Every finding on record at Villa del Rio

Based on observation, interview, and record review, the facility failed to provide a safe and sanitary environment for residents and staff. This deficient practice had the potential for unsafe and unsanitary environment and could negatively impact residents' health, safety and well-being.Findings: During an observation on 8/6/2026 at 9:31 a.m., the following were observed:In the residents' library room, a corner shelf had a hole in the bottom, and dirty plastic bags.In the activity room, the left-side window was dirty with dried food particles and stains.In Hall 2, near the exit door, spider webs were observed. During a concurrent observation and interview on 8/7/2026 at 8:50 a.m. with Housekeeping (HK) in Hall 4 and Hall 5 residents' shower rooms, cockroaches were observed behind plastic containers. HK picked up a cockroach with a paper towel and stated, I will inform the maintenance about the cockroaches. During a concurrent observation and interview on 8/7/2026 at 9:00 a.m. with the Housekeeping Supervisor (HKS), the following were observed: Dirty shower curtains in Hall 2 and Hall 3A spider web in Hall 2 cornerDry food particles on the left-side window of the activity roomIn the library room, there is a corner shelf with a hole in the bottom shelf and dirty plastic bags present. HKS stated I will tell the housekeeping and have the curtains changed. During an interview on 8/7/2026 at 11:15 a.m. with HK, HK stated that she had seen cockroaches in the shower room last week and that she reported this to the maintenance supervisor. HK stated she had observed cockroaches in Hall 4 shower rooms. HK stated she had not cleaned the library or activity room. HK stated that if the library room was cleaned in the morning, there should have been no trash on the shelf. HK stated that keeping the facility clean is very important to prevent cockroach infestations and reduce the risk of infection. HK stated, This is the residents' home, and it needs to always be kept clean. During an interview on 8/7/2026 at 11:52 p.m. with the Maintenance Supervisor (MS), the MS stated that HK has not reported any cockroaches found in the shower rooms. MS stated he was not made aware that the library room shelf had a hole in the bottom. An open hole can be a source of pest infestation. MS stated it was important to report observed cockroaches, issues with holes in the shelving immediately to prevent a roach infestation in the facility. During an interview on 8/7/2026 at 3:37 p.m. with the Director of Nursing (DON), the DON stated maintaining a clean environment is essential for infection prevention and control and to avoid any type of infestation. The DON stated that everyone in the facility was responsible for informing the appropriate personnel when something needs to be fixed or cleaned. During a review of facility's policy and procedure (P&P) titled, Safe and Homelike Environment, dated 1/2025, the P&P indicated the facility will maintain a clean environment. Report any furniture in disrepair to Maintenance promptly. During a review of facility P&P titled, Pest Control Program undated, the P&P indicated the facility to maintain an effective pest control program that eradicates and contains common household pests. During a review of facility P&P titled, Housekeeping Policy, undated, the P&P indicated consistent housekeeping practices that promote cleanness, infection prevention, resident safety, and compliance with applicable regulations. The activity room, hallways, dust furniture and horizontal surfaces should be cleaned routinely.

Based on interview and record review, the facility failed to provide sufficient staffing when certified nursing assistants (CNAs) were assigned two resident work assignments (assigned residents for the staff member to provide care to).This deficient practice had the potential to result in a delay in care and unsafe care practices.Findings:1. During a review of Certified Nursing Assistant (CNA) 4's Personnel Action Form (PAF), dated [DATE], the PAF indicated CNA 4 was hired to the facility on [DATE]. During a review of CNA 4's Notice of Certification, dated [DATE], the Notice of Certification indicated CNA 4's Nurse Assistant Certification was valid from [DATE] through [DATE].During a review of CNA 4's Certification Verification, dated [DATE], the Certification Verification indicated CNA 4's Nurse Assistant Certification was valid from [DATE] through [DATE].During a review of the facility's unnamed document containing the nursing staffing assignment for the day, dated [DATE] through [DATE], the document indicated CNA 4 had a resident work assignment (assigned residents for the staff member to provide care to) for three shifts. During a phone interview on [DATE] at 12:17 p.m., with CNA 4, CNA 4 stated her Nurse Assistant Certification expired on [DATE] and there was an issue with processing her certification renewal. CNA 4 stated her Nurse Assistant Certification was renewed on [DATE]. CNA 4 stated she did not provide direct care to the residents assigned to her while her certification was expired and assisted the other nursing staff.During an interview on [DATE] at 7:59 a.m., with the Assistant Director of Staff Development (ADSD), the ADSD stated CNA 4 was assigned a resident work assignment, however, CNA 4 was partnered with another CNA near CNA 4's assigned area. The ADSD stated CNA 4 was instructed not to perform any direct resident care and to assist the CNA she was partnered with. The ADSD stated the partnered CNA was assigned daily and not indicated on the staffing sheet. 2. During a review of CNA 5's PAF, dated [DATE], the PAF indicated CNA 5 was hired to the facility on [DATE]. During a review of CNA 5's Notice of Certification, dated [DATE], the Notice of Certification indicated CNA 5's Nurse Assistant Certification was valid from [DATE] through [DATE].During a review of CNA 5's Certification Verification, dated [DATE], the Certification Verification indicated CNA 4's Nurse Assistant Certification was valid from [DATE] through [DATE].During a review of the facility's unnamed document containing the nursing staffing assignment for the day, dated [DATE] through [DATE], the document indicated CNA 5 had a resident work assignment for 29 shifts.During a phone interview on [DATE] at 12:28 p.m., with CNA 5, CNA 5 stated her Nurse Assistant Certification expired on [DATE] and there was an issue with processing her certification renewal. CNA 5 stated she did not perform direct care to the residents while her certification was expired. CNA 5 stated she assisted the other nursing staff and eventually assigned to assist the activity staff until her certification was renewed on [DATE]. During an interview on [DATE] at 7:597 a.m., with the ADSD, the ADSD stated CNA 5 was assigned a resident work assignment, however, CNA 5 was partnered with another CNA near CNA 5's assigned area. The ADSD stated CNA 5 was instructed not to perform any direct resident care and to assist the CNA she was partnered with. The ADSD stated the partnered CNA was assigned daily and not indicated on the staffing sheet.During an interview on [DATE] at 8:37 a.m., with the ADSD, the ADSD stated uncertified nursing assistants (NAs) could not perform direct resident care tasks, however, NAs were allowed to answer call lights to ask what the residents needed and relay the information to the CNA or other nursing staff. The ADSD stated NAs were assigned a resident work assignment, however, the NAs were partnered with the closest CNA. The ADSD stated the CNA would perform the direct care and the NA would assist. The ADSD stated the CNA was responsible for the direct care for two resident assignments, which meant the CNA had twice as many residents compared to the other CNAs. The ADSD stated having twice as many residents under the CNA's care would negatively affect the residents' quality of care and safety.During an interview on [DATE] at 10:13 a.m., with the Director of Nursing (DON), the DON stated the workload should be assigned equally between the CNAs. The DON stated one CNA should not be assigned two resident work assignments because two assignments could mean the CNA would be unable to attend to all the residents' needs. The DON stated having a double resident work assignment placed the residents at risk for falls and other safety issues. During a review of the facility's Nurse Assistant Job Description, undated, the Job Description indicated the NAs duties included but not limited to:- Providing supportive services to the CNAs and other staff as needed.- Assisting with distributing meal trays to residents who could feed themselves; NAs did not assist with feeding assistance.- Completing housekeeping duties while CNAs provide care. - Assisting with transporting residents within the facility once the resident was safely transferred to the wheelchair by certified staff.

Based on interview and record review, the facility failed to conduct the annual performance evaluation for one of one sampled licensed vocational nurse (LVN 9).This deficient practice had the potential to result in LVN 9 being unaware of any areas in their performance requiring improvement to better care for the residents in the facility.Findings:During a review of Licensed Vocational Nurse (LVN) 9's Personal Action Form (PAF), dated 3/29/2024, the PAF indicated LVN 9 was hired to the facility on 3/29/2024. During a review of LVN 9's Employee File, the Employee File did not contain documentation that LVN 9 received an annual performance evaluation in 2025 or 2026. During an interview on 7/16/2026 at 8:55 a.m. with the Assistant Director of Staff Development (ADSD), the ADSD stated when performance evaluations were completed, the performance evaluations should be in the employee's physical file or in a binder the Director of Staff Development (DSD) kept. The ADSD stated annual performance evaluations were necessary to determine areas for improvement to better the care for the residents. During an interview on 7/16/2026 at 10:16 a.m. with the Director of Nursing (DON), the DON stated she was responsible for conducting annual performance evaluations for the licensed nurses. The DON stated there was no documentation the performance evaluations were completed for the licensed nurses. The DON stated annual performance evaluations were a tool to ensure the licensed nurses were competent in their job and could provide safe care to the residents.During a review of the facility's Policy and Procedure (P&P) titled, Performance Evaluations, undated, the P&P indicated a performance evaluation would be completed for each employee at the conclusion of his/her 90-day probationary period, and at least annually thereafter.

Based on interview and record review, the facility failed to ensure one of four staff members (Social Services Coordinator [SSC]), who worked as an uncertified nursing assistant (NA) from 5/1/2023 through 7/31/2024, did not exceed a 4-month employment as an NA and did not perform duties and tasks reserved for certified staff.This deficient practice had the potential for the SSC to provide incompetent care to the assigned residents, which could affect the residents' safety and well-being.Findings:During a review of the Social Services Coordinator's (SSC) Personnel Action Form (PAF), dated 11/8/2022, the PAF indicated the SSC was initially hired to the facility's housekeeping department on 11/8/2022.During a review of the SSC's PAF, dated 4/1/2023, the PAF indicated the SSC became an employee under the nursing department on 4/1/2023. During a review of the SSC's Timecard Report, dated 5/1/2023 through 7/31/2024, the Timecard Report indicated, from 5/1/2023 through 7/31/2024, the SSC worked as a certified nursing assistant (CNA) and an uncertified nursing assistant (NA).During a review of the facility's unnamed document containing the nursing staffing assignment for the day, dated 5/1/2023 through 12/30/2023, the document indicated the SSC had a resident work assignment (assigned residents for the staff member to provide care to) for 130 shifts. During a review of the SSC's Employee File, the Employee File did not indicate the SSC had a Nurse Assistant Certification from 5/1/2023 through 7/31/2024.During an interview on 7/15/2026 at 8:13 a.m., with the SSC, the SSC stated she was initially hired to the facility as a housekeeper and transitioned to working as an NA before her current position in the social services department. The SSC stated, on 4/16/2023, she completed her CNA program and began working in the facility as an NA shortly after. The SSC stated in 2023, she was notified she passed the nursing assistant certification exams and was waiting for her nursing assistant certification card to arrive in the mail, however, the certification never appeared. The SSC stated while she waited for her nursing assistant certification to process, she worked at the facility as an NA with another CNA. The SSC stated she was always partnered with another CNA and they would both have a resident work assignment, however, they would perform all resident care tasks together. The SSC stated with the other CNA, she would change residents' diapers and clothing, pass meal trays, assist the residents with feeding, assist with Hoyer lift (a mechanical device used to lift and/or transfer a person) transfers, and document in the residents' chart. During an interview on 7/15/2026 at 11:32 a.m. with the Assistant Director of Staff Development (ADSD), the ADSD stated the SSC worked as an NA prior to working in the social services department. The ADSD stated the SSC's nursing assistant certification was not properly processed. The ADSD stated the SSC should have only done NA tasks such as answering call lights to ask what the residents needed and relay the information to the CNA or other nursing staff. The ADSD stated NAs were allowed to pass meal trays, supervise smoking breaks, assist activity staff, answer phones, and obtain supplies for the nursing staff.During an interview on 7/16/2026 at 8:32 a.m. with the ADSD, the ADSD stated NAs were allowed to work at the facility for a four-month period until the NA received their nursing assistant certification. The ADSD stated the SSC worked as an NA for longer than four months and the SSC's nursing assistant certification was never processed and verified. The ADSD stated without the required nursing assistant certification, the SSC may not have been competent to work as an NA in the facility.During an interview on 7/16/2026 at 8:37 a.m., with the ADSD, the ADSD stated uncertified nursing assistants (NAs) could not perform direct resident care tasks. The ADSD stated NAs could assist with changing a resident, however, the NAs were allowed very limited participation, such as holding the resident in position while the CNA cleaned the resident. The ADSD stated NAs were not allowed to assist with feeding, perform transfers, or document in the residents' chart. The ADSD stated NAs were assigned a resident work assignment, however, the NAs were partnered with the closest CNA. The ADSD stated the CNA would perform the direct care and the NA would assist. During an interview on 7/16/2026 at 9:57 a.m., with the Director of Nursing (DON), the DON stated NAs were hired to the facility for a four-month period to transition into the CNA role after their nursing assistant certification was processed and verified. The DON stated without the nursing assistant certification, the NA should not be employed or assisting residents after the four-month period ended. The DON stated NAs were hired to the facility to assist the CNAs and other facility staff. The DON stated NAs were not allowed to perform direct resident care tasks because they did not have the nursing assistant certification to support the NA's competency and skills. The DON stated having an NA perform CNA tasks put the residents' at risk for quality of care and safety issues. During a review of the facility's Nurse Assistant Job Description, undated, the Job Description indicated the NAs duties included but not limited to:- Providing supportive services to the CNAs and other staff as needed.- Assisting with distributing meal trays to residents who could feed themselves; NAs did not assist with feeding assistance.- Completing housekeeping duties while CNAs provide care. - Assisting with transporting residents within the facility once the resident was safely transferred to the wheelchair by certified staff.During a review of the facility's Certified Nursing Assistant Job Description, undated, the Job Description indicated CNAs must be licensed in accordance with the laws of the state.

Based on interview and record review, the facility failed to conduct the annual performance evaluations for three of three sampled certified nursing assistants (CNAs 4, 5, and 6).This deficient practice had the potential to result in CNAs 4, 5 and 6 being unaware of areas in their performance requiring improvement to better care for the residents in the facilityFindings:1. During a review of Certified Nursing Assistant (CNA) 4's Personal Action Form (PAF), dated 5/6/2022, the PAF indicated the facility hired CNA 4 on 5/6/2022.During a review of CNA 4's Employee File, the Employee File did not contain documentation indicating CNA 4 received an annual performance evaluation from 2023 through 2026.2. During a review of CNA 5's PAF, dated 3/7/2022, the PAF indicated the facility hired CNA 5 on 3/7/2022.During a review of CNA 5's Employee File, the Employee File did not contain documentation indicating CNA 5 received an annual performance evaluation from 2023 through 2026.3. During a review of CNA 6's PAF, dated 1/19/2018, the PAF indicated the facility hired CNA 6 on 1/19/2018.During a review of CNA 6's Employee File, the Employee File did not contain documentation indicating CNA 6 received an annual performance evaluation from 2018 through 2026. During an interview on 7/16/2026 at 8:55 a.m. with the Assistant Director of Staff Development (ADSD), the ADSD stated she recalled performance evaluations were completed, however, there was no documentation of their completion. The ADSD stated when performance evaluations were completed, the performance evaluations should be in the employee's physical file or in a binder the Director of Staff Development (DSD) kept. The ADSD stated annual performance evaluations were necessary to determine areas for improvement to better the residents' care. During an interview on 7/16/2026 at 10:16 a.m., with the Director of Nursing (DON), the DON stated the DSD was responsible for conducting annual performance evaluations for the CNAs. The DON stated there was no documentation indicating the performance evaluations were completed for the CNAs. The DON stated annual performance evaluations were a tool to ensure the CNAs were competent in their job and could provide safe care for the residents.During a review of the facility's Policy and Procedure (P&P) titled, Performance Evaluations, undated, the P&P indicated a performance evaluation would be completed for each employee at the conclusion of his/her 90-day probationary period, and at least annually thereafter.

Based on observation, interview, and record review, the facility failed to ensure containers of ground rosemary, ground dill weed, ground oregano, ground chili powder, and a bag-in-box juice dispenser system were labeled with an open date.These failures had the potential for bacterial growth in potentially hazardous foods (PHFs, foods that require strict time and temperature control to prevent the growth of harmful bacteria or the formation of toxins) and increased the risk for food borne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) for 153 residents who consumed food prepared and served from the kitchen.Findings:During a concurrent observation and interview on 7/13/2026 at 8:33 a.m. with the Dietary Manager (DM) during the initial kitchen tour, there were open containers of ground rosemary, ground dill weed, ground oregano, ground chili powder, and an open bag-in-box juice dispenser system were not labeled with an open date. The DM stated unlabeled items may place residents at risk for foodborne illness and expired food products. During a concurrent interview and record review on 7/15/2026 at 10:11 a.m., with District Dietary Manager (DDM), the facility's P&P titled, Receiving, revised 2/2023, was reviewed. The P&P indicated, all food items will be appropriately labeled and dated. DDM stated these errors may place residents at risk for foodborne illness, cross-contamination, poor food quality, and unsafe meal service.

Based on observation, interview and record review, the facility failed to honor three of ten sampled residents' (Residents 5, 34, and 150) right to be informed of and participate in their treatment by failing to: 1. Ensure an informed consent was obtained for Resident 5's use of Olanzapine (medication used to balance brain chemicals to treat mental health conditions such as schizophrenia) and Trazadone Hydrochloride (medication that works to increase serotonin [chemical messenger often associated with mood and happiness] sometimes used as a sleep aid).2. Ensure an informed consent was obtained for Resident 34's use of Celexa (an antidepressant).3. Ensure the name of medications and their indications (reason for the use of the medication) were provided to Resident 150 prior to the administration of the medications.These deficient practices resulted in Residents 5, 34, and 150 being unable to make an informed decision about their care. Findings:1. During a review of Resident 5's admission Record, the admission Record indicated Resident 5 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 5's diagnoses included Parkinson's Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), schizophrenia (a mental illness that is characterized by disturbances in thought) and diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 5's History and Physical (H&P) dated 5/29/2026, the H&P indicated Resident 5 had fluctuating capacity to understand and make decisions. During a review of Resident 5's Minimum Data Set (MDS, a resident assessment tool) dated 5/29/2026, the MDS indicated Resident 5 's cognition (ability to think and process) moderately impaired. The MDS indicated Resident 5 was dependent (helper does all of the effort) on staff for toileting, bathing and required supervision (helper provides verbal cues or steading or contact guard assistance as resident completes activity) for eating. During a review of Resident 5's physician orders dated 5/24/2026, the physician order indicated to administer Olanzapine 5 milligrams (mg-metric unit of measurement, used for medication dosage and/or amount) by mouth every 12 hours. During a review of Resident 5's physician orders dated 5/24/2026, the physician order indicated to administer Trazadone Hydrochloride 50 mg by mouth at bedtime for inability to sleep. During a concurrent interview and record review on 7/14/2026 at 12:37 p.m. with Licensed Vocational Nurse (LVN) 2, Resident 5's medical records were reviewed. Resident 5's medical records indicated informed consents were not obtained for Olanzapine or Trazadone. LVN 2 stated informed consents should have been obtained for Resident 5's psychotropic medications and failure to obtain the consents placed resident at risk of being unable to make an informed decision about his care. During an interview on 7/14/2026 at 1:00 p.m. with Registered Nurse (RN) 2, RN 2 stated informed consents should have been obtained for Resident 5's psychotropic medications (medications that affect mood, thoughts, perceptions, and behavior) Trazadone and Olanzapine. RN 2 stated the licensed nurses and physicians collaborate to ensure residents are fully informed and consent to psychotropic medications prior to administration. RN 2 stated informed consents were required for psychotropic medications because residents had the right to know what medications they were taking, the indication for the medication, and be involved in their own care. 2. During a review of Resident 34's admission Record, the admission Record indicated Resident 34 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 34's diagnoses included major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) and intracranial injury (any trauma or damage to the brain that occurred inside the skull). The admission Record indicated Resident 34 was self-responsible (able to make their own decisions). During a review of Resident 34's MDS, dated [DATE], the MDS indicated Resident 34's cognition was moderately impaired. The MDS indicated Resident 34 required substantial assistance (helper does more than half the effort) with eating, oral hygiene, upper body dressing, and personal hygiene. The MDS indicated Resident 34 took antidepressant medication (medication to treat depression). During a review of Resident 34's H&P, dated 9/13/2025, the H&P indicated Resident 34 could make needs known but could not make medical decisions. During a review of Resident 34's Physician Order, dated 9/13/2025, the Physician Order indicated to administer Celexa 10 mg by mouth once a day for major depressive disorder manifested by sad facial expression. During a review of Resident 34's Medication Administration Record (MAR, a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 9/1/2025 through 9/30/2025, the MAR indicated Resident 34 received her first dose of Celexa 10mg on 9/14/2025. During a concurrent interview and record review on 7/15/2026 at 7:59 a.m. with the Social Services Director (SSD), Resident 34's Notice of Probate Referral (Request to appoint a legal guardian for an individual without decision-making capability), dated 4/30/2025, was reviewed. The Notice of Probate Referral indicated Resident 34 was denied an appointed legal guardian. The SSD stated Resident 34 did not have the capacity to make medical decisions and did not have family to appoint as her responsible party (RP, an individual appointed to make decisions for an individual without decision-making capabilities). The SSD stated because Resident 34's Probate Referral was denied, the interdisciplinary team (IDT, a group of healthcare professionals with various areas of expertise who work together towards the goals of the residents) made Resident 34's medical decisions for her. During an interview on 7/15/2026 at 9:24 a.m. with RN 2, RN 2 stated informed consent for psychotropic medications protected the resident and their RP's rights to approve or deny the medication treatment. RN 2 stated informed consent must be obtained from an individual with medical decision-making capability, whether from the resident or their RP. During a concurrent interview and record review on 7/15/2026 at 9:31 a.m. with RN 2, Resident 34's Verification of Resident Informed Consent, dated 9/13/2025, was reviewed. The Verification of Resident Informed Consent indicated informed consent for the use of Celexa 10 mg was obtained from Resident 34. RN 2 stated Resident 34 was not self-responsible and could not make an informed decision regarding her care. RN 2 stated informed consent should not have been obtained from Resident 34 because Resident 34 was unable to understand the risks and benefits of taking Celexa and could not make an informed decision. During an interview on 7/15/2026 at 2 p.m. with the Director of Nursing (DON), the DON stated obtaining informed consent for psychotropic medications meant the resident or their RP understood the risks and benefits of the medication and was able to make an informed decision to approve or deny the administration. The DON stated Resident 34's Celexa treatment should have been discussed with the IDT, who would determine whether Celexa was appropriate to treat Resident 34's behavior. The DON stated Resident 34 did not have the capacity to understand the risks associated with taking Celexa. 3. During a review of Resident 150's admission Record, the admission Record indicated Resident 150 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 150's with diagnosis included hypertensive heart disease (any heart condition caused by long-term, unmanaged high blood pressure) and hyperlipidemia (a medical condition where there is too much fat in the blood). During a review of Resident 150's MAR, dated 6/2026, the MAR indicated Resident 20 was prescribed amlodipine (a medication used to treat high blood pressure) 5 mg one tablet once a day, multivitamin with minerals one tablet once a day, and cholecalciferol (Vitamin D) 25 microgram (mcg, a unit of measurement) two tablets once a day. During an observation on 7/14/2026 at 8:40 a.m., licensed vocational nurse (LVN) 3 administered amlodipine, multivitamins with minerals, and vitamin D orally to Resident 150. LVN 3 did not inform Resident 150 the name of the medications administered or their indications. During an interview on 7/14/2026 at 8:43 a.m., with LVN 3, LVN 3 stated she administered amiodarone, multivitamins with minerals, and vitamin D orally to Resident 150 but failed to inform Resident 150 of the names and indications of the medications prior to Resident 150 swallowing them. LVN 3 stated according to the facility's policy and procedures (P&P), LVN 3 should have informed Resident 150 of the name and indication of all the medications administered because Resident 150 had the right to be involved in their care and treatment and make choices such as refusing a specific medication. LVN 3 stated not providing this information during medication administration restricted Resident 150's right to choose. During a review of the facility's P&P titled, Use of Psychotropic Medication(s) undated, the P&P indicated prior to initiating or increasing a psychotropic medication, the resident, family and/or resident representative must be informed of the benefits, risks, and alternatives for the medication, including any black box warmings for antipsychotic medications (class of medications primarily used to manage psychosis [disconnection from reality]), in advance of such initiation or increase. The P&P indicated the resident had the right to accept or decline the initiation or increase of a psychotropic medication. During a review of the facility's P&P, titled Resident Rights, dated 1/2026, the P&P indicated the resident had the right to be informed of, and participate in, his or her treatment, including the right to be informed in advance, of the care to be furnished and the right to request, refuse, and/or discontinue treatment.

Based on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for six of 12 sampled residents (Resident 15, 30, 48, 78, 89, and 133) by failing to ensure:A clock was present in Resident 15 and Resident 89's rooms. Resident 48 and Resident 133 did not sleep on a bare mattress.Resident 78 had a headboard attached to the resident's bed.The wall behind Resident 30's headboard was kept in good repair. This deficient practice had the potential to negatively impact Residents 15, 30, 48, 78, 89 and 133's well-being and contributed to an environment that did not promote a comfortable and homelike atmosphere for the residents.Findings: a. During a review of Resident 89's admission Record, the admission Record indicated Resident 89 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 89's diagnoses included schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and anxiety (an overwhelming feeling of uneasiness). During a review of Resident 89's Minimum Data Set (MDS- a resident assessment tool), dated 5/14/2026, the MDS indicated Resident 89's cognitive skills (ability to think and reason) for daily decision making were moderately impaired. The MDS indicated Resident 89 required supervision for activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily). During an observation and interview on 7/13/2026 at 9:20 a.m., with Resident 89, in Resident 89's room, there was no clock observed in the resident's room. Resident 89 stated she was upset that the facility staff had purposely removed the clocks to prevent her from knowing the time for scheduled smoke breaks. During a concurrent observation and interview on 7/14/2026 at 1:57 p.m., with Licensed Vocational Nurse (LVN) 10, in Resident 89's room, there was no clock observed in the resident's room. LVN 10 stated Resident 89 smoked cigarettes and was depended on a clock to determine whether it was time for the designated smoke breaks. LVN 10 stated access to a clock was a resident's right, and enabled residents to be aware of their smoke break schedule. b. During a review of Resident 15's admission Record, the admission Record indicated Resident 15 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 15's diagnoses included bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), dementia (a progressive state of decline in mental abilities), and schizoaffective disorder, During a review of Resident 15's MDS, dated [DATE], the MDS indicated Resident 15 had moderate cognitive impairment. The MDS indicated Resident 15 required setup or clean-up assistance from staff for ADLs such as eating, oral hygiene, toileting and dressing. During a concurrent observation and interview on 7/13/2026 at 9:55 a.m., with Resident 15, there was no clock observed in the resident's room. Resident 15 stated a working wall clock would help him track the time during the day. During a concurrent observation and interview on 7/13/2026 at 10:01 a.m., with LVN 10 in Resident 15's room, there was no clock observed on the wall. LVN 10 stated residents should have a working clock on the wall to ensure they were provided with a homelike environment. During an interview on 7/14/2026 at 11:23 a.m., with LVN 10, the LVN 10 stated facility staff were responsible for ensuring requests were placed for missing wall clocks or repairs on maintenance communication logbook (a notebook where a person writes down important information and requests in order). LVN 10 stated ensuring residents had wall clock was important for resident rights to have a homelike environment. During an interview on 7/16/2026 at 11:20 a.m., with the Director of Nursing (DON), the DON stated maintaining a homelike environment helped residents feel safe, comfortable, respected and promote their dignity. c. During a review of Resident 48's admission Record, the admission Record indicated Resident 48 was initially admitted to the facility on [DATE] and readmitted [DATE]. Resident 48's diagnoses included encephalopathy (a broad term for any syndrome of overall brain dysfunction), epilepsy (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness), and schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of Resident 48's MDS, dated [DATE], the MDS indicated Resident 48's cognitive skills for daily decision making were moderately impaired. During a review of Resident 48's MDS, dated [DATE], the MDS indicated Resident 48 required supervision for ADLs. During an observation on 7/14/2026 at 10:00 a.m., in Resident 48's room, Resident 48 slept on a mattress without a bed sheet. During an interview on 7/15/2026 at 8:40 a.m., with Resident 48, Resident 48 stated his bed did not have bed sheets yesterday and it made him feel cold. d. During a review of Resident 133's admission Record, the admission Record indicated Resident 133 was initially admitted to the facility on [DATE] with diagnoses including dementia, diabetes, and cataracts (a painless clouding of the eye's natural lens, which is typically clear). During a review of Resident 133's MDS, dated [DATE], the MDS indicated Resident 133's cognitive skills for daily decision making were severely impaired. The MDS indicated Resident 133 required partial to moderate assistance (helper does less than half the effort) for ADLs such as toileting, bathing, and lower body dressing. During an observation on 7/14/2026 at 10:02 a.m., in Resident 133's room, Resident 133 was observed sleeping on a mattress without a bed sheet. During an interview on 7/14/2026 at 2:36 p.m., with Certified Nursing Assistant (CNA) 9, CNA 9 stated she was assigned to Resident 48 and Resident 133, and he was responsible for changing the resident's bed linens. CNA 9 stated, earlier that morning, she removed the soiled bed linens from the residents' mattresses, cleaned the mattresses, and air-dried them. CNA 9 stated the bed linens should have been replaced immediately. Residents should not sleep directly on bare mattresses, as this practice does not support a dignified standard of care. e. During a review of Resident 78's admission Record, the admission Record indicated Resident 78 was admitted to the facility on [DATE] with diagnoses including DM, anemia (a condition where the body does not have enough healthy red blood cells), and schizophrenia. During a review of Resident 78's H&P dated 12/23/2025, the H&P indicated Resident 78 could make needs known but could not make medical decisions. During a review of Resident 78's MDS, dated [DATE], the MDS indicated Resident 78's cognitive function was intact. The MDS indicated Resident 78 required setup or clean-up assistance from staff for ADLs such as eating, oral hygiene, toileting and dressing. During a concurrent observation and interview on 7/13/2026 at 10:01 a.m., with LVN 6 in Resident 78's room, Resident 78 was observed lying in a bed without a headboard. LVN 6 stated residents should have headboards attached to their beds to ensure they were provided with a homelike environment. During an interview on 7/13/2026 at 1:23 p.m., with LVN 10, LVN 10 stated facility staff were responsible for ensuring maintenance requests were placed for missing or damaged equipment. LVN 10 stated ensuring residents had headboards was important for the residents' safety, comfort and to respect residents' rights to have a homelike environment. During an interview on 7/16/2026 at 8:50 a.m., with the DON, the DON stated residents had the right to a homelike environment. f. During a review of Resident 30's admission Record, the admission Record indicated Resident 30 was originally admitted to the facility on [DATE] and was readmitted on [DATE]. Resident 30's diagnoses included chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in beathing), DM and dementia. During a review of Resident 30's H&P dated 9/29/2025, the H&P indicated Resident 30 did not have the capacity to understand and make decisions. During a review of Resident 30's MDS, dated [DATE], the MDS indicated Resident 30's cognitive skills for daily decision making was severely impaired. The MDS indicated Resident 30 required supervision or touching assistance from staff for all attempted mobility activities while in and out of bed. During an observation on 7/13/2026 at 9:34 a.m., inside Resident 30's room, the lower portion of the resident's wall, behind the resident's headboard was observed with damaged (cracked and crumbling) drywall, and exposed, peeling materials (the inside of the wall is visible due to holes or cracks). During a concurrent observation and interview on 7/14/2026 at 10:08 a.m., with CNA 3 in Resident 30's room, CNA 3 stated Resident 30's wall was damaged and could cause injury to the resident. The resident could come in contact with the broken area of the wall, if the wall was not repaired promptly. During an interview on 7/15/2026 at 3:38 p.m., with the Maintenance Supervisor (MS), the MS stated staff were expected to report damaged drywall using the communication book, which was reviewed daily to identify needed repairs. The MS stated if staff did not report damage to the walls promptly, it could increase the risk of injury, negatively affect the cleanliness and comfort of the resident's room, and undermine the resident's homelike environment During an interview on 7/15/2026 at 3:55 p.m., with the DON, the DON stated maintaining a safe, and functional environment was essential to resident care. The DON stated environmental concerns, including damaged walls, should be promptly reported and corrected to prevent potential hazards and to maintain a homelike environment. During a review of the facility's Policy and Procedure (P&P) titled, Safe and Homelike Environment dated 1/2025, the P&P indicated the facility will provide a safe, clean, comfortable and homelike environment. This includes ensuring that the residents can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. The P&P indicated the facility will maintain a clean environment and provide bed linens that are clean and in good condition. During a review of the facility's P&P titled, Resident Rooms dated 2026, the P&P indicated each resident would have bedding that was appropriate to the weather or climate and will be furnished with functional furniture according to the resident's needs and preferences.

Based on interview and record review the facility failed to: 1). Ensure the rexulti (a medication used for depression) medication was available on 7/14/2026, 9 a.m. for one (1) of four (4) observed residents (Resident 482), medication administration. 2). Reconcile (the process of comparing transactions and activity to supporting documentation) two (2) medication-Ekits (emergency kit- a sealed container with supply of urgent prescription drugs kept stocked in nursing homes) containing controlled medications (CM, also known as Controlled Drug and Controlled Substance [CM, CD, CS]- medications which have a potential for abuse and may also lead to physical or psychological dependence) with an inventory count at each shift change for July 2026, in one (1) of one (1) inspected Medication Rooms (Medication room [ROOM NUMBER]), as indicated in its facility and procedure (P&P) titled, Controlled Substances. 3). Account for one (1) dose of CM for Resident 153 in one (1) of three (3) inspected medication carts (Medication Cart 2). These failures had the potential to result in Resident 482 receiving suboptimal (less than standard) care and the risk in experiencing adverse effects (unwanted, uncomfortable, or dangerous effects that a medication may have).These failures had the potential for increased opportunity for CM diversion (the transfer of a controlled medication or other medication from a lawful to an unlawful channel of distribution or use) and exposing residents in the facility to harmful medications, leading to physical and psychosocial harm, hospitalization and death.These failures had the potential for Resident 153 to have accidental overdose (administration of more than the prescribed dose) to CMs, resulting in Residents 153's and 482's health and well-being to be negatively impacted. Findings: During a concurrent observation and interview on 7/14/2026 at 8:50 a.m., in Medication Cart 3, Licensed Vocational Nurse (LVN) 5 was observed preparing docusate (a stool softener,) ascorbic acid (a supplement,) divalproex (a medication used for depression,) Eliquis (a medication used for thinning blood,) quetiapine (a medication used for schizophrenia,) senna (a laxative,) and multivitamin with minerals (a supplement) medications for administration to Resident 482. LVN 5 was not observed preparing rexulti for Resident 482. LVN 5 stated rexulti was not available in Medication Cart 3 or the facility to prepare for administration to Resident 482, as prescribed by Resident 482's physician for the 9 a.m. dose. LVN 5 stated medications should be readily available to ensure timely administration at the scheduled times. LVN 5 stated that medications should be ordered five (5) days in advance of last dose and followed up with pharmacy to prevent missing doses. LVN 5 stated rexulti was a medication used for depression and that missing a dose or failing to administer as prescribed, could increase Resident 482's risk of self-isolation. LVN 5 stated facility failed to ensure rexulti was readily available in Medication Cart 3 or facility, resulting in Resident 482 not having an available supply for administration of the 9 a.m. dose that day. LVN 5 stated LVN 5 will follow up with pharmacy to expedite the refill of rexulti. During a concurrent observation and interview on 7/14/2026 at 10:40 a.m., with Licensed Vocational Nurse (LVN) 3, in Medication Cart 2, a discrepancy in the count of Resident 153's lorazepam (a CM used for anxiety) between the Controlled Drug Record accountability log and the amount of medication remaining in the medication cart or medication bubble pack (medication packaging system that contains individual doses of medication per bubble) was observed. The Controlled Drug Record accountability log for Resident 153 indicated one (1) tablet of lorazepam was missing from the bubble pack. The medication bubble pack contained 11 lorazepam 1 mg tablets. The Controlled Drug Record accountability log for lorazepam indicated the bubble pack should have contained a total of 12 lorazepam 1 mg tablets, after the last administration of lorazepam 1 mg tablet documented/signed off, on 7/13/2026 at 9:57 p.m. The Controlled Drug Record accountability log contained no other documentation of subsequent administrations. LVN 3 stated LVN 3 administered one (1) lorazepam 1 mg tablet to Resident 153 on 7/14/2026 at 9:39 a.m. and forgot to sign the Controlled Drug Record accountability log. LVN 3 stated there was failure to follow the facility's policy to sign off each CM dose on the Controlled Drug Record accountability log after preparing the dose for the resident. LVN 3 stated it was important to sign out each dose once administered to ensure accountability, prevention of CM diversion, and accidental exposures of harmful substances to residents. LVN 3 stated if documentation was not accurate, it could lead to medication error and overdosage (giving more than the prescribed amount), leading to stoppage of breathing, hospitalization and possibly death for Resident 153. During a concurrent observation and interview on 7/14/2026 at 11 a.m., with LVN 4, in Medication room [ROOM NUMBER]. The following were observed:1). One (1) medication Ekit was stored in the refrigerator containing CMs, labeled [NAME].REF-49, without an accountability log for the inventory reconciliation of CMs at every shift change for July 2026.2). One (1) medication Ekit was stored at room temperature containing CMs, labeled S20, without an accountability log for the inventory reconciliation of CMs at every shift change for July 2026.LVN 4 stated all CMs, including medication Ekits containing CMs, should be reconciled every shift. LVN 4 stated that the Ekit labeled [NAME].REF-49 in the refrigerator and S20 in the cabinet of Medication room [ROOM NUMBER] contained CMs and were not reconciled with an inventory count every shift in July 2026. LVN 4 stated it was important to account all CMs to ensure accountability, prevent CM diversion and residents' accidental exposure to harmful substances. During an interview on 7/14/2026 at 12:42 p.m., with the Director of Nursing (DON,) the DON stated per facility policies, medications should be ordered five (5) days in advance, Prescribed medications should be readily available to administer. The DON stated LVN's were expected to re-order medications timely and follow-up with pharmacy on the refills to ensure medications were available to the residents. The DON stated LVN 5 failed to administer Resident 482's rexulti medication on 7/14/2026 9 a.m. dose. This placed Resident 482 at risk for adverse consequences of exacerbating (making worse) the depression. The DON stated several licensed nurses failed to follow policy and procedures for medication reordering resulting in unavailability and interruption of medication administration and continuity of care for Resident 482. The DON stated LVN 3 failed to follow the facility's P&P in immediately documenting a CM on the Controlled Drug Record accountability log for Resident 153. The DON stated not documenting the Controlled Drug Record timely can lead to accountability failures, CM diversion, inaccurate clinical records, and accidental use and overdose of lorazepam for Resident 153. The DON stated medication Ekits containing CMs should be counted and reconciled at every shift change to ensure accountability and prevent CM diversion. The DON stated the Ekits containing CMs in Medication Room1 refrigerator labeled [NAME].REF-49 and in the cabinet labeled S20 were not accounted for with an inventory count on an accountability log at each shift change in July 2026. The DON stated that the facility will immediately implement an accountability log for reconciliation of EKIT inventory count at each shift change in Medication room [ROOM NUMBER]. During a review of Resident 153's admission Record (a document containing demographic and diagnostic information), the admission Record indicated Resident 153 was originally admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 153 had diagnoses that included depression, psychosis (a mental health state characterized by a disconnection from reality) and bipolar disorder (a mental health condition that causes extreme, uncontrollable shifts in mood, energy, and activity levels.) During a review of Resident 153's Order Summary Report (a report listing the physician order for the resident) dated 7/14/2026, the report indicated an order of Lorazepam one (1) milligram ([mg] - a unit of measure of mass) tablet, to give one (1) orally every 12 hours, for anxiety manifested by inability to relax, starting 9/25/2025. During a review of Resident 153's Medication Administration Record ([MAR] - a document of the medications administered to a resident that is part of the resident's permanent medical record) for July 2026, the MAR indicated Resident 153 was prescribed: 1). Lorazepam one (1) mg tablet orally every 12 hours for anxiety manifested by inability to relax, to give at 9 a.m. and 9 p.m. During a review of Resident 482's admission Record, the admission Record indicated Resident 482 was originally admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 482's diagnosis included depressive disorder. During a review of Resident 482's Order Summary Report dated 6/2/2026, the report indicated Resident 482 was prescribed rexulti 0.5 mg tablet, to give one (1) tablet orally once a day, for depressive disorder manifested by self-isolation, starting 4/16/2026. During a review of Resident 482's MAR for July 2026, the MAR indicated Resident 482 was prescribed: 1). Rexulti 0.5 mg tablet orally once a day for depressive disorder manifested by self-isolation, to give at 9 a.m. During a review of the facility's undated P&P titled Medication Administration -General Guidelines, the P&P indicated, medications should be administered in accordance with written orders of the prescriber. Medications should be administered within 60 minutes of scheduled. During a review of the facility's undated P&P titled Controlled Substances, the P&P indicated medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and record keeping at the nursing care center, in accordance with federal and state laws and regulations. The P&P indicated:When a controlled medication is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record when removing dose from controlled storage.a). Date and time of administrationb). Amount administeredc). Signature of the nurse administering the dose2.) At each shift change, a physical inventory of controlled medications, as defined by state regulation, should conducted by two (2) licensed clinicians and is documented on an audit record. During a review of the facility's undated P&P titled, Ordering and Receiving Non-controlled Medications, the P&P indicated medications and related products should be received from the dispensing pharmacy on a timely basis. The P&P indicated to reorder routine medications by the reorder date on the label to assure an adequate supply is on hand. All medications should be reordered in advance. Timely delivery of new orders is required so that medication administration is not delayed.

Based on observation, interview, and record review the facility failed to: Label and store one (1) opened levalbuterol (a medication used to treat chronic obstruction pulmonary disorder [COPD - a condition with shortness of breath, cough and chest tightness]) inhalation (a form of a medication to be inhaled as a vapor or spray) foil pouch (package made of foil protecting the inhalation solution from light and degradation) with an open date for Resident 28, in accordance with the manufacturer's requirements and facility policies and procedures (P&P) in one (1) of three (3) inspected Medication Carts (Medication Cart 2.) 2. Remove and discard from use one (1) expired inhalation treatment for Residents 35 in accordance with manufacturer's requirements in one (1) of three (3) inspected Medication Carts (Medication Cart 2.) 3. Remove and discard 15 expired Afluria (an influenza [also known as flu] vaccine [a substance that provides immunity to an infectious disease] used to provide protection against the flu vaccine for the 2025 -2026 flu season) syringes, and sixteen expired loperamide (medication used for diarrhea) oral tablets from the facility stock, in accordance with manufacturer's requirements and facility P&P in one (1) of one (1) Medication Rooms (Medication room [ROOM NUMBER].) These deficient practices increased the risk for Residents 28, 35 and other residents in the facility to received medication that had become ineffective or toxic due to improper storage or labeling, possibly leading to health complications resulting in harm, hospitalization or death. Findings: During a concurrent observation and interview on 7/14/2026 at 10:40 a.m., of Medication Cart 2, with Licensed Vocational Nurse (LVN) 3, the following medications were found either stored in a manner contrary to their respective manufacturer's requirements, not labeled with an open date as required by their respective manufacturer's specifications, or stored and labeled contrary to facility policies: One (1) opened levalbuterol inhalation foil pouch containing unused vials (container filled with the medication) for Resident 28 was found stored at room temperature and not labeled with a date indicating when the foil pouch was opened. According to the manufacturer's product storage and labeling, levalbuterol inhalation vials should be stored at room temperature between 68 to 77 degrees Fahrenheit and once the foil pouch opened to use the vials within two (2) weeks. One (1) opened and expired fluticasone with salmeterol (a combination medication used to prevent and treat COPD) Diskus (a device used to deliver measured amount of medication in a powder form) inhalation powder for Resident 35 was found stored at room temperature without a foil pouch and labeled with a date indicating the device was opened on 6/3/2026. According to the manufacturer's product storage and labeling, fluticasone with salmeterol Diskus should be stored at room temperature between 68 to 77 degrees Fahrenheit and discarded one (1) month after opening the pouch.LVN 3 stated the Resident 28's levalbuterol inhalation pouch was opened and stored at room temperature and was not labeled with a date when the foil pouch was opened. LVN 3 stated she was unaware when Resident 28's levalbuterol inhalation pouch was opened. LVN 3 stated Resident 35's fluticasone with salmeterol Diskus was labeled with a date indicating the foil pouch was opened on 6/3/2026. According to the manufacturer guidelines, once the levalbuterol foil pouch was opened the vials should be used and discarded within two (2) weeks and considered expired after that timeframe. LVN 3 stated the fluticasone with salmeterol Diskus foil pouch for Resident 35 was opened on 6/3/2026 and according to the manufacturer guidelines the Diskus expired one (1) month later, on 7/3/2026. LVN 3 stated the unlabeled levalbuterol foil pouch for Resident 28 and the fluticasone with salmeterol Diskus for Resident 35 were considered expired. LVN 3 stated expired medications have lost potency (strength) and will not be effective in treating Resident 28 and 35's COPD and could harm the residents by making their condition worse, cause shortness of breath, possibly leading to hospitalization and death. LVN 3 stated several licensed nurses failed to follow the facility's policy of labeling the inhalation treatments with a date when the foil was first opened and discarding expired medications. LVN 3 stated both medications for Residents 28 and 35 should be removed from Medication Cart 1, discarded and replaced with new ones from pharmacy.During a concurrent observation and interview on 7/14/2026 at 11 a.m., in Medication room [ROOM NUMBER], with LVN 4, the following medications were found either stored in a manner contrary to their respective manufacturer's requirements, expired and not discarded, or stored contrary to facility policies: Fifteen syringes of Afluria 2025-2026 formula vaccines for facility stock were found stored in the refrigerator. According to the manufacturer expiration dating, the Afluria syringes should be stored in the refrigerator and discarded by 6/30/2026. Sixteen loperamide oral tablets for facility stock were found stored at room temperature in the cabinet with other unexpired facility stock medications and labeled with an expiration date of 4/2026. According to the manufacturer date imprinted on the loperamide oral tablets, the medication should be used or discarded by 4/2026. LVN 4 stated the Afluria syringes, and loperamide tablets were expired, needed to be removed from use and placed in a designated area for disposal to prevent accidental use. LVN 4 stated administering expired vaccines and medications to residents in the facility would not provide protection for residents from the flu and not help treat diarrhea, because expired medications had lost potency and effectiveness. LVN 4 stated licensed nurses failed to remove expired medications from Medication room [ROOM NUMBER] and increased the risk of using expired medications and harming residents. During an interview on 7/14/2026 at 12:42 p.m., with the Director of Nursing (DON,) the DON stated expired medications should be removed from use and placed in the expired medication bin to be disposed of to prevent accidental use. The DON stated expired medications have lost potency, are ineffective and may not work properly when used in error for residents in the facility. The DON stated licensed nurses failed to remove fifteen expired Afluria syringes before 6/30/2026 and sixteen expired loperamide tablets before 4/2026 from use in Medication room [ROOM NUMBER], failed to remove fluticasone with salmeterol Diskus for Resident 35 from Medication Cart 2 by 7/3/2026, and place them in a designated area intended for disposal. The DON stated these failures increased the potential for use of expired loperamide, Afluria and fluticasone with salmeterol and could harm residents by not treating their condition or protecting their health and well-being. During the same interview, the DON stated licensed nurses failed to follow the facility's policy of labeling levalbuterol inhalation foil pouch with a date when the foil was first opened for Resident 28. The DON stated an opened levalbuterol foil pouch was good for two (2) weeks and beyond that, would be considered expired. The DON stated administering expired levalbuterol could potentially harm Resident 28 by not treating the resident's COPD and shortness of breath. During a review of the facility's P&P titled, Disposal of Medications, undated, the P&P indicated, Outdated medications, contaminated or deteriorated mediations, and the contents of containers with no label shall be destroyed according to the above policy. During a review of the facility's P&P titled Storage of Medications, undated, the P&P indicated, Outdated, contaminated, discontinued or deteriorated mediations and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal and reordered from the pharmacy, if a current order exists. During a review of the facility's P&P titled, Medication Administration General Guidelines, undated, the P&P indicated, no expired medication will be administered to a resident. 8b. the nurse shall place a date opened sticker on the mediation of one is not provided by the dispensing pharmacy and enter the date opened.8c. Certain products or package types.have specified shortened end-of-use dating, once opened, to ensure medication purity and potency.8d. The beyond use dating, which only lists month/year, falls to the last day of that month. During a review of the facility's P&P titled Abridged List of Medications with Shortened Expiration Dates undated, the P&P indicated: Once certain products are opened and in use, they must be used within a specific timeframe to avoid reduced stability, sterility and potentially reduced efficacy. Product-specific storage and expiration details can be found in the drug product's Package Insert under the How Supplied/Storage & Handling section. A drug product's Beyond Use Date is the manufacturer supplied expiration date or the shortened date after opening, whichever comes first. These In-Use medications should be labeled such that the Date opened is noted, clearly visible and securely attached to a part of the package to not be discarded. Fluticasone with Salmeterol - 30 days after removal from foil pouchLevalbuterol - if not used immediately, should be protected fromlight and used within one (1) week.

Based on interview and record review, the facility failed to maintain documentation of COVID-19 (a contagious respiratory illness) vaccination (a medicine that trains your body to fight off harmful germs or viruses) records and vaccine offerings for three of three sampled residents (Residents 47, 101 and 146). These failures had the potential to result in double dosing (taking or administering two amounts of medication close to the same time) and missed vaccinations for Residents 47, 101 and 146, and increased the risk of COVID-19 outbreaks in the facility. Findings:a. During a review of Resident 47's admission Record, the admission Record indicated Resident 47 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 47's diagnoses included schizophrenia (a mental illness that can affect thoughts, mood, and behavior) disorder, chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing) and anxiety (an overwhelming feeling of uneasiness).During a review of Resident 47's Immunization Report, dated 7/15/2026, the report did not indicate Resident 47's previous administrations or refusals of the COVID 19 vaccine were documented. b. During a review of Resident 101's admission Record, the admission Record indicated Resident 101 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 47's diagnoses included schizoaffective disorder, diabetes (poor blood sugar control) and anxiety.During a review of Resident 101's Immunization Report, dated 7/15/2026, the report did not indicate Resident 101's previous administrations or refusals of the COVID 19 vaccine were documented. c. During a review of Resident 146's admission Record, the admission Record indicated Resident 101 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 146's diagnoses included hypertension (high blood pressure), schizoaffective disorder, and anxiety.During a review of Resident 146's Immunization Report, dated 7/15/2026, the report did not indicate Resident 146's previous administrations or refusals of COVID 19 vaccine were documented. During an interview on 7/15/2026 at 1:56 p.m., with the Infection Prevention Nurse (IPN), the IPN stated it was not in his practice to maintain records of current and previous COVID-19 vaccine administrations in the resident's medical record because he did not have access to the California Immunization Registry (CAIR2, a secure, confidential, statewide computerized immunization information system for California residents). The IPN stated he recently (date unspecified) received access to CAIR since the start of his employment dating back to 11/2024. The IPN explained access to CAIR would have allowed him to extract and enter COVID 19 immunization data from the website to input into the residents' medical records. The IPN explained he held clinics for the administration of the COVID 19 vaccinations in the facility but did not maintain documentation. The IPN stated he provided the COVID 19 medication drug information sheets to residents and their responsible parties but did not maintain documentation of the specific education provided. The IPN stated it was important to maintain documentation of COVID-19 vaccine administration to determine if the resident already received the vaccine, and to avoid double dosing. The IPN stated documentation of COVID-19 vaccine offerings and education to residents was critical for continuity of care, disease prevention, and outbreak mitigation. The IPN stated the lack of documentation could possibly lead to double dosing, missed vaccinations, and potential COVID-19 outbreaks.During a review of the facility's Policy and Procedure (P&P) titled, COVID 19 Vaccination, dated 2026, the P&P indicated COVID-19 vaccinations will be offered to residents when supplies were available, as per Centers for Disease Control and Prevention (CDC) and, or Federal Drug Administration (FDA) guidelines unless such immunization is medically contraindicated, the individual has already been immunized during this time period, or refuses to receive the vaccine. The P&P indicated the resident's medical record will include documentation of the following:a. Education to the resident or resident representative regarding the risks, benefits, and potential side effects of the COVID-19 vaccine;b. Each dose of the vaccine administered to the resident, or;c. If the resident did not receive the COVID-19 vaccine due to medical contraindication or refusal.

Based on observation, interview, and record review, the facility failed to ensure privacy curtains were installed and privacy was maintained for one out of six sampled residents (Resident 14) when Resident 14's colostomy (a surgical procedure that brings one end of the large intestine out through the abdominal wall to allow waste to leave the body) bag, which was filled with stool (bodily waste), was assessed by the licensed nursing staff.This deficient practice had the potential to result in Resident 14 experiencing a diminished sense of dignity and self-worth.Findings:During a review of Resident 14's admission Record, the admission Record indicated Resident 14 was initially admitted to the facility on [DATE] and readmitted [DATE]. Resident 14's diagnoses included Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), aphasia (a disorder that makes it difficult to speak) following cerebral infarction (stroke, loss of blood flow to a part of the brain), and colostomy status (a surgical procedure that brings one end of the large intestine out through the abdominal wall to allow waste to leave the body). During a review of Resident 14's Minimum Data Set (MDS, a resident assessment tool), dated 4/12/2026, the MDS indicated Resident 14's cognition (ability to think and process) was severely impaired. The MDS indicated Resident 14 required partial assistance (helper does less than half the effort) from staff for toileting hygiene and showering. During a review of Resident 15's admission Record, the admission Record indicated Resident 15 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 15's diagnoses included bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), dementia (a progressive state of decline in mental abilities), and schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of Resident 15's MDS, dated [DATE], the MDS indicated Resident 15's cognition was intact. The MDS indicated Resident 15 required setup or clean-up assistance from staff for eating, oral hygiene, toileting and dressing. During a concurrent observation and interview on 7/14/2026 at 10:13 a.m. with Licensed Vocational Nurse (LVN) 9, in Resident 14 and Resident 15's room, Resident 15 (Bed A) and Resident 14 (Bed B) were lying in their beds. LVN 9 assessed Resident 14's colostomy bag, which contained stool, without utilizing a privacy curtain between the two residents. LVN 9 stated the room did not have a privacy curtain installed, which compromised Resident 14's privacy during the procedure. LVN 9 stated a privacy curtain should have been provided to maintain Resident 14's dignity and ensure proper privacy during the assessment. During a review of the facility's Policy and Procedure (P&P), titled, Resident Rooms, dated 2026, the P&P indicated all resident bedrooms would be equipped to assure full visual privacy for each resident. Including ceiling suspended curtains which extend around each bed in non-private bedrooms. During a review of the facility's P&P, titled, Resident Rights, dated 1/2026, the P&P indicated the residents had a right to personal privacy and confidentiality of his or her personal and medical records. The P&P indicated personal privacy included accommodations, medical treatment, and personal care.

Based on interview and record review, the facility failed to determine the responsible party (RP- an individual appointed to make decisions for an individual without decision-making capabilities) for one of two sampled residents' (Resident 9).This deficient practice resulted in Resident 9 not having an RP who could make medical decisions for her.Findings:During a review of Resident 9's admission Record, the admission Record indicated Resident 9 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 9's diagnoses included metabolic encephalopathy (a broad term for brain dysfunction caused by chemical imbalances, systemic illnesses, or organ failure), schizophrenia (a mental illness that is characterized by disturbances in thought) and heart failure (when the heart does not pump blood to the body as well). The Face Sheet listed two family members as Resident 9's emergency contacts. During a review of Resident 9's Minimum Data Set (MDS, a resident assessment tool), dated 5/29/2026, the MDS indicated Resident 9's cognition (ability to think and process) was severely impaired. The MDS indicated Resident 9 was dependent (helper does all of the effort) on staff for oral hygiene, toileting, bathing, upper/lower body dressing, and putting on/taking off footwear. During a review of Resident 9's History and Physical (H&P), dated 5/22/2026, the H&P indicated Resident 9 could make needs known but could not make medical decisions.During an interview on 7/14/2026 at 2:49 p.m. with the Social Services Director (SSD), the SSD stated when a resident was self-responsible, the resident was deemed capable of making their own medical decisions, consent to medications, and advocate for themselves. The SSD stated based on Resident 9's H&P, Resident 9 was unable to make medical decisions for herself. The SSD stated Resident 9 had a sister and a son listed as her emergency contacts. The SSD stated they should have been contacted and asked if one of them wanted to be appointed as Resident 9's RP.During an interview on 7/15/2026 at 1:55 p.m., with the Director of Nursing (DON), the DON stated Resident 9 was unable to make medical decisions for herself and required an RP. The DON stated her family members should have been asked to be Resident 9's RP to consent for medications and make other medical decisions for Resident 9.During review of the facility's Policy and Procedure (P&P) titled Advising Surrogate or Representative of Resident's Rights and Responsibilities, updated 2026, the P&P indicated should a resident be declared incompetent or incapable of understanding his or her rights, the resident's surrogate and/or representative would be advised of the resident's rights and their responsibilities as the resident's surrogate/representative.

Based on observation, interview and record review, the facility failed to notify two of two sampled residents' (Residents 135 and 9) physician and responsible party (RP- appointed individual to make medical decisions) of changes in condition by failing to: 1. Ensure Resident 9 had hypotensive (blood pressure below 90 over 60 [90/60] millimeters of mercury [mmHg, a unit of measuring blood pressure]) blood pressure readings taken on 7/5/2026 and 7/14/2026.2. Notify the physician when Resident 135 had bleeding scabs on his forehead on 7/10/2025. This deficient practice had the potential to result in Resident 9 experiencing adverse side effects of hypotension, including dizziness, nausea, and fainting. This deficient practice had the potential to result in Resident 135's wound to go unmonitored, worsen and become infected. Findings: 1. During a review of Resident 9's admission Record (Face Sheet, front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 9 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 9's diagnoses included metabolic encephalopathy (a broad term for brain dysfunction caused by chemical imbalances, systemic illnesses, or organ failure), schizophrenia (a mental illness that is characterized by disturbances in thought) and hypertension (high blood pressure). During a review of Resident 9's History and Physical (H&P), dated 5/22/2026, the H&P indicated Resident 9 could make needs known but could not make medical decisions. During a review of Resident 9's Care Plan titled, Receiving Multiple Different Medications Daily, dated 5/27/2026, the Care Plan's interventions indicated to monitor vital signs, report results to the physician and follow-up if indicated. During a review of Resident 9's Care Plan titled, Risk for Complications Related to Diagnosis of Hypertension, dated 5/27/2026, the Care Plan's interventions indicated to monitor blood pressure and heart rate prior to administering medications, assess for signs and symptoms of hypotension, and notify the physician. During a review of Resident 9's Minimum Data Set (MDS, a resident assessment tool), dated 5/29/2026, indicated Resident 9's cognition (process of thinking) was severely impaired. The MDS indicated Resident 9 was dependent on staff's assistance with oral hygiene, toileting, bathing, upper/lower body dressing, and putting on/taking off footwear. During a review of Resident 9's Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 7/1/2026 through 7/31/2026, the MAR indicated on 7/5/2026, Resident 9's blood pressure was 86 over 43 (86/43) millimeters of mercury (mm Hg, a unit of measuring blood pressure), and on 7/14/2026, Resident 9's blood pressure was 71/40 mm Hg. During a review of Resident 9's electronic health record (eHR), dated 7/5/2026 to 7/14/2026, the eHR did not indicate Resident 9's physician was notified of Resident 9's hypotension (blood pressure below 90/60 mmHg) on 7/5/2026 or 7/14/2026. During an interview on 7/14/2026 at 11:45 a.m., with Licensed Vocational Nurse (LVN) 5, LVN 5 stated, on 7/14/2026, when she checked Resident 9's blood pressure reading it was 71/40 mm Hg. LVN 5 stated Resident 9's blood pressure of 71/40 mmHg was not Resident 9's usual blood pressure reading and she did not recheck Resident 9's blood pressure to confirm the reading. LVN 5 stated she did not notify Resident 9's physician of her hypotension. LVN 5 stated she should have notified Resident 9's physician right away because hypotension could be a sign of something more severe. During an interview on 7/14/2026 at 12:12 p.m., with the Director of Nursing (DON), the DON stated licensed nurses check the resident's vital signs routinely and prior to certain medication administration. The DON stated Resident 9's physician should have been notified of the two hypotensive readings to intervene if something more severe was occurring. During a review of the facility's Policy and Procedure (P&P) titled Change in a Resident's Condition or Status, update 2026, the P&P indicated the Nurse Supervisor or Charge Nurse was to notify the resident's Attending Physician or On-Call Physician when there had been a significant change in the resident's physical condition. During a review of the facility's undated P&P titled, Blood Pressure, Monitoring, the P&P indicated hypotension should be reported to the physician. During a review of the facility's P&P titled, Vital Signs, dated 2026, the P&P indicated, Licensed Nurses are responsible for knowing the usual range of a resident's vital signs, analyzing and interpretating vital signs, and notifying the physician of abnormal findings. 2. During a review of Resident 135's admission Record, the admission Record indicated Resident 135 was initially admitted to the facility on [DATE] and readmitted [DATE]. Resident 135's diagnoses included schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), epilepsy (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness) muscle weakness, muscle wasting (weakening, shrinking, and loss of muscle), and lack of coordination. During a review of Resident 135's Minimum Data Set ([MDS], a resident assessment tool), dated 5/4/2026, the MDS indicated Resident 1's cognitive skills (ability to think and reason) for daily decision making were moderately impaired. During a review of Resident 135's MDS, dated [DATE], the MDS indicated Resident 135 required supervision for eating, dressing, personal hygiene, sitting to lying, sitting to standing, transferring from the bed to the chair, and walking ten feet to 150 feet. During a review of Resident 135's History and Physical (H&P), dated 6/25/2026, the H&P indicated Resident 135 lacked the capacity to understand and make decisions. During a review of all of Resident 135's Progress Notes and Situation, Background, Assessment, Recommendation (SBAR- a communication tool used by healthcare workers when there is a change of condition among the residents) Notes, dated 6/2026 through 7/12/2026, there were no notes to indicate Resident 135 had developed scattered, circular scabs on his forehead. During an observation and interview on 7/13/2026 at 9:30 a.m. of Resident 135, in Resident 135's room, Resident 135 had a blue to purple discoloration noted under the left eye with several, round, small, scattered scabs across his forehead. During a phone interview on 7/14/2026 at 3:50 p.m. with Certified Nursing Assistant (CNA) 7, CNA 7 stated she was Resident 135's assigned CNA on 7/10/2026 for the 3 p.m. to 11 p.m. shift. CNA 7 recalled Resident 135 had scattered scabs to his forehead. CNA 7 stated one of Resident 135's scabs began bleeding during his shower, and this was reported to LVN 8. During an interview on 7/15/2026 at 7:39 a.m. with Licensed Vocational Nurse (LVN) 8, LVN 8 stated she was the assigned nurse for Resident 135 on 7/10/2026 for the 3 p.m. to 11 p.m. shift. LVN 8 stated she recalled CNA 7 informed her that Resident 135's forehead scabs were bleeding during a shower. LVN 8 stated she administered treatment to the affected areas but did not document her assessment or the interventions provided. LVN 8 stated a change of condition note should have been documented at that time to alert the physician, the responsible party, and licensed nursing staff, facilitate ongoing monitoring, and secure appropriate orders for managing the scabs. LVN 8 stated there was a risk for the scabs to worsen or become infected. During an interview on 7/15/2026 at 2:40 p.m. with the Director of Nursing (DON), the DON stated that if licensed nursing staff had assessed and treated Resident 135 for a bleeding scab, the responsible party should have been notified and the physician consulted to obtain appropriate treatment orders. During a review of the facility's Policy and Procedure (P&P), titled, Notification of Changes, dated 1/2026, the P&P indicated the facility was to ensure the facility promptly consulted the resident's physician; and notified, consistent with his or her authority, the resident's representative when there was a change requiring notification.

Based on interview and record review, the facility failed to verify the Notice of Medicare Non-Coverage Coverage (NOMNC, a form that notifies Medicare residents that their covered services are going to end) and Advance Beneficiary Notice (ABN, a notice notifying that Medicare may deny payment for specific treatments, and provides residents the opportunity to accept or refuse services if Medicare denies payment) forms were signed by someone with decision making capabilities when the Medicare Part A (insurance that primarily covers inpatient skilled nursing facility stays) coverage ended for two of three sampled residents (Resident 24 and Resident 157).This deficient practice resulted in Residents 24 and 157 being unable to make an informed decision about their care.Findings:a. During a review of Resident 24's admission Record, the admission Record indicated Resident 24 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 24's diagnoses included anemia (a condition where the body does not have enough healthy red blood cells), schizophrenia (a mental illness that is characterized by disturbances in thought) and hypertension (HTN-high blood pressure). The admission Record indicated Resident 24 was conserved (when a judge legally appoints someone to manage personal and financial affairs of someone who can no longer make decisions for themselves).During a review of Resident 24's History and Physical (H&P) dated 5/31/2026, the H&P indicated Resident 24 had fluctuating capacity to understand and make decisions.During a review of Resident 24's Minimum Data Set (MDS, a resident assessment tool) dated 6/20/2026, the MDS indicated Resident 24's cognition (ability to think and process) was moderately impaired. The MDS indicated Resident 24 required supervision from staff for toileting, bathing and personal hygiene.During a review of Resident 24's Skilled Nursing Facility (SNF) Beneficiary Notification Review form, indicated Resident 24's last covered date for Medicare Part A skilled services was 3/18/2026.During a review of Resident 24's NOMNC form dated 3/4/2026, the NOMNC form indicated Resident 24 signed and acknowledged coverage end date on 3/4/2026.During a review of Resident 24's ABN form dated 3/4/2026, the ABN form indicated Resident 24 chose to continue Inpatient Skilled Nursing services (24-hour medical, nursing and rehabilitative care provided in skilled nursing facilities) but not bill Medicare. The ABN form indicated Resident 24 signed the form on 3/4/2026.During a phone interview on 7/15/2026 at 3:55 p.m. with Responsible Party (RP) 1, RP 1 stated no one from the facility had contacted him to inform him of Resident 24's Medicare Part A coverage ending. RP 1 stated the facility should have notified him so he could review Resident 24's options for coverage.During an interview on 7/15/2026 at 2:36 p.m. with the Social Services Director (SSD), the SSD stated Resident 24 did not have the capacity to understand or make informed medical decisions, and he should have contacted Resident 24's conservator to fill out the NOMNC and ABN forms. The SSD stated conservators should be involved in the decision-making process for residents to ensure information was understood and informed decisions could be made.b. During a review of Resident 157's admission Record, the admission Record indicated Resident 157 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 157's diagnoses included schizophrenia (a mental illness that is characterized by disturbances in thought), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and chronic obstructive pulmonary disease (a chronic lung disease causing difficulty in breathing). The admission Record indicated Resident 157's responsible party was a public guardian (a court appointed professional authorized to make personal and financial decisions for someone who could no longer make decisions for themselves).During a review of Resident 157's History and Physical (H&P) dated 5/25/2026, the H&P indicated Resident 157 was able to make needs known but could not make medical decisions.During a review of Resident 157's Minimum Data Set (MDS-a resident assessment tool), dated 7/10/2026, the MDS indicated Resident 157's cognition was moderately impaired. The MDS indicated Resident 157 required supervision from staff for toileting, bathing and dressing.During a review of Resident 157's Skilled Nursing Facility (SNF) Beneficiary Notification Review form, the form indicated Resident 157's last covered date for Medicare Part A skilled services was 7/10/2026.During a review of Resident 157's NOMNC form dated 6/1/2026, the NOMNC form indicated Resident 157 refused to sign but made decision verbally on 6/1/2026.During a review of Resident 157's ABN form dated 6/1/2026, the ABN form indicated Resident 157 chose to continue Inpatient Skilled Nursing services (24-hour medical, nursing and rehabilitative care provided in skilled nursing facilities), but not to bill Medicare. The ABN form indicated Resident 157 refused to sign but made decision verbally on 6/1/2026.During a phone interview on 7/15/2026 at 2:48 p.m. with RP 2, RP 2 stated she had not been notified that Resident 157's Medicare Part A services ended. RP 2 stated the facility should have notified and included her in the decision-making process for Resident 157's Medicare coverage part A termination.During an interview on 7/15/2026 at 2:36 p.m. with the Social Services Director (SSD), the SSD stated he should have contacted Resident 157's RP 2 to fill out the NOMNC and ABN forms. The SSD stated involving a resident's RP 2 in the decision-making process was important to ensure all of the residents options were understood and an informed decision could be made.During an interview on 7/16/2026 at 8:58 a.m. with the Administrator (ADM), the ADM stated the NOMNC and ABN forms were important because they allow residents and their representatives to appeal Medicare part A termination and determine which services they want to continue to receive and take financial responsibility for. The ADM stated facility staff should notify and involve conservators and public guardians in the decision-making process once a residents Medicare Part A coverage ends, to ensure an informed decision was made.During a review of the facility's Policy and Procedure (P&P) titled, Advance Beneficiary Notices dated 2026, the P&P indicated a NOMNC form will be issued to the resident or representative when Medicare covered services were ending, and the NOMNC informs the resident on how to request an appeal.During a review of the facility's P&P titled, Advising Surrogate or Representative of Resident's Rights and Responsibilities dated 2026, the P&P indicated the facility will seek a health care decision from a representative when the resident is determined to be incompetent in accordance with state law.

Based on interview and record review, the facility failed to ensure the quarterly Minimum Data Set (MDS, a resident assessment tool) assessments were completed and submitted within the required federal timeframe for four of 24 sampled residents (Residents 44, 46, 47, and 75).The deficient practice had the potential to affect the accuracy and timeliness of resident assessments, care planning decisions, and the facility's compliance with federal Medicare and Medicaid requirements.Findings: During a review of Resident 44's admission Record, the admission Record indicated Resident 7 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 44's diagnoses included schizophrenia (a mental illness that is characterized by disturbances in thought), dementia (a progressive state of decline in mental abilities), chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs) and diabetes (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 44's MDS dated [DATE], the MDS indicated Resident 44's cognition (ability to think and process) was moderately impaired. During a review of Resident 46's admission Record, the admission Record indicated Resident 46 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 46's diagnoses included diabetes, schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior) and hyperlipidemia (high cholesterol). During a review of Resident 46's MDS dated [DATE], the MDS indicated Resident 46's cognition was moderately impaired. During a review of Resident 47's admission Record, the admission Record indicated Resident 47 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 47's diagnoses included bipolar disorder, schizophrenia, COPD and insomnia (trouble falling asleep or staying asleep). During a review of Resident 47's MDS dated [DATE], the MDS indicated Resident 47's cognition was moderately impaired. During a review of Resident 75's admission Record, the admission Record indicated Resident 75 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 75's diagnoses included schizoaffective disorder, psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality) and hypertensive heart disease (heart conditions caused by long-term, unmanaged high blood pressure). During a review of Resident 75's MDS dated [DATE], the MDS indicated Resident 75's cognition was moderately impaired. During a concurrent interview and record review on 7/16/2026 at 9:38 a.m. with Minimum Data Set Nurse (MDSN) 2, the process for completing and submitting quarterly MDS assessments were reviewed. MDSN 2 stated the MDS was a federally required resident assessment that must be completed and electronically submitted within the required Assessment Reference Date (ARD, the specific endpoint for the observation or look-back period used when completing the MDS) completion timeframe. MDSN 2 stated in accordance with federal requirements, quarterly MDS assessments must be submitted on or before 14 days from the assessment start date to ensure compliance with Medicare and Medicaid regulations and to maintain an accurate, timely assessment of each resident's clinical status. During a concurrent interview and record review on 7/16/2026 at 9:38 a.m. with MDSN 2, the quarterly MDS assessments for Residents 44, 46, 47, and 75 were reviewed. The quarterly MDS assessment for Resident 44 was initiated on 5/17/2026 but was not submitted until 7/15/2026. MDSN 2 stated the assessment should have been submitted on or before 5/31/2026 and not 45 days late. The quarterly MDS assessment for Resident 46 was initiated on 5/14/2026 but was not submitted until 7/13/2026. MDSN 2 stated the assessment should have been submitted on or before 5/28/2026 and not 46 days late. The quarterly MDS assessment for Resident 47 was initiated on 3/12/2026 but was not submitted until 4/27/2026. MDSN 2 stated the assessment should have been submitted on or before 3/26/2026 and not 32 days late. The quarterly MDS assessment for Resident 75 was initiated on 5/18/2026 but was not submitted until 7/10/2026. MDSN 2 stated the assessment should have been submitted on or before 6/1/2026 and not 39 days late. MDSN 2 stated that there was no documented explanation or justification in the medical records for the delayed submissions of the quarterly MDS assessments for Residents 44, 46, 47, and 75. MDSN 2 stated the timely completion and submission of MDS assessments was essential to ensure compliance with federal Medicare and Medicaid requirements, accurately reflect each resident's current clinical condition, support appropriate care planning and reimbursement, and maintain the facility's compliance with regulatory requirements. MDSN 2 stated these quarterly MDS assessments were not submitted within the required timeframe. During an interview on 7/16/2026 at 10:40 a.m. with the Director of Nursing (DON), the facility's process for monitoring completion and submission of MDS assessments was reviewed. The DON stated failure to submit MDS assessments within the required timeframe may result in noncompliance with Medicare and Medicaid requirements and the facility should have identified and addressed the delays to prevent recurrence. During a review of the facility's policy and procedure (P&P) titled, MDS 3.0 Completion dated 2026, the P&P indicated the facility would initially and periodically conduct a comprehensive, accurate and standardized assessment of each resident's functional capacity, using the RAI specified by the State. The P&P indicated Quarterly Assessment would be completed using an Assessment Reference Date [ARD] no greater than 92 days from the most recent prior quarterly or comprehensive assessment counting ARD to ARD and Care Area Assessment [CAA's] were completed no later than 14 days after admission and each time a comprehensive MDS was completed.

Based on interview and record review, the facility failed to ensure a fall care plan was revised after a fall for one out of two sampled residents (Resident 135).This deficient practice placed Resident 135 at risk for bodily injury from another fall. Findings:During a review of Resident 135's admission Record, the admission Record indicated Resident 135 was initially admitted to the facility on [DATE] and readmitted [DATE]. Resident 135's diagnoses included schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), epilepsy (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness) muscle weakness, muscle wasting (weakening, shrinking, and loss of muscle), and lack of coordination. During a review of Resident 135's Minimum Data Set (MDS, a resident assessment tool), dated 5/4/2026, the MDS indicated Resident 1's cognition (ability to think and process) was moderately impaired. During a review of Resident 135's MDS, dated [DATE], the MDS indicated Resident 135 required supervision from staff for eating, dressing, personal hygiene, sitting to lying, sitting to standing, transferring from the bed to the chair, and walking ten feet to 150 feet. During a review of Resident 135's History and Physical (H&P), dated 6/25/2026, the H&P indicated Resident 135 lacked the capacity to understand and make decisions. During a review of Resident 135's Fall Risk Evaluation, dated 6/22/2026 and 6/30/2026, the Fall Risk Evaluation indicated Resident 135 was at risk for falls. During a record review of Resident 135's Situation, Background, Assessment, Recommendation (SBAR, a communication tool used by healthcare workers when there is a change of condition among the residents), dated 6/30/2026, the SBAR indicated Resident 135 fell, hit the back of his head, and was bleeding. During a review of Resident 1's care plan titled, Risk for falls and, or Injuries Related to [incomplete], dated 7/1/2026, the care plan indicated the interventions included conduct visual checks and monitoring every shift, provide assistance with bed mobility and transfer as indicated, and provide the resident with a safe environment. During a record review of Resident 135's SBAR, dated 7/13/2026 at 10:42 a.m., the SBAR indicated Resident 135 leaned forward in his wheelchair and hit his face against the wall. During a concurrent interview and record review, on 7/14/2026 at 3:09 p.m., with Registered Nurse (RN) 1, Resident 135's care plans, titled Actual Fall, dated 6/30/2026 and 7/1/2026, were reviewed. Both care plans indicated Resident 135 fell backwards while ambulating and both care plans had interventions that remained unchanged. RN 1 stated the facility's practice was to ensure fall care plans were updated to implement alternative fall interventions. RN 1 stated she developed both care plans but did not ensure different interventions were implemented after Resident 135's second fall on 7/1/2026. RN 1 stated this placed Resident 135 at risk for subsequent falls. During an interview on 7/15/2026 at 8:13 a.m. with the Minimum Data Set Nurse (MDSN) 1, MDSN 1 stated a post fall Interdisciplinary Team (IDT) Meeting was important to allow the representative party, resident, and the IDT to collaborate on a plan of care and modify existing fall interventions. MDSN 1 stated the post fall IDT should be conducted within 72 hours post fall so that interventions could be implemented. MDSN 1 stated that because a post fall IDT has not occurred after Resident 135's falls on 6/30/2026 and 7/1/2026, Resident 135 was at risk for another fall. During a review of the facility's Policy and Procedure (P&P), titled, Care Plan Revision Upon Status Change, dated 2018, the P&P indicated the following:Upon identification of a change in status, the nurse would notify the MDS Coordinator, the physician, and the resident representative, if applicable.The MOS Coordinator and the Interdisciplinary Team would discuss the resident condition and collaborate on intervention options.The team meeting discussion would be documented in the nursing progress notes.The care plan would be updated with the new or modified interventions.Care plans would be modified as needed by the MDS Coordinator or other designated staff member. During a review of the facility's P&P, titled, Resident-Oriented Approach to Safety, dated 1/2025, the P&P indicated the following:The facility-oriented and resident-oriented approaches to safety were used together to implement a systems approach to safety, which considered the hazards identified in the environment and individual resident risk factors, and adjusts interventions accordingly.The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for that resident. The care team shall target interventions to reduce the potential for accidents.

Based on interview and record review, the facility failed to conduct the assessments for one of three sampled residents (Resident 38) in accordance with the physician's orders on 6/13/2026.This deficient practice had the potential to result in Resident 38 experiencing undetected adverse reactions of medications, changes of conditions, and abnormal vital signs requiring intervention.Findings:During a review of Resident 38's admission Record, the admission Record indicated Resident 38 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 38's diagnoses included hypertension (high blood pressure), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety disorder (a mental health condition characterized by excessive, persistent fear or worry), schizophrenia (a mental illness that is characterized by disturbances in thought), and schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior). During a review of Resident 38's Minimum Data Set (MDS, a resident assessment tool), dated 6/9/2026, the MDS indicated Resident 38's cognition (ability to think and process) was moderately impaired. The MDS indicated Resident 38 required substantial assistance (helper does more than half the effort) from staff with toileting, bathing, lower body dressing, and putting on/taking off footwear. The MDS indicated Resident 38 took antipsychotic (medication that affects mood and behavior), antianxiety (medication to treat anxiety), and antiplatelet (blood thinner) medication.During a review of Resident 38's History and Physical (H&P), dated 6/2/2026, the H&P indicated Resident 38 had the capacity to understand and make decisions.During a review of Resident 38's Physician Orders, dated 6/2/2026, the Physician Orders indicated to:1. Auscultate (listen to) lung sounds every shift.2. Monitor behavior episodes of anxiety manifested by the inability to relax every shift.3. Monitor behavior episodes of depression manifested by sad facial expression every shift.4. Monitor behavior episodes of schizoaffective disorder manifested by labile mood every shift.5. Monitor behavior episodes of schizophrenia manifested by delusions (misconceptions or beliefs firmly held, contrary to reality) that someone is stealing from her) every shift.6. Monitor for central nervous system (CNS) adverse effects such as cognitive changes and drowsiness every shift.7. Monitor signs and symptoms of dehydration, hypotension (low blood pressure), dizziness, increased confusion, and muscle cramps every shift.8. Monitor for signs and symptoms of bleeding every shift.9. Monitor oxygen saturation (O2 sat, measurement of oxygen in the blood) every shift.10. Monitor pain every shift.11. Monitor signs and symptoms of tardive dyskinesia (abnormal facial and tongue movement), cognitive impairment, akathisia (inability to sit still), and parkinsonism (abnormal movements such as tremors, drooling, and rigidity) every shift.12. Monitor Patient 38's orthostatic blood pressure (a measurement of the change in blood pressure between lying down and standing up) every Saturday in a lying and sitting position.During a concurrent interview and record review, on 7/15/2026 at 2:02 p.m., with the Director of Nursing (DON), Resident 38's Medication Administration Record (MAR, a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 6/1/2026 through 6/30/2026, was reviewed. The MAR indicated on 6/13/2026, the following assessments were not done: 1. Auscultate lung sounds.2. Monitor behavior episodes of anxiety manifested by the inability to relax.3. Monitor behavior episodes of depression manifested by sad facial expression.4. Monitor behavior episodes of schizoaffective disorder manifested by labile mood ever.5. Monitor behavior episodes of schizophrenia manifested by delusions that someone is stealing from her.6. Monitor for CNS adverse effects such as cognitive changes and drowsiness.7. Monitor signs and symptoms of dehydration, hypotension, dizziness, increased confusion, and muscle cramps.8. Monitor for signs and symptoms of bleeding.9. Monitor oxygen saturation.10. Monitor pain.11. Monitor signs and symptoms of tardive dyskinesia, cognitive impairment, akathisia, and parkinsonism.12. Monitor Patient 38's orthostatic blood pressure in a lying and sitting position.The DON stated the empty areas on Resident 38's MAR indicated the assessments were not done. The DON stated the purpose of the assessments was to monitor the occurrences of Resident 38's behaviors and any adverse effects of medications. The DON stated without the ordered monitoring done, Resident 38 could have experienced an undetected adverse reaction of medications, changes of conditions, and abnormal vital signs requiring intervention.During a review of the facility's Policy and Procedure (P&P) titled, Vital Signs, dated 2026, the P&P indicated vital signs would be obtained by the nurse, as indicated.During a review of the facility's P&P titled, Use of Psychotropic Medications, undated, the P&P indicated the resident's response to the medications, including progress towards the goal and presence/absence of adverse consequences, shall be documented in the resident's medical record.

Based on observation, interview, and record review, the facility failed to ensure three of four sampled residents (Residents 135, 12, and 9) were free of accidents and hazards by failing to:1. Ensure adequate supervision and visual checks were rendered and documented for Resident 135.2. Ensure orthostatic blood pressure (a measurement of the change in blood pressure between lying down and sitting up) orders were followed for Resident 12 for May 2026, June 2026, and July 2026. 3. Ensure Resident 9's orthostatic blood pressure was monitored on 6/13/2026.These deficient practices resulted in Resident 135 falling and sustaining a bruise under his left eye and scattered scabs across his forehead with the potential for Resident 135 to sustain more falls and had the potential to result in Residents 12 and 9 experiencing adverse effects of hypotension (low blood pressure), including dizziness, lightheadedness, fatigue, nausea, blurred vision, and fainting. Cross reference F657Findings: 1. During a review of Resident 135's admission Record, the admission Record indicated Resident 135 was initially admitted to the facility on [DATE] and readmitted [DATE]. Resident 135's diagnoses included schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), epilepsy (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness) muscle weakness, muscle wasting (weakening, shrinking, and loss of muscle), and lack of coordination. During a review of Resident 135's Minimum Data Set (MDS, a resident assessment tool), dated 5/4/2026, the MDS indicated Resident 1's cognition (ability to think and process) was moderately impaired. During a review of Resident 135's MDS, dated [DATE], the MDS indicated Resident 135 required supervision from staff for eating, dressing, personal hygiene, sitting to lying, sitting to standing, transferring from the bed to the chair, and walking ten feet to 150 feet. During a review of Resident 135's History and Physical (H&P), dated 6/25/2026, the H&P indicated Resident 135 lacked the capacity to understand and make decisions. During a review of Resident 135's Fall Risk Evaluation, dated 6/22/2026 and 6/30/2026, the Fall Risk Evaluation indicated Resident 135 was at risk for falls. During a review of Resident 135's Situation, Background, Assessment, Recommendation (SBAR, a communication tool used by healthcare workers when there is a change of condition among the residents), dated 6/30/2026, the SBAR indicated Resident 135 was witnessed falling and hitting the back of his head, and was bleeding. During a review of Resident 135's SBAR, dated 7/1/2026, the SBAR indicated Resident 135 had an unwitnessed fall and was found lying down on the ground on his back with bleeding noted to the back of his head. During a review of Resident 135's care plan titled, Risk for falls and, or Injuries Related to [incomplete], dated 7/1/2026, the care plan indicated the interventions included to conduct visual checks and monitoring every shift, provide assistance with bed mobility and transfer as indicated, and provide the resident with a safe environment. During a review of Resident 135's SBAR, dated 7/13/2026, timed at 10:42 a.m., the SBAR indicated Resident 135 had a change in skin color and after speaking to the resident with an interpreter, Resident 135 leaned forward in his wheelchair and hit his face against the wall. During an observation and interview on 7/13/2026 at 9:30 a.m. in Resident 135's room, Resident 135 had a blue to purple discoloration noted to the area under his left eye and several, round, small scabs scattered scabs across his forehead. During a concurrent record review on 7/15/2026 at 8:20 a.m. with Minimum Data Set Nurse (MDSN) 1, Resident 135's nursing progress notes, dated 7/5/2026 through 7/12/2026, were reviewed. The nursing progress notes indicated, from 7/5/2026 through 7/12/2026, there was no documentation indicating visual monitoring was performed for Resident 135 prior to the identification of the discoloration to his left eye and scattered scabs on his forehead on 7/13/2026. MDSN 1 stated Resident 1 required visual monitoring every 15 minutes because he was more prone to falls. During an interview on 7/15/2026 at 2:40 p.m. with the Director of Nursing (DON), the DON stated nursing staff usually conducted head count rounds every two hours; however, supervisory checks should have been performed and documented more frequently for Resident 135. The DON stated Resident 135 was at risk for falls and had poor safety awareness. The DON stated adequate supervision could not be verified without proper documentation and insufficient supervision increased the risk of falls or altercations for Resident 135. 2. During a review of Resident 12's admission Record, the admission Record indicated Resident 12 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 12's diagnoses included atrial fibrillation (an irregular and often very rapid heart rhythm), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), dysphagia (difficulty swallowing) and schizoaffective disorder. During a review of Resident 12's H&P, dated 1/3/2026, the H&P indicated Resident 12 could make needs known but could not make medical decisions. During a review of Resident 12's physician order, dated 3/14/2026, the physician order indicated to obtain orthostatic blood pressure monitoring weekly and notify the medical doctor if the systolic blood pressure's difference was 20 millimeters of mercury (mmHg, a unit for measuring blood pressure) or greater, every Saturday evening with Resident 12 lying down. During a review of Resident 12's physician order, dated 3/14/2026, the physician order indicated to obtain orthostatic blood pressure monitoring weekly and notify the medical doctor if the systolic blood pressure's difference was 20 mmHg or greater, every Saturday evening with Resident 12 sitting down. During a review of Resident 12's Weights and Vitals Summary record for the months of May, June, and July 2026, the records did not indicate Resident 12's orthostatic blood pressures were monitored on Saturday's 5/2/2026, 5/9/2026, 5/16/2026, 5/23/2026, 5/30/2026, 6/6/2026, 6/13/2026, 6/20/2026, 6/27/2026, 7/4/2026 and 7/11/2026. During a concurrent record review and interview on 7/15/26 at 10:55 a.m., with the Licensed Vocational Nurse (LVN) 12, Resident 12's physician orders, dated 3/14/2026 and Resident 12's Weights and Vital summary for the months of May, June, and July were reviewed. LVN 12 stated the physician order directed staff to obtain and document Resident 12's orthostatic blood pressure every Saturday evening by measuring the resident's blood pressure while lying down and while sitting. LVN 12 stated there was no documentation indicating the orthostatic blood pressure assessments had been obtained or recorded during the months of May, June, or July 2026. During an interview on 7/15/2026 at 1:30pm with the DON, the DON stated nursing staff were expected to carry out all physician orders as written and accurately document the completion of ordered assessments in the resident's medical record. The DON stated orthostatic blood pressure monitoring was used to assess postural blood pressure changes, evaluate the effectiveness and safety of prescribed medications, identify residents at risk for dizziness, falls, or syncope, and promptly notify the physician of any abnormal findings. The DON stated the lack of documentation indicated the physician's order had not been followed as prescribed and the ordered monitoring should have been performed and documented each Saturday. 3. During a review of Resident 9's admission Record, the admission Record indicated Resident 9 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 9's diagnoses included metabolic encephalopathy (a broad term for brain dysfunction caused by chemical imbalances, systemic illnesses, or organ failure), schizophrenia (a mental illness that is characterized by disturbances in thought) and heart failure (when the heart does not pump blood to the body as well). During a review of Resident 9's MDS, dated [DATE], the MDS indicated Resident 9's cognition was severely impaired. The MDS indicated Resident 9 was dependent on staff for oral hygiene, toileting, bathing, upper/lower body dressing, and putting on/taking off footwear. During a review of Resident 9's H&P, dated 5/22/2026, the H&P indicated Resident 9 could make needs known but could not make medical decisions. During a review of Resident 9's Physician Order, dated 5/22/2026, the Physician Order indicated to monitor Resident 9's orthostatic blood pressure every Saturday in a lying and sitting position and to notify the physician for blood pressure differences of 20 mmHg or greater. During a review of Resident 9's Care Plan titled, Risk for Complications Related to Orthostatic Hypotension, dated 5/27/2026, the Care Plan's interventions indicated to monitor Resident 9's blood pressure as ordered. During a review of Resident 9's MAR, dated 6/1/2026 through 6/30/2026, the MAR indicated on 6/13/2026, Resident 9 had a lying and sitting position blood pressure of 128 over 78 (128/78) mmHg. During a phone interview on 7/13/2026 at 3:42 p.m., with LVN 11, LVN 11 stated he was a registry nurse (temporary employee) and worked one shift at the facility. LVN 11 stated he recalled checking the vital signs of his assigned residents but did not do any orthostatic blood pressure monitoring. LVN 11 stated on 6/13/2026, he must have overlooked Resident 9's order for orthostatic blood pressure and documented the same blood pressure for both positions. LVN 11 stated monitoring orthostatic blood pressures was necessary to understand how Resident 9's blood pressures varied from lying to sitting position. LVN 11 stated a change in orthostatic blood pressures could cause dizziness which could cause a fall. During an interview on 7/14/2026 at 12:21 p.m. with the DON, the DON stated orthostatic blood pressure monitoring was different from regular blood pressure readings because during orthostatic blood pressure monitoring, blood pressures were checked in different positions. The DON stated if the blood pressures were not monitored, the resident could have a missed change of condition requiring intervention. During a review of the facility's Policy and Procedure (P&P), titled, Resident-Oriented Approach to Safety, dated 1/2025, the P&P indicated the facility strived to make the environment as free from accident hazards as possible. The P&P indicated implementing interventions to reduce accident risks and hazards shall include ensuring interventions were implemented and documented. The P&P indicated resident supervision was a core component of the systems approach to safety and the type and frequency of resident supervision was determined by the individual resident's assessed needs and identified hazards in the environment. The P&P indicated the type and frequency of resident supervision may vary among residents and over time for the same resident. During a review of the facility's P&P, titled, Fall Prevention Program, dated 1/2026, the P&P indicated each resident would receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. During a review of the facility's P&P titled, Vital Signs, dated 1/2026, the P&P indicated vital signs would be obtained by the nurse, as indicated.

Based on interview and record review, the facility failed to inform the responsible party for one of seven sampled residents (Resident 30) when Resident 30's initial podiatry appointment (a specialized medical visit to diagnose and treat conditions affecting the feet, ankles) was canceled due to lack of transportation.This deficient practice had the potential to place Resident 30 at risk for delayed diagnosis, treatment and delivery of care. Findings:During a review of Resident 30's admission Record, the admission Record indicated Resident 30 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 30's diagnoses included chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in beathing), Diabetes Mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), and dementia (a progressive state of decline in mental abilities).During a review of Resident 30's History and Physical (H&P), dated 9/29/2025, the H&P indicated Resident 30 did not have the capacity to understand and make decisions.During a review of Resident 30's Minimum Data Set (MDS, a resident assessment tool), dated 5/3/2026, the MDS indicated Resident 30's cognition (ability to think and process) was severely impaired. The MDS indicated Resident 30 required supervision or touching assistance (helper provides verbal cues or steadying or contact guard assistance as resident completes activity) from staff for all attempted mobility activities while in and out of bed.During a telephone interview on 7/14/2026 at 9:16 a.m. with Resident 30's Responsible Party (RP) 3, RP 3 stated the Social Services Coordinator (SSC) did not notify her about Resident 30's missed podiatry appointment or provided updates. RP 3 stated after a week, RP 3 contacted the facility and learned from Licensed Vocational Nurse (LVN 10) that transportation was not scheduled, which led to concerns about delayed notification.During an interview on 7/14/2026 at 1:32 p.m. with Licensed Vocational Nurse (LVN) 10, LVN 10 stated failure to notify the RP and document the canceled appointment could result in delays in necessary medical care, and unmet healthcare needs.During a review of Resident 30's Social Services Notes, dated 5/18/2026 to 6/18/2026, the Social Services Notes indicated there was no entry made indicating the appointment scheduled for 5/18/2026 was canceled and RP 3 was informed about the cancellation because transportation was unavailable.During an interview on 7/16/2026 at 10:26 a.m. with the Social Services Director (SSD), the SSD stated it was important to document the residents' appointments, along with follow-up measures to maintain consistent care and clear communication with staff, residents, and the RP in the social services progress notes.During a review of the facility's Policy and Procedure (P&P) titled, Resident Medical Appointment and Scheduling, undated, the P&P indicated social services staff would schedule, coordinate, and document all resident medical appointments and missed or delayed appointments must be recorded with the reason and care coordination details involving the attending physician and RP.

Based on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 1), who was assessed as at risk for elopement (the act of leaving a facility unsupervised and without prior authorization) and diagnosed with paranoid schizophrenia (a mental illness that was characterized by disturbances in thought), chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing), hypertension (HTN- high blood pressure), and epilepsy (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness) did not leave the facility through an unlocked and disarmed door, by failing to: 1. Supervise Resident 1's whereabouts who had behaviors of wandering to the exit door and waiting by the front door. 2. Ensure the licensed nursing staff on duty activated the exit door alarm at 7 p.m. on [DATE]. 3. Ensure Resident 1's environment was safe and secured, as indicated in Resident 1's Elopement Risk Care Plan, when the exit door alarm was not manually armed by the licensed nursing staff on [DATE]. As a result, Resident 1 eloped from the facility on [DATE] at 10:13 p.m. and was found slumped over and deceased by the police on the roof of a building (not the facility's building) on [DATE]. On [DATE] at 4:08 p.m., an Immediate Jeopardy ([IJ], a situation in which the facility's noncompliance with one or more requirements of participation had cause, or was likely to cause serious injury, harm, impairment, or death to a resident) was called in the presence of the Administrator (ADM) and the Director of Nursing (DON) due to the facility's failure to effectively monitor Resident 1's whereabouts, follow Resident 1's care plan, and ensure the exit door was manually armed before Resident 1 exited the facility building at 9:59 p.m. and subsequently eloped from the gated facility grounds 13 minutes after on [DATE]. On [DATE] at 11:30 a.m., the facility submitted an acceptable IJ Removal Plan (IJRP). After onsite verification of the IJRP implementation through observation, interview, and record review, the IJ was removed onsite at [DATE] at 4:33 p.m., in the presence of the ADM. The IJRP included the following immediate actions: 1. Review and update of the elopement risk evaluation for each resident to ensure all elopement risk residents were identified and monitored. 2. The Maintenance Director (MD) checked all the alarms functionality. 3. The maintenance staff were assigned to check the door alarms for proper functioning at the beginning and end of shift of their shift. 4. In-services were provided to maintenance staff regarding proper perimeter and door alarm checks documentation. 5. The maintenance staff performed a perimeter check to ensure the fences and the gates around the facility were not broken. 6. The 3 p.m. to 11 p.m. and the 11 p.m. to 7 a.m. licensed nurses would be assigned to check the exit door alarms during their routine rounds. 7. The licensed nurses would be assigned to turn on the exit door alarm on at 7 p.m. and the RN Supervisor on duty would check if the alarm was armed. 8. Staff and an alternate would be assigned at the exit points of the hallways from 7 p.m. to 7 a.m. in Building A. Assignments would be reflected on the Staffing Assignment Sheet under special needs. 9. Licensed Nurses will ensure that assigned staff for the exit doors of the secure building are in their designated location. 10. Staff must identify who exited the door and redirect the resident back inside the building once the exit door alarm is triggered. 11. A headcount would be done at the beginning of each shift, every two hours, and at the end of the shift to prevent elopement. 12. An update of elopement risk evaluations were completed on [DATE]. Out of an inhouse census of 165, a total of 24 residents are elopement risk. Care plans were completed for all 24 residents. 13. An in-service was given on [DATE] to 32 staff members and on [DATE] to 40 staff members regarding Head Counts and Shift Reports. An in-service was given on [DATE] to 39 staff members regarding procedure for door alarm activation and staff responsibility. An in-service was given on [DATE] to 14 staff members regarding head counts, shift reports and Safety and Supervision of Residents. An in-service was given on [DATE] to 15 staff members regarding the activation of door alarms to maintain safety for the wandering and elopement risk resident. An in-service was given on [DATE] to 18 staff members and on [DATE] to 22 staff members regarding safety and supervision of residents and elopement precautions. 14. In-services would be ongoing of the procedure to secure the exits and door alarm activation in Building A, until all staff are covered. As of [DATE] only 15 staff members have not been in-serviced due to not being on schedule at this time. 15. In-services on Safety and Supervision of Residents & Elopements and Wandering to prevent elopement and other accidents/incidents, will be ongoing until all staff are covered, as of today only 15 staff members have not been in-serviced due to not being on schedule at this time. They will be in-serviced when they return to work. 16. The Nursing Supervisors, DON or Designee shall monitor compliance with the above plan of actions. Any episodes of non-compliance shall be reported to the Administrator for further corrective action, as necessary. The administrator shall report any findings to the Quality Assurance Committee (QA&A). The QA&A Committee shall review the systems and revise as necessary. Findings: a. During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility in Building A on [DATE] with diagnoses that included restlessness, agitation (a state of unease, restlessness, or disturbance), epilepsy, depression (a feeling of sadness and hopelessness), paranoid schizophrenia, anxiety (an overwhelming feeling of uneasiness), COPD, and HTN. During a review of Resident 1's Minimum Data Set ([MDS], a resident assessment tool), dated [DATE], the MDS indicated Resident 1 had serious mental illness and severely impaired cognition (process of thinking). The MDS indicated Resident 1 required supervision for Activities of Daily Living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) such as performing oral hygiene, toileting, upper and lower body dressing, and performing personal hygiene. The MDS indicated Resident 1 required supervision (helper provided verbal cues and, or touching, steadying or contact guard assistance as resident completes activity) when he walked beyond 10 feet (ft- a unit of measurement), transitioned from a sitting to a standing position, transferred from the bed to a chair, and transferred from the toilet. During a review of Resident 1's History and Physical (H&P), dated [DATE], Resident 1's H&P indicated Resident 1 had fluctuating capacity to understand and make decisions. During a review of Resident 1's Elopement Risk Evaluation, dated [DATE], Resident 1's evaluation indicated Resident 1 was at risk for elopement. During a review of Resident 1's Care Plan, titled, Baseline Care Plan, dated [DATE], the Care Plan indicated Resident 1 was an elopement risk. The Care Plan indicated a plan of care would be implemented to meet Resident 1's needs while in the facility. During a review of Resident 1's Nursing Progress Note, dated [DATE], the Nursing Progress Note indicated, on [DATE] at 11:10 p.m., a charge nurse informed Registered Nurse (RN) 2 that Resident 1 was last seen at approximately 10:41 p.m. by Licensed Vocational Nurse (LVN) 1. The note indicated a facility-wide search was conducted and was unsuccessful. The note indicated on [DATE] at 12:23 a.m., the local authorities were notified. During a concurrent interview and record review on [DATE] at 1:30 p.m. with the Social Services Director (SSD), Resident 1's Social Service History and Initial Assessment, dated [DATE], was reviewed. The Social Service History and Initial Assessment indicated Resident 1 exhibited behaviors such as exit-seeking, agitation, aggressiveness, impulsiveness, and lack of safety awareness. The SSD stated he included Resident 1's behaviors of exit-seeking and lack of safety awareness in the assessment because Resident 1's Responsible Party (RP) 1 informed him of Resident 1's previous attempts to leave a previous facility and of the resident's exit-seeking behaviors. The SSD stated this information was not shared during the interdisciplinary care team (IDT, a group of healthcare professionals from different specialties who collaborated to provide comprehensive and coordinated care to individuals) meeting because Resident 1's exit-seeking behavior was not observed by the facility staff. The SSD stated he should have shared the information with the IDT and nursing staff to ensure person-centered safety interventions were included in Resident 1's plan of care. During a concurrent interview and record review on [DATE] at 3:04 p.m., with Minimum Data Set Nurse (MDSN) 1, Resident 1's Care Plan titled At Risk for Elopement, dated [DATE], was reviewed. The Care Plan indicated Resident 1 continued to wander to the gate and sometimes waited by the front door. The Care Plan goals indicated to ensure Resident 1 was kept in a safe environment and free from injury daily. The Care Plan interventions indicated the facility was to 1) assure Resident 1's environment was kept safe and secured, and 2) ensure shift huddles (a quick meeting amongst nursing staff to communicate any important safety information about certain residents or reminders) at the beginning of each shift to make staff aware of residents with exit-seeking behaviors. MDSN 1 stated he initiated the Care Plan on [DATE] based on an interview with an unidentified licensed nurse who informed him (MDSN 1) that Resident 1 was observed walking around the unit, wandering around the nurses' station, and going out to the gate in the yard and patio during the evening shift. MDSN 1 stated the nurses performed room rounds every two hours to monitor Resident 1's whereabouts. During a telephone interview on [DATE] at 3:12 p.m. with RP 1, RP 1 stated Resident 1 had a history of unsuccessful elopement attempts in a previous Skilled Nursing Facility (SNF) and was at high risk of absence without leave (AWOL, away without permission). RP 1 stated Resident 1 was not happy about being placed in a locked facility and wished to live in the woods. RP 1 stated she (RP 1) could see that Resident 1 was building up anger for being locked in a facility. RP 1 stated she notified LVN 3 prior to Resident 1's admission to the facility that Resident 1 had a history of elopement attempts. During a concurrent observation and interview on [DATE] at 1:49 p.m. with the Administrator (ADM), the facility's security surveillance video footage, dated [DATE] from 9:59 p.m. to 10:13 p.m., was observed. The surveillance footage revealed on [DATE] at 9:59 p.m. Resident 1 exited his room located at the end of Hallway A (in Building A), adjacent to the exit door, and walked out the unlocked and disarmed exit door. The ADM stated there was no staff present in Hallway A when Resident 1 exited the building. The surveillance footage revealed Resident 1 walking in the back parking lot at 10:11 p.m., proceeded to walk down a road adjacent to the facility grounds (off the facility's property). Resident 1 was last observed leaving the facility from the parking lot at 10:13 p.m. During a concurrent interview and record review on [DATE] at 2:47 p.m. with the DON, Resident 1's IDT Conference record, dated [DATE], was reviewed. The IDT conference record did not indicate Resident 1's history of elopement or exit seeking behavior was discussed. The DON stated that the IDT should have discussed Resident 1's history of elopement and wandering behavior and develop a plan to prevent elopement. During an interview on [DATE] at 3:15 p.m. with the DON, the DON stated adequate supervision was important to prevent elopement, especially for residents with a known history of elopement attempts. The DON stated she was not aware Resident 1 had a prior history of elopement and exhibited exit-seeking behaviors. The DON stated the SSD should have made nursing aware of Resident 1's prior history of elopement and behaviors so proper interventions and adequate supervision could have been implemented. The DON stated the RN Supervisors were responsible for ensuring the care plan interventions were implemented and communicated with relevant staff every shift. The DON stated the lack of communication and implementation of effective shift huddle led to lack of adequate supervision for Resident 1, which placed Resident 1 at risk for elopement. During a telephone interview on [DATE] at 10:04 a.m. with LVN 1, LVN 1 stated he worked the evening shift on [DATE] and was Resident 1's assigned nurse. LVN 1 stated he (LVN 1) was not made aware of Resident 1's history of elopement attempts or exit-seeking behaviors and nursing staff did not perform a huddle before the start of the shift. LVN 1 stated he was unsure if any staff were outside in the yard to supervise Resident 1 when the resident exited Building A. LVN 1 stated supervision was required for all residents to prevent elopement and avoid any incidents, accidents, and ensure safety. LVN 1 stated if he was aware of Resident 1's exit-seeking behaviors, he would have implemented a one-on-one supervision (1:1, a type of supervision that required a staff member to supervise a resident at all times) measures for Resident 1, placed his medication cart in front of Resident 1's room (Room A), while he charted, and assigned a certified nursing assistant (CNA) to monitor Resident 1's whereabouts. During an interview and concurrent record review on [DATE] at 2:41 p.m. with RN 1, Resident 1's Care Plan titled At Risk for Elopement, dated [DATE], was reviewed. The Care Plan indicated Resident 1 continued to wander to the gate and sometimes waited by the front door. The Care Plan goals indicated to ensure Resident 1 would be kept in a safe environment and free from injury daily. The Care Plan interventions indicated the facility was to assure Resident 1's environment was kept safe and secure. RN 1 stated she did not read and was not made aware of the nursing goals and interventions identified in Resident 1's Care Plan. RN 1 stated she would have ensured Resident 1 received constant monitoring and supervision and would have assigned CNA to keep an eye on the resident if she had known of Resident 1's history of exit-seeking behavior, as indicated in Resident 1's Care Plan. RN 1 stated Resident 1 was at risk for elopement because he was newly admitted to the facility, new to the environment, and staff were unfamiliar with his behaviors. RN 1 stated the facility's elopement prevention and resident safety practices were to redirect residents away from the exit doors, unless a staff member was available to supervise the resident, ensure all exit door alarms were armed, inform staff of residents with exit-seeking behaviors, supervise residents at all times, perform a head count of the residents, and room rounds every two hours to ensure all residents were visible to staff. b. During a review of Resident 2's admission Record, the Face Sheet indicated Resident 2 was admitted to the facility on [DATE] with diagnoses that included polyosteoarthritis (diagnosis that means five or more of your joints have arthritis at the same time), COPD, and paranoid schizophrenia. During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2's cognition was moderately impaired. The MDS indicated Resident 2 required supervision with ADLs. During an interview on [DATE] at 11:37 a.m. with Resident 2 (Resident 1's roommate), Resident 2 stated the exit door, located adjacent to his room, was not armed on [DATE]. Resident 2 stated he usually exited through the door around 9 p.m. or 10 p.m., or whenever he wished without triggering an alarm. During a concurrent observation and interview on [DATE] at 1:04 p.m. with the ADM, Hallway A video footage, dated [DATE] and timed from 9:59 p.m. to 10:04 p.m., was reviewed. The video footage revealed Resident 1 opened the exit door and exited Building A unnoticed at 9:59 p.m. The video footage did not show the alarm had flashing lights and there was no staff observed running toward the exit door. The video footage revealed three minutes later at 10:02 p.m., CNA 1 exited Room B, located across from Room A, passed the exit door, and proceeded to walk away from the exit door towards the linen storage. The ADM stated the exit door alarm was not activated at 7 p.m. on [DATE], when Resident 1 eloped from the facility. The ADM stated it was important to ensure exit door alarms were armed to alert staff when a resident attempted to leave the facility. During an interview on [DATE] at 1:07 p.m. with LVN 2, LVN 2 stated she worked the 3 p.m. to 11 p.m. shift on [DATE] and did not check if the exit doors were armed and did not hear the sound of an exit door alarm during that shift. During an interview on [DATE] at 2:06 p.m. with RN 2, RN 2 stated she was the assigned RN Supervisor on [DATE] from 7 p.m. to 7 a.m. RN 2 stated all licensed nursing staff were expected to arm the exit door alarms at 7 p.m. or after the resident's smoke break at 8:30 p.m. RN 2 stated the exit door alarms alerted staff whenever a resident entered or exited Building A during the 3 p.m. to 11 p.m. and the 11 p.m. to 7 a.m. shifts. RN 2 stated she did not check if the exit door alarms were armed and did not recall hearing the distinct sound of the door alarm activate on [DATE] from 7 p.m. to 7 a.m. RN 2 stated Resident 1 was at an increased risk for elopement due to the unarmed exit door and she should have ensured the door alarms were on. During an interview on [DATE] at 3:15 p.m. with the DON, the DON stated there were no systems in place to ensure all licensed nurses manually armed the exit door alarms and ensure the alarms were armed after 7 p.m. The DON stated there was an increased potential for a resident to elope if the alarms were not armed. The DON stated staff would not be aware if a resident was no longer in the building without the use of the alarms. The DON stated, if exit door alarms were armed on [DATE] at 7 p.m., staff could have been alerted when Resident 1 left the building. During an interview on [DATE] at 10:04 a.m. with LVN 1, LVN 1 stated he worked the 3 p.m. to 11 p.m. shift on [DATE] and was Resident 1's assigned nurse. LVN 1 stated he did not arm the exit door because he was not in-serviced or advised to arm the exit door. c. During a concurrent interview and record review on [DATE] at 2:40 p.m., with RN 1, Resident 1's At Risk for Elopement Care Plan, dated [DATE], was reviewed. The Care Plan interventions indicated the facility was to assure Resident 1's environment was kept safe and secure. RN 2 stated the specific care plan intervention meant licensed nurses were to ensure all exit door alarms were armed especially at night. RN 1 stated it was very important to know the whereabouts of the residents to ensure their safety, especially if the resident was new or recently admitted to the facility. During an interview on [DATE] at 3:50 p.m., with the DON, the DON stated Resident 1's At Risk for Elopement Care Plan intervention to keep Resident 1's environment safe and secure meant the door alarms should have been armed on [DATE] at 7 p.m. The DON stated the unarmed exit door did not align with Resident 1's At Risk for Elopement Care Plan intervention of maintaining a safe and secure environment, and placed Resident 1 at an increased risk for any injuries or accidents to occur. During a review of the facility's P&P titled, Safety and Supervision of Residents, dated 1/2025, the P&P indicated the facility's priorities was to keep the environment free from accident hazards, supervise and assist residents, and ensure residents' safety to prevent accidents. The P&P indicated the IDT shall analyze information obtained from assessments to identify any specific accident hazards or risks for each resident. The P&P indicated the care team shall target interventions to reduce the potential for accidents such as communicating specific interventions to all relevant staff; assigning responsibility for carrying out interventions; providing training as necessary; and ensuring interventions were implemented and documented. During a review of the facility's P&P titled, Elopements and Wandering Residents, undated, the P&P indicated the facility was to ensure residents who were at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. The P&P indicated elopement occurred when a resident left the premises or a safe area without authorization and, or any necessary supervision to do so. The P&P indicated adequate supervision would be provided to help prevent accidents or elopements.

Based on interview and record review, the facility failed to follow its policy and procedure (P&P) titled, Resident Examination and Assessment, which indicated the facility will assess a resident for any abnormalities in health status, such as abdominal distention, pain duration, severity and factors that worsen the pain, for one of three sampled residents (Resident 65), when Resident 65 complained of severe abdominal pain on 8/24/2024 at 11:00 p.m. and on 8/25/2024 at 2:30 p.m. This failure caused Resident 65 to be emotionally distressed (angry, scared, and frustrated), suffer severe pain for an extended period and was transferred to a general acute care hospital (GACH) for evaluation and treatment. Findings: During a review of Resident 65 ' s Admission Record, the Admission Record indicated Resident 65 was admitted to the facility on [DATE] with diagnoses including urinary tract infection (UTI- a bacterial infection in the organ that removes urine) and hereditary (inborn)and idiopathic (a disease of unknown cause) neuropathy (nerve pain). During a review of Resident 65 ' s physician orders dated 7/29/2024, the physician orders indicated the following: 1. Monitor level of pain every shift (using 0-10 pain scale). 2. Oxycodone-Acetaminophen (a strong pain medicine) 5 milligrams (mg)/ 300 mg one (1) tablet by mouth (PO) every six (6) hours (Q6hrs) as needed (PRN) for moderate to severe pain. 3. Monitor suprapubic catheter (a medical device that helps drain urine from the bladder through a small incision in the abdomen) drainage bag every shift and document signs and symptoms (S/S) of UTI such as bladder distention and burning sensation. 4. Change suprapubic catheter by wound care consultant every 6 months and PRN if blocked (obstructed) or pulled out. During a review of Resident 65 ' s History and Physical (H&P) dated 7/30/2024, the H&P indicated Resident 65 had the capacity to understand and make decisions. The H&P indicated Resident 65 had an intact suprapubic catheter. During a review of Resident 65 ' s Minimum Data Sheet ([MDS] a standardized care screening and assessment tool) dated 8/18/2024, the MDS indicated Resident 65 had an intact cognition (understanding). The MDS indicated Resident 65 had a suprapubic catheter. The MDS indicated Resident 65 required moderate assistance (helper does less than half the effort) with eating, maximal assistance (helper does more than half the effort) with oral hygiene and dependent with toileting hygiene, personal hygiene, showers, and upper and lower body dressing. The MDS indicated Resident 65 was dependent with toilet transfer, sit to stand position and chair/bed-to-chair transfer (the ability to transfer to and from a bed to a chair (or wheelchair). During a review of Resident 65 ' s Medication Administration Record (MAR) dated 8/25/2024, the MAR indicated Resident 65 had a pain level of 10/10 ([numeric pain scale] a pain scale used in a facility with 0 no pain, 1-3 mild pain, 4-6 moderate pain, 7-8 severe pain, 9-10 worst pain possible) during the 11:00 p.m. to 7:00 a.m. shift ([(11 p.m. on 8/24/2024 to 7 a.m. on 8/25/2024] no specific time indicated). The MAR indicated a signature next to Oxycodone on 8/25/2024 (time not specified), indicating the resident was medicated. During a review of Resident 65 ' s Nurses ' Notes dated 8/25/2024, at 1:03 a.m., the Nurses ' Notes indicated Resident 65 complained of abdominal pain. The notes did not indicate Resident 65 was assessed for the pain level and pain characteristics. The notes indicated Resident 65 was offered (unspecified) pain medication, but the resident refused. The Nurses ' Notes at 2:00 a.m. indicated Resident 65 was offered pain medication and he refused. The notes indicated Resident 65 requested to go to hospital, and that Resident 65 ' s doctor was notified on 8/25/2024 at 1:00 a.m. The nurse ' s note at 5:30 a.m. indicated Resident 65 ' s doctor called the facility and ordered Resident 65 be transferred to the GACH on 8/25/2024 at 10:30 a.m. The nurses ' notes at 2:30 p.m. indicated Resident 65 was picked up by the ambulance on 8/25/2024 at 2:30 p.m., with a pain level of 7/10 pain (severe pain). The nurses ' notes did not indicate any pain interventions were provided to Resident 65. During a review of the GACH emergency department (ED) notes dated 8/25/2024 at 7:10 p.m., the ED notes indicated Resident 65 arrived at the GACH on 8/25/2024 at 3:25 p.m. with a chief complaint of abdominal pain radiating (spreading) to the flank (sides of the body between ribs and hips) area that started last night on 8/24/2024. The ED notes indicated Resident 65 had gross pus (large amount of thick yellowish, whitish, or greenish fluid) from the suprapubic catheter and sepsis (a life-threatening complication of an infection). The ED notes indicated Resident 65 ' s suprapubic catheter was changed by the ED staff, and the abdominal pain improved. The ED notes indicated Resident 65 received antibiotics and pain medications, was admitted to the GACH for evaluation, treatment, and care for urinary tract infection, dehydration (body does not have enough water), and acute kidney injury (an abrupt decrease in kidney function). During an interview on 9/17/2024 at 4:23 p.m. with Resident 65, Resident 65 stated on 8/24/2024 at 11:00 p.m., he complained of severe abdominal pain to LVN 9 and Registered Nurse 4 (RN 4). Resident 65 stated LVN 9 and RN 4 did not assess his pain, and he suffered severe abdominal pain from 11:00 p.m., on 8/24/2024 to 8/25/2024, when he received treatment at the GACH. Resident 65 stated on 8/25/2024 at 2:00 a.m., he asked LVN 9 to call 911 (emergency phone number) because he could not handle the pain anymore. Resident 65 stated LVN 9 did not assess his pain or suprapubic catheter and did not call 911 to assess him or take him to a GACH. Resident 65 stated, Isuffered severe abdominal pain and felt angry, scared, and frustrated until I was transferred to the GACH on 8/25/2024 at 2:30 p.m. Resident 65 stated, I would rather be dead than re-experience the pain on 8/25/2024. During a concurrent interview and record review on 9/18/2024 at 3:53 p.m., with RN 4, Resident 65 ' s care plan titled Potential for Pain, dated 7/25/2024, physician orders dated 7/29/2024, August 2024 MAR and nurses ' notes dated 8/24/2024 and 8/25/2024 were reviewed. RN 4 stated the care plan interventions indicated staff will assess Resident 65 ' s pain symptoms, identify the frequency, location, quality, onset, and how Resident 65 expressed pain, provide non-pharmacological interventions such as relaxation techniques, deep breathing exercises, proper positioning, and provide 1 to 1 interaction, monitor effectiveness of non-pharmacologic interventions, and notify the physician of increasing pain. RN 4 stated the nurses ' notes did not indicate Resident 65 was assessed when he complained of severe abdominal pain on 8/24/2024 and on 8/25/2024. RN 4 stated Resident 65 ' s suprapubic catheter should have been assessed for blockage (obstruction) and output because it might have been the cause of pain. RN 4 stated the nurse ' s assessment should have been documented in the progress notes. RN 4 stated, a blockage to the suprapubic catheter could result in pain, fever, and sepsis. RN 4 stated she did not know if Resident 65 had a fever, or his catheter was blocked when the resident complained of severe abdominal pain. RN 4 stated she did not assess Resident 65 ' s suprapubic catheter, or the location, frequency, duration, onset, and pattern of pain, on 8/24/2024 at 11:00 p.m., and 8/25/2024 at 2:30 p.m. RN 4 stated the failure to assess Resident 65 ' s pain for prompt interventions, caused the resident to experience severe pain for a long time (approximately 15 hours). RN 4 stated on 8/25/2024, during the 11:00 p.m. to 7:00 a.m. shift, the MAR indicated Resident 65 had a pain level of 10/10 (location unspecified) with a staff ' s initial next to Oxycodone on 8/25/2024 (time not specified), indicating the resident was medicated. RN 4 stated Resident 65 ' s nurses ' notes and MAR did not indicate Resident 65 ' s pain was assessed on 8/25/2024 prior to the medication administration (Oxycodone) and did not indicate a reassessment after the medicine was administered to evaluate for its effectiveness. RN 4 stated Resident 65 should have been assessed prior to and one hour after Resident 65 ' s Oxycodone administration. RN 4 stated when Resident 65 complained of 7/10 abdominal pain on 8/25/2024 at 2:30 p.m. (prior to ambulance transport to GACH), Resident 65 was not assessed. RN 4 stated Resident 65 ' s licensed nurse should have assessed the resident (Resident 65). RN 4 stated, the nurse ' s notes indicated Resident 65 asked LVN 9 to call the paramedics (medical emergency personnel). RN 4stated the nurses ' notes also indicated on 8/25/2024 at 3:00 a.m., Resident 65 ' s family member (FM 1), called LVN 9 and requested for LVN 9 to call the paramedics. During an interview on 9/18/2024 at 4:45 p.m., with the Director of Nursing (DON), the DON stated Resident 65 ' s unresolved pain should have been reassessed frequently and interventions provided according to the facility ' s policy and resident ' s plan of care. The DON stated Resident 65 ' s physician should have been notified of Resident 65 ' s pain condition. The DON stated pain assessment and reassessment could identify the cause of pain and guide interventions. The DON stated unresolved severe abdominal pain was considered a medical emergency (a serious condition that requires immediate medical attention to prevent a person's worsening health and death) requiring immediate transfer to a GACH. The DON stated the delay in providing interventions and addressing Resident 65 ' s severe pain could result in worsening condition and complications. During a review of the facility ' s undated policy and procedure (P&P) titled, Resident Examination and Assessment, the P&P indicated the facility will examine and assess the resident for any abnormalities in health status, such as abdominal distention and hardness, urine output if they were clear or cloudy, presence of foley catheter (a flexible tube that is inserted into the bladder through the urethra to drain urine), description, location, duration, severity of pain and factors that worsened the pain, current medication and treatments for pain. During a review of the facility ' s undated P&P titled, Pain Management, the P&P indicated the facility will ensure pain management was provided to residents who required such services consistent with professional standards of practice, the comprehensive person-centered care plan and the resident ' s goals and preferences. The P&P indicated pain assessment and evaluation should be done by nurses, practitioners and review resident ' s diagnosis or conditions and any additional factors that may have caused or contributed to pain, identifying the location, frequency, duration, onset, and pattern of pain. The P&P indicated staff will identify the current prescribed pain medications, dosage and frequency, resident ' s goals for pain management and the effectiveness of drugs and other treatments used in the past to treat pain. The P&P indicated, if the resident ' s pain was not controlled with the current treatment regimen, the practitioner should be notified.

Based on observation, interview, and record review, the facility failed to provide services to maintain mobility (ability to move) for four of six sampled residents (Resident 91, Resident 92, Resident 93, and Resident 113) with limited range of motion ([ROM] full movement potential of a joint (where two bones meet) and mobility by failing to: 1. Monitor Resident 91's ROM in both arms and legs quarterly (every three months) in accordance with Resident 91's care plan between 4/21/2021 and 3/27/2024 (approximately 3 years). 2. Provide Resident 91 with Restorative Nursing Aide ([RNA] certified nursing aide program that helps residents to maintain their function and joint mobility) services for ambulation (the act of walking) using a front-wheeled walker ([FWW] an assistive device with two front wheels used for stability when walking) in accordance with the physician orders, dated 5/5/2020, for the months of 3/2022, 4/2022, 5/2022, 7/2022, and 8/2022. 3. Provide Resident 91 with intervention to prevent a decline in ROM of both legs and a decline in the ability to walk prior to changing Resident 91's RNA program from walking using a FWW to sit to stand transfers (ability to come to a standing position from sitting) on 9/15/2022. 4. Provide Resident 91 with intervention to prevent a decline in ROM of both arms and a decline in the ability to use both hands prior to applying hand rolls (soft fabric and positioned in the palm of the hand to protect from skin irritation) on 9/28/2022. 5. Provide Resident 91 with RNA services for sit to stand transfers and application of both hand rolls in accordance with the physician orders, dated 9/15/2022 and 9/28/2022, for the months of 12/2022, 2/2023, 3/2023, 9/2023, and 1/2024. 6. Provide Resident 91 with interventions to prevent further ROM loss in both arms and both legs when a decline was identified on Resident 91's Joint Mobility Assessment ([JMA] brief assessment of a resident's range of motion in both arms and both legs), dated 3/27/2024, in accordance with the facility's policy. 7. Ensure Resident 92, Resident 93, and Resident 113 were provided RNA services as ordered. These deficient practices caused Resident 91 to develop moderate joint mobility limitations (50 to 75 percent [50-75%] available ROM; 25-50% ROM loss) in both elbows, both wrists, and the right hand and minimal joint mobility limitations (75-100% available ROM; 0-25% ROM loss) in both hips, both knees, and both ankles, which limited Resident 91's ability to participate in activities of daily living ([ADLs] tasks related to personal care including bathing, dressing, hygiene, eating, transfers, and walking) and prevented Resident 91 from being able to stand upright. This deficient practice also had the potential to cause joint mobility limitations for Resident 92, 93, and 113. Cross reference F580, F641, and F657. Findings: 1. A review of Resident 91's Resident Status History List (record of hospitalization s and room changes) indicated the facility originally admitted Resident 91 on 11/14/2014, readmitted Resident 91 on 4/21/2020, and discharged Resident 91 on 1/1/2023. A review of Resident 91's Face Sheet (admission record) indicated the facility admitted Resident 91 on 1/1/2023 with diagnoses including chronic obstructive pulmonary disease ([COPD] lung disease that causes constriction of the airways making it difficult or uncomfortable to breathe), intracranial injury (brain injury), and epilepsy (abnormal electrical activity in the brain marked by sudden, recurrent episodes of loss of consciousness or uncontrolled body shaking). A review of Resident 91's physician orders, dated 5/5/2020, included RNA for ambulation with front-wheeled walker ([FWW] an assistive device with two front wheels used for stability when walking) five times per week as tolerated. A review of Resident 91's JMA, dated 4/21/2021, indicated both of Resident 91's shoulders, elbows, wrists, hips, knees, and ankles were within functional limits ([WFL] sufficient movement without significant limitation). The JMA indicated Resident 91 had minimal to moderate joint mobility limitations to the left hand and had minimal joint mobility limitations in the right hand. A review of Resident 91's Minimum Data Set ([MDS] a comprehensive assessment and care planning tool), dated 2/15/2022, indicated Resident 91 had intact cognition (ability to think, understand, learn, and remember). The MDS indicated Resident 91 had a ROM limitation in one arm and no ROM limitations in both legs. The MDS indicated Resident 91 used a walker and wheelchair for mobility and required extensive assistance (resident involved in activity while staff provide weight-bearing support) for transfers between surfaces, walking in room, walking in the corridor, and eating. A review of Resident 91's Restorative Record ([RNA Record] record of RNA treatment sessions) for 2/2022 indicated the RNA Record included a weekly summary, dated 2/17/2022, which indicated Resident 91 required moderate assistance (requires 25-50% physical assistance) to maximum assistance (requires 50-75% physical assistance to perform the task) to stand up from the wheelchair and walked 30 to 40 (30-40) steps with rest breaks. A review of Resident 91's RNA Record for 3/2022 indicated the RNA Record had a slash (/) and did not have RNA initials to indicate a treatment was provided to Resident 91 for ambulation with a FWW on 3/1/2022, 3/4/2022, 3/14/2022, 3/16/2022, 3/25/2022, and 3/28/2022. A review of Resident 91's RNA Record for 4/2022 indicated the RNA Record had a slash (/) and did not have RNA initials to indicate treatment was provided to Resident 91 for ambulation with a FWW on 4/1/2022, 4/11/2022, 4/19/2022, and 4/25/2022. A review of Resident 91's RNA Record for 5/2022 indicated the RNA Record had a slash (/) and did not have RNA initials to indicate treatment was provided to Resident 91 for ambulation with a FWW on 5/2/2022, 5/4/2022, 5/5/2022, 5/10/2022, 5/11/2022, 5/12/2022, and 5/30/2022. A review of Resident 91's RNA Record for 7/2022 indicated the RNA Record had a slash (/) and did not have RNA initials to indicate treatment was provided to Resident 91 for ambulation with a FWW on 7/1/2022, 7/4/2022, 7/5/2022, 7/6/2022, 7/7/2022, 7/8/2022, 7/28/2022, and 7/29/2022. A review of Resident 91's RNA Record for 8/2022 indicated the RNA Record had a slash (/) and did not have RNA initials to indicate treatment was provided to Resident 91 for ambulation with a FWW on 8/1/2022, 8/11/2022, 8/25/2022, 8/26/2022, and 8/29/2022. A review of Resident 91's RNA Record for 9/2022 indicated the RNA Record included a weekly summary, dated 9/12/2022, indicating Resident 91 required maximum assistance to stand with two RNAs (unknown) and moderate to maximum assistance to maintain balance while walking with the FWW. The weekly summary also indicated Resident 91 dragged both feet while walking 10-20 short, slow steps with rest breaks. A review of Resident 91's Nurses Notes, dated 9/15/2022 timed at 9:30 a.m., indicated to discontinue the current RNA program and begin RNA to assist with a sit to stand program, every day, five times per week as tolerated. A review of Resident 91's physician orders, dated 9/15/2022 (untimed), indicated to discontinue current RNA program and begin RNA to assist with a sit to stand program, every day, five times per week as tolerated. A review of Resident 91's Nurses Notes, dated 9/28/2022 timed at 12:00 p.m., indicated the Occupational Therapist [[OT] profession aimed to increase or maintain a person's capability of participating in everyday life activities (occupations)] evaluated Resident 91 who had contractures (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to joint stiffness) in both hands. The Nurses Notes indicated for RNA to apply hand rolls, every day, five times per week for four to six (4-6) hours or as tolerated. A review of Resident 91's physician orders, dated 9/28/2022 timed at 12:00 p.m., indicated for the RNA to apply both hand rolls, every day for 4-6 hours, five times per week or as tolerated. A review of Resident 91's RNA Record for 10/2022 included a weekly summary, dated 10/24/2022, indicating the RNA (unspecified) assisted Resident 91 to place hands on the hallway handrail and required moderate to maximum assistance to perform 5-10 repetitions of sit to stand exercises. The RNA weekly summary also indicated Resident 91 tolerated both hand rolls for 4-6 hours with checks every 2 hours as Resident 91 removed the hand rolls. A review of Resident 91's care plan for RNA, dated 11/15/2022, indicated Resident 91 required the RNA program to maintain and/or improve joint mobility. The goal for Resident 91 was to maintain maximum joint capacity (greatest possible amount) for the next three months. The care plan's approach (treatment) plan included to provide RNA program as ordered, position the resident to prevent further contractures with pillow or splint (material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion) as needed, and quarterly assessments of joint mobility or as needed. A review of Resident 91's RNA Record for 12/2022 indicated a slash (/) but did not have RNA initials to indicate treatment was provided for sit to stand exercises and application of both hand rolls on 12/1/2022, 12/2/2022, 12/5/2022, 12/26/2022, 12/28/2022, and 12/30/2022. A review of Resident 91's RNA Record for 2/2023 indicated a slash but did not have RNA initials to indicate treatment was provided for sit to stand exercises and application of both hand rolls on 2/1/2023, 2/2/2023, 2/6/2023, 2/8/2023, 2/9/2023, 2/17/2023, 2/20/2023, 2/21/2023, 2/22/2023, 2/23/2023, 2/27/2023, and 2/28/2023. A review of Resident 91's RNA Record for 3/2023 indicated a slash but did not have RNA initials to indicate treatment was provided for sit to stand exercises and application of both hand rolls on 3/1/2023, 3/9/2023, 3/16/2023, 3/17/2023, 3/20/2023, 3/21/2023, 3/22/2023, 3/23/2023, and 3/28/2023. A review of Resident 91's RNA Record for 4/2023 indicated a weekly summary, dated 4/24/2023, indicating Resident 91 required moderate to maximum assistance from two RNAs (unspecified) to perform 4-6 repetitions of sit to stand exercises, take breaks during exercises due to tiring easily, and required RNA encouragement to maintain an upright posture. The weekly summary also indicated Resident 91 tolerated both hand rolls for 4-6 hours with checks every 2 hours. A review of Resident 91's RNA Record for 9/2023 indicated a slash but did not have RNA initials to indicate treatment was provided for sit to stand exercises and application of hand rolls on 9/14/2023, 9/18/2023, 9/19/2023, 9/20/2023, 9/21/2023, 9/22/2023, and 9/27/2023. A review of Resident 91's RNA Record for 1/2024 indicated a slash but did not have RNA initials to indicate treatment was provided for sit to stand exercises and application of both hand rolls on 1/1/2024, 1/2/2024, 1/4/2024, 1/11/2024, 1/22/2024, 1/24/2024, 1/25/2024, 1/29/2024, and 1/31/2024. A review of Resident 91's MDS, dated [DATE] indicated Resident 91 had clear speech, expressed ideas and wants, had clear understanding of verbal content, and had moderately impaired cognition. The MDS indicated Resident 91 used a wheelchair for mobility, required substantial/maximal assistance (helper does more than half the effort) for sit to stand and chair/bed-to-chair transfers (ability to transfer to and from a bed to a chair or wheelchair), and walking 10 feet was not attempted due to medical condition or safety concerns. A review of Resident 91's Joint Mobility Assessment ([JMA] brief assessment of a resident's range of motion in both arms and both legs), dated 3/27/2024, indicated Resident 91 had moderate joint mobility limitations in both elbows, both wrists, both hands and minimal joint mobility limitations in both hips, both knees, and both ankles. The JMA indicated Resident 91 maintained assessed mobility and to continue the RNA program. A review of Resident 91's RNA Record for 4/2024 indicated a weekly summary, dated 4/15/2024, indicating Resident 91 required maximum assistance from two RNAs (unspecified) to perform 2-3 repetitions of sit to stand exercises with both knees bent and required encouragement to straighten posture. The weekly summary also indicated Resident 91 tolerated both hand rolls for 4-6 hours. During an interview on 4/15/2024 at 11:36 a.m., with the Director of Rehabilitation (DOR), the DOR stated the OT or Physical Therapist (PT, profession aimed in the restoration, maintenance, and promotion of optimal physical function) performed the JMA for each resident (in general) upon admission, annually (every year), and during a change of condition to monitor for ROM and mobility. The DOR also stated the JMA form also included a quarterly screening (on the back of the JMA form) of each resident for ROM and mobility. During a concurrent observation and interview on 4/16/2024 at 8:31 a.m., with Restorative Nursing Aide 2 (RNA 2) and RNA 3, in Resident 91's room, Resident 91's hands were in a closed fist position and Resident 91 was unable to open either hand. RNA 2 and RNA 3 applied hand rolls into Resident 91's palms. Resident 91 stated, This is the first time I remember these hand rolls. Resident 91 stated the RNAs usually applied terry cloth rags in his hands. RNA 2 and RNA 3 stated towel rolls were applied to Resident 91's hands when the hand rolls were washed. During observation on 4/16/2024 at 8:40 a.m., RNA 2 and RNA 3 wheeled Resident 91 into the hallway facing the hallway handrails. RNA 2 placed a cloth gait belt (assistive device placed around a person's waist to assist with safe transferring between surfaces or while walking) around Resident 91's waist and removed both hand rolls. RNA 2 was positioned on Resident 91's left side, and RNA 3 was positioned on Resident 91's right side. Each RNA placed Resident 91's hand onto the handrail and assisted the resident to stand from the wheelchair. Both of Resident 91's knees remained bent. Both of Resident 91's ankles were bent downward, causing Resident 91 to stand on the toes of both feet. Resident 91 performed two repetitions of sit to stand exercises. RNA 2 removed the cloth gait belt, and RNA 3 wheeled Resident 91 back to the room. During an interview on 4/16/2024 at 9:22 a.m., with RNA 2 and RNA 3, RNA 2 and RNA 3 stated Resident 91 used to walk years ago (unknown length of time). RNA 2 and RNA 3 stated Resident 91 required two people to perform sit to stand transfers because Resident 91 cannot stand without assistance and cannot stand all the way upright. During an interview on 4/16/2024 at 9:50 a.m., with Certified Nursing Assistant 4 (CNA 4), CNA 4 stated Resident 91 required assistance with feeding because she cannot hold a spoon. CNA 4 stated Resident 91 used to stand and transfer to a wheelchair and shower chair approximately 8 months ago. CNA 4 stated Resident 91 currently required a mechanical lift (device used to assist with transfers and movement of residents who require support for mobility) for transfers because Resident 91 had contractures (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to joint stiffness) in both legs and cannot fully extend both legs. During a concurrent interview and record review on 4/16/2024 at 12:14 p.m., with the Director of Medical Records (DMR), Resident 91's Resident Status History List (record of hospitalization s and room changes) was reviewed. The DMR stated the facility readmitted Resident 91 on 4/21/2020 and has remained at the facility since 4/21/2020. During a concurrent interview and record review on 4/16/2024 at 1:35 p.m., with the DMR, the DMR reviewed all of Resident 91's current clinical records binder and paper records for JMA records between 4/21/2021 and 3/27/2024. The DMR stated Resident 91's clinical record included 4/21/2021 and 3/27/2024 and was unable to locate any JMA for Resident 91 in 2022 and 2023. During a concurrent observation and interview on 4/16/2024 at 1:47 p.m., in Resident 91's room, Resident 91 was observed sitting on a wheelchair. Resident 91 stated she was unable to use both hands and required staff assistance for eating. Resident 91 stated she stopped walking when both of her knees started to change (unknown time). Resident 91 stated she had difficulty standing because both of her legs were weak and could not fully extend the legs. Resident 91 was observed extending both knees from a bent position while seated in the wheelchair but unable to completely extend knees. During a concurrent interview and record review on 4/16/2024 at 2:34 p.m., with the Director of Rehabilitation (DOR), the DOR stated Resident 91 had never received PT or OT services. The DOR searched the electronic documentation system for any PT and OT records on Resident 91 and was unable to locate any documentation. During an interview on 4/19/2024 at 10:55 a.m., with CNA 8, CNA 8 stated Resident 91 used to walk with a FWW and stood for transfers. CNA 8 stated Resident 91 started to slowly decline and not walk as much. CNA 8 stated Resident 91 currently required two people for transfers. During an interview on 4/19/2024 at 11:26 a.m., with RNA 2, RNA 2 stated Resident 91 could not hold onto a utensil and required assistance for eating. RNA 2 stated Resident 91 previously had a hand roll for the right hand (unknown time) but currently had hand rolls for both hands to prevent contractures. RNA 2 stated she did not know when Resident 91 started needing both hands rolls. RNA 2 stated Resident 91 used to help staff with dressing by standing in the shower room after showers and used to walk outside of the facility using the FWW. RNA 2 stated Resident 91 stopped walking about 2-3 years ago due to difficulty placing weight on both legs and started walking with both knees bent and on the tips of both feet. RNA 2 stated Resident 91 currently needs to be dressed in the bed after showers and required maximum assistance of two people to perform sit to stand exercises. RNA 2 stated Resident 91's decline in walking was reported to the charge nurse about 2-3 years ago. RNA 2 was unsure if the PT or the charge nurse changed the RNA order from walking using the FWW to sit to stand exercises. During an interview on 4/19/2024 at 11:55 a.m., with RNA 2, RNA 2 stated the slashes (/) in the RNA Record (in general) indicated there was no RNA available to provide the treatment so the resident did not receive RNA. During an observation on 4/19/2024 at 11:57 a.m. in the Recreation Room, Resident 91 slept while sitting up in the wheelchair. Both of Resident 91's hands were positioned in a closed fist and did not have any hand rolls applied to either hand. Both knees were bent and both ankles were bent with the toes pointing downward. Resident 91's wheelchair did not have any footrests (footplate attached to the wheelchair to allow the feet to rest and assist with positioning). During a telephone interview on 4/19/2024 at 2:04 p.m., with the DOR, the DOR stated the therapists completed a Joint Mobility Assessment [JMA] upon the resident's admission, checked in with the resident and nursing quarterly to determine if there was a decline in ROM or mobility, and then do another JMA annually. The DOR stated the JMA was completed to ensure a resident (in general) did not experience a decline or change in ROM or mobility. The DOR stated the therapist would report to nursing if there was a change or decline in the resident's JMA, provide therapy services to improve and maintain ROM, and provide RNA as necessary. The DOR stated the PT and OT services were important to attempt to restore and achieve a resident's highest practicable (capable of being done) independence with ADLs and prevent decline as much as possible. During a concurrent interview and record review on 4/19/2024 at 3:18 p.m., with MDS Coordinator (MDS 2) and the DMR, Resident 91's JMA, dated 4/21/2021, was reviewed. The DMR stated Resident 91's JMA was one-sided and did not include quarterly assessments, which were supposed to be located on the back of the double-sided JMA form, after 4/21/2021. MDS 2 stated Resident 91's JMA, dated 4/21/2021, indicated both of Resident 91's arms and legs were WFL for ROM except the right hand had minimal joint mobility limitations and the left hand had minimal to moderate joint mobility limitations. MDS 2 reviewed Resident 91's care plan for RNA, which included interventions to perform quarterly assessments of joint mobility. MDS 2 stated the therapy staff was responsible to perform the JMA quarterly. MDS 2 stated the facility did not follow Resident 91's care plan if Resident 91's clinical record did not include a JMA for 2022 and 2023. MDS 2 reviewed Resident 91's JMA, dated 3/27/2024, and stated Resident 91 had a decline in ROM in both elbows, both wrists, and the right hand from WFL to moderate impairments and a decline in ROM in both hips, knees, and ankles from WFL to minimal impairments. During a concurrent interview and record review on 4/19/2024 at 4:19 p.m., with MDS 2 and the Director of Nursing 2 (DON 2), Resident 91's RNA Records from 3/2022 to 9/2022 were reviewed. MDS 2 stated Resident 91 did not receive RNA for ambulation using a FWW, five times a week, in accordance with the physician orders for multiple dates during the months of 3/2022, 4/2022, 5/2022, 7/2022, and 8/2022. Resident 91's physician order, dated 9/15/2022, for RNA to assist with sit to stand program, five times per week as tolerated, and physician order, dated 9/28/2022, for RNA to apply both hand rolls, 4-6 hours, five times per week as tolerated were reviewed. DON 2 stated the therapists should have done an assessment to determine the RNA program and if hand splints (material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion), including the hand rolls, were appropriate. The DON 2 stated the facility did not maintain or improve Resident 91's mobility and ROM if Resident 91 did not receive any therapy services. Resident 91's RNA Records, dated 9/2022 to 4/2024, were reviewed. MDS 2 stated Resident 91 did not receive RNA for sit to stand exercises and application of both hand rolls, five times a week, in accordance with the physician orders for multiple dates during the months of 12/2022, 2/2023, 3/2023, 9/2023, and 1/2024. The DON 2 stated ROM exercises and therapy services were important to prevent a decline, including the development of contractures, and to increase ROM and mobility. DON 2 stated there was no documented evidence indicating Resident 91 received a JMA in 2022 and 2023, which was at least eight missed opportunities (every three months starting from 4/2022 to 3/27/2024) to monitor Resident 91's ROM. DON 2 reviewed Resident 91's JMAs, dated 4/21/2021 and 3/27/2024, and stated Resident 91 had a decline in ROM in both elbows, both wrists, the right hand, both hips, both knees, and both ankles. DON 2 stated there was no documented evidence Resident 91 received any ROM exercises to prevent ROM decline or further decline after a decline in ROM was identified on 3/27/2024. DON 2 and MDS 2 stated Resident 91's decline in mobility and ROM was preventable since the facility failed to properly screen Resident 91 quarterly and did not provide therapy services to prevent a decline in mobility and ROM, properly evaluate the use of splints, and determine the RNA exercise program to prevent ROM and mobility loss, including the development of contractures. DON 2 reviewed the facility's undated Policy and Procedures (P&P) titled, Activities of Daily Living (ADLs) and Prevention of Decline in Range of Motion. DON 2 stated the facility did not follow its policies to maintain Resident 91's ADLs, which included mobility, and prevent ROM decline. During an interview on 4/19/2024 at 5:25 p.m., with the DON 2, DON 2 stated the therapists should have performed an annual JMA on 4/2022. During an interview and record review on 4/19/2024 at 5:45 p.m., with the DMR, Resident 91's Face Sheet was reviewed. The DMR stated Resident 91's Face Sheet indicated an admission of 1/1/2023 since the facility merged two buildings into one license (legal authority to provide services). The DMR stated Resident 91 had not physically left the facility since re-admission on 4/21/2020. A review of the facility's undated P&P titled, Activities of Daily Living (ADLs), indicated the facility will ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable which included the resident's ability to transfer, ambulate (walk), and eat. The P&P indicated the facility will provide a maintenance and restorative program to assist the resident in achieving and maintaining the highest practicable outcome based on the comprehensive assessment. A review of the facility's undated P&P titled, Prevention of Decline in Range of Motion, indicated a resident who enters the facility without limited range of motion will not experience a reduction in range of motion unless the resident's clinical condition demonstrated that a reduction in range of motion is unavoidable. The P&P also indicated licensed nurses will assess a resident's ROM on admission/readmission, quarterly, and upon a significant change Residents who exhibit limitations in range of motion, initially and thereafter, will be referred to the therapy department for a focused assessment of range of motion. 47858 2a. A review of Resident 113's Admission Record (Face Sheet), indicated Resident 113 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included but not limited to muscle wasting and atrophy (decreased muscle size), major depressive disorder (mood disorder), and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). A review of Resident 113's MDS, dated [DATE], indicated Resident 113's cognition was moderately impaired. The MDS indicated Resident 113 required substantial assistance sitting to standing, toilet transfers and bed to chair transfers. A review of Resident 113's Physician Orders, dated 3/1/2023, indicated that Resident 113 was to receive RNA for passive range of motion to bilateral upper and lower extremities as tolerated daily, five times a week. 2b. A review of Resident 92's Admission Record (Face Sheet) indicated Resident 92 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included but not limited to muscle weakness, major depressive disorder, and dementia. A review of Resident 92's MDS, dated [DATE], indicated Resident 92's was severely impaired. The MDS indicated Resident 92 required moderate assistance sitting to standing, toilet transfers and bed to chair transfers. A review of Resident 92's Physician Orders, dated 11/21/2023, indicated that Resident 92 was ordered RNA to ambulate with front wheeled walker daily for five times a week as tolerated. 2c. A review of Resident 93's Admission Record (Face Sheet) indicated Resident 93 was admitted to the facility on [DATE] with diagnoses that included but not limited to tachycardia (fast heart rate), and hyperlipidemia (high cholesterol). A review of Resident 93's MDS, dated [DATE], indicated Resident 93's cognition was severely impaired. The MDS indicated Resident 93 required substantial assistance with showering and toileting, was dependent on staff for chair to bed transfers and sitting to standing. A review of Resident 93's Physician Orders, dated 12/20/2023, indicated that Resident 93 was ordered RNA for passive range of motion to bilateral upper and lower extremities as tolerated daily for five times a week and RNA to apply right lower extremities knee splint for four to six hours daily five times a week as tolerated. A review of the Physician Orders List, dated 4/2024, the list indicated that there 19 residents with active RNA orders. During an interview with RNA 2, on 4/19/2024, at 11:55 a.m., RNA 2, stated that there were usually about 20 residents total on RNA therapy and that the facility had asked RNAs to perform CNA work often when they worked their shifts. RNA 2 stated that some of their duties included, performing range of motion exercises, applying, and removing splints, and feeding and weighing residents. RNA 2 stated that some of the residents did not get their RNA sessions on a consistent basis. During a concurrent review and interview, on 4/19/2024, at 11:55 a.m., with RNA 2, Resident 113's Restorative Record, dated 4/2024, was reviewed. The Restorative Record had a slash marked in the box for 4/5/2024. RNA 2 stated that the slash indicated that there was no RNA available to perform the RNA order. During an interview with RNA 3, on 4/19/2024, at 12:39 p.m., RNA 3 stated she was the only RNA for the entire facility (Building A and B) today because the other RNA that was scheduled was pulled to perform CNA duties due to a lack of CNAs on the floor. RNA 3 stated that there needed to be two RNAs working in Building A and two RNAs working in Building B to ensure all the residents on RNA therapy received good, quality RNA sessions and to ensure that all orders would be carried out. RNA 3 stated that the facility normally asked the RNAs to perform CNA duties about once or twice a week and this affected their workload. RNA 3 stated she knew that she would not be able to physically work with all the residents that had RNA orders today (4/19/2024) because she would need the help of another RNA. RNA 3 stated that the lack of RNAs and CNAs negatively affected the quality of care provided to the residents. RNA 3 stated that the quality of the RNA sessions for the residents ordered to have RNA services would be better if there were more RNAs to help perform the work. RNA 3 stated that the residents were at risk for the development of contractures and decreased mobility if the RNA orders were not provided as prescribed by the Physician. During a concurrent review and interview, on 4/19/2024, at 12:39 p.m., with RNA 3, Resident 92's Restorative Record, dated 1/2024, was reviewed. The Restorative Record had a slash marked in the boxes corresponding to following dates 1/2/2024, 1/4/2024, 1/11/2024, 1/22/2024, 1/24/2024, 1/25/2024, and 1/31/2024. RNA 2 stated that the slash indicated that there was no RNA available to perform the RNA order due to either a lack of CNAs on the floor and that the RNAs did not work overtime and weekends. During a concurrent review and interview, on 4/22/2024, at 1:35 p.m., with RNA 1, Resident 93's Restorative Record, dated 4/2024, was reviewed. The Restorative Record had a slash marked in the boxes corresponding to two of Resident 93's RNA orders on 4/5/2024. RNA 1 stated that she worked 7 a.m. to 3 p.m. on 4/5/2023 and RNA 4 were both reassigned to work as CNAs that day because of a lack of CNA staff. RNA 1 stated that all the residents that were ordered to have RNA therapy five times a week missed their session that day, including Resident 93. RNA 1 stated that the lack of consistent provision of RNA therapy could have led to a gradual decline in range of motion or ability to perform activities daily living. During an interview, on 4/22/2024, at 2:05 p.m. with the Director of Staff Development (DSD), the DSD stated that the best practice was staff four RNAs total to meet the needs of the facility. The DSD stated that RNAs must be reassigned to take on CNA roles instead of performing the RNA orders about two to three times a week. The DSD stated the if the RNAs were not able to consistently carry out the RNA orders, due to staffing issues, then the residents would decline and that the needs of the facility would not be met. A review of the facility's undated P&P title [TRUNCATED]

Based on observation, interview, and record review, the facility failed to maintain an infection control and prevention program by failing to: 1. Implement proper infection prevention and control interventions for one of 15 residents, (Resident 1), who was positive for coronavirus virus (COVID-19, a highly contagious viral infection). Resident 1 walked out of her isolation room, grabbed a cup from the top of the facility's medication cart and touched other clean medical supplies on the left side of the medication cart without staff intervention. 2. Ensure three of the 15 COVID-19 positive residents (Residents 1, 2, and 3) did not co-mingle with the five COVID-19 negative residents (Residents 4, 5, 6, 7, and 8) who were smoking in the patio with staff supervision. 3. Report the facility's COVID-19 positive cases to the Department of Public Health Licensing and Certification. These deficient practices resulted to the cross-contamination of the supplies placed on top of the medication cart, placed the five COVID-19 negative smoking residents (Residents 4, 5, 6, 7, and 8) at a high risk for contracting (become sick) the COVID-19 virus that can potentially cause respiratory (breathing) problems, hospitalization , and death, and spread the COVID-19 virus infection to the other residents and staffs in the facility and the Department not aware of the COVID-19 cases in the facility. On 9/27/2023 at 5:04 p.m., while onsite at the facility, the Administrator (ADM), the Director of Nursing (DON) and the Assistant Infection Preventionist (AIP) Nurse were verbally notified of an Immediate Jeopardy ([IJ], a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident) was called due to the facility's failure to implement proper infection prevention and control interventions. The facility's ADM, DON, and AIP nurse were notified of the seriousness of the five residents' health and safety by exposing the residents to COVID-19 virus, failing to implement proper infection prevention and control interventions and failure to report the COVID-19 positive resident cases to the Department. An IJ Removal Plan to immediately correct the deficient practices, was requested. On 9/28/2023 at 3:13 p.m., the IJ was removed in the presence of the ADM and DON after the facility submitted an acceptable IJ Removal Plan, and the surveyor verified and confirmed onsite the facility's implementation of the IJ Removal Plan. The IJ removal plan was implemented immediately and included the following, the facility will: a. Ensure proper infection prevention and control. b. Ensure that staff are following proper protocol regarding COVID-19 transmission precautions. 1. Disposable items on top of Medication Cart were discarded for possible contamination. 2. Medication Cart was disinfected and placed in medication room inaccessible to any COVID-19 positive residents while cart is unsupervised. 3. Signs/Notice of COVID-19 isolation smoking area only was placed at appropriate location; outside of Hall two. 4. COVID-19 positive residents were notified where their smoking area was located and the change of smoking times. Residents that are exposed in the same hall were instructed to smoke at regular smoking time in the designated COVID-19 positive smoking area. A change in smoking times was to prevent any improper comingling of residents. Smoke times will only be posted inside each room that was affected (COVID-19 Positive/ COVID-19 Exposed) without violating the Health Insurance Portability and Accountability Act (HIPAA, a law that sets the standard for sensitive patient data protection) Compliance. 5. Staff informed of smoking time changes for COVID-19 positive residents only. Staff will clean/disinfect COVID-19 positive smoking area prior to and after COVID-19 positive residents smoking breaks. Assigned Certified Nurse Assistant (CNA) in the COVID-19 positive area will monitor and supervise residents during smoking times. All residents will be supervised during smoke breaks. 6. Any exposed, newly admitted residents or any residents who also smoke but with pending COVID-19 test results, can go to the appropriate location outside of their assigned halls, at a different scheduled time from the COVID-19 positive residents. 7. At the beginning of each shift, Licensed nurses will inform the CNAs of their assignments and discuss residents current COVID-19 status to ensure the CNAs are informed which residents are allowed to smoke at appropriate times and location. 8. Proper notices and precautions regarding the smoke break schedule of COVID-19 positives are placed at appropriate areas. 9. In-services of licensed staff started 9/27/2023 and will be completed by 9/29/2023 on ensuring COVID-19 positive residents do not have access to medication cart. Inservice will be done monthly for three (3) months, and as needed thereafter. 10. In-services regarding the monitoring/supervising of residents in the designated smoking areas at scheduled times to ensure COVID-19 positive residents do not co-mingle with the non-COVID-19 residents started on 9/27/2023 and will be completed by 9/29/2023. In-service will be done monthly for 3 months, and as needed thereafter. 11. In-services regarding COVID- 19 transmission precautions started on 9/27/2023 and will be completed by 9/29/2023. In-service will be done monthly for 3 months, and quarterly, thereafter. 12. The Nursing Supervisors, Director of Nursing or Designee shall monitor compliance for the above plans of actions on a daily basis. Any episodes of noncompliance shall be reported to the Administrator immediately. Administrator shall report any findings to the Quality Assurance Committee (QAA) on a quarterly basis. QAA Committee shall review the systems and revise as necessary. Findings: During an interview with the Licensed Vocational Nurse (LVN) on 9/26/2023 at 8:25 a.m., the LVN stated the facility has a total of 15 COVID-19 confirmed residents. The LVN provided the facility census and had a total of 169 residents. a. During a concurrent observation and interview with the AIP nurse on 9/26/2023 at 12:06 p.m., in the facility, a yellow, plastic, waist-high barrier was observed in the hallway (safety barrier) separating the back area of the hallway from the rest of the facility. A medication cart was observed in the front area of the hallway. Resident 1, who was a COVID- 19 positive resident, was observed coming out of her room and moved the barrier to come out to the front area of the hallway. Resident 1 grabbed a cup from the medication cart and went back behind the barrier to her room without any staff intervention. The AIP nurse stated Resident 1 was not supposed to come out of her room to get a cup because the resident was positive for COVID-19. The AIP nurse stated the COVID-19 positive residents were supposed to stay in their rooms as much as possible and facility staff were supposed to redirect the residents back to their room. During an interview with the DON on 9/27/2023 at 4:04 p.m., the DON stated Resident 1, a COVID-19 positive resident, who went out of the barrier and touched the medication cart can expose other residents and staff to COVID-19 because the cart was shared between different halls. During a review of Resident 1's Face Sheet (admission record), dated 9/1/2023, the Face Sheet indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities), and anxiety disorder (a mental health disorder characterized by feelings of worry or fear that are strong enough to interfere with one's daily activities). During a review of Resident 1's history and physical (H&P), dated 8/26/2023, the H&P indicated Resident 1 was conserved. During a review of Resident 1's Minimum Data Set ([MDS], a standardized assessment and care planning tool), dated 7/7/2023, the MDS indicated Resident 1 understood and was able to be understood by others. The MDS indicated Resident 1 required supervision (the act of watching a person or activity and making certain that everything is done correctly and safely) for all activities of daily living. During a review of Resident 1's Situation Background Assessment and Recommendation (SBAR) report, dated 9/17/2023, the SBAR indicated Resident 1 had symptoms of COVID-19 on 9/13/2023 such as headache and sore throat and Resident 1 tested positive for COVID-19 on 9/17/2023. During a review of Resident 1's care plan titled, COVID-19 dated 9/17/23, indicated that Resident 1 is on contact and droplet precautions and the approach indicated frequent monitoring of condition. b. During a concurrent observation and interview on 9/27/2023 at 11:33 a.m. with the DON and AIP nurse in the smoking patio while eight (8) residents were observed smoking together. The DON stated the residents in the smoking patio were Residents 1, 2, and 3 who were COVID-19 positive and Residents 4, 5, 6, 7, and 8 were exposed and tested negative for COVID 19 During an interview with the AIP nurse on 9/27/2023 at 11:53 a.m., the AIP nurse stated the residents that smoked together lived in the same hallway and the facility does not want the residents to cross over to another hallway. The AIP nurse stated the COVID-19 positive residents were noncompliant. When asked what can happen to the residents who get infected with a COVID-19 virus while comingling the COVID positive residents and the non-COVID residents, the DON and AIP nurse stated, the residents could experience severe breathing problems and/or hospitalization . During a telephone interview on 9/29/2023 at 11:00 a.m., with Public Health Nurse (PHN), the PHN stated, COVID-19 negative, exposed residents, while waiting for the COVID-19 Polymerase chain reaction (PCR, a more sensitive test that can detect small amounts of the virus that the antigen test cannot detect) test must wear a surgical mask when outside of their rooms. The PHN stated, COVID -19 negative and COVID -19 positive residents should be separated and should not be smoking together in the small patio. The separation will prevent the spread of the COVID -19 virus to COVID -19 negative residents. During a review of Resident 2's Face Sheet, dated 9/26/2023, the Face Sheet indicated Resident 2 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including chronic obstructive pulmonary disease [(COPD), a group of lung diseases that block airflow and make it difficult to breathe], schizophrenia, and anxiety disorder. During a review of Resident 2's H&P, dated 9/15/2023, the H&P indicated Resident 2 could make needs known but could not make medical decisions. During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 understood and was able to be understood by others. The MDS indicated Resident 2 supervision for all activities of daily living. During a review of Resident 2's Situation Background Assessment and Recommendation (SBAR) report, dated 9/19/2023, the SBAR indicated Resident 2 tested positive for COVID-19 on 9/19/2023. During a review of Resident 2's care plan dated 9/19/23, indicated Resident 2 tested for COVID-19. Another care plan dated 9/24/22 indicated Resident 2 was noncompliant with facemask. One of the interventions indicated to observe infection prevention and control at all times, as much as possible avoid outdoor activity and encourage resident to social distance as much as possible. During a review of Resident 3's Face Sheet, dated 9/26/2023, the Face Sheet indicated, Resident 3 was admitted to the facility on [DATE] with diagnoses including metabolic disorder (disorder with the body's metabolism - the ability to turn food into energy and get rid of waste) and schizophrenia. During a review of Resident 3's H&P, dated 5/14/2023, the H&P indicated, Resident 3 has alternating ability to understand and make medical decisions. During a review of Resident 3's MDS dated [DATE], the MDS indicated, the resident's cognition (ability to think and understand) was severely impaired. Resident 3 required supervision and/or extensive assistance (resident involved in activity, staff provide weight-bearing support) for most activities of daily living. During a review of Resident 3's SBAR report, dated 9/19/2023, the SBAR indicated, Resident 3 tested positive for COVID-19 on 9/19/2023. During a review of Resident 3's care plan titled Smoking, dated 5/12/23, indicated Resident 3 is a smoker and needs constant supervision and observation while smoking. During a review of Resident 3's care plan titled, COVID-19, indicated Resident 3 tested positive for COVID-19 and is on contact, droplet and airborne precautions. During a review of Resident 4's Face Sheet, dated 7/20/2023, the Face Sheet indicated, Resident 4 was admitted on [DATE] and readmitted on [DATE] to the facility with diagnoses including, severe sepsis (is the body's extreme response to an infection) with septic shock (a life-threatening condition that happens when your blood pressure drops to a dangerously low level after an infection) and schizophrenia. During a review of Resident 4's MDS, dated [DATE], the MDS indicated, the resident's cognition (ability to think and understand) was moderately impaired. Resident 4 required supervision and/or limited assistance (resident involved in activity, staff provide some weight-bearing support) for most activities of daily living. During a review of Resident 5's Face Sheet, dated 7/11/2023, the Face Sheet indicated, Resident 5 was admitted on [DATE] and readmitted on [DATE] to the facility with diagnoses including, polyneuropathy (is a condition in which multiple nerves in the body are not working), and major depressive disorder. During a review of Resident 5's H&P, dated 7/6/2023, the H&P indicated, Resident 5 was able to understand and make medical decisions. During a review of Resident 5's MDS dated [DATE], the MDS indicated, the resident's cognition (ability to think and understand) was intact. Resident 5 required supervision and/or limited assistance (resident involved in activity, staff provide some weight-bearing support) for most activities of daily living. During a review of Resident 6's Face Sheet, dated 6/28/2023, the Face Sheet indicated, Resident 6 was admitted on [DATE] and readmitted on [DATE] to the facility with diagnoses including, chronic obstructive pulmonary disease and schizophrenia. During a review of Resident 6's H&P, dated 6/23/2023, the H&P indicated, Resident 6 does not have the ability to understand and make medical decisions. During a review of Resident 6's MDS dated [DATE], the MDS indicated, the resident's cognition (ability to think and understand) was intact. Resident 6 required supervision and/or limited assistance (resident involved in activity, staff provide some weight-bearing support) for most activities of daily living. During a review of Resident 7's Face Sheet, dated 9/1/2023, the Face Sheet indicated, Resident 7 was admitted on [DATE] and readmitted on [DATE] to the facility with diagnoses including, hypertensive heart disease (is a condition in which high blood pressure [a measure of force that the heart uses to pump blood around the body] increases the workload on the heart and changes how the heart functions) and paranoid (is a pattern of behavior where a person feels distrustful and suspicious of other people) schizophrenia. During a review of Resident 7's MDS dated [DATE], the MDS indicated, the resident's cognition (ability to think and understand) was intact. Resident 7 required supervision and/or limited assistance (resident involved in activity, staff provide some weight-bearing support) for most activities of daily living. During a review of Resident 8's Face Sheet, dated 12/28/2021, the Face Sheet indicated, Resident 8 was admitted to the facility on [DATE] with diagnoses including, type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar in the body) and schizophrenia. During a review of Resident 8's H&P, dated 6/11/2023, the H&P indicated, Resident 8 has alternating ability to understand and make medical decisions. During a review of Resident 8's MDS dated [DATE], the MDS indicated, the resident's cognition (ability to think and understand) was mildly impaired. Resident 8 required limited to extensive assistance (resident involved in activity, staff provide weight-bearing support) for most activities of daily living. During a review of the facility's undated policy and procedure (P&P), titled Isolation Precautions, the P&P indicated the facility would take appropriate precautions, including isolation, to prevent transmission of infectious agents. The P&P also indicated the isolation refers to the practices employed to reduce the spread of an infectious agent and/or minimize the transmission of infection. During a review of the facility's P&P, titled Coronavirus Surveillance, dated 2023, the P&P indicated COVID-19 is spread between people less than six feet apart through respiratory droplets when an infected person coughs or sneezes and between people more than six feet apart through airborne transmission in an enclosed space with inadequate ventilation. During a review of the COVID-19 Outbreak Notification, dated 9/21/2023, the notification indicated per the Department of Public Health, the residents who have confirmed COVID-19 infection should be isolated in the designated COVID-19 isolation area of the facility. During a review of the Centers for Disease Control and Protection's recommendation titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, the recommendation indicated facilities should limit transport and movement of the resident outside of the room to medically essential purposes. c. During an interview on 9/26/2023, at 10:38 a.m., with the AIP nurse, the AIP nurse stated, the facility did not report their COVID-19 positive cases to the Department of Public Health Licensing and Certification (Department). During a review of the All Facilities Letter (AFL) 23-09 dated January 18, 2023, with subject, Coronavirus Disease 2019 (COVID-19) Outbreak investigation and Reporting Thresholds, indicated that the AFL reminds licensed health facilities of requirements to report outbreaks and unusual infectious disease occurrences to their local health department and Licensing and Certification District Office and provided investigation and reporting thresholds for reporting for COVID-19.

Based on interview and record review the facility failed to ensure the resident, who was assessed as high risk for falls, was not left unattended on the bed raised from the floor above a safe height and without a floor mat next to the residents' bed for one of three sampled residents (Resident 1). The facility failed to: 1. Ensure a Certified Nursing Assistant (CNA 1) did not leave Resident 1 unattended on a elevated bed from the floor above safe level after feeding Resident 1 breakfast. 2. Ensure CNA 1 lowered Resident 1's bed after feeding the resident breakfast and before leaving the resident's room. 3. Ensure Resident 1 was provided with a safe environment as indicated in Resident 1's care plan titled Resident is at risk for falls and injuries related to dementia, impaired vision and hearing problems. 4. Ensure CNA 1 followed the facility Policy and Procedure (P&P) titled, Fall Prevention Program to minimize the likelihood of Resident 1 falling by having Resident 1's bed lowered to a level that allows the resident's feet to be flat on the floor when the resident is sitting on the edge of the bed. 5. Ensure CNA 1 placed a floor mat next to Resident 1's bed in accordance with the resident's care plan titled Risk is present Primarily as a Result of Physical Limitation. These deficient practices resulted in Resident 1 falling from the bed to the floor face down and sustaining two bumps on the forehead that required evaluation at an acute care hospital (GACH). According GACH's record, Resident 1 had a left frontal scalp (forehead) soft tissue swelling and hematoma (clotted blood that forms in the body due to broken blood vessels) to the head. Findings: During a review of Residents 1's face Sheet (Admission Record), dated 6/16/2023, the face sheet indicated Resident 1 was originally admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses including schizoaffective disorder (a mental illness that can affect a person's thoughts, mood, and behavior), epilepsy (a disorder of the brain characterized by repeated seizures), unspecified abnormality of gait and mobility. During a review of Residents 1's History and Physical (H&P), dated 9/29/2022, the H&P indicated, Resident 1 had a fluctuating capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 5/10/2023, the MDS indicated Resident 1 was not able to recall information. The MDS indicated Resident 1 required a one-person physical assistance with bed mobility, transfer (how resident moves between surfaces including from bed, chair and standing position), walking eating, bathing, and locomotion. The MDS indicated Resident 1 required a two-persons physical assistance with dressing, toilet use and personal hygiene. During a review of Resident 1's care plan titled, Risk is Present Primarily as a Result of Physical Limitation dated 6/12/2023, the care plan indicated staff will perform frequent visual checks, ensure the floor was uncluttered, lighting was adequate, use personal or pressure sensor alarms (if ordered) when the resident was in a chair or bed, and floor mats when in bed. During a review of Resident 1's care plan titled, Resident is at risk for falls and injuries related to dementia, impaired vision and hearing problems dated 6/5/23, the care plan indicated staff will assess Resident 1 for propensity for falls, evaluate current fall prevention interventions, provide resident with safe and clutter free environment assess, anticipate, and intervene for factors causing prior falls. During a review of Resident 1's Fall Risk assessment dated [DATE], the assessment indicated Resident 1 had a fall risk score of 16 and a score of 10 or greater indicated the resident had a high potential for falls. The fall risk assessment indicated a fall protocol should be initiated immediately and care planned. During a review of Resident 1's Body Assessment Post Incident report dated 6/15/2023, the report indicated Resident 1 had two bumps on the forehead. During a review of Resident 1's Physician order dated 6/15/23, the order indicated transfer to GACH. During a review of Resident 1's, Nurses Notes (NPN) dated 6/15/2023, the NPN indicated, during medication administration (Med Pass) on 6/15/2023, at 8:15 a.m., in Resident 1's room, the Licensed Vocation Nurse (LVN 1), observed Resident 1 lying face down on the floor next to her bed. The NPN indicated Resident 1 had labored breathing and was no longer stable. The NPN indicated upon assessing Resident 1, LVN 1 observed two bumps on Resident 1's forehead. According to the NPN, Resident 1 was assisted back to bed and observed to still have labored breathing and a hard time focusing. The NPN indicated Resident 1's heart rate was 144 beats (reference range is 60-100) per minute (bpm), respiration rate 26 (reference range is 16-20), oxygen saturation (amount of oxygen in blood) 86 (reference range is 90-100) percent ([%] unit of measurement). The NPN indicated Resident 1's was transferred to a GACH for further evaluation. During a review of Resident 1's Fall Investigation Report (FIR) dated 6/15/2023, the FIR indicated at 8:10 a.m., Resident 1 was found on the floor next to her bed. The FIR indicated Resident 1 tried to transfer herself unassisted and fell from the bed to the floor, in her room. The FIR indicated Resident 1 was bare feet, did not use a gait assist or an alarm at the time of the fall. The report also indicated Resident 1 appeared restless. During a review of Resident 1's Interdisciplinary team ([IDT] a group of healthcare providers from different fields who work together or toward the same goal to provide the best care or best outcome for residents) Meeting/Care Conference report dated 6/15/23, the report indicated CNA 1 left Resident 1 unattended on a bed after breakfast. The report indicated Resident 1's bed was left in higher-than-normal position, and the resident fell off the bed. The report indicated Resident 1 had no capacity to transfer herself and required a total assistance from staff. According to https://www.sondercare.com/learn/senior-caregiving/how-high-should-caregiver-raise-height-of-clients-bed/ a hospital bed has an adjustable height range. The height off the floor to the top of the mattress can be as low as 16 inches, with the upper limit going as high as 39 inches. A safe bed height is between 18 inches to 23 inches, roughly the same as the seat of a chair. During an interview on 6/28/2023 at 2:00p.m., LVN 1 stated on 6/15/2023, around 8:15 a.m., during med pass, he (LVN 1) walked into Resident 1's room but did not see Resident 1 in bed. LVN 1 stated he observed Resident 1's bed was in High Fowlers (the head of the bed elevated between 60 to 90 degrees), and the bed was elevated from the floor higher than normal. LVN 1 stated Resident 1's bed should be raised from the floor low enough for the resident's feet to touch the floor when in a sitting position. LVN 1 stated he observed Resident 1 was on the floor, next to her bed, facing down. LVN 1 stated he observed Resident 1 had two bumps on the forehead, was agitated and had trouble breathing. LVN 1 stated Resident 1's oxygen saturation was 70% and the resident was transferred to the GACH via 911. LVN 1 stated to prevent falls and injuries, Resident 1's bed should not have been elevated high from the floor and the resident should not have been left unattended on an elevated bed. During an interview on 6/28/23 at 3:20p.m., the Director of Nursing (DON) stated that on 6/15/2023, after feeding Resident 1 breakfast, CNA 1 took the meal tray out of the resident's room without lowering Resident 1's bed back in a low position and without ensuring the floor mat was in place to prevent Resident 1 from injuries in case she fell from the bed. The DON stated Resident 1 fell out of bed to the bare floor, was in respiratory distress and sustained two bumps on her forehead. The DON stated, when the bed is in high (elevated) position from the floor the resident is at risk for falling, especially when the resident lacking cognitive skills to assess surrounding environment safety properly to evaluate if he/she could fall or not. The DON stated, Resident 1 did not have any understanding of safety and as a resulted she fall out of bed. During a concurrent interview and record review on 6/28/2023 at 4:00p.m. with Human Resource (HR) 1, CNA 1's Counseling Record dated 6/15/2023 was reviewed. HR 1 stated, on 6/15/2023, CNA 1 forgot to put Resident 1's floor mat back after feeding the resident breakfast. HR 1 stated CNA 1 did not lower Resident 1's bed. CNA 1 left Resident 1 unattended after breakfast and forgot to lower the bed. Resident 1 fell from bed. During a review of the GACH emergency room (ER) note, dated 6/15/2023 the note indicated, Resident 1 had a hematoma (clotted blood that forms in the body due to broken blood vessels) to the head. During a review of the GACH computerized tomography ([CT] an imaging test that helps healthcare providers detect diseases and injuries) scan, dated 6/15/2023, the scan indicated Resident 1 had a left frontal scalp soft tissue swelling. During a review of the facility's Policy and Procedure (P&P) titled, Fall Prevention Program dated 2022, the P&P indicated, Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. The P&P indicated the resident's bed is locked and lowered to a level that allows the resident's feet to be flat on the floor when the resident is sitting on the edge of the bed. The P&P indicated staff will monitor changes in resident's cognition, gait, ability to rise/sit, and balance and then provide additional interventions as directed by the resident's assessment, including but not limited to a low bed. During a review of the facility's P&P titled, Safety and Supervision of Residents undated, the P&P indicated, Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accident are facility-wide priorities .Employees shall be trained and in-serviced on potential accident hazards and how to identify and report accident hazards and try to prevent avoidable accidents.

Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person entered care plan, and the residents' choices. Based on observation, interview, and record review, the facility failed to treat one of five sampled resident's (Resident 1) right eye corneal abrasion (a scratch or scrape on the surface of the cornea, the eye's clear, protective outer layer), by failing to: 1. Follow the general acute care hospital (GACH) physician's referral orders for an ophthalmologist (specialist in the treatment and study of disorders and diseases of the eye). 2. Accurately assess and report Resident 1's corneal abrasion to the physician. 3. Assess and evaluate Resident 1's corneal abrasion by the physician. 4. Address Resident 1's concern for seeing an ophthalmologist by making the appropriate referrals to the ophthalmologist by the Social Worker (SW) 5. Develop a care plan specific to Resident 1's corneal abrasion with meaningful interventions to treat and heal the corneal abrasion in accordance with the interdisciplinary team (IDT, a group of health care professionals with various areas of expertise who work together toward the goals of their residents) recommendations. This deficient practice resulted in Resident 1's right eye corneal abrasion worsening to a corneal ulcer (open sore) requiring additional antibiotics, with the potential for [CONDITION(S)], scarring, [CONDITION(S)] (clouding of the normally clear lens of the eye), [CONDITION(S)] (group of eye conditions that damage the optic nerve), and unnecessary pain suffering. On 7/1/2021 at 3:15 p.m., the Administrator (ADM) and the Director of Nursing (DON), were notified of an Immediate Jeopardy ([IJ], a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) due to the facility's inability to follow up with Resident 1's ophthalmologist referral. The facility's ADM and DON were notified of the immediacy and seriousness of the residents' health and safety being threatened. On 7/2/2021 at 1 p.m., the ADM submitted an acceptable Plan of Action (POA) for the correction of the IJ which included: 1. To ensure no other residents were affected by the same deficient practice, the director of nursing and the nursing management team reviewed all other resident charts on 7/1/2021, to ensure that all residents who might have an ophthalmologist referral are being followed up. Any resident that was identified to need a consult was referred to the ophthalmologist to schedule an appointment. Care plan for Resident 1 was updated on 7/2/2021 for infection on both eyes due to corneal ulcer. 2. On 7/1/2021 and 7/2/2021 all licensed nurses were in serviced on policy and procedure on change of condition and physician orders, resident assessment and pain management, and proper documentation, to ensure that residents are free of pain, any changes are reported to the physician in a timely manner, and all orders are carried out properly. On 7/1/2021 the Administrator in serviced social services designees on the importance of following up with ancillary (medical services or supplies that are not provided by acute care hospitals, doctors or health care professional) recommendations to ensure residents are being seen by ancillary care providers. 3. The director of nursing and nursing management team will review charts upon admissions to ensure all ancillary consults are being followed up. The director of nursing services or designee will complete random daily chart audits to ensure any ancillary referrals are being followed up and is coordinated accordingly with social services. Audited records will be reviewed quarterly by the Quality Assurance Committee until such time consistent substantial compliance has been achieved as determined by the committee. 4. Corrective actions will be completed no later than 7/2/2021. On 7/2/2021 at 2:05 p.m., while onsite the surveyor verified and confirmed the POA was implemented through observation, interviews and record reviews including in services provided to the licensed nurses by the nurse educator. The IJ was lifted and the ADM and DON were notified. Findings: During a review of Resident 1's undated Admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 1's History and Physical (H/P), dated 8/11/2020, the H/P indicated Resident 1 was oriented to person, place and time. During a review of Resident 1's GACHs Emergency Department (ED) note, dated 8/30/2020, the ED note indicated Resident 1 had a right corneal abrasion, discharge orders for [MEDICATION(S)] (antibiotic used to treat infections) drops and a follow up with ophthalmologist the next day after discharge. During a review of Resident 1's Minimum Data Set (MDS) a resident assessment and care screening planning tool, dated 3/20/2021, indicated Resident 1 had no memory problems or decision making, and was able to make needs known and understand others. The MDS indicated Resident 1 required extensive assist of one-person physical assist for transfers and bed mobility. During an observation of Resident 1's room and concurrent interview on 6/18/21 at 1:06 p.m., Resident 1 stated he has been requesting to be seen by ophthalmologist for almost one year (after the initial ED visit on 8/30/2020). Resident 1 stated he was sent to the GACH and was told he had a scratched cornea. Resident 1 stated the GACH's ED physician informed him it was very important for him to see an ophthalmologist because he was at risk of losing his sight. Resident 1 stated he feels awful because he can go blind. Resident 1 right sclera (the white outer layer of the eyeball) was observed to be reddened with a small amount of white discharge to the outer edge of the right eye. Resident 1's left sclera did not have redness or drainage. During a telephone interview on 6/28/2021 at 4:00 p.m., physician 1 stated corneal abrasions were a medical emergency and Resident 1 should have been seen by an ophthalmologist immediately but was not. Physician 1 stated he did not recall if Resident 1 complained of issues to the right eye during Resident 1's examinations. Physician 1 stated he did not assess the patient for corneal abrasions or eye pain because Resident 1 did report any concerns regarding Resident 1's eyes. Physician 1 also stated he did not assess Resident 1's eyes because the nurses did not report to Physician 1 that Resident 1 had any concerns with his eyes. During a telephone interview on 6/29/2021 at 10:56 a.m., the Director of Nursing (DON) stated the nurse who admitted Resident 1 was supposed to report to the physician Resident 1 had a right eye corneal abrasion, but she did not. The DON stated the admitting nurse was responsible for following up with the ophthalmologist referral and setting up appointments but did not. The DON confirmed there was no documented evidence the admitting nurse addressed and assessed Resident 1's right eye. The DON stated the IDT should have developed a care plan specific to the corneal abrasion with meaningful interventions and services to treat and heal the corneal abrasions but did not. The DON acknowledged an intervention should have been developed regarding the ophthalmologist referral but was not. During an interview on 7/1/2021 at 12:43 p.m., the DON stated the referral should not have been delayed for more than a day, but it was. The DON stated a failure to follow up for a corneal abrasion with an ophthalmologist referral can result in Resident 1's right eye infection or [CONDITION(S)]. During an interview on 7/1/2021 at 1:47 p.m., the Social Worker (SW) stated it was sometime this year (2021 but specific date unknown) when Resident 1 expressed concerns about seeing an eye specialist. The SW stated it was not her responsibility to make ophthalmologist referrals. The SW admitted she did not document Resident 1's concerns regarding seeing an eye specialist. During a review of Resident 1's Ophthalmology Consultation Reported, dated 5/7/2021, the Ophthalmology Consultation Report indicated Resident 1 was diagnosed with a right eye corneal ulcer with right eye keratitis (an inflammation of the cornea). The Ophthalmologist recommended Resident 1 go directly to a corneal specialist STAT (Immediately) without delay to see a cornea specialists and attending physician (doctor who is responsible for the overall care of a patient in a hospital or clinic setting) and obtain culture and sensitivity (A culture is a test to find germs [such as bacteria or a fungus] that can cause an infection. A sensitivity test checks to see what kind of medicine, such as an antibiotic, will work best to treat the illness or infection) of the right eye. During a review of Resident 1's GACH 2's Consultation Notes, dated 5/8/21, the Consultation Note indicated the patient (Resident 1) had been having right eye symptoms over the past year, but feels that his vision in both eyes have been getting more blurry over this time period. The report indicated Resident 1 had pain and discharge from the right eye. During a review Resident 1's GACH 2's Discharge Documentation, dated 5/8/21, the discharge Documentation indicated Resident 1 was diagnosed with a corneal ulcer. Resident 1 was prescribed [MEDICATION(S)] ophthalmic (antibiotics for the eyes) 2 (two) drops each eye 4 (four) times a day for 5 (five days) and [MEDICATION(S)] [MEDICATION(S)] ophthalmic (antibiotics for the eyes) 1 (one) drop each eye 4 times a day for 10 days. During a review of the facility's policy and procedure (P/P) titled, Provision of Physician Ordered Services, the P/P indicated a qualified nursing personnel would submit timely requests for physician ordered services (laboratory, radiology, consultations) to the appropriate entity, documentation of consultations, diagnostic tests, the results, and date/time of physician notification will be maintained in the resident's clinical record. During a review of the undated facility's job description titled, Social Services Designee, the job description indicated the SW will coordinate support services as needed for optometry, dental, audiology, and all other support services. During a review of the undated job description titled, Charge Nurse LVN Licensed Vocational Nurse), the job description indicated the LVN's specific job functions included, but were not limited to: communicating residents' condition and nursing care to appropriate people (i.e., supervisor, administrator, physician, family, etc.); coordinating nursing care and care rendered by others through an appropriate individualized care plan; and observing, reporting, and recording findings/changes in resident condition (i.e., signs, symptoms, reactions, behaviors, and complaints) to physician and nursing personnel. During a review of the undated facility's policy titled, Care Planning Interdisciplinary Team, the policy indicated our facility's Care planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident. During a review of the undated facility's policy titled, Physician Services, the policy indicated the medical care of each resident is under the supervision of a Licensed Physician. The resident's Attending Physician participates in the resident's assessment and care planning, monitoring changes in the resident's medical status, and providing consultation or treatment when called by the facility.

Based on interview and record review, the facility failed to follow its policy and follow a residents' plan of care for one of three sampled residents (Resident 1). Resident 1 sustained two (2) falls that resulted in a transfer to the general acute care hospital (GACH) on 6/20/17. As a result, Resident 1 sustained injuries requiring a transfer to the GACH and diagnosed with [REDACTED]. Findings: A review of Resident 1's Admission Record (face sheet) indicated Resident 1 was admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS), a standardized care screening and assessment tool, dated 6/12/17, indicated a Brief Interview for Mental Status (BIMS) indicated Resident 1 was moderately impaired in cognitive skills (thought process), had poor decision-making, and required cues to remember. The MDS indicated Resident 1 required extensive physical assistance of a two person assist for toilet use. According to the MDS, Resident 1 had history of falls. On 9/12/17 at 4:31 p.m., during a telephone interview, Resident 1's family member (FM 1) stated that on the morning of 6/12/17, Certified Nurse Assistant 1 (CNA 1) left Resident 1 unattended to get an adult diaper from outside the resident's room, which resulted in Resident 1 falling from the bed to the floor. FM 1 stated that when she opened the room's curtain, Resident 1 was lying on the floor on his right side naked. FM 1 stated that she observed Resident 1's bed in a high position. A review of a Fall Assessment, dated 4/17/17, indicated Resident 1 had a score of 18 (total score above 10 represented a high risk for falls). On 9/12/17 at 2 p.m., during an interview, Director of Nursing 1 (DON 1) stated she was not aware if Resident 1's bed was in a low position at the time of the fall. On 9/12/17 at 3:26 p.m., during an interview and concurrent record review, Registered Nurse 1 (RN 1) stated that she performed a post-fall head to toe assessment on Resident 1 on 6/12/17 and notified the physician. RN 1 stated that FM 1 was in the room when the incident happened. A review of Resident 1's care plan titled, Incident/Accident Short Term Care Plan, dated 6/12/17, indicated Resident 1 would remain free of injuries by the review date of 6/15/17. The staff's intervention indicated for staff to monitor the resident for 72 hours, continue with 15-minute checks, bed alarm, low bed, and notify the physician of any pain or discoloration noted on the resident. On 9/13/17 at 10:46 a.m., during a telephone interview, CNA 3 stated that on 6/16/17, during Resident 1's shower, a large skin discoloration was observed to resident's right side of the chest. A review of the Nurses' note, dated 6/16/17, and timed at 12:25 p.m., indicated CNA 3 notified Licensed Vocational Nurse 1 (LVN 1) that during Resident 1's shower the right chest area was pale/purple and green/yellowish in color, measuring three (3) inches in length and 1.5 inches in width. The note indicated the physician was notified and no new orders was given. A review of a Nurses' note, dated 6/19/17, and timed at 9 a.m., three days later, indicated that Resident 1's right chest discoloration had increased in size to 10 centimeters (cm) by (x) three (3) cm in size and Resident 1 complained of pain to the right shoulder and arm. On 9/13/17 at 1:45 p.m., during a concurrent interview and record review, RN 2 stated that she did not notified Resident 1's physician of a second fall that occurred on 6/14/17. A review of the physicians' orders, dated 6/19/17, indicated for an x-ray to Resident 1's right shoulder and right humerus (long bone in the upper arm) due to discoloration. A review of Resident 1's x-ray results, dated 6/19/17, indicated there was a non-displaced (bone cracks either part or all of the way through) [MEDICAL CONDITION] and non-displaced humerus fracture. On 9/14/17 at 2:23 p.m., during a concurrent interview and record review, RN 1 stated that 72-hour monitoring observation meant that the CNA's were responsible for monitoring the resident's. A review of the GACH's Emergency Department Report, dated 6/20/17, and timed at 3:36 p.m., indicated Resident 1 had a right clavicle and humerus fracture. On 9/14/17 at 3:15 p.m., during an interview, DON 1 stated that 72 hour meant that staff monitors the resident at all times. DON 1 stated that the Physician should have been notified of Resident 1's falls, and the care plans updated after each fall to assess the interventions. On 3/8/18 at 10:57 a.m., during a telephone interview, CNA 1 stated that on 6/12/17, while changing Resident 1's adult brief, the resident fell from the bed. CNA 1 stated that he left Resident 1 to go get the dirty linen hamper, and when he returned to the room; CNA 2 notified him that Resident 1 had fallen off of the bed. On 3/8/18 at 11:44 a.m., during a telephone interview, CNA 2 stated that while she was providing care to Resident 1's roommate she saw CNA 1 leave the room. CNA 2 stated that FM 1 overheard a loud noise, and upon checking, CNA 1 found Resident 1 on the floor next to his bed. On 5/23/18 at 4:38 p.m., during a telephone interview and record review, DON 2 stated that he was not able to locate nursing notes, care plans, and assessment regarding Resident 1's fall on 6/2017, while the resident was being changed by CNA 1. A review of the facility's policy titled Fall Prevention Program Overview-Post Fall Procedures/Management, revised 6/14/17, indicated that the first priority of the staff was to assess the patient for any obvious injuries. A licensed or registered nurse must assess any patient that has a fall before being moved .The DON or charge nurse will notify the Physician and responsible party after the fall .a fall incident report form will be completed for each patient fall episode.

Based on observation, interview, and record review, the facility failed to follow is policy, physician orders, and plan of care to assess, treat, and document a resident's wound care for one of four residents (Resident 1). Resident 1 had a six (6) inch mass (large body of matter with no definite shape) to the left lower leg, after bumping the leg on the bed frame. The wound progressed to 8 centimeters (cm) by 17 cm in size within one day. (Cross Reference F 726). These deficient practices resulted in a delay in the evaluation and treatment of [REDACTED]. Findings: A review of Resident 1's Admission Record (Face Sheet) indicated the resident was initially admitted to the facility on [DATE], and last readmitted on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS), a standardized care screening and assessment tool, dated 2/4/18, indicated a Brief Interview for Mental Status (BIMS) score of 9 (8 to 12= cognition moderately impaired (thought process)) requiring cues to remember. The MDS indicated Resident 1 required limited assist of a one staff for locomotion on unit (how resident moves between locations in room and corridors). According to the MDS, Resident 1 was dependent on a wheelchair for mobility. On 2/22/18 at 8:38 a.m., during a concurrent interview and treatment observation, Licensed Vocational Nurse 1 (LVN 1) stated that Resident 1 had a ruptured hematoma (solid swelling of clotted blood within the tissues) measuring 15 cm width by (x) 13 cm length x 3.2 cm in depth with 1.4 cm tunneling (channels that extend from a wound into and through subcutaneous tissue or muscle) on the upper left side of the ruptured hematoma near the knee cap. LVN 1 stated that Resident 1 bumped her left lower extremity (LLE) on the bed frame on 1/25/18 that resulted in a hematoma. A review of a Nurses Note, dated 1/25/18, and timed at 10:15 a.m., indicated Resident 1 complained of pain to the left shin (the front of the leg below the knee) after bumping the LLE on the bed frame, resulting in a large bump. The Physician was notified and ordered to perform a STAT (immediately) x-ray to the LLE. Another nurse's note, dated 1/25/18, and timed at 12:50 p.m., indicated swelling to the LLE was noted to be the size of a half-dime (0.705 inch). The Nurses' Note timed at 3:30 p.m., indicated Resident 1's hematoma increased in size and was bleeding, while the resident was in the patio. Resident 1 was noted disoriented and with low blood pressure 61/36 (120/80 normal reference ranges (NRR)). Another note indicated that Resident 1 was transfer to the general acute care hospital (GACH) at 3:50 p.m., on 1/25/18 and returned back to the facility (SNF) at 11:10 p.m., on 1/25/18. A review of the physician's orders [REDACTED]. A review of a Nurse's Note, dated 1/26/18, and timed at 4:42 p.m., indicated the physician saw Resident 1 on 1/26/18 and ordered the resident to be seen by the wound specialist as soon as possible. The note indicated the LLE wound had sanguineous (fresh blood) drainage and measured 17.5 cm by 17 cm by 3 cm in depth. On 2/22/18 at 10:01 a.m., during a concurrent interview and review of Resident 1's clinical record, the Director of Nursing (DON) stated that the physician orders [REDACTED]. The DON stated that she was not aware that the wound consult was not carried out and the treatment assessments not documented. The DON stated that she was not able to find Resident 1's wound assessments from 2/5/18 through 2/21/18 (16 days). A review of the physician's orders [REDACTED]. On 2/27/18 at 12:46 p.m., during a telephone interview, LVN 2 stated that she was told by LVN 1 not to document the resident's ruptured hematoma assessment in the chart. A review of the GACH's Standard Chart-Physical Exam, dated 1/25/18, and timed at 11:43 p.m., indicated Resident 1 had an 18 cm x 17 cm hematoma to the anterior LLE and an internal seven (7) cm laceration (cut). A review of the physician orders, dated 1/25/18, and timed at 11:10 p.m., indicated to readmitted Resident 1 to the SNF, blood drawn on 1/26/18 to check for complete blood count ((CBC) measures the concentration of white and red blood cells, platelets in the blood) and chemistry 7 (group of blood tests that provides information about the body's metabolism), and a wound follow-up by a wound specialist on 1/28/18. On 2/28/18 at 6:35 a.m., during a telephone interview, Registered Nurse 1 (RN 1) stated that the physician ordered a STAT x-ray to the LLE after being notified that Resident 1 developed a hematoma after bumping her leg on the bed frame. RN 1 stated that he was not able to place the order for the X-ray because the telephone line was busy. RN 1 stated that Resident 1 was transferred to the GACH on 1/25/18 due to the large amount of bleeding from the LLE with lethargy (state of tiredness, weariness, fatigue, or lack of energy). On 3/20/17 at 11:45 p.m., during an interview and review of the physician orders, RN 2 stated that she had mentioned to LVN 2 to contact the wound specialist for a follow up on 1/28/18, because of the severity of Resident 1's LLE injury. RN 2 stated that she was not able to locate Resident 1's wound specialist follow-up. A review of Resident 1's Treatment Record, dated 1/26/18, indicated an order to clean the anterior aspect of the LLE with normal saline (NS), pat dry, apply oil [MEDICATION NAME] (droplets of one liquid in another immiscible liquid) and cover wound with dry dressing every other day for 21 days. A review of Resident 1's care plan titled, At Risk for Bleeding, dated 1/26/18, indicated the resident would not have excessive bleeding. The staff interventions included to observe for changes in the resident's general condition and the presence of bleeding. A review of Resident 1's care plan titled, LLE Wound Infection, dated 1/26/18, indicated that the facility's staff would administered treatments as prescribed, assess for effectiveness, notify the physician for treatment effectiveness, and assess for signs of infection (redness, drainage, and foul odor). On 2/28/18 at 6:44 a.m., during a telephone interview, LVN 3 stated that she performed treatments on Resident 1's wound as ordered by the physician, but did not assess and/or document the assessment of the wound as stated on the care plans. LVN 3 stated that she was not able to state if the treatment was working or not since she did not document the progress. On 3/20/18 at 11:50 a.m., during an interview and review of Resident 1's care plans, RN 2 stated that Resident 1's care plan to assess the wound for signs of infection were not followed. A review of the Nurse's Note, dated 1/30/18, and timed at 1:30 p.m., indicated Resident 1 was transfer to the GACH on 1/30/18 at 3:55 p.m., for a low hemoglobin (red protein responsible for transporting oxygen in the blood) results of 6.8 ((NRR)12.0 to 15.5 grams per deciliter (g/dl) for females) g/dl. A review of the GACH's Wound/Impairment Skin Assessment, dated 1/31/18, indicated Resident 1 had an unstageable (full thickness tissue loss) left leg blister, moderate serosanguineous (thin and watery leakage) with no odor, surrounding skin reddened in color, pink/beefy red tissue/non-granulating (part of the healing process), and black/brown eschar (dry, dark scab or falling away of dead skin). A review of the GACH's History and Physical (H/P) Examination, dated 1/31/18, indicated Resident 1 was transfused with two (2) units of Red Blood Cells (RBC). The H/P exam indicated Resident 1 was anemic (the blood does not have enough healthy red blood cells) due to the hematoma on the left leg. A review of the Nurses' Note, dated 2/4/18, and timed at 5 p.m., indicated Resident 1 was readmitted to the SNF (five days later). A review of Resident 1's Lower Extremity Wound Assessment, dated 2/5/18, indicated a Doppler test (test that uses high-frequency sound waves to measure the amount of blood flow through your arteries and veins) was conducted and there was no stenosis (narrowing of artery or vein) found on the LLE. The note indicated there was tissue involvement of the skin, fascia, fat, and muscle with 60 percent (%) necrosis (death of most or all of the cells in a tissue) and heavy serosanginous drainage. A review of the Physician's Progress Note, dated 2/11/18, and timed at 11 a.m., indicated that Resident 1's primary physician (MD) assessed the resident's large loosened eschar (dry, dark scab) that had increased in odor. The note indicated neuro (related to the nervous system)/vascular (related to the vessels)/musculoskeletal (related to the bones and joints) were non-contributory to the left lower extremity (LLE) wound. The note indicated the wound measurements were 14.9 cm x 13.6 cm x 0.4 cm on anterior left leg with exposed fascia (thin sheath of fibrous tissue enclosing a muscle), fat and muscle, serosanguineous drainage with malodor of necrosis, thickened and irregular edges, with 40% pink and 60% eschar to the LLE. On 3/20/18 12:25 p.m., in the presence of RN 2, LVN 3 stated that she did not assess Resident 1's wound, only provided the wound care treatment. A review of the facility's undated policy titled, Change in Condition, indicated all changes in condition should be handled promptly. Daily assessments of condition changes shall be handle by nurse supervisor under the direction of the DON.

Based on observation, interview, and record review, the facility failed to implement a resident's plan of care and the facility's policy to ensure appropriate supervision was provided for one of three sample residents (Resident 1) that was on one-to-one supervision. This deficient practice resulted in Resident 1 rapidly propelling herself out of the dining room, causing Resident 2 to trip over the wheelchair's anti-tip bars and sustaining a displaced nasal fracture (a bone break with displacement), and a proximally non-displaced fracture with a hematoma (solid swelling of clotted blood within the tissues) on the forehead. Findings: A review of Resident 1's Admission Record (face sheet) indicated Resident 1 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS), a resident assessment and care-screening tool, dated 7/26/17, and the Mini-Mental State Exam (MMSE) score of 3 (0-7: severe impairment) indicated Resident 1 was severely impaired of cognition. The MDS indicated Resident 1 required limited assistance from one staff for locomotion off unit (how resident moves between locations such as dining are, activities and treatments), and was dependent on a wheelchair for locomotion. A review of Resident 1's Assessment for Elopement (to leave the facility without permission)/Unsafe Wandering Risk, dated 4/13/17, indicated Resident 1 would wander into resident's room and collect belongings. The Assessment for Elopement/Unsafe Wandering indicated that Resident 1 required frequent monitoring and constant observation. A review of Resident 1's Care Plan titled, Wandering dated 4/13/17, indicated Resident 1 hada history of wandering behavior episodes, such as wandering around the facility, hallway, other residents' rooms, and attempted to go in the nursing station. The staff interventions included placing Resident 1 on 1:1 supervision and monitoring while providing frequent visual checks. On 8/23/17 at 3:09 p.m., during a concurrent interview and record review, the Assistant Administrator (AA) stated that frequent monitoring meant as soon as possible; and 1:1 supervision meant that the staff would monitor the resident at all times. AA stated that the resident's care plans did not specify the duration of the interventions to be implemented. A review of the facility investigation, dated 8/9/17, indicated Resident 2 tripped over Resident 1's anti-tip bars causing resident to fall and have a bloody nose. The investigation report indicated that the facility failed to provide the 1:1 supervision for Resident 1 due to assigned staff not been present. A review of Resident 2's Admission Record (face sheet) indicated Resident 2 was admitted to the facility on [DATE]. Resident 2's [DIAGNOSES REDACTED]. A review of Resident 2's Minimum Data Set (MDS), a standardized care screening and assessment tool), dated 7/14/17, indicated a brief interview for mental status (BIMS) score of 10 (8-12 moderately impaired in cognitive skills) and had no memory problems. The MDS indicated Resident 2 did not require assistance from staff to walk in the corridors and/or any mobility devices for ambulation. On 8/23/17 at 1:30 p.m., during an interview, Registered Nurse 2 (RN 2) stated that they were not able to provide the nursing per hour per patient a day (NHPPD) and was unable to locate that the 1:1 monitoring log for 8/8/17. On 8/23/17 at 3:11 p.m., during an interview, Registered Nurse 2 stated that Resident 1 wheeled herself out of the dining room and hit Resident 2 with the wheelchair anti tip bars, causing Resident 2 to fall. On 8/23/17 at 3:48 p.m., during an interview, Certified Nurse Assistant 2 (CNA) stated that Resident 1 had not been supervised because the facility had been short of staff. CNA 2 stated that CNA 1 was assigned to Resident 1 for 1:1 supervision. A review of a Nurses Progress Note, dated 8/7/17, and timed at 9:10 p.m., indicated Resident 2 was transfer to a General Acute Care Hospital (GACH) via ambulance. A review of Resident 2's GACH report dated 8/7/17, and timed at 10:57 a.m., indicated the resident had a displaced and non-displaced nasal fracture and a hematoma on the forehead. On 8/23/17 at 4:47 p.m., during an interview, Registered Nurse 1 (RN) stated that the fall on 8/7/17 could had been prevented if they had enough staff to supervise Resident 1 as indicated in the resident's care plan. A review of Resident 2's Nurses Progress Note dated 8/9/17 and timed at 9 a.m., indicated Resident 2 returned to the facility from with a swollen face, bilateral black eyes, and was agitated. A review of facility's policy and procedure titled, Unsafe Wandering, dated 6/5/17, indicated that any unsafe wandering/potential AWOL resident that are identified would be immediately placed on one to one. A review of the facility's policy and procedure titled, 1:1 Supervision, dated 8/17/17, indicated that a resident that wanders would be placed on 1:1 supervision.

Based on observation, interview, and record review, the facility failed to ensure Resident 1 was free of verbal abuse by Certified Nursing Assistant 1 (CNA 1). Resident 1 was told by CNA 1 to stop talking and shut up. This deficient practice resulted in Resident 1 not being free of verbal abuse, and had the potential to cause emotional distress and psychological trauma. This deficient practice had the potential to place other residents at risk of verbal abuse. Findings: On July 18, 2017 at 1 p.m., during the facility's initial tour, Resident 1 was observed in the library. Resident 1 was reclined in a Geri Chair (a large, padded, reclining chair designed to allow residents to get out of a bed and sit comfortably while being fully supported) speaking to staff and other residents. A review of Resident 1's Admission Face Sheet indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's [DIAGNOSES REDACTED]. According the face sheet, Resident 1 was self responsible. A review of Resident 1's Minimum Data Sheet (MDS), a standardized assessment and care-screening tool, indicated Resident 1's cognition (ability to think and reason) was intact. The MDS indicated Resident 1 was totally dependent for transferring, mobility, dressing, eating, and hygiene. On July 31, 2017 at 8:30 a.m., during a telephone interview, Certified Nursing Assistant 2 (CNA 2) stated, she heard CNA 1 tell Resident 1 to stop talking and to shut up. CNA 2 stated, CNA 1 told Resident 1, Shut up! Shut up! Shut up! in an aggressive and loud manner. A review of Resident 1's Licensed Nurses Note, dated July 9, 2017, and timed at 2 a.m., indicated that CNAs 2 and 3 overheard CNA 1 tell the resident to shut up! The note indicated Resident 1 was assessed by the licensed nurse on duty and denied pain, discomfort, or any physical injury. On July 18, 2017 at 1:26 p.m., during an interview, Resident 1 stated CNA 1 told him to shut up and go back to his country. Resident 1 stated he told CNA 1 not to insult him in his own room. Resident 1 stated he tried not tell on the staff because he knows how hard it was for them to find a job. A review of CNA 1's employee file indicated that CNA 1 was hired February 13, 2017. A document titled Employers Choice Screening, dated June 13, 2017, indicated that a National Federal Criminal search was conducted on June 13, 2017, which was four months after CNA 1 was hired. A form titled, Termination Resignation Report, dated July 11, 2017, indicated CNA 1 was terminated for violation of the facility's policies/procedures due to verbal abuse toward a resident. A review of the facility's policy and procedures titled, Policy Regarding Hiring of All Employees and Criminal Background Check, with a revision date of August 29, 2016, indicated that the facility would utilize an independent company to perform criminal background checks on all non-certified, licensed or registered employees prior to their starting employment. A review of the facility's undated policy and procedures titled, Patient Abuse Prohibition, indicated the facility was committed to protecting the physical and emotional well-being of every resident. The policy indicated that all prospective employment candidates would be screened for whether they engaged in incidents of abuse, neglect and /or misappropriation of property.

Based on observation, interview, and record review, the facility failed provide necessary care and services to three of eight sampled residents (Resident 1, 2, and 3) residents with dementia (decline in mental ability severe enough to interfere with daily life) and who exhibited wandering behaviors to other residents' rooms for by failing to: 1. Assess Resident 1's, 2's, and 3's behaviors of wandering inside other residents' rooms. 2. Conduct an interdisciplinary team meeting (IDT, a group of health care professionals from diverse fields who work in a coordinated fashion toward a common goal for the resident) to discuss and develop interventions to manage wandering behaviors of Resident 1, 2, and 3. 3. Establish appropriate and effective interventions to prevent Resident 1, 2, and 3 from entering other residents' rooms; prevent resident-to-resident altercations and potential injuries caused by the wandering behaviors' and prevent a feeling and an atmosphere of fear from developing amongst female residents. 4. Establish a policy and procedure to manage a resident with a wandering behavior in the facility. Resident 1, 2, and 3 had dementia and these residents exhibited behaviors of wandering inside other residents' rooms. The facility did not have a policy and procedure of assessing and identifying residents with wandering behaviors, and developing individualized interventions to prevent residents from wandering inside other residents' room. These deficient practices resulted in actual psychosocial harm for Resident 4, 5, 6, and 7 and had the potential to result in physical harm to Resident 1, 2, and 3 and other residents. On 4/12/17 at 6 p.m., an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was declared and the facility's administrator (ADM, a person responsible for managing an organization) and the acting director of nursing (ADON, a person who provides direction to the nursing staff and coordinate health services) were notified of the serious findings that threatened the health and safety of the residents. Resident 1, 2, and 3 were known by the facility staff, residents, and visitors to have a behavior of wandering in and out of male and female residents' rooms. The facility did not have established and effective measures to prevent Resident 1, 2 and 3 from entering other residents' rooms without permission. Resident 1's, 2's, and 3's wandering behaviors had the potential to result in altercation with other residents that may result in physical injury to Resident 1, 2, and 3 and other residents, as well as psychosocial harm to female residents. The IJ was lifted on 4/14/17 at 2:20 p.m. in the presence of the ADM after the facility provided an acceptable plan of correction (POC). The facility's POC indicated that the facility would maintain a one-on-one monitoring until Resident 1, 2, and 3 were transferred to a different facility or until Resident 1's, 2's, and 3's wandering behaviors ceased. The facility created a policy for unsafe wandering and a wandering/elopement assessment tool. The ADON gave the nurses an in-service regarding the new wandering policy and wandering assessment tool. Findings: On 4/5/17 at 12 p.m., an unannounced visit was conducted at the facility to investigate an entity reported incident regarding resident's safety. On 4/5/17 at 12:20 p.m., during a tour of the facility with the ADON, the facility was observed with four (4) halls with residents' rooms. Hall 3 and 4 had rooms designated for female residents and Hall 2 and 5 had rooms designated for male residents. Resident 1 (a male resident) was observed propelling his wheelchair independently in Hall 3, which had rooms for female residents. Resident 1 resided in Hall 2. During a concurrent observation, the ADON stated that male residents were not supposed to be in halls with female residents' rooms and that female residents were not supposed to be in halls with male residents' rooms. The ADON stated that Resident 1 was confused and he had the daily tendency to go inside other residents' rooms (male and female residents) since he was admitted to the facility and that the facility staff would redirect him back to the main (central) hall, where the nursing station was located. On 4/5/17 at 2:25 p.m., during an interview, the ADON stated that Resident 1 did not have an individualized care plan to address the resident's wandering behavior for going inside and out of other residents' rooms. On 4/12/17 at 12:19 p.m., during an observation with the ADON, Resident 1 was in a corner inside the dining room (TV room), sitting in a wheelchair and trying to get out from between two chair benches. Resident 1 was not able to propel his wheelchair out from between the two chair benches. The ADON stated that Resident 1 was not supposed to be placed in between the chair benches because it was a form of restraining Resident 1's movement. During the concurrent observation, a certified nursing assistant (CNA 1) was interviewed and she stated that she (CNA 1) placed Resident 1 in the corner to restrict him from wandering because it was time to eat lunch. CNA 1 stated that Resident 1 did not understand instructions because he was confused and that he did not listen to the instruction not to be propelling himself in his wheelchair all over the facility especially during lunch time. CNA 1 stated that Resident 1 went inside other residents' rooms (female rooms and male rooms) daily many times a day (CNA 1 did not state the exact number of times). (Cross refer F221) On 4/12/17 at 4:50 p.m., during an interview, a licensed vocational nurse (LVN 3) stated that Resident 1 had the behavior of going inside other residents' rooms since his admission to the facility and that other residents had gotten upset when Resident 1 went inside their rooms uninvited. A review of Resident 1's face sheet (admission record), indicated Resident 1 was first admitted to the facility on [DATE] and was re admitted on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 2/28/17, indicated Resident 1 had severe impairment for daily decision making, unable to walk, used a wheelchair for mobility, and required limited assistance (staff provide guided maneuvering or other non-weight bearing assistance) for locomotion off unit (how resident moved to and returned from areas such as the dining room, and activity room) with the assistance of one person. A review of Resident 1's record titled Initial Psychosocial Assessment, dated 2/16/17, indicated Resident 1 was able to propel himself in the wheelchair and had poor safety awareness and wandered in and out of the halls. A review of Resident 1's record titled Nurses Notes, dated 2/17/17, and timed 11 p.m., indicated Resident 1 propelled himself in the hallways. On 4/12/17 at 1:51 p.m., during an interview, LVN 1 stated that Resident 2 (a female resident) was a confused resident. LVN 1 stated that Resident 2 was able to propel her wheelchair independently and had wandered in the male and female halls. LVN 2 stated that there was a risk for Resident 2 to enter other residents' rooms and that there was a potential for other residents to get upset if Resident 2 enters their rooms uninvited. LVN 1 stated that there was no care plan in place to manage Resident 2's wandering behavior. On 4/12/17 at 4:03 p.m., during an observation, Resident 2 was propelling her wheelchair independently through a male residents' hall. On 4/12/17 at 4:48 p.m., during an interview, CNA 1 stated that Resident 2 went inside other residents' rooms (male and female residents) since she was admitted . On 4/14/17 at 3:52 p.m., during an interview, the ADON stated that the facility did not have an individualized care plan to manage Resident 2's wandering behaviors of going in and out of other residents' rooms. A review of Resident 2's face sheet indicated resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 2 resided in Hall 4. A review of Resident 2's MDS, dated [DATE], indicated Resident 2 had severe impairment in cognitive skills, was unable to walk, used a wheelchair for mobility, and required supervision while in locomotion off the unit. A review of Resident 2's record titled Progress Note, dated 4/1/17, indicated Resident 2 had history of stealing things from other people's rooms. On 4/12/17 at 4:01 p.m., during an observation, Resident 3 (female resident) was propelling her wheelchair independently in a male residents' hall. A facility staff re-directed Resident 3 to the TV room. On 4/12/17 at 4:48 p.m., during an interview, CNA 1 stated that Resident 3 went inside other residents' rooms (male and female residents) since she was admitted (on 11/2/16). On 4/12/17 at 4:06 p.m., during an interview, LVN 2 stated that Resident 3 did not have a care plan to address Resident 3's wandering behavior of going in and out of other residents' rooms. A review of Resident 3's face sheet indicated the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 3 resided in Hall 4. A review of Resident 3's MDS, dated [DATE], indicated Resident 3 had severe impairment in cognitive skills, unable to walk, used a wheelchair for mobility, and was able to move independently between locations on and off the unit. A review of Resident 3's record titled Progress Notes, dated 4/1/17, indicated Resident 3 was confused and had a history of [REDACTED]. On 4/12/17 at 12:44 p.m., during an interview, Resident 4 (a male resident residing in Hall 2) stated that Resident 1 (who resident in Hall 2), Resident 2 (who resided in Hall 4), and Resident 3 (who resided in Hall 4), went inside his (Resident 4's) room daily, approximately three to four times a day, for several months without permission and touched his personal belongings. Resident 4 stated that Resident 1 went inside his room on 4/11/17 in the evening. Resident 4 stated that he used his call light to call a facility staff to take Resident 1 out of his room and that the staff took more than 15 minutes to come to his (Resident 4's) room. During the interview, Resident 4 stated that Resident 1, 2, and 3 made him very angry every time they (Resident 1, 2, and 3) went inside his room. Resident 4 stated that he felt like hitting Resident 1 when Resident 1 went inside his (Resident 4) room because Resident 1 was a man. Resident 4 stated that he had to yell very loud at Resident 1 so that Resident 1 would leave his (Resident 4) room. Resident 4 stated that Resident 2 and 3 made him angry when they touch his things. A review of Resident 4's record titled, Record of Admission, indicated the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 4's MDS, dated [DATE], indicated the resident was alert and cognitively intact for daily decision making. On 4/12/17 at 1:33 p.m., during an interview, Resident 5 (a female resident) stated that Resident 1 went inside her room three to four times a day every day. Resident 5 stated the Resident 1 last went inside her room on 4/11/17; she used the call light to call a facility staff to get Resident 1 out of her room; and she had to wheel Resident 1 out of her room because the facility staff took about half an hour to answer her call light. Resident 5 stated that she felt violated and scared when Resident 1 stared at her while Resident 1 was inside her room. A review of Resident 5's record titled, Record of Admission, indicated the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 5 resided in Hall 4. A review of Resident 5's MDS, dated [DATE], indicated that the resident was cognitively intact for daily decision making and had no limitations in range of motion (the full movement of the joints) in her upper extremities (shoulder, elbow, wrist, and hand). On 4/12/17 at 12:59 p.m., during an interview, a family member (FAM 1) stated that Resident 1 and other confused female residents (FAM 1 did not identify the female residents) went inside Resident 6's room (a female resident's room located in Hall 4) and that they (FAM 1, FAM 2, and Resident 6) were scared because they did not know what Resident 1 and the other confused residents were capable of doing. During the interview, FAM 1 stated that the facility staff was aware that Resident 1 entered Resident 6's room daily. FAM 1 stated Resident 1 last entered Resident 6's room on 4/8/17 and FAM 1 and FAM 2 pushed Resident 1 out of Resident 6's room, left him outside the hall (Hall 4), and that FAM 1 and FAM 2 saw Resident 1 entered other female resident's room. A review of Resident 6's face sheet indicated the resident was admitted to the facility on [DATE] and was readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 6's MDS dated [DATE], indicated the resident had severe impairment for daily decision making and required extensive assistance (staff provide weight-bearing support) to total assistance from staff for activities of daily living (ADLs). On 4/5/17 at 12:32 p.m., during an observation, Resident 7 (a female resident) was awake, lying in bed inside her room. Resident 7 stated, during an interview, that a male resident (Resident 7 could not remember the male resident's name) went inside her room in a wheelchair daily without permission and that the last time the male resident came in her room was on 4/4/17 after lunch time. Resident 7 stated that she was scared and concerned. Resident 7 stated that she reported the male resident to the facility staff (Resident 7 could not remember the staff's name) every time the male resident came inside her room and that the staff would take 10-15 minutes to go inside her room and take the male resident out of her room. Resident 7 stated that she had a hidden wooden stick inside her room and that she was planning to use it to hit any resident who came inside her room uninvited. A review of Resident 7's face sheet indicate the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 7 resided in Hall 3. A review of Resident 7's MDS, dated [DATE], indicated the resident was cognitively intact for daily decision making; was independent (no help from staff) for walking and transferring (how resident moves between surfaces including to or from bed, chair, standing position); and had no limitations in range of motion in her upper extremities. On 4/12/17 at 12:26 p.m., during an interview, Resident 8 (a male resident) stated that confused residents (Resident 1, 2, and 3) went inside his room and touched his personal belongings. Resident 8 stated that Resident 4 (his roommate) got extremely mad and yelled derogatory words to Resident 1, 2, and 3. Resident 8 stated that Resident 4 called the nurses using his call light on 4/11/17 in the evening to let the nurses know that Resident 1 was inside their (Resident 4's and Resident 8's) room. Resident 8 stated that the nurses took more than fifteen minutes to respond to Resident 4's call for help. Resident 8 did not state how Resident 2 and 3 left or was removed from his room. A review of Resident 8's face sheet indicated the resident was admitted to the facility on [DATE] and was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 8's MDS, dated [DATE], indicated the resident was cognitively intact for decision making and was total dependent on staff for all ADLs. On 4/12/17 at 4:46 p.m., during an interview, CNA 2 stated that Residents 1, 2, and 3 were confused and wandered inside other residents' rooms, including those rooms of Residents 4, 5, 6, 7, and 8, since their (Resident 1, 2, and 3) admission. On 4/12/17 at 4:48 p.m., during an interview CNA 1 stated that Residents 1, 2, and 3 wandered in other residents' rooms including the rooms of Residents 4, 5, 6, 7, and 8 and other residents' rooms. On 4/12/17 at 4:53 p.m., during an interview, the ADM stated that he was not sure if the facility had residents who wandered inside other residents' rooms and that the facility did not have a policy to address and manage the wandering behaviors of residents. The ADM stated that he could not remember if Resident 1's, 2's, and 3's wandering behaviors of going in and out of other residents' rooms were discussed with the IDT and that he did not have any documentation to verify if Resident 1's, 2's, and 3's wandering behaviors of going in and out of other residents' rooms were addressed during the IDT meetings. On 4/14/17 at 3:49 p.m., during an interview, the director of staff development (DSD) stated that she did not provide an in-service to the facility staff regarding how to manage the wandering behaviors for going in and out of residents' rooms prior to 4/12/17 and that she should have given an in-service to the facility staff because the residents, who wandered, needed to have an individual care plan. On 4/14/17 at 3:52 p.m., during an interview, the ADON stated that the facility did not have individualized care plans for Resident 1, 2, and 3 to address and manage their wandering behaviors of going in and out of other residents' rooms. The ADON stated that that the facility did not conduct screening or assessments to identify residents with wandering behaviors and that the facility did not have a policy to address wandering behaviors of the residents. The ADON stated that staff only conducted frequent visual monitoring for residents who were involved in resident to resident altercations because sometimes the facility did not have enough staff. A review of the facility's undated policy and procedure titled, Care Plans Comprehensive indicated that a comprehensive care plan that included measurable objectives and timetables to meet residents' medical, nursing, mental and psychological needs were to be developed for each resident to incorporate problem areas that were identified and to enhance the optional functioning of each resident. On 4/12/17 at 6 p.m., an Immediate Jeopardy (IJ) was declared and the ADM and ADON were notified of the serious findings. After confirming that the facility's plan of correction was implemented, the IJ was lifted on 4/14/17 at 2:20 p.m. in the presence of the ADM. The facility's plan of correction was implemented as follows: 1. Resident 1, 2, and 3 were provided with a one-on-one monitoring (one facility staff monitoring one resident) and the one-on-one monitoring would continue until Resident 1, 2, and 3 were transferred to a different facility or until the wandering behaviors ceased. 2. The licensed nurses assessed each resident in the entire facility to ensure any identified residents, who were unsafe wanderers, were reassessed using a new assessment tool to identify elopement/wandering behaviors and licensed nurses updated or residents' care plans. 3. The ADON provided in-services to the nursing staff on the new unsafe wandering and assessment for elopement tool policy. Any pending staffs (staffs who were off work) would be in-serviced by the director of staff development (DSD). 4. The ADON monitored unsafe wanderers daily during rounds and in weekly care plan meetings to ensure staffs were following the wandering policy and ensured the facility staffs were identifying residents with wandering behaviors. 5. The facility created and implemented a wandering assessment tool and an unsafe wandering and elopement policy for unsafe wandering.

Based on observation, interview, and record review, the facility failed to implement its policies and procedures to control and prevent the development and transmission of a disease and infection for 94 of 94 residents and 121 of 121 employees. The facility failed to: 1. Implement contact precautions when providing care to 38 of 94 residents and the 28 of 121 employees with suspected scabies (a contagious skin infestation, caused by tiny mites that burrow into your skin, causing a very itchy skin) in accordance with the facility's policy and procedure. Contact precautions are measures that are intended to prevent transmission of infectious agents, which are spread by direct contact (involves skin to skin contact and physical transfer of microorganisms (any organism too small to be viewed by the eye) to a susceptible host from an infected or colonized person) or indirect contact with the resident or the resident's environment. 2. Post a contact precaution sign outside the resident's room for 38 of 94 residents identified with suspected scabies to alert and remind staff and visitors to wear gloves and a long sleeve gown (a gown is used to protect the health care worker's arms and exposed body area and prevent contamination of clothing with potentially infectious material) in accordance with the facility's policy and procedure. 3. Designate an infection control preventionist designee to serve as the coordinator for implementing and overseeing the facility's infection prevention and control program in the absence of the infection control preventionist. 4. Develop a contact identification list, as soon as a possible case of scabies was identified, that identified every resident, health care worker, visitor, and volunteer who may have direct, physical contact with the residents with suspected scabies within the previous month, in accordance with the facility's policy and procedure. 5. Develop a separate list, identifying each resident and employee with suspected scabies, when more than one symptomatic resident was identified in accordance with the facility's policy and procedure. 6. Properly discard the used disposable protective gown and gloves inside the resident's room in accordance with the CDC (Centers for Disease Control and Prevention) guideline for isolation precautions. 7. Wash hands inside the resident's bathroom after removing the disposable protective gown and gloves before leaving the resident's room in accordance with the CDC guideline for isolation precautions. 8. Report the scabies outbreak to the Department of Public Health and the licensing and certification district office when the facility received the dermatology report, dated 5/18/15, of Resident 15, which indicated a [DIAGNOSES REDACTED]. This deficient practice resulted in 38 residents and 28 facility staff developing an itchy rash, which required treatment for [REDACTED]. Findings: On 6/5/15 at 5:35 p.m., an unannounced visit was made to the facility to investigate a complaint regarding a possible scabies outbreak affecting the residents and employees of the facility. On 6/5/15 at 5:35 p.m., during the initial tour with the licensed vocation nurse (LVN 1), the facility was observed with four (4) hallways (Hallway 2, 3, 4, and 5) with residents' rooms. There was no contact precaution signage posted in any of the residents' rooms to alert staff and visitors to wear personal protective equipment (PPE, refers to protective items, such as gloves, and garments, such as a long sleeve gown, worn to protect the body from contact with infectious agents) when anticipating or providing direct contact with a resident known or suspected with a contagious rash or indirect contact with items in the resident's environment. There was no cart containing PPE outside of any of the residents' rooms to make the PPE, such as the long sleeve gown, accessible to staff and visitors, before entering the room of a resident with a suspected scabies. On 6/5/15 at 5:40 p.m., the clinical record of Resident 1 was reviewed with LVN 1. During an interview, LVN 1 stated a resident (Resident 1), who resided in Hallway 4 and who was transferred to an acute care hospital on [DATE], had generalized rash. The Nurses Notes, dated 5/7/15 at 12 p.m., indicated Resident 1 was observed with generalized rash over her entire body from neck to toes and in between her fingers. Current treatment was not helping and the resident was noted scratching self and complaining of pruritus (itchiness). The physician was notified and an order was given to obtain a dermatology consult for the resident and to apply [MEDICATION NAME] cream (a medication applied to the skin and used to treat scabies) from head to toe, shower off the cream in 12 hours and repeat the [MEDICATION NAME] cream treatment two (2) more times for a total of three treatments. The Treatment Record of Resident 1 indicated one application of [MEDICATION NAME] cream, on 5/8/15, was given. The Non-Pressure Sore Skin Problem Report, dated 6/1/15, of Resident 1's roommate, Resident 16, indicated the resident developed scattered rash on her body. The surveyor conducted a telephone interview with Staff 1 of the acute care hospital, on 6/9/15 at 4:30 p.m. According to Staff 1, Resident 1 was being treated with [MEDICATION NAME] cream for scabies. Staff 1 stated that according to the acute care hospital's physician, the hospital was treating Resident 1 with [MEDICATION NAME] cream once a week for five (5) weeks and one dose of Ivermectin (a medication given by mouth and used to treat scabies). On 6/5/15 at 5:45 p.m., the list of 94 residents in the facility was reviewed with LVN 2. LVN 2 stated four (4) of 26 residents in Hallway 2 had a rash (Resident 17, 18, 19, and 20); two (2) of 22 residents in Hallway 3 had a rash (Resident 2 and 3); 10 of 26 residents in Hallway 4 had a rash (Resident 4, 5, 6, 7, 8, 9, 10, 11, 13, and 16); and four (4) of 20 residents in Hallway 5 had a rash (Resident 15, 21, 22, and 23). There were 20 of 94 residents identified with a rash. During the interview, LVN 2 stated, currently, residents with rashes were being treated with [MEDICATION NAME] cream (a medication used to treat the itching, redness, dryness, crusting, scaling, inflammation, and discomfort of various skin conditions) and no resident was placed on contact precaution or contact isolation precaution. LVN 2 stated an in-service was given to the facility staff earlier that day and the in-service did not mention the need for the staff to wear a long sleeve gown when providing care to the residents. The in-service training record, dated 6/5/15 and timed at 3:15 p.m., indicated the registered nurse supervisor (RN 1) gave an in-service to the staff regarding the plan of action for the management of rash. A brief summary of the in-service indicated that all residents and staff, who wanted treatment (the type of treatment was not specified), would be treated over four (4) days, beginning on 6/8/15 (Monday). On 6/5/15 at 6:50 p.m., during an interview, Family Member 1 stated he noticed the rash on Resident 13's palms during the last week of May. Family Member 1 stated he had informed the charge nurse about the rash, and he was informed at that time that the resident would receive treatment (the type of treatment was not specified by Family Member 1). Family Member 1 stated, today (6/5/15), the rash on Resident 13's body was worse and the resident was itching. According to the Non-Pressure Sore Skin Problem Report, Resident 13 developed a rash in her right inner arm on 5/29/15. The skin report indicated that on 6/5/15, scattered rash was noted. The surveyor conducted a skin assessment in the presence of Family Member 1 and Resident 13 was observed with a red rash on her arms and trunk (upper body). Family Member 1 stated he was not informed by the facility to wear PPE when in contact with Resident 13. On 6/5/15 at 7:45 p.m., during a telephone interview, the administrator stated, the unidentified rash was possibly scabies and the suspected scabies outbreak was not reported to the Department. The administrator stated the director of nursing (DON), who was the Infection Control Coordinator and who was currently on vacation, had the list of residents and employees with rashes and he (the administrator) did not have access to the list. The administrator stated the Medical Director ordered for the residents with rashes to be treated [MEDICATION NAME] starting Monday, 6/8/15. Since the treatment plan was to start on 6/8/15 (in 3 days), the facility staff was wearing only gloves and not a gown or was not provided with a gown when anticipating or providing care to the resident to prevent the prevent the transmission of the suspected scabies to residents and employees, in accordance with the facility's standard precautions policy and procedure. On 6/5/15 at 7:50 p.m., during an interview, the certified nursing assistant (CNA 2) stated she developed a rash. The surveyor conducted a skin assessment and observed a red rash on CNA 2's mid-abdomen and the sides of her abdomen. On 6/5/15 at 9 p.m., during an interview, CNA 3 stated she developed a rash. The surveyor conducted a skin assessment and observed a rash on CNA 3's left arm and wrist, abdomen, and right leg. CNA 3 stated that she informed RN 1 about her rash but she was informed that her rash was not scabies. CNA 3 stated that she felt upset that the facility did not tell the staff what was going on and she was concerned that we (referring to the staff) had to take care of themselves and their families. The undated facility's policy and procedure titled Scabies, Prevention and Control Of, as soon as a possible case of scabies is identified, the infection control nurse should develop a contact identification list. The list will contain the names of every person who may have had direct, physical contact with the case suspected of scabies. If more than one symptomatic case is identified, a separate contact list for each case may be required. The control procedure for typical infestation included placing symptomatic patient on isolation precautions in their assigned room. The treatment of [REDACTED]. Symptomatic cases should be treated during the first 24 hour treatment period. Asymptomatic contacts can be treated during the second 24-hour treatment period. The facility's policy and procedure for prevention of scabies indicated one (1) confirmed case and at least two (2) suspect cases occurring among patients, health care workers, visitors or volunteers during a 2-week period should be considered an outbreak for reporting purposes. The outbreak should be reported to the local health officer and the licensing and certification district office. The undated facility's policy and procedure titled Isolation Measures, General Policy Statement, indicated To ensure appropriate communication of isolation precautions, a stop sign will be posted on the resident's door directing individuals to report to the Nurses Station for further information .Nursing will complete the Room Sign for Precautions or Isolation based on the Disease-Specific Isolation Precautions and post on the resident's door. The undated facility's policy and procedure titled Synopsis of Types of Precautions and Patients Requiring the Precautions, indicated in addition to Standard Precaution, to use Contact Precautions for patients known or suspected to have serious illnesses easily transmitted by direct patient contact or by contact with items in the patient's environment. Scabies was an example of such illnesses. The undated facility's document titled Standard Precautions for Infection Control indicated standard precautions included hand washing, wearing gloves and a gown. The facility's position description for an Infection Control Nurse included monitoring nursing personnel performance and evaluates quality of care provided to residents with infections; monitoring and educating nursing personnel on infection control issues; and acting as a liaison with local public health department in reporting infection diseases/infections. On 6/5/15 at 9:35 p.m., an immediate jeopardy (IJ) was declared in the presence of LVN 2 for the facility's failure to implement its policies and procedures, which included implementing contact precautions, to control and prevent the development and transmission of a suspected scabies. The facility did not provide an acceptable plan of correction, as requested, to abate the immediate jeopardy. On 6/6/15 at 9:30 a.m., during an interview, CNA 4 stated an in-service (regarding the management of rash) was given to the staff on 6/5/15. CNA 4 stated it was discussed during the in-service that staff should wear gloves and wash their hands. CNA 4 stated staff members were not informed during the in-service to wear a gown when providing care to residents. On 6/6/15 at 10 a.m., during an observation, CNA 5, who was wearing a short sleeve nursing uniform, assisted Resident 15 in changing his shirt. Resident 15 was observed having a red, raised, scattered rash on his arms and upper body. The resident was scratching his arms. CNA 5 was wearing only gloves while providing care to Resident 15. On 6/6/15 at 11:20 a.m., Resident 15 was walking in the hallway, without a shirt, and scratching his upper arm. According to the dermatology report, dated 5/18/15, Resident 15 had a rash for almost three (3) months and had a [DIAGNOSES REDACTED]. On 6/6/15 at 10:10 a.m., during an observation, CNA 6 was holding Resident 2's arm while assisting the resident to walk towards the shower. CNA 6 was not wearing gloves while in direct contact (skin to skin) with the resident to prevent the transmission of suspected scabies. On 6/6/15 at 10:30 a.m., during an observation, LVN 3 was giving a cup with medications to Resident 8 for the resident to hold. LVN 3 was not wearing gloves during direct contact with Resident 8 while administering the medications to prevent the transmission of suspected scabies. On 6/6/15 at 11:30 a.m., during an interview, RN 1 stated there was no resident currently in contact isolation precaution. RN 1 stated he heard that there were 27 residents currently with rashes. RN 1 did not provide a list of the 27 residents, but 20 of the 27 residents (Residents 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 13, 15, 16, 17, 18, 19, 20, 21, 22, and 23) were previously identified by LVN 2 as having a rash. RN 1 stated he did not know how many employees were symptomatic nor had rashes. On 6/6/15 at 11:32 a.m., during an interview, the administrator stated without the Infection Control Coordinator present in the facility, the staff would not know when the facility first suspected an outbreak of scabies infestation. The administrator stated the type of residents (residents with mental illness), which the facility cared for, could not be isolated in their respective rooms because this would escalate aggressive behavior; the facility could not limit their activities and the residents could not understand an instruction not to touch each other because of their mental illness. The administrator stated, for this type of residents, the staff had to exercise universal precautions (currently known as standard precautions) when providing care. The administrator stated the staff would be provided with long sleeve gowns (a gown is a PPE which was an infection control measure in the standard precautions). During the interview with the administrator, he stated the facility had a treatment plan of treating residents, with [MEDICATION NAME] cream, in one (1) hallway per day for the next 4 days. The administrator stated the residents in Hallway 4 would be treated on Monday, 6/8/15; the residents in Hallway 3 would be treated on Tuesday, 6/9/15; the residents on Hallway 2 would be treated on Wednesday, 6/10/15; and the residents in Hallway 5 would be treated on Thursday, 6/11/15. The administrator stated the reason the facility wanted to wait till Monday to start the treatment was because the facility wanted to make sure the staff apply the [MEDICATION NAME] cream treatment correctly. A discussion was conducted with the administrator and RN 1, on 6/6/15 at 12:30 p.m., that their plan of treating residents in one (1) hallway per day for the next four (4) days would not be effective because the residents, who were already treated, would just be mingling and interacting with residents, who were not treated. The facility was not able to provide an acceptable plan of correction to abate the immediate jeopardy. On 6/7/15 at 8:50 a.m., during an observation, Hallways 2, 3, 4, and 5 had a table containing disposable long sleeve gowns and boxes of gloves. On 6/7/15 at 9 a.m., during an observation, Housekeeper 1, who was wearing a short sleeve shirt and jeans, was wearing gloves but not a long sleeve gown while collecting dirty linens from a barrel labelled Soiled Linen that was lined with a clear plastic bag. Housekeeper 1 was tying the clear plastic bag containing dirty linens and placing the bag on a rolling cart. During an interview, on 6/7/15 at 10:30 a.m., the administrator and RN 1 stated the housekeeping staff should wear a long sleeve gown when collecting dirty linen and they (the housekeeping staffs) were already given an in_x001e_service about this. On 6/7/15 at 9:05 a.m., during an interview, CNA 2 stated the staff members were instructed to wear gloves and a long sleeve gown when providing care to all residents. When asked to explain how she removes the gloves and gown after providing care to a resident, CNA 2 stated she removes the disposable gown and gloves inside the resident's room, throw the dirty gown and gloves in the trash barrel outside the resident's room, and wash her hands in the nursing station. During an observation, on 6/7/15 at 9:15 a.m., CNA 2 put on gloves and a disposable long sleeve gown, without securing or tying the back of the gown around her neck and waist, before entering the room of Resident 35 in Hallway 5. After providing care to a resident inside the room, CNA 2 removed the gloves and gown inside the resident's room, stepped out of the room to throw the gown and gloves inside the trash barrel at the hallway, walked towards the nursing station, and entered the nursing station to wash her hands on the sink. During an observation, on 6/7/15 at 9:20 a.m., there were no trash cans inside Resident 15's room and rest of the six (6) residents' rooms in Hallway 5. There was a trash can in each of the resident's bathroom. During an observation, on 6/7/15 at 9:30 a.m., CNA 6 removed her gloves and gown inside a resident's room, room [ROOM NUMBER], that was located in the middle of Hallway 3; stepped out of the room to throw the gloves and gown inside a trash barrel located at the end of the hallway; spoke with another staff while placing her hands on her hips, potentially contaminating her clothing; walked towards the nursing station; and entered the nursing station to wash her hands on the sink. On 6/7/15 at 9:10 a.m., during an interview, CNA 7 stated there was a trash can in each of the resident's bathroom but not in the resident's room. During an interview, on 6/7/15 at 10:30 a.m., RN 1 stated he did not address during the in-service on 6/5/15 that staff should throw their used/dirty gloves and gowns, and wash their hands inside the resident's bathroom before leaving the resident's room. The 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Setting, p. 85, remove gown and observe hand hygiene before leaving the patient-care environment. After gown removal, ensure that clothing and skin do not contact potentially contaminated environmental surfaces that could result in possible transfer of microorganism to other patients or in the environmental surfaces. On 6/7/15 at 9:20 a.m., during an observation, CNA 8 prepared to enter the room of Resident 4. CNA 8 put on clean gloves first and then a long sleeve gown. According to the Centers for Disease Control and Prevention (CDC) website at http://www.cdc.gov/hai/pdfs/ppe/PPESequence.pdf, the type of personal protective equipment (PPE) will vary based on the level of precautions required, such as standard and contact precautions. The sequence for putting on personal protective equipment (PPE) is wearing the gown first and then the gloves. On 6/7/15 at 12 p.m., the facility submitted a plan of correction which was discussed with the administrator and RN 1. According to RN 1, the Medical Director ordered, as [MEDICATION NAME] measure, the facility to treat all 94 of 94 residents with [MEDICATION NAME] cream. The administrator stated a mass [MEDICATION NAME] treatment would be difficult to conduct within a 24-hour period so the treatment of [REDACTED]. The surveyor informed the administrator that the infection control team needed to meet and present an acceptable plan of correction and designate an Infection Control Coordinator Designee. The Management of Scabies Outbreaks In California Health Care Facilities by the California Department of Public Health Division of Communicable Disease Control, March 2008, indicated that once it has been determined whether limited or facility wide mass treatment is necessary, a treatment schedule should be defined. To prevent silent transmission of scabies, all those included in the treatment schedule should be treated in the same 24-hour treatment period. On 6/8/15 at 10:35 a.m., RN 1 submitted a list of residents with an unidentified rash. The list indicated the number of residents with rashes increased to 32 of 94 residents (34% of the total number of residents in the facility). RN 1 stated all the residents would be treated. Those residents with rashes would be treated with two (2) doses of [MEDICATION NAME] cream and Ivermectin, and the doses would be given seven (7) days apart. Those residents without rashes would be treated with Ivermectin. RN 1 stated the treatment for [REDACTED]. During the interview, on 6/8/15 at 12:50 p.m., RN 1 stated all employees were required to be treated with [MEDICATION NAME] cream. Those employees, who would be working tomorrow, 6/9/15, would have treated themselves with [MEDICATION NAME] cream before starting their work. RN 1 stated the belongings of residents inside the room would be placed in a plastic bag and stored in a storage located in the facility grounds for seven (7) to 10 days, all curtains and linens would be removed and washed, and all rooms would be deep cleaned. On 6/8/15 at 1 p.m., during an interview, the administrator stated RN 1 had been designated as the Infection Control Coordinator designee. The facility failed to submit an acceptable written plan of correction to abate the immediate jeopardy. On 6/9/15 at 8:10 a.m., during an observation, while the residents were in the dining room and activity room, the housekeeping staff started bagging the belongings of residents in Hallway 4, transporting the bagged belongings to the storage room, and then deep cleaning the rooms. No residents were allowed to enter their rooms during the process. The CNA shower team was bringing symptomatic residents in Hallway 4 to the shower room one at a time and the treatment nurse was applying the [MEDICATION NAME] cream to each symptomatic resident after their shower. This process was repeated in Hallway 2, 3, and 5. During an interview, on 6/10/15 at 8:35 a.m., LVN 4, the treatment nurse, stated the last symptomatic resident to receive the [MEDICATION NAME] cream on 6/9/15 was at 3:20 p.m. According to the Unidentified Rash Mass [MEDICATION NAME] Shower List, dated 6/9/15, there were 38 symptomatic residents who were treated with [MEDICATION NAME] Cream. These 38 residents received a shower to wash off the [MEDICATION NAME] cream at least 9 hours after the application of the cream, according to the list. These 38 residents were Resident 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 36, 37, 38, 39, and 40. On 6/9/15 at 3:50 p.m., during an interview, LVN 3 stated she had completed giving the medication, Ivermectin, to all residents residing in Hallway3. During a concurrent interview, LVN 5 stated she had completed giving Ivermectin to all residents residing in Hallway 2. LVN 5 stated the evening shift (3 p.m. to 11 p.m.) medication nurses would be giving the Ivermectin to all residents residing in Hallway 4 and 5. During an interview, on 6/10/15 at 8:10 a.m., RN 2 stated the last resident to receive Ivermectin in Hallway 4 and 5 were at 5 p.m. on 6/9/15. RN 2 was reviewing the medication administration record during the interview. On 6/9/15 at 9:50 a.m., the list of employees with rashes was reviewed with the director of staff development (DSD). The list indicated there were 28 employees with rashes (Housekeeper 2 and 3; Laundry Staff 1, 2, and 3; social service designee (SSD 1); LVN 4, 5, 6 ,7, and 8; and CNA 2, 3, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, and 23). On 6/9/15 at 11 a.m., during an interview, RN 1 stated a contact precaution sign and a sign instructing the staff the proper order of putting on and removing gloves and gown would be posted outside the doors of the residents with rashes as a reminder to staff and visitors. On 6/10/15 at 9:30 a.m., during an inspection with RN 2, there was no contact precaution sign and a sign instructing the staff and visitors of the proper order of putting on and removing gloves and gown, posted outside the rooms of the 38 symptomatic residents. RN 2 stated, during a concurrent interview, she would be placing the signs outside the rooms of the symptomatic residents. On 6/10/15 at 10:35 a.m., LVN 2 was requested to submit a list of residents who were seen by a dermatologist. At 11:05 a.m., after reviewing the clinical records of the 38 symptomatic residents, LVN 2 stated only Resident 1 and 15 were seen by a dermatologist. On 6/10/15 at 12:25 p.m., during an inspection, a sign indicating contact precaution, and a sign indicating the proper order for wearing and removing gloves and gown was posted outside the doors of the 38 symptomatic residents. On 6/10/15 at 12:30 p.m., the immediate jeopardy was lifted after receiving the facility's written plan of correction, which included the infection control measures and treatment that were implemented and observed during the survey from 6/9/15 to 6/10/15 at 12:30 p.m. The administrator and RN 2 were notified. Cross refer to F425.