition caused by severed fluid loss), acute kidney injury (a sudden decrease in kidney function), electrolyte imbalance (abnormal levels of minerals in the blood), and other complications associated with inadequate hydration when Resident 1's fluid intake and output were not monitored and documented every shift as ordered. During a review of Resident 1's admission Record (contains demographic and medical information), the admission Record it indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included obstructive and reflux uropathy (a condition in which urine does not flow normally and may back up toward the kidneys, which can cause kidney problems), acute kidney failure (a sudden decrease in the kidneys ability to properly filter waste and fluid from the blood), and retention of urine (a condition in which a person is unable to completely empty the bladder.) During a telephone interview on August 13, 2026, at 10:23 AM, with Resident 1's family member/responsible party (FM/RP), FM/RP stated Resident 1 previously required IV hydration (fluids given directly into a vein through a small tube to replace fluids in the body) due to dehydration (lacks enough water and other fluids to function normally). The FM/RP further stated that during a subsequent hospitalization, a physician informed him Resident 1 was severely dehydrated and malnourished (when a person's body does not get the right amount of nutrients, calories, vitamins, or minerals needed for good health and growth). The FM/RP stated he was concerned that Resident 1 was not receiving adequate nutrition and hydration at the facility. During an observation on August 20, 2026, at 12:27 PM, in the dining room, Resident 1 was seated in a wheelchair. Resident 1 had a Foley catheter (a tube that drains urine from the bladder) in place. Resident 1's meal ticket indicated a fortified, pureed diet and assisted dining. Resident 1's lunch tray contained four portions of pureed food of different colors and consistencies, including light/tan, pale pink, green, and dark - colored purees, along with ice cream, a 8 fluid ounces (237 mL ) Glucose Control Boost nutritional supplement drink, and beverages. Approximately 20% (percent) of the pureed meal was consumed. The Glucose Control Boost cartoon was open and empty. An eight-ounce cup contained approximately (240 mL of pink -colored liquid, with approximately three-quarters remaining. Other food and beverages remained on the tray and were not completely consumed. During a review of Resident 1's MDS Section GG - Functional Abilities (a section of the resident assessment that identified how much help a resident need with daily activities such as eating and moving), dated June 30, 2026, the MDS indicated, (GG130 A. Eating) was coded 03 (Partial/moderate assistance - helper does LESS THAN HALF the effort. Helper lifts, hold, or supports truck or limbs, but provides less than half the effort.)During a review of Resident 1's Care Plan Report (a document that describes a resident's health needs, goals, and the care staff should provide), date initiated March 24, 2026, the Care Plan Report indicated, . focus, has episode of dehydration as Evident by scoring of elevated BUN (blood urea nitrogen, and blood test that measures waste in the blood and can increase when a person is dehydrated or when the kidneys are not working properly) and Creatinine (a higher - than normal level of a waste product in the blood that is normally removed by the kidneys; an elevated level may indicate decreased kidney function or dehydration) and low GFR (glomerular filtration rate, an Estimate of how well the kidneys are filtering waste from the blood; a lower number means the kidneys are filtering less effectively) .Goal, Resident will remain hydrated . Intervention, Monitor Resident's urine output. During a review of Resident 1's Physician Order, dated June 24, 2026, the physician orders indicated, Monitor fluid intake & output QS for 72 hours every shift for 3 days. During a review of Resident 1's Intake documentation for the 72 hours period dated June 24, 2026, through June 26, 2026, the following documentation was missing:June 24, 2026, at 1:56 PM, (afternoon shift) No intake amount documented.June 24, 2026 (Night shift) No intake amount documented.June 25, 2026 (afternoon shift) No intake amount documented.June 26, 2026, at 6:59 AM (Morning shift) No intake amount documented.June 26, 2026, at 7:55 PM ( afternoon shift) No intake amount documented.June 26, 2026 (Night Shift) no intake amount documented. During a concurrent interview and record review on August 21, 2026, at 9:45 AM, with the Quality Assurance (QA) Nurse (a nurse who reviews resident care and facility records to identify problems and help ensure appropriate care is provided), the QA Nurse reviewed Resident 1's fluid intake documentation for June 1, 2026, through June 9, 2026, prior to Resident 1's hospitalization, and confirmed the facility did not have the missing fluid intake documentation for June 1, 2026, through June 9, 2026.During a concurrent interview and record review on August 21, 2026, at 12:05 PM, with the Director of Nursing (DON), the facility policy and procedure (P&P) titled Resident Hydration and Prevention of Dehydration, dated October 2017, was reviewed. The P&P indicated this facility will strive to provide adequate hydration and to prevent and treat dehydration. 5. Nurses will assess for signs and symptoms of dehydration during daily care. 6. Nurses' Aides will provide and encourage intake.,meal fluids.a. Intake will be documented in the medical records. B. Aides will report intake less than 1200 ml/day to nursing staff.,7. If potential inadequate intake and/or signs and symptoms of dehydration are observed, intake and output monitoring will be initiated and incorporated into the care plan.,12. Nursing will monitor and document fluid intake and the dietitian will be kept informed of status. The interdisciplinary Team will update the care plan and document resident response to interventions until the team agrees that fluid intake and relating factors are resolved. The DON stated the policy was not followed.

Based on observation, interview, and record review, the facility failed to ensure enteral nutrition (Nutrition provided directly into the stomach or intestines through a feeding tube) and hydration were administered in accordance with physician orders and acceptable standards of practice for one of three sampled residents (Resident 2).This failure had the potential to result in incorrect administration of enteral nutrition and hydration for Resident 1, placing his health at risk.During a review of Resident 2's admission Record (contains demographic and medical information), indicated Resident 2 was admitted to the facility on [DATE], with diagnosis of dysphagia (difficulty swallowing), esophageal obstructions (a blockage in the tube that carries food and liquids from the mouth to the stomach) and gastrostomy status (the resident has a feeding tube place through the abdomen into the stomach for nutrition and / or medications. During a review of Resident 2's Physician Orders, dated August 13, 2026, indicated Resident 1 was ordered to receive Jevity 1.2 Cal (a liquid nutritional formula that provides calories, protein, vitamins, minerals, and other nutrients through a feeding tube) at 67 ml/hr (milliliters per hour) for 20 hours to provide 1340/1608 Kcals (Kilocalories, a measure of the amount of energy provided by the feeding) /75 g prot (75 grams of protein, a nutrient that helps maintain and repair the body) /1081 mls (milliliters, a measurement of liquid volume) free H20 (water given separately from the tube feeding for hydration) every shift (during each shift) During a review of Resident 2's Physician Orders indicated, Run H20 (water) @ (at) 30 MLS (milliliters) /HR (hour) x (for) 20 hrs (hours) = (a total of) 600 mls total dated August 3, 2026. During a concurrent observation and interview on August 20, 2026, at 2:28 PM, with Licensed Vocational Nurse (LVN 1), inside Resident 2 's room, Resident 2 was lying in bed, awake, alert, oriented to name, place and able to verbalize her needs. The head of the bed was elevated. Resident 2 was receiving Jevity 1.2 Cal and water through a gastrostomy tube (G-tube) (a tube placed through the abdomen directly into the stomach to provide nutrition, hydration, and/or medications). The Jevity 1.2 Cal feeding container was connected to an enteral feeding pump (a machine programmed to deliver liquid nutrition through a feeding tube at a controlled rate). The feeding pump was actively running and displayed a feeding rate of 67 milliliters per hour (mL/hr) (67 milliliters of liquid delivered each hour). The label affixed to the Jevity 1.2 Cal feeding container indicated a feeding rate of 60 mL/hr. (The feeding rate documented on the enteral feeding container did not correspond with the 67 mL/hr rate displayed on the feeding pump.)During further observation and interview, LVN 1 inspected Resident 1's Jevity 1.2 Cal feeding container and confirmed that the Jevity label indicated the feeding should be running at 60 ml/hr and not 67 ml/hr. LVN 1 stated that the feeding container had been hung by the night shift nurse and confirmed that the rate documented on the feeding label should correspond with the feeding pump setting. During an interview on August 21, 2026, at 10:48 PM, in the facility conference room, with the Director of Nursing (DON), the DON acknowledged that the enteral feeding rate documented on Resident 2's feeding container label did not match the rate displayed on the feeding pump. The DON stated that nursing staff were expected to follow the physician's order and ensure the feeding rate documented on the feeding container label corresponded with the rate programmed into the feeding pump. The DON also acknowledged the Resident 2.s enteral water bag was not labeled and stated that nursing staff were expected to properly label the water bag with the required resident and administration information.During a review of the facility's policy and procedure (P&P) titled, Enteral Feedings - Safety Precautions, revised November 2018, the p&p indicted, Purpose to ensure the safe administration of enteral nutrition.Preventing errors in administration, 1. Check the enteral nutrition label against the order before administration. Check the following information: a. Resident name ID and room number; b. type of formula; c. date and time formula was prepared, d. Route of delivery; e. Access site; f. Method (pump, gravity, syringe; and Rate of administration (mL/hour) 2. On the formula labeled document initials, date and time the formula was hung and initial that the label was checked against the order.

Based on interview and record review and, the facility failed to ensure a Change in Condition (COC)/SBAR assessment was completed in its entirety for one of three sample residents (Resident 1) who exhibited decreased food and / or fluid intake and weight loss beginning June 5, 2026, and was subsequently hospitalized on [DATE].This failure had the potential to delay timely assessment, physician notification, intervention, and treatment of Resident 1's change in condition.During a review of Resident 1's admission Record (contains demographic and medical information), the admission Record it indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included obstructive and reflux uropathy (a condition in which urine does not flow normally and may back up toward the kidneys, which can cause kidney problems), acute kidney failure (a sudden decrease in the kidneys ability to properly filter waste and fluid from the blood), and retention of urine (a condition in which a person is unable to completely empty the bladder.) During a concurrent interview and record review on August 20, 2026, at 3:45 PM with the Director of Nursing (DON), the Resident 1's SBAR Communication Form (a communication tool use by facility) dated June 5, 2026, was reviewed. The SBAR did not contain the following information: Vital signs, (measurement of the body's basic functions) including blood pressure (the force of blood against the blood vessels walls) , pulse (number of heartbeats per minute), respiration rate (number of breaths per minute), temperature (measurement of the body heat) and weight. Documentation of the resident's appearance. Documentation describing the lower abdominal pain or tenderness identified under the GU (genitourinary) /Urine Evaluation. Documentation of primary care clinician notification. Clinician recommendations. Name of Family/ Health Care Agent Notified. Staff Name (RN (Register Nurse) /LPN (License Practical Nurse) /LVN (License Vocational Nurse) and Signature. The DON acknowledged that the form was left incomplete. During a review of the facility's policy and procedure titled Change in a Resident's Condition or Status Revised date December 2025, indicated, Policy Statement The facility promptly notifies the resident, resident's attending physician.,3. Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the INTERACT SBAR communication Form.,8. The nurse will record in the resident's medical record information relative to change in the resident's medical / mental condition or status.

Based on interview, and record review the facility failed to ensure and follow facility policy and procedure for providing a log for signing out for one of four residents (Resident 4), for overnight pass. This failure had the potential to place a clinically compromised resident (Resident 4 ' s overall health and safety at risk. Findings: During a review of Resident 4 ' Face Sheet (general demographics) on April 2, 2025, the document indicated Resident 4 was last admitted to the facility on [DATE], with diagnoses that included Gout (a condition with form of pain and swelling in the joints), hypertension (a condition with a high blood pressure), contracture of muscle unspecified site (a condition where the muscle tissue becomes stiff and shortened and able to move) and history of falling (a fall in the past), major depressive disorder (a condition that causes sadness and loss of interest) and anxiety (a condition of feeling of worry and fear), and responsible party as Resident 4 ' s son, [Name of responsible party]. During concurrent observation and interview on April 2, 2025, at 11:10 AM, with Resident 4, Resident 4 was sitting in a wheelchair. Resident 4 stated, Ok, wait throughout the interview. A review of History and physical dated June 10, 2022, with diagnoses included cardiovascular accident (stroke), aphasia (a condition that makes it hard to use words). A review of Physician Orders dated September 2022, included: 1. September 9, 2022 May go out on therapeutic pass tomorrow between 1:00 PM to 5:00 PM with [Name of a person] and his son. 2. September 10, 2022 May have out on pass from September 9 to September 12. A review of Departmental Notes, dated September 10, 2022, at 3:14 PM, indicated, Resident stable and left with family via wheelchair at 2:00PM. During an interview on April 2, 2025, at 11:20 AM, with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated, We usually check to make sure the person the resident is going out with is a responsible party and the resident is signed out before leaving the facility. During an interview on April 2, 2025, at 11:25 AM, with Registered Nurse 1 (RN 1), RN 1 stated, The facility protocol is a resident must be signed for out on pass by a responsible party before leaving the facility and when they return back to the facility. During an interview on April 2, 2025, at 11:30 AM, with Director of Nurse (DON), DON stated, Our protocol is to notify the doctor when a resident wants to go out on pass, have contact information of whom they are going out with before signing resident out. It ' s been a couple of years now, and I don ' t remember if [Resident 4 ' s name] was signed out During an interview on April 2, 2025, at 12:15 AM, with Administrator (Admin), Admin stated, We know [Resident 4 ' s name] was signed out. We don ' t seem to see the sheet for sign out and return is, but we continue to look for it. A review of facility ' s Policy and Procedure (P&P) titled, Signing Residents Out, revised and dated, August 2006, the P&P indicated, Policy Statement All residents leaving the premises must be signed out. 1. Each resident leaving the premises (excluding transfers/discharges) must be signed out. 9. Residents must be signed in upon return to the facility.

Based on observation, interview, and record review, the facility failed to ensure the environment was free from potential serious accident hazards for residents and staff in the facility when: 1. The facility failed to assess and identify one of 10 residents (Resident 104) for smoking upon admission and failed to complete quarterly smoking assessments (an evaluation used to determine a resident's ability to smoke safely) for four of 10 residents (Residents 4, 13, 31, and 71). 2. The facility failed to ensure safety when eight of 10 residents (Residents 4, 13, 26, 32, 71, 79, 82, and 104) were observed smoking unsupervised in a non-oxygen free facility. 3. The facility failed to provide safe storage of a lighter for five of 10 residents (Residents 13, 31, 71, 82, 96), who had a physician's order for supplemental oxygen (a medical treatment delivering additional oxygen to a patient that significantly increases both the risk and intensity of fires). 4. The facility failed to ensure safety measures were followed by allowing four of 10 residents (Residents 4, 13, 96, and 104) possess lighters and were in proximity of other residents who used supplemental oxygen. 5. The facility failed to ensure the safety of all residents due to fire risk when 10 of 10 residents (Residents 4, 13, 26, 31, 32, 71, 79, 82, 96, and 104) were in possession of lighters. 6. The facility failed to update the smoking care plans (the plans showing specific interventions to provide effective and person-centered care to meet the resident's needs) for 5 of 10 sampled residents (Residents 4, 13, 26, 79, and 96) and failed to develop an individualized care plan related to smoking for one of 10 sampled residents (Resident 104), addressing safe storage, supervision, and the use of smoking materials. These failures placed residents at risk of serious harm, including fire hazards, burns, and other preventable injuries. Without proper supervision and safe storage of smoking materials, there was an increased likelihood of accidental fires, which could result in property damage, smoke inhalation, or even fatalities. Additionally, inadequate oversight could lead to residents with cognitive impairments or physical limitations mishandling smoking materials, further heightening the risk of injury to themselves and others. Findings: A. During the Entrance Conference on 3/3/25 at 8:58 a.m. with Administrator and Director of Nursing (DON), a list of residents who smoke was requested. Review of the Smoker Worksheet indicated there were eight residents who were smokers in the facility (Residents 4, 13, 26, 31, 32, 71, 79, and 82). The Administrator stated the list needed to be updated to reflect the current number of residents who smoked. The Administrator then provided the Smoker Worksheet showing nine residents who smoked (Residents 4, 13, 26, 31, 32, 71, 79, and 96). During an observation and concurrent record review on 3/4/25 at 9:58 a.m., two residents were observed smoking on the patio unsupervised (Residents 79 and 104). Resident 104 stated he had cigarettes and a lighter in possession. During an interview with Resident 104 on 3/4/25 at 10:15 a.m., Resident 104 stated he was able to smoke whenever I feel like it. During a concurrent observation on 3/4/25 at 10:25 a.m., in Resident 104's room, a sign outside of the room indicated, No smoking oxygen in use. The sign was also noted to have two circles with a slash over a cigarette. Inside the room where Resident 104 resided was also Resident 36 who shared the room. Resident 104's roommate, Resident 36, was observed with 2 liter (L- a unit of measurement) per minute (min) of oxygen in use via nasal cannula (NC - a small, flexible tube with two prongs, used to deliver supplemental oxygen or increased airflow to a patient through their nostrils). During a review of Resident 104's Admission Record (a document showing a summary of the resident's information) dated 3/5/25, indicated Resident 104 was admitted to the facility on [DATE]. A review of Resident 104's History and Physical (Amended) dated 3/3/25 indicated Resident 104's diagnoses included but not limited to Chronic Obstructive Pulmonary Disorder (COPD - a group of lung diseases that makes it hard to breathe leading to damaged and inflamed airways), polysubstance abuse, schizoaffective disorder (a mental health condition where a person experiences both schizophrenia [a condition that affects how people think, feel, and behave] and a mood disorder [a condition that impacts a person's emotional state]). A review of Resident 104's Care Plan Report undated, indicated a comprehensive care plan was developed for the resident. However, further review of the Care Plan Report indicated there was no documented evidence a care plan problem was developed to address Resident 104's smoking. During a concurrent interview and record review with the DON on 3/4/25 at 11:28 a.m., the DON reviewed the clinical record for Resident 104 and verified Resident 104 did not have a care plan for smoking. During a concurrent interview and record review on 3/4/25 at 12:07 p.m. with the Activities Director (AD), Resident 104's Activities - Initial Review dated 2/24/25, indicated one of Resident 104's hobbies included smoking. The AD stated she completed an assessment on 3/2/25 when she saw Resident 104 smoking. During an interview and concurrent record review on 3/4/25 at 2:45 p.m. with the Minimum Data Set Nurse Assistant (MDSNA), the MDSNA verified Resident 104 was not on the current Smoker Worksheet provided by the facility. The MDSNA stated, she was unsure if Resident 104 was a smoker when he was admitted to the facility. A review of Resident 104's Clinical Admission (an evaluation conducted upon a patient's arrival or admission to a facility, focusing on gathering data to determine their health status, identify potential problems, and develop a plan of care) dated 2/24/25, indicated under Safety section number 72 for smoking, Resident 104 was marked as being not assessed. An initial screening for smoking was not completed for Resident 104. In addition, Resident 104 was not on the list of smokers on the Smoker Worksheet provided by the facility. During an interview and concurrent record review with the Administrator and DON, on 3/6/25 at 11:43 a.m., the DON reviewed Resident 104's Clinical admitted d 2/24/25, and verified Resident 104's smoking use was not assessed upon admission. The DON further stated that she was responsible for failing to ensure the baseline screening was completed for the smokers. B. A review of Resident 4's Admission Record, dated 3/5/25 indicated Resident 4 was readmitted to the facility on [DATE]. Resident 4's diagnoses included but not limited to CHF (Congestive Heart Failure - a condition that develops when the heart does not pump enough blood for the body's needs), COPD, history of CVA (Cerebral Vascular Accident - an interruption in the flow of blood to the cells in the brain) with right upper weakness, and PVD (Peripheral Vascular Disease - a condition where blood vessels outside of the heart and brain become narrowed or blocked). During a concurrent observation and interview with Resident 4 on 3/3/25 at 10:15 a.m., in his room., Resident 4 stated he smoked about 10 packs of cigarettes daily. Resident 4 displayed that he currently had two packs of cigarettes and two disposable lighters in his possession. Resident 4 further stated that he was able to smoke on the patio whenever he wanted. During an observation on 3/4/25 at 9:14 a.m., Resident 4's room was observed to be located next to a room with a sign outside that indicated, No smoking oxygen in use. The sign was also noted to have two circles with a slash over a cigarette. During a concurrent observation and interview with Resident 4 on 3/4/25 at 9:38 a.m., Resident 4 was smoking unsupervised by staff. Resident 4 was observed in possession of and displayed two packs of cigarettes and two lighters in a bag. Resident 4 stated he kept the lighters and cigarettes with him. Review of the Smoker Worksheet provided by the Administrator showed Resident 4 was a smoker. Review of the Smoking and Safety, assessment dated [DATE], showed Resident 4 follows the facility's policy on location and time of smoking. During a concurrent interview and record review on 3/4/25 at 2:25 p.m. with the MDSNA, the MDSNA stated Resident 4's smoking assessment was completed on 11/11/24. The MDSNA further stated the assessment was not current according to the facility's policy which indicated assessments need to be done quarterly. The MDSNA stated the assessments should be up to date because there could be a change in condition where residents were no longer a safe smoker (a resident who was assessed to have appropriate cognitive, vision, communication, and physical functions and was able to verbalize understanding of the facility's smoking policies as per the facility's Safe Smoking Assessment form). A review of Resident 4's Care Plan Report undated, indicated a care plan problem was developed for the use of tobacco. The goals indicated the resident will adhere to the facility's smoking policies and will not suffer injury from unsafe smoking practices. The interventions indicated to Conduct Smoking Safety Evaluation on admission and PRN [as needed] . If a smoking facility, orient Resident to smoking times and procedures .The resident does not require supervision while smoking. However, there was no documented evidence showing the care plan was updated to reflect the most current smoking assessment and addressed safe storage, supervision, and the use of smoking materials. C. A review of Resident 13's Admission Record, dated 3/5/25, indicated Resident 13 was readmitted to the facility on [DATE]. Resident 13's diagnoses included but not limited to COPD, schizoaffective disorder, bipolar type (a chronic mental health condition characterized by extreme mood swings, alternating between periods of mania [elevated mood] and depression [a persistent state of sadness and loss of interest that can significantly impact daily life]), and cerebral infarction (a condition where blood flow to the brain is interrupted, causing brain cells to die). Review of the Smoker Worksheet provided by the Administrator showed Resident 13 was a smoker. During an interview with Resident 13 on 3/4/25 at 9:08 a.m., Resident 13 stated that she used a motorized wheelchair to go outside of the facility to buy cigarettes and lighters. Resident 13 further stated she stored and secured her own cigarettes and lighters. Resident 13 stated she smoked in the patio without supervision. During an observation on 3/4/25 at 9:13 a.m. Resident 13's room was observed to be located next to a room with a sign outside of the room that indicated, No smoking oxygen in use. The sign was also noted to have two circles with a slash over a cigarette. During a concurrent observation and interview on 3/4/25 at 9:43 a.m., Resident 13 was smoking in the patio unsupervised. Resident 13 stated she was enjoying her cigarettes and kept her own cigarettes and lighters. During a review of the Oxygen Order Listing Report, dated 3/4/25, an active physician's order for Resident 13 with a revised date of 7/1/24 indicated the use for oxygen 3 liters per min via NC PRN for shortness of breath (SOB) to maintain oxygen at greater than 90% every shift. During a concurrent interview and record review on 3/4/25 at 2:25 p.m. with the MDSNA, The MDSNA stated Resident 13's smoking assessment was completed on 11/8/24. The MDSNA further stated the assessment was not current according to the facility's policy which indicated assessments need to be done quarterly. The MDSNA stated the assessments should be up to date because there could be a change in condition where residents are no longer a safe smoker. A review of Resident 13's Care Plan Report undated, indicated a care plan problem was developed for the use of tobacco. The goals indicated the resident will adhere to the facility's smoking policies and will not suffer injury from unsafe smoking practices. The interventions indicated to Conduct Smoking Safety Evaluation on admission and PRN .If a smoking facility, orient Resident to smoking times and procedures .The resident does not require supervision while smoking. However, there was no documented evidence showing the care plan was updated to reflect the most current smoking assessment and addressed safe storage, supervision, and the use of smoking materials. D. A review of Resident 26's Admission Record dated 3/5/25, indicated Resident 26 was readmitted to the facility on [DATE]. Resident 26's diagnoses included but not limited to metabolic encephalopathy (a condition where the brain does not function properly due to an underlying metabolic imbalance) and COPD. During a concurrent observation and interview with Resident 26 on 3/3/25 at 10:30 a.m., Resident 26 was smoking in the patio area unsupervised. Resident 26 stated residents were allowed to smoke in the patio at any time without staff permission or notice. Resident 26 further stated his friends would provide cigarettes and lighters for use while he was in the facility. A review of Resident 26's Care Plan Report undated, indicated a care plan problem was developed for the use of tobacco. The goals indicated the resident will adhere to the facility's smoking policies and will not suffer injury from unsafe smoking practices. The interventions indicated to Conduct Smoking Safety Evaluation on admission and PRN .Educate Resident/Responsible Party on the facility's tobacco/smoking policy(s) .If a smoking facility, orient Resident to smoking times and procedures .The resident does not require supervision while smoking. However, there was no documented evidence showing the care plan was updated to reflect the most current smoking assessment and addressed safe storage, supervision, and the use of smoking materials. E. A review of Resident 31's Admission Record, dated 3/5/25, indicated Resident 31 was readmitted to the facility on [DATE]. Resident 31's diagnoses included but not limited to muscle weakness (generalized), acute respiratory failure with hypoxia, and COPD with (acute) exacerbation (a worsening or intensification of a pre-existing disease or condition). During a concurrent observation and interview on 3/4/25 at 9:32 a.m., Resident 31 was observed sitting in his motorized wheelchair. Resident 31 stated the cigarettes and lighters in his possession were provided by his caregiver and were kept in a drawer in his room. Resident 31 further stated smoking in the patio unsupervised was permitted at any time. A review of the Oxygen Order Listing Report, dated 3/4/25, indicated an active physician's order for Resident 31 was revised on 11/6/24 for O2 2L per min via NC PRN for SOB and wheezing related to COPD with acute exacerbation (a sudden and serious worsening of a condition or its symptoms). F. A review of Resident 32's Admission Record, dated 3/5/25, indicated Resident 32 was readmitted to the facility on [DATE]. Resident 32's diagnoses included but not limited to encephalopathy, multiple sclerosis (a chronic autoimmune disease that affects the central nervous system (brain and spinal cord) that can lead to numbness and tingling, weakness, vision problems, balance and coordination difficulties, fatigue and cognitive (relating to thought processes) problems. During a concurrent observation and interview with Resident 32 on 3/3/25 at 10:30 a.m., Resident 32 was observed smoking unsupervised. Resident 32 stated she smoked daily and can smoke any time during the day. Resident 32 further stated she kept her lighter in her pocket. During an interview on 3/3/25 at 10:30 a.m., Certified Nursing Assistant (CNA) 2 stated Resident 32 was not supervised during Resident 32's smoking activities. Review of the Smoker Worksheet provided by the Administrator showed Resident 31 was a smoker. During a concurrent interview and record review on 3/4/25 at 2:25 p.m. with the MDSNA, The MDSNA stated Resident 32's smoking assessment was completed on 11/29/24. The MDSNA further stated the assessment was not current according to the facility's policy which indicated assessments need to be done quarterly. When asked if the assessment should be up to date, the MDSNA replied yes, because there could be a change in condition where they are no longer a safe smoker. G. A review of Resident 71's Admission Record dated 3/5/25, indicated Resident 71 was admitted to the facility on [DATE]. A review of Resident 71's History and Physical dated 11/1/24 indicated Resident 71's diagnoses included but not limited to depression, anxiety (feelings of worry, nervousness, or dread), and insomnia (difficulty sleeping). During a concurrent observation and interview with Resident 71 on 3/4/25 at 9:14 a.m., Resident 71 was observed smoking in the patio unsupervised. Resident 71 was observed to be in possession of a lighter. Resident 71 stated there were instances when no staff were available to supervise the residents while the residents smoked. Resident 71 further stated residents who smoked were all allowed to carry their own lighters. During a follow-up observation on 3/4/25 at 9:25 a.m. Resident 71 was still smoking in the patio unsupervised. A review of the Oxygen Order Listing Report, dated 3/4/25, indicated an active physician's order for Resident 71 was revised on 10/31/24 for O2 2L per min via NC PRN for SOB every 24 hours. Review of the Smoker Worksheet provided by the Administrator showed Resident 71 was a smoker. During a concurrent interview and record review on 3/4/25 at 2:25 p.m. with MDSNA, the MDSNA stated Resident 71's smoking assessment was completed on 10/31/24. The MDSNA further stated the assessment was not current according to the facility's policy which indicated assessments need to be done quarterly and should have been done 2/25. When asked if the assessment should be up to date, the MDSNA replied yes, because there could be a change in condition where they are no longer a safe smoker. H. A review of Resident 79's Admission Record dated 3/5/25, indicated Resident 79 was admitted to the facility on [DATE]. A review of Resident 79's History and Physical dated 7/26/24 indicated Resident 79's diagnoses included but not limited to asthma (a chronic lung condition that causes the airways to become inflamed and narrow) and hypertension (high blood pressure). During an observation on 3/4/25 at 09:58 a.m., Resident 79 was smoking in the patio unsupervised and accompanied by Resident 104. During an interview on 3/5/25 at 10:00 a.m. with Resident 79, Resident 79 stated he bought and kept his own cigarettes and lighter. A review of Resident 79's Care Plan Report undated, indicated a care plan problem was developed for the use of tobacco. The goals indicated the resident will adhere to the facility's smoking policies and will not suffer injury from unsafe smoking practices. The interventions indicated to Conduct Smoking Safety Evaluation on admission and PRN .Educate Resident/Responsible Party on the facility's tobacco/smoking policy(s) .If a smoking facility, orient Resident to smoking times and procedures .The resident does not require supervision while smoking. However, there was no documented evidence showing the care plan was updated to reflect the most current smoking assessment and addressed safe storage, supervision, and the use of smoking materials. I. During a review of Resident 82's Admission Record dated 3/5/25, indicated Resident 82 was admitted to the facility on [DATE]. Resident 82's diagnosis included but not limited to COPD, acute respiratory failure with hypoxia (a condition where there is not enough supply of oxygen to the body's tissues), schizoaffective disorder, major depressive disorder, and anxiety. During a concurrent observation and interview with Resident 82 on 3/4/25 at 9:20 a.m., Resident 82 was observed in his room while using supplemental oxygen. Resident 82 stated he had his own lighter then proceeded to show a disposable lighter in his hand. Resident 82 also stated he would borrow other residents' lighters if necessary, and residents borrowed lighters from one another. Resident 82 further stated the facility staff did not supervise the residents while smoking. During a follow-up observation and interview with Resident 82 on 3/4/25 at 3:00 p.m., Resident 82 was smoking in the patio. Resident 82 stated he could smoke at any time and did not need to notify staff. A review of the Oxygen Order Listing Report, dated 3/4/25, indicated an active physician's order for Resident 82 was revised on 7/3/24 for O2 2L per minute via NC PRN for SOB or pain which may be increased up to 5L per min every 24 hours. J. A review of Resident 96's Admission Record dated 3/5/25, indicated Resident 96 was admitted to the facility on [DATE]. A review of Resident 96's History and Physical dated 1/12/25 indicated Resident 96's diagnoses included but not limited to lung adenocarcinoma (A type of cancer that starts in the cells that line the insides of organs and produces substances like mucus), PTSD (Post-Traumatic Stress Disorder - a mental health condition that can develop after experiencing or witnessing a traumatic event causing persistent distress and difficulty functioning), and depression. During a concurrent observation and interview on 3/4/25 at 9:09 a.m., Resident 96 stated he received his cigarettes from other residents who smoke. Resident 96 stated residents who smoked would light their own cigarettes with a lighter that residents had in their possession. Resident 96 further stated that if he did not have his lighter, he would borrow other residents' lighter to smoke a cigarette. A review of the Oxygen Order Listing Report, dated 3/4/25, indicated an active physician's order for Resident 96 was revised on 1/10/25 for O2 3L per minute via NC PRN. A review of the facility's Daily Census, dated 3/2/25, indicated Resident 96's room was located next to non sampled resident (Resident 81). During a concurrent observation and interview on 3/5/25 at 10:07 a.m. with Resident 2, who was not a smoker, was observed with a nasal cannula and oxygen concentrator (medical device that delivers oxygen and increases the amount of oxygen in the air you breathe) machine at the bedside. Resident 2 stated he felt uneasy and unsafe knowing residents can carry lighters and did not know residents were in possession of lighters. Resident 2 stated lighters posed a concern for safety because he used oxygen. A review of Resident 96's Care Plan Report undated, indicated a care plan problem was developed for the use of tobacco. The goals indicated the resident will adhere to the facility's smoking policies and will not suffer injury from unsafe smoking practices. The interventions indicated to Conduct Smoking Safety Evaluation on admission and PRN .Educate Resident/Responsible Party on the facility's tobacco/smoking policy(s) .If a smoking facility, orient Resident to smoking times and procedures .The resident does not require supervision while smoking. However, there was no documented evidence showing the care plan was updated to reflect the most current smoking assessment and addressed safe storage, supervision, and the use of smoking materials. During a concurrent interview and record review with the DON on 3/3/25 at 03:44 p.m., the DON was asked to review the care plans for Residents 4, 13, 26, 79, and 96. The DON verified the care plans were not updated. The DON stated the facility was behind on updating the care plans The DON stated the purpose of developing a care plan was to ensure the staff knew how to care for the residents. The DON stated Resident 4's smoking care plan was last revised on 6/2024. During an interview on 3/5/25 at 8:52 a.m., CNA 3 stated residents who smoked did not need supervision from facility staff to perform smoking activities. During an interview on 3/5/25 at 8:52 a.m., Licensed Vocational Nurse (LVN) 4 stated residents who smoked were not supervised or monitored for smoking. During an interview on 3/5/25 at 9:02 a.m. the Social Services Designee (SSD) stated residents are able to smoke in the patio without supervision. The SSD stated residents who smoke can receive their cigarettes and lighters from family and friends or purchase their own cigarettes and lighters. The SSD stated residents were able to keep their own cigarettes and lighters. During an interview on 3/5/25 at 10:12 a.m. RNA stated residents who smoked were not allowed to carry personal lighters because it could be dangerous and stated accidents such as a fire could occur. During an interview on 3/5/25 at 10:24 a.m. CNA 5 stated residents should not be allowed to carry lighters because it can be unsafe, especially around other residents who are using oxygen. CNA 5 stated lighters around residents using oxygen could cause a fire. During a concurrent interview and record review on 3/7/25 at 2:31 p.m. with Quality Assurance Nurse (QA), Residents 4, 13, 26, 31, 32, 71, 79, 82, 96, and 104's Resident's Clothing and Possessions, was reviewed. The list did not include a lighter for Residents 4, 13, 26, 31, 32, 71, 79, 82, 96, and 104. The QA verified that there was no lighter present upon admission for Residents 4, 13, 26, 31, 32, 71, 79, 82, 96, and 104. The QA stated the Resident's Clothing and Possessions, should be completed upon admission for each resident. During a review of the facility's policy and procedure titled, Smoking Policy - Residents dated 7/2017, showed the . Resident will be evaluated on admission to determine if he or she is a smoker or non-smoker. If a smoker, the evaluation will include: a. Current level of tobacco consumption; b. Method of tobacco consumption (traditional cigarettes; electronic cigarettes; pipe, etc.); c. Desire to quit smoking, if a current smoker; and d. Ability to smoke safely with or without supervision (per a completed Safe Smoking Evaluation . A review of the facility's policy and procedure Personal Property, dated 9/2012 showed . A representative of the admitting office will advise the resident, prior to or upon admission, as to the types and amount personal clothing and possessions that the resident may keep in his or her room .The resident's personal belongings and clothing shall be inventoried and documented upon admission and as such items are replenished . During a review of the facility's policy and procedure titled Oxygen Administration dated 10/2010, indicated under .Steps in the Procedure .step four, remove all potentially flammable items (e.g., lotions, oils, alcohol, smoking articles, etc.) from the immediate area where the oxygen is to be administered . A review of the facility's policy and procedures titled Goals and Objectives, Care Plans, revised 4/2009, indicated Care plans shall incorporate goals and objectives that lead to the resident's highest obtainable level of independence .4. Goals and objectives are entered on the resident's care plan so that all disciplines have access to such information and are able to report whether or not the desired outcomes are being achieved . An Immediate Jeopardy (IJ-a situation that has threatened or is likely to threaten the health and safety of a resident) was called under F689 S483.25(d)(1) (The resident environment remains as free of accident hazards as is possible;) and was identified on 3/4/25 at 6:53 p.m., regarding the following deficient practices: *The facility failed to ensure safe smoking practices were followed when smoking residents were in possession of smoking materials (cigarettes and lighters) and smoking unsupervised. *The facility failed to conduct smoking assessments on admission and on a quarterly basis to ensure smokers were identified in the facility and monitored for smoking activities. *The facility failed to develop individualized care plans addressing smoking activities. The IJ was called in the presence of the Administrator and DON Corrective Action Plan (CAP- a plan which includes interventions to remove the potential or actual harm of an immediate jeopardy situation) was requested and a preliminary CAP was received on 3/6/25, at 12:35 p.m. and included the following: *Conducted a thorough and complete smoking assessments for all residents who smoke in the facility. *Implementation of a new smoking screening assessment which screens the resident for safety and capability to participate in smoking activities. *Secured all lighters from smoking residents and ensured lighters were kept in a locked box located in the medication room. *Monitored and supervised the residents during smoking activities, with staff responsible for securing and distributing lighters. *Updated the admission process to include admitting nurse to interview and assess the resident for smoking and complete the smoking assessment. *Updated the Medication Administration Record for resident who are an identified smoker so Licensed nurses can monitor and observe residents who smoke. *Updated the care plans for all smoking residents. *In-serviced all staff on the facility's smoking policy and procedures and safety measures related to smoking. * The QA nurse and DSD met with all 10 residents who were identified as a smoker to inform the residents regarding the new protocol with disposable lighters. The disposable lighters will now be in possession of the facility instead of residents who smoke. *Continuous monitoring of the designated smoking area will take place every half hour by staff to ensure that any residents who are smoking, are smoking in a safe manner and no changes of condition are taking place. A monitoring log will be filled out by the staff member and kept on file for further evaluation and review. The acceptable corrective action was verified with the facility to be implemented through observation, interview, and record review. The IJ was lifted on 3/6/25, at 4:15 p.m., in the presence of the Administrator and DON.

Based on observation, interview, and record review, the facility failed to adhere to established food safety and sanitation standards when: 1. A container of parsley flakes was past the best buy date. 2. Two unopened bags of bread were past the best buy date. 3. Food debris was found on the floor under the stove and under the large food mixer. 4. A scoop was on top of grains and cereals container. 5. Wet trays that were stacked together and not air dried. These had the potential to place susceptible residents who receives food from Dietary Services at risk for food-borne illnesses. Findings: 1. During a concurrent observation of the kitchen and interview, on 3/3/25, at 8:39 a.m., with the Dietary Services Supervisor (DSS), a container of parsley flakes was found on the spice rack with past best buy date of 02/23/2025. DSS confirmed that the container of parsley flakes was past the best buy date and should be discarded. During a concurrent interview and record review on 3/7/25 at 11:10 a.m., with the DSS, Quality Assurance (QA) Nurse, and Administrator, the undated facility's policy and procedure (P&P) titled, Non-Leftover Food Products (Including Labeling & Dating of Products), was reviewed. The P&P indicated, .It is the policy of this facility to use food products by the manufacturers expiration date or, when no expiration date is provided, within time periods generally accepted as safe .DSS stated that she threw away all food that was past the best buy date as that was the facility's best practice. 2. During a concurrent observation of the kitchen and interview on 3/3/25, at 09:02 a.m., with the DSS, two bags of bread were found on the bread rack with a past best buy date of 2/26/25. DSS verified that the two bags of bread were past the best buy date. During a concurrent interview and record review on 3/7/25 at 11:10 a.m., with the DSS, QA Nurse, and Administrator, the undated facility's policy and procedure (P&P) titled, Non-Leftover Food Products (Including Labeling & Dating of Products), was reviewed. The P&P indicated, It is the policy of this facility to use food products by the manufacturers expiration date or, when no expiration date is provided, within time periods generally accepted as safe. DSS stated that she threw away all food that was past best the buy date as that was the facility's best practice. 3. During an observation of the kitchen on 3/3/25, at 8:35 a.m., with the DSS, food debris were found on the floor under the kitchen stove. During an observation of the kitchen and interview on 3/3/25, at 8:42 a.m., with the DSS, food debris were found on the floor under the large food mixer. DSS stated, the kitchen area was expected to always be clean. During a concurrent interview and record review on 3/7/25 at 11:10 a.m., with the DSS, QA Nurse, and Administrator, the facility's P&P titled, Sanitation dated October 2008 was reviewed. The P&P indicated, .1. All kitchens, kitchen areas and dining areas shall be kept clean, free from litter and rubbish and protected from rodents, roaches, flies and other insects . 4. During an initial observation tour of the kitchen and interview on 3/3/25 at 08:53 a.m., with the DSS, a scoop was found on top of the grains/cereal container. The DSS stated that it should not be placed on top of the grains/cereal container and pointed to another shelf where the scoop should be kept inside a clear container. During a concurrent interview and record review on 3/7/25 at 11:10 a.m., with the DSS, QA Nurse, and Administrator, the facility's P&P titled, Food Receiving and Storage, revised October 2008 was reviewed. The P&P indicated, .Foods shall be received and stored in a manner that complies with safe food handling practices .1. Food Services. or other designated staff, will maintain clean food storage areas at all times . The DSS stated the facility did not follow their policy. 5. During an observation of the kitchen and interview on 3/3/25, at 09:20 a.m., with the Dietary Services Supervisor (DSS), wet trays were found stacked together and not air dried. DSS stated that all trays should be air dried before storing. During a concurrent interview and record review on 3/7/25 at 11:10 a.m., with the DSS, QA Nurse, and Administrator, the facility's P&P titled, Sanitation dated October 2008 was reviewed. The P&P indicated, .10. Food preparation equipment and utensils that are manually washed will be allowed to air dry whenever practical. The DSS stated they did not follow the facility policy. During a review of the 2022 FDA (Food and Drug Administration) Food Code, 4-901.11 indicated, Equipment and Utensils, Air-Drying Required .After cleaning and SANITIZING, EQUIPMENT and UTENSILS: ((A) Shall be air-dried or used after adequate draining as specified in the first paragraph of 40 CFR 180.940 Tolerance exemptions for active and inert ingredients for use in antimicrobial formulations (food-contact surface SANITIZING solutions), before contact with FOOD; and (B) May not be cloth dried except that UTENSILS that have been air-dried may be polished with cloths that are maintained clean and dry .

Based on observation, interview, and record review, the facility failed to ensure garbage and refuse was not overflowing and dumpster's lids were completely closed. This failure had the potential to attract pests (like flies and rodents) and spread diseases and infection to the residents. Findings: During a concurrent observation and interview on 3/5/25, 3:25 p.m., with the Maintenance Supervisor (MS), two dumpsters located at the side of the facility across the parking lot were observed with the lid not completely closed and not covering the dumpsters. Multiple bags of trash created an overflow on the dumpster's lid. Maintenance Supervisor stated the trash should not be overflowing, and lids should be closed completely. During a concurrent interview and record review on 3/7/25, at 11:10 a.m. with the Dietary Services Supervisor (DSS), Quality Assurance (QA) Nurse, and Administrator, the facility's undated policy and procedure (P&P) titled, Food-Related Garbage and Refuse Disposal, the policy indicated, .6. Outside dumpsters provided by garbage pickup service will be kept closed and free of surrounding litter . The Administrator confirmed the facility was not in compliance and the lid should always be closed all the way. During a review of the 2022 FDA (Food and Drug Administration) Food Code, 5-501.115 titled Maintaining Refuse Areas and Enclosures the Food Code indicated, .Outside receptacles must be constructed with tight-fitting lids or covers to prevent the scattering of the garbage or refuse by birds, the breeding of flies, or the entry of rodents .

Based on interview and record review, the facility failed to provide written information concerning the right to formulate an Advance Directive (a written document specifying an individual's medical care wishes) for nine of 10 sampled residents (Residents 4, 13, 15, 16, 18, 34, 35, 49, and 55). This failure had the potential for the residents' decisions regarding their healthcare and treatment options not being honored. Findings: a. During a review of Resident 4's Admission Record, (a document showing a summary of the resident's information) dated 3/5/25, indicated Resident 4 was readmitted to the facility on [DATE]. A review of Resident 4's POLST, (Physician Orders for Life-Sustaining Treatment - a form that documents an individual's preferences for end-of-life care), dated 10/24/24, indicated Resident 4 did not have an Advance Directive. A review of Resident 4's Advance Directive Acknowledgement form, dated 1/24/25, indicated Resident 4 understood that he was not required to have an Advance Directive to receive medical treatment at the facility. However, the form was incomplete and did not indicate documented evidence that Resident 4 was provided additional written information concerning his right to formulate an Advance Directive. b. A review of Resident 13's Admission Record, dated 3/5/25, indicated Resident 13 was readmitted to the facility on [DATE]. A review of Resident 13's POLST, dated 1/25/24, indicated Resident 13 did not have an Advance Directive. A review of Resident 13's Advance Directive Acknowledgement form, dated 1/24/25, indicated Resident 13 understood that she was not required to have an Advance Directive to receive medical treatment at the facility. However, the form was incomplete and did not indicate documented evidence that Resident 13 was provided additional written information concerning her right to formulate an Advance Directive. c. A review of Resident 15's Admission Record, dated 3/5/25, indicated Resident 15 was readmitted to the facility on [DATE]. A review of Resident 15's POLST, dated 10/26/22, indicated Resident 15 did not have an Advance Directive. A review of Resident 15's Advance Directive Acknowledgement form, dated 2/3/25, indicated Resident 15 understood that he was not required to have an Advance Directive to receive medical treatment at the facility. However, the form was incomplete and did not indicate documented evidence that Resident 15 was provided additional written information concerning his right to formulate an Advance Directive. d. A review of Resident 16's Admission Record, dated 3/5/25, indicated Resident 16 was readmitted to the facility on [DATE]. A review of Resident 16's POLST, dated 8/9/16, indicated Resident 16 did not have an Advance Directive. A review of Resident 16's Advance Directive Acknowledgement form, dated 1/24/25, indicated the resident understood that she was not required to have an Advance Directive to receive medical treatment at the facility. However, the form was incomplete and did not indicate documented evidence that Resident 16 was provided additional written information concerning her right to formulate an Advance Directive. e. A review of Resident 18's Admission Record, dated 3/5/25, indicated Resident 18 was readmitted to the facility on [DATE]. A review of Resident 18's POLST, dated 11/24/24, indicated Resident 18 did not have an Advance Directive. A review of Resident 18's Advance Directive Acknowledgement form, dated 1/24/25, indicated Resident 18 understood that she was not required to have an Advance Directive to receive medical treatment at the facility. However, the form was incomplete and did not indicate documented evidence that Resident 18 was provided additional written information concerning her right to formulate an Advance Directive. f. A review of Resident 34's Admission Record, dated 3/5/25, indicated Resident 34 was admitted to the facility on [DATE]. A review of Resident 34's POLST, dated 9/25/20, indicated Resident 34 did not have an Advance Directive. A review of Resident 34's Advance Directive Acknowledgement form, dated 1/28/25, indicated Resident 34 understood that he was not required to have an Advance Directive to receive medical treatment at the facility. However, the form was incomplete and did not indicate documented evidence that Resident 34 was provided additional written information concerning his right to formulate an Advance Directive. g. A review of Resident 35's Admission Record, dated 3/5/25, indicated Resident 35 was admitted to the facility on [DATE]. A review of Resident 35's POLST, dated 5/19/22, indicated Resident 35 did not have an Advance Directive. A review of Resident 35's Advance Directive Acknowledgement form, dated 2/7/25, indicated Resident 35 understood that she was not required to have an Advance Directive to receive medical treatment at the facility. However, the form was incomplete and did not indicate documented evidence that Resident 35 was provided additional written information concerning her right to formulate an Advance Directive. h. A review of Resident 49's Admission Record, dated 3/5/25, indicated Resident 49 was readmitted to the facility on [DATE]. A review of Resident 49's POLST, dated 7/8/22, indicated Resident 49 did not have an Advance Directive. A review of Resident 49's Advance Directive Acknowledgement form, dated 1/31/25, indicated Resident 49 understood that she was not required to have an Advance Directive to receive medical treatment at the facility. However, the form was incomplete and did not indicate documented evidence that Resident 49 was provided additional written information concerning her right to formulate an Advance Directive. i. A review of Resident 55's Admission Record, dated 3/5/25, indicated Resident 55 was readmitted to the facility on [DATE]. A review of Resident 55's POLST, dated 5/22/24, indicated the form was incomplete. The boxes were not marked to indicate whether the resident had or did not have an Advance Directive. A review of Resident 55's Advance Directive Acknowledgement form, dated 1/24/25, indicated Resident 55 understood that he was not required to have an Advance Directive to receive medical treatment at the facility. However, the form was incomplete and did not indicate documented evidence that Resident 55 was provided additional written information concerning his right to formulate an Advance Directive. During a concurrent interview and record review on 3/5/25 at 2:38 p.m. with the Social Services Designee (SSD), the SSD was asked to explain the facility's process and policies concerning Advance Directives. The SSD stated when a resident was admitted , she explained the purposes of having an Advance Directive and POLST. The SSD offered written materials explaining what an Advance Directive was and how to formulate one. The materials were offered to the residents or their responsible parties. When asked where the SSD documented that written materials concerning the right to formulate an Advance Directive were offered, the SSD verified she documented in the resident's Advance Directive Acknowledgement form. The SSD verified she did not document anywhere else. The SSD was then asked to review Residents 4, 13, 15, 16, 18, 34, 35, 49, and 55's Advance Directive Acknowledgement forms. The SSD verified the form was incomplete and did not show documented evidence indicating written information concerning Advance Directives were provided to the residents. The SSD stated that she provided the written materials but did not document. The SSD stated the importance of having an Advance Directive was to ensure someone was designated to make medical decisions when residents were no longer able to make decisions for themselves. A review of the facility's policy and procedures titled Advance Directives, revised 12/2016, indicated .1. Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so .8. If the resident indicates that he or she has not established advance directives, the facility staff will offer assistance in establishing advance directives a. The resident will be given the option to accept or decline the assistance, and care will not be contingent on either decision .b. Nursing staff will document in the medical record the offer to assist and resident's decision to accept or decline assistance .

Based on interview and record review, the facility failed to provide a written Bed-Hold (the process of holding or reserving a resident's bed while the resident is in the acute care hospital) Notification to one of three closed sampled residents (Resident 45) at the time of Resident 45's transfer to the hospital. This failure had the potential for Resident 45 and/or the resident's responsible party to be unaware of their rights to return to the facility. Findings: A review of Resident 45's admission Record, (a document showing a summary of the resident's information) dated 3/6/25, indicated Resident 45 was readmitted to the facility on [DATE]. A review of Resident 45's Progress Notes, dated 2/5/25, indicated the staff was unable to obtain the resident's oxygen saturation (the amount of oxygen circulating in the blood) level. The staff then administered 10 liters of oxygen via a non-rebreather mask (an oxygen mask that delivers high concentrations of oxygen) to Resident 45. The document indicated Resident 45's responsible party was notified via phone call and agreed for the resident to be transferred to the hospital. A review of Resident 45's Order Summary Report, dated 2/1/25 to 2/28/25, indicated to transfer the resident to the emergency room (ER) secondary to desaturation (a condition where the blood oxygen levels fall below the normal range) on 2/5/25. Further review of Resident 45's closed clinical record showed no documented evidence a written Bed-Hold Notification was provided to the resident and/or his Responsible Party. During a concurrent interview and record review on 3/6/25 at 5:05 p.m. with Registered Nurse (RN) 3, Resident 45's closed clinical record was reviewed. RN 3 stated if there was an order to transfer the resident to the hospital, the staff would call and inform the Responsible Party. The staff would then write a progress note, enter the physician's order in the Electronic Medical Record (EMR), fill out the transfer sheet, and print other pertinent documents to send with the resident to the hospital. RN 3 stated the facility did not discharge the resident in the system right away and did not place the resident on a bed-hold. When asked if a written Bed-Hold Notification was provided to Resident 45 and/or his Responsible Party at the time of transfer, RN 3 stated there was no written notification provided. RN 3 stated the staff only informed the Responsible Party when they called and placed a note in the EMR indicating Resident 45 was placed on a bed-hold. A review of the facility's policy and procedures titled Bed-Holds and Returns, revised 3/2017, indicated Prior to transfers and therapeutic leaves, residents or resident representatives will be informed in writing of the bed-hold and return policy .

Based on interview and record review, the facility failed to ensure timely completion of the comprehensive admission Minimum Data Set (MDS - a federally mandated resident assessment tool) assessments for two of 20 sampled residents (Residents 104 and 204). This deficient practice had the potential to delay the care planning process to meet Resident 104 and Resident 204's comprehensive and individualized care needs. Findings: During a review of Resident 104's Admission Record, (a document showing a summary of the resident's information) dated 3/5/25, indicated Resident 104 was admitted to the facility on [DATE]. During a concurrent interview and record review on 3/7/25 at 10:30 a.m. with MDSNA, (Minimum Data Set Nurse Assistant) Resident 104's MDS record was reviewed. The MDSNA reviewed the MDS Section A - Identification Information, dated 2/21/25, and verified Resident 104's most recent admission or entry to the facility was on 2/21/25. Review of the MDS Section Z - Assessment Administration, dated 2/21/25 showed the assessment was incomplete and the signature of RN Assessment Coordinator Verifying Assessment Completion was left blank. The MDSNA stated the assessment was due on 3/4/25 and the MDS was not submitted for completion on or before 3/4/25. During a review of Resident 204's Admission Record, dated 3/5/25, indicated Resident 204 was admitted to the facility on [DATE]. During a concurrent interview and record review on 3/7/25 at 10:30 a.m. with the Minimum Data Set Nurse Assistant (MDSNA) Resident 204's MDS record was reviewed. The MDSNA reviewed the MDS Section A - Identification Information, dated 2/26/25, and verified Resident 204's most recent admission or entry to the facility was on 2/19/25. Review of the MDS Section Z - Assessment Administration, dated 2/26/25 showed the assessment was incomplete and the signature of RN Assessment Coordinator Verifying Assessment Completion was left blank. The MDSNA stated the assessment was due on 3/6/25 and the MDS was not submitted for completion on or before 3/6/25. The Centers for Medicare & Medicaid Services (CMS)'s Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated October 2024, indicated Comprehensive assessments are completed upon admission, annually, and when a significant change in a resident's status has occurred .01. Admission Assessment is a comprehensive assessment for a new resident and, under some circumstances, a returning resident that must be completed on the end of day 14, counting the date of admission to the nursing home as day 1 .The MDS completion date (item Z0500B) must be no later than day 14 .

Based on interview and record review, the facility failed to ensure the individualized care plans (the plans showing specific interventions to provide effective and person-centered care to meet the resident's needs) were developed for two of 20 sampled residents when: 1. Resident 70 did not have the care plans developed for the use of divalproex (a medication that affects mood, behavior, or thought processes) and quetiapine (an antipsychotic medication used to treat conditions where someone experiences hallucinations, delusions, or disorganized thinking). 2. Resident 104 did not have the care plan developed for the active medical diagnosis of schizoaffective disorder (a mental health condition where a person experiences both schizophrenia [a condition that affects how people think, feel, and behave] and a mood disorder [a condition that impacts a person's emotional state]) These failures created the risk of inadequately monitoring the residents which can lead to serious adverse consequences and reduced resident safety. Findings: 1. A review of Resident 70's Admission Record, (a document showing a summary of the resident's information) dated 3/7/25 indicated Resident 70 was admitted to the facility on [DATE]. A review of Resident 70's Order Summary Report, dated as of 3/7/25, indicated the following physician's active orders: -Administer divalproex sodium 125 mg (milligrams - a unit of measurement), give two capsules by mouth two times a day for poor impulse control manifested by yelling, starting on 2/20/25. -Administer quetiapine fumarate 25 mg, give one tablet by mouth at bedtime for schizoaffective disorder manifested by visual hallucinations, starting on 2/20/25. A review of Resident 70's Medication Administration Record, dated 2/1/25 to 2/28/25 and 3/1/25 to 3/31/25, indicated divalproex and quetiapine were administered to Resident 70 as per the physician's orders. A review of Resident 70's Care Plan Report undated, indicated there was no documented evidence showing the care plan problems related to Resident 70's use of divalproex and quetiapine were developed. During a concurrent interview and record review on 3/7/25 at 09:41 a.m. with the Minimum Data Set Nurse Assistant (MDSNA), Resident 70's Care Plan Report, undated, was reviewed. The MDSNA verified there were no care plan problems developed for Resident 70's use of divalproex and quetiapine. The MDSNA stated she was one of the staff responsible for developing and updating the residents' care plans. If new medications were ordered for the resident, she developed the care plans as well. Care plans were developed as soon as possible. The care plan problems should have included the side effects and behaviors that staff needed to monitor. The MDSNA stated the purpose of developing care plans was to ensure the staff knew the resident's plan of care and how to monitor the resident properly. 38492 2. A review of Resident 104's Admission Record, dated 3/5/25, indicated Resident 104 was admitted to the facility on [DATE]. During a concurrent interview and medical record review on 3/7/25 at 11:11 a.m. with the MDSNA, Resident 104's medical record was reviewed. Review of Resident 104's History and Physical (Amended), dated 3/4/25, indicated Resident 104 had an active diagnosis of schizoaffective disorder. A review of Resident 104's Care Plan Report undated, failed to show a care plan problem related to the diagnosis of schizoaffective disorder was developed. The MDSNA stated Resident 104 should have a care plan problem for each diagnosis and verified there was no care plan problem addressing Resident 104's active diagnosis of schizoaffective disorder. The MDSNA further stated the purpose of a care plan was to ensure staff knew how to care for the resident and staff was able to address and monitor their individualized needs. A review of the facility's policy and procedures titled Goals and Objectives, Care Plans, revised 4/2009, indicated Care plans shall incorporate goals and objectives that lead to the resident's highest obtainable level of independence .4. Goals and objectives are entered on the resident's care plan so that all disciplines have access to such information and are able to report whether or not the desired outcomes are being achieved .

Based on observation, interview, and record review, the facility failed to ensure that the appropriate respiratory care was provided to two of two final sampled residents (Residents 51 and 67) when: 1. The facility failed to follow the physician's order for oxygen administration for Resident 51. 2. The facility failed to obtain a physician's order for oxygen administration for Resident 67. This failure had the potential for respiratory complications related to inadequate oxygen administration for Residents 51 and 67. Findings: 1. During a facility tour on 3/3/25 at 8:50 a.m., Resident 51 was observed in room with nasal cannula cannula (NC - a small, flexible tube with two prongs, used to deliver supplemental oxygen or increased airflow to a patient through their nostrils) using oxygen concentrator at the rate of 1 LPM (Liters Per Minute - a unit that express flow rate). In addition, a sign oxygen in use was also observed outside Resident 51's door. During an interview on 3/3/25 10:10 a.m., with Licensed Vocational Nurse (LVN 3), LVN 3 confirmed Resident 51 was using an oxygen concentrator with nasal cannula at the rate of 1 LPM instead of 2 LPM. During a concurrent interview and electronic record review with Medical Records (MR) on 3/3/25 at 11 a.m., MR confirmed Resident 51's current physician's orders indicated, O2 (oxygen) at 2 LPM via NC (nasal cannula) for SOB (shortness of breath) every shift. During an interview on 3/7/25 at 3 p.m. with Licensed Vocational Nurse (LVN4), LVN4 stated the charge nurse is responsible for checking resident's oxygen concentrator for the correct rate of flow. A review of Resident 51's admission record dated 3/7/25 indicated Resident 51 was admitted to facility on 12/19/24 with diagnoses (process of identifying disease process) which included chronic obstructive pulmonary disease ([COPD]a lung and airway disease causing breathing problem). A review of Resident 51's History and Physical (H&P), dated 12/20/24, the H & P indicated, Resident 51 had the mental capacity to make own decision. A review of Resident 51's Minimum Data Sheet ([MDS] - (a federally mandated resident assessment tool) dated 12/26/24, section C, indicated Resident 51 has no cognitive impairment. In addition, Resident 51's MDS section O indicated Resident 51 is on oxygen therapy. A review of Resident 51's Order Summary Report dated 3/3/25, indicated an active physician's order dated 1/15/25 for O2 at 2 LPM via nasal cannula for SOB. A review of Resident 51's Care Plan Report dated 12/26/24, indicated, .Provide oxygen as indicated by resident condition and/or provider order. A review of the facility's policy and procedure (P&P) titled, Oxygen Administration, revised 10/2010, the P&P indicated, .Steps in the Procedure . 8. Turn on the oxygen. Unless otherwise ordered, start the flow of oxygen at the rate of 2 to 3 liters per minute. 2. During a facility tour on 03/3/25 at 8:50 a.m., Resident 67 was observed in his room with nasal cannula using his oxygen concentrator at the rate of 5 LPM. In addition, a sign oxygen in use was also observed outside Resident 67's door. During an interview on 3/3/25 10:10 a.m., with Licensed Vocational Nurse (LVN 3), LVN 3 confirmed Resident 67 was using an oxygen concentrator with nasal cannula at the rate of 5 LPM. During an interview with the Medical Records (MR) on 3/3/25 at 11 a.m., MR confirmed there is no physician's order for Resident 67 for oxygen administration. During a concurrent interview and electronic record review with MR on 3/4/25 at 2:45 p.m., MR confirmed Resident 67 had a new physician's order for oxygen administration dated 3/4/25. A review of Resident 67's physician's order indicated, Oxygen at 2-5 L (liters) per N/C (nasal cannula) for SOB (Shortness of Breath), low O2 (oxygen) sats (saturation), comfort. PRN (as needed) every shift for history of respiratory failure. Start Date: 3/4/2025 15:00 (3 p.m.). During an interview with Registered Nurse (RN 1) on 3/7/25 at 2:50 p.m., RN 1 stated the charge nurse is responsible for carrying out the all the physician's order including oxygen administration at start of resident admission. During a review of Resident 67's admission record dated 3/7/25 indicated Resident 67 was admitted to facility on 12/18/24 with diagnoses (process of identifying disease process) which included acute respiratory failure with hypoxia (lack of oxygen in the tissues of the body). A review of Resident 67's History and Physical (H&P), dated 12/20/24, the H & P indicated, Resident 67 had the mental capacity to make own decision. A review of Resident 67's Minimum Data Sheet ([MDS] - a resident assessment tool) dated 12/24/24, section C, indicated Resident 67 has no cognitive impairment. A review of Resident 67's Weekly assessment dated [DATE] indicated Resident 67 was assessed as independent. A review of Resident 67's Care Plan initiated on 3/3/25 indicated, Oxygen settings: O2 via nasal prongs at 2-5 liters as needed. For low oxygen saturation for SOB (shortness of breath) and comfort. A review of the facility's policy and procedure (P&P) titled, Oxygen Administration, revised 10/2010, the P&P indicated, . Preparation 1. Verify there is a physician's order for this procedure.

Based on interview, and record review, the facility failed to provide the necessary care for one of one sampled residents (Resident 204). The facility failed to ensure Resident 204's Sevelamer (a medication used to control high blood levels of phosphorus in people with chronic kidney disease who are on dialysis) was administered as ordered by the physician on the days the resident left the facility for dialysis (also known as hemodialysis; a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly). This had the potential for Resident 204 not getting the appropriate doses of medications as ordered, resulting in health complications. Findings: A review of Resident 204's Admission Record, dated 3/5/25, indicated Resident 204 was admitted to the facility on [DATE]. A review of Resident 204's History and Physical Examination, dated 2/21/25, indicated Resident 204 had a diagnosis of ESRD (End-Stage Renal Disease, a severe and irreversible condition where the kidneys have lost most of their function and can no longer adequately filter waste products from the blood) on HD (hemodialysis) Tuesdays, Thursdays, and Saturdays. During a concurrent interview and record review on 3/7/25 at 9:03 a.m. with Registered Nurse (RN) 1, Resident 204's medical record was reviewed. RN 1 verified Resident 204's Order Summary Report, dated 3/6/25 had the following physician's active orders: - A physician's order dated 2/20/25, for Sevelamer HCl (hydrochloride) oral tablet 800 mg (milligrams - a unit of measurement), give two tablets by mouth with meals for on HD. - A physician's order dated 3/3/25, for dialysis every Tuesday, Thursday, and Saturday with a pickup time of 11:00 a.m., and drop off time at 4:45 p.m. A review of Resident 204's Medication Administration Record (MAR), dated for 2/1/25 to 2/28/25, showed Sevelamer with a chart code of 1 documented on 2/27/25 for the 12:00 p.m. dose. RN 1 stated a documentation of 1 of the MAR meant absent from home without meds and verified Resident 204's Sevelamer was not administered. Further review of Resident 204's MAR, dated for 3/1/25 to 3/31/25, indicated Sevelamer with a chart code of 1 was documented on 3/1/25, 3/4/25, and 3/6/25 for the 12;00 p.m. dose. RN 1 stated Sevelamer was not given to Resident 204 on 3/1/25, 3/4/25, and 3/6/25 because Resident 204 was absent from home without meds. RN 1 stated the facility was supposed to send the medication with Resident 204 on dialysis days or communicate with dialysis to ensure the resident received the medication. During an interview on 3/7/25 at 9:11 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 204 did not receive the Sevelamer medication as ordered by the physician and verified the medication was not administered consistently before Resident 204 left for dialysis. During a review of the facility's policy and procedure titled End-Stage Renal Disease, Care of a Resident with, dated 10/01, indicated . education and training of staff includes, specifically . timing and administration of medications, particularly those before and after dialysis and . agreements between this facility and the contracted ESRD facility include all aspects of how the resident's care will be managed including how information will be exchanged between the facilities.

Based on observations, interviews, and record reviews, the facility failed to ensure a resident's nutritional and dietary needs were met when the Registered Dietitian (RD) failed to review the quarterly assessment. This had the potential for nutritional and dietary needs to remain unmet for one of six sampled residents (Resident 18). Findings: During an interview on 3/3/25 at 11:28 a.m. with Resident 18, Resident 18 stated she had episodes of weight fluctuations due to her advanced age. Resident 18 further stated she received Lasix (a medication that helps reduce fluid buildup in the body) for fluid retention. During a record review on 3/5/25 at 8:31 a.m. of Resident 18's profile on the Electronic Medical Record (EMR), the profile indicated Resident 18 was initially admitted to the facility on [DATE], with diagnoses including acute (sudden) kidney failure, morbid obesity among others. During a concurrent interview and record review on 3/7/25 at 9:05 a.m., with the Dietary Services Supervisor (DSS), Resident 18's Nutritional Screening Assessment (NSA) was reviewed. The DSS stated the last assessment done for Resident 18 was on 11/27/24. During a phone interview on 3/7/25 at 9:07 a.m. with the RD, the RD stated the duties and responsibilities of an RD included completing assessments of residents' nutritional status. RD further stated that residents, at the least, will be seen quarterly and annually, and as needed . During a concurrent interview and record review on 3/7/25 at 9:48 a.m. with the Quality Assurance Nurse (QA), Resident 18's NSA (Nutritional Screening Assessment) was reviewed. The QA stated the facility's expectation was for the RD to visit and see residents on admission, quarterly, annually, and as necessary. The QA stated the last RD visit for Resident 18 was on November 27, 2024, further stating the next visit for the quarterly assessment should have been completed before the end of February 2025. The QA stated Resident 18 should have been seen by the RD, even though the expected quarterly assessment was missed. The QA stated the RD was in the facility on March 5, 2025, but Resident 18's record did not indicate the RD visited and assessed Resident 18. During a concurrent interview and record review on 3/7/25 at 11:10 a.m. with the QA, the facility's policy and procedure (P&P) titled, Dietitian, revised October 2017, was reviewed. The P&P indicated, .A qualified, competent, and skilled Dietitian will help oversee the food and nutrition services in the facility .9. Our facility's Dietitian is responsible for, but not necessarily limited to: a. Assessing nutritional needs of residents .f. Participating in quality assurance and performance improvement (QAPI) when food and nutrition services are involved . The QA stated the RD should assess all residents for nutritional needs on admission, quarterly and annually as the minimum expectation. During the same concurrent interview and record review with the QA, the facility's P&P titled, QAPI- Role of the Dietitian/Food Services Manager, revised April 2014, was reviewed. The P&P indicated, .Duties and Responsibilities .10. Visiting residents periodically to evaluate the excellence of meals served, likes and dislikes, etc .16 . Reviewing and revising care plans and assessments as necessary, but at least quarterly . The QA stated periodically meant visits done for quarterly and annually at the minimum, further stating they did not follow their policy.

Based on observation, interview, and records review, the facility failed to obtain initial screening for rehabilitative services for one of 20 sampled residents, (Resident 455) upon admission. This failure had the potential to result in a decrease in resident's range of motion (the extent and degree of movement a joint or series of joints can achieve) mobility and muscle strength. Findings: During a review of Resident 455's Admission Record, (a document showing a summary of the resident's information), dated 3/5/25, indicated, Resident 455 was admitted to the facility on [DATE]. During a review of Resident 455's History and Physical Examination, (H&P) dated 1/29/25, indicated, Resident 455 had a past medical history of Cerebrovascular accidents (CVA), (commonly known as stroke, occur when blood flow to the brain is interrupted, leading to brain damage), Hemiplegia ( a condition characterized by paralysis or severe weakness on one side of the body). H&P indicated Resident 455 has the capacity to make needs known but cannot make medical decisions. H&P further indicated that Resident 455 is on hospice ( a program that gives special care to people who are near the end of life and have stopped treatment to cure or control their disease). During a review of Resident 455's MDS (MDS, a federally mandated assessment tool), section GG (Functional Abilities and Goals), dated 1/29/25, Resident 455 needed substantial maximal assistance for mobility. During an interview on 3/3/25 at 11:37 a.m., with Resident 455, Resident 455 stated that he wanted to regain strength and function of his left arm and left leg and wanted to be able to stand up again. Resident 455 stated that he does exercises only three to five times a week. During a concurrent interview and record review, on 3/06/25 at 1:45 p.m., with Restorative Nurse Assistant (RNA), RNA stated that Resident 455 has no orders for rehabilitative therapy. Furthermore, Resident 455 has orders for omni cycle (a motorized rehabilitation system used in nursing homes to help patients with limited strength and muscle control participate in therapeutic exercise, focusing on improving balance, coordination, and muscle function) three to five times per week for sixty days. RNA confirmed that Resident 455 has orders for omni cylce. During an interview on 3/07/25 at 9:40 a.m., with Director of Rehab (DOR), DOR stated that residents on hospice upon admission, are not being assessed or screened for the need for rehab services. DOR stated that rehab services for hospice residents are provided by the hospice facility. During a concurrent interview and record review on 3/07/25 at 2:07 p.m., with the Director of Rehab (DOR), the facility's undated policy and procedure (P&P) titled PT/OT/ST Therapy services Resident Screening, indicated that, A therapy screen will be completed upon admission, readmission, quarterly or when any resident shows a significant change in functional ability or safety. A screen indicates if an evaluation is warranted or not . DOR confirmed that as per policy, a therapy screening will be completed upon admission on all residents. Furthermore, DOR confirmed that Resident 455 should have been screened upon admission.

Based on observation, interview, and record review, the facility failed to implement infection control and prevention measures when: 1. Licensed Vocational Nurse (LVN) 2 did not perform proper hand hygiene (the process of cleaning one's hands to remove dirt, germs, and microorganisms with soap and water or an alcohol based foam or gel) during medication administration for Residents 48, 58, and 59. 2. Certified Nurse Assistant (CNA) 1 failed to perform hand hygiene and don (put on) gloves and an isolation gown before entering Resident 355 room, who was on Contact Isolation Precautions (a set of precautions used to stop the spread of germs from a patient to others). 3. Two sharps containers (used for safe disposal of used needles and syringes) were observed filled past the full line indicator (a line marker indicating the container needs to be replaced) for two of three sampled medication carts (Carts 2 & 3). This had the potential risk for infections related to needlestick injuries (injuries caused by punctures from needles used in medical procedures). These failures had the potential for cross contamination and spread of infection which can adversely affect the health and wellbeing of the residents, staff, and visitors. Findings: 1. During a Medication Administration observation on 3/5/25 at 9:09 a.m., LVN 2 prepared the medications for Resident 59. LVN 2 donned (put on) a new pair of gloves and sanitized the wrist BP (Blood Pressure - the force of blood pushing against the walls of the arteries) monitor. LVN 2 then placed the BP monitor on top of the medication cart, doffed (removed) the used pair of gloves, and waited two minutes for the wrist BP monitor to dry. Afterwards, LVN 2 entered Resident 59's room and placed the BP monitor on the resident's wrist. LVN 2 did not perform hand hygiene after sanitizing the wrist BP monitor, and before and after touching Resident 59. After obtaining Resident 59's BP, LVN 2 proceeded to prepare Resident 59's medications. Once all the medication tablets were placed inside a plastic cup, LVN 2 proceeded to administer the medications to Resident 59. LVN 2 did not perform hand hygiene before and after medication administration. After administering medications to Resident 59, LVN 2 stated he will proceed to administer medications to Resident 58. During another Medication Administration observation on 3/5/25 at 9:26 a.m., LVN 2 used hand sanitizer prior to donning a new pair of gloves. LVN 2 proceeded to sanitize the wrist BP monitor, doffed the used gloves, and then waited for the BP monitor to dry for two minutes. Once the BP monitor was dry, LVN 2 entered Resident 58's room and placed the BP monitor on the resident's wrist. After obtaining the BP, LVN 2 prepared the medications. LVN 2 did not perform hand hygiene after sanitizing the BP monitor and before and after touching the resident. Once all the medication tablets were placed inside a plastic cup, LVN 2 administered the medications to Resident 58. LVN 2 did not perform hand hygiene before and after medication administration. During a follow-up Medication Administration observation on 3/5/25 at 10:45 a.m., LVN 2 stated he will be administering insulin (a medication that helps regulate blood sugar levels) to Resident 48. Prior to administering the medication, LVN 2 sanitized his hands and donned a new pair of gloves. LVN 2 then placed the glucose meter (a device that measures the amount of sugar in the blood) and lancet (a sharp tool used to make incisions or pricks in the skin) on a clean tray and entered Resident 48's room. LVN 2 used an alcohol pad to clean Resident 48's finger and waited for it to dry. Upon pricking the finger with the lancet, no blood came out. LVN 2 removed his gloves, did not perform hand hygiene, and proceeded to retrieve a new lancet from the medication cart. LVN 2 donned new gloves, cleaned the resident's finger with an alcohol pad, waited for it to dry, and pricked the finger using the lancet. Upon pricking the finger, LVN 2 wiped away the first drop of blood with gauze. However, LVN 2 realized he did not have a glucose test strip (a small strip of material used with a glucose meter to measure blood sugar levels) available in the tray. While still wearing both gloves on, LVN 2 went back to the medication cart located in the doorway. LVN 2 kept the right glove on and only removed the left glove to retrieve a glucose test strip from the medication cart. LVN 2 did not perform hygiene. Once LVN 2 obtained the glucose test strip and placed it on the tray, LVN 2 donned a new glove on his left hand and proceeded to check the resident's glucose level. There was no hand hygiene performed after wiping the first drop of blood from the resident's finger, before opening the medication cart, and before checking the resident's glucose level. LVN 2 proceeded to administer the correct dose of insulin to Resident 48. However, LVN 2 did not perform hand hygiene before and after administering the medication. During an interview on 3/5/25 at 11:00 a.m. with LVN 2, LVN 2 was asked about the facility's infection control practices during medication administration. LVN 2 stated hand hygiene should be performed before and after administering medications. LVN 2 stated hand hygiene should also be performed before and after touching the resident. LVN 2 was informed of the observation findings. LVN 2 acknowledged the findings. LVN 2 stated he should have performed hand hygiene and removed both gloves after checking the resident's glucose level. During an interview on 3/6/25 at 3:50 p.m. with the Director of Staff Development (DSD), the DSD was asked about the facility's infection control policies during Medication Administration. The DSD stated the policy was for the staff to perform hand hygiene before and after administering medication, anytime a staff entered and left the resident's room, and before and after touching the resident. The DSD stated the importance of performing hand hygiene was to ensure infection was not transmitted to other people. A review of the facility's policy and procedure titled Administering Medications, revised 4/2019, indicated .Staff follows facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable . A review of the facility's policy and procedure titled Handwashing/Hand Hygiene, revised 8/2019, indicated .6. Wash hands with soap (antimicrobial or non-antimicrobial) and water for the following situations: a. When hands are visibly soiled .7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: .b. Before and after direct contact with the residents .c. Before preparing or handling medications .g. Before handling clean or soiled dressings, gauze pads, etc .i. After contact with a resident's intact skin .j. After contact with blood or bodily fluids .k. After handling used dressings, contaminated equipment, etc l. After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident .m. After removing gloves . 46488 2. During a review of Resident 355's Admission Record, (a document showing a summary of the resident's information) dated 3/5/25, indicated Resident 355 was admitted to the facility on [DATE]. A review of Resident 355's Order Summary Report, dated 3/7/25, showed an active physician's order dated 2/18/25, indicating Contact Isolation Precautions R/T (related to) Bacteremia. During an observation on 3/3/25 at 12:45 p.m., in front of Resident 355's room, CNA 1 entered Resident 355's room without wearing gloves and a gown. Resident 355's room had a sign in front of the room indicating, See nurse before entering the room and a plastic bin with drawers containing Personal Protective Equipment ([PPE] - items like gloves, gowns, masks, respirators, goggles or face shields, used to protect from infectious agents) outside the door. CNA 1 assisted Resident 355 with his cellphone, then returned the cellphone to Resident 355 and proceeded to exit the room without performing hand hygiene. During an interview on 3/3/25 at 12:50 p.m. with CNA 1, CNA 1 stated the facility's policy was to use PPE when providing direct care for a resident on Contact Isolation Precautions. CNA 1 verified she did not wash her hands after assisting Resident 355 and the next time CNA 1 would perform hand hygiene is when she entered another resident's room. During an interview on 3/4/25 at 9:35 a.m. with Treatment Nurse (TN) 2, TN 2 acknowledged Resident 355 was on Contact Precautions due to an active infection in urine. TN 2 stated prior to entering Resident 355's room, staff must perform hand hygiene and don PPEs including a gown and gloves. TN 2 further stated that if staff entered Resident 355's room and touched any of Resident 355's belongings, including a cellphone, donning PPEs were required, and hand hygiene must be performed prior to the exit of Resident 355's room. During an interview on 3/5/25 at 8:55 a.m. with Registered Nurse (RN) 1, RN 1 verified Resident 355 was on Contact Isolation and stated the expectation prior to entering the room was to perform hand hygiene and don PPEs and prior to exiting of the room was to remove PPEs and perform hand hygiene. RN 1 stated the importance of hand hygiene and following the infection control protocol for a resident in isolation, was to prevent spread of infection, organism, and bacteria. During a concurrent interview and record review with the DSD on 3/7/25 at 8:52 a.m., the facility's policy and procedure titled, Handwashing/Hand Hygiene, revised August 2019, indicated .7. Use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: . b. before and after direct contact with residents; .l. After contact with objects (e.g. medical equipment) in the immediate vicinity of the resident; .n. Before and after entering isolation precaution settings . The DSD verified the facility's hand hygiene policy and stated staff must adhere and follow the policy as mentioned above. 44529 3. During a concurrent observation and interview on 3/3/25 at 10:40 a.m. with LVN 3, LVN 3 was observed attending to Medication Cart 3. There was a sharps container attached to the side of the medication cart that was filled past the full line indicator. LVN 3 stated whoever was assigned to the cart is responsible for changing and disposing sharps container when it is full, further stating the container on Medication Cart 3 should have been replaced because the contents were past the full line indicator. During a concurrent observation and interview on 3/5/25 at 9:02 a.m. with LVN 2, LVN 2 was observed attending to Medication Cart 2. The sharps container attached to the side of the medication cart was observed filled past the full line indicator. LVN 2 stated whoever was assigned to the cart is responsible for changing and disposing sharps container when it is full, further stating the container on Medication Cart 2 should have been replaced because the contents were past the full line indicator. During a concurrent interview and record review with the Quality Assurance (QA) Nurse , on 3/7/25, at 11:10 a.m., of the facility's P&P, titled, Sharps Disposal, revised January 2012, indicated, .The facility shall discard contaminated sharps into designated containers .Policy Interpretation and Implementation .3 .c. Designated individuals will be responsible for sealing and replacing containers when they are 75% to 80% full to protect employees from punctures and/or needlesticks when attempting to push sharps into the container . The QA Nurse stated they did not follow their policy.

Based on observation, interviews, and record review, the facility failed to follow its policy and procedure to provide care and services for residents and ensure call lights are answered in a timely manner for all four sampled residents (Residents 1, 2, 3, and 4). This failure has the potential to jeopardize the health and safety of clinically compromised Residents (Residents 1, 2, 3, and 4) when their requests for assistance with activities of daily living were not responded to promptly. Findings: During the review of Resident 1's admission record (It contains important information about the patient such as their personal details, the reason for their admission, and their medical history), the document indicated Resident 1 was admitted to the facility on [DATE], with a diagnosis that included metabolic encephalopathy (brain is not working properly because of imbalance in the body's chemicals). During a review of the clinical record for Resident 1's, the Brief Interview for Mental Status (BIMS- screening tool to identify and monitor cognitive decline), dated October 7, 2024, indicated, Resident 1's score was a 15, which indicated Resident 1 had no mental impairment. During interview and observation with Resident 1 on November 23, 2024, at 10:00 a.m., Resident 1 stated that the responds to all lights with delays that can be immediate or not at all. Sometimes, staff enter his room, and mistakenly think he is asleep. As a result, the staff turn off the call light without checking if he needs help. During the review of Resident 2's admission record, the document indicated Resident 2 was admitted to the facility on [DATE], with a diagnosis that included anemia ( a condition where the body does not have enough healthy red blood cells, which can lead to a lack of oxygen). During a review of the clinical record for Resident 2's, the Brief Interview for Mental Status (BIMS- screening tool to identify and monitor cognitive decline), dated November 6, 2024, indicated, Resident 1's score was a 15, which indicated Resident 1 had no mental impairment. During an interview and observation with Resident 2 on November 23, 2024, at 11:07 a. m., Resident 2 stated that he has to wait for assistance. Resident 2 mentioned that it usually takes at least 30 minutes and that this happens too often, at least once a day. During the review of Resident 3's admission record, the document indicated Resident 3 was admitted to the facility on [DATE], with a diagnosis that included multiple sclerosis (A chronic disease that affects the brain and spinal cord; symptoms can include double vision, difficulty walking, loss of balance, numbness and tingling, muscle weakness or spasms, and fatigue.). During a review of the clinical record for Resident 3's, the Brief Interview for Mental Status (BIMS- screening tool to identify and monitor cognitive decline), dated October 1, 2024, indicated, Resident 1's score was a 15, which indicated Resident 1 had no mental impairment. During an interview and observation with Resident 3 on November 23, 2024, at 11:24 a.m., Resident 3 reported the staff takes a long time to answer his call, with a wait time of about 45 minutes to an hour. During the review of Resident 4's admission record, the document indicated Resident 4 was admitted on [DATE], with a diagnosis that included Parkinson's disease without dyskinesia ( a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination). During a review of the clinical record for Resident 4's, the Brief Interview for Mental Status (BIMS- screening tool to identify and monitor cognitive decline), dated November 15, 2024, indicated, Resident 1's score was a 15, which indicated Resident 1 had no mental impairment. During an interview and observation with Resident 4 on November 23, 2024, at 11:34 a.m., Resident 4 stated the staff sometimes delays responding to her call lights, stated that she has to wait for up to an hour. During an interview with the administrator (ADM) 1, on November 25, 2024,at 3:54 p.m., ADM 1 acknowledged that the staff needed to respond to call lights more promptly. During a review of the facility's policy and procedure (P&P) titled, Answering the Call Light. dated March 2021, The P&P indicated, The purpose of this procedure is to ensure timely responses to the resident's requests and needs.

Based on observation, interview, and record review, the facility failed to adhere to its food-related garbage disposal policy when two outdoor dumpsters were left open. This failure had the potential to attract vermin (pest or animals that spread diseases) which could pose a significant health risk to the 100 clinically compromised residents currently residing in the facility. Findings: During a concurrent observation and interview, on November 23, 2024, at 1:20 p.m., with Director of Staff Developer (DSD) 1, I brought her to the garbage disposal area outside the facility and showed her that two of the dumpsters were open. During an interview on November 25, 2024, at 3:54 p.m., with Administrator (ADM) 1, I informed ADM 1 that during my inspection of the dumpsters on November 23, 2024, I discovered that two of the dumpsters was left uncovered. I mentioned to ADM 1 that it should be closed at all times with tight fitting lids if it is not in continuous use, in accordance with facility policy. During a review of the facility's policy and procedure (P&P) titled, Food-Related Garbage and Rubbish Disposal, dated October 2017, the P&P indicated, .6. Outside dumpsters provided by garbage pickup services will be kept close and free of surrounding litter. During a review of the FDA Federal Food Code, 2022, it indicated, .Proper storage and disposal of garbage and refuse are necessary to minimize the development of odors, prevent such waste from becoming an attractant and harborage or breeding place for insects and rodents .

Based on interview and record review the facility failed to follow their policy when a staff did not notify the responsible party of blisters observed on the right hand of one of three sampled residents (Resident 1) and document in the medical record. This had the potential to exclude the family and responsible party of (Resident 1) to actively participate in the plan of care related to the resident's change of condition. Findings: During a review of Resident 1 ' s Face Sheet (general demographics) on August 28, 2024, the document indicated Resident 1 was admitted to the facility on [DATE], with diagnosis that included Alzheimer ' s (a brain condition that slowly destroys memory), dementia (a condition of loss of memory and thinking caused by brain damage of blood flow to the brain). During a review of Resident 1 ' s Face Sheet indicated, Responsible Party, Wife [Name of wife] with phone number provided. During a review of Resident 1 ' s History and Physical Examination (H&P), the H&P dated July 16, 2024, indicated, .This resident (Resident 1): .B. does NOT have the capacity to understand and make decisions. Reason: Dementia . A review of Resident 1 ' s Order Summary dated August 26, 2024, indicated, Right Hand Multiple Intact Blisters . During an interview on August 28, 2024, at 11:05 AM, with Licensed Vocational Nurse (LVN 1), the LVN 1 stated, I forgot to notify the responsible party of the blisters on the resident ' s right hand when I noticed them. During an interview on August 28, 2024, at 11:10 AM, with the Director of Nurse (DON), the DON acknowledged the LVN 1 did not inform the Resident 1 ' s responsible party of the blisters on the Resident 1 ' s right hand. The DON further stated, I expected the nurse to have notified the responsible party of the blisters. During a review of the facility ' s policy and procedure (P&P), titled, Change in a Resident ' s Condition or Status, dated, February 2021, the P&P indicated, Policy Statement: Our facility shall promptly notify the resident, his or her attending physician, and representative of changes in the resident ' s medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc . Policy Interpretation and Implementation . 4. Unless otherwise instructed by the resident, a nurse will notify the resident ' s representative when . b. there is a significant change in the resident ' s physical, mental, or psychosocial status; .

Based on observation, interview, and record review, the facility failed to ensure: 1. The call lights are answered in a timely manner for two of three residents (Resident 2 and Resident 3). This failure placed two clinically compromised Residents (Resident 2 and Resident 3) health and psychosocial (emotional) status at risk when their need for nursing care was not met timely. 2. Nursing staff monitor one of three residents (Resident 1) every shift for hydration after a change of condition. This failed practice had the potential for a delay in treatment and placed Resident 1 at risk for dehydration. Findings: 1. During a review of Resident 2's clinical record, the face sheet (contains demographic and medical information), indicated Resident 2 was admitted on [DATE], with diagnoses which included: Multiple sclerosis (disease of the nervous system, which gradually makes a person weaker), paraplegia (inability to voluntarily move the lower parts of the body) and pressure ulcer (injuries to skin and underlying tissue resulting from prolonged pressure.) During a review of Resident 3's clinical record, the face sheet (contains demographic and medical information), indicated Resident 3 was admitted on [DATE], with diagnoses which included: muscle weakness, osteoarthritis (degenerative joint disease, in which the tissues in the joint break down over time causing pain and stiffness). and abnormalities of gait and mobility. During a review of the clinical record for Resident 2, the Brief Interview for Mental Status dated January 2, 2024, indicated a score of 15 which indicated Resident 2 was cognitively intact. During a review of the clinical record for Resident 3, the Brief Interview for Mental Status dated November 16, 2023, indicated a score of 15 which indicated Resident 3 was cognitively intact. During a interview on January 16, 2024, at 11:56 AM in Resident 2 ' s room, Resident 2 stated, Call lights? The time it takes to answer the call lights is Poor. On average it takes an hour or more for the call light to be answered. I ' m asking mostly to be moved in bed. I can ' t move. I ' m a paraplegic. I ' m lying on my wounds. Resident 2 stated further, The weekends are awful. I won ' t say the help is bad. It is almost non-existent. If I hit the button, if someone comes in a couple of hours then I am lucky. I call the main desk if they don ' t answer the call light and, on the weekend, it does not help to call the main desk. It can take up to a couple of hours to get help. I ' ve had many times that it has taken so long, I have forgotten why I called. I call the nurses because I want water, or my pillow fell off my bed, or to be repositioned. During an interview with a Certified Nursing Assistant (CNA 1) on January 16, 2024, at 12:46 PM, CNA 1 stated, It should take two to three minutes to answer the call lights. Someone else should answer the call light if I ' m with a resident. All staff should answer the call lights. During an observation and concurrent interview with Resident 3 on January 16, 2024, at 1:16 PM, Resident 3 stated, It ' s not coming in a timely manner. The call lights. It takes them hours to answer it. On average, it takes them maybe thirty minutes. I call them to be changed. Resident 3 was asked how does it make you feel? Resident 3 growled and stated it made her upset. They don ' t tell me why it ' s taken an hour. That ' s probably how I got this UTI (urinary tract infection). During a review of the clinical record for Resident 2, the care plan dated December 13, 2023, indicated Ulcer will heal. Interventions: Repositioning: Develop plan with resident input. During a review of the clinical record for Resident 3, the care plan dated May 18, 2023, indicated Urinary Continence. Interventions: Assist with perineal cleaning as needed. Monitor for signs of emotional distress with incontinence. During an interview with the Director of Staff Development on January 16, 2024, at 3:35 PM, DSD stated, Call lights. The expectation, they should be answered in a timely manner. 30 minutes or an hour is too long to answer a call light. Timely manner considered; I would say 5 minutes. It should be right away. Why? To attend to their needs. To meet their needs. It ' s simple. They can ' t get up and do themselves. They need us to provide hydration, transfer, changing. DSD stated further, How does that make them feel? Not important or that we don ' t care. During an interview with the Director of Nursing on January 16, 2024, at 4:58 PM, DON stated, Call lights are to be answered timely. It should be answered timely. DON stated further, We should be more timely. The facility policy and procedure titled, Answering the Call Light dated March 2021, indicated The purpose of this procedure is to ensure timely responses to the resident ' s requests and needs 2. Identify and politely respond to the resident . a. If the resident needs assistance, indicate the approximate time it will take for you to respond . 2. During a review of Resident 1's clinical record, the face sheet (contains demographic and medical information), indicated Resident 1 was readmitted on [DATE], with diagnoses which included: diarrhea, diabetes (high blood sugar) and pressure ulcer (injuries to skin and underlying tissue resulting from prolonged pressure.) During a review of the clinical records for Resident 1, the nurses notes indicated: 1. The note dated November 10, 2023, at 7:43 PM indicated Resident 1 was admitted at around 4:45 PM coming from home accompanied by his wife with a diagnosis of diarrhea and pressure injury of skin. 2. The note dated November 12, 2023 at 1159 AM, Messaged (Name od Physician) regarding wife of pt concerned about pt that he looks dehydrated and weak .Dr ordered to hold diuretics and blood pressure medicine today and stat order of CBC (complete blood count, blood test used to look at overall health), chem seven (test that looks at seven different substances in the blood) and to push fluid as tolerated. 3. The note dated November 12, 2023, at 10:40 PM (Name of Physician) with new order obtained normal saline 0.9% (commonly used for management and treatment of dehydration with the presence of fluid loss, and mild sodium depletion) 125ml (milliliters, unit of measure) an hour via IV (intravenously, into the vein) for 3 days for Hydration . During a review of the clinical record for Resident 1, the Physician's Orders dated November 12, 2023, indicated Normal Saline 0.9% 125 ml (milliliters, unit of measure) an hour via IV (intravenously, into the vein) for 3 days for Hydration. During an interview and concurrent record review of Resident 1 ' s nurses notes with the Director of Staff Development (DSD) on January 16, 2024, at 3:35 PM, DSD stated, we should have monitored for hydration. Its focused monitoring. Let me see the start date. According to physicians order it was to start on November 12, 2023. The new order (for IV fluids) was to start on November 13, 2023. We are to monitor every shift every day on all three shifts (days, evenings, and night shift). DSD stated further, On November 13, 2023: there was nothing documented on night shift. On November 14, 2023, there was no documentation for hydration on night shift or day shift. We don ' t say document every 8 hours, but they should be documenting on all three shifts. DSD then read the policy and procedure for change of condition/status and stated, he should have been monitored for hydration on every shift. DSD did not provide documentation that indicated Resident 1 was monitored every shift or every 8 hours for signs and symptoms related to hydration. During an interview and concurrent record review with the Supervising Registered Nurse (SRN) on January 16, 2024, at 4:45 PM, Change of conditions are done for medication or change in resident status. We monitor them every shift and document. We document related to the change of condition. We document every shift. Charting is for 72 hours. After reviewing Resident 1 ' s nurses notes, SRN stated on November 12, 2023, and November 13, 2023, Nursing (staff) didn ' t document every 8 hours. They should have. During a review of Resident 1 ' s clinical records, the nurse ' s notes dated November 10, 2023, to November 15, 2023, indicated: 1. On November 13, 2023, the night shift nurse did not document that Resident 1 was monitored for signs and symptoms related to hydration. 2. On November 14, 2023, the day and night shift nurses did not document that Resident 1 was monitored for signs and symptoms related to hydration. The facility did not provide documentation that Resident 1 was monitored for hydration every shift or every 8 hours and for a period of 72 hours from November 12, 2023 to November 15, 2023 During an interview with the Director of Nursing on January 16, 2024, at 4:58 PM, DON stated Monitoring is done for medication or change of condition and change of status. It ' s done every shift for 72 hours. DON was asked should the nursing staff have monitored Resident 1 every shift for 72 hours after the order for IV hydration was received? DON stated, IV hydration. Yes, they should have, documentation wise. DON confirmed the nursing staff did not complete monitoring every shift once the order for hydration was received. The facility did not provide documentation that Resident 1 was monitored for hydration every shift or every 8 hours and for a period of 72 hours. The facility policy and procedure titled, Change in Residents Condition or Status dated February 2021 indicated Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the residents medical/mental condition and/or status (e.g., changes in level of care, billing payments, resident rights) 1. The nurse will notify the resident attending physician or physician on call when there has been a significant change in the resident ' s physical/emotional/mental condition; need to alter the resident ' s medical treatment significantly .2.A significant change of condition is a major decline in the resident ' s status that will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions (is not self-limiting.) . The nurse will record in the resident ' s medical record information relative to changes in the resident ' s medical/mental condition or status.

Based on observation, interview, and record review, the facility failed to ensure adequate supervision for three of 95 residents (Resident 15, 22, and 43), when Residents 15, 22, and 43 were found outside of facility premises, alongside of the main road, smoking, and waiting for a friend. These findings had the potential for Residents 15, 22, 43 to be at risk for accidents which can result in life-threatening injuries. Findings: During an observation of the facility environment, on (MONTH) 8, 2019, at 2:40 PM, Resident 15, 22, and 43 were going outside the facility premises heading toward North (name of the street) Street and East (name of the street) Street. The three Residents (Resident 15, 22, and 43) were observed as follows: Resident 15 was sitting in a wheelchair and was wearing a pair of sunglasses. Resident 22 was ambulatory, with a left foot wound dressing, and was pushing the wheelchair of Resident 15. Resident 15 and 22 were on the sidewalk of North (name of the street) Street toward East (name of the street) Street. Resident 43 was in a motorized wheelchair and was cruising in the middle part of the road on North (name of the street) Street toward East (name of the street) Street. Resident 43 took the last ramp on the left side of North (name of the street) Street toward East (name of the street) Street. Resident 15, 22, and 43 were smoking alongside of East (name of the street) Street, and across the street were residential houses. A review of Resident 15's medical records indicated an admitted on (MONTH) 23, (YEAR), with [DIAGNOSES REDACTED]. A review of Resident 22's medical records indicated an admitted on (MONTH) 29, (YEAR), with [DIAGNOSES REDACTED]. A review of Resident 43' medical records indicated an admitted (MONTH) 14, (YEAR), with [DIAGNOSES REDACTED]. During an interview with a Licensed Vocational Nurse (LVN 1), on (MONTH) 8, (YEAR), at 2:57 PM, when asked for the location of the three residents(Resident 15, 22, and 43) LVN 1 stated, I do not know where they (Residents 15, 22, and 43) are at right now. During an interview with a Registered Nurse (RN 1), on (MONTH) 8, (YEAR), at 3 PM, RN 1 stated, If they (Residents 15, 22, and 43) are not here, they (Residents 15, 22, and 43) are in the parking lot. The RN 1 also stated, No one is allowed to go outside the facility premises without a doctor's order. During an interview with the Medical Record (MR) staff, on (MONTH) 8, (YEAR), at 3:08 PM, the MR stated, I am not aware that the residents (Residents 15, 22, and 43) goes there (name of the street). A review of Resident 15's medical record with the MR staff, the Interdisciplinary Team Meeting, since Resident 15's admitted , on (MONTH) 23, (YEAR), indicated no documented discussions of Resident 15's meeting a friend on East (name of the street) Street. A review of Resident 43's medical record with the MR staff, the Interdisciplinary Team Meeting, since Resident 43's admitted , on (MONTH) 14, (YEAR), indicated no documented discussions of Resident 15's meeting a friend on East (name of the street) Street. A review of Resident 15, 22, and 43's Physician Orders, indicated there was no physician order allowing the residents (Residents 15, 22, and 43) to leave the facility premises and meet with a friend on East (name of the street) Street. A review of medical records entitled, Resident Care Plan, indicated: Resident 15's Resident Care Plan: Activity, dated (MONTH) 13, (YEAR), indicated Resident prefer to go out in the parking lot to socialize with friends and family. Monitor for alteration in safety. A review of Resident 22's Resident Care Plan: Activity, dated (MONTH) 16, (YEAR), indicated Resident prefer to go out in the parking lot to socialize with friends and family. Monitor for alteration in safety. A review of Resident 43's Resident Care Plan: Activity, dated (MONTH) 15, (YEAR), indicated Enjoys going out to parking lot/sidewalks to spend times with friends and family. During an interview with the Licensed Vocational Nurse (LVN 2), on (MONTH) 8, 2019, at 4 PM, LVN 2 stated, These residents (Residents 15, 22, and 43) have no out on pass physician order. Requested a policy and procedure for physician order for [REDACTED]. During an interview with Resident 15, on (MONTH) 8, 2019, at 4:12 PM, Resident 15 stated, Me and my friends (Resident 22 and 43) always go there (name of the street) after lunch, to wait for my fiancé. She (Resident 15's fiancé) lives across the street. We also smoke and eat there. Resident 15 further stated, People from here (facility) just wave their (facility staff) hands when they see us (Residents 15, 22 and 43) there (street). During an interview with Resident 22, on (MONTH) 8, 2019, at 4:18 PM, Resident 22 stated, We (Resident 15 and 43) wait for her (Resident 15's fiancé) every day after lunch and she gives us cigarettes. Resident 22 stated, I think they (facility staff) know that we were there. During an interview with the Registered Nurse (RN 2), on (MONTH) 8, 2019, at 4:35 PM, the RN 2 stated, If they are (Residents 15, 22, and 43) on (name of the street) without our (facility staff) supervision, there is a possibility of accidents. A review of the facility logbook for Out on Pass (allowing residents to leave the facility in a certain period of time), indicated Resident 15 and 22 have no sign in and out records, and Resident 43 had one sign in and out with relatives dated (MONTH) 27, (YEAR). During an interview with the Certified Nursing Assistant (CNA 1), on (MONTH) 9, 2019, at 10:53 AM, CNA 1 stated, Sometimes, we (facility staff) do not know where they (residents) are at. If we (facility staff) look for them, that is the only time we found out that they are in the parking lot. The CNA 1 further stated, I am not aware that they (Resident 15, 22, and 43) go to (name of the street) street. During an interview with the Minimum Data Set (MDS) staff, on (MONTH) 9, 2019, at 11:41 AM, the MDS nurse stated, We (facility staff) do visual checking, if we notice that they (residents) are not here (facility), we will look for them. We are not aware that they (Residents 15, 22, and 43) were leaving the premises. During an observation of the facility camera monitor in Nurses' Station 1, on (MONTH) 9, 2019, at 12:23 PM, the monitor showed eight (8) different views from the facility camera as follows: - Camera 1 views the front area of the parking lot; - Camera 2 views the left side corner of the parking lot; - Camera 3 views the front area of the parking lot towards medical group clinic; - Camera 4 views the main door of the facility; - Camera 5 views the right side corner of the lot from the kitchen; - Camera 6 views the Medication Storage 1; - Camera 7 views the Medication Storage 2; and - Camera 8 views the back door of the facility. During an interview with the Maintenance Supervisor (MS), on (MONTH) 9, 2019, at 2:30 PM, the MS stated, There was no facility camera focusing toward the street. During an interview with the Director of Staff Development (DSD 1), on (MONTH) 9, 2019, at 2:48 PM, the DSD 1 stated, No one is monitoring the camera, unless something came up, then we (facility staff) can review it (recorded videos). During an interview with the MDS nurse, on (MONTH) 10, 2019, at 8:10 AM, the MDS nurse stated, The residents (Resident 15, 22, 43) has a BIMS (Brief Interview for Mental Status - a test given by medical professionals that helps determine a patient's cognitive understanding) score of 15 (15 as the highest). (Resident 15) is dependent on wheelchair and can wheel himself in a short distance only. (Resident 22) is ambulatory, with left leg wound: shin area. (Resident 43) is on motorized chair needs, has [MEDICAL CONDITION] (mental disorder). During an environmental observation with the MDS nurse, on (MONTH) 10, 2019, at 8:37 AM, the MDS nurse was made aware that Resident 15, 22, and 43 were found on East (name of the street) street. The MDS nurse stated, That (pointing to east street) is considered as a main road. They (Residents 15, 22, and 45) are prone to accidents. During an observation of the facility, on (MONTH) 10, 2019, at 9 AM, Resident 15 was not in the facility for a scheduled removal of cataract (opacity of the eye) surgery. During an interview with Resident 43, on (MONTH) 10, 2019, at 9:16 AM, Resident 43 stated, We goes to the street (name of the street) to meet (name of the resident) fiancé and we smoke. His (referring to Resident 15) fiancé is a troublemaker. I wished marijuana could be legal. I do not want to be in trouble so it is better for me to shut my mouth. The Resident 43 also stated, I love socialization while smoking. I, sometimes, go to the bus stop station in (name of the street) just to socialize. A review of facility policy and procedures entitled, Signing Residents Out, indicated Policy Statement: All residents leaving the premises must be signed out. Policy Interpretation and Implementation: 1. Each resident leaving the premises (excluding transfers/discharges) must be signed out. 2. A sign-out register is located at each nurses' station. Registers must indicate the resident's expected time of return . 6. Staff observing a resident leaving the premises, and having doubts about the resident being properly signed out, should notify their supervisor at once . 9. Residents must be signed in upon return to the facility. 10. Inquiries concerning the signing out of residents should be referred to the Director of Nursing Services or to the Administrator.

Based on observation, interview, and record review, the facility failed to provide care and service in accordance with acceptable professional standards of quality for one of three sampled residents (Resident A) when: 1. For Resident A, the facility failed to ensure assessment and monitoring was provided for Resident A according to his plan of care when Resident A complained of a sore penis on September 22, 2017, and perineal site discomfort on October 3, 2017. 2. For Resident A, the facility failed to ensure Resident A received urinary catheter (flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) care in accordance with the facility policy and procedure and professional standards to include the use of a leg strap to prevent trauma to the urinary meatus (external orifice of the urethra from which the urine is ejected during urination) from pressure. These failures resulted in Resident A to be transferred to the general acute care hospital (GACH) on October 6, 2017 due to a urethral erosion (adverse complication associated with long term use of urinary catheter wherein there is tearing of the urethra (tube that leads from the bladder and transports and discharges urine outside the body). Findings: An unannounced visit was made to the facility on [DATE] at 2:25 PM, to investigate a complaint regarding quality of care for Resident A. 1. During a review of the clinical record for Resident A, it reflected Resident A was initially admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. activity that can cause symptoms such as muscle spasms, limb twitches, and loss of consciousness), and left eye [MEDICAL CONDITION]. During an observation and concurrent interview with Resident A on November 9, 2017 at 3:45 PM, Resident A was seen in bed, in fowler's (semi-upright) position. Resident A stated it has been three days since the licensed nurses have checked on his penis. During an observation with Treatment Nurse 1 (TXN 1) on November 9, 2017 at 4 PM, Resident A's penis was noted to be swollen. An indwelling urinary catheter was noted inserted below the tip of Resident A's penis, covered by foreskin. Resident A denied any pain or discomfort on his penis. A review of Resident A's physician order sheet, dated April 12, 2017, indicated Foley catheter (type of indwelling urinary catheter to drain urine from the bladder) 16F/10cc (French 16 (size of tubing) with 10 cc (cubic centimeters - unit of measurement) water). Drainage to gravity. Change catheter and drainage bag on the 10th of every month. Dx: (Diagnosis) Stage 4 Pressure ulcer (injury to the skin and underlying tissue down to bone and muscle resulting from prolonged pressure on the skin). A review of Resident A's care plan for the Foley catheter, initiated on April 12, 2017, reflected a goal that included Will be provided with adequate catheter care. Further review indicated Intervention: . Observe evidence of change in resident's condition like presence of fever, change in urine output; report to MD . Further review reflected the care plan did not indicate how often catheter care will be provided to Resident A and how often Resident A's catheter must be assessed or monitored. A review of Resident A's physician progress notes [REDACTED]. Further review indicated A/P (Assessment and Plan) . Urethral tear Urology (field of medicine that focuses on diseases of the urinary tract and the male reproductive tract). A review of Resident A's nursing notes, documented by TXN 1, dated October 3, 2017 at 11:41 AM, indicated received a complaint from resident regarding discomfort to peri (perineal) site. client (resident) has a standing order for an indwelling foly (foley) cath (catheter) to maintain skin integrity to resident's wounds. Wound care nurse reached out to MD for a request to schedule resident with urology consult. MD has approved. Order was noted and appointment coordinator notified. Awaint (await) appointment date. will follow up. There was no documented evidence on Resident A's chart regarding an assessment or monitoring of Resident A's penis when he complained of discomfort to TXN 1 on October 3, 2017. A review of Resident A's social service notes, dated October 4, 2017 at 8:33 AM, reflected a request for authorization was faxed to the case manager of Resident A's insurance for the urology consult. A note dated October 4, 2017 at 11:37 AM, reflected Resident A's insurance authorized for the urology consultation. The available appointment given to the social service staff was December 11, 2017 at 2:10 PM. Further review indicated the social service staff documented, Suggested we should call primary doctor, have him call attending physician in their clinic to schedule apt (appointment) sooner. Endorsed to treatment nurse. Will continue to follow up. A review of Resident A's nursing notes, from October 4, 2017 to October 6, 2017, was conducted. There were no documented evidence that TXN 1 had contacted the MD to inquire if he could call urology for an earlier appointment. A review of Resident A's nursing notes, dated October 6, 2017 at 5 PM, reflected Resident A called the paramedics to take him to the hospital at 3 PM. Further review indicated Resident stated that he was bleeding from his penis and no one was doing anything about it so he called 911. There was no documented evidence that a licensed nurse assessed Resident A's penis to confirm if he was bleeding, swollen or had any change in his condition. A review of Resident A's GACH emergency department notes, dated October 6, 2017, indicated [MEDICAL CONDITION] (genitals and urinary organs): swelling of gland, shaft and base of penis, Penis: Ventral (bottom side), glans, shaft, erosion of ventral surface of glans and shaft down to foley catheter with surrounding scant purulent discharge, Urinary catheter: Indwelling. Further review indicated Examination demonstrates erosion of ventral surface of penile glans and shaft. Patient's urethra is open. Minimal purulent discharge surrounding wound. Swelling of wound. A review of Resident A's GACH history and physical, dated October 7, 2017, indicated ventral area of penis is open and has yellowish pus looking stuffs all around it . CT (Computerized Tomography scan - procedure that assists in diagnosing tumors, fractures, bony structures, and infections) pelvic showed soft tissue swelling and gas in scrotal region. Further review reflected CT scan impression indicated The tip and balloon of the Foley catheter are in the urethra and not in the bladder. A review of Resident A's clinical chart reflected Resident A was readmitted to the facility October 10, 2017 at 9:26 PM. There was no documented evidence on Resident A's chart regarding an order for [REDACTED]. A review of Resident A's urology consultation notes, dated November 2, 2017, reflected the characteristic of Resident A's urethra was described as [DIAGNOSES REDACTED] - penoscrotal (penis to scrotum) (due to erosion from a foley catheter). Further review indicated Current plans . 18F Foley changed and bladder irrigated. Foley attached to a leg bag to minimize any further urethral erosion. Pt (patient) told to have the bag drained as often as necessary to prevent erosion due to weight of the bag . A review of Resident A's urology consultation notes, dated December 3, 2017, indicated Pt (patient) underwent cytoscopy (procedure to examine the lining of the bladder and the tube that carries urine out of the body) with dilatation and debridement (medical removal of dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue) of a urethral erosion secondary to chronic foley catheter. His urethra is eroded to the penoscrotal junction. During an interview with TXN 1 on December 29, 2017, at 3:30 PM, TXN 1 reviewed the clinical record of Resident A and was unable to find documentation that Resident A was assessed and monitored by the nurses after Resident A was diagnosed by the MD with urethral tear on September 22, 2017, and after Resident A complained of discomfort on his penis with TXN 1 on October 3, 2017. TXN 1 stated he assessed Resident A when he complained of discomfort on his penis on October 3, 2017. When asked to describe what the appearance of Resident A's penis was on October 3, 2017, TXN 1 was unable answer. When asked if Resident A's foley catheter was checked, the TXN 1 was unable to answer. During a concurrent interview and record review with TXN 1 of the facility policy and procedure titled Change in a Resident's Condition or Status, undated, TXN 1 stated according to the policy and procedure, Resident A should have been assessed and a change of condition monitoring should have been initiated for the pain on his penis. TXN 1 stated he should have initiated it but he got busy being the lead treatment nurse and being on the floor. During an interview with the Director of Nursing (DON) on December 29, 2017 at 4:20 PM, the review of the facility policy and procedure titled Change in Resident's Condition or Status was conducted. The DON stated the licensed nurses would sometimes assess the residents but would not always document about it. The DON stated the soreness on Resident A's penis was considered a change of condition and monitoring should have been initiated. The facility policy and procedure titled Change in a Resident's Condition or Status, undated, indicated A significant change of condition is a decline or improvement in the resident's status that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical intervention (is not self-limiting); . The Nurse Supervisor/Charge Nurse will record in the resident's medical record information related to changes in the resident's medical/mental condition or status. The facility policy and procedure titled Urinary Catheter Care revised October 2010, indicated Review the resident's care plan to assess for any special needs of the resident . Observe the resident for complications associated with urinary catheters . Report any complaints the resident may have of burning, tenderness, or pain the urethral area During a telephone interview with a Licensed Vocational Nurse (LVN 1), on January 4, 2018 at 2:02 PM, LVN 1 stated Resident A complained of pain on his penis in between late September 2017 to early October 2017 . LVN 1 stated she was able to assess Resident A's penis. LVN 1 stated The side of the penis had damage. When asked to clarify what she meant by damage, she stated she was uncomfortable in answering the question. LVN 1 stated she talked to TXN 1 and was informed that there was an order for [REDACTED]. During a telephone interview with Resident A, on January 17, 2018 at 10:25 AM, Resident A stated he told the MD that his penis was sore when he was seen by the MD on September 22, 2017. Resident A stated there was a tear on his penis where the foley catheter was placed. Resident A stated he told TXN 1 of his penis discomfort prior to October 3, 2017. Resident A stated TXN 1 did not check and assess his penis when he complained about it. 2. During a review of the clinical record for Resident A, it reflected Resident A was initially admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. activity that can cause symptoms such as muscle spasms, limb twitches, and loss of consciousness), and left eye [MEDICAL CONDITION]. During an observation and concurrent interview with Resident A on November 9, 2017 at 3:45 PM, Resident A was seen in bed, in fowler's (semi-upright) position. Resident A stated it has been three days since the licensed nurses have checked on his penis. During an observation with Treatment Nurse 1 (TXN 1) on November 9, 2017 at 4 PM, the observation of Resident A's penis was conducted. Resident A was in bed with his urinary catheter bag attached at the left side of the bed. Resident A's penis was noted to be swollen. An indwelling urinary catheter was noted inserted below the tip of Resident A's penis, covered by foreskin. Resident A denied any pain or discomfort on his penis. There was no leg strap or other anchoring device in place to relieve tension from the urinary catheter on the urinary meatus. A review of Resident A's physician order sheet, dated April 12, 2017, indicated Foley catheter (type of indwelling urinary catheter to drain urine from the bladder) 16F/10cc (French 16 (size of tubing) with 10 cc water). Drainage to gravity. Change catheter and drainage bag on the 10th of every month. Dx: (Diagnosis) Stage 4 Pressure ulcer (injury to the skin and underlying tissue down to bone and muscle resulting from prolonged pressure on the skin). A review of Resident A's physician progress notes [REDACTED]. Further review indicated A/P (Assessment and Plan) . Urethral tear Urology (field of medicine that focuses on diseases of the urinary tract and the male reproductive tract). A review of Resident A's nursing notes, dated October 6, 2017 at 5 PM, reflected Resident A called the paramedics to take him to the hospital at 3 PM. Further review indicated Resident stated that he was bleeding from his penis and no one was doing anything about it so he called 911. The facility policy and procedure titled Urinary Catheter Care revised October 2010, indicated Review the resident's care plan to assess for any special needs of the resident . Ensure that the catheter remains secured with a leg strap to reduce friction and movement at the insertion site. (Note: Catheter tubing should be strapped to the resident's inner thigh. There were no documented evidence on Resident A's chart showing the leg strap for the urinary catheter was offered and refused by Resident A. During a telephone interview with LVN 2, on January 18, 2018 at 5:30 PM, LVN 2 stated It's up to the resident if they want us to place a leg strap. Whatever the resident requests. That is what we do. LVN 2 stated it is not a common practice to place a leg strap on a resident who has a urinary catheter. LVN 2 stated she doubts that a leg strap was used for Resident A's foley catheter. During an interview with Certified Nursing Assistant (CNA 1) on January 19, 2018 at 10:30 AM, a leg strap was not being provided for Resident A's foley catheter tubing. CNA 1 stated Sometimes when the residents come from the hospital or from the doctor's clinic, they would have that. But we don't really use it (leg strap). During an interview with LVN 3, on January 19, 2018 at 10:40 AM, LVN 3 stated We have it (leg strap) on some residents but not all. I haven't seen a lot of residents with it. LVN 3 stated she has not seen a leg strap used for Resident A's foley catheter tubing. During an interview with LVN 1 on January 19, 2018 at 10:50 AM, LVN 1 stated not all residents with foley catheter are provided with leg straps. LVN 1 stated she does not think Resident A was provided with a leg strap. During an interview with TXN 1 on January 19, 2018 at 11 AM, TXN 1 stated Not everybody has it (leg strap). We only place it on residents that pulls them (urinary catheter tubing) out. TXN 1 stated Resident A only used the leg strap for a few times. TXN 1 stated, He is alert and oriented. He doesn't really pull his catheter out. A review of Resident A's GACH emergency department notes, dated October 6, 2017, indicated [MEDICAL CONDITION]: swelling of gland, shaft and base of penis, Penis: Ventral, glans, shaft, erosion of ventral surface of glans and shaft down to foley catheter with surrounding scant purulent discharge, Urinary catheter: Indwelling. Further review indicated Examination demonstrates eriosn of ventral surface of penile glans and shaft. Patient's urethra is open. Minimal purulent discharge surrounding wound. Swelling of wound. A review of Resident A's GACH history and physical, dated October 7, 2017, indicated ventral area of penis is open and has yellowish pus looking stuffs all around it . CT (Computerized Tomography scan - procedure that assists in diagnosing tumors, fractures, bony structures, and infections) pelvic showed soft tissue swelling and gas in scrotal region. Further review reflected CT scan impression indicated The tip and balloon of the Foley catheter are in the urethra and not in the bladder. A review of Resident A's urology consultation notes, dated November 2, 2017, reflected the characteristic of Resident A's urethra was described as [DIAGNOSES REDACTED] - penoscrotal (penis to scrotum) (due to erosion from a foley catheter). Further review indicated Current plans . 18F Foley changed and bladder irrigated. Foley attached to a leg bag to minimize any further urethral erosion. Pt (patient) told to have the bag drained as often as necessary to prevent erosion due to weight of the bag . A review of Resident A's urology consultation notes, dated December 3, 2017, indicated pt underwent cytoscopy (procedure to examine the lining of the bladder and the tube that carries urine out of the body) with dilatation and debridement (medical removal of dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue) of a urethral erosion secondary to chronic foley catheter. His urethra is eroded to the penoscrotal junction. A review of Resident A's clinical chart reflected Resident A was readmitted to the facility October 10, 2017 at 9:26 PM. There was no documented evidence on Resident A's chart regarding an order for [REDACTED]. The clinical practice guidelines from the Society of Urologic Nurses titled Care of the Patient with an Indwelling Catheter, dated 2015, indicated Secure the catheter to either the patient's thigh or the abdomen. This helps to decrease the risk of bleeding, trauma, meatal necrosis, and bladder spasms from pressure and traction.

Based on observation, interview, and record review the facility failed to provide protection for one (1) of three (3) sampled residents (Resident A) from physical and emotional abuse by a staff member, when a Certified Nurses Aide (CNA 1) was rough while changing Resident A's under pad in spite of the resident's request to stop because it was causing pain. This resulted in Resident A experiencing physical and emotional abuse. Findings: On April 9, 2015 at 4:30 PM, an unannounced visit was made to the facility to investigate an entity reported incident of physical abuse to Resident A. During an interview with the Director of Nursing (DON) on April 9,2015 at 4:30 PM, she described Resident A as, "nice, not an aggressive resident," and the DON said she, "doesn't recall an incident with other residents or staff." The DON stated, "It happened at NOC shift (night-11:00 PM to 7 AM) at around 2 to 3 AM, it was reported CNA 1 was taking care of Resident A. The resident (Resident A) requested to be cleaned up, and later said, 'don't clean me up.' This was stated by the roommate (Resident B) who was alert. The curtain was pulled over, and the roommate (Resident B)did not hear Resident A stating she was being hurt. CNA 1 reported to the charge nurse(Registered Nurse Supervisor) that she was pinched by Resident A. We did an investigation and interviewed Resident A, she stated CNA 1 was upset that she (Resident A) could not help with the turning, and said sometimes CNA 1, "had two personalities, sometimes she's nice and sometimes she's not." During a phone interview with the Administrator on April 9, 2015 at 5:00 PM, he was asked if he knew about the allegation made by Resident A about CNA 1. The Administrator stated, "I am aware about it, on early day of April 6, 2015, Resident A talked with the DON and said that CNA 1 was rough. I talked with the CNA over the phone. I had the Social Services Director (SSD) interview Resident A. The SSD stated that Resident A told her everything was okay. the next day (April 7, 2015) she (SSD) went to interview her (Resident A) again. She (Resident A) stated CNA 1 had a problem with her. According to CNA 1, she was changing Resident A and the resident stated that she was hurting her. Resident A pinched CNA 1. CNA 1 asked the resident why she was pinched and Resident A responded that she was hurting (to CNA 1). Both CNA 1 and Resident A stated this happened." The Administrator stated Resident A was coherent and was able to tell staff what she needs. The Administrator stated, "We assigned CNA 1 to another group of people(residents) when Resident A retracted her allegation and said that everything was wonderful. The investigation started on April 6, 2015." When asked why CNA 1 was placed back on schedule while the investigation was in process,on April 7, 2015, the Administrator stated, "If the Resident said differently, then we could not have let her work." The SSD talked to Resident A again on April 7, 2015." CNA 1 was suspended on the 7th, and was terminated on the 8th of April 2015." A review of the SSD noted documented on April 7, 2015 at 4:38 PM, indicated the SSD and Corporate Quality Assurance Nurse met again with Resident A and asked if anything had occurred on April 6, 2015, with a staff member. Resident A stated, "A CNA ( CNA 1) was rough during providing care and she felt fearful of her (CNA 1) due to the CNA ,"was walking back and forth past her doorway and it made her feel fearful." An interview was conducted on April 21, 2015 at 10:55 AM, with the Social Services Director (SSD). When asked if she was aware of the incident between Resident A and CNA 1, the SSD stated, "Yes. The Quality Assurance Nurse and me (I) met with Resident A, we asked if there was something that concerns her. Resident A said "yes" and said that there was a particular CNA (CNA 1) who was turning her, was rough during turning, and she did not feel comfortable with the CNA. The resident thought that the CNA was [MEDICAL CONDITION] (a mood disorder with unpredictable swings from happy to angry and sad)." The SSD stated when she had visited Resident A after she had reported the incident on April 6, 2015, Resident A told the SSD everything was okay. On the visit on April 7, 2015, Resident A shared about the incident with CNA 1 and stated, "It sounded like the incident really happened for her to be so upset like that." Resident A said she felt safe, but we decided to re-locate her to another room, near the nurse's station where she sees a lot of people." An interview was conducted with Resident A on April 21, 2015 at 11:15 AM. She was asked if she remembered an encounter with a CNA (CNA 1). Resident A said, "Yes, that particular CNA (CNA 1) was changing my under pad and pulled it too hard that it hurt me. I told her I was hurting, but she kept going so I tried to stop her, and told her, 'don't do it because I'm hurting.' She had done it several times. I couldn't take the pain anymore,that's why I had to hold her hand to stop her. I repeatedly say, "don't do it I'm hurting." The CNA (CNA 1) is nice, she took care of me, but sometimes she was rough so I had to say something. She (CNA 1) did it before. I did not want to say anything just to get things done, but that time it was really hurting me. I felt like she (CNA 1) was intentionally hurting me, that was why I had to tell, and stop her. I want to walk again, both of my legs hurts, my back hurts, I was told my spine has a fracture that's why it hurts." During a clinical record review for Resident A. The facesheet (a document containing demographics) indicated Resident A was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. The Physician order [REDACTED]." During a review of Resident A's Minimum Data Set (MDS- computerized assessment) dated February 23, 2015, under section C0500:Cognitive/Decision making,revealed Resident A's cognitive level was 15 (translated as coherent and appropriate). In section E0100 and E0200: Mood/Behavior/Psychosocial: No noted untoward behavior towards others was listed. In section G0100: ADL (activities of daily living), Resident A was noted to need extensive assistance, G0400- B lower extremity, Noted: 0 (no impairment), on section G0100- C, D: Ambulation: Noted: 8 (8 means activity of ambulating never occurred.) During an interview on April 21, 2015 at 11:35 AM,with the Director of Staff Development (DSD), the DSD was asked to describe CNA 1. The DSD stated, "I like (used CNA 1's name), she was an employee of the month. When I check her assigned rooms they look great; she was always in a good mood; and I had no other concerns until this case (incident of rough handling of Resident A)... I actually like her, she's always happy, that's why this shocked me." During a review of CNA 1's employee file, the file indicated that she was hired on April 26, 2013, and had initial abuse training on April 26,2013 which included the following: a. Persons who are required to report Abuse b. Persons who are subject of the report c. When reporting abuse is required d. Penalty for failure to report e. Confidentiality of reporting and abuse reports f. Abuse that must be reported g. Definitions of abuse h. Where to call in and send the written abuse report A review of the document titled, "Employee Separation Report" in CNA 1's employee file indicated the separation date was April 8, 2015. The reason for termination was listed in the section,"Reason for Discharge: Acts of or threats of violence, other misconduct, Explanation: Resident reported allegation employee was rough when providing care for patient..." The form contained only the Administrator's signature and was dated April 8, 2015, CNA 1 had not signed the separation notice. A review of the facility's policy and procedure titled, "Abuse Prevention," dated October 11,1999, indicated under the, "Policy Statement: Our facility will not permit residents to be subjected to abuse by anyone, including staff members, other residents, ..." The policy indicated under, "Procedures, 9. Employees of this facility that have been accused of resident abuse will be reassigned to non-resident care duties or removed from the schedule until the results of the investigation have been reviewed by the Administrator..." A review of the "Witness Statement Form," dated April 6, 2015, documented by the Registered Nurse (RN) supervisor, indicated Resident A had reported the incident of rough handling by CNA 1 to her and had requested another CNA take care of her. The RN Supervisor documented she informed Resident A she would report the incident to the Administrator and DON. There was no documented evidence CNA 1 was removed from Resident A's care.

Based on observation, interview and record review, the facility failed to protect one of 3 residents (Resident 3) from verbal abuse by a staff member when a certified nursing assitant (CNA 1) made sexual comments to the resident while providing perineal care (washing of the genital and rectal area of the body). This resulted in Resident 3 to feel "degraded and upset". Finding: On February 19, 2015 at 11:00 AM, an unannounced visit was made to the facility to investigate an entity reported incident of alleged abuse. During a review of the clinical record for Resident 3 the face sheet (contains demographic information) indicated Resident 3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the nurses' notes dated February 3, 2015 through February 9, 2015 indicated Resident 3 was alert, oriented, and able to make her needs known. During a review of the Social Service Designee (SSD) notes dated February 9, 2015, Resident 3's roommate was interviewed (Resident 4). The documentation indicated Resident 4 heard CNA 1 ask her roommate (Resident 3) if she had a husband or boyfriend and when the last time she had sex was. Resident 4 indicted she did not want the CNA to care for her anymore. Review of the assignment list dated February 4, 2015 indicated CNA 1 was the CNA assigned to care for Resident 3. During an interview with CNA 1 on February 19, 2015 at 11:45 AM, CNA 1 stated he did ask Resident 3 how long it had been since she had been with a man. CNA 1 stated Resident 3 had begun the conversation and he had been attempting to be polite. During an interview with the facility Administrator on February 19, 2015 at 11:50 AM, the Administrator stated he had suspended CNA 1 during the investigation but he was reinstated. The Administrator stated he did not feel this allegation constituted abuse. During an interview with Resident 3 on March 19, 2015 at 4:00 PM, Resident 3 stated CNA 1 had taken about 10 minutes to clean her vaginal area and she felt this was too long. CNA 1 then asked her how long it had been since she had sex. Resident 3 stated she felt degraded and very upset by this. The resident further stated CNA 1 still worked in the facility and a week after this incident he came into her room and tried to give her a bath. Resident 3 said she told CNA 1, "No," and told him to leave. Resident 3 expressed that she was very upset CNA 1 was still employed at the facility. Resident 3 stated she felt he should not be working at the facility anymore. A review of CNA 1's employee file was conducted and indicated CNA 1 had been disciplined: 1. On May 29, 2010 for leaving patients on the commode or toilet unattended. 2. On February 8, 2011 for failing to position a resident properly this resulted in a fall. 3. On May 10, 2011 for failing to provide ADL care to patients. 4. On May 29, 2012 for failing to provide ADL care to patients. The file reflected CNA 1 had been trained February 15, 2010, on which behaviors were considered abusive. There was no indication the allegation of abuse had been reported to the Certified Nurses' Aide board. During a review of the facility's policy and procedure titled, "Reporting Abuse to Facility Management," undated, the policy identified the facility defined verbal abuse as: "any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, to describe residents, regardless of their age, ability to comprehend, or disability." The policy defined, "sexual abuse as, but not limited to, sexual harassment, sexual coercion, or sexual assault." A review of the facility's policy and procedure titled, "Abuse Prevention," dated October 11, 1999, reflected the following: "Our facility will not permit resident to be subjected to abuse by anyone, including staff members, other residents, consultants, volunteers, staff of other agencies serving the residents, family members, legal guardians, sponsors, friends, or other individuals."

Based on observation, interview, and record review, the facility failed to protect one of three sampled residents (Resident 1) from verbal abuse by a staff member when a certified nursing assistant (CNA 1) refused to take the resident to the bathroom and called the resident a "f-----g a--h---." This failure caused emotional distress for Resident 1. Finding: On August 25, 2014 at 3:06 PM, an unannounced visit was made to the facility to investigate an entity reported incident of verbal abuse. During a review of Resident 1's clinical record, the face sheet (contains resident demographics) indicated Resident 1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the facility form, "History and Physical," dated June 30, 2014, and signed by the resident's physician indicated Resident 1 had the mental capacity to make and understand decisions. During an observation of Resident 1 on August 25, 2014 at 3:25 PM, the resident was observed sitting in a wheelchair engaged in activities. During an interview with Resident 1 on August 25, 2014 at 3:25 PM, the resident stated Certified Nurse's Aide 1 (CNA 1) had been mean to him and had refused to take him to the bathroom. The resident further stated CNA 1 informed him he could only go to the bathroom three times during a shift. Resident 1 stated "I got mad and told her that wasn't right." He stated the CNA then called him a "f-----g a--h---". Resident 1 stated his roommate was present and heard the exchange. He stated he was really upset and had informed the facility and had not seen the CNA since then. During an interview with Resident 1's roommate (Resident 2) on August 25, 2014 at 3:30 PM, Resident 2 stated he was in their room and CNA 1 was helping his roommate. Resident 2 stated CNA 1 told his roommate that he could only go the bathroom three times. He further stated that his roommate had to go to the bathroom a lot since he was sick. He stated then CNA 1 called his roommate "f-----g a--h---." Resident 2 stated he had never had a problem with the CNA before that. During a review of the social service notes, dated August 14, 2014, the note indicated that Resident 1 had "voiced a concern over a staff member being verbally inappropriate." The note indicated that the Administrator was notified, an investigation was started, and the Ombudsman and DPHS (Department of Public Health Services, now California Department of Public Health) had been notified of the allegation. Review of the assignment list dated August 12, 2014, indicated CNA 1 was the CNA assigned to care for Resident 1. During a review of the employee file for CNA 1, the file reflected CNA 1 had been trained January 27, 2014, on which behaviors were considered abusive. CNA 1 was suspended during the investigation of the allegation. There was no indication that the allegation of abuse had been reported to the Certified Nurses Aide Board. During an interview with the facility Administrator on February 17, 2015 at 3:48 PM, the Administrator stated the incident had not been reported to theCertified Nurse's Aide Board. He further stated that he did not believe the allegation was true as the resident had a "Bathroom fetish." He stated the resident had a history of [REDACTED]. During an interview with CNA 1 on February 17, 2015 at 3:54 PM, the CNA stated that on August 12, 2014 she had been working with Resident 1. She answered his call light and the resident needed to go to the bathroom. She told the resident she needed to get a blanket for the resident next door. CNA 1 stated she came right back and helped Resident 1 to the bathroom. She mentioned to the resident that she had noticed he had to use the bathroom a lot. She asked him if anything was wrong and maybe she should let the charge nurse know so she could check him. She stated he told her, "No, he was fine," and she told him, "Goodnight." She stated the roommate was in the room, but asleep. CNA 1 stated she never used foul language at all and would never use that type of language to a resident. Review of the facility policy and procedure titled, "Abuse Prevention," dated October 11, 1999, reflected the following: "Our facility will not permit residents to be subjected to abuse by anyone, including staff members, other residents, consultants, volunteers, staff of other agencies serving the residents, family members, legal guardians, sponsors, friends, or other individuals."