Every finding on record at Villa Serena Healthcare Center

Based on interview and record review, the facility failed to revise the care plan for one of three sampled residents (Resident 2) when Resident 2 experienced a change of condition on 4/5/2026 and 4/9/2026.This had the potential to result in not meeting Resident 2's needs, poor resident outcomes, or risk of serious injury.Findings:During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including metabolic encephalopathy (any damage or disease that affects the brain), dysphagia (difficulty swallowing), and chronic bronchitis (inflammation of airways in the lungs.)During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool), dated 1/27/2026, the MDS indicated Resident 2 had severe cognitive (ability to learn, reason, remember, understand, and make decisions) impairment, required supervision when eating, for oral and personal hygiene, and upper body dressing, required moderate assistance (helper does less than half the effort) for toileting and lower body dressing, and required maximal assistance (helper does more than half the effort) for bathing.During a concurrent interview and record review on 4/28/2026 at 1:34 p.m. with Licensed Vocational Nurse (LVN) 1, Resident 2's change of condition (COC) dated 4/5/2026 and COC dated 4/9/2026 were reviewed. LVN 1 stated the COC on 4/5/2026 indicated Resident 2 was coughing while drinking liquids. LVN 1 stated the COC on 4/9/2026 indicated Resident 2 was pocketing food (storing food in the mouth instead of chewing and swallowing it).During a concurrent interview and record review on 4/28/2026 at 3:26 p.m. with the MDS Coordinator (MDSC), Resident 2's COC dated 4/5/2026, 4/15/2026 and care plans were reviewed. The MDSC stated Resident 2's care plan tilted Resident 2 is at risk for impaired nutritional and hydration status was not revised to reflect Resident 2's COC episodes of coughing while drinking liquids on 4/5/2026 and pocketing food on 4/9/2026. The MDSC stated the care plan should have been revised at the time of the COC's on 4/5/2026 and 4/29/2026. The MDSC stated if care plans are not revised right away, there is a risk for resident decline, not meeting the resident's needs, or risk of serious injury.During an interview on 4/29/2026 at 2:18 p.m. with the Director of Nursing (DON), the DON stated Resident 2's care plans should have been revised on 4/5/2026 and 4/9/2026 when the COC's were identified to ensure the appropriate interventions were implemented.During a review of the facility's policy and procedure (P&P), titled Care Planning, dated 2/9/2024, the P&P indicated a licensed nurse will initiated the care plan, and the plan will be finalized in accordance with OBRA/MDS guidelines and updated as indicated for change in condition, onset of new problems, resolution of current problems, and as deemed appropriate by the clinical assessment and judgment on an as needed basis.

Based on interview and record review, the facility failed to meet professional standards of quality for one of three sampled residents (Resident 2) by failing to communicate Resident 2's change of condition and indication for the Speech Language Pathologist (SLP - profession that identifies, assesses, and treats speech, language, cognitive communication and swallowing disorders) evaluation. This had the potential to result in a delay of care or treatment for Resident 2.Findings:During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including metabolic encephalopathy (any damage or disease that affects the brain), dysphagia (difficulty swallowing), and chronic bronchitis (inflammation of airways in the lungs.)During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool), dated 1/27/2026, the MDS indicated Resident 2 had severe cognitive (ability to learn, reason, remember, understand, and make decisions) impairment, required supervision when eating, for oral and personal hygiene, and upper body dressing, required moderate assistance (helper does less than half the effort) for toileting and lower body dressing, and required maximal assistance (helper does more than half the effort) for bathing.During a concurrent interview and record review on 4/28/2026 at 1:34 p.m. with Licensed Vocational Nurse (LVN) 1, Resident 2's change of condition (COC) dated 4/5/2026, COC dated 4/9/2026, orders, and facility communication notes were reviewed. LVN 1 stated the COC on 4/5/2026 indicated Resident 2 was coughing while drinking liquids. LVN 1 stated the COC on 4/9/2026 indicated Resident 2 was pocketing food (storing food in the mouth instead of chewing and swallowing it). LVN 1 stated the physician ordered a SLP evaluation on 4/9/2026. LVN 1 stated there was no documentation in the nursing notes, SLP notes, communication orders, or change to the order indicating the SLP evaluation had taken place. LVN 1 stated when a SLP evaluation had been completed by the SLP, the SLP either documents the new recommendations in the communication orders and/or modifies the SLP evaluation order to indicate the evaluation had been completed. LVN 1 stated when an SLP evaluation is ordered, nursing prints the order and provides it to the director of rehabilitation services.During a concurrent interview and record review on 4/28/2026 at 2:35 p.m. with the Director of Rehabilitation Services (DOR), Resident 2's comprehensive rehab screen dated 4/15/2026 and orders were reviewed. The DOR stated Resident 2's comprehensive rehab screen dated 4/15/2026 indicated Resident 2's reason for screening was because patient was referred for ST due to family request for diet upgrade. The DOR stated the rehab screen did not indicate the SLP was aware that Resident 2 had episodes of coughing while drinking liquids or was pocketing food. The DOR stated the SLP evaluation order on 4/9/2025 did not indicate the reason for referral. The DOR stated when there is a speech evaluation ordered, nursing provides the printed order and verbalizes resident concerns to the DOR.During an interview on 4/28/2026 at 3:00 p.m. with the Speech Language Pathologist (SLP), the SLP stated they (SLP) recently evaluated Resident 2 on 4/15/2026 because Resident 2's responsible party (RP) had requested to upgrade Resident 2's diet. The SLP stated it was not communicated to the SLP that Resident 2 had episodes of coughing while drinking liquids on 4/5/2026 or was pocketing food on 4/9/2026. The SLP stated if the coughing while drinking liquids and pocketing food was communicated as the indication for the SLP evaluation, the SLP would have educated with the staff on precautions and strategies for Resident 2.During an interview on 4/29/2026 at 2:29 p.m. with the Director of Nursing (DON), the DON stated it was important for the LVN to communicate the reason for evaluation to the DOR and the SLP. The DON stated it was important for the SLP to communicate with nursing and review the resident's record for COC's as part of the SLP evaluation and screening.During a review of the facility's policy and procedure (P&P), titled Specialized Rehabilitative Services, dated 2/9/2024, the P&P indicated licensed nursing staff will refer resident's assessed to have a clinical need for rehabilitative therapy for a screening by the appropriate discipline.During a review of the facility's job description (JD), titled Licensed Vocational Nurse (LVN), undated, the JD indicated the LVN demonstrated ability to provide appropriate and quality nursing care to residents including ensuring that problems/concerns regarding activities in the facility/department are communicated appropriately and exchanges and communicates resident care information with interdisciplinary team. During a review of the facility's job description (JD), titled Speech and Language Pathologist/Therapist (SLP), undated, the JD indicated the SLP screens and evaluates residents and develops appropriate care plan and communicates patient status and need to the patients, family, caregivers, or other members involved with patient care.

Based on interview, and record review, the facility failed to report an allegation of verbal abuse for one of four sampled residents (Resident 2) when Resident 2's Family Member (FM) reported to Licensed Vocational Nurse (LVN 1) that Certified Nursing Assistant (CNA) used inappropriate words in an aggressive and frustrated tone when providing care to Resident 2. This deficient practice resulted in the inability of the California Department of Public Health (CDPH) to conduct a timely investigation and had the potential for information to be lost and/or forgotten.Findings: During a review of Resident 2's admission Record (Face Sheet) the Face Sheet indicated Resident 2 was admitted to the facility on [DATE] with a diagnosis of hepatic encephalopathy (a reversible, serious neurological condition causing brain dysfunction-including confusion, personality changes, and coma-due to advanced liver disease). During a review of Resident 2's Minimum Data Set ([MDS] a resident assessment tool) dated 1/16/2026, the MDS indicated Resident 2's cognition was intact and she required partial/moderate assistance (helper does less than half the effort) to complete her activities of daily living ([ADLs) activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 2's Licensed Nurses Notes dated 3/27/2026 and timed at 11:41 p.m., the Licensed Nurses Notes indicated LVN 1 received a telephone call (3/27/2026 time unknown) from Resident 2's FM reporting the FM overheard inappropriate words from CNA 1 when CNA 1 was talking to Resident 2. The Licensed Nurses Notes indicated LVN 1 reported the allegation to the Director of Staff Development (DSD) and the Director of Nursing (DON). During a review of the DSD's Statement (Investigation) dated 3/27/2026 and timed at 7:14 p.m., the Investigation indicated the DSD received a telephone call (3/27/2026) from the Administrator (ADM) reporting Resident 2 was crying alleging CNA 1 called her stupid. During a review of a Text Message sent to the DSD from CNA 2 dated 3/30/2026 and timed at 11:24 a.m., the Text Message indicated CNA 2 heard CNA 1 tell Resident 2 you f*ckin bug so much and sh*t what the f*ck do you want now. I'm so f*ckin tired of your sh*t. During an interview on 4/7/2026 at 3:04 p.m., the DON stated the incident was not reported to the CDPH because the FM could not hear what was said by CNA 1 and CNA 1 denied saying inappropriate words to Resident 2. During an interview on 4/7/2026 at 3:21 p.m., the ADM stated the incident was not reported to the CDPH because Resident 2 reported she felt rushed during care so there was no need for the incident to be reported. The ADM stated they could not prove what actually happened, the FM could not make out the actual words said by CNA 1, and CNA 1 denied saying anything wrong. During an interview on 4/7/2026 at 3:45 p.m., Resident 2's FM stated on 3/27/2026 (time unknown) while staff (unknown) was providing care to Resident 2 she (FM) was on the phone with Resident 2 and overheard staff (unknown) speak to Resident 2 in a frustrated and aggressive voice. The FM stated she could not hear what was being said to Resident 2 but Resident 2 was crying and said, I'm not stupid. Resident 2's FM stated Resident 2 told her this was not the first time CNA 1 treated her that way. During a review of the facility's Policy and Procedure (P&P) titled Abuse Prevention and Prohibition Program dated 2/9/2024, the P & P indicated facility employees are obligated by the Elder Justice Act and the California Elder Abuse and Dependent Adult Civil Protection Act to report known or suspected instances of abuse of elder or dependent adult. The facility will report allegations of abuse, neglect, mistreatment, injuries of unknown source, misappropriation of resident property, or other incidents that qualify as a crime.

Based on observation, interview and record review, the facility failed to treat one of four sampled residents (Resident 2) with respect and dignity when Resident 2's family member (FM) while on the phone with Resident 2 overheard CNA 1 speak to Resident 2 using an aggressive and frustrated tone. This deficient practice resulted in Resident 2 crying and responding I'm not stupid to CNA 1 and had the potential for Resident 2 to become afraid of and withdrawn when interacting with facility staff.Findings: During a review of Resident 2's admission Record (Face Sheet) the Face Sheet indicated Resident 2 was admitted to the facility on [DATE] with a diagnosis of hepatic encephalopathy (a reversible, serious neurological condition causing brain dysfunction-including confusion, personality changes, and coma-due to advanced liver disease). During a review of Resident 2's Minimum Data Set ([MDS] a resident assessment tool) dated 1/16/2026, the MDS indicated Resident 2's cognition was intact and she required partial/moderate assistance (helper does less than half the effort) to complete her activities of daily living ([ADLs) activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 2's Licensed Nurses Notes dated 3/27/2026 and timed at 11:41 p.m., the Licensed Nurses Notes indicated LVN 1 received a telephone call (3/27/2026 time unknown) from Resident 2's FM reporting the FM overheard inappropriate words from CNA 1 when CNA 1 was talking to Resident 2. The Licensed Nurses Notes indicated LVN 1 reported the allegation to the Director of Staff Development (DSD) and the Director of Nursing (DON). During a review of the DSD's Statement (Investigation) dated 3/27/2026 and timed at 7:14 p.m., the Investigation indicated the DSD received a telephone call (3/27/2026) from the Administrator (ADM) reporting Resident 2 was crying alleging CNA 1 called her stupid. During a review of a Text Message sent to the DSD from CNA 1 dated 3/27/2026 and timed 8:50 p.m., the Text Message indicated CNA 1 said to Resident 2, if you don't want me to help, you can do it yourself. The Text Message indicated CNA 1 stated it's hard for me to help her (Resident 2) when she wants everything done her way. During a review of a Text Message sent to the DSD from CNA 2 dated 3/30/2026 and timed at 11:24 a.m., the Text Message indicated CNA 2 heard CNA 1 tell Resident 2 you f*ckin bug so much and sh*t what the f*ck do you want now. I'm so f*ckin tired of your sh*t. During an interview on 4/7/2026 at 12:15 p.m., the DSD stated she spoke to Resident 2's FM who told her (DSD) she could not really hear what was said to Resident 2 but from the tone she knew it was inappropriate. During an interview on 4/7/2026 at 12:48 p.m., Resident 2 stated CNA 1 was very bad, and said bad things to her while she (CNA 1) was changing her brief (adult diaper). Resident 2 stated CNA 1 said you can do it yourself which made her (Resident 2) cry. Resident 2 stated CNA 1 treated her like this often, it was her habit. During an interview on 4/7/2026 at 2:27 p.m., CNA 2 stated on the day of the incident (3/27/2026) she passed by Resident 2's room and overheard CNA 1, who was by the entrance of the room, say I f*ckin hate this job and I am tired of this sh*t. During an interview on 4/7/2026 at 2:54 p.m., LVN 1 stated he received a telephone call from Resident 2's FM (3/27/2026) who reported she overheard inappropriate words being said by staff (unknown) to Resident 2. LVN 1 stated after the telephone call, he spoke to Resident 2 who was very emotional and stated she was being rushed while receiving care. LVN 1 stated CNA 1 had an attitude problem and an anger issue and would blow up at him. During an interview on 4/7/2026 at 3:04 p.m., the DON stated CNA 1 would use profanity and curse but would not direct her words at any specific person. The DON stated it was possible for a resident to hear CNA 1 use inappropriate words that were spoken in a elevated tone and think it was directed at them, which could hurt the resident' feelings. The DON stated Resident 2 was emotional and felt rushed while CNA 1 was providing care. During an interview on 4/7/2026 at 3:21 p.m., the ADM stated Resident 2 was upset because she felt she was being rushed during care. The ADM stated CNA 1 was being monitored for negative feelings and behavior of lashing out at staff including the DON. During an interview on 4/7/2026 at 3:45 p.m., Resident 2's FM stated on 3/27/2026 (time unknown) while staff (unknown) was providing care to Resident 2 she (FM) was on the phone with Resident 2 and overheard staff (unknown) speak to Resident 2 in a frustrated and aggressive voice. The FM stated she could not hear what was being said to Resident 2 but Resident 2 was crying and said, I'm not stupid. Resident 2's FM stated Resident 2 told her this was not the first time CNA 1 treated her that way. During a review of the facility's Policy and Procedure (P&P) titled Resident Rights dated 2/9/2024, the P&P indicated the facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment, that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality.

Based on observation, interview, record review, the facility failed to keep waste contained (trash covered and secure) when two large trash bins in the facility's parking lot were left open.This failure had the potential to allow pests (tiny living things that can make people sick) to enter the area and result in spread of disease.Findings:During an observation on 2/5/2026 at 10:20 a.m. in the facility's parking lot near the rear kitchen entrance, two large trash bins holding garbage and food waste were observed uncovered.During a follow up observation on 2/6/2026 at 9:35 a.m. in the facility's parking lot, the same two trash bins were observed uncovered.During a concurrent observation and interview on 2/6/2026 at 10:20 a.m. with Maintenance Director (MD) 1 in the facility parking lot near the rear kitchen entrance, two large trash bins confining garbage and food waste were observed uncovered. MD 1 stated, outdoor trash bins must remain closed when not in use all the time to prevent pests.During a concurrent interview on 2/6/2026 at 2:18 p.m. with the Infection Preventionist Nurse (IPN), the IPN stated, trash bins must stay closed all the time to prevent pests and germs.During an interview on 2/26/2026 at 11:33 a.m. with the Director of Nursing (DON), the DON stated, residents with low immune systems could get sick easily if pests enter their area.During a review of the facility's policy and procedure (P&P) dated 2/9/2024 indicated, .waste must be placed in covered bins, which are cleaned daily or more frequently if needed.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services to meet the needs of three of eight sampled residents (Resident 6, 13, and 19) by failing to: a. Assess Resident 6 for the pre (before) and post (after) RASS Assessment (administered tool used to assess a patient's level of agitation or sedation, ranging from +4 (combative) to -5 (unarousable) for administration of narcotic pain medication (powerful drugs used to treat moderate to severe pain) as ordered.This deficient practice had the potential to compromise safe medication administration and increase the risk of adverse outcomes.b. Ensure the gastrostomy (g-tube, a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), was flushed before and after medication administration as ordered for Resident 13.This deficient practice had the potential to block the gastrostomy (g-tube, a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) and create unnecessary complications. c. Administer warfarin (medication used to prevent blood clots) as ordered to Resident 19. The deficient practice had the potential to increase Resident 19's risk for blood clots. Findings: a. During a review of Resident 6's admission Record, the admission Record indicated Resident 6 was admitted to the facility on [DATE] with diagnoses including malignant neoplasm of prostate (slow-growing cancer forming in the prostate glands [gland in the male reproductive system] tissues potentially causing urinary issues (weak flow, frequency), and bone pain), secondary malignant neoplasm of bone (when cancer cells spread from a primary site (prostate) to the bones, causing pain and decreased mobility), and encounter for palliative (focus on relieving pain and stress to enhance quality of life) care. During a review of Resident 6's history and physical (H&P) dated 10/27/2025, the H&P indicated Resident 6 had the capacity to understand and make decisions. During a review of Resident 6's Minimum Data Set (MDS, a resident assessment tool), dated 1/16/2026, the MDS indicated Resident 6 had mild cognitive impairment. The MDS indicated Resident 6 required substantial assistance (Helper does more than half the effort) from staff for toileting hygiene, bathing, taking off footwear, lower body (waist below) dressing, and partial assistance (Helper does less than half the effort) from staff for upper body (above waist) dressing, personal hygiene, oral hygiene, and roll from left to right. The MDS indicated, Resident 6 required supervision from staff for eating. During a record review of Resident 6's medication administration record (MAR), dated 1/1/2026 – 1/31/2026, the MAR indicated facility staff administered oxycodone-acetaminophen (percocet, medication used to treat moderate to severe pain) oral tablet 5-325 milligram (mg, a unit of measurement) 2 tablets by mouth every 8 hours as needed for severe pain (7-10) on 1/17/2026 to 1/24/2026 to Resident 6. The MAR additionally indicated the RASS assessment pre-administration and RASS assessment post-administration was not completed. During a review of Resident 6's order summary report, dated 2/9/2026, the order summary report indicated Resident 6's medications included oxycodone-acetaminophen (Percocet) oral tablet 5-325 mg 2 tablet by mouth every 8 hours as needed for severe pain (7-10), Percocet oral tablet 5-325 (oxycodone w/acetaminophen) 2 tablet by mouth every 8 hrs as needed for moderate pain (4-6), RASS assessment pre-administration to be done pre-administration of narcotic pain medication score as follows + 4=Combative, +3=Very agitated, +@=Agitated, +1=Restless, 0=Alert and calm, -1=Drowsy, -2=Light sedation -3=Moderate sedation, -4=Deep sedation, -5=Unarousable as needed for pre-administration of narcotic pain medication, and RASS assessment post-administration to be done post-administration of narcotic pain medication score as follows + 4=Combative, +3=Very agitated, +@=Agitated, +1=Restless, 0=Alert and calm, -1=Drowsy, -2=Light sedation -3=Moderate sedation, -4=Deep sedation, -5=Unarousable as needed for post-administration of narcotic pain medication. b. During a review of Resident 13's admission Record, the admission Record indicated Resident 13 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including g-tube dysphagia (difficulty swallowing), and a history of malignant neoplasm of large intestine (cancer in the large intestine) During a review of Resident 13's H&P dated 11/2/2025, the H&P indicated Resident 13 did not have the capacity to understand and make decisions. During a review of Resident 13's MDS, dated [DATE], the MDS indicated Resident 13 had mild cognitive impairment. The MDS indicated Resident 13 required substantial assistance (Helper does more than half the effort) from staff for toileting hygiene, bathing, taking off footwear, upper (above waist) and lower body (waist below) dressing, roll from left to right and partial assistance (Helper does less than half the effort) from staff for oral and personal hygiene. During an observation on 2/5/2026 at 8:43 a.m., Resident 13's g-tube was clamped with no active feeding running. The Licensed Vocational Nurse 1 (LVN 1) did not flush Resident 13's g-tube prior to administrating the first medication lasix (treat fluid retention and swelling) tablet 40 mg 1 tablet via g-tube one time a day. During an observation on 2/5/2026 at 8:48 a.m., with LVN 1, LVN 1 was observed flushing potassium chloride (mineral supplement to prevent low blood potassium) oral packet 20 milliequivalents (mEq, unit of measure) 1 packet via g-tube one time a day for supplement with 15 milliliter (mL, unit of volume) water. During a concurrent interview and record review on 2/5/2026 at 8:50 a.m., with LVN 1, LVN 1 stated prior to administering mediation she would usually flush the g-tube. LVN 1 stated she would flush the g-tube again before administering the medication to ensure any residue is cleared and the g-tube is patent. LVN 1 stated if the g-tube was not flushed, it could get clogged, medications can get stuck in the tubing and it would be unclear will how much of the medication Resident 13 received. During an interview on 2/9/2026 at 3:00 p.m., with the Director of Nursing (DON), the DON stated there is an order to flush the g-tube prior to mediation administration with 30 mL pre and post medication administration through the g-tube. The DON stated the g-tube is flushed to ensure the patency of the tube and ensure the resident received the entire dose of the medication. The DON stated if the g-tube is not flushed, it can get clogged by feeding in the tube, stomach contents or medications. During a concurrent interview and record review on 2/9/2026 at 3:11 p.m., with the DON, the DON stated the pre and post RASS assessments for medication administration should be done if it is the physicians orders. C. During a review of Resident 19's admission Record, the admission Record indicated Resident 19 was admitted to the facility on [DATE] with diagnoses including chronic thrombosis (blood clot) of deep veins (DVT) of left lower extremity and atrial fibrillation (an irregular, rapid heart rate that may cause symptoms like heart palpitations, fatigue, and shortness of breath and increases risks for blood clots.) During a review of Resident 19's MDS, dated [DATE], the MDS indicated Resident 19 had moderate cognitive (ability to learn, reason, remember, understand, and make decisions) impairment, required setup assistance when eating and for oral hygiene, required moderate assistance (helper does less than half the effort) for toileting and upper and lower body dressing, and required maximal assistance (helper does more than half the effort) for bathing. During a review of Resident 19's Physician Order Summary, the Order Summary indicated an order for: Warfarin sodium oral tablet 5 milligrams (MG – a unit of measure), 1 tablet to be given in the evening every Tuesday, Wednesday, Thursday, Saturday, and Sunday related to (R/T) chronic DVT of left lower extremity (Start date 1/15/2026) Warfarin sodium oral tablet 7.5 MG, 1 tablet to be given in the evening every Monday R/T chronic DVT of left lower extremity (Start date 1/15/2026) During a review of Resident 19's care plan titled, Ineffective peripheral (upper or lower extremities) tissue perfusion (healthy blood flow) R/T DVT, initiated 1/13/2026, with goals including Resident 19 will report decreased burning, tingling, and numbness in the extremities through the review date. Interventions included the facility would administer medications as prescribed: Warfarin sodium tablet. During an interview on 2/2/2026 at 10:15 a.m., with Resident 19, Resident 19 stated the facility did not give him his scheduled warfarin for 1 or 2 days. During a concurrent interview and record review on 2/6/2026 at 10:40 a.m., with the MDS Coordinator (MDSC), Resident 19's Medication Administration Record (MAR) for January 2025 was reviewed. The MDSC stated the 1/25/2026 warfarin dose on the MAR is blank. The MDSC stated Resident 19's MAR did not indicate that the warfarin dose scheduled on 1/25/2026 was administered or addressed. The MDSC stated not administering the scheduled warfarin dose placed Resident 19 at risk of blood clots. During an interview on 2/6/2026 at 2:34 p.m., with the DON, the DON stated medications should be given according to the doctor's order. The DON stated if there was a scheduled dose, the medication needs to be given. The DON stated there should not be any blanks or unaddressed medication doses on the MAR. If the dose is not addressed or administered, there is a increased risk for Resident 19 developing a blood clot or DVT. During a review of the facility's policy and procedures (P&P) titled, Enteral Tube Medication Administration, dated 8/2014, the P&P indicated enteral tubes are flushed with at least 15ml of water before administering medications. During a review of the facility's P&P titled, Job Title: Licensed Vocation al Nurse (LVN), undated, the P&P indicated under essential responsibilities and job functions, resident re-assessments: consistently and accurately performs reassessments during each shift and when the resident condition changes, other resident assessments: completes other assessment tools as defined in policy when appropriate (i.e., pain assessment), resident medications: demonstrates ability to provide appropriate nursing medication management including, but not limited to: administering medications as ordered by physician, appropriately transcribing, administering and documenting medications according to policy and process, documentation: demonstrates ability to appropriately document resident care including but not limited to appropriately transcribing, administering, and documenting medications according to P&P, documenting nursing interventions and resident responses including physical and psychological response, ensuring accuracy regarding transcribing of physician orders, ensuring appropriate documentation regarding resident response to medications. During a review of the facility's P&P titled, Physician Orders, dated 2/9/2024, the P&P indicated whenever possible, the Licensed Nurse receiving the order will be responsible for documenting and implementing the order.

Based on interview and record review, the facility failed to ensure one of five employees [Certified Nurse Assistant (CNA) 5] received a performance evaluation annually.This failure had the potential to result in resident injury or decline in level of care because the staff skills are not being evaluated or monitored.Findings:During a concurrent interview and record review on 2/6/2026 at 1:18 p.m. with the Director of Staff Development (DSD), CNA 5's employee files were reviewed. The DSD stated CNA 2 did not receive performance evaluations in the last twelve months. The DSD stated performance evaluations should be completed every year and filed in their employee file. The DSD stated the performance evaluation should have been completed January 2026.During an interview on 2/6/2026 at 2:34 p.m. with the Director of Nursing (DON), the DON stated performance evaluations should be completed annually or every twelve months. The DON stated if performance evaluations are not completed annually, there is a risk of resident injuries and a decline in level of care because the staff skills are not being evaluated or monitored.During a review of the facility's policy and procedure (P&P), titled Performance Evaluations, revised July 2025, the P&P indicated a performance evaluation will be completed on each employee at the at least annually.

Based on interview and record review, the facility failed to ensure facility staff did not administer medication used to treat sever pain when the resident only had mild pain or no pain to one of four sampled residents (Residents 6). This deficient practice had the potential to result in inconsistent medication administration and Resident 6 receiving unnecessary medication.Findings:During a review of Resident 6's admission Record, the admission Record indicated Resident 6 was admitted to the facility on [DATE] with diagnoses including malignant neoplasm of prostate (slow-growing cancer forming in the prostate glands [gland in the male reproductive system] tissues potentially causing urinary issues (weak flow, frequency), and bone pain), secondary malignant neoplasm of bone (when cancer cells spread from a primary site (prostate) to the bones, causing pain and decreased mobility), and encounter for palliative care (focus on relieving pain and stress to enhance quality of life). During a review of Resident 6's history and physical (H&P) dated 10/27/2025, the H&P indicated Resident 6 had the capacity to understand and make decisions. During a review of Resident 6's Minimum Data Set (MDS, a resident assessment tool), dated 1/16/2026, the MDS indicated Resident 6 had mild cognitive (ability to make decisions of daily living) impairment. The MDS indicated Resident 6 required substantial assistance (Helper does more than half the effort) from staff for toileting hygiene, bathing, taking off footwear, lower body (waist below) dressing, and partial assistance (Helper does less than half the effort) from staff for upper body (above waist) dressing, personal hygiene, oral hygiene, and roll from left to right. The MDS indicated, Resident 6 required supervision from staff for eating. During a record review of Resident 6's medication administration record (MAR), dated 1/1/2026 - 1/31/2026, the MAR indicated facility staff administered oxycodone-acetaminophen (Percocet, medication to treat moderate and severe pain) oral tablet 5-325 milligram (mg, a unit of measurement) 2 tablets by mouth every 8 hours as needed for severe pain (pain scale used to assess level of pain 1-3 mild pain, 4-6 moderate pain, and 7-10 extreme pain) on 1/9/2026 with a pain level of 5, and on 1/20/2026 with a pain level of 0 to Resident 6. The MAR indicated Resident 6 received Percocet oral tablet 5-325 mg 1 tablet by mouth every 8 hours as needed for moderate pain (4-6) on 1/14/2026 at a pain level of 2. During a review of Resident 6's order summary report, dated 2/9/2026, the order summary report indicated Resident 6's medications included Percocet, medication to treat moderate and severe pain) oral tablet 5-325 mg 2 tablet by mouth every 8 hours as needed for severe pain (7-10) and Percocet oral tablet 5-325 2 tablet by mouth every 8 hrs as needed for moderate pain (4-6). The order summary report indicated Percocet oral tablet 5-325 was not ordered for pain level of 0-3.During a concurrent interview and record review on 2/9/2026 at 3:05 p.m., with the Director of Nursing (DON), the DON stated on 1/9/2026, the order indicated to give Percocet as needed for severe pain (7-10) and indicated if the pain level is 5, there should be another medication that should be given based on the pain level. The DON stated per order, if the pain range is from 7-10, this medication should not have been given for a pain level of 5 or 0. The DON stated Resident 6 received Percocet as needed for pain level of 4-6 when the pain level was 2 on 1/14/2026. The DON stated they would have to check what the doctors' orders are and follow it. The DON stated pain medication would not be given if the resident had no pain. During a review of the facility's policy and procedure (P&P) titled, Job Title: Licensed Vocation al Nurse (LVN), undated, the P&P indicated under essential responsibilities and job functions, resident medications: demonstrates ability to provide appropriate nursing medication management including, but not limited to: administering medications as ordered by physician, appropriately transcribing, administering and documenting medications according to policy and process, documentation: demonstrates ability to appropriately document resident care including but not limited to appropriately transcribing, administering, and documenting medications according to P&P, .ensuring accuracy regarding transcribing of physician orders.During a review of the facility's P&P titled, Physician Orders, dated 2/9/2024, the P&P indicated whenever possible, the Licensed Nurse receiving the order will be responsible for documenting and implementing the order. During a review of the facility's P&P titled, Pain Management, dated 2/9/2024, the P&P indicated the licensed nurse will administer pain medication as ordered.

Based on observation, interview, and record review, the facility failed to promote and maintain dignity for one of three sampled Residents (Resident 40) when the resident's meal tray was placed on a cluttered bedside table. This failure resulted in Resident 40's feeling unimportant during meal service. Findings: During a meal observation on 2/4/2026 at 12:52 p.m., in Resident 40's room, Resident 40 was observed seated upright at the edge of the bed with a lunch tray on a cluttered (too many things in one place) bedside table.During a follow up meal observation on 2/5/2026 at 8:16 a.m., in Resident 40's room, Resident 40 was observed seated upright at the edge of the bed with a breakfast tray on a cluttered bedside table.During a concurrent observation and interview on 2/5/2026 at 8:30 a.m. with Certified Nurse Assistant (CNA) 1 at Resident 40's room, Resident 40 was observed seated upright at the edge of the bed with breakfast tray placed on a cluttered bedside table. CNA1 stated that the requested extra bedside table was not provided.During an interview on 2/5/2026 at 10:01 a.m. with Resident 40, Resident 40 stated she had requested an extra bedside table for meals but had not received one for a month. Resident 40 further stated, I feel like I don't matter.During a review of Resident 40's admission Record (Face Sheet), the admission Record indicated the facility admitted the resident on 11/28/2025, with diagnoses including, diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control) urinary tract infection (UTI- an infection in the bladder/urinary tract), and liver cell carcinoma (a type of cancer that starts in the email cells of the liver.During a review of Resident 40's Minimum Data Set (MDS-an assessment and care screening tool) dated 1/16/2026 indicated the resident was cognitively (ability to think and understand) intact. The MDS indicated the resident was able to feed herself during meals and was dependent on staff for toilet use and transfers, personal hygiene, and with bed mobility.During an interview on 2/6/2026 at 11:36 a.m. with the Director of Nursing (DON), the DON stated, staff must ensure residents receive meals with dignity and provide an extra table as needed for a clean eating space.During a review of the facility's policies and procedures (P&P) titled Privacy and Dignity, dated February 9, 2024, indicated, . the facility promotes independence and dignity during mealtime.

Based on interview and record review, the facility failed to initiate a care plan to address the resident's risk for aspiration (inhalation of foreign materials) for one of three sampled residents (Resident 33).This deficient practice had the potential to increase Resident 33's risk for aspiration and choking.Findings:During a review of Resident 33's admission Record, the admission Record indicated Resident 33 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 33's diagnoses included chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), dysphagia (difficulty swallowing), and dementia (a progressive state of decline in mental abilities).During a review of Resident 33's Minimum Data Set (MDS - a resident assessment tool), dated 10/28/2025, the MDS indicated Resident 33 had severe cognitive (ability to learn, reason, remember, understand, and make decisions) impairment, required moderate assistance (helper does less than half the effort) for eating, oral hygiene and upper body dressing, and required maximal assistance (helper does more than half the effort) for toileting, bathing, and lower body dressing. During an interview on 2/4/2026 at 9:56 a.m. with Resident 33's Responsible Party (RP), the RP stated they observed staff feeding Resident 33 without seating Resident 33 all the way up multiple times in December 2025. The RP stated when Resident 33 was hospitalized in December 2025, Resident 33 had food and fluid in their lungs.During a concurrent interview and record review on 2/6/2026 at 11:05 a.m. with the MDS Coordinator (MDSC), Resident 33's General Acute Care Hospital (GACH) follow up pulmonary and medicine note dated 12/23/2025, Resident 33's Speech Language Pathologist (SLP) Evaluation, Plan of Treatment Notes dated 12/27/2025, and Resident 33's Care plans were reviewed. The MDSC stated the GACH follow up pulmonary and medicine note dated 12/23/2025 indicated Resident 33 had a diagnosis for acute bronchitis (inflammation of the airways of the lungs)/aspiration pneumonitis (inflammation of lung tissue) and that Resident 33 was a very high risk for aspiration. The MDSC stated the SLP Evaluation and Plan of Treatment Notes dated 12/27/2025 indicated the SLP Resident 33 was referred to the SLP services for dysphagia to minimize risk of aspiration and presented with severe oropharyngeal dysphagia (difficulty moving food from mouth to the throat) and esophageal dysphagia (the sensation of food getting stuck in the chest after swallowing). The MDSC stated care plans are initiated on admission and reviewed and revised quarterly and as needed for changes of resident condition. The MDSC stated the facility reviews GACH discharge summaries, clinicals, and documentation to create or initiate care plans for the Resident 33. The MDSC stated a care plan was not initiated on readmission to address Resident 33's risk for aspiration. The MDSC stated a care plan should have been initiated when Resident 33 was readmitted on [DATE] to address risk of aspiration.During an interview on 2/6/2026 at 2:34 p.m. with the Director of Nursing (DON), the DON stated care plans are important so the facility will know how to take care of Resident 33 based on their diagnosis, medications, and medical problems. The DON stated care plans are initiated on admission and when there is a significant change, change of conditions, quarterly, annually, and as needed. The DON stated if Resident 33, who is at risk for aspiration does not have a care plan to address the risk for aspiration, the staff may not implement appropriate precautions placing the resident at risk of receiving the wrong diet or choking.During a review of the facility's P&P titled, Care Planning, dated 2/9/2024, the P&P indicated the facility will develop a person-centered baseline care plan for each resident within 48 hours of admission. The P&P indicated baseline care plan will be updated to reflect changes in the resident's condition or needs occurring prior to the development of the comprehensive care plan.During a review of the facility's P&P titled, Eating and Swallowing, dated 2/9/2024, the P&P indicated eating activities are individualized to the resident's needs, planned, monitored, evaluated, and documented in the resident's medical record.

Based on observation, interview and record review, the facility failed to ensure two of 19 residents' bedroom rooms (2 and 3) accommodate no more than four residents in each room. This deficient practice had the potential to result in inadequate space to provide nursing care. Findings: During an observation on 2/2/2026 at 12:57 p.m., room [ROOM NUMBER] and 3 were occupied with six residents each. The residents were observed to have no issues moving in and out of rooms and had enough space for wheelchairs, beds, and bedside tables. During a record review of the waiver signed by the administrator dated 3/7/2025 submitted by the Administrator (ADM) indicated resident rooms are permitted to have no more than four beds per room and rooms [ROOM NUMBERS] did not meet the four resident per room requirement by federal regulation. During an interview on 2/9/2025 at 3:51p.m. with the ADM, the ADM stated the residents in room [ROOM NUMBER] and 3 and ensured they are compatible as they have dementia (a progressive state of decline in mental abilities) and the residents have been able to comfort one another.

Based on observation, interview, and record review the facility failed to ensure 17 of 19 resident rooms met the requirements of 80 square feet ([sq. ft.] a unit of area measurement) per residents in multi-bed resident rooms. This deficient practice had the potential to result in an inadequate provision of safe nursing care, and privacy for the residents.Findings: During an observation on 2/2/2026 at 2:02p.m., residents in a three (3) room bedroom were observed having a wheelchair that was not blocking or hindering other residents, had bedside tables, and had enough space going in and out of room. During a review of the Client Accommodations Analysis (identifies approved use ot induvial rooms and approved capacities) dated 2/2/2026, the Client Accommodations Analysis indicated the following: room [ROOM NUMBER] (6 beds) 470 sq. ft. room [ROOM NUMBER] (6 beds) 426 sq. ft.room [ROOM NUMBER] (2 beds) 143 sq. ft.room [ROOM NUMBER] (2 beds) 155 sq. ft.room [ROOM NUMBER] (2 beds) 146 sq. ft.room [ROOM NUMBER] (2 beds) 145 sq. ft.room [ROOM NUMBER] (2 beds) 144 sq. ft.room [ROOM NUMBER] (2 beds) 144 sq. ft.room [ROOM NUMBER] (2 beds) 146 sq. ft.room [ROOM NUMBER] (3 beds) 213 sq. ft.room [ROOM NUMBER] (3 beds) 187 sq. ft.room [ROOM NUMBER] (2 beds) 129 sq. ft.room [ROOM NUMBER] (2 beds) 133 sq. ft.room [ROOM NUMBER] (3 beds) 210 sq. ft.room [ROOM NUMBER] (3 beds) 214 sq. ft.room [ROOM NUMBER] (3 beds) 216 sq. ft. The minimum sq. ft. for two bedrooms is 160 sq. ft. The minimum sq. ft for a three bedroom is 240 sq. ft. The minimum sq. ft. for a six bedroom, is 480 sq. ft. During an interview on 2/9/2026 at 1:03p.m. with the Maintenance Director 1 (MD 1), the MD 1 stated he does not know how many sq. ft. per resident in multi-patient rooms are required and how many residents are supposed to be in one room. The MD 1 stated he does have a room waiver but has not read the room waiver. During a concurrent interview and record review on 2/9/2026 at 3:51p.m. with the Administrator (ADM), the ADM stated they apply for a room waiver every year due to the layout of the facility not meeting the square footage per resident in multi-patient rooms. The ADM stated effort is made to ensure residents are safe, the room is free from clutter as the room size does not meet the 80 sq. ft. per resident. The ADM stated rooms 2 to 9, 11 to 19 are the rooms that do not meet the required footage. The ADM stated the room sq. ft. not meeting the requirement has not affected the care provided to the residents and will be accommodated as needed. During a review of the facility's policy and procedures (P&P) titled, Resident Rooms and Environment, dated 2/9/2024, the P&P indicated the unless a waiver applies, resident rooms must measure at least 80 square feet per resident in multiple resident rooms and 100 square feet in single resident rooms.

Based on interview and record review, the facility failed to ensure the legally recognized decisionmaker and physician signed the Physician Orders for Life-Sustaining Treatment ([POLST] form that contains written medical orders for healthcare professionals regarding specific medical treatments that can or cannot be done at the end-of life) form for one of three sampled residents (Resident 1). This deficient practice had the potential to cause Resident 1 to receive treatment or services against their wishes.Findings:During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE], and originally admitted to the facility on [DATE], with a diagnosis including chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing) and atherosclerotic heart disease (the buildup for plaque on the artery walls causing reduced blood flow to the tissues and increases risk for a blood clot).During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated [DATE], the MDS indicated Resident 1's cognition (ability to think and reason) was moderately impaired and was fully dependent on staff with toileting hygiene, showering/bathing, and putting on footwear.During a review of Resident 1's History and Physical (H&P) dated [DATE], the H&P indicated Resident 1 did not have capacity to understand and make decisions. The H&P indicated Family Member (FM) 1 was the surrogate decision maker.During a review of Resident 1's POLST dated [DATE], the POLST indicated Resident 1 was designated as Do Not Resuscitate ([DNR] a medical order written by a doctor to instruct health care providers NOT to do cardiopulmonary resuscitation (CPR) if breathing stops or the heart stops beating ) status and was to receive medical interventions which included comfort-focused treatment (primary goal of maximizing comfort - relieve pain and suffering with medication by any route as needed; use oxygen, suctioning, manual treatment of airway obstruction, and transfer to the hospital only if comfort needs cannot be met) for medical interventions. The POLST form indicated it was signed by Resident 1's physician (MD) 1 on [DATE].During a review of Resident 1's POLST dated [DATE], the POLST indicated Resident 1 was designated as DNR status and was to receive medical interventions which included comfort-focused treatment. The POLST form indicated it was signed by MD 1 on [DATE].During a review of Resident 1's POLST dated [DATE], the POLST indicated Resident 1 was designated as DNR status and was to receive medical interventions which included selective treatment (goal of treating medical conditions while avoiding burdensome measures - in addition to treatment described in Comfort-Focused Treatment, use medical treatment, intravenous ([IV] fluids or medications given directly into the bloodstream) antibiotics, IV fluids as indicated, do not intubate (to insert a tube into a person's airway [usually through the mouth or nose] to help them breathe), may use non-invasive positive airway pressure, and generally avoid intensive care). The POLST indicated there was no signature from Resident 1's legally recognized decisionmaker (FM 1) although it was signed by MD 1 on [DATE].During a review of the 911 Incident Report dated [DATE], the 911 Incident Report indicated facility staff called 911 due to Resident 1 having rapid respirations (abnormally fast breathing greater than 20 breaths per minute) but hypoxia (when the body's tissues don't get enough oxygen) but presented with bilateral expiratory (exhale) wheezing (a high-pitched, whistling sound heard when a person breathes out) and tachycardia (abnormally fast heart rate greater than 100 beats per minute). The 911 Incident Report indicated paramedics were provided with a POLST for selective treatment that was incomplete and unsigned, and paramedics were unable to get a hold of FM 1 to clarify Resident 1's wishes, and as a result, Resident 1 was transferred to a General Acute Care Hospital (GACH).During an interview on [DATE] at 11:31 a.m., the Director of Nursing (DON) stated it was important for Resident 1's POLST dated [DATE] to be signed because it would be what the paramedics will follow with a change of condition, and since it has changed from comfort measures to selective treatment.During an interview on [DATE] at 12:06 p.m., with the Medical Records Director (MRD), the MRD stated she believed she obtained the signature for Resident 1's POLST dated [DATE] on [DATE], and it was backdated. The MRD stated the POLST form should be signed by the physician as soon as possible, and no later than 72-hours.During an interview on [DATE] at 12:55 p.m., with the Social Services Director (SSD), the SSD stated on [DATE] she spoke to FM 1 regarding her desire to change Resident 1's POLST from comfort measures to selective measures, and it should have been signed that day by the physician to be acted upon, but she was not sure why it was not signed. During review of facility's policy and procedure (P&P) titled Physician Orders for Life Sustaining Treatment (POLST), dated [DATE], the P&P indicated the purpose of the P&P was to help ensure the facility honors residents' treatment wishes concerning resuscitation and life-sustaining treatment. The P&P indicated for the POLST form to be valid, it must be signed by a physician, a nurse practitioner, or a physician assistant acting under the supervision of the physician. The P&P indicated a Licensed Nurse or Social Service Designee must ensure the new POLST form is signed by the physician, and the resident, and the revoked POLST form is voided.

Based on interview and record review, the facility failed to initiate a change of condition (COC) when one of five sampled residents (Resident 1) was found with unknown skin discoloration on his right arm and not doing a pain assessment when Resident 1 was found with a skin tear. This deficient practices placed Resident 1 not being monitored for the COC and had the potential for delay in care. Findings: During a review of Resident 1's Admission record (Face Sheet), the Face Sheet indicated Resident 1 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), muscle wasting and atrophy, and Type 2 (II) Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 1/3/2025 the MDS indicated Resident 1's cognitive skills (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) were moderately impaired. The MDS indicated Resident 1 required moderate assistance for performing Activities of Daily Living (ADL: bathing, dressing, toileting hygiene, personal hygiene, chair/bed-to-chair transfer, and required supervision for oral hygiene and eating. During a review of the Situation, Background, Assessment, Recommendation (SBAR: structured communication tool used to ensure clear and concise information exchange) Communication Form and progress note dated 3/22/2025 at 9:16a.m., the SBAR indicated Resident 1 was being monitored following an incident where another resident was found on top of Resident 1 with a skin tear on the left arm. The SBAR indicated Resident 1 had a left antecubital skin tear and does not indicate Resident 1's pain status. During a review of Resident 1's progress note dated 3/25/2025, the progress note indicated the Nurse Practitioner 1 (NP) assessed Resident 1. Resident 1's left arm skin tear was reclassified to left forearm skin tear. The skin assessment was done with two other licensed nurses with findings of: left forearm skin tear, left upper arm multiple abrasions, and multiple discolorations on right upper extremity. During an interview on 3/27/2025 at 11:49a.m. with Treatment Nurse (TXN), TXN stated he did a skin assessment on 3/25/2025 and indicated there was a skin tear on the left arm and discoloration on the right arm and is not sure if the skin discoloration was observed on 3/24/2025 TXN stated when the new skin discoloration was identified, he notified the doctor and updated the care plan. TXN stated the skin assessment is done when there is a change of condition (COC) or at admission TXN stated he wrote a licensed note indicating the doctor was aware but indicated a COC was not done since this was more of a follow up. A COC is done when there are new findings or if the condition has gotten worse. During an interview on 3/28/2025 at 6:12a.m with Licensed Vocational Nurse 3 (LVN 3), LVN 3 stated she noticed Resident 1 had a skin tear on his arm when she observed another resident on top of Resident 1 and does not know where it came from LVN 3 stated a COC is done when something is different from the resident's baseline such as a cough. LVN 3 stated a COC will still be completed despite the doctor being onsite when the COC is occurring for documentation purposes and as the resident would need to be on continuous monitoring and would additionally indicate the time the doctor was notified. During an interview on 3/28/2025 at 9:08a.m. with DON, DON stated if there was a division from baseline, the nurses do a COC. DON stated the SBAR specify the COC that was observed, assess, stay at bedside until stable, notify the doctor, provide nursing intervention, notify the family, and carry out doctors' orders. DON stated if the resident is having pain, the pain assessment is initiated. DON stated Resident 1 is prone to discoloration due to his frail skin but does not know what caused the skin discoloration. DON stated if the skin discoloration was observed, an SBAR needs to be initiated. DON stated the TXN admitted he should have done an SBAR the day the skin discoloration was identified. DON stated the COC still needs to be initiated as the nurses need to monitor the resident for 72 hrs to identify any changes . DON stated they should have had a pain assessment when Resident 1 had the skin tear on 3/22/2025. DON stated if a pain assessment was not done, there are no documentation that the pain was addressed at that time and there will be a possibility that the pain will be uncontrolled. During a review of the facility's policy and procedure (P&P) titled, Change of Condition dated 2/9/2024, the P&P indicated the licensed nurse will assess the resident's change of condition and document the observations and symptoms. Notification to the Attending Physician will include a summary of the condition change and an assessment. A licensed nurse will document the following: date, time and pertinent details of the incident and the subsequent assessment in the Nursing Notes. The time the Attending Physician was contacted, the method by which he was contacted, the response time .the time the family/responsible person was contacted. A Licensed Nurse will document each shift for at least seventy-two (72) hours. Documentation pertaining to a change in the resident's condition will be maintained in the resident's medical record and on the 24-hour report. During a review of the P&P titled, Pain Management dated 2/9/2024, the P&P indicated the purpose is to ensure accurate assessment and management of the resident's pain.

Based on interview and record review, the facility failed to ensure the resident, who had a Full Code (resident wants all life saving measures in case of emergencies) status and was in distress received Cardiopulmonary Resuscitation ([CPR] an emergency procedure to restart a person's heart (chest compressions) to increase the chances of a resident's survival for one of 39 residents who had a Full Code status (Resident 45). The facility failed to: 1. Ensure facility staff were knowledgeable what actions to take when responding to a resident in distress. 2. Ensure Licensed Vocational Nurse (LVN )1 announced a Code Blue (an announcement that signifies a medical emergency where a patient is experiencing a life-threatening situation) when he found Resident 45 unresponsive. 3. Ensure LVN 1 provided resuscitation (action or process of reviving someone from unconsciousness or apparent death) and basic life support ([BLS], basic care healthcare professionals provide to anyone who's heart stops beating suddenly) such as CPR, immediately without loss of critical time to Resident 45 when the resident was found unresponsive (a person is unable to respond to their surrounding and do not react to stimulation like touch, sound, or pain) on [DATE] at 4:30 p.m. 4. Ensure Certified Nursing Assistant (CNA) 1 and CNA 2 did not stop delivering chest compressions (involves giving strong, rapid pushes to the chest to keep blood moving through the body) to Resident 45's before the Paramedics were able to take Resident 45's CPR over. 5. Ensure staff implemented the facility's policy and procedure (P&P) titled, Cardiopulmonary Resuscitation dated February 21, 2024, which indicated to sustain or support a resident's cardiac (related to heart) and/or pulmonary (related to lungs) function(s) until medical emergency personnel are available to take over the resuscitation efforts and the American Heart Association ([AHA] the leader in resuscitation science, education, and training, and publisher of the official Guidelines for CPR) guidelines that indicated First responder would call for help, send available staff to call a Code Blue and retrieve emergency medical equipment, assess the residents' level of consciousness, circulation, airway, and breathing and begin CPR, call 911, CPR will continue until the paramedics arrive and assume responsibility. These deficient practices resulted in the delay of life saving measures such as CPR for Resident 45 when she was found unresponsive on [DATE] at 4:30 p.m., and pronounced dead on [DATE] at 5:07 a.m. These deficient practices placed 38 residents, who had a Full Code status at risk not to receive CPR. On [DATE] at 6:55 p.m., an Immediate Jeopardy ([IJ] a situation in which the facility's noncompliance with one or more requirements of participation had caused, or is 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 ensure the facility staff provided basic life support to Resident 45, including CPR immediately upon discovering the resident had difficulty breathing and became unresponsive. On [DATE] at 2:57 p.m., the Facility submitted an acceptable IJ removal plan ([IJRP], an intervention to immediately correct the deficient practices). After verification the IJRP was implemented through observation, interview, and record reviews, the IJ was removed while onsite on [DATE] at 5:50 p.m., in the presence of the ADM and the DON. The IJRP included the following: 1. Thirty eight of the 48 residents in the facility were Full Code. All 38 residents have the potential to be affected by the same deficient practice. There were no medical emergencies that occurred in the last 24 hours. 2. On [DATE], a BLS certified instructor provided BLS training to 11 licensed nurses (91.6% of total licensed staff) and 18 CNAs (64.2%). The training consisted of in person instructions on when to initiate CPR and how to perform the CPR correctly according to the American Heart Association guidelines, and skills demonstration of the proper CPR procedure. 3. On [DATE], the DON and the Nurse Consultant conducted a Code Blue drill for nursing staff to simulate a medical emergency. The drill emphasized the staff's responsibility to respond to a medical emergencies, the various roles and responsibilities of the staff when responding to a medical emergency, how to operate emergency equipment found in the crash cart (cart stocked with emergency medical equipment, supplies, and drugs for use by medical personnel especially during efforts to resuscitate a patient experiencing cardiac arrest), including the Ambu-bag (a medical device that helps patients breathe by forcing air into their lungs) and cardiac board (a rigid board used to provide a firm surface for chest compressions during CPR). There were 12 licensed nurses (92.3% of total number of licensed nurses) and 18 CNAs (64.2%) who participated in the drill. Nursing staff who were currently on vacation or on leave will be provided the in-service and post-test upon their return to work. 4. Starting [DATE], the DON and Nurse Consultant will conduct a Code Blue drill for nursing staff quarterly for one year and then annually thereafter. 5. On [DATE], the DON and Nurse Consultant provided an in-service to three Registered Nurses (RNs) (100%) and 10 LVNs (76.9%) regarding managing changes of condition. The in-service emphasized the following points: a. Conducting timely assessments, including vital signs, of a resident who has a change in condition. b. Notifying the physician of changes in condition. c. Monitoring the resident's condition. d. Reassessing the resident to determine the resident's response and the effectiveness of the interventions. e. Initiating CPR promptly when the resident is not breathing and/or does not have a pulse. f. The licensed nurses were given a post-test at the end of the in-service to evaluate their knowledge of the information they received. Passing score was 5 out of 5. Licensed nurses who don't pass will be asked to attend the in-service and take the post-test again. Staff who are currently on vacation or on leave (three licensed nurses) will be provided the in-service and post-test upon their return to work. g. The DON will review changes in condition daily, from Monday through Friday, to ensure that prompt resident assessment was conducted in response to the change in condition. Changes in condition that occur on the weekend will be reviewed the following Monday. Findings will be corrected immediately. h. The DON will report findings and trends from the change in condition review to the Quality Assessment and Assurance ([QAA ] process to identify how the facility is performing and maintain quality of care) Committee during the Quality Assurance Performance improvement ([QAPI] process to improve services and outcomes) meeting monthly for three months. i. The Medical Records Director will report findings and trends from the change in condition audits to the QAA Committee during the QAPI meeting monthly for 3 months. Findings: During a review of Resident 45's Admission record, the Admission Record indicated Resident 45 was initially admitted to the facility on [DATE] and was readmitted from a general acute hospital (GACH) on [DATE] with diagnoses including Chronic Obstructive Pulmonary disease (COPD: progressive lung disease causing difficulty in breathing), End Stage Renal Disease (ESRD: irreversible kidney failure), Congestive Heart Failure (CHF: a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), and Type II Diabetes Mellitus (DM: a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 45's History and Physical (H&P) dated [DATE], the H&P indicated Resident 45 had fluctuating (varied) capacity to understand and make decisions. The H&P indicated Resident 45 was a Full Code (FC) status. During a review of Resident 45's Minimum Data Set ([MDS] a resident assessment tool), dated [DATE], the MDS indicated Resident 45's cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making were mildly impaired. The MDS indicated Resident 45 required moderate assistance for most of her activities of daily living (sit to stand, chair/bed to chair transfer, walking 10 feet, shower transfer, dressing, bathing, oral and toileting hygiene), required supervision (no physical assistance) for personal hygiene, and required set up for eating. The MDS indicated Resident 45 utilized a wheelchair and did not have any impairments on both the upper (arms/shoulders) and lower extremities (hip/legs). During a review of Resident 45's Order Summary Report (physician's orders), the Order Summary Report indicated an order dated [DATE] to monitor the resident's vital signs (measurements of the body's basic functions including oxygen saturation [amount of oxygen in blood], blood pressure [force of blood pushing against the blood vessels walls in the heart], respiration [process of breathing in and out], heart rate (pulse : number of times the heart beats per minute), and temperature (measure how well the body can make and get rid of heat) every shift for 72 hours (every shift for baseline vital signs for three days). During a review of the Paramedics (emergency medical responders) report dated [DATE] at 4:45 a.m., the Paramedics report indicated when the Paramedics arrived to Resident 45's room, Resident 45 was lying on her back, pulseless (no heart beat), apneic (involuntarily and temporarily stops breathing), had an oxygen saturation (amount of oxygen in blood) of 79 percent (%) (COPD resident reference rate 88% to 92%), and a blood glucose (amount of sugar in blood) level of 45 (reference range 70 milligrams per deciliter (mg/dL: unit of measure used to report concentration of a substance in a fluid) to 100mg/dL). The Paramedics report indicated the staff did not conduct CPR prior to the Paramedics arrival. The report indicated the Paramedics initiated CPR at 4:45a.m., and after 20 minutes of performing CPR with no change, Resident 45 was pronounced dead at 5:07 a.m. During a review of the Nursing Admission assessment dated [DATE] at 8:43 p.m., the Nursing Admission Assessment indicated Resident 45 was admitted on [DATE] at 6:55p.m. Resident 45 was alert, oriented to person, had weakness in both upper and lower extremities. During a review of the Nurses Progress Notes dated [DATE] at 7:25 a.m., documented by LVN 1, the Nurses Progress Notes indicated around 2:20 a.m., Resident 45 was resting and responsive to verbal stimuli (sounds or words produced by a speaker to get attention) with no complications. The Nurses Progress Notes indicated at 4:25a.m., Resident 45 was unresponsive to sternal rub (painful stimulus with the knuckles at the center of the chest), CPR was initiated, 911 was called, and the doctor was notified. The Nurses Progress Notes indicated at 4:41 a.m., Paramedics arrived at the facility and took over Resident 45's CPR. The Nurses Progress Notes indicated at 5:07a.m., Paramedics pronounced Resident 45 deceased . During an interview on [DATE] at 2:32p.m., RN 1 stated when Resident 45 arrived at the facility on [DATE], she appeared unkempt, speech was clear and seemed tired. RN 1 stated during Resident 45's admission assessment, Resident 45 was able to state her name, her oxygen saturation (measure of how much oxygen is in the blood cells [COPD resident reference rate 88% to 92%] was in the low 90s. so she gave the resident oxygen at 3.0 liters ([L] unit of measure) per minute (min) via nasal canula ([NC] device that delivers oxygen through a very small thin tubes placed into each nostril ). RN 1 stated she was uncomfortable with the way Resident 45 presented because she seemed out of it. RN 1 stated Resident 45 was too weak to sign admission documents or the Physician Orders for Life-Sustaining Treatment ([POLST] residents' preferences for medical treatment) and indicated she would do it tomorrow. RN 1 stated at the end of her shift she gave report to LVN 1 (the incoming nurse) to monitor Resident 45. RN 1 stated Resident 45 came to the facility with her LifeVest (a wearable device to monitor for abnormal heart rhythms and deliver a shock to restore normal rhythm) but she was not wearing it. RN 1 stated 1. RN 1 stated when Resident 45 was admitted , she did not look right. During an interview on [DATE] at 3:55p.m., LVN 1 stated he worked on [DATE] during the night shift (11p.m. to 7 a.m.). LVN 1 stated when he came to work, he made rounds and visually checked on all the residents, to see if the residents were breathing. LVN 1 stated he received report from the outgoing RN 1 read Resident 45's H&P and continued to provide care to other residents after he observed Resident 45 at 2:20 a.m. was doing okay. LVN 1 stated he normally makes rounds every one to two hours. LVN 1 stated around 4:00 a.m., he noticed Resident 45 was not communicating and unresponsive. LVN 1 stated Resident 45 was laying down and was warm to the touch. LVN 1 stated he initiated CPR, went to call 911, and had to go back to continue CPR. LVN 1 stated CNA 1 and CNA 2 were in Resident 45's room to help with CPR while he called 911. LVN 1 stated CNA 1 and CNA 2 took turns to do CPR. LVN 1 stated Resident 45 was wearing her nasal canula and he placed the flat board (provide a firm surface when chest compressions are performed to provide adequate and effective compressions) underneath the resident. During an interview on [DATE], at 9:15 a.m., CNA 1, stated she went to check on Resident 45 between 4:00 a.m. and 4:05 a.m., and the resident was breathing. CNA 1 stated she went back to Resident 45's room around 4:26 a.m., when she heard LVN 1 calling Resident 45's name out loud four times. CNA 1 stated LVN 1 told her that Resident 45 was unresponsive. CNA 1 stated LVN 1 to her nothing needed to be done, and she did not need to check Resident 45's vital signs. CNA 1 stated she still went to get the vital signs machine and asked CNA 2, who was in the hallway, to join her to assist. CNA 1 stated when CNA 2 and her went back into Resident 45's room with the vitals machine, LVN 1 instructed CNA 2 and her (CNA 1) to start CPR. CNA 1 stated when they started CPR, Resident 45 was cold to the touch on her face, hands, and legs. CNA 1 stated LVN 1 brought in the crash cart. CNA 1 stated no one provided rescue breaths to Resident 45 during CPR, no one took her vital signs and no one placed a Back Board under Resident 45. CNA 1 stated she did not witness LVN 1 perform CPR on Resident 45 at any time. CNA 1 stated LVN 1 stated he was going to call the Paramedics and never came back to Resident 45's room after that. CNA 1 stated she and CNA 2 took turns doing compressions, but they did not provide any rescue breaths as they did not have an Ambu-bag. CNA 1 stated while CNA 2 was doing compressions, she heard the Paramedics entering the facility and she instructed CNA 2 to stop doing compressions since the Paramedics were in the building. During an interview on [DATE], at 10:07 a.m., CNA 2 stated at the on [DATE] at the beginning of the shift (11:00 p.m. to 7:00 a.m.), CNA 1 notified LVN 1 that Resident 45 did not look-well and they together went to observe Resident 45. CNA 2 stated upon observation Resident 45 had oxygen via nasal cannula, but seemed weak as she was not able to move her arms and could not change positions in bed and appeared to have issues breathing. CNA 2 stated on [DATE], when he was going to take the trash out after changing one of the residents, he saw CNA 1 walking towards him and asked for his help with Resident 45, who was in distress. CNA 2 stated he did not know there was a Code Blue because he did not hear the code to be announced overhead . During an interview on [DATE] at 2:32 p.m., with the Director of Staff Development (DSD), the DSD stated during any shift, if a resident is in respiratory distress, licensed staff must assess the resident, call the doctor, check vital signs, and to give oxygen if the resident is desaturating (blood oxygen level is dropping). The DSD stated someone will call a Code Blue on the overhead to ensure everyone in the facility is aware and can respond immediately. The DSD stated staff must work together to gather supplies such as the crash cart, check and document the vital signs, and call 911. The DSD stated if a resident has a change of condition staff should take vital signs. The DSD stated an Ambu-bag is on the Crash Cart to provide breaths during compressions. The DSD stated staff should use a Back Board from the Crash Cart to provide effective compressions, if there is no Back Board, then staff need to put the resident on the floor for effective compressions. The DSD stated CPR needs to be continuous until there is a pulse or until the Paramedics arrive and take over. During an interview on [DATE] at 1:56 p.m., CNA 3 stated she worked the 11 p.m. to 7 p.m. shift on [DATE]. CNA 3 stated she did not hear any Code Blues called on [DATE] during the 11:00p.m. to 7:00a.m. During an interview on [DATE] at 3:21 p.m., the DON stated if a resident is nonresponsive the licensed nurses should assess the resident's breathing, heartbeat, and if indicated start chest compressions while another staff member calls 911, bring the Crash Cart, use the Ambu-bag. The DON stated chest compressions should be continuous until the Paramedics come and take CPR over. During a concurrent interview and record review on [DATE] at 4:42 p.m., with the DON, Resident 45's Nurses Progress Notes dated [DATE] were reviewed. The DON stated Resident 45 was admitted back to the facility on [DATE] and passed at the facility on [DATE]. The DON stated the resident's vital signs were not recorded during the 11 p.m. to 7 a.m. shift. The DON stated if it was not documented, it was not done. The DON stated during a life-threatening emergency someone will call a Code Blue on the overhead speaker to ensure everyone in the facility is aware and can respond immediately. The DON stated on [DATE] at 11:10 p.m. when CNA 1 reported to LVN 1 that Resident 45 was having difficulty breathing, LVN 1 should have assessed Resident 45 immediately, including taking vital signs and checking oxygen saturation. The DON stated since Resident 45 was a Full Code, the life saving measures such as CPR should have been initiated immediately when the resident was found unresponsive. During a concurrent interview and record review on [DATE] at 4:53 p.m., with the DON Resident 45's GACH records were reviewed. The DON stated on the Cardiology Note dated [DATE], Resident 45 had a risk for sudden cardiac arrest as she had refused the LifeVest and further implantable cardioverter defibrillator ([ICD] small device that monitors and responds to abnormal heart rhythm) workup. During a concurrent interview and record review on [DATE] at 5:13 p.m., the Paramedic Run Sheet dated [DATE] was reviewed with the Emergency Medical Services Captain (EMSC).The EMSC stated when the Paramedics arrived on scene (Resident 45's bedside), Resident 45 was found pulseless and apneic lying on her back in bed. The EMSC stated staff did not start CPR prior to the Paramedics arrival. The EMSC stated initiating CPR timely may increase the chances of survival of the resident and the facility was not doing CPR when they arrived. During a review of the facility's P&P titled, Cardiopulmonary Resuscitation dated February 21, 2024, the P&P indicated to sustain or support a resident's cardiac and/or pulmonary function(s) until medical emergency personnel are available to take over the resuscitation efforts. Cardiopulmonary resuscitation is instituted on all residents except those designated as No Code or No CPR. In the absence of a Do Not Resuscitate ([DNR] medical order that instructs healthcare providers not to perform cardiopulmonary resuscitation (CPR) order, CPR will be performed. The facility will perform CPR in accordance with the guideline set forth by the American Heart Association. Establish unresponsiveness, verify code status prior to the initiation of CPR, alert the emergency response team (call 911), check for pulse, CPR will be initiated using the standards outline in the American Heart Association's most current CPR guidance, continue CPR until paramedics arrive and take over, Documentation: Whether the incident was witnessed: A. Date and time event was recognized. B. When you found the resident and started CPR. C. Condition of the resident when ventilation (respiration status), chest compressions or defibrillation needed. D. How long the resident received CPR. E. The resident's response to CPR. F. Any interventions taken to correct complications. During a review of the facility's P&P titled, Change of Condition Notification, dated February 9, 2024, the P&P indicated an acute change of condition (ACOC) is a sudden, clinically important deviation from a patient's baseline in physical, cognitive, behavior, or functional domains. Clinically important means a deviation that, without intervention, may result in complications or death. The Licensed Nurse will assess the resident's change of condition and document the observations and symptoms. A Licensed Nurse will document the following: Date, time, and pertinent details of the incident and the subsequent assessment in the Nursing Notes. The time the Attending Physician was contacted, the method by which he was contacted, the response time, and whether or not orders were received. A Licensed Nurse will document each shift for at least seventy-two (72) hours. During a review of the facility's P&P titled, Medical Emergencies-Code Blue dated February 9, 2024, the P&P indicated to ensure the prompt and effective response by Facility personnel during medical emergencies through the use of the Code Blue procedure. A medical emergency is defined as one of the following conditions requiring immediate medical intervention and the initiation of the Code Blue procedure: Respiratory or cardiac arrest (when the heart suddenly and unexpectedly stops beating). Once CPR is initiated, it will continue until Paramedics arrive. I. First Responder A. The first of Facility personnel to arrive and find a resident with any of the above conditions will: 1. Call for help. 2. Send available staff to call a Code Blue and retrieve emergency medical equipment. 3. Assess the resident's level of consciousness, circulation, airway, and breathing; begin CPR according to the current practice. Note: The first responder should not leave the victim to call for help unless absolutely necessary according to the situation. 4. When the second responder arrives, have the second responder place the cardiac arrest board under the resident and assist with two-rescuer CPR. II. Subsequent Responder(s): A. Active the Emergency Response System-Call 911. B. Direct all needed personnel to the Code Blue site. C. Send a Staff member to the entrance door to wait where the ambulance is expected to arrive. D. The first RN to respond will lead the code unless responsibility is transferred to another licensed staff member (RN or Medical Doctor). E. If no other RN or MD is available, the RN will follow the procedure as given in the Unit Nurse or Designee section below. F. Note: One person CPR will be maintained until there is a second responder available to begin two person CPR. G. CPR will continue until the paramedics arrive and assume responsibility. III. Roles During the Code: Any available Nursing Staff will complete the tasks as directed in the First Responder and Subsequent Responder sections of this procedure. IV. Licensed Nurse: A. In the absence of an Attending Physician, it will be the responsibility of the first licensed staff member responding to the code to lead, and coordinate the resuscitation efforts until paramedics arrive. B. The nurse will assure that the following tasks have been completed and/or assigned: 1. CPR has been initiated. 2. 911 has been called. 3. Code Blue or STAT (immediately) has been paged overhead. 4. Emergency Cart is on the scene. 5. Staff have been assigned to monitor other residents and move them to a safe area during the code blue. 6. Attending MD and/or MD on-can has been notified Director of Nursing/Nurse Manager has been notified. 7. Document the event in the resident record. 8. Charting of time and condition of the resident at the time of discovery, CPR initiated, when Code Blue called, when physician and family notified, and when nursing staff responded.

Based on interview and record review, the facility failed to protect the Resident's right to be free from neglect when licensed nurses did not provide needed services to prevent the resident, who had difficulty breathing, from becoming unresponsive and die for one of one sampled resident (Resident 45). The facility failed to: 1. Ensure licensed nurses conducted timely assessments of Resident 45's physical condition when the resident developed breathing difficulty. 2. Ensure Licensed Vocational Nurse (LVN) 1 had Resident 45 vital signs (measurements of the body's basic functions including oxygen saturation [amount of oxygen in blood], blood pressure [force of blood pushing against the blood vessels walls in the heart], respiration [process of breathing in and out], heart rate ( pulse : number of times the heart beats per minute), and temperature (measure how well the body can make and get rid of heat) taken and monitored when Certified Nursing Assistant (CNA 1) notified LVN 1 on [DATE] at 11:10 p.m., that the resident was having difficulty breathing. 3. Ensure Registered Nurse (RN) 1 monitored Resident 45's condition when she noted Resident 45 was having out of range oxygen saturation level (measure of how much oxygen is in the blood cells. For residents with Chronic Obstructive Pulmonary [referencing to lungs] disease ([COPD] a progressive lung disease that causes difficulty breathing) the reference range is 88% to 92%) on room air and was weak. 4. Ensure RN 1 notified Resident 45's physician of the resident's weakness and refusal to wear a LifeVest (a wearable device that help treat heart failure by monitoring for abnormal heart rhythms and deliver a shock to restore normal rhythm) upon admission. 5. Ensure staff followed the facility's policy and procedures (P&P) titled, Abuse Prevention and Prohibition Program, dated February 9, 2024, which indicated residents would be protected from neglect. These deficient practices resulted in Resident 45 not being monitored by the licensed nurses when Resident 45 had difficulty breathing and weakness on [DATE] at 11:10 p.m. On [DATE] at 4:26 a.m., Resident 45 was found unresponsive and was pronounced dead at 5:07 a.m., by the Paramedics (emergency medical response staff). These deficient practices placed 48 residents in the facility at risk to be neglected by licensed nurses in case their condition was changed. On [DATE] at 6:55p.m., an Immediate Jeopardy ([IJ] a situation in which the facility's noncompliance with one or more requirements of participation had cause, or is 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). On [DATE] at 2:57 p.m., the ADM submitted an acceptable IJ removal plan ([IJRP], an intervention to immediately correct the deficient practices). After verification of the IJRP implementation through observation, interview, and record reviews, the IJ was removed on [DATE] at 5:50p.m. in the presence of the ADM and the DON. The IJRP included the following: 1. Resident 45 expired on [DATE]. 2. On [DATE], the DON provided RN 1 with a one-to-one in-service (education) regarding responsibilities of a licensed nurse when assessment findings are outside the normal range. The in-service emphasized the importance of monitoring and reassessing the resident to determine the effectiveness of interventions and the resident's response to the interventions. 3. On [DATE], at 8:34 p.m., LVN 1 was sent home on an administrative leave pending the results of the facility's investigation of the allegation. 4. The facility has 48 residents in-house. All residents have the potential to be affected by the same deficient practice. 5. On [DATE], the DON reviewed changes in condition that occurred in the last 24 hours to ensure that the residents were assessed timely and appropriately. There were four residents with changes in condition. Licensed nurses assessed the residents timely and appropriately. 6. On [DATE] and [DATE] the Administrator and Director of Staff Development (DSD) provided an in-service to 47 facility's employees (62.6% of the total staff) regarding the facility's policy on Abuse and Neglect Prohibition. The in-service emphasized the following: a. Different types of abuse, including neglect. b. The definition and examples of neglect. c. The responsibility of the staff to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. 7. The facility staff were given a post-test at the end of the in-service to evaluate their knowledge of the information they received. Passing score is 6 out of 6. Staff who don't pass will be asked to attend the in-service and take the post-test again. Staff who are currently on vacation or on leave (three licensed nurses) will be provided the in-service and post-test upon their return to work. 8. All new hires will be provided with an in-service and post-test by the Director of Staff Development (DSD) regarding the facility's policy on Abuse and Neglect Prohibition. Staff who don't pass will be asked to attend the in-service and take the post-test again. The in-service will address the following: a)Different types of abuse, including neglect; b)The definition and examples of neglect; c)The responsibility of the staff to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. 9. Starting [DATE], the Administrator or designee will provide Abuse and Neglect Prevention in-service to staff quarterly for 1 year and twice a year thereafter. 10. On [DATE], the DON and Nurse Consultant provided an in-service to three RNs (100% of facility RNs) and 10 LVNs (76.9% of facility LVNs) regarding managing changes of condition. The in-service emphasized the following points: a) Conducting timely assessments, including vital signs, of a resident who has a change in condition; b) Notifying the physician of changes in condition; c) Monitoring the resident's condition; d) Reassessing the resident to determine the resident's response and the effectiveness of the interventions. 11. The licensed nurses were given a post-test at the end of the in-service to evaluate their knowledge of the information they received. Passing score is 5 out of 5. Licensed nurses who don't pass will be asked to attend the in-service and take the post-test again. Staff who are currently on vacation or on leave (three licensed nurses) will be provided the in-service and post-test upon their return to work. 12. Starting [DATE], the DON will provide training on managing changes in condition for all newly hired licensed nurses. 13. The DON will review changes in condition daily, from Monday through Friday, to ensure that prompt resident assessment was conducted in response to the change in condition. Changes in condition that occur on the weekend will be reviewed the following Monday. Findings will be corrected immediately. 14. The Medical Records Director will audit changes in condition daily, from Monday through Friday, to ensure that the medical provider was notified of changes in condition. Changes in condition that occur on the weekend will be audited the following Monday. Findings will be reported to the DON for follow-up. 15. The DSD will report the number of new hires for the month and if the abuse in-service training was provided for them to the Quality Assessment and Assurance ([QAA] process to identify how the facility is performing and maintain quality of care) Committee during the Quality Assurance Performance improvement ([QAPI] process to improve services and outcomes) meeting monthly for three months. 16. The DON will report findings and trends from the change in condition review to the QAA Committee during the QAPI meeting monthly for three months. 17. The Medical Records Director will report findings and trends from the change in condition audits to the QAA Committee during the QAPI meeting monthly for three months. Findings: During a review of Resident 45's Admission record, the Admission Record indicated Resident 45 was initially admitted to the facility on [DATE] and was readmitted from a general acute care hospital (GACH) on [DATE] with diagnoses including COPD, End Stage Renal Disease ([ESRD] irreversible kidney failure), Congestive Heart Failure ([CHF] a disorder which causes the heart not to pump blood efficiently, sometimes resulting in leg swelling), and Type II Diabetes Mellitus ([DM] a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 45's History and Physical (H&P) dated [DATE], the H&P indicated Resident 45 had fluctuating (varied) capacity to understand and make decisions. The H&P indicated Resident 45 was a full code (resident chooses to receive all life saving measures in case of an emergency) status. During a review of Resident 45's Minimum Data Set ([MDS] a resident assessment tool), dated [DATE], the MDS indicated Resident 45's cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making were mildly impaired. The MDS indicated Resident 45 required moderate assistance for most of her activities of daily living (sit to stand, chair/bed to chair transfer, walking 10 feet, shower transfer, dressing, bathing, oral and toileting hygiene), required supervision (no physical assistance) for personal hygiene, and required set up for eating. The MDS indicated Resident 45 utilized a wheelchair and did not have any impairments on both upper (arms/shoulders) and lower extremities (hip/legs). During a review of Resident 45's Order Summary Report (Physician's orders), the Order Summary Report indicated an order dated [DATE] to monitor the resident's vital signs every shift for 72 hours (every shift for baseline vital signs for three days). During a review of the Nurses Progress Notes dated [DATE] and timed at 7:25 a.m., completed by LVN 1, the Nurses Progress Notes indicated that on [DATE] around 2:20 a.m., Resident 45 was resting and was responsive to verbal stimuli (sounds or words produced by a speaker to get attention) with no complications. The Nurses Progress Notes indicated at 4:25 a.m., Resident 45 was unresponsive even after a Sternal Rub (painful stimulus with the knuckles at the center of the chest) to the center of the chest, so Cardiopulmonary Resuscitation (CPR an emergency procedure to restart a person's heart [chest compressions] and breathing after one or both have stopped) was initiated, 911 was called, and the doctor was notified. The Nurses Progress Notes indicated at 4:41a.m., Paramedics arrived at the facility and took over Resident 45's CPR. The Nurses Progress Notes indicated at 5:07a.m., Paramedics pronounced Resident 45 deceased . During a review of the Nurses Progress Notes dated [DATE] at 8:49 p.m., documented by RN 1, the Nurses Progress Notes indicated Resident 45 was alert and oriented, her respirations were even and unlabored (easy, effortless breathing, without any signs of difficulty or struggle), her blood pressure was ,d+[DATE] millimeters of mercury ([mmHg] unit of measure. Reference range ,d+[DATE] mmHg), heart rate of 80 beats per minute (reference range 60 to 100), respiratory rate of 17 breath per minute (reference range 12 to 20 breaths per minute), and 94% oxygen saturation on 3.0 ([L]unit of measure) per minute (min) L/M through a nasal cannula ([NC] device that delivers oxygen through thin tube s placed into nostrils). RN 1 stated she was uncomfortable with the way Resident 45 presented as she (Resident 45) seemed being out of it. RN 1 stated Resident 45 was too weak to sign the admission documents and the Physician Orders for Life-Sustaining Treatment ([POLST]residents' preferences for medical treatment) and said she would do it tomorrow on [DATE]. RN 1 stated when a resident is newly admitted or readmitted , the nurse that admits the resident completes a head-to-toe assessment, reviews the residents' medications and notifies the admitting physician for admission orders. RN 1 stated Resident 45 came to the facility with her LifeVest but she was not wearing it. RN 1 stated the nurse, who gave report over the phone from the GACH, told her Resident 45 refused the LifeVest. RN 1 stated when Resident 45 was admitted she did not look right. RN 1 stated she relayed this information to LVN 1 to ensure LVN 1 would monitor Resident 45 closely. RN 1 stated she should have informed the doctor that Resident 45 was not doing well upon admission. RN 1 stated the interventions to implement when a resident found unresponsive and pulseless (no heartbeat) include the following: 1. Do an assessment. 2. Get the crash cart (trays and drawers on wheels that contains emergency medication and equipment for life threatening emergencies). 3. Put the back board under the resident. 4. Announce a Code Blue (an announcement that signifies a medical emergency where a patient is experiencing a life-threatening situation) through the overhead paging system. 5. Take vital signs. 6. Put a nonrebreather mask (oxygen mask that delivers high concentrations of oxygen) on the resident. 7. Initiate chest compressions immediately. RN 1 stated the chest compressions should continue until the paramedics arrive at the room and take over. During an interview on [DATE] at 3:55p.m., LVN 1 stated he worked on [DATE] during the night shift (11 p.m. to 7 a.m.). LVN 1 stated when he came to work, he made rounds and visual checks on all residents to see if the residents were breathing. LVN 1 stated he received report from the outgoing RN 1, read Resident 45's H&P, and continued to provide care to other residents after he observed Resident 45 was doing okay at 2:20 a.m., on [DATE]. LVN 1 stated he normally makes rounds every one to two hours. LVN 1 stated facility residents' vital signs are taken at the beginning of the shift. LVN 1 stated around 4:00 a.m., he noticed Resident 45 was not communicating and unresponsive. LVN 1 stated Resident 45 was lying in bed and was warm to the touch. LVN 1 stated assessing a resident included to check vital signs and to document in the progress notes. LVN 1 stated vital signs are taken to identify the actual state of the resident since he would not know what is going on with the resident otherwise. During an interview on [DATE], at 9:15 a.m., CNA 1, stated on [DATE] at 11:10 p.m., she notified LVN 1 that Resident 45 was gasping for air and did not look well. CNA 1 stated she went to Resident 45's room with LVN 1. CNA 1 stated she did not witness LVN 1 assessing the resident or taking Resident 45 vital signs. CNA 1 stated LVN 1 told her he would go and look in Resident 45's chart. CNA 1 stated she went to check on Resident 45 again between 4:00 a.m. and 4:05 a.m., and she was still breathing. CNA 1 stated she went back to Resident 45's room around 4:26 a.m., when she heard LVN 1 in Resident 45's room calling Resident 45's name out loud four times. CNA 1 stated LVN 1 told her that Resident 45 was unresponsive, and they did not need to do anything. CNA 1 stated LVN 1 told her we do not need to check Resident 45's vitals. CNA 1 stated she still went to get the vital signs machine and asked CNA 2, who was in the hallway, to join her to assist. CNA 1 stated when CNA 2 and her went back into Resident 45's room with the vitals machine, LVN 1 instructed CNA 2 and her (CNA 1) to start CPR. CNA 1 stated when they started CPR Resident 45 was cold to the touch on her face, hands, and legs. CNA 1 stated LVN 1 brought in the crash cart, did not provide oxygen rescue breaths to Resident 45 during CPR, did not take the vital signs, and did not place the Back Board under Resident 45. CNA 1 stated she did not witness LVN 1 perform CPR on Resident 45 at any time. CNA 1 stated LVN 1 stated he was going to call the Paramedics and did not return to Resident 45's room after that. CNA 1 stated she and CNA 2 took turns to do Resident 45's chest compressions, but they did not provide any rescue breaths as they did not have an Ambu-Bag (handheld device to provide respiratory support to patients who are not breathing). CNA 1 stated while CNA 2 was doing chest compressions, she heard the Paramedics entering the facility and she instructed CNA 2 to stop doing chest compressions since the Paramedics were in the building. During an interview on [DATE], at 10:07 a.m., CNA 2 stated when he was going to take the trash out after changing a resident, he saw CNA 1 walking towards him. CNA 2 stated he did not know what was going on as he did not hear any Code Blue called. CNA 2 stated he walked with CNA 1 to Resident 45's room per CNA 1's request and observed Resident 45 laying in bed with the head of bed elevated. CNA 2 stated CNA 1 asked LVN 1 if he wanted to take vitals and he said, no it is fine and instructed him and CNA 1 to begin CPR, as he (LVN 1) left the room to call Paramedics. CNA 2 stated CNA 1 was looking out in the hallway and heard the Paramedics were coming so she told him (CNA 2) to stop doing chest compressions. CNA 2 stated Paramedics came in and took over the situation. CNA 2 stated at the beginning of the shift (11:00 p.m. to 7:00 a.m.), CNA 1 notified him (CNA 2) that Resident 45 did not look well so CNA 1 and him went to observe Resident 45 together. CNA 2 stated upon observation, Resident 45 had the oxygen via nasal cannula on, but seemed weak as she was not able to move her arms or change positions in her bed and appeared to have issues with breathing. During a concurrent interview and record review on [DATE] at 1:47 p.m., with RN 1, Resident 45's Medication Administration Record ([MAR] document that tracks medications given to residents) dated [DATE] - [DATE] was reviewed. RN 1 stated there were no vital signs documented but considering Resident 45's history of COPD, the oxygen saturation should have been checked and documented. RN 1 stated a review of the doctor's order indicated to monitor vital signs every shift for 72 hours (every shift for baseline vital signs for three days) on [DATE]. RN1 stated since Resident 45's vital signs were not taken; the doctors' orders were not followed. RN 1 stated if it was not documented it was not done. RN 1 stated doctors' orders have to be followed, not following the orders can compromise the residents' health. During an interview on [DATE] at 2:32 p.m., the DSD stated if a Code Blue is called, someone gets supplies, check oxygen saturation, have someone documenting the vital signs, get the crash cart, and call 911. The DSD stated the blood pressure cuff will not be taken off and the vital signs will be continuously checked. The DSD stated every resident's vital signs should be checked at the beginning of the shift. The DSD stated there is a nonrebreather (a manual device used to deliver oxygen) mask on the crash cart, and a Back Board that is needed to provide effective chest compressions. The DSD stated during a Code Blue, while one staff is performing chest compressions another staff member gives rescue breaths with the Ambu-Bag. The DSD stated someone calls the code blue on the overhead paging system to ensure everyone in the facility is aware of the emergency and can respond immediately. The DSD stated CPR needs to be continuous until there is a pulse or until Paramedics arrive and take over the CPR. During an interview on [DATE] at 3:21p.m., the DON stated if a resident is nonresponsive the most important body systems to assess are airways (a passage where air reaches a person's lungs), breathing, and blood circulation. The DON stated if it is appropriate, to start chest compressions, have someone call 911, bring the crash cart, use the Ambu-Bag for rescue breaths. The DON stated chest compressions will be continuously provided until the Paramedics will arrive and take over. During an interview on [DATE] at 4:22 p.m., the DON, stated when a new admission or readmission arrives at the facility, the licensed nurse should accompany the resident to the room to observe the resident's condition and ensure the resident is stable. The DON stated when a resident has a change in condition (COC) the licensed staff are expected to check the resident's blood sugar level and vital signs to see if they are within normal reference range. The DON stated when a resident is having shortness of breath, the licensed nurse cannot leave the resident unmonitored until the resident's condition is stable. During a concurrent interview and record review on [DATE] at 4:42 p.m., LVN 1's Progress Notes were reviewed. The DON stated Resident 45 was admitted back to the facility on [DATE] and passed at the facility on [DATE]. The DON stated the vital signs should have been taken within the shift 11 p.m. to 7 a.m. The DON stated the vital signs were not recorded and if it was not documented it was not done The DON stated LVN 1 and/or RN 1 did not check Resident 45's blood sugar level since Resident 45 was a diabetic and was unresponsive. The DON stated the licensed nurses did not check Resident 45's vital signs during 11:00 p.m. to 7:00 a.m. shift and the last vital signs were taken on [DATE] at 8:49 p.m. during the resident's admission. The DON stated there were no documentations to indicate whether LVN 1 checked Resident 45's pulse prior to instructing CNA 1 and CNA 2 to start CPR. The DON stated when CNA 1 reported to LVN 1 that Resident 45 was not doing well, LVN 1 should have assessed Resident 45 immediately when he went to the resident's room and to check vital signs. During a concurrent interview and record review on [DATE] at 4:53 p.m., with the DON, Resident 45's the Cardiology (a department responsible for concerns with diagnosis and treatment of heart-related diseases and disorders) Note and Supportive Care and Palliative (care focused on improving quality of life for individuals with serious illness without curing the condition) Visit Notes from the GACH were reviewed. The DON stated the Cardiology Note dated [DATE], indicated Resident 45 had a risk for sudden cardiac arrest (an unexpected condition where the heart stops breathing). The DON stated since Resident 45 refused the LifeVest and further implantable cardioverter defibrillator ([ICD] small device that monitors and responds to abnormal heart rhythm), Resident 45 was a high risk for cardiac arrest without interventions from the LifeVest or the ICD. The DON stated the Supportive Care and Palliative Visit Note from the GACH indicated Resident 45 wanted CPR. The DON stated when a resident has a Full Code status, the CPR is expected to be initiated when a resident unresponsive. During a concurrent interview and record review on [DATE] at 5:13 p.m., with the Emergency Medical Services Captain (EMSC), the Paramedic Run Sheet dated [DATE] was reviewed. The EMSC stated when the Paramedics arrived on scene, Resident 45 was found lying on her back in bed pulseless and apneic (involuntarily and temporarily stoped breathing). The EMSC stated the facility's staff were not doing CPR when they arrived. The EMSC stated initiating CPR may increase the chances of a resident survival. During an interview on [DATE] at 6:28 p.m., the DON stated neglect constitutes when staff does not provide needed care and staff is not doing their job in such instances if a resident needs medication and it is not given, that would be considered negligence. During a review of the facility's P&P titled, Abuse Prevention and Prohibition Program, dated February 9, 2024, the P&P indicated each resident has the right to be free from neglect, and mistreatment. The facility has zero-tolerance for neglect, staff must not permit anyone to engage in neglect, and mistreatment. The facility maintains adequate staffing on all shifts to ensure that the needs of each resident are met. Neglect: inadequate provision of care, caregiver indifference to resident's personal care and needs. During a review of the facility's P&P, titled, Change of Condition Notification, dated February 9, 2024, the P&P indicated an acute change of condition (ACOC) is a sudden, clinically important deviation from a patient's baseline in physical, cognitive, behavior, or functional domains. Clinically important means a deviation that, without intervention, may result in complications or death. The Licensed Nurse will assess the resident's change of condition and document the observations and symptoms. A Licensed Nurse will document the following: Date, time, and pertinent details of the incident and the subsequent assessment in the Nursing Notes. The time the Attending Physician was contacted, the method by which he was contacted, the response time, and whether or not orders were received. A Licensed Nurse will document each shift for at least seventy-two (72) hours. During a review of the facility's P&P, titled, Admission Assessment, dated February 9, 2024, the P&P indicated the assessment process must include direct and indirect observation and communication with the resident, as well as communication with licensed and non-licensed direct care staff members on all shifts. Assessment findings may necessitate communication with attending physician for treatment or care orders. The assessment will be documented and will be communicated with licensed and nonlicensed direct care staff members on all shifts. During a review of the facility's P&P, titled, Cardiopulmonary Resuscitation, dated February 21, 2024, the P&P indicated to sustain or support a resident's cardiac and/or pulmonary function(s) until medical emergency personnel are available to take over the resuscitation efforts. Cardiopulmonary resuscitation is instituted on all residents except those designated as No Code or No CPR. In the absence of a DNR order, CPR will be performed. The facility will perform CPR in accordance with the guideline set forth by the American Heart Association. Establish unresponsiveness, verify code status prior to the initiation of CPR, alert the emergency response team (call 911), check for pulse, CPR will be initiated using the standards outline in the American Heart Association's most current CPR guidance, continue CPR until paramedics arrive and take over.

Based on observation, intervention, and record review the facility failed to provide a minimum of 80 square feet (sq. ft. ) for resident per resident in multiple rooms resident bedrooms ( 2, 3, 4, 5, 6, 7, 8, 9, 10, 11,12, 13, 14, 15, 16, 17, 18, and 19 for (17 of 19 residents room). This deficient practice had the potential to impact the ability to provide nursing care to the residents. Findings : During and observation on 1/14/2025 at 00:00 a.m., with the Maintenance (MN), observed multiple resident's rooms with two, three and six beds in a room. Observed residents go in and out of beds with adequate spacing, side tables, chairs, wheelchairs readily available without impending any movement. During an interview on 1/14/2025 at 00:00 a.m., with the MN , the MN stated we have a room waiver now and will apply for one in 2025. During a review of the room size waiver dated 1/2024 submitted by the Administrator (ADM), for 17 residents' room was reviewed, the letter indicated there was ample room to accommodate residents and enough space for residents care and health and safety of the residents occupying these rooms. The letter indicated the following : Room Number Beds Per Room Square Footage Total 2 6 470 sq. ft. 3 6 426 sq. ft. 4 2 153 sq. ft. 5 2 155 sq. ft. 6 2 146 sq. ft. 7 2 145 sq. ft. 8 2 144 sq. ft. 9 2 144 sq. ft. 11 2 146 sq. ft. 12 3 213 sq. ft. 13 3 187 sq. ft. 14 2 129 sq. ft. 15 2 133 sq. ft. 16 3 210 sq. ft. 17 3 214 sq. ft. 18 3 216 sq. ft. 19 3 217 sq. ft. The minimum sq. ft. for a two bedroom is 160 sq. ft. The minimum sq. ft for a three bedroom is 240 sq. ft. The minimum sq. ft. for a six bedroom, is 480 sq. ft. During the survey from 1/13/2025 to 1/18/2025, there were no observed adverse effects as to the adequacy of space nursing care comfort and privacy to the residents. There was ample space to accommodate wheelchairs, beds and other medical equipment including space for mobility and locomotion of residents.

Based on interview and record review, the facility failed to provide documented evidence of all employees screening, education, offering, and current Corona virus disease, COVID-19 (contagious infectious disease), vaccination (medications used to prevent diseases usually given by injection or by mouth) status. This failure had the potential to place staff and residents at risk for serious outcomes such as being hospitalized due to COVID-19. Findings: During an interview and record review on 1/16/2025 at 12:07 p.m., with the Infection Prevention Nurse (IPN), the facility's employee records of COVID-19 status 2024 to 2025 was reviewed, and the physicians and consultants COVID-19 immunization status were unknown. The IPN stated she did not know she had to get the physicians and consultants Covid-19 immunization status. During a review of the facility's policy and procedure (P&P) titled, Covid-Vaccination, implemented 2/9/2024, the P&P indicated the policy was to prevent and minimize transmission of Covid-19. The P&P indicated the facility will educate and offer Covid-19 vaccinations to facility staff and consultants. The P&P indicated facility staff include all paid and unpaid individuals who work in indoor settings where care is provided to residents or have resident access for any purpose.

Based on interview and record review the facility failed to ensure the facility's Water Management Plan (plan that identifies hazardous conditions and steps to take to minimize the growth and spread of bacteria[germs]) was implemented when the water management assessment was not completed. This deficient practice had the potential to expose residents and staff to Legionella (bacteria that can cause serious lung infections) and waterborne infections. Findings: During an interview and record review on 1/16/2025 at 9:19 a.m., there was no documented facility water management plan, and the Infection Prevention Nurse (IPN) confirmed the water management assessment was not completed. The IPN stated we need to complete the assessment to ensure microbial growth (germs) was not spreading. During an interview with the Administrator on 1/16/2025 at 1:00 p.m. the administrator stated the facility will complete the water management assessment because it was required. During a review of the facility policy and procedure (P&P) titled Legionella, implemented 2/9/2024, the P&P indicated the facility will follow guidance issued by the Centers for Disease Control (CDC) and complete the risk assessment in developing a water management plan to reduce Legionella. As indicated the facility will contract with experts to assist in the development of the water management plan. The facility will consider internal and external factors that may contribute to legionella growth.

Based on observation, interview and record review, the facility failed to ensure one of two sampled residents (Resident 4), who was assessed at a moderate risk for developing a skin injury and had intact skin, did not develop the following: a. Stage II (Partial-thickness loss of skin, presenting as a shallow open sore or wound) pressure injury (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) on the sacrum area (tailbone) measuring 0.5 centimeters [(cm) unit of measurement] in length, 0.5 cm in width and 0 cm in depth on 1/5/2025. b. An open area 0.5 cm round superficial red open area on the right buttocks area on 5/25/2024, resolved (healed) on 6/7/2024. c. Stage II pressure injury on coccyx (tailbone area) measured 1.5 cm length by 1.3 cm in width, and 0.2 cm in depth on 6/21/2024, resolved on 7/16/2024. The facility failed to: 1. Implement Resident 4's (untitled) care plan intervention to turn and reposition the resident as needed when in bed or the wheelchair, to prevent the resident from developing a pressure injury by relieving the pressure from the sacrum area. 2. Implement the facility's policy and procedure (P&P) titled, Wound Management revised 2/9/2024, that indicated to prevent the development of skin breakdown/pressure injuries to: a) minimize pressure on the wound, b) notify the Interdisciplinary Team (IDT) to discuss and recommend new interventions for pressure ulcers that reoccur and about pressure ulcers that do not respond to treatment or worsen. These deficient practices resulted in Resident 4 developing a facility-acquired, preventable, Stage II pressure injury on the sacrum area measuring 0.5 cm in length and 0.5 cm in width on 1/5/2024, an open area on the buttocks area measuring 0.5 cm round in the buttocks area on 5/25/2024, and a Stage II pressure injury on the coccyx on 6/21/2024 measuring 1.5 cm long by 1.3 cm wide by 0.2 cm depth. Findings: During a review of Resident 4's Admission Record, the Admission Record indicated Resident 4 was admitted to the facility on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), age related osteoporosis (a disease that causes bones to become weak and more likely to break) without current pathological fracture (broken bones), type 2 diabetes mellitus ([DM]-a disorder characterized by difficulty in blood sugar control and poor wound healing), and mild protein calorie malnutrition (condition where body does not get enough protein and energy). During a review of Resident 4's Minimum Data Set ([MDS], a resident assessment tool), dated 12/4/2024, the MDS indicated Resident 4's cognitive skills (ability to think and reason) for daily decision-making were severely impaired. The MDS indicated Resident 4 required partial assistance (helper does less than half the effort helper lifts support or holds trunk or limbs but provides less than half the effort) with personal hygiene, substantial assistance (helper does more than half the effort, helper lifts or hold trunk or limbs and provides more than half the effort) with eating, dressing, and Resident 4 was dependent (helper does all the effort. Resident does none of the effort to complete activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity) with toileting hygiene and rolling left and right (ability to roll from lying on back to left and right side and return to lying on back on the bed). The MDS indicated Resident 4was at risk for developing pressure injuries. The MDS indicated Resident 4 did not have pressure ulcers or any unhealed pressure injuries. The MDS indicated Resident 40's skin was intact and did not have any ulcers, wounds, and skin problems. The MDS indicated Resident 4 was NOT on a turning and repositioning program. During a review of Resident 4's Braden Scale (a scoring tool used to predict residents' risk of developing a pressure injury, total scores range from 6 - 23. A lower score indicating a higher risk of developing a pressure injury) assessment, dated 3/6/2024, the Braden Scale assessment indicated Resident 4's score was 13 indicating Resident 4 was at moderate risk for developing a pressure injury. The Braden Scale indicated Resident 4's skin was very moist, the resident was chairfast (capable of maintaining a sitting position but lacking the capacity of bearing own weight), had very limited mobility, was unable to make frequent or significant positional changes independently and required moderate to maximum assistance when moving. During an interview and record review on 1/15/2025 at 10:31 a.m. with Certified Nurse Assistant (CNA) 4 Resident 4's CNA flowsheet for January 2025 there was no documented evidence of Resident 4 being turned and repositioned. CNA 4 stated there was no documentation Resident 4 was turned and repositioned. During an interview and record review on 1/15/2025 at 11:28 a.m., with Treatment Nurse 1 (TX 1) Resident 4's Braden Scale for Predicting Pressure Score Risk, dated 3/6/2024, was reviewed and TX 1 confirmed and stated Resident 4's score was 13 indicating Resident 4 was at moderate risk for developing a pressure injury. The Braden Scale indicated Resident 4's skin was very moist, the resident was chairfast, had very limited mobility, was unable to make frequent or significant positional changes independently and required moderate to maximum assistance when moving. During an interview and record review on 1/15/2025 at 11:30 a.m., with TX 1, Resident 4's Skin Weekly Assessment, dated 3/7/2024, was reviewed and TX 1 confirmed and stated Resident 4' did not have a pressure injury in the buttocks or sacrum and coccyx area. During an interview and record review on 1/15/2025 at 11:31 a.m., with TX 1, Resident 4's SBAR (Situation, Background, Assessment, request) Form and progress note, dated 5/25/2024, was reviewed and TX 1 confirmed and stated Resident 4 developed a 0.5 cm superficial red open area on the right buttocks area. During an interview and record review on 1/15/2025 at 11:33 a.m., with TX 1, Resident 4's Skin Weekly Assessment, dated 6/7/2024, was reviewed and TX 1 confirmed and stated Resident 4 developed a facility acquired 0.5 cm superficial red open area on the right buttocks area on 5/25/2024 and it was resolved on 6/7/2024. TX 1 stated the wound was cleansed daily with normal saline (saltwater solution used to clean wounds) and zinc oxide ointment (medicated cream to treat skin irritations) was applied and covered with a dry dressing (gauze dressing that protects wound and helps it heal. During an interview and record review on 1/15/2025 at 11:36 a.m., with TX 1, Resident 4's SBAR Form and progress note, dated 6/21/2024, was reviewed and TX 1 confirmed and stated Resident 4 developed a Stage II pressure injury in the coccyx area measuring 1.5 cm in length by 1.3 cm in width and 0.2 cm in depth and the physician ordered the wound to be cleansed with normal saline, apply zinc oxide, and cover with dressing daily. TX 1 stated this pressure injury was healed on 7/16/2024. During an interview and record review on 1/15/2025 at 11:40 a.m., with TX 1, Resident 4's SBAR Form and progress note, dated 1/5/2025, was reviewed and TX 1 confirmed and stated Resident 4 developed a Stage II pressure injury in the sacrum area measuring 0.5 cm in length by 0.5 cm in width and 0 cm in depth and the physician ordered the wound to be cleansed with normal saline, apply zinc oxide, and cover with dressing daily. TX 1 stated the IDT should meet to discuss new interventions because this was a pressure ulcer that reoccurred. TX 1 stated there was no documented evidence that Resident 4 was repositioned and turned at least every 2 hours and there should be because if it was not documented it was not done. During an interview and record review on 1/15/2025 at 11:42 a.m., with TX 1, Resident 40's Order Summary report as of 1/15/2025, was reviewed and the summary report indicated the following: a. A physician's order dated 10/16/2021, seat cushion while in wheelchair. b. A physician's order dated 3/8/2024, for Multivitamin and minerals (supplement) tablet daily. c. A physician's order dated 3/15/2024, Pro-Stat Oral liquid (supplement liquid protein for wound healing) sugar free, give 30 milliliters one time a day. d. A physicians order dated 6/28/2024 for Ascorbic acid (Vitamin C supplement) 500 milligrams by mouth two times a day e. A physician's order dated 1/6/2025, for Sacrum pressure injury cleanse with normal saline, pat dry, apply zinc oxide and cover with dry dressing daily x 30 days. f. A physician's order dated 1/7/2025, for a low air loss mattress (mattress designed to prevent and treat pressure wounds). g. A physician's order dated 1/19/2025, for Boost (Nutrition powder to promote wound healing) one can two times a day for dietary supplement. TX 1 stated the orders indicated were interventions initiated because of Resident 4's recurring pressure ulcer. During an observation and interview on 1/16/2025 at 9:35 a.m. with the Treatment Nurse 1 (TX 1) at Resident 4's room, Resident 4 was noted to have a Stage II pressure injury on the coccyx area that had no drainage and was 100% epithelial tissue (light pink tissue) and it measured 1 cm in length and 1.2 cm in width. During a record review of Resident 4's untitled care plan initiated on 1/5/2025, The care plan indicated Resident 4 was at risk for developing pressure injuries related to reduced mobility, impaired cognition, variable oral intake, diabetes, malnutrition, osteoporosis, dementia, and history of pressure injuries. The care plan goal indicated Resident 4's risk for skin breakdown will be minimized through review on 3/4/2025.The care plan interventions included Resident 4 would turn and repositioned as necessary, use turn, or lift sheets with position changes, and encourage resident to turn and reposition changes. During an interview on 1/17/2025 at 6:10 p.m., with the Director of Nursing (DON), the DON stated the facility goal was to prevent pressure ulcer development so, the IDT needs to discuss new interventions if not working. The DON also stated the facility need to turn resident at least every 2 hours to prevent pressure ulcers from developing. The DON stated if it was not documented it was not done. During a review of Pressure Injury Prevention Points Portable Document Format (PDF) published by the National Pressure Injury Prevention Advisory Panel, copyright 2020, the PDF indicated the following pressure injury prevention points: 1. Consider bedfast and chairfast individuals to be at risk for development of pressure injury. 2. Develop a plan of care based on the areas of risk, rather than on the total risk assessment score. For example, if the risk stems from immobility, address turning, repositioning, and the support surface. 3. Turn and reposition all individuals at risk for pressure injury, unless contraindicated due to medical condition or medical treatments. 4. Continue to reposition an individual when placed on any support surface. 5. Reposition weak or immobile individuals in chairs hourly (www.npiap.com) During a review of the facility's P&P titled, Wound Management revised 2/9/2024, the P&P indicated to prevent the development of skin breakdown/pressure injuries to: a) minimize pressure on the wound, b) notify the Interdisciplinary Team (IDT) and physician to discuss and recommend new interventions for pressure ulcers that reoccur and about pressure ulcers that do not respond to treatment or worsen. Rehabilitation Services will be notified for appropriate devices and pressure redistributing devices. During a review of the facility's P&P titled, Pressure Ulcer Prevention, implemented 2/9/2024, the P&P indicated the purpose of the policy was to implement measures to prevent and or manage pressure ulcers and minimize complications. The P&P indicated care, and services will be provided to promote and prevent pressure ulcer development. The P&P indicated the nurse will consult with the IDT - Skin Committee.

Based on observation, interview, and record review, the facility failed to ensure accurate monitoring bowel movement and implementing physician's orders to promote health and prevent complications for one of 11 sample residents (6). For Resident 6, who was assessed at risk for constipation and had history of fecal impaction (an accumulation of hardened stools in the rectum or sigmoid colon that the individual is unable to move), the characteristics of the stool (color, consistency, degree of hardness and size) were not monitored resulting in the resident developing fecal impaction. After the resident was treated at a general acute care hospital (GACH) for fecal impaction and readmitted to the facility, nursing staff continued to not monitor the stool characteristics and failed to give laxatives when the resident did not have bowel movements for three days as ordered by the physician and as stated in the plan of care, placing the resident at risk for further fecal impaction. Findings: On 1/6/13 at 9:45 a.m., Resident 6 was observed in bed, had a GT feeding and an indwelling urinary catheter (tubing inserted into the bladder to allow drainage of urine) connected to a draining bag. The resident was unable to communicate to participate in an interview. A review of the clinical record indicated the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident was transferred to a GACH on 11/23/12 due to rectal bleeding and was readmitted on [DATE], after the resident was treated for [REDACTED]. The MDS assessment dated [DATE], indicated the resident had memory problems, was severely impaired in cognitive skills for daily decision-making, had no speech, rarely/never understood or was understand, did not walk and required total assistance with transfer, dressing, eating, toilet use, personal hygiene, and bathing. The resident used a wheelchair as mobility device, was incontinent (unable to voluntarily control) of bowel and had an indwelling catheter for urinary drainage. The resident had a GT used to flush water and for medication administration and had a mechanical altered (blended, chopped, ground, or mashed) diet by mouth. A care plan dated 1/20/11, and last revised on 11/2012, developed for the resident's risk for constipation due to decreased mobility, had a goal for the resident to have bowel movements at least every three days. The approaches included to monitor and record bowel movements daily, and to assess and monitor sign and symptoms of constipation. Another plan of care dated 1/20/11, last updated on 6/1/12, and last revised on 11/2012, developed for the resident's risk for dehydration related to the use of [MEDICATION NAME] (diuretic), use of GT for water flushing, oral nectar-thickened liquids (consistency of nectar), and dependent on staff for eating, had a goal for the resident to be free from of signs and symptoms of dehydration. The approaches included to monitor the residents for signs and symptoms of dehydration. A care plan dated 2/28/12, and last revised on 11/2012, was developed for the resident's risk for constipation and risk for dehydration related to pureed diet (pudding-lice), GT, and use of diuretic, had a goal for the resident to be well nourished and hydrated, have good skin turgor and routine elimination. The approaches included to give diet as ordered, fluids per GT as ordered and monitor for dry, cracked lips, sunken eyes, dark colored urine, increased confusion, and decreased skin turgor. The physician's orders dated 9/30/08, included [MEDICATION NAME] Sodium (stool softener) 25 cubic centimeters (cc) via GT/orally twice a day for constipation, milk of magnesia (MOM - to loosen the stool) at bedtime as needed if no bowel movements in three days, and to flush the GT with 330 cc of water every six hours. A physician's order dated 4/20/09, indicated pureed diet with nectar thick liquid. A physician's order dated 8/31/09, indicated digital disimpaction (manual removal of feces (stool) from the rectum) if no bowel movements for three days and as needed. According to the National Digestive Diseases Information Clearinghouse (NDDIC) website http://digestive.niddk.nih.gob/ddiseases/pubs/constipation_ez/, constipation occurs when stool passes through the large intestine too slowly. When stools stays in the large intestine too long, the intestine removes too much water, and the stool becomes hard and dry. One of the causes of constipation is not drinking enough liquids. Dehydration can cause constipation. According to PubMed Health, a service of the National Library of Medicine, National Institutes of Health, http://www.ncbi.nlm.nih.gov/pubmedhealth/, fecal impaction is a large lump of dry, hard stool that remains stuck in the rectum. It is most often seen in patients with long-term constipation. A review of the Nurse Assistant Notes form for the three shifts (morning, evening and night) from 11/1/12 to 11/23/12, revealed the bowel movement was recorded by number of times; however, the stools characteristics such as color, consistency, degree of hardness and size, were not recorded to determine if the resident was constipated. The pre-printed form for CNAs' documentation did not include description of the stool. On 1/6/13 at 10:35 a.m., a record review was conducted with LVN 4. The Nurse Assistant Notes from 11/1/12 to 11/23/12, indicated the number of times the resident had bowel movements; however, there was no monitoring of the size and consistency (hardness) of the bowel movement to determine if the resident had constipation which was confirmed by LVN 4. According to a nursing note dated 11/23/12, indicated the resident was noted with blood on the diaper, the physician was notified and the resident was transferred to a GACH for further evaluation. According to the GACH documentation dated 11/23/12, the resident arrived to the emergency room with rectal bleeding. On 11/26/12, a colonoscopy (a test that allows looking at the inner lining of the intestine with the use of a thin, flexible tube (scope)) procedure found solid stool up to the proximal splenic flexure (the sharp bend of the colon (large intestine) where the [MEDICATION NAME] colon joins the descending colon and it is located under the spleen) making further scope passage unsafe and without purpose. The recommendation was to do more preparation of the colon and to repeat the procedure. On 11/27/12, a repeat colonoscopy was done and the findings indicated the patient was further manually disimpacted (despite repeat preparation) revealing several non-bleeding stercoral ulcerations (ulcers of the colon due to pressure and irritation from retained fecal masses) in the rectum (final section of the large intestine, terminating at the anus). The resident returned to the facility on [DATE]. The physician's orders upon readmission on 11/28/12, included [MEDICATION NAME] Sodium (stool softener) 25 cubic centimeters (cc) via GT/orally twice a day for constipation, MOM 30 cc via GT/orally at bedtime if no bowel movement for three days and [MEDICATION NAME] suppository at bedtime if the Milk of Magnesia was not effective. A care plan developed on 12/1/12, for the resident's risk for fecal impaction, included in the approaches to monitor and record bowel movements every shift and to give laxatives (promotes the expulsion of feces) as ordered. The CNA - ADL Tracking Form for the month of 12/2012, indicated the resident did not have bowel movement from 12/2/12 to 12/6/12 (five days) and from 12/23/12 to 12/26/12, (four days), however, there was no documented evidence the license nurses were made aware and no evidence laxatives were administered as ordered. In addition, the CNAs' documentation only included the number of bowel movements but not the characteristics of the stool. The pre-printed form for CNAs' documentation did not include description of the stool. According to a facility's undated policy and procedure on Maintenance of Regular Bowel Movement, the purpose of the policy is to ensure all residents are monitored for regular bowel movements. CNAs are to log the resident's bowel movement every shift. For any resident with no bowel movements for three days, CNAs are to report to licensed nurses for laxatives to be administered as ordered. The policy did not address monitoring the stool characteristics. Pursuant to Clinical Gerontological Nursing: A Guide to Advanced Practice/1999 Saunders Co./Joyce Takano Stone, Jean F. Wyman, Sally A. Salisbury. 2nd ed. Page 240, 241: Assessment of Constipation included a patient history, a physical examination and a bowel record. Bowel history and associated symptoms include characteristics of bowel function, frequency of defecation, stool consistency and color, straining, pain with defecation, sensation of incomplete evacuation. On 1/6/13 at 1 p.m., during an interview, LVN 1 stated she was not aware the resident did not have bowel movement for more than three days. LVN 1 stated she sometimes checks the CNAs records of residents' bowel movements. LVN 1 was unable to provide evidence the resident was administered laxative as ordered when there was no bowel movement for three or more days. On 1/6/13, at 1:30 p.m., the DON was unable to explain the reason the licensed nurses did not monitor the resident's bowel movements characteristics and the CNAs' documentation. The DON confirmed the pre-printed form for the CNAs' documentation did not have a section to indicate stool characteristics but only the number of episodes.

Based on observation, interview, and record review, the facility failed to ensure residents with pressure sores and at risk for pressure sore development were provided with the necessary treatment and services to promote healing and prevent further pressure sores from developing for two of 11 sample residents (6, 1). Resident 6 was not provided with pressure relieving devices on the right elbow pressure sore. Resident 6's pressure sore evolved into a Stage IV pressure sore and had [MEDICAL CONDITION] infection (MRSA - contagious infection that does not respond to some antibiotics). Resident 1, who developed a Stage III pressure sore to the right ischial area (buttock area), was not provided pressure relieving devices in wheelchair as ordered by the wound specialist (a physician). Although the pressure sore healed on 9/13/11, no pressure relieving devices were provided to prevent further recurrence. This deficient practice resulted in residents having delayed healing of pressure sores, lack of treatment and potential recurrence of pressure sores. Findings: 1. On 9/19/11, at 9 a.m., Resident 6 was observed in his room sitting in a wheelchair with a dressing on the right elbow. The resident's right elbow was resting directly on the armrest of the wheelchair and there was no device on the right elbow to reduce the pressure. The resident was observed applying pressure to the elbow as he repositioned himself in the wheelchair and then was noted to quickly remove the elbow away from the armrest. At the time of the observation, during an interview with the resident, who was alert and oriented to place and person, he stated that one day, while he was in the patio, another resident told him there were flies on his elbow. The resident informed the nurses and the nurses started providing treatment on his elbow. The resident stated that somehow his elbow kept rubbing on his mattress and it probably caused the sore. The resident also stated he did not have any prior history of open sores to the right elbow. The resident also stated he was never provided with a device to prevent his elbow from rubbing against his bed or the wheelchair. The resident's bed was observed not to have any pressure relieving mattress or an overlay pressure relieving pad. On 9/19/11, at 10:15 a.m., observation of the resident's right elbow wound with Treatment Nurse 1, revealed the wound measured 1.7 centimeters (cm) in length, 2.0 cm in width and 0.5 cm in depth, with 0.5 undermining. Muscle was exposed with a small amount of yellow drainage and there was also dry dark brown drainage. According to the National Pressure Ulcer Advisory Panel (NPUAP - 2007), the definition of a pressure ulcer is a localized injury of the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction. The staging system provides a name to the amount of anatomical tissue loss. According to the admission record, the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the quarterly Minimum Data Set (standardized assessment and care planning tool) dated 7/15/11, indicated the resident had no problem with long or short-term memory, was able to communicate his needs, was independent with daily decision-making, required limited assistance, with one person physical assistance with bed mobility, required extensive assistance in transfers, dressing, personal hygiene, and toileting, and could eat without assistance. The resident was assessed as having a Stage III pressure sore (to the right heel) and was at risk for pressure sores. There was no documented assessment of a pressure sore to the right elbow. A Pressure Ulcer Risk Assessment form dated 1/2011, indicated the resident's total score was eight, which according to the form represented a high risk for skin breakdown. The plan of care developed on 5/19/10, addressed a problem being at risk for skin breakdown due to the history of skin breakdown, decreased mobility, [DIAGNOSES REDACTED]. On 9/10/10, an entry was added to the plan of care indicating a problem with the resident spending long periods of time sitting in the wheelchair. The approach added was to explain to the resident to raise self to relieve pressure by lifting self using the armrests. Further record review revealed the resident had history of multiple pressure sores that had developed at different times and were healed, except for an unstageable pressure sore to the right lateral heel. According to NPUAP -2007, unstageable sore is full thickness tissue loss in which the base of the ulcer is covered by slough (dead tissue - yellow, tan, gray, green or brown) and/or eschar (dry dead tissue - tan, brown or black) in the wound bed. The resident's pressure sores had been under the care of a physician wound specialist since 4/2011. According to the nursing notes, physician's orders [REDACTED]. The wound specialist ordered oral antibiotic and local treatment to the elbow wound. The Wound Care form dated 8/2/11, indicated the right elbow wound of unknown etiology (origin) measured 1.0 cm in length, 1.0 cm in width and the depth was undetermined. The plan/orders included aggressive off-loading (minimizing/relieving pressure) of the area at all times. The wound specialist recommended again on 8/16/11, 8/23/11, 8/30/11, 9/6/11 and 9/13/11, to do aggressive off-loading of the affected areas. The wound specialist assessment of the elbow wound dated 9/13/11, indicated the size was 1.7 cm in length 1.5 cm in width and 1.0 in depth. The the wound bed consisted of 40% yellow slough and 60 percent granulation (healing) tissue. A review of a Non-Pressure Sore Skin Problem Reports (completed by the treatment nurse) were incomplete and only indicated the measurement of the wound. The assessments did not indicate the status of the wound such as drainage, the condition of the surrounding tissue, open or not open or swelling. (The same was noted for assessments on 8/10/11, 8/16/11 and 8/23/11). A laboratory result of a culture of the elbow wound dated 9/3/11, indicated the resident [MEDICAL CONDITION] infection and oral antibiotics were ordered. The facility's undated policy and procedure on Guidelines For Assessing Potential for Decubitus, indicated the use of pressure preventing devices when providing care to residents identified as having skin problems or the potential for skin problems. On 9/21/11, at approximately 9 a.m., the resident was seen by the attending physician who documented and assessed the resident's elbow wound as a Stage IV pressure sore. NPUAP define Stage IV pressure sore as full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed, often include undermining and tunneling. On 9/21/11, at 10 a.m., during an interview, the director of nursing acknowledged the resident was not provided with pressure relieving devices to promote healing and was not able to explain why the facility's policy and the resident plan of care were not implemented to prevent skin breakdown, or promptly identify skin problems. The director of nursing further stated the treatment nurses are to do a complete documentation of the status of the wounds. 3. On 9/15/11, on 9/19/11, and on 9/20/11, from 7:30 a.m. to 1:30 p.m., Resident 1 was observed sitting up in the wheelchair. The resident remained in the same sitting position and had no pressure relieving device in the wheelchair. The resident was alert, but confused, and the skin was pale in color and was noted to be emaciated (very thin). A review of the clinical record revealed the resident was admitted to facility on 9/9/05, with [DIAGNOSES REDACTED]. The MDS assessment dated [DATE], indicated the resident was severely impaired for daily decision-making, was incontinent of bowel and bladder function, needed extensive assistance with all activities of daily living and did not have pressure sores. A pressure ulcer risk assessment dated ,[DATE], revealed the resident had a total score of 11. According to the form, a total score of eight or above represented high risk for pressure sore development. A care plan dated 4/19/11, had an identified problem of being at risk for skin breakdown, related to decreased mobility and GT feeding, with a goal for the resident to be free from skin breakdown. The approaches included to keep the resident clean a dry and to turn every two hours. A Decubitus (pressure sore) Report documented the resident was identified on 8/14/11, with a Stage I pressure sore to the right ischial (buttock) area, that measured 2.0 cm in length by 2.0 cm in width and treatment was started. The treatment was to apply [MEDICATION NAME] (over the counter moisture barrier) ointment. The form defined a Stage I as an inflammation or redness of the skin. The form further documented that the following day, 8/15/11, the right ischial pressure sore was a Stage II measuring 2.3 cm in length by 1.5 cm in width. The form defined a Stage II as a superficial break with redness of surrounding area. On 8/16/11, the documentation indicated the pressure sore was assessed as unstageable with the same size and an undetermined depth. A new treatment was ordered with Santyl ointment ([MEDICATION NAME] - active enzymatic therapy that continuously removes necrotic tissue from wounds at the microscopic level).The form defined a Stage III as a skin break involving full thickness skin loss and possible eschar/necrosis. According to the wound specialist (a physician) documentation dated 8/16/11, the right ischial pressure sore had 70 % black necrotic tissue and 30 % granulating tissue. The plan/orders included aggressive off-loading of the area at all times. The wound specialist assessed the wound on a weekly basis and each time ordered aggressive off-loading of the area. Although the wound was assessed as healed on 9/13/11, there was no documented evidence the pressure sore area was kept off pressure (off-loading) as ordered by the wound specialist. During an interview on 9/19/11, at 9:30 a.m., Treatment Nurse 1 could not explain why the resident did not have a pressure relieving device in her wheelchair to prevent further skin breakdown.

Based on observation, interview, and record review, the facility failed to provide necessary respiratory care and services to a resident receiving continuous oxygen due to a history of [MEDICAL CONDITION] (low blood oxygen) and [MEDICAL CONDITIONS], by not monitoring the resident's blood oxygen levels to ensure appropriate oxygenation, promptly detect changes and implement interventions to prevent complications for 1 of 11 sample residents (8). On four occasions during the past three months, Resident 8 developed altered level of consciousness (ALOC) with low oxygen saturation levels requiring transfer to the acute care hospital for further evaluation. The oxygen saturation was only checked when the resident had ALOC. Findings: On 9/14/11, at 2 p.m., Resident 8 was observed in bed, unable to communicate, had a gastrostomy tube (GT- a tube placed through the skin and the stomach wall to provide nutrition and medications) feeding infusing at 65 cubic centimeters (cc) per hour by the way of a feeding pump, had bilateral hand mittens and was receiving oxygen at two liters per minute (L/min) by way of a nasal cannula (a device for delivering oxygen by way of two small tubes that are inserted into the nares). On 9/14/11, a review of the clinical record revealed Resident 8 was readmitted to the facility 6/15/11, with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS - standardized assessment and care planning tool) dated 7/6/11, revealed the resident was severely impaired for daily decision-making, needed total assistance for all activities of daily living (ADLs) and was incontinent of bowel and bladder functions. A Licensed Nurses Progress Note dated upon readmission on 6/15/11, at 7 p.m., indicated the resident was readmitted to the facility from an acute hospital with [DIAGNOSES REDACTED]. A plan of care dated 6/16/11, developed for the resident's risk for ineffective airway exchange/chest congestion and shortness of breath secondary to [MEDICAL CONDITION], had a goal for the resident to have an effective airway exchange evidenced by no chest congestion or shortness of breath. The approaches did not include the use of oxygen or to monitor the oxygen saturation. Arterial oxygen saturation can be monitored continuously and non-invasively using pulse oxymetry. The techniques involves attaching a probe to the ear, finger , toe, forehead, or bridge of the nose. Pulse oxymetry is valuable when determining oxygen flow rates for the patient on long-term oxygen therapy.(Medical-Surgical Nursing: Assessment and Management of Clinical Problems, Mosby, Lewis, Heitkemper. 5th Edition, 2000. Pages 558-561). Further record review revealed no documented physician's orders for oxygen administration or to monitor oxygen saturation levels. There was no documented evidence the licensed nurses brought to the physician's attention the lack of order to check the resident's oxygen saturation levels. A Licensed Nurses Progress Note dated 7/6/11, at 11 a.m., documented the resident was noted was hard to wake up and his skin was cold and clammy. The oxygen saturation was measured at 86%. An ambulance was called and the resident was transported to an acute care hospital, where he remained until 7/12/11. A Licensed Nurses Progress Note dated 7/12/11, at 4:45 p.m., documented the resident was readmitted from the acute care hospital receiving oxygen at three L/min, was non-responsive and the oxygen saturation fluctuated from 88% to 89%. The physician was informed and the resident was transferred to an acute care hospital at 6 p.m. the same day. The resident remained in the acute hospital until 7/20/11. According to http://www.mayoclinic.com/health/hypoxemia, oxygen is carried in the blood attached to hemoglobin (red blood cells) molecules. Oxygen saturation is a measure of how much oxygen the blood is carrying as a percentage of the maximum it could carry. The blood oxygen level can be determined using a pulse oximeter - a small device that clips on the finger. Normal pulse oximeter readings range from 95 to 100 percent, under most circumstances. Values under 90 percent are considered low. Another Licensed Nurses Progress Note dated 7/20/11, at 5 p.m., documented the resident came back from the acute hospital receiving oxygen at two L/min, was non-responsive and the report from the ambulance crew indicated the pulse oxymetry reading fluctuated from 80% to 85%. The physician was informed and the resident was transferred to an acute care hospital for evaluation, where he stayed until 7/23/11. The resident was readmitted back to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident was admitted with orders for two intravenous antibiotic for pneumonia. There was no physician's order to monitor oxygen saturation and no plan of care addressing the oxygen therapy was developed. There were no interventions developed to determine how the nurses would evaluate the efficacy of the oxygen therapy. A care plan dated 8/15/11, disclosed the resident had a problem of pulling out the GT and the nasal cannula resulting in decreased oxygen saturation. However, there was no documented evidence of an assessment of how this problem (pulling out the nasal cannula) was related to low oxygen saturation. The was no documentation of the number of times the resident removed the nasal cannula, the length of time the resident did no receive the oxygen as result of removing the cannula and measurement of the oxygen saturation during the times the resident was off the oxygen. The interventions included an order for [REDACTED]. There was no documented evidence the resident's oxygen saturation was monitored from 7/23/11 to 9/15/11, at 7 a.m., when a nurse's note disclosed the resident was noted weak and the oxygen saturation measured and fluctuated between 93 to 85%. The physician was informed and the resident was transferred to an acute care hospital for evaluation. The resident returned the same day at 1:30 p.m., with orders to resume previous orders. Again there was no physician's order to monitor oxygen saturation and no plan of care addressing the oxygen therapy was developed. Although the resident had just been sent to the hospital due to fluctuating oxygen saturation, there was no documentation the oxygen saturation was further monitored. A Licensed Nurses Progress Note dated 9/15/11, at 10:30 p.m., indicated the resident was noted to have a temperature of 103 degrees Fahrenheit. The physician was made aware and ordered the resident to be transferred to an acute care hospital for evaluation. The oxygen saturation was not checked prior to transfer. According to an undated facility's policy and procedure on Oxygen Use, the objective of the policy is to provide adequate oxygen to body tissues when there is an existing condition that is inhibiting adequate oxygenation of body tissue. However, the policy did not indicate how the licensed nurses would ensure the adequacy of the oxygen to the body tissues. The policy did not include monitoring the oxygen saturation level. During an interview on 9/20/11, at 10:30 a.m., with Licensed Vocational Nurse 1 (LVN 1), she stated the resident's oxygen saturation was not taken on a daily basis, along with his vital signs. During an interview on 9/20/11, at 4:15 p.m., the MDS coordinator stated the resident had oxygen therapy for shortness of breath and acknowledged the oxygen therapy was not addressed in a care plan. The MDS coordinator stated a care plan should have been developed and must have been overlooked.

Based on observation, interview, and record review, the facility failed to ensure that each resident was provided adequate supervision and assistance devices to prevent accidents for one of 11 sample residents (11). Resident 11, who had history of fall and was assessed as having a decline in ambulation status and in bladder continence, had no interventions addressing the decline with ambulation including supervision, assistive devices, toileting program and referral to specialized rehabilitative services for safe walking and to prevent further falls. This deficient practice resulted in the resident falling on the floor and sustaining a laceration to the right eyebrow that required transferring the resident to an acute care hospital emergency room for the application of five sutures (stitches). Findings: On 9/19/11, at 8 a.m., Resident 11 was observed sitting on the side of his bed with his eyes closed. The resident did not respond to an attempted interview. Observation of the resident's room revealed the resident did not have any walker, cane or other assistive device available to use when walking and transferring. It was also noted the room had no bathroom. The closest restroom was located across the hallway next to the room in front of the resident's room. According to the clinical record review, the resident was admitted to the facility on 5/15/08, with [DIAGNOSES REDACTED]. A review of the resident's Minimum Data Set (MDS - standardized assessment and care planning tool) dated 1/5/11, indicated the resident had a problem with long and short-term memory, was moderately impaired with daily decision-making, had unclear speech, was independent with transfers, ambulation and toilet use and was continent of bowel and bladder function. According to the nurses' notes, the resident sustained [REDACTED]. The resident was found on the floor by the nurses' station and he was unable to recall what happened. The resident was noted with redness and swelling at the left elbow and the left knee. The physician ordered x-rays of the right and left knees and the left elbow and the result dated 1/26/11, indicated no fractures. According to Follow-up Investigation report, the recommendation/intervention included to have physical therapy evaluate the resident's gait and ambulation status. There was no plan of care developed after the resident's fall to address interventions to prevent further falls. According to the Social Service assessment dated [DATE], the resident showed a decline in ambulation and had bladder continence. The resident leaned forward, walked very slow and needed more assistance with activities of daily living (ADLs). The social services note also documented nursing had decided not to provide the resident with a bladder training because of the resident's fall risk. According to an interdisciplinary team note documented in the Nursing Assessment form dated 4/7/11, the resident's quarterly MDS was not completed due to a possible significant change in the status of the resident. The resident had declined in continence and ambulation status. The note further indicated they will continue to observe and consider a significant change of status assessment. Although the resident was identified with a decline in his ambulation abilities, there were no interventions implemented or a plan addressing actual and potential for falls, need of assistive devices to assist with ambulation, need of supervision or physical assistance with walking. There was also no referral for physical therapy to evaluate the resident's physical deterioration and based on the assessment to provide the resident with a rehabilitation program to improve gait, balance, muscle strength and training for the use of mobility devices if needed. The resident who continued to use the toilet, was not placed on a toileting program to promote safety. According to a nurse's note dated 4/10/11, at 9:36 a.m., the resident was found on the floor, calling for help. The resident was noted with a cut on the right eyebrow. The physician was notified and ordered to transfer the resident to an emergency room . A Post-Fall Assessment form dated 4/10/11, indicated the laceration measured 3.5 centimeters (cm) in length by 0.5 in width. A Follow-up Investigation report dated 4/10/11, indicated the resident was trying to go the bathroom and was found by the bed side. Another nurse's note dated 4/10/11, at 2:01 p.m., indicated the resident returned from the acute hospital with five stiches on the right eyebrow and a treatment order was obtained. A (head) computerized tomography (CT - radiological study) scan was negative. According to the Emergency department report from the acute care hospital dated 4/10/11, the resident has a head injury with a simple laceration of the scalp. A nurse's note dated 4/11/11, at 10 a.m., documented the resident was observed continuing to use the toilet as desired, however, daily incontinence was also noted. The documentation did not indicated the resident was receiving supervision and assistive devices to prevent falls. On 4/11/11, at 11:30 a.m., a physician's orders [REDACTED]. However, there was no documentation the physical therapist was involved in assessing and evaluating the type of walker or other assistive device the resident would benefit from. There was no training on the use of the walker and no fitting of the height of the walker based on the resident's height. A care plan dated 4/13/11, addressed the resident's problem of being a risk for fall and injury due to poor safety awareness, history of falls, the use of psychoactive medications and decline in cognitive status due to the disease process of dementia. The interventions included to encourage the use of a front wheel walker when walking and keep close observation to minimize potential for falls. A plan of care dated 4/13/11, developed for the resident's problem of requiring extensive assistance with walking in the corridor, had approaches to keep the front wheel walker always available and to encourage its use. A significant change of condition MDS assessment dated [DATE], indicated the resident had long and short-term memory problems, was independent with bed mobility, transfers, and walking in the room, but needed extensive assistance with a one person physical assist to walk in the corridor. The assessment further documented the resident's walking was not steady and he needed a walker as a mobility device. The resident was always continent of bowel and frequently incontinent of urine. An interdisciplinary team note documented in the Nursing Assessment form dated 4/15/11, the resident had a significant change in status assessment and declined in ambulation and bladder continence. The resident had an actual fall on 4/10/11, possibly related to a decline in the gait. The resident's was slow with the tendency to lean forward. The last physical therapy evaluation was dated 1/25/11. Although the interdisciplinary team addressed the last physical therapy evaluation was done on 1/25/11 (after the fall without injury), there was no documented rationale related to the lack of referral to physical therapy when the resident was identified having a decline in ambulation and when the resident sustained [REDACTED]. On 5/12/11, an order was obtained for the resident to walk with a front wheel walker daily as tolerated with a restorative nursing assistant (RNA). There was no documented evidence there was input from the physical therapist for the RNA exercise program. Another nurse's note dated 9/14/11, at 8:45 a.m., documented the resident was found laying face down in the hallway near the railing by Room 12 (the room across from the resident's room and next to the restroom). The resident sustained [REDACTED]. The physician was informed and x-rays were ordered. The x-ray results were negative for fractures. According to the Initial Investigation Report dated 9/6/11, the resident stated he was trying to go to the bathroom and fell . The report documented the resident did not use the walker and would be encouraged to use the walker at all times. Observation on 9/19/11, 9/20/11, and 9/21/11, from 7:30 p.m. to 2 p.m., revealed the resident did not have a front wheel walker at his bedside. On 9/20/11, at 8:30 a.m., during an interview, the director of nursing confirmed there was no plan of care developed to reduce the resident's risk for fall after the first fall on 1/25/11. The director of nursing could not explain why there was no input obtained from physical therapy to promote a safe ambulation and why there was no toileting program to ensure supervision and assistance to prevent falls. The director of nursing did not explain why there was no front wheel walker in the resident's room. The director of nursing further stated the facility had no policy and procedure to monitor, prevent and reduce the number of falls in the facility.

Based on observation, interview and record review, the facility failed to ensure that a resident maintained acceptable body weight for one of two residents with unplanned weight loss in a sample of 11 residents (1). Resident 1 who was dependent on a gastrostomy tube (GT- a tube placed through the skin and the stomach wall to provide nutrition and medications) lost 13.6 percent (%) of her total body weight within six months after her continuous feeding was changed to [MEDICATION NAME] feeding (a set amount of formula run down the feeding tube at specific times during the day). As a result Resident 1 had a low body weight, a low pre-[MEDICATION NAME] level and developed skin breakdown. This deficient practice resulted in the resident sustaining a severe unplanned weight loss and [MEDICAL CONDITION]. Findings: On 9/14/11, at 2 p.m., Resident 1 was observed in bed, the skin was pale in color and was noted to be emaciated (very thin). The resident was non-verbal and had involuntary body movements. On 9/15/11, a clinical record review revealed the resident was admitted to the facility 9/9/05, with [DIAGNOSES REDACTED]. feeding. The Minimum Data Set (MDS - standardized assessment and care planning tool) dated 7/28/11, indicated the resident was severely impaired for daily decision-making, needed total assistance with all activities of daily living (ADLs) and had a GT for feeding. The Nutritional Assessment form indicated on the date of admission, 9/9/05, the resident's height was 68 inches, the weight was 119 pounds (lbs) and the ideal body weight ranged between 126 to 154 lbs. The Monthly Record of Vital Signs and Weight form for the year 2010 indicated the resident's weight ranged from 119 to 126 pounds. A review of the dietary progress notes dated 1/19/11, revealed the resident's weight was 119 lbs and was receiving [MEDICATION NAME] HN (High in calories (2 calories per milliliter cal/ml) and high-nitrogen liquid formula) one can (eight ounces)every four hours [MEDICATION NAME] feeding. However, on 2/1/11, the resident's weight was 116 lbs (three lbs weight loss) and on 2/7/11, the enteral feeding was changed to [MEDICATION NAME] HN continuous feeding at 85 cubic centimeter (cc) per hour in 18 hours via enteral pump to provide 1530 cc and 3060 calories per day. The resident's weight increased to 120 lbs by 3/1/11, and to 125 lbs by 4/1/11. According to the dietary progress notes dated 3/25/11, the registered dietitian (RD) documented the resident's [MEDICATION NAME] (the major plasma protein) level was within normal levels (between 3.4 to 4.8 grams per deciliters - G/dl). The resident's estimated needs were 1909 to 2227 calories per day, 76 to 95 grams of protein per day and 1636 cc of fluids per day. The RD documented the feeding ordered met the resident's estimated needs. During the last six months from 4/1/11 to 9/2/11, according to the monthly weight record, the resident's sustained a 15 lbs weight loss as follows: On 4/1/11= the resident's weight was 125 lbs. On 5/2/11= the resident's weight was 125 lbs. On 6/1/11= the resident's weight was 123 lbs. On 7/1/11= the resident's weight was 119 lbs. On 8/1/11= the resident's weight was 110 lbs. On 9/2/11= the resident's weight was 110 lbs. A plan of care developed on 4/19/11, for the resident's problem of altered nutrition and GT, included in the goals that the resident will be able to tolerate feeding and will receive adequate calorie and nutritional requirement daily. The approaches included to observe for tolerance to the feeding like presence of diarrhea, nausea and vomiting. According to a dietary progress note dated 4/22/11, the RD documented the resident was tolerating the continuous GT and the feeding met the resident's estimated needs. The RD further documented the laboratory test dated 3/9/11, indicated the resident's hemoglobin (protein in the red blood cells) and hematocrit (the percentage of the volume of whole blood that is made up of red blood cells) were within normal levels. According to a nurse's note dated 5/18/11, the physician was called regarding the resident pulling the GT and the physician ordered to change the continuous feeding to [MEDICATION NAME] HN one can, every four hours to deliver 2850 calories/1400 cc per day. However, further review of the nursing notes and the interdisciplinary noted prior to 5/18/11, did not indicate the resident had episodes of pulling the tubing. There was no plan of care addressing the resident's behavior of pulling the tubing. There was no documentation the RD was notified of the new order. The RD documented in the dietary progress notes dated 5/27/11, the resident was pulling out the GT, was placed on [MEDICATION NAME] feeding and the nutritional needs were met with the current order. On 6/24/11, the RD documented in the dietary progress notes the resident had a weight loss of two pounds and the laboratory tests results dated 6/8/11, indicated the hemoglobin and hematocrit were below the normal levels. Hemoglobin was 10.6 with a reference range from 11.5 to 15.0 G/d and the hematocrit was 32.7 with a reference range from 34.0 to 44.0 percent (%). There was no [MEDICATION NAME] level obtained. The RD further indicated the resident will be monitored for change of weight, adjust or change the GT feeding. A plan of care developed on 7/15/11, due to the resident's problem of having a GT feeding, had a goal for the resident to be well nourished and hydrated daily. The approaches included to give the formula as ordered, observe for feeding intolerance, nausea, vomiting and diarrhea and adjust calories as needed for weight gain. On 7/22/11, the RD documented the resident was tolerating well the formula and the formula exceeded the resident's nutritional estimated needs per day. The RD documented that if the resident had further weight loss, the GT formula would be increased the following month. The RD did not recommend to monitor the resident's weight more frequently than monthly when the resident by 7/1/11, had already lost six pounds of body weight. On 8/11/11, the RD documented in the dietary progress notes she was informed by the interdisciplinary team the resident was not tolerating the GT. The RD recommended to change the formula to Carnation VHC (very high calorie liquid nutrition) one can (250 cc) five times a day, to provide 2813 calories/1250 cc per day. However, a review of the nursing notes and interdisciplinary team notes prior to 8/11/11, revealed no documentation of intolerance to the GT feeding formula. The nursing documentation did not indicate the resident had diarrhea, nausea, vomiting, abdominal distention or any other symptom suggesting feeding intolerance. By 8/1/11, the resident had lost a total of 15 lbs since the change of feeding formula on 5/18/11, from continuous feeding via pump to [MEDICATION NAME] feeding. A Decubitus Report form dated 8/14/11, indicated the resident had developed a Stage II pressure sore to the left lower buttock (ischial area) with a size of 2.3 centimeter (cm) by 1.5 cm. A treatment with [MEDICATION NAME] (over the counter moisture barrier) was started. A review of a laboratory report dated 8/19/11, revealed the resident's pre-[MEDICATION NAME] level was 9.7 milligrams (mg) per deciliters with a reference range from 18-45 mg/dl. Pre-[MEDICATION NAME] is a protein produced in the liver, it has a short half-life (two days), which makes it a good indicator of nutritional status (Lippincott William & Wilkins, Diagnostic Tests Made Incredibly Easy! 2nd edition, 2009, Page 46). Another, dietary progress note dated 8/26/11, revealed the resident was tolerating the GT feeding well with no problems. A laboratory blood test report dated 9/19/11, indicated an abnormal hemoglobin level of 10.1 G/dl and an abnormal hematocrit level of 31.1%. The resident sustained [REDACTED]. However, there was no documented evidence the interdisciplinary team investigated possible causal factors for the weight loss including accurate administration of the feeding formula. There was no intake and output monitoring, calorie count, or other interventions to ensure adequate intake and tolerance. There was no documented communication with the physician related to the unplanned progressive weight loss for further assessment to identify underlying medical conditions causing the continuous weight loss. On 9/19/11, at 10:30 a.m., upon the Evaluator's request, the resident's weight was obtained and was 108 lbs The resident had a weight loss of two pounds since 9/1/11 and a total of 17 pounds in six months. During an interview on 9/19/11, at 11 a.m., with the dietary supervisor, she stated the reason the resident was changed from continuous GT feeding was because the resident would turn over the feeding pole (the stand where the feeding and the enteral pump are hung) every day. She further stated the reason the resident's feeding formula was changed from the HN formula to VHC formula was because the resident could not tolerate the HN formula and would have diarrhea several times a day. However, there was no documented evidence in the clinical record to confirm the dietary supervisor's statement. By the last day of the survey, 9/21/11, attempts to interview the RD failed. On 9/20/11, at 7:45 a.m., during an interview, the charge nurse stated the resident did not receive continuous feeding because she kept on pulling the tubing causing the GT pole to fall. On 9/20/11, at 10 a.m., during an interview, the director of nursing was unable to explain the lack of nursing documentation related to the resident's feeding intolerance and diarrhea episodes. The director of nursing could not provide documented evidence that the causal/risk factors were evaluated and analyzed for the resident's gradual weight loss. In addition, the director of nursing did not provide documented evidence that the feeding intake was consistently monitored to ensure effectiveness of interventions.