Every finding on record at Walnut Creek Skilled Nursing & Rehabilitation Cent

Based on observation, interview and record review, the facility failed to ensure for one of two sampled residents (Resident 1) who received enteral nutrition via PEG (Percutaneous Endoscopic Gastrostomy, a flexible feeding tube inserted through the abdomen directly into the stomach. It provides nutrition, fluids, and medications for individuals who cannot eat or swallow by mouth, also referred to as g-tube) tube was provided care and services in accordance with physician orders and accepted standards of practice when:- Resident 1's head of bed (HOB) was not elevated during feeding as required.- The g-tube placement was not measured prior to administration of feeding and medications.- Dressing-change order for the PEG-tube site was not followed.This failure placed Resident 1 at risk for complications including infection at the tube site and aspiration during feeding.Findings:During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility in June 2022 with diagnoses that included presence of gastrostomy, cerebral infarction (commonly known as an ischemic stroke, is the death of brain tissue caused by a blocked blood vessel that stops blood and oxygen flow), gastroesophageal reflux disease (GERD, a long-term condition where stomach acid flows back up into the tube connecting your mouth and stomach, causing frequent heartburn and irritation) and dysphagia (difficulty swallowing).During a concurrent observation and interview on 7/22/26 at 11:08 a.m. inside Resident 1's room, Registered Nurse (RN) 1 was at Resident 1's bedside, the feeding machine was running. RN 1 stated she was administering the prescribed water flush prior to initiating the feeding. Resident 1 positioned in bed with HOB at a low angle, RN 1 stood on the left side of the bed near the feeding machine. When asked whether any steps had been overlooked at the start of the feeding, RN 1 did not respond and remained at the bedside. Upon inquiry regarding the adequacy of Resident 1's head elevation, RN 1 stated that the head of the bed was elevated to approximately 20-25 degrees. RN 1 stated it was important to raise the head of the bed while feeding to prevent aspiration.During a review of Resident 1's enteral feeding tube care plan last revised 10/22/25 and OSR as of 7/22/26, the care plan indicated Resident 1 was at risk for aspiration pneumonia (a lung infection caused by inhaling foreign material, such as food, liquid, saliva, or vomit into your airways instead of swallowing it) related to enteral feeding. One of the interventions to avoid aspiration was to elevate HOB to 30-45 degrees during feeding infusion and at least thirty minutes after feeding. Both the care plan and OSR also indicated to verify placement of feeding tube before administration of medications and/or feeding by measuring the external length of the g-tube from the insertion site to tube end and to hold if current length exceeds 1 cm difference. During an interview on 7/22/26 at 3:10 p.m. with RN 1, RN 1 stated she had not measured Resident 1's g-tube length during her shift starting at 7 am. RN 1 stated she had already administered feeding for both breakfast and lunch, and scheduled morning medications were already given.During a review of the Medication Administration Record (MAR) for July 2026, the MAR indicated that RN 1 signed off several medications and ordered water flushes via g-tube as administered: aspirin, cholecalciferol, folic acid, omega 3, thiamine hydrochloride, cholestyramine, lamotrigine, levetiracetam, magnesium, Nutri source fiber, tizanidine, Vimpat, magnesium (all scheduled for 9 a.m.), omeprazole at 11 a.m. and Liquacel at 12 noon. The MAR also indicated an order for Isosource 1.5 Cal (200 ml), three times daily with 75 ml water flush before and after feeding, which RN 1 signed off for the 9 a.m. dose.During further review of Resident 1's clinical record, the clinical record indicated the following past hospitalizations:- Hospitalist Discharge Summary (HDS) dated 6/21/25, the HDS indicated Resident 1 was sent to the hospital on 6/14/25 following nausea, vomiting, fever and mild hypoxia. Resident 1 was admitted to the hospital and received antibiotics (treats infection) for sepsis (a life-threatening medical emergency that happens when the body has an extreme, harmful response to an infection) likely caused by aspiration pneumonia and was discharged from the hospital on 6/21/25.-On 7/3/25, Resident 1 was hospitalized for seizures (a sudden, abnormal burst of electrical activity in the brain that can cause temporary changes in movement, behavior, feelings, or awareness), tachycardia (fast resting heart rate of more than 100 beats per minute), hypoxia (low levels of oxygen in your body tissues) with oxygen saturation (measures the percentage of hemoglobin in your blood carrying oxygen, 95%-100% normal level, below 90% is low oxygen) as low as 89 %, increased respiratory rate and fever of 100 deg F. Resident 1 was admitted for sepsis secondary to pneumonia, received antibiotics for five days and returned to the facility on 7/8/25.-On 7/15/25, Resident 1 was brought to the hospital for shortness of breath and hypoxia, with oxygen saturation down to 88%. Antibiotics were started for pneumonia, which resolved the hypoxia. Resident 1 returned to the facility on 7/17/25.During a review of the facility's policy and procedure (P&P) titled Enteral Feedings-Safety Precautions last revised November 2018, the P&P indicated, to prevent aspiration during feeding, the g-tube placement should be checked prior to feeding or administration of medications and the HOB should be elevated at least 30 degrees during tube feeding and at least an hour after feeding.During a review of Resident 1's Progress Notes (PN), the PN indicated the following:-On 4/10/26 at 5:50 a.m., Resident 1's g-tube leaked, the licensed staff notified Attending Physician (AP), who ordered a hospital transfer for g-tube replacement. -On 4/10/26 at 10:40 a.m., Resident 1 returned to the facility from the hospital after g-tube replacement and repositioning, g-tube stoma (small opening made through the skin of the abdomen directly into the stomach to allow for feeding, fluids, and medications) site had scant drainage/leakage, dressing was changed, and feeding via g-tube continued.-On 4/10/26 at 10:15 p.m., Resident 1's g-tube was observed leaking around the insertion site.-On 4/11/26 at 8:46 a.m., Resident 1's g-tube continued to leak and soaked Resident 1's gown and blanket. AP was again notified, and Resident 1 was sent back to the hospital for g-tube replacement.-On 4/11/26 at 4:08 p.m., Resident 1 returned to the facility after another g-tube replacement.During a review of Emergency Department (ED) After Visit Summary (ED AVS) dated 4/11/26, the ED AVS indicated instructions that included wound care follow-up, changing the g-tube dressing three times daily or more often if dressing becomes saturated, and regular close follow-up with the primary doctor.During a review of Resident 1's Order Summary Report (OSR) as of 7/22/26, the OSR indicated a physician's order dated 6/21/25 to cleanse g-tube stoma site with normal saline and cover with dry clean dressing daily and/or as needed if soiled or dislodged. However, the order did not indicate or confirm whether it had been updated to match the latest dressing instructions provided by the Emergency Department dated 4/11/26.During a concurrent interview and record review on 7/21/26 at 4:53 p.m. with Unit Manager (UM) 1, Resident 1's OSR, ED AVS dated 4/11/26 and Monitoring Records (MR) were reviewed. UM 1 stated the ED physician instructions were not followed because staff adhered to the facility's policy of changing the stoma dressing once daily. UM 1 was uncertain why the instructions were not followed but suggested AP might have altered the order after verifying the ED instructions. However, the clinical records, including the PN did not show that ED instructions were verified with AP. During a review of AP's SOAP (Subjective, Objective, Assessment and Plan, a clear, four-part way for doctors, nurses, and therapists to write down patient visits) Notes dated 4/13/26 and 4/27/26, the SOAP Notes did not indicate changes to the ED dressing order. During a review of Resident 1's MR for the months of April 2026, May 2026, June 2026 and July 2026, the MRs indicated the dressing on the g-tube site was changed once daily during the night shift.

Based on observation, interview, and record review, facility failed to maintain complete and accurate medical records for three out of four (Residents 1, 2, and 3) reviewed residents. This failure had the potential to lead to incorrect monitoring for residents in the behavioral health unit, potentially leading to harm. During a review of facility's document titled, admission Record, for Resident 1, printed 5/19/26, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with multiple diagnoses, including schizoaffective disorder (a mental health condition that is marked by a mix of symptoms, including hallucinations and delusions and mood disorder symptoms). During a record review of facility's document titled, Close Observation Log, for Resident 1, dated 5/19/26, the Close Observation Log indicated Resident 1 was on monitoring for auditory hallucination (hearing things or voices that are not real) and self-harm. During an observation on 5/19/26 at 2:07 p.m., Licensed Vocational Nurse (LVN) 2 got up from the nursing station, went to the room for Resident 1 and observed Resident 1. LVN 2 then charted that Resident 1 was observed on 5/19/26 at 1:45 pm and 2:00 p.m.During an interview and concurrent record review on 5/19/26 at 2:09 p.m. with LVN 2, facility's document titled, Close Observation Log, dated 5/19/26, for Resident 1, was reviewed. LVN 2 stated she had just entered that Resident 1 had been observed at 1:45 p.m. and 2:00 p.m. and she had made the 1:45 p.m. entry late.In a record review of facility's document titled Close Observation Log, dated 5/19/26, for Resident 1, the entry at 1:45 p.m. on 5/19/26 did not state it was a late entry.During a review of facility's document titled, admission Record, for Resident 2, printed 5/20/26, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with multiple diagnoses, including schizoaffective disorder.In a record review of facility's document titled Close Observation Log, dated 5/19/26, for Resident 2, the Close Observation Log indicated Resident 2 was being monitored because she was a new admission to the behavioral health unit.During a record review on 5/19/26 at 2:12 p.m., facilities document titled, Close Observation Log, for Resident 2, dated 5/19/26 was reviewed. The Close Observation Log on 5/19/26 at 2:12 p.m. indicated that Resident 2 was last observed on at 5/19/26 at 1:30 p.m.During an observation on 5/19/26 at 2:13 p.m., Certified Nursing Assistant (CNA) 2, at the nursing station of the behavioral health unit, charted on the Close Observation Log, dated 5/19/26, that Resident 2 was observed on 5/19/26 at 1:45 p.m. and 2:00 p.m.During an interview on 5/19/26 at 2:14 p.m. with CNA 2, CNA 2 stated she had entered the times for both 1:45 p.m. and 2:00 p.m. at 2:13 p.m.During a record review of facility's document titled Close Observation Log, dated 5/19/26, for Resident 2, the entry on 5/19/26 at 1:45 p.m. did not indicate that it was a late entry.During a concurrent interview and record review on 5/20/26 at 5:18 a.m. with Certified Nursing Assistant (CNA) 1, facility's documents titled, Close Observation Log for Resident 1 and Resident 2, dated 5/19/26, were reviewed. CNA 1 stated the Close Observation Log for Resident 1 and Resident 2, dated 5/19/26, indicated Resident 1 and Resident 2 were observed on 5/20/26 at 5:30 a.m. and 5:45 a.m. and those times are in the future, and the log should not be filled out in advance.During a concurrent interview and record review on 5/20/26 at 8:45 a.m., with Behavioral Health Director (BHD), photographs of facility's documents titled Close Observation Log, dated 5/19/26 at 5:19 a.m., for Residents 1 and 2 were reviewed. BHD stated the photograph of the Close Observation Log, dated 5/19/26, indicated that at 5:19 a.m. it was charted that Residents 1 and 2 were checked on at 5:30 a.m. and 5:45 a.m. BHD stated it is never OK to chart early; it is impossible to know what will happen in the future and it is incorrect documentation. BHD stated that if CNA 1 made a mistake and charted too early, they should have put a line through their initials and then documented that they checked at the correct time.During an interview on 5/20/26 at 9:00 a.m. with the Director of Nursing (DON), the DON stated it is never acceptable to chart too early and if a staff member realized that they charted too early, they should put a line through what they charted and then document at the correct time.During a concurrent interview and record review on 5/20/26 at 8:15 a.m., with Licensed Vocational Nurse (LVN) 1, facility's document titled, SBAR Summary for Providers, for Resident 1, dated 5/17/26 at 3:16 p.m. was reviewed. LVN 1 stated she wrote the SBAR Summary for Providers, for Resident 1, dated 5/17/26, which states .Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: A. Recommendations: 1:1 Close Observations for 72 hours. LVN 1 stated this was incorrect documentation and that this was not the Primary Care Provider's recommendation. LVN 1 stated putting Resident 1 on one to one monitoring (residents may be placed on one-to-one observation when it is determined that they need additional monitoring for safety or other reasons) was a nursing decision and she should have written the recommendation for one to one monitoring in a different box on the form. During a concurrent interview and record review on 5/20/26 at 8:20 a.m. with BHD, facility's documents titled, Health Status Note, dated 5/20/26, 5/19/26, and Change of Condition Note x 72 hours, dated 5/19/26 were reviewed. BHD stated the documents indicate Resident 1 was on one to one monitoring on 5/19/26 and 5/20/26. BHD stated the documents are incorrect and Resident 1 was on every 15 minute monitoring on those dates.During a concurrent interview and record review on 5/20/26 at 8:25 a.m. with LVN 2 and BHD, facility's document titled Change in Condition Note x 72 hours, dated 5/18/26 at 4:07 p.m., LVN 2 stated she wrote this note and it states, .Q15 minute monitoring continues BHD stated the note is confusing and it should have stated that Resident 1 was no longer on one to one monitoring and Resident 1 was now on every 15 (Q15) minute monitoring. BHD stated this note is unclear medical chart documentation.During a concurrent interview and record review on 5/20/26 at 8:47 a.m., with BHD, facility's document titled, Close Observation Log, dated 5/18/26 and 5/19/26 for Resident 1 was reviewed. BHD stated the Close Observation Log indicated Resident 1 was on one to one monitoring. BHD stated on 5/18/26 after 4:07 p.m. and on 5/19/26, Resident 1 was on Q15 monitoring and the Close Observation Log, dated 5/18/26 and 5/19/26 is incorrect documentation.During a concurrent interview and record review on 5/20/26 at 11:45 a.m. with BHD, facility's document titled Close Observation Log, dated 5/18/26 for Resident 2, was reviewed. BHD stated the document does not indicate if Resident 2 is on one to one observation or Q 15 monitoring and it is incomplete and potentially confusing and is incomplete medical chart documentation. During a review of facility's document titled, admission Record, for Resident 3, printed 5/19/26, the admission Record indicated Resident 3 was admitted to the facility on [DATE] with multiple diagnoses, including schizoaffective disorder.During a concurrent phone interview and record review on 5/21/26 at 12:41 p.m. with BHD, facility's documents titled, NSG: Skilled Charting, dated 4/25/26 and 4/27/26 and Health Status Note, dated 4/29/26 for Resident 3 were reviewed. BHD stated NSG: Skilled Charting, dated 4/25/26 indicated Resident 3 was started on 1 to 1 monitoring at 5:17 p.m. on 4/25/26. BHD stated NSG: Skilled Charting, dated 4/27/26, indicated Resident 3 was transitioned from 1 to 1 monitoring to Q15 monitoring on 4/27/26 at 9:52 p.m. BHD also stated NSG: Skilled Charting, dated 4/27/26, was a confusing note, as it stated Resident 3 .remains on close 15-minute observation. and it does not clearly state that Resident 3 was transitioned from 1 to 1 monitoring to Q15 monitoring and is unclear medical chart documentation.During a concurrent phone interview and record review on 5/21/26 at 12:41 p.m. with BHD, facility's document titled, Change in Condition Note x 72 hours for Resident 3, dated 4/28/26 at 14:27 p.m. was reviewed. BHD stated this note indicated Resident 3 was continuing on 1:1 monitoring on 4/28/26. BHD stated he believed this note was incorrect medical chart documentation.During a review of facility's policy and procedure, titled, Guidelines for Charting and Documentation, dated 2012, the policy indicated, .If an error is made while recording data in the medical record, line through the error with a single line and then record the correct data. If a chart entry must be made late, enter the current date and time and indicate that it is a late entry.During a review of facility's policy and procedure, titled, Guidelines for Charting and Documentation, dated 2012, the policy indicated, Documentation should also include .whenever the level of care changes .

Based on interview and record review, the facility failed to ensure the comprehensive care plan was reviewed and revised for two out of four sampled residents (Residents 1 and 3). This failure had the potential to result in incorrect or delayed monitoring interventions, miscommunication among staff, and increased risk of harm for residents requiring enhanced behavioral safety supervision.During a review of facility's document titled, admission Record, for Resident 1, printed 5/19/26, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with multiple diagnoses, including schizoaffective disorder (a mental health condition marked by a mix of symptoms including hallucinations, delusions, and mood disorders, such as depression or mania). During an interview on 5/19/26 at 4:30 p.m. with Licensed Vocational Nurse (LVN) 3, LVN 3 stated there was an incident on 4/25/26 between Resident 1 and Resident 3 when Resident 3 became very agitated and suddenly escalated and tried to attack Resident 1. LVN 3 stated staff immediately separated the residents and both Resident 1 and Resident 3 were placed on 1 to 1 monitoring (residents may be placed on one-to-one observation when it is determined that they need additional monitoring for safety or other reasons). During a concurrent phone interview and record review with Behavioral Health Director (BHD) on 5/21/26 at 12:18 p.m., facility's document titled Health Status Note for Resident 1, dated 4/27/26 at 10:34 p.m., was reviewed. BHD stated the Health Status Note indicated Resident 1 was transitioned from 1 to 1 monitoring to every 15 (Q15) minute monitoring on 4/27/26 at 10:34 p.m. BHD stated the Health Status Note is potentially confusing, as it states Resident 1 .remained on continuous Q15-minute close observation. and does not clearly state that Resident 1 was transitioned from 1 to 1 monitoring to Q15 minute monitoring. BHD also stated there was an interdisciplinary team (IDT) meeting to discuss transitioning Resident 1 from 1 to 1 monitoring to Q15 and this meeting was not documented. BHD stated there should have been a clear note in Resident 1's medical record stating that there was an IDT meeting to discuss and that Resident 1 was switched from 1 to 1 monitoring to Q15 minute monitoring to avoid confusion.During a concurrent phone interview and record review on 5/21/26 at 12:18 p.m. with BHD, facility's document titled, Care Plan Report, printed 5/19/26, for Resident 1 was reviewed. BHD stated the Care Plan Report indicated Resident 1 was placed on 1 to 1 monitoring on 4/25/26. BHD stated Resident 1 was transitioned to Q15 minute monitoring on 4/27/26 and this was not reflected on Resident 1's care plan.During an interview on 5/20/26 at 8:35 a.m. with BHD, BHD stated when residents are changed from 1 to 1 monitoring to Q15 monitoring, it should be reflected in the care plan and that helps staff be aware of what's going on with the residents. BHD also stated the purpose of a care plan is to provide appropriate care and interventions to the residents.During a concurrent interview and record review on 5/20/26 at 8:25 a.m. with LVN 2 and BHD, facility's document titled Change in Condition Note x 72 hours, dated 5/18/26 at 4:07 p.m., was reviewed. LVN 2 stated this note indicated Resident 1 was transitioned to Q15 monitoring on 5/18/26 at 4:07 p.m. LVN 2 stated this was done because Resident 1 had been on 1 to 1 monitoring for over 24 hours. During a concurrent interview and policy review on 5/20/26 at 8:40 a.m. with BHD, facility's policy titled, Close Observation One-to-One Monitoring, revised March 2024 was reviewed. BHD stated the policy indicated an interdisciplinary team would meet to discuss transitioning residents from 1 to 1 monitoring to Q15 monitoring. BHD stated he was on vacation on 5/18/26 and staff would have met with the Director of Nursing (DON) in his absence to discuss transitioning Resident 1 from 1 to 1 monitoring to Q15 minute monitoring.During an interview on 5/20/26 at 8:56 a.m. with the DON, DON stated there was not an IDT meeting on 5/18/26 to discuss transitioning Resident 1 from 1 to 1 monitoring to Q15, therefore the Close Observation One-to-One Monitoring policy was not followed.During a review of facility's document titled, admission Record, for Resident 3, printed 5/19/26, the admission Record indicated Resident 3 was admitted to the facility on [DATE] with multiple diagnoses, including schizoaffective disorder.During an interview on 5/20/26 at 9:13 a.m., with DON, DON stated Resident 3 was involved in an altercation with Resident 1 on 4/25/26. DON stated at that time, Resident 3 was a danger to self and to other residents and was put on 1 to 1 monitoring. During a concurrent phone interview and record review on 5/21/26 at 12:41 p.m. with BHD, facility's document titled, Care Plan for Resident 3, print date 5/19/26, was reviewed. BHD stated the document indicated on 4/25/26, Resident 3 would be placed on 1 to 1 monitoring for 72 hours. During a concurrent phone interview and record review on 5/21/26 at 12:41 p.m. with BHD, facility's documents titled, NSG: Skilled Charting, dated 4/25/26 and 4/27/26 and Health Status Note, dated 4/29/26 for Resident 3 were reviewed. BHD stated NSG: Skilled Charting, dated 4/25/26 indicated Resident 3 was started on 1 to 1 monitoring at 5:17 p.m. on 4/25/26. BHD stated NSG: Skilled Charting, dated 4/27/26, indicated Resident 3 was transitioned from 1 to 1 monitoring to Q15 monitoring on 4/27/26 at 9:52 p.m. BHD also stated NSG: Skilled Charting, dated 4/27/26, was a potentially confusing note, as it stated Resident 3 .remains on close 15-minute observation. and it does not clearly state that Resident 3 was transitioned from 1 to 1 monitoring to Q15 monitoring. BHD also stated that there was an IDT meeting to discuss and this was not documented in Resident 3's medical record. BHD stated there was approximately 52 hours between Resident 3 starting 1 to 1 monitoring on 5:17 p.m. on 4/25/26 and transitioning to Q15 monitoring at 9:52 p.m. on 4/27/26 and this was less than the 72 hours stated on the care plan.During a phone interview on 5/20/26 at 11:59 a.m. with Facility Psychiatrist (MD 1), MD 1 stated there should be an IDT meeting to discuss if patients should be transitioned from 1 to 1 monitoring to Q15 minute monitoring and it should be a team decision.During a review of facility's policy and procedure titled, Special Treatment Program (STP) - Care Planning, dated 7/1/25, the policy indicated, .The care plan must be:. Modified as needed based on progress toward goals or change in diagnosis or level of care.During a review of facility's policy and procedure titled, Close Observation One-to-One Monitoring, revised March 2024, the policy indicated, . Once the resident no longer displays the targeted concern, the interdisciplinary team will convene to assess the necessity of continuing the close observation one-to-one monitoring and move to the close observation every 15-minute monitoring.

Based on interview and record review, the facility failed to obtain daily weights as ordered by the physician for one of four sampled residents (Resident 4). This failure had the potential to lead to fluid overload (a condition where there is too much fluid in the body) in a patient with heart failure (a condition where the heart cannot pump enough blood to meet the body's needs) which could result in Resident 4 needing to be readmitted to the hospital.During a record review of facility's document titled, admission Record, printed 5/22/26, for Resident 4, Resident 4 was admitted to the facility on [DATE] with multiple diagnoses including heart failure, fluid overload (a condition where there is too much fluid in the body) and localized edema (swelling caused by excess fluid trapped in the body's tissues).During a concurrent interview and record review on 5/19/26 at 3:35 p.m. with the Director of Nursing (DON), facility's documents titled Order Summary Report, printed 5/20/26, for Resident 4, was reviewed. DON stated the Order Summary Report indicated there was an order dated 9/3/25 stating Weight Daily in the morning for Heart Failure Monitoring for Resident 4. During a concurrent interview and record review on 5/19/26 at 3:35 p.m. with the DON, facility's document titled Order Summary Report, printed 5/20/26, for Resident 4, was reviewed. DON stated the Order Summary Report indicated there was an order dated 9/3/25 for Furosemide Oral Tablet 20 MG (a medication that helps the body get rid of excess water) stating Give 1 tablet by mouth as needed for weight gain if weight gain of 2 or more pounds in 1 day or 4 or more pounds in 4 days, take 2 tabs every morning for 3 days. DON stated this order is written so the nurses can adjust the medication based on the resident's weight. DON also stated it would be impossible to follow this order without checking Resident 4's weight every day.During a concurrent interview and record review on 5/19/26 at 4:03 p.m. with DON and Registered Dietician (RD), facility's document titled, Treatment Administration Record, dated September 2025, for Resident 4, was reviewed. DON stated the Treatment Authorization Record indicated Resident 4 did not have daily weights entered on 9/4/25, 9/5/25, and 9/6/25. During a concurrent interview and record review on 5/19/26 at 4:03 p.m. with DON and Registered Dietician (RD), facility's documents titled, Medication Administration Record, dated September 2025, for Resident 4, was reviewed. RD stated the Medication Administration Record indicated that Resident 4 had an order for weekly weights and this was completed on 9/4/25. RD and DON confirmed that Resident 4 did not have his weight checked in the morning on 9/5/25 or 9/6/25. During a telephone interview on 5/22/26 at 1:52 p.m., with DON, DON stated it is potentially confusing to have weekly weights on the Medication Administration Record and daily weights on the Treatment Administration Record. DON also stated if there is an order to give Furosemide for weight gain and weights are not checked, then there is a risk that a resident would not get Furosemide and that could lead to more fluid overload and potentially to rehospitalizationDuring a record review of facility's document titled, admission Record, printed 5/22/26, for Resident 4, Resident 4 was sent to an acute care hospital on 9/6/25 at 6:53 p.m.During a review of facility's policy titled, Weight Assessment and Intervention, dated 2001, the policy indicated .Residents are weighed upon admission and at intervals established by the interdisciplinary team.

Based on observation, interview, and record review, the facility failed to ensure that Resident 1 was treated with dignity and respect when staff placed a timer on the resident's table to indicate the duration of feeding and repositioning. This failure created pressure on Resident 1, making the resident feel rushed during meals, which had the potential to compromise Resident1's dignity and safety.Findings:A review of Resident 1's admission Record (AR), printed on 2/12/26, indicated, Resident 1 was admitted to the facility in April 2023, with a diagnosis of Quadriplegia (paralysis of all four limbs).A review of Resident 1's Minimum Data Set, (MDS, a standardized assessment tool used to evaluate a resident's physical, mental, and psychosocial health), dated 12/3/25, indicated, Resident 1's Brief Interview of Mental Status (BIMS, a score that measures cognition) score was 12. A BIMS score of 12 indicates that the resident has moderate cognitive impairment.A review of Resident 1's MDS dated [DATE], indicated, Resident 1 was completely dependent on staff during meals and required staff assistance with feeding. During an interview on 2/11/26 at 10:00 a.m., Certified Nursing Assistance (CNA) 1 stated that they regularly provide care to Resident 1. CNA 1 stated they were aware of the timer that was placed inside the resident's room.During an observation on 2/11/25 at 10:05 a.m., Resident 1 was seen lying in bed with the head of the bed elevated. A small, white-colored, rectangular timer that was palm-sized, with visible red markings on the front display, was seen on the resident's overbed table. Resident 1 stated that the Director of Nursing (DON) put the timer on the table two months ago. Resident 1 stated he felt rushed and worried that eating too fast could cause choking. Resident 1 stated that no one at the facility asked for his permission and/or consent before placing a timer in front of him. Resident 1 stated the last time staff used the timer was about a month ago.During an interview on 2/11/26 at 12:46 p.m., with the DON, DON stated that Resident 1 required two CNAs for one to two hours, and sometimes longer, to provide care. DON stated that Resident 1 had complained that CNAs did not spend enough time on his care. DON stated that after discussion with the Interdisciplinary Team (IDT), the team decided to place a timer in Resident 1's room to make Resident 1 aware of the amount of time CNAs were spending with him. During an interview on 2/12/26 at 11:01 a.m., with the Unit Manager (UM), UM stated that he placed the timer in Resident 1's room in December 2025 after speaking with Resident 1 and obtaining verbal permission from Resident 1. UM was unable to locate any documentation regarding the resident's agreement and/or consent for use of the timer. A review of facility's Policy and Procedure (P&P) titled, Resident Rights, dated February 2021, indicated, Employees shall treat all residents with kindness, respect, and dignity. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to a. dignified existence. be treated with respect, kindness, and dignity. self-determination.

Based on observation, interview, and record review, the facility failed to provide the necessary activities of daily living (ADL) care for one dependent resident (Resident 2) when Resident 2's face appeared oily, crust-like matter was stuck between the eyelids, and pale, white-color dry matter was noted on the mouth and teeth.Failure to provide grooming and personal hygiene has the potential to affect the resident's physical and psychosocial comfort and wellbeing and could also place the resident at risk for aspiration and infection. Findings:During a review of Resident 2's admission Record (AR) printed on 2/12/25, the AR indicated Resident 2 was admitted to the facility on [DATE].A record review of Resident 2's Minimum Data Set (MDS, an assessment tool to evaluate a resident's physical, mental, and functional status, and help determine the resident's care needs.) dated 12/12/25, indicated, Resident 2's Brief Interview of Mental Status (BIMS, a score that measures cognition) score was 8. A BIMS score of 8 indicates that the resident has moderate cognitive impairment. A record review of Resident 2's MDS dated [DATE], indicated, Resident 2 had diagnoses that included, Traumatic Brain Injury and Dysphagia (difficulty swallowing). The MDS also indicated that Resident 2 was dependent on staff for ADLs including oral hygiene and personal hygiene. During a concurrent observation and interview on 2/11/26 at 10:46 a.m., with Licensed Vocational Nurse (LVN) 1, Resident 2 was observed lying in bed with head of the bed elevated. Gastrostomy tube (GT) feeding (providing nutrition directly into the stomach through a tube for individuals unable to eat by mouth) was ongoing. Resident 2's face appeared oily, pale, white-color dry matter was noted between the upper roof of the mouth and the tongue, as well as between the upper and lower teeth. LVN 1 stated Resident 2 required oral care. LVN 1 explained that Resident 2's oral care involves suctioning, which is the responsibility of a licensed nurse. LVN 1 stated they would provide oral care for Resident 2 immediately.During a concurrent observation and interview on 2/11/26 at 12:07 p.m., with Certified Nursing Assistant (CNA) 2, CNA 2 stated Resident 2's face needed to be washed and shaved.During a concurrent observation and interview on 2/11/26 at 3:28 p.m., with the Infection Preventionist (IP) present, Resident 2 was noted to have crust-like matter stuck between the left upper and lower eye lids. IP stated Resident 2's eyes needed to be cleaned. IP stated that good oral care was important for residents who are dependent on GT feeding to reduce the risk of bacterial growth in the mouth, prevent the development of aspiration pneumonia, and maintain personal hygiene, which supports the resident's dignity and comfort.During an interview on 2/12/26 at 11:20 a.m., with the Unit Manager (UM), UM stated that oral hygiene and personal hygiene should be provided at least twice a day and as needed. The UM emphasized that it was the responsibility of licensed staff and CNAs to ensure residents receive proper ADL care.A review facility's Policy and Procedure (P&P) titled, ADL Care Provided for Dependent Residents, revised in January 2025, indicated, the facility provides assistance to ensure that a resident who is unable to carry out activities of daily living receive necessary services to maintain good nutrition, grooming, personal and oral hygiene.

Based on interview and record review, for one of three sampled residents (Resident 1), the facility failed to ensure Resident 1 was not charged for services covered by Medicare when the facility repeatedly billed Resident 1 and/or Resident Representative (RR) for an extended stay at the facility. This failure resulted in unnecessary billing, inconvenience and potential for emotional distress to RR. During a review of Resident 1's admission Record (AR) printed 2/5/26, the AR indicated Resident 1 was admitted on [DATE] with diagnoses that included chronic kidney disease stage 3 (kidneys have mild to moderate damage and are less able to filter waste and fluid out of your blood), abnormalities of gait (manner of walking) and mobility, depression (a common, serious mood disorder characterized by persistent sadness, loss of interest in activities, fatigue, and physical pain) and transient ischemic attack (short period of symptoms similar to those of a stroke, caused by a brief blockage of blood flow to the brain). The AR indicated Resident Representative (RR) was Resident 1's Guarantor.During a concurrent interview and record review on 2/5/26 at 10:15 a.m. with Case Manager (CM) 1, Resident 1's Referral Information dated 2/17/23 and NOMNC (Notice of Medicare Non-Coverage, a mandatory Centers for Medicare and Medicaid Services-approved form delivered to patients in skilled nursing facilities when their Medicare-covered services are ending, notifying beneficiaries of the last day of coverage, expected financial liability, and their right to an expedited, fast-track appeal) dated 3/17/23 were reviewed. CM 1 stated Resident 1 was a Kaiser member who had full Medicare coverage for 100 days of services upon admission. CM 1 stated the NOMNC indicated Medicare-covered services would end on 3/20/23, with the discharge scheduled for 3/21/23. CM 1 also stated the NOMNC was unsigned and lacked attestation.During a review of Resident 1's Progress Notes, the Progress Notes indicated the following:- On 3/20/23, a Health Status Note indicated Resident 1 had an oxygen saturation of 85 percent (%) in the morning, which remained low after repositioning. Oxygen was administered at two liters via nasal cannula, and the physician was informed.-A late entry Physician/NP (Nurse Practitioner)/PA (Physician Assistant) Note dated 3/20/23, indicated Resident 1 was transferred to the hospital for further evaluation after a desaturation episode (low level of oxygen in the blood).- The Plan of Care Note dated 3/20/23 at 4:16 p.m., indicated Resident 1's Kaiser Case Manager (KCM) sent a NOMNC via email to the Facility Case Manager (FCM), stating that Resident 1 was to be discharged on 3/21/23 to a board and care. KCM was informed the FCM would follow up the next day.- Another Plan of Care Note dated 3/20/23 at 4:32 p.m., indicated KCM had reached out to FCM about Resident 1's board and care and the need for a physician to sign the 602 (mandatory document for seniors entering residential care in California, outlining medical needs). - A Social Services Note dated 3/20/23 at 4:42 p.m., indicated Social Service Assistant (SSA) 1 called the board and care to schedule discharge assessment for Resident 1 but did not receive an answer.- The Health Status Note dated 3/21/23 at 12:49 a.m., indicated Resident 1 returned to the facility from the Emergency Department.- Social Service Note dated 3/21/23 at 11:36 a.m., indicated SSA 1 called the board and care again with no answer.- Social Service Note dated 3/21/23 at 11:38 a.m., indicated SSA 1 told RR that Resident 1's discharge is on hold for two days for observation due to a recent emergency room visit.- Physician/NP/PA Note dated 3/21/23 at 3:50 p.m., indicated Resident 1 was seen by Attending Physician (AP) after hospitalization. AP ordered CBC with diff (a complete blood count measures the number and type of cells in your blood. It may be done as part of a routine exam or to monitor or diagnose health conditions), CMP (Comprehensive Metabolic Panel, a blood test measuring 14 different substances to assess kidney and liver function, blood sugar, and protein levels) and chest x-ray done STAT (critical diagnostics required immediately, within minutes to a few hours). - A Physician/NP/PA Note dated 3/23/23 at 2:40 p.m., indicated AP saw Resident 1 again for lab follow-up and planned to continue current management and monitoring.- Physician/NP/PA Note late entry dated 3/23/23 at 2:50 p.m., indicated Resident 1 should be discharged with home health services and Primary Care Physician (PCP) follow-up.- A Social Service Note dated 3/24/23 at 3:36 p.m., indicated Resident 1 was discharged to board and care on the same day.During a concurrent interview and record review on 2/5/26 at 11:25 a.m. with Business Office Manager (BOM), Resident 1's Census List (insurance coverage information) was reviewed. BOM stated, Resident 1's Payer Change was changed effective 3/21/23, requiring private payment for services from 3/21/23 to discharge on [DATE] due to lack of a secondary insurance. BOM stated the change in payor was based on an unsigned NOMNC dated 3/17/23. BOM acknowledged that the NOMNC should have been signed by Resident 1 and a notice of private pay costs provided, but neither occurred.During an interview on 2/5/26 at 11:36 a.m. with Travelling Business Office Manager (TBOM), TBOM stated the facility should review Resident 1's Emergency Department visit and request authorization for Resident 1's stay upon return. TBOM stated the Admissions Department should review the case and request authorization from Kaiser. TBOM stated the Business Office acts based on insurance information provided by the Admissions Department.During a concurrent interview and record review on 2/5/26 at 11:40 a.m. with Admissions Coordinator (AC), Resident 1's Census List was reviewed. AC stated that if a resident returns from the hospital with remaining Medicare days, coverage should continue automatically. AC also stated the Admissions Department checks coverage for new referrals but not after admission when a resident is sent to the hospital. AC also stated she was unsure about what happened with Resident 1's coverage since he still had remaining Medicare days when the NOMNC was issued.During a concurrent interview and record review on 2/5/26 at 1:50 p.m. with TBOM, the Statement dated 5/1/23 was reviewed. TBOM stated the first bill for Resident 1's three-day Room and Board Charges of $1,425 was sent to Resident 1's RR on 5/1/23. TBOM stated Kaiser was not billed due to lack of authorization to change the NOMNC to the new discharge date .During an interview on 2/5/26 at 2:15 p.m. with SSA 2, SSA 2 stated the facility should have requested an extension of the NOMNC with a new discharge date after Resident 1's return from the hospital. SSA 2 stated the extension request was sent to Kaiser long after Resident 1 had been discharged , following several attempts by the facility to collect payments from RR.During a review of the Notes Info, undated, the Notes Info indicated Kaiser sent a referral message to the facility on 3/21/23 at 5:54 p.m. that showed Resident 1's discharge date was 3/21/23, with 3/20/23 as the last covered day. The note was the final documented communication between the facility and Kaiser regarding Resident 1's NOMNC. No authorization request was documented by the facility.During a review of the Business Office Activity Report dated 2/5/26, the Activity Report indicated that on 4/14/23, facility Business Office was to generate collection letter # 1 to Resident 1. On 7/19/23, RR called and inquired about Kaiser covering the three-day stay; RR was informed the facility would contact Kaiser due to the absence of an updated NOMNC on file. The Activity Report further indicated, after multiple communications with Kaiser about RR 1's grievance, collection letters # 2 and #3 were generated and sent to RR, exhausting all collection efforts. Resident 1 passed away on 5/31/25. Numerous communications between RR, Kaiser and facility occurred before the payment was settled by Kaiser to the facility on [DATE].During a review of the facility's contract with Kaiser titled Healthcare Services Agreement. effective 7/18/22, the contract indicated if the facility provides non-covered or unauthorized services, the resident may be billed only if the resident is notified beforehand and signs a Financial Responsibility Form. If these conditions are not met, the facility cannot charge more than the resident's cost of share as if the services were authorized. Further review of the facility's contract with Kaiser, titled, First Amendment to the Health Care Services Agreement . effective 1/1/23, the contract also required regular communication between Kaiser and the facility regarding each resident, with both parties documenting these communications in their records.During a review of the facility's Policy and Procedure (P&P), titled, Notice of Covered and Non-Covered Services, dated March 2021, the P&P indicated, Residents are notified of the covered and non-covered items and services provided by the facility.

Based on interview and record review, for one of three sampled residents (Resident 1), the facility failed to notify Resident 1 and/or Resident Representative (RR) of potential financial liability for an extended stay when the payer source changed to private pay.This failure had the potential to result in uninformed decisions about care, and emotional distress due to unnecessary financial liability.During a review of Resident 1's admission Record (AR) printed 2/5/26, the AR indicated Resident 1 was admitted on [DATE] with diagnoses that included chronic kidney disease stage 3 (kidneys have mild to moderate damage and are less able to filter waste and fluid out of your blood), abnormalities of gait (manner of walking) and mobility, depression (a common, serious mood disorder characterized by persistent sadness, loss of interest in activities, fatigue, and physical pain) and transient ischemic attack (short period of symptoms similar to those of a stroke, caused by a brief blockage of blood flow to the brain). The AR indicated Resident Representative (RR) was Resident 1's Guarantor.During a concurrent interview and record review on 2/5/26 at 10:15 a.m. with Case Manager (CM) 1, Resident 1's Referral Information dated 2/17/23 and NOMNC (Notice of Medicare Non-Coverage, a mandatory Centers for Medicare and Medicaid Services-approved form delivered to patients in skilled nursing facilities when their Medicare-covered services are ending, notifying beneficiaries of the last day of coverage, expected financial liability, and their right to an expedited, fast-track appeal) dated 3/17/23 were reviewed. CM 1 stated Resident 1 had full Medicare coverage for 100 days of services upon admission. CM 1 stated the NOMNC indicated Medicare-covered services would end on 3/20/23, with the discharge scheduled for 3/21/23. CM 1 also stated the NOMNC was unsigned and lacked attestation.During a review of the Plan of Care Note dated 3/20/23 at 16:16, the note indicated Resident 1's Kaiser Case Manager (KCM) sent a NOMNC via email to Facility Case Manager (FCM), stating that Resident 1 was to be discharged on 3/21/23 to a board and care. KCM was informed the FCM would follow up the next day.During a concurrent interview and record review on 2/5/26 at 11:25 with Business Office Manager (BOM), Resident 1's Census List (insurance coverage information) was reviewed. BOM stated, Resident 1's Payer Change was effective 3/21/23, requiring private payment for services from 3/21/23 to discharge on [DATE] due to a lack of secondary insurance. BOM stated the change in payor was based on an unsigned NOMNC dated 3/17/23. BOM acknowledged that the NOMNC should have been signed by Resident 1 and a notice of private pay costs should have been provided, but neither occurred.During a telephone interview on 2/9/26 at 2:07 p.m. with Medical Records Assistant (MRA), MRA stated she could not find a signed NOMNC in Resident 1's chart, also there was no documentation that a notice about the private pay cost was issued to Resident 1.During a review of the facility's contract with Kaiser titled Healthcare Services Agreement. effective 7/18/22, the contract indicated, if the facility provides non-covered or unauthorized services, the resident may be billed only if the resident is notified beforehand and signs a Financial Responsibility Form. If these conditions are not met, the facility cannot charge more than the resident's cost of share as if the services were authorized. Further review of the facility's contract with Kaiser, titled, First Amendment to the Health Care Services Agreement . effective 1/1/23, the contract also required regular communication between Kaiser and the facility regarding each resident, with both parties documenting these communications in their records.During a review of the facility's policy and procedure (P&P) titled Notice of Covered and Non-Covered Services last revised 3/2021, the P&P indicated, residents must receive a notice detailing covered (items and services that are included as part of a covered Medicare/Medical stay and for which a resident may not be charged) and non-covered (those that are not included as part of the Medicare/Medicaid covered stay or the facility per diem rate, but that the facility offers and for which the resident may be charged) services upon admission and periodically throughout their stay. The notice includes available services and charges for those services.

Based on observation, interview, and record review, the facility failed to ensure five of five sampled residents (Residents 148, 68, 109, 133, and 140) were provided a clean, sanitary and homelike environment when whitish grime, stains and dried matter were sticking on the surroundings of Residents 148, 68, 109, 133, and 140's mattresses. These failures had the potential to cause discomfort, emotional distress, and spread of disease-causing organisms to Residents 148, 68, 109, 133, and 140. Findings: During a review of Resident 148's admission Record (AR) printed on 6/12/25, the AR indicated, Resident 148 was admitted to the facility in June 2024 with diagnoses that included intracerebral hemorrhage (bleeding into the brain tissue), Alzheimer's Disease (progressive disease that destroys memory and other important mental functions), and unspecified stage pressure ulcer (o localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device) of sacral region. During an observation on 6/9/25 at 11:34 a.m., Resident 148 was awake in bed and had tracheostomy and TF. Resident 148's blue mattress had a whitish grime on the bottom left portion the mattress. During a review of Resident 68's AR, printed on 6/12/25, the AR indicated, Resident 68 was admitted to the facility in February 2025 with diagnoses that included diagnosis of hemiplegia (a condition caused by brain damage or spinal cord injury that leads to paralysis on one side of the body) and hemiparesis (a condition characterized by weakness on one side of the body, making it hard to perform everyday activities like eating or dressing) following cerebral infarction (occurs when blood flow to a part of the brain is blocked, depriving brain cells of oxygen and nutrients, leading to tissue damage or death) affecting left non-dominant side and persistent vegetative state (a condition where a person is alive but has no awareness of themselves or their environment). During an observation on 6/10/25 at 11:21 a.m. in Resident 68 was not in the room. Resident 68's dark blue mattress had whitish stains and dust like powder on the top, middle, and bottom portion of the mattress. During a review of Resident 133's AR printed on 6/13/25, the AR indicated, Resident 133 was admitted to the facility in June 2024 with diagnoses that included traumatic brain injury (brain dysfunction caused by an outside force, usually a violent blow to the head) and persistent vegetative state. During an observation and interview on 6/10/25 at 12:36 p.m. with Certified Nurse Assistant (CNA) 1, Resident 133's was sleeping in his bed. Resident 133 had tracheostomy (medical procedure that helps a person breathe better) that was hooked up in a ventilator (a type of breathing apparatus, a class of medical technology that provides mechanical ventilation by moving breathable air into and out of the lungs, to deliver breaths to a patient who is physically unable to breathe or breathing insufficiently). Resident 133 also had a tube feeding (TF, medical device used to provide nutrition to people who cannot obtain nutrition by mouth, are unable to swallow safely, or need nutritional supplementation) connected to a feeding pump (a medical device used to deliver nutrition to patients who cannot obtain nutrition by mouth, usually through a feeding tube). Resident 133's dark blue mattress had whitish stain on the right side and bottom portion of the mattress. CNA 1 stated the whitish stain on Resident 133's mattress looked like it was from an old ointment or lotion. CNA 1 stated when CNAs were supposed to wipe down and clean the mattress after performing care to the residents. CNA 1 also stated housekeeping (HK) department was also responsible in daily and deep cleaning residents' rooms per schedule. CNA 1 stated it was important to make sure the mattresses were cleaned and sanitized to prevent unwanted odor from body fluids like urine and bowel movement. During a review of Resident 109's AR printed on 6/12/25, the AR indicated, Resident 109 was admitted to the facility in October 2024 with diagnoses that included anoxic brain damage (An anoxic brain injury occurs when the brain receives no oxygen at all) and persistent vegetative state. During an observation on 6/10/25 at 12:39 p.m., Resident 109 was sleeping in the bed with tracheostomy connected to a ventilator and TF. Resident 109's dark blue mattress had a yellowish dried matter on the upper left side portion of the mattress. During an observation and interview on 6/10/25 at 12:54 p.m. with HK Supervisor in Resident 68 and Resident 109's room. HK Supervisor stated Resident 109's dark blue mattress looked like a dried stain from Resident 109's formula feeding (a liquid food, often called formula, which are given through a special tube to make sure you get the nutrition and water you need). HK Supervisor stated licensed nurses who were responsible for giving the formula to the residents on TF should have called the HK department for spills or if there was a need to clean an area. HK Supervisor further stated HK were also not comfortable wiping down areas like the ventilator and the feeding pump because they were scared, they might pull a plug or tube that could cause distress to the residents. HK Supervisor stated licensed nurses or CNAs should have tried to wipe down a spill or dirt on the mattress immediately to prevent from staining. HK Supervisor stated cleaning and sanitizing the mattresses were very important in preventing infection that could have affected the residents. During a review of Resident 140's AR printed on 6/12/25, the AR indicated, Resident 140 was admitted to the facility in December 2024 with diagnoses that included chronic respiratory failure with hypercapnia (a condition in which the lungs have a hard time loading blood with oxygen or removing carbon dioxide) and history of cardiac arrest (when the heart stops beating suddenly). During a record review of Resident 140's Brief Interview for Mental Status (BIMS, is a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score 13 to 15 is an indication of an intact cognitive response.), dated 3/18/25, the record indicated Resident 140's BIMS score was 15. During an observation and interview on 6/11/25 at 1:20 p.m. with Resident 140, Resident 140 was connected to a ventilator and TF. Resident 140's dark blue mattress had whitish spot stains, brownish drip like stains and powder like grime on the top left top portion of the mattress. Resident 140 stated the mattress was dirty when Resident 140 looked over to her left side. Resident 140 stated no one from the facility had come to clean her mattress. Resident 140 stated she preferred her mattress clean. During an interview on 6/13/25 at 11:35 a.m. with Infection Preventionist (IP), IP stated it was important to make sure residents' mattresses were maintained clean and disinfected per schedule to eliminate microorganisms such as bacterial infection. During an interview on 6/13/25 at 1:40 p.m. with the Director of Nursing (DON), the DON state the staff should have cleaned and disinfected the mattress after they have provided personal care to a resident. The DON stated this will prevent increase in the infection rate. The DON stated the residents also have the rights to have a clean and homelike environment including clean mattresses. During a record review of the facility's document, titled, Daily Patient Room Cleaning, revised on 9/5/17, the document indicated, Every room to be cleaned is that resident's home - treat it as such .The gold of cleaning is Infection Control . During a record review of the facility's policy and procedure (P&P), titled, Homelike Environment, dated February 2021, the P&P indicated, Residents are provided with a safe, clean, comfortable and homelike environment .The facility staff and management maximizes, to extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include .a. clean, sanitary and orderly environment .

Based on observation, interview, and record review, the facility failed to ensure for two out of 31 (Residents 138 and 49), were routinely given pain medications without clarification of physician's order and adequate indications. For Resident 138, he was regularly given Norco oral tablet (medication used to treat moderate to severe pain) 5-325 milligram (mg) tablet to be administered one tablet three times a day, and Tylenol Extra Strength oral tablet (medication used to treat minor pain and fever reducer) 500 mg tablet to be administered one tablet two times a day. For Resident 49, was regularly given Acetaminophen 325 mg tablet to be administered two tablets via gastric tube (g-tube - surgically tube placed through the abdominal wall used to administer fluid, nutrition, and medication) two times a day. These failures had a potential to affect Resident 138 and 49's health and safety due to regular use of pain and fever reducing medications without pain manifestations or could masks symptoms of illnesses. Findings: 1. During a review of Resident 138's admission Record (AR), indicated Resident 1 was admitted on [DATE] with diagnoses that included end stage renal disease (chronic and advance stage of kidney disease). Resident 138's Minimum Data Set (MDS - resident assessment tool) dated 05/19/25, indicated a Brief Interview for Mental Status (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information) score of 13, (BIMS score of 13 - 15, cognitively intact). During a review of Resident 138's physician's Order Summary Report for the month of 06/2025 indicated the following medications: 1. Norco Oral Tablet 5-325 MG (Hydrocodone-Acetaminophen) Give 1 tablet by mouth three times a day for pain, with an order date of 02/13/25. 2. Norco Oral Tablet 5-325 MG (Hydrocodone-Acetaminophen) Give 1 tablet by mouth every 6 hours as needed for Moderate to severe pain. Hold for sedation or RR [respiratory rate] less than 12. NTE [not to exceed] 3 gm per day, with an order date of 02/13/25 3. Tylenol Extra Strength Oral Tablet 500 MG (Acetaminophen) Give 1 tablet by mouth two times a day for pain NTE 3 grams in 24 hours, with an order date of 09/9/24. 4. Tylenol Acetaminophen Oral Tablet 500 MG (Acetaminophen) Give 1 tablet by mouth every 4 hours as needed for mild pain. NTE [not to exceed] 3 grams per day, with an order date of 08/22/24. 5. Pain - Monitor For Presence of Pain - Verbal/Non-verbal Every Shift Using Pain Scale 0 - 10. 0 = No Pain. 1 - 2 = Least Pain. 3 - 4 = Mild Pain. 5 - 6 Moderate Pain . During a concurrent observation and interview on 06/11/25 06:46 a.m., with Licensed Vocational Nurse (LVN) 6, LVN 6 stated she would prepare Resident 138's medications. Resident 138's medications included Norco oral tablet 5/325 mg tablet. LVN 6 asked Resident 138, if he have any pain, and Resident 138 did not respond. LVN 6 administered Resident 138's medications including Norco oral tablet 5/325 mg tablet. During a review of Resident 138's medication administration record (MAR) for the months of 02/2025 through 06/2025, the MAR indicated: Norco oral tablet 5-325 mg tablet, give 1 tablet by mouth three times a day for pain, was scheduled for administration at 6:00 a.m., 2:00 p.m., and 11:00 p.m. Resident 138 was given Norco oral tablet 5-325 mg tablet three times a day as scheduled, and the pain level was written as 0 most of the time. Resident 138's Tylenol Extra Strength oral tablet 500 mg, give 1 tablet by mouth two times a day for pain, was scheduled at 9:00 a.m. and 5:00 p.m. Resident 138 was given Tylenol Extra Strength oral tablet given two times a day as scheduled, and the pain level was written at 0 most of the time. The ordered Pain - Monitor For Presence of Pain - Verbal/Non-Verbal Ever Shift Using Pain Scale indicated 0 or no pain most of the time. During a concurrent interview and record review on 06/11/25 at 03:12 p.m., with LVN 4, LVN 4 stated Resident 138 could report to the staff if he was having pain. LVN 4 reviewed Resident 138's physician's order summary report for the month of 06/25, LVN 4 stated Resident 138's Norco oral tablet 5-325 mg tablet and Tylenol Extra Strength oral tablet 500 mg tablet were ordered to be administered routinely so it would be administered as ordered. LVN 4 stated that Norco oral tablet 5-325 mg tablet and Tylenol Extra Strength 500 mg tablet would be administered routinely even if Resident 138 did not report having any pain. LVN 4 stated the Norco and Tylenol were given to Resident 138 to control pain, LVN 4 reviewed Resident 138's diagnoses, and LVN 4 stated Resident 138 did not have a chronic pain diagnosis. During a concurrent interview and record review on 06/13/25 at 12:19 p.m., with Director of Nursing (DON), DON reviewed Resident 138's physician's order summary report and MAR, DON stated the nurse needs to assess Resident 138 if he was having pain. DON stated just because Norco oral tablet 5-325 mg tablet and Tylenol Extra Strength 500 mg tablet were ordered routinely, the nurses should not administer the pain medications if Resident 138 was not having pain. DON stated the nurses should have clarified the pain medication orders with the physician for Resident 138. 2. During a review of Resident 49's AR, the AR indicated Resident 49 was admitted on [DATE] with diagnoses that included persistent vegetative state (chronic state of brain dysfunction in which a person shows no signs of awareness). During a review of Resident 49's Order Summary Report for the month of 6/2025 indicated: 1. Acetaminophen Tablet 325 MG give 2 tablets via G-Tube two times a day for pain management. APAP [Acetaminophen] NTE [not to exceed] 3 grams/day from all sources with an order date of 5/10/24. 2. Acetaminophen Tablet 325 MG Give 2 tablets via G-Tube every 4 hours as needed for Moderate breakthrough pain, scale 4 - 6 APAP [Acetaminophen] NTE [not to exceed] 3 grams/day from all sources with an order date of 5/10/24. 3. Pain - Monitor For Presence of Pain - Verbal/Non-verbal Every Shift Using Pain Scale 0 - 10. 0 = No Pain. 1 - 2 = Least Pain. 3 - 4 = Mild Pain. 5 - 6 Moderate Pain . During a concurrent observation and interview on 06/11/25 at 08:26 a.m., with LVN 7, LVN 7 stated she would prepare Resident 49's medications that included Acetaminophen 325 mg tablet, give two tablets administered via g-tube. LVN 7 administered Resident 49's medications including two tablets of Acetaminophen 325 mg tablet. During a review of Resident 49's MAR for the months of 3/2025 and 6/2025, the MAR indicated Acetaminophen Tablet 325 MG Give 2 tablet[s] via G-Tube two times a day for pain management was scheduled at 9:00 a.m. and 9:00 p.m. Resident 49 was given two tablets of Acetaminophen Tablet 325 mg tablet as scheduled, and with pain level written 0 most of the time. During a concurrent interview on 06/13/25 at 12:19 p.m., with Director of Nursing (DON), DON stated the nurses should have clarified the pain medication orders with the physician for Resident 49. During an interview on 06/12/25 at 12:44 p.m., with LVN 5, LVN 5 stated Resident 38 was non-verbal, LVN 5 stated Acetaminophen 325 mg tablet was given routinely for pain. LVN 5 stated the pain level monitoring was recorded in Resident 38's MAR.

Based on observation, interview and record review, the facility failed to prepare food in accordance with professional standards of food service safety when Facility [NAME] (FC) touched ready-to-eat food on multiple plates with the same gloved hand that was used to hold oven handles. This failure had the potential to result in cross-contamination and food-borne illness. Findings: During trayline observation and concurrent interview on 6/12/25 from 11:32 a.m. through 1:10 p.m. with Facility [NAME] (FC) and Kitchen Manager (KM), FC began to scoop food from the trays on the steam table, placed the food items on individual plates by pushing them off the ladle while wearing disposable gloves, at times gently pushing the food item towards the center of the plate. FC opened and closed handles of steamer and oven multiple times in-between plating food from the steam table with the same gloved hand. KM stated I can see what you are trying to say and told FC to stop touching the food on the plates. FC acknowledged, apologized for the mistake, continued with food service, and occasionally touched the food with the same gloved hand before placing the plates on individual trays. During a review of the facility's policy and procedure (P&P) titled General Food Preapartion and Handling last copyrighted 2023, the P&P indicated Bare hands should never touch ready to eat food directly. Disposable gloves are a single use item and should be discarded after each use . Food should be prepared and served with clean tongs, scoops, spatulas or other suitable implements to avoid manual contact of prepared foods.

Based on observation, interview and record review, the facility failed to implement their infection prevention and control program for two of three sampled residents (Residents 125 and Resident 46) when two staff members did not wear appropriate Personal Protective Equipment (PPE, protective items or garments worn to protect the body or clothing from hazards that can cause injury and to prevent the transmission of infectious agents from one person to another, also known as cross-contamination) while providing care to Resident 125 and Resident 46, who were placed on enhanced barrier precaution (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities). This failure had the potential to result in spread of infection. Findings: During a record review of Resident 125's admission Record (AR), printed on 6/13/25, the AR indicated Resident 125 was admitted to the facility in November 2024 with diagnoses of quadriplegia (a loss of motor function can present as either weakness or paralysis leading to partial or total loss of function in the arms, legs, trunk, and pelvis) and dependence to ventilator (a type of breathing apparatus, a class of medical technology that provides mechanical ventilation by moving breathable air into and out of the lungs, to deliver breaths to a patient who is physically unable to breathe, or breathing insufficiently) status. During a review of the facility's undated signage titled, Enhanced Barrier Precaution (EBP), the EBP indicated, Anyone participating in any of these six moments must also: [NAME] gown and gloves .Device care or use . During an observation and interview on 6/9/25 at 11:42 a.m., inside Resident 125's room located in the subacute unit, where an Enhanced Barrier Precaution sign was posted on the door, Respiratory Therapist (RT) 1 was not wearing a gown while performing oral suctioning to Resident 125 who had a tracheostomy (an opening surgically created through the neck into the trachea to allow air to fill the lungs) connected to a ventilator. Inside, Resident RT 1 asked Resident 125 if she needed another round of suctioning to which Resident 125 refused. RT 1 stated he did not really need to wear PPE when providing care for Resident 125. When RT 1 was asked about the EBP sign on the door, RT 1 then stated he should have performed proper PPE as protection to prevent contamination and transmission of secretions and bodily fluid. During a concurrent observation and interview on 6/10/25 at 10:33 a.m., inside Resident 46's room where an Enhaced Barrier Precaution sign was posted on the door, Certified Nursing Assistant (CNA) 5 and Resident 46's family member were at the bedside providing care. CNA 5 did not wear PPE while the family member did. CNA 5 stated, it was an Enhanced-Barrier Precaution room and one should wear PPE when providing care to the resident. During an interview on 6/13/25 at 11:20 a.m. with the Infection Preventionist (IP), IP stated the EBP signs were posted on the door for staff's compliance. IP stated all residents in the subacute unit were placed under EBP. IP stated not wearing PPE inside EBP rooms had the risk of spreading the infection. IP stated PPE was used as a protection from transmitting diseases to the residents and the community. During an interview on 6/13/25 at 1:47 p.m. with the Director of Nursing (DON), the DON stated the staff who were assigned to subacute unit should have known better that wearing PPE was a must when providing care to protect the residents and the staff. The DON stated not wearing PPE was a break in their infection control protocol. During a record review of the facility's policies and procedures, titled, Enhance Barrier Precautions, revised in December 2024, the P&P indicated, EBPs refer to infection prevention and control interventions designed to reduce the transmission of multi-drug-resistant organisms (MDROs) during high contact resident care activities .7. EBPs employ targeted gown and glove use in addition to standard precaution () during a high contact resident care activities when contact precautions do not otherwise apply .a. Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room) .8. Example of high-contact resident care activities requiring the use of gown and gloves for EBPs include .e. transferring .f. providing bed mobility .i. device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.) Based on observation, interview and record review, the facility failed to implement their infection prevention and control program to two of three sampled residents (Residents 125 and Resident 46) when two staff members did not wear appropriate Personal Protective Equipment (PPE, protective items or garments worn to protect the body or clothing from hazards that can cause injury and to prevent the transmission of infectious agents from one person to another, also known as cross-contamination) while providing care to Resident 125 and Resident 46 who were placed on enhanced barrier precaution (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities). This failure had the potential to result in spread of infection. Findings: During a record review of Resident 125's admission Record (AR), printed on 6/13/25, the AR indicated Resident 125 was admitted to the facility in November 2024 with diagnoses of quadriplegia (a loss of motor function can present as either weakness or paralysis leading to partial or total loss of function in the arms, legs, trunk, and pelvis) and dependence to ventilator (a type of breathing apparatus, a class of medical technology that provides mechanical ventilation by moving breathable air into and out of the lungs, to deliver breaths to a patient who is physically unable to breathe, or breathing insufficiently) status. During a review of the facility's undated signage titled, Enhanced Barrier Precaution (EBP), the EBP indicated, Anyone participating in any of these six moments must also: [NAME] gown and gloves .Device care or use . During an observation and interview on 6/9/25 at 11:42 a.m., inside Resident 125's room located in the subacute unit, where an Enhanced Barrier Precaution sign was posted on the door, Respiratory Therapist (RT) 1 was not wearing a gown while performing oral suctioning to Resident 125 who had a tracheostomy (an opening surgically created through the neck into the trachea to allow air to fill the lungs) connected to a ventilator. Inside Resident RT 1 asked Resident 125 if she needed another round of suctioning to which Resident 125 refused. RT 1 stated he did not really need to wear PPE when providing care for Resident 125. When RT 1 was asked about the EBP sign on the door, RT 1 then stated he should have performed proper PPE as protection to prevent contamination and transmission of secretions and bodily fluid. During an interview on 6/13/25 at 11:20 a.m. with the Infection Preventionist (IP), IP stated the EBP signs were posted on the door for staff's compliance. IP stated all residents in the subacute unit were placed under EBP. IP stated not wearing PPE inside EBP rooms had the risk of spreading the infection. IP stated PPE was used as a protection from transmitting diseases to the residents and the community. During an interview on 6/13/25 at 1:47 p.m. with the Director of Nursing (DON), the DON stated the staff who were assigned to subacute unit should have known better that wearing PPE was a must when providing care to protect the residents and the staff. The DON stated not wearing PPE was a break in their infection control protocol. During a record review of the facility's policies and procedures, titled, Enhance Barrier Precautions, revised in December 2024, the P&P indicated, EBPs refer to infection prevention and control interventions designed to reduce the transmission of multi-drug-resistant organisms (MDROs) during high contact resident care activities .7. EBPs employ targeted gown and glove use in addition to standard precaution () during a high contact resident care activities when contact precautions do not otherwise apply .a. Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room) .8. Example of high-contact resident care activities requiring the use of gown and gloves for EBPs include .e. transferring .f. providing bed mobility .i. device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.)

Based on observation, interview and record review the facility did not respect the right to maintain personal belongings securely for one of 18 sampled residents (Resident 53) when Resident 53's transfer sling, wheel chair and shoes had been missing. This created unnecessary distress for Resident 53's family. Findings: Record review of the document admission Record showed the facility admitted Resident 53 on 4/14/2017. Diagnoses included Intracranial Injury (brain injury). During an interview on 6/11/2025 at 2:25 p.m. Family Member 1 stated she had concerns regarding her son's missing items. She stated she had purchased a personal transfer sling for her son which was missing. In the past, he was missing a shoe which she also replaced for him. Family Member 1 stated she had not been reimbursed by the facility for these items. She stated the money wasn't important but she found it frustrating that staff could not keep her son's belongings in his room. During an interview on 6/12 at 9:20 a.m. Resident 53 was observed in bed nodding to questions, making audible sounds but not interviewable. Record review of the document Progress Notes *NEW* dated 4/21/2025, showed Family Member 1 had met with social services and had grievances which included (1) She personally bought a transfer sling for him - its labeled but has been missing for over 2 months. She has notified nursing. (2) The resident's wheelchair, that has his name labeled on it, had gone missing, nursing eventually found it in subacute. She is upset of the mishandling as it's usually and supposed to be outside of his room against the wall. (3) Resident has a pair of black shoes to prevent his feet from curling and one shoe went missing for about 3 months - she eventually bought a new pair for him. She states she brought the receipt and dropped it off at Social Services for potential reimbursement. Overall, the resident's mother is not concerned about the costs of the items, but more so that she feels there is a lack of care for the resident and his belongings. She got emotional and left before she could cry. Record review of the document Progress Notes *NEW* dated 5/5/2025, showed the ombudsman had visited social services to discuss the missing items. Review of the progress note showed Sling is still missing and black shoes have not been reimbursed. During an interview on 6/10/2025 at 9:30 a.m., Social Services Assistant (SSA) stated she believed Resident 53's family had been reimbursed for the missing items but confirmed there was no documentation in the record which showed it had been done. During an interview on 6/10/2025 at 9:45 a.m., Certified Nursing Assistant 4 (CNA 4) stated Resident 53's transfer sling had been Missing. In a concurrent observation, the facility's transfer sling was hanging in the closet but not Resident 53's personal sling. Two black orthopedic support shoes were observed at the bedside. Record review of the facility document Personal Property, dated August 2022, showed Resident belongings are treated with respect by facility staff, regardless of perceived value. Based on interview and record review, for one of seven sampled residents (Resident 127) who needed help with activities of daily living, the facility failed to ensure Resident 127 was treated with respect and dignity when rolled towels were placed inside Resident 127's briefs. This failure had resulted in Resident 127's emotional distress. Findings: During a review of Resident 127's admission Record (AR), the AR indicated Resident 127 was admitted to the facility in December 2023, with diagnoses that included chronic kidney disease, heart failure and need for assistance with personal care. During a review of Resident 127's Minimum Data Set Assessment (MDS, an assessment tool used to direct resident care) dated 3/13/25, the MDS indicated a Brief Interview for Mental Status (BIMS, is a scoring system used to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information) score of 15. A BIMS score of thirteen to fifteen is an indication of intact cognitive status. The MDS also indicated Resident 127 was incontinent of bowel and bladder and was dependent on staff for toileting and personal hygiene. During a joint interview on 6/9/25 at 11:40 a.m., Resident 127 and Resident Representative (RR) 1 both stated Certified Nursing Assistant (CNA) 2 left two rolled towels in Resident 127's briefs. Both stated Resident 127 was very upset about the incident. During an interview on 6/12/25 at 11:09 a.m. with CNA 3, CNA 3 stated, it was sometime last month, when CNA 3 walked into Resident 127's room at the start of the day shift. Resident 127 was very upset about the previous shift and wanted CNA 3 to check Resident 127's disposable brief. CNA 3 stated Resident 127 complained about feeling uncomfortable like something was stuck there. CNA 3 stated she opened Resident 127's brief to find two rolled towels that were wet with urine. During an interview on 6/13/25 at 10:36 a.m. with Unit Manager (UM), UM stated it was inappropriate to place rolled towels in Resident 127's brief. UM stated short cuts such as this was not allowed because it placed Resident 127 at risk for skin breakdown from moisture. During a telephone interview on 6/13/25 at 2:47 p.m. with CNA 2, CNA 2 stated Resident 127 was always wet. CNA 2 stated Resident 127 had always wanted to be dry at all times and CNA 2 placed wash towels, and sometimes paper towel to keep Resident 127 dry. During a review of Resident 127's bladder incontinence care plan (CP), undated, the CP indicated Resident 127 was at risk for incontinence-associated dermatitis. Staff was to provide perineal care (washing the genitals and the anal area) after each incontinent episode, and to offer toileting/change on rising, before and after meals and as needed.

Based on interview and record review, for one of four sampled residents (Resident 23) who were transferred to the hospital for acute care, the facility failed to notify Resident Representative (RR) 2 when Resident 23 vomited on 4/5/25. Resident 23's condition worsened and was transferred to the hospital the same day for fever and weakness. This failure had the potential to result in delayed interventions. Findings: During a review of Resident 23's admission Record (AR), the AR indicated Resident 23 was admitted to the facility in August 2022 with diagnoses that included senile degeneration of the brain (age-related cognitive decline, often used interchangeably with dementia) and major depressive disorder (persistent sadness, loss of interest, and difficulty functioning in daily life). The AR indicated Resident Representative (RR) 2 as Resident 23's emergency contact and guarantor. During a telephone interview on 6/9/25 at 9:55 a.m. with RR 2, RR 2 stated Resident 23 became very sick in the evening of 4/5/25. RR 2 stated receiving a call from facility staff when Resident 23 developed a high fever and was very weak that RR 2 strongly requested the facility to transfer Resident 23 to the hospital for further management. RR 2 stated she did not know Resident 23 had vomited early in the morning before getting very sick. RR 2 stated, had the facility called about Resident 23's vomiting, RR 2 would have taken Resident 23 to the hospital sooner. During an onsite interview on 6/10/25 at 2:52 p.m. with RR 2, RR 2 stated Resident 23 had severe infection and would have been gone if RR 2 had not made the decision to take Resident 23 to the hospital in time. During a concurrent interview and record review on 6/12/25 at 8:41 a.m. with Assistant Director of Nursing (ADON), ADON confirmed Resident 23's face sheet indicated RR 2 was Resident 23's Representative. ADON stated, because the change in condition happened early morning, there was chance the facility staff notified RR 2 later in the morning. ADON stated the clinical record did not indicate that RR 2 was notified of Resident 23's vomiting until Resident 23 developed fever of 100.2 degrees Fahrenheit (deg. F) later in the evening. During a review of Resident 23's clinical record, eInteract SBAR Summary for Providers (SBAR) dated 4/5/25 at 06:13 a.m. indicated Resident 23 had a Change in Condition for nausea/vomiting. The SBAR indicated the physician was notified but there was no documentation that RR 2 was notified. Change in Condition (CIC) notes that followed the SBAR dated 4/5/25 with timestamp 06:38 a.m., 16:46 p.m., and 19:07 p.m. did not indicate RR 2 was notified. During an interview on 6/13/25 at 10:13 a.m. with Unit Manager (UM), UM stated the SBAR indicated the AR indicated RR 2 was Resident 23's guarantor and the first emergency contact, so RR 2 should have been notified of the Change in Condition. UM stated it was important to let the representative know should there be a change in resident's condition for them to provide support to the resident.

Based on observation, interview, and record review, the facility failed to ensure two of three sampled residents (Residents 60 and Resident 142) received necessary care to maintain good grooming and personal hygiene when Resident 60 and Resident 142 had long fingernails. This failure resulted in Residents 60 and Resident 142 at risk for skin irritation and infection. Findings: During a review of Resident 60's admission Record (AR), printed on 6/12/25, the AR indicated, Resident 60 was admitted to the facility in July 2024 with diagnosis that included hemiplegia (a condition caused by brain damage or spinal cord injury that leads to paralysis on one side of the body) and hemiparesis (a condition characterized by weakness on one side of the body, making it hard to perform everyday activities like eating or dressing) following cerebral infarction (occurs when blood flow to a part of the brain is blocked, depriving brain cells of oxygen and nutrients, leading to tissue damage or death) affecting right dominant side. During a record review of During a review of Resident 60's Activities of Daily Living (ADLs, are those needed for self-care and mobility and include activities such as bathing, dressing, grooming, oral care, ambulation, toileting, eating, transferring, and communicating) care plan initiated 8/16/24 and revised on 2/21/25, the care plan indicated Resident 60 had ADL self-care performance and dependent to staff. Resident 60's care plan had an intervention to check the nail length and trim on bath day as necessary. During an observation between 6/9/25 at 10:30 a.m., Resident 60 was sleeping in bed while hooked up to a ventilator (a device used medically to support or replace the breathing of a person) and feeding tube (a medical device used to provide nutrition to people who cannot obtain nutrition by mouth, are unable to swallow safely, or need nutritional supplementation). Resident 60 had long fingernails. During a follow-up observation and interview on 6/12/25 at 9:30 a.m. with Restorative Nurse Assistant (RNA) 1, who was also working on the floor as Certified Nurse Assistant (CNA), RNA 1 stated Resident 60's fingernails were long and needed to be trimmed. RNA 1 stated she noticed Resident 60's fingernails were long the other day. RNA 1 stated she was going to trim Resident 60's nails but could not find a clipper in the room. During a review of Resident 142's admission Record (AR), printed on 6/12/25, the AR indicated, Resident 142 was admitted to the facility in May 2025 with diagnoses that included malignant neoplasm (cancer) of tongue, systemic lupus erythematosus (chronic systemic rheumatic disease that can involve joints, kidneys, skin, mucous membranes, and blood vessel walls), and need for assistance with personal care. During a record review of Resident 142's Brief Interview for Mental Status (BIMS, is a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score 8 to 12 is an indication of moderate cognitive impairment.), dated 5/22/25, the record indicated Resident 142's BIMS score was 12. During a record review of During a review of Resident 142's Activities of Daily Living care plan initiated 5/16/25 and revised on 5/20/25, the care plan indicated Resident 142 had ADL self-care performance and required one to two persons assist to start and complete most ADL task including hygiene and grooming. During an observation and interview on 6/10/25 at 12:24 p.m. with Resident 142, Resident 142 had long fingernails. Resident 142 who had a tracheostomy (a surgical procedure that creates an opening in the neck to access the trachea and insert a tube, called a tracheostomy tube to help with breathing) mouthed words and stated she preferred hair nails shorter and nobody from the staff had offered to trim her nails. During a concurrent observation and interview on 6/12/25 at 9: 28 a.m. with RNA 1, RNA 1 stated she was also assigned as a CNA to Resident 142. RNA 1 stated Resident 142's fingernails were long. RNA 1 stated she was going to speak with Resident 142 in Spanish to understand Resident 142 clearly. RNA 1 confirmed Resident 142 preferred her fingernails shorter. During a follow up interview on 6/12/25 at 9:32 a.m. with RNA 1, RNA 1 stated keeping Resident 60 and Resident 142's fingernails short was important and necessary to prevent them from becoming dirty and to avoid bacterial growth. During an interview on 6/13/25 at 11:43 a.m. with Director of Staff Development (DSD), DSD stated CNAs, and licensed nurses were responsible in maintaining residents' fingernails. DSD stated CNAs should have reported to licensed nurses if a diabetic resident needed a nail trim. DSD stated having clean and trimmed fingernails could give residents self-esteem and prevent skin issues. During an interview on 6/13/25 at 1:51 p.m. with the Director of Nursing (DON), the DON stated nail care should have been provided to Resident 60 and Resident 142 to maintain good hygiene, promote dignity and self-respect, and to prevent risk for infections. During a review of the facility's undated policy and procedure (P&P), titled, Fingernails/Toenails, Care of, the P&P indicated, The purpose of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections .1. Nail care includes cleaning and trimming regularly .2. Proper nail care aid in the prevention of skin problems around the nail bed . During a review of the facility's P&P titled, ADL Care Provided for Dependent Residents, revised in January 2025, the P&P indicated, The facility provides assistance for residents unable to carry out ADLs .To ensure facility staff provide a necessary care and services that are based on the resident's comprehensive assessment, to ensure that a resident who is unable to carry out activities of daily living receive necessary services to maintain good nutrition, grooming, personal and oral hygiene . During a review of the facility's P&P titled, ADL Care Provided for Dependent Residents, revised in February 2021, the P&P indicated, Each resident shall be cared for manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem .When assisting with care, residents are supported in exercising their rights. For example, residents are .groomed as they wish to be groomed (hair styles, nails, facial hair, etc.) .

Based on observation, interview and record review, the facility failed to provide appropriate treatment and services to prevent further decrease in range of motion when Restorative Nursing Assistant (RNA) services ( RNA program, focuses on nursing interventions that help residents in long-term care maintain or regain their ability to perform activities of daily living (ADLs) and improve their overall well-being) to three of four sampled residents (Residents 60, 120 and 126) who were reviewed for range of motion/mobility needs, as indicated in the physician orders and comprehensive care plan. This failure had the potential to result in further decline in range of motion. Findings: 1. During a review of Resident 60's admission Record (AR), printed on 6/12/25, the AR indicated, Resident 60 was admitted to the facility in July 2024 with diagnosis of hemiplegia (a condition caused by brain damage or spinal cord injury that leads to paralysis on one side of the body) and hemiparesis (a condition characterized by weakness on one side of the body, making it hard to perform everyday activities like eating or dressing) following cerebral infarction (occurs when blood flow to a part of the brain is blocked, depriving brain cells of oxygen and nutrients, leading to tissue damage or death) affecting right dominant side. During a review of Resident 60's Order Summary Report, dated 6/12/25, the Order Summary Report had an active physician order to provide RNA program three times a week for both upper and lower extremities. During a review of Resident 60's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 5/8/25, the MDS indicated Resident 60 had functional limitation in range of motion on both sides of the upper and lower extremity. During an observation 6/9/25 at 10:30 a.m., Resident 60 was sleeping in bed while hooked up to a ventilator (a device used medically to support or replace the breathing of a person) and feeding tube (a medical device used to provide nutrition to people who cannot obtain nutrition by mouth, are unable to swallow safely, or need nutritional supplementation). 2. During a review of Resident 120's admission Record (AR), printed on 6/12/25, the AR indicated, Resident 120 was admitted to the facility in December 2024 with diagnoses that included cerebral infarction and persistent vegetative state (a condition where a person is alive but has no awareness of themselves or their environment). During a review of Resident 120's range of motion care plan initiated 2/8/25, the care plan indicated Resident 120 had limited range of motion related to contracture (a condition where muscles, tendons, or skin shorten and tighten, causing reduced range of motion and stiffness in a joint or body part) and Resident 120 was at risk for further decline of range of motion, stiffness, deformity, and joint pain. The care plan also indicated an intervention for Resident 120 to participate in RNA program three times weekly for bilateral upper and lower extremities passive range of motion (PROM, the movement of a joint through its range of motion by an external force, like a therapist or a machine, without any effort from the individual, who remains relaxed). During an observation on 6/9/25 at 10:51 a.m., Resident 120 was awake in bed. Resident 120 was also connected to a ventilator and feeding tube. Resident 120 had stiffness on bilateral upper extremities. During a concurrent record review and interview on 6/12/25 at 9:16 a.m., with RNA 1, the facility's document titled, Restorative Nursing Program Master List/Schedule dated from 5/26/25 to 6/8/25 was reviewed. RNA 1 stated Resident 120 and Resident 60 only received two sessions of PROM on the week of 5/26/25 to 6/1/25 and one session on the week of 6/2/25 to 6/8/25 instead of three times a week. RNA 1 stated she was unable to consistently provide RNA program to Resident 60 and Resident 120 because there were times that she had been re-assigned as a Certified Nurse Assistant (CNA) to work on the floor when the facility was short of staff. RNA 1 stated it was very important for Resident 60 and Resident 120 to receive PROM for muscle strengthening. RNA 1 stated not providing PROM had the risk for Resident 60 and Resident 120 in becoming weaker. During a record review of the facility's policy and procedure (P&P), titled, Range of Motion Exercises, dated October 2010, the P&P indicated, The purpose of this procedure is to exercise the resident's joints and muscles .Verify that there is a physician's order .Review the resident's care plan .

Based on observation, interview, and record reviews, the facility did not provide immediate necessary care and investigate potential self-harm for two of 18 sampled residents (Residents 101 and 210). Staff did not implement safety measures when Residents 101 and 210 expressed feeling suicidal. Staff did not investigate the cause of Resident 210's wrist wound. These failures have the potential to not ensure the residents' safety and/or promote and maintain the residents' highest practicable physical, mental, and psychosocial well-being. Findings: Record review of the document admission Record showed the facility admitted Resident 101 on 11/29/2024. Resident 101's diagnoses included depression. Record review of the document MDS 3.0 Nursing Home Quarterly (NQ) Version 1.19.1 (resident assessment) dated 5/29/2025, showed Resident 101 was alert and oriented to the day, month, and year. Record review of the document Progress Notes dated 6/13/2025, showed Resident 101 required some assist with ADLs (activities of daily living), was able to move all extremities and could feed herself. Record review of the document Progress Notes *NEW* dated 5/27/2025 showed Resident 101 had a weight loss of 28 pounds over the past 6 months. Record review of the document Progress Notes dated 6/11/2025 showed Resident 101 reported to Licensed Vocational Nurse 1 (LVN 1) she was feeling suicidal. On 6/12/2025 at 1:10 p.m. Resident 101 was observed asleep in bed with a gait belt hanging on the wall across from her bed. (gait belt: long narrow belt used by physical therapy which is placed around the resident's waist and used to support the resident during transfer/ambulation). During an interview on 6/12/2025 at 1:15 p.m., Resident 101's nurse, Licensed Vocational Nurse 2 (LVN 2) stated she had no concerns regarding Resident 101's behaviors or mental state. LVN 2 stated at times Resident 101 required encouragement to take her medication. She stated Resident 101 was depressed and needed to be Encouraged but had no concerns regarding her mental health status. During an interview on 6/12/2025 at 3:05 p.m. LVN 1 stated the physical therapist had reported to her Resident 101 was depressed. On 6/11/2025 LVN 1 then met with Resident 101 who reported she wanted To kill herself. LVN 1 reported this information to the Unit Manager and took no further action. LVN 1 confirmed there was no 1:1 monitoring form in the clinical record which would have shown staff remained with her in the room. During an interview on 6/12/2025 at 4:20 p.m., the Unit Manager (UM) stated the speech therapist had reported to him Resident 101 was depressed and Refusing to work with rehab or get out of bed. The UM stated he then sent an email/request for a psychological referral. Record review of the document Clinical Documentation MH/BH dated 6/9/2025, showed Resident 101 had been seen by mental health and Acknowledged feelings of depression . There was no documentation regarding suicidal thoughts. The mental health assessment on 6/9/2025 took place two days prior to Resident 101 stating she was feeling suicidal. During an interview on 6/12/2025 at 4:18 p.m. Resident 101 stated she thinks about suicide Daily. Record review of the document Care Plan Report dated 2/25/2025 showed the plan of care for Resident 101 was to be free from discomfort related to antidepressant therapy. There was no plan for suicidal ideation. During an interview on 6/13/2025 at 11:15 am, the UM stated, when a resident reports to staff they are suicidal staff should Immediately provide one-on-one monitoring, remove all sharp objects from the room, call the doctor and family. The UM stated a Social Service evaluation would need to be completed and the resident should be sent out to the hospital. The UM stated these steps were necessary to prevent the resident from Harming themselves. Record review of the document admission Record showed the facility admitted Resident 210 on10/4/2023. Resident 210's diagnoses included depression. Record review of the document Progress Notes *NEW* (Physician/NP/PA note) dated 9/18/2024 showed Patient does have the capacity to make medical decisions. Record review of the document Progress Notes *NEW* (doctor's progress note) dated 5/18/2025 showed Resident 210 had Normal Range of Motion and was alert and oriented to person, place and time. Record review of the document Care Plan Report dated 9/16/2024 showed Resident 210 had Body weakness and a goal was to Provide supportive care, assistance with mobility (transfer/ambulation/bed mobility). Further review of the care plan dated 8/28/2024 showed Resident 210 was At risk for self-harm due to resident being observed with placement of scissors on wrist and stated to licensed nurse I want to die. Record review of the document Progress Notes *NEW* dated 8/28/2024 showed licensed staff had gone into Resident 210's room to administer medication. Resident 210 was Crying holding scissors on his left wrist. Staff removed the scissors, notified the doctor and sent Resident 210 to the hospital. Record review of the document SBAR Communication Form dated 5/8/2025 showed Licensed Vocational Nurse 3 (LVN 3) documented he had observed a skin tear on Resident 210's right wrist area. The doctor had been notified, and treatment orders were provided. There was no documentation which showed staff investigated how the tear happened. During an interview on 6/10/2025 at 9:52 a.m. Resident 210 was observed moving from lying to sitting position at the bedside independently. Resident 210 stated he could Use more mental health support as he had Screaming episodes which the staff knew about because they happened A lot. During an interview on 6/10/2025 at 11:30 a.m., LVN 1 stated Resident 210 had Behaviors, anxiety, depression and he will Yell out and cry. LVN 1 stated the behaviors would occur Every other day and her typical response was to go into his room and provide reassurance. Record review of the document Social Service Note dated 6/10/2025 showed the SSA had met with Resident 210, and he was Very depressed and said that he thought he was running out of energy and can't do this anymore. He stated a few months ago he was Using a butter knife to mark his arm. When asked if he intended to harm himself, Resident 210 stated If I were to ever say something like that, this is the closest I've ever been. During an interview on 6/10/2025 at 2:15 p.m., the Social Services Assistant (SSA) stated she had spoken with Resident 210 earlier in the day and was concerned because he mentioned Something about hurting himself. The SSA stated she emailed the staff, so everyone was aware of the situation. The SSA stated she was not aware of Resident 210's yelling and crying behaviors. In a concurrent interview the Social Services Director (SSD) stated clinical nursing staff initiate psych consults (referrals for mental health services) and not social work. However, the SSD stated it would have been good for nursing to have notified social services regarding the behaviors as they could have been able to provide More frequent visits with him. During an interview on 6/10/2025 at 2:30 p.m. Resident 210 stated he was Emotionally unstable and needed to Talk to someone. Resident 210 stated he was having trouble Dealing with life and was trying to Get control of himself as sometimes Bad thoughts sneak in. During an interview on 6/10/2025 at 2:45 p.m. the Director of Nursing (DON) stated if a resident expresses a desire to hurt themselves, staff are expected to look for things in the room that could be used for harming oneself, review the medications, increase monitoring of the resident and make a referral for psychological support. The DON stated he had not been made aware of Resident 210's behaviors. On 6/10/2025 at 3:15 p.m. Resident 210 was observed in his room without staff present with a floor fan chord on the floor, TV chords on the walls and a plastic bag draped over the entrance door's handle. During an interview on 6/10/2025 at 4 p.m., LVN 3 stated he was not sure how the cut happened, and he didn't know If he was trying to kill himself or not. During an interview on 6/12/2025 at 1:55 p.m., the Assistant Director of Nursing (ADON) stated, if a resident reports they are suicidal, even if they say they can't go through with it, staff must Act. The ADON stated the resident would require One to one monitoring and staff notify the doctor, administrator, social services, family or responsible party. Record review of the document Suicide Threats dated 12/2007 showed Resident suicide threats shall be taken seriously and addressed appropriately. A staff member shall remain with the resident until the nurse supervisor/charge nurse arrives to evaluate the resident. After assessing the resident in more detail, the nurse supervisor/charge nurse shall notify the resident's attending physician and responsible party and shall seek further direction from the physician. All nursing personnel and other staff involved in caring for the resident shall be informed of the suicide threat and instructed to report changes in the resident's behavior immediately.

Based on observation, interview and record review, the facility failed to ensure Resident 1 had privacy during care when staff transferred Resident 1, who was not wearing clothes and uncontrollably yelling fuck repeatedly, from a shower chair into his room without adequately covering his genitals. This failure had the potential for psychosocial harm when Resident 1 ' s genitals were exposed and viewable to anyone in the hallway when Resident 1 was being transferred from the shower chair into the room and was yelling uncontrollably. Findings: A review of Resident 1 ' s admission record indicated Resident 1 was admitted with diagnoses for vascular dementia (loss of mental function due to loss of brain tissue from reduced blood supply), Tourette syndrome (disorder involving repetitive movements or unwanted sounds which a person has little or no control over), seizures (changes in brain electrical activity), intracranial injury (injury in the head) and need for assistance with personal care. During a record review of Resident 1 ' s minimum data set (MDS, an assessment tool to guide resident care), dated 3/31/25, the MDS indicated Resident 1 was unable to communicate with others and was dependent on staff for all aspects of care including eating, toileting, personal hygiene and transfers in and out of bed. During an observation on 3/21/25, at 10:00 a.m., Certified Nursing Assistant (CNA) 1, CNA 1 and Resident 1 were in the hallway outside Resident 1 ' s room. Resident 1 was sitting on a shower chair covered with linens but did not have clothes underneath. While CNA 1 and another CNA were lifting Resident 1 out of the chair with a mechanical lift, staff tried to cover Resident 1 with linens, but Resident 1 ' s scrotum remained visible. A privacy curtain was not utilized during the transfer. Resident 1 ' s genitals remained exposed and viewable from the hallway while they moved Resident 1 into his room. Though the entire transfer, Resident 1 repeatedly said fuck loudly and in an agitated tone which drew attention from staff and other individuals in the hallway. During a concurrent observation and interview on 3/21/25, at 10:15 a.m., with CNA 1, Resident 1 was in his bed with clothing on and covered with a blanket. CNA 1 stated Resident 1 could not be transferred from chair to bed inside his room because there was not enough room to transfer safely. CNA 1 stated the width of Resident 1 ' s bed prevented placement of the shower chair next to the bed. CNA 1 stated Resident 1 had to be taken out to the hallway on a mechanical lift for all transfers for as long as CNA 1 could remember. CNA 1 stated Resident 1 usually yelled out fuck during transfers in and out of bed. During an interview on 4/24/25, at 1:00 p.m., with the Director of Nursing (DON), the DON stated residents have an expectation of privacy when receiving care and was not acceptable to have their genitals visible in the hallway. During a record review of Resident 1 ' s care plan titled, Care Plan Report, dated 4/24/25, the care plan indicated Resident 1 needed use of mechanical lift for transfer with 2 persons assist. During a review of facility policy and procedure (P&P) titled Resident Rights, dated 10/2017, the P&P indicated residents in long term care facilities have rights guaranteed to them .including those specified in this section. Employees shall treat residents with kindness, dignity and respect .the facility promotes the rights of each resident, including .privacy and confidentiality .the facility promotes the rights of all residents including any who face barriers (such as communication problems).

Based on interviews and record reviews, the facility failed to ensure one of three sampled residents (Resident 1) received medications as ordered by the physician and was free of significant medication error (one which cause the resident discomfort or jeopardizes his or her health and safety), when Resident 1's Midodrine HCL (medication used to treat low blood pressure, helps prevent symptoms of dizziness when a Residents or person move from a sitting to a standing position) was held and not administered on multiple occasions, on 2/16/2025, 2/20/2025, and 2/21/2025. This failure resulted in Resident 1 not getting medication to treat his low blood pressure (BP) and potential return of symptoms to manage low blood pressure such as dizziness, lightheadedness, fainting spells, including decrease or limitation in Resident 1's activities of daily function, participation in his physical therapy treatment care, increased fall risk, injury and possible hospitalization . Findings: During a review of Resident's 1 Facesheet (FS), the FC indicated Resident 1 is [AGE] years old and was admitted to the facility in 2025. The FS indicated Resident 1's spouse is listed as emergency contact #1 and Resident as number 2. The FS also indicated Resident 1 had diagnosis of Injury at CS level of Cervical Spinal Cord (spinal cord in the neck region is damaged), Quadriplegia (partial or total loss of functions in all four limbs) , Hypotension (low blood pressure which can cause fainting or dizziness), Disorder of the Autonomic Nervous System (dysfunction of the nerves that regulate nonvoluntary body functions such as heart rate, BP), Muscle Weakness Generalized , and Depression. During a review of Resident 1's Minimum Data Set Record (MDS, a resident assessment tool use to guide care), dated 2/20/2025, the MDS indicated Resident 1 had a score of 15 on the Brief Interview for Mental Status exam. (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status). During a review of Resident 1's Medication Administration Record (MAR), Midodrine was not administered or held on 2/16/2025, 2/20/2025, and 2/21/2025. Resident 1's MAR indicated, Schedule for [DATE], Midodrine HCL Oral 10 MG (milligram) . Give 2 tablet via G-Tube every 8 hours for hypotension . Hold for SBP (systolic blood pressure) > (greater) 140 . start date 2/4/2025 . Sun (Feb) 16 .2100 . BP (blood pressure) 140/80 . 2 (code) . Midodrine HCL Oral 10 MG . Give 1.5 tablet via G-Tube three times a day for hypotension . Hold for SBP > 140 . start date 2/18/2025 .Thu (Feb) 20 . 0800 . BP 140/62 . 2 (code) . Fri (Feb) 21 . 2000 . BP 140/90 . 2 (code) . Resident 1's MAR also indicated, Chart Codes / Follow Up Codes . 2 = No Med Required - Outside of Parameter . During a record review and an interview on 3/21/25 at 12:09 p.m., with Unit Supervisor (US), US stated the physician's order on the MAR indicated hold Midodrine medication for Systolic Blood Pressure (SBP) greater than 140, meaning if Resident 1's SBP was at 141, then the nurse or staff passing the medication will hold the medication, but when it was at 140, the staff should have given the medication. When asked for the reason Midodrine medication was held and not given, when Resident's 1 SBP was at 140, US stated it was the facility's expectation for Licensed Vocational Nurse (LVN) 2 to have notified the Physician. US also stated LVN 2 should have documented in Resident 1's progress notes that Midodrine HCL was not given and was held because BP did not meet physician order parameters. US stated for Resident 1's Midodrine medication, facility nursing staff were trying to prevent from lowering Resident 1's BP, so if the medication was not given there is a possibility Resident 1's BP would have dropped. During an interview on 3/21/25 at 12:35 p.m., with the Administrator (ADM), ADM stated LVN 2 should have followed the physician's orders, which states on the MAR to hold for SBP greater than 140, because it's the physician's orders. During an interview on 4/22/25 at 6:36 p.m. with Resident 1, Resident 1 stated his Midodrine medication was never given the morning of 2/20/25. Resident 1 stated his primary charge nurse, LVN 1 did not come to his room in the morning of 2/20/2025 and that LVN 1 sent another nurse to help pass his medications. During an interview on 4/22/25 at 11:36 a.m. with listed Responsible Party (RP) on Resident 1's FS, RP stated Resident 1 is a paraplegic and unable to move both legs. RP stated Resident 1 wants to move and needed his medications in other to get physical therapy (PT). The RP stated she was at the facility and was in the room with Resident 1 all morning until the afternoon on 2/20/2025 when LVN 2 held and did not give Midodrine dose scheduled at 8:00 a.m. RP further stated Resident 1's primary nurse did not come into Resident 1's room and instead it was another nurse (LVN 2) who came to Resident 1's room. During an interview on 4/17/25 at 3:45 p.m., with LVN 1, LVN 1 stated she was very busy taking care of other residents on the morning of 2/20/25, and the desk nurse, LVN 2 had stepped in to help her. During an interview on 3/21/2025 at 12:42 p.m., with LVN 2, LVN 2 stated if she had held Resident 1's medication, the process is to have notified the physician the Midodrine was held and not given, in case there is any drug interaction with the upcoming medications due to be given to Resident 1. During a review of the facility's policy and procedure (P&P), titled, Administrating Medications dated 2001, the P&P indicated, Medication shall be administered in a safe and timely manner and as prescribed . 3. Medication must be administered in accordance with the orders, including any required time frame.

Based on interviews and record reviews, the facility failed to ensure medications were administered as ordered by the physician, for one of three sampled residents (Resident 1) when Resident 1's Midodrine HCL (medication used to treat low blood pressure, helps prevent symptoms of dizziness when a Residents or person move from a sitting to a standing position) was held and not administered on multiple occasions, on 2/16/2025, 2/20/2025, and 2/21/2025. This failure resulted in Resident 1 not getting medication to treat his low blood pressure (BP) and potential return of symptoms to manage low blood pressure such as dizziness, lightheadedness, fainting spells, including decrease or limitation in Resident 1's activities of daily function, participation in his physical therapy treatment care, increased fall risk, injury and possible hospitalization . Findings: During a review of the facility's policy and procedure (P&P), titled, Administrating Medications dated 2001, the P&P indicated, Medication shall be administered in a safe and timely manner and as prescribed . 3. Medication must be administered in accordance with the orders, including any required time frame. During a review of Resident's 1 Facesheet (FS), the FC indicated Resident 1 is [AGE] years old and was admitted to the facility in 2025. The FS also indicated Resident 1 had diagnosis of Injury at CS level of Cervical Spinal Cord (spinal cord in the neck region is damaged), Quadriplegia (partial or total loss of functions in all four limbs) , Hypotension (low blood pressure which can cause fainting or dizziness), Disorder of the Autonomic Nervous System (dysfunction of the nerves that regulate nonvoluntary body functions such as heart rate, BP), Muscle Weakness Generalized , and Depression. During a review of Resident 1's Medication Administration Record (MAR), Midodrine was not administered or held on 2/16/2025, 2/20/2025, and 2/21/2025. Resident 1's MAR indicated, Schedule for [DATE], Midodrine HCL Oral 10 MG (milligram) . Give 2 tablet via G-Tube every 8 hours for hypotension . Hold for SBP (systolic blood pressure) > (greater) 140 . start date 2/4/2025 . Sun (Feb) 16 .2100 . BP (blood pressure) 140/80 . 2 (code) . Midodrine HCL Oral 10 MG . Give 1.5 tablet via G-Tube three times a day for hypotension . Hold for SBP > 140 . start date 2/18/2025 .Thu (Feb) 20 . 0800 . BP 140/62 . 2 (code) . Fri (Feb) 21 . 2000 . BP 140/90 . 2 (code) . Resident 1's MAR also indicated, Chart Codes / Follow Up Codes . 2 = No Med Required - Outside of Parameter . During a record review and an interview on 3/21/25 at 12:09 p.m., with Unit Supervisor (US), US stated the physician's order on the MAR indicated hold Midodrine medication for Systolic Blood Pressure (SBP) greater than 140, meaning if Resident 1's SBP was at 141, then the nurse or staff passing the medication will hold the medication, but when it was at 140, the staff should have given the medication. When asked for the reason Midodrine medication was held and not given, when Resident's 1 SBP was at 140, US stated it was the facility's expectation for Licensed Vocational Nurse (LVN) 2 to have notified the Physician. US also stated LVN 2 should have documented in Resident 1's progress notes that Midodrine HCL was not given and was held because BP did not meet physician order parameters. US stated for Resident 1's Midodrine medication, facility nursing staff were trying to prevent from lowering Resident 1's BP, so if the medication was not given there is a possibility Resident 1's BP would have dropped. During an interview on 3/21/25 at 12:35 p.m., with the Administrator (ADM), ADM stated LVN 2 should have followed the physician's orders, which states on the MAR to hold for SBP greater than 140, because it's the physician's orders. During an interview on 3/21/2025 at 12:42 p.m., with LVN 2, LVN 2 stated if she had held Resident 1's medication, the process is to have notified the physician the Midodrine was held and not given, in case there is any drug interaction with the upcoming medications due to be given to Resident 1.

Based on observation, interview and record review, the facility failed to monitor and revise the interventions developed for potential skin breakdown for one of three residents (Resident 41) who was at risk for skin breakdown. Resident 41 developed redness/discoloration over the coccyx/sacrum (large triangular bone at the base of the spine also know as the tailbone) which was not acted upon until two months later when the reddened area progressed into an unstageable pressure ulcer (obscured full thickness skin and tissue loss) containing seventy-five percent slough (soft, moist, dead tissue). Findings: A review of Resident 41's Admission Minimum Data Set (MDS- an assessment tool) dated 2/19/18 showed Resident 41 was admitted to the facility on [DATE], required two persons physical assist to position body while in bed, move to and from a lying position, and turn side to side, and was always incontinent of bladder and bowel. The MDS showed Resident 41 had no healed or unhealed pressure ulcers upon admission, but was at risk for developing a pressure ulcer. A review of Resident 41's Quarterly MDS dated [DATE] showed Resident 41 had no pressure ulcers but was at risk for developing a pressure ulcer. During a review of Resident 41's quarterly Braden scale (a tool for assessing a patient's risk for developing a pressure ulcer) indicated, on 6/1/18 a score of fifteen (at risk), 10/8/18 a score of thirteen (moderate risk), and 11/22/18 a score of fourteen (moderate risk). Review of Resident 41's care plan initiated on 2/16/18 indicated, Monitor/document/report to MD (Medical Doctor) PRN (as needed) changes in skin status: appearance, color, wound healing, signs and symptoms of infection, wound size (length X width X depth), stage. Resident has pressure relieving mattress and chair cushion. Resident needs assistance to turn/reposition at least every two hours, more often as needed or requested. A review of Resident 41's skin/wound note dated 11/30/18 at 12:01 p.m., indicated an unstageable pressure ulcer to coccyx was observed by the wound treatment registered nurse (WTRN), and measured 1.2 centimeters by 0.9 centimeters with seventy-five percent slough and twenty-five percent granulation (new tissue). During an observation and concurrent interview on 2/6/19 at 9:36 a.m., Resident 41 was given wound care to sacral pressure ulcer by WTRN. An approximate four centimeter by one and one half centimeter open area was observed on sacrum. WTRN stated the pressure ulcer was unstageable with fifty percent slough and fifty percent granulation and tunneling (a passageway underneath the skin through soft tissue with potential for abscess formation) from seven o'clock to five o'clock. Resident 41 was given routine Tylenol for pain but was yelling at times during procedure. WTRN stated the sacral pressure ulcer was discovered on 11/30/18. During a review of the Certified Nursing Assistant's (CNA) documented skin observations for Resident 41 for (MONTH) (YEAR) and (MONTH) (YEAR), discoloration was documented on 10/5/18 and 11/22/18; and red area was documented on the following dates: 10/8/18, 10/11/18, 10/16/18, 10/17/18, 10/18/18, 10/27/18, 11/3/18, 11/4/18, 11/19/18, 11/26/18, 11/28/18, and 11/29/18. During a phone interview with CNA 4 on 2/11/19 at 10:15 a.m., he stated he documented redness of the skin on Resident 41's buttocks area on 10/16/18, 10/27/18, 11/3/18, 11/4/18, 11/19/18, and 11/26/18, and reported it to the charge nurse every time. During a phone interview with CNA 5 on 2/7/19 at 1:35 p.m., she stated on 11/4/18 she documented redness of the skin on Resident 41's buttocks area and notified the charge nurse. During an interview and concurrent record review with licensed vocational nurse (LVN) 3 on 2/7/19 at 8:45 a.m., LVN 3 stated she was unable to locate the weekly skin integrity forms, progress notes or any report to the physician regarding a change in Resident 41's skin condition in the medical record for Resident 41. LVN 3 stated that weekly skin checks were to be completed by the licensed nurses every week on all residents. LVN 3 stated she was unable to locate any notification of changes of Resident 41's skin until 11/30/18 when an unstageable pressure ulcer was discovered. LVN 3 stated she had to discipline licensed nurses on 11/30/18 for not reporting the CNA's findings when the licensed nurses were notified by the CNAs of the reddened area on Resident 41's skin on 10/16/18, 10/27/18, 11/3/18, 11/4/18, 11/19/18, and 11/26/18. During a review of Resident 41's weekly licensed nurse progress notes on 10/10/18, 10/17/18, 10/24/18, 11/7/18, 11/14/18 and 11/21/18 indicated, Resident has no new skin issues. Review of the facility's policy and procedure titled, Prevention of Pressure Ulcers, revised (MONTH) 2013 indicated, Routinely assess and document the condition of the resident's skin per Weekly Skin Integrity form for any signs and symptoms of irritation or breakdown. Report any signs of a developing pressure ulcer to the physician.

Based on observation, interview and record review the facility failed to assure one (Resident 1) of three sampled residents received supervision to prevent accidents when the resident was served hot tea in a pliable foam cup without a lid that fit. This failure resulted in Resident 1 spilling hot tea on her abdomen and sustaining a second degree burn (involves first two layers of skin which may appear as deep reddening and blistering of the skin) producing pain and the risk of skin infection. Findings: The facility reported an incident on 5/22/17: On 5/16/17 Resident's caregivers reported a wound on her abdomen. The wound was a burn from hot tea spilled on herself, as she was given a foam cup with, The wrong lid. The Administrator reported that foam cups were not going to be used in the facility any more. Resident 1 was given two tumblers in place of the foam cups. Review of the record on 5//18/17 indicated Resident 1 was admitted on [DATE] with [DIAGNOSES REDACTED]. Symptoms can include vision loss, numbness, dizziness, lack of coordination and weakness). Resident 1 was receiving oxycodone (a narcotic medication) for moderate to severe lower back pain, which could make her light headed and drowsy. Review of the Minimum Data Set Assessment, dated 5/6/17, on 5/23/17 indicated, Resident 1 had a Brief Interview for Mental Status score of 15 (no deficits in mental ability). The assessment indicated Resident 1 needed supervision and setup help for eating and drinking (food and utensils set up so the resident could feed herself and drink safely). During an interview and observation with Resident 1 on 5/18/17 at 3:20 p.m., Resident 1 lifted her gown and showed a bright red open wound on her abdomen about two inches long with no dressing on it. Resident 1 stated it (the wound) was supposed to have a (brand name film) dressing on the wound. Resident 1 stated it was painful. Resident 1 said she had been served hot tea in a foam cup. Resident 1 stated the cup usually came with a slitted top for sipping. Resident 1 took a plain plastic cover that was lying on her table and put it over a foam cup to show the way she was given the hot tea when she got burned. The lid was larger than the cup opening and did not fit. Resident 1 said she spilled the hot tea on herself. Resident 1 stated, was her left hand wasn't working so well and the tea had been placed on the overbed table to her left side. Resident 1 stated someone brought her a cold towel and an ice pack for the burn. Resident 1 stated the burned area blistered, then the skin came off. During an interview with Certified Nurse Assistant (CNA) 1 on 5/17/17 at 3:15 p.m. CNA 1 stated Resident 1 liked to use the foam cup with a lid, rather than a regular coffee cup for tea, because the coffee taste stayed in the cups. CNA 1 did not know when Resident 1 spilled the hot tea. During an interview with the Administrator on 5/18/17 at 3:10 p.m. she stated the temperature of the hot water from the kitchen was 175 to 180 degrees Fahrenheit (F). The Administrator stated no one reported the accident with the hot tea and it was not known when it actually happened. Review of the medical record Progress Notes, written by Registered Nurse (RN) 1, dated 5/16/17 12:55 a.m. indicated, Situation: skin excoriation to left lower abdomen. Measurement 4.2 cm (centimeters) by 3.1 cm. CNA called writer and reported about the skin issue noted on patient's left lower abdomen .Assessed skin, noted redness, irregular size, skin is excoriated (damaged to the skin, causing redness), no drainage. Surrounding skin is normal. Cleansed affected site and kept dry, patients denies pain or discomfort, no itchiness. A physician's orders [REDACTED]. to wounds) and cover with foam dressing every day shift every other day. A review of the facility's policy, Guidelines for Hot Beverages, dated 10/31/08, indicated the temperature for coffee was 185 to 200 degrees F, the recommended temperature for brewing black teas .This temperature can result in a burn if the beverage comes in contact with the skin. Precautions can be implemented to limit the risk of burns from hot beverages. General Guidelines: 5. When serving hot liquids to residents, consider the following: a. don't overfill drinking cups b. place beverage away from the edge of the table and near resident's dominant hand. 6. Identify residents who may be at greater risk of spilling hot beverages on themselves, which may include but are not limited to: a. residents with tremors (shaking) b. Resident with poor hand control from CVA (stroke), arthritis (inflammation and pain of joints), weakness, etc.

Based on interview and record review the facility failed to provide the proper [MEDICAL CONDITION] treatment and care for Resident 1, by not following their own policy and procedure for [MEDICAL CONDITION] change and failed to provide effective resuscitation for an unsuccessful [MEDICAL CONDITION] change. This failure resulted in Resident 1's subsequent death. Definitions: [MEDICAL CONDITION]: a surgical opening through the neck into the trachea (windpipe) to allow for mechanical breathing in patients with [MEDICAL CONDITION]. [MEDICAL CONDITION] cuff: a balloon that seals off the space between the wall of the trachea and [MEDICAL CONDITION]. Subcutaneous Tissue [MEDICAL CONDITION]: air trapped under the skin. Stoma: an artificial opening in the neck area to allow for the [MEDICAL CONDITION]. Hyperextend: to extend beyond the normal range of motion. Oxygen saturation level: O2 sat- a measurement of oxygen concentration in the blood. Crepitus: A clinical sign characterized by a crackling or popping sound of air in the soft tissue around the lungs in an area where it should not be. Findings: Review of the clinical record showed Resident 1 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident 1 had a [MEDICAL CONDITION] and was dependent on a ventilator (a breathing machine). On 10/28/15 The Director of Respiratory Therapy (DRT), Respiratory Therapist (RT) 1, RT 2, and Medical Doctor (MD) 1 performed a scheduled [MEDICAL CONDITION] change ordered for Resident 1. DRT documented vital signs for Resident 1's prior to the [MEDICAL CONDITION] change as followed: oxygen saturation level 99% (normal: 95-100%), heart rate was 73 beats/minute (normal: 60-100), respiratory rate was 14 breaths/minute (normal: 10-20). RT 2 stated Resident 1 did not have any respiratory issues prior to the [MEDICAL CONDITION] change. Review of facility's policy and procedures [MEDICAL CONDITION] change, revised on 10/31/08 indicated to, Hyperextend the resident's neck by placing a folded towel under the neck. Inflate the [MEDICAL CONDITION] cuff, if physician ordered: a. Fill syringe with 10 ml of air, and attach to cuff inflation port. b. Place stethoscope over trachea. c. Slowly inflate the cuff until no airflow is heard during inspiration. d. Slightly deflate the cuff until a minimal amount of airflow is heard . According to the Science Journal of the American Association for Respiratory Care: When to change a [MEDICAL CONDITION], dated 8/2010 indicated, Failure to replace the [MEDICAL CONDITION] at the time of a routine change can rapidly create an emergency with loss of the airway. Figure 10 shows a suggested algorithm (a process) to help guide practitioners when this occurs. The algorithm to Figure 10 indicated the following: Failed [MEDICAL CONDITION] change > Adequate oxygenation and ventilation? > No > Supplemental oxygen, oral bag-mask ventilation. Reference ( http://rc.rcjournal.com/content/55/8/1056.full.pdf+html ) In an interview on 11/9/15 at 8:48 a.m., DRT confirmed Resident 1 was placed in a semi-fowler's position (a position with the head of the bed elevated approximately 30 to 45 degrees) with Resident 1's neck extended. DRT stated Resident 1's stoma was patent and opened as he withdrew the old [MEDICAL CONDITION]. DRT stated he met resistance when he inserted Resident 1's new [MEDICAL CONDITION]. DRT stated 15 seconds after he connected Resident 1's [MEDICAL CONDITION] to the ventilator, Resident 1's condition changed. DRT stated Resident 1's oxygen saturations decreased, Resident 1's heart rate was above 100 (60 to 100 beats per minute is normal), subcutaneous tissue [MEDICAL CONDITION] was noted on the left side of Resident 1's neck, and Resident 1's lungs felt tight. DRT stated he deflated Resident 1's [MEDICAL CONDITION] cuff and attempted to realign Resident 1's [MEDICAL CONDITION] by backing it out, but he did not take the [MEDICAL CONDITION] completely out. DRT stated Resident 1's oxygen saturation levels went up and down. DRT stated he ventilated Resident 1 via Resident 1's [MEDICAL CONDITION] with a bag-valve mask (BVM, a hand-held, manual, self-inflating bag used to provide ventilation) until the paramedics arrived. In an interview on 11/9/15 at 9:40 a.m., RT 1 confirmed Resident 1's skin color on her face turned to ashy color and her oxygen saturation levels dropped and fluctuated between 58 to 80% after the [MEDICAL CONDITION] change. In an interview on 11/18/15 at 10:45 a.m., RT 2 stated moments after Resident 1's [MEDICAL CONDITION] was attached to the ventilator, Resident 1 developed subcutaneous tissue [MEDICAL CONDITION] on the left side of her neck and her skin changed to greyish-blue, dusky. RT 2 confirmed Resident 1 had diminished breath sounds in the left lung after the [MEDICAL CONDITION] change. RT 2 confirmed Resident 1's skin color remained dusky when Resident 1 was taken to the hospital by paramedics. RT 2 stated Resident 1's [MEDICAL CONDITION] could have been misplaced during the [MEDICAL CONDITION] change. In a telephone interview on 11/18/15 at 11:45 a.m., RT 1 confirmed she had met resistance when she attempted to suction Resident 1 via the [MEDICAL CONDITION]. RT 1 stated there were scant, blood-tinged secretions when she tried to suction the [MEDICAL CONDITION]. RT 1 stated Resident 1's oxygen saturation levels were in the 80s and her heart rate was in the 120s after DRT manipulated and repositioned Resident 1's [MEDICAL CONDITION]. In a telephone interview on 12/31/15 at 9:00 a.m., RT 2 stated a misalignment of a [MEDICAL CONDITION] would cause subcutaneous tissue [MEDICAL CONDITION] in the neck. RT 2 confirmed Resident 1 was ventilated with a BVM through the [MEDICAL CONDITION] and not through the mouth when subcutaneous tissue [MEDICAL CONDITION] was noted on the left side of Resident 1's neck. In a telephone interview on 12/31/15 at 9:20 a.m., RT 1 confirmed Resident 1 was ventilated with a BVM through the [MEDICAL CONDITION] and not through the mouth. RT 1 confirmed Resident 1 was placed in a semi-fowler's position with no support under the neck. RT 1 stated Resident 1 started to develop subcutaneous tissue [MEDICAL CONDITION] in the left neck area after her new [MEDICAL CONDITION] was inserted. In a telephone interview on 12/31/15 at 11:00 a.m., an Ears, Nose and Throat Doctor (ENT, an expert in [MEDICAL CONDITION] from the General Acute Care Hospital that treated Resident 1 in the emergency room ) stated the best position to do a [MEDICAL CONDITION] change was to have a patient in a supine (flat on the back facing up) position with the neck extended and a towel placed under the neck, which would allow the neck to be more exposed visibly. The ENT stated to indicate if a [MEDICAL CONDITION] was placed correctly staff could pass a suction catheter through the [MEDICAL CONDITION] without resistance, and listen to both lungs for good air exchange. The ENT stated manipulating the [MEDICAL CONDITION] while still in the trachea would not help and may create a false passage. The ENT stated the [MEDICAL CONDITION] must be taken out and re-inserted with a smaller sized [MEDICAL CONDITION] if there were any problems in ventilation. The ENT stated covering the stoma and using a BVM via mouth was a way to properly ventilate someone in an emergency if ventilating via the [MEDICAL CONDITION] was not an option. In a telephone interview on 12/31/15 at 11:40 a.m., DRT stated there were no emergency protocols or policy and procedures in an event like this, only to call 911. DRT stated he did not feel comfortable to change the [MEDICAL CONDITION] to a smaller size. DRT confirmed he ventilated Resident 1 via the [MEDICAL CONDITION] and not by the mouth with a BVM. In an interview on 6/23/16 at 11:45 a.m., an Expert Respiratory Therapist Consultant (ERTC) from the Respiratory Care Board of California stated Resident 1 had the signs and symptoms (the low oxygen saturation, fast heartbeat, change in color of skin, the inability for RT 2 to suction via the [MEDICAL CONDITION], and the tissue [MEDICAL CONDITION]) that indicated her [MEDICAL CONDITION] was in the wrong place. Furthermore the ERTC stated the continuous resuscitation of Resident 1's [MEDICAL CONDITION] when not in the correct place would lead to oxygen not going to the lungs and into the tissue space, which would lead to subsequent death if not corrected. The ERTC stated the facility's staff should have recognized that Resident 1's [MEDICAL CONDITION] was not in the right place from the signs and symptoms that were present, and should have removed the [MEDICAL CONDITION], cover Resident 1's stoma and provided oxygen to Resident 1's mouth with a BVM. Record review of Progress notes, dated 10/28/15 by DRT showed, Upon insertion DRT met resistance approximately two inches into stoma. Clear (breath sounds) on the right (lung), diminished on the left (lung). Shortly after Resident 1's oxygen saturation levels began to drop. Resident 1 placed on 100% oxygen via BVM. Resident 1 had a change in color, absent breath sounds on the left. Heart rate in the 120s. MD 1 noticed crepitus (subcutaneous tissue [MEDICAL CONDITION]) around neck. Resident 1 suctioned several times, blood tinged secretions. Record review of MD 1's Progress Note dated 10/28/15 showed, Resident 1's [MEDICAL CONDITION] change got complicated with acute [MEDICAL CONDITION], RT 1 realigned the [MEDICAL CONDITION] and did multiple suctions which were blood tinge for decrease oxygenation. Although her oxygen improved to the 90's initially and later fluctuated between 53-98%, also Resident 1 developed chest crepitus, 911 was called, started bagging (artificial respiration with a hand held air bag) and patient was transferred to acute care for [MEDICAL CONDITION](rapid ineffective heart beat) with decrease oxygen saturation (amount of oxygen in the blood). Record review of the Emergency Medical Technician-Paramedic Patient care report, dated 10/28/15 showed, Per RT upon insertion of new ([MEDICAL CONDITION]) tube resistance was met and blood was noted around stoma. Staff member states poor BVM compliance noted. RT states subcutaneous (tissue) [MEDICAL CONDITION] noted to left chest and believes [MEDICAL CONDITION] may be displaced. Skin temperature cool, Skin color cyanotic, left lung sounds absent, right lung sounds decreased, capillary refill (a quick test to indicate blood flow in the tissue) absent, level of consciousness unresponsive, heart rate 134, and oxygen saturations 70% with supplemental oxygen. Record review of Emergency Department (ED) nursing notes, dated 10/28/15 showed, Blood coming from [MEDICAL CONDITION]. Crepitus around trachea. Resident 1 is mottled (spots or patches with different colors). Record review of the ED physician progress notes [REDACTED].(Resident 1) with emergent airway issue and prolonged anoxia (absence of oxygen) with apparent severe [MEDICAL CONDITION] .Unable to ventilate [MEDICAL CONDITION] place with subterranean air(crepitus) felt in surrounding tissue .Time of death 1:20 (pm). Record review of the Coroner's Report, dated 3/31/16 showed, Autopsy (an examination used to determine the cause of death) findings: Perforation (a hole made by piercing) of posterior wall of esophagus (throat) and trachea due to improper placement of [MEDICAL CONDITION], with tip of [MEDICAL CONDITION] impacting fifth cervical vertebrum (the upper spine that form the neck). These findings are consistent with placement of the tube in the esophagus with perforation. There is also evidence of the [MEDICAL CONDITION] causing perforation of the trachea and entry of the tip of the tube into the lower esophagus. Cause of Death: Acute [MEDICAL CONDITION], with bilateral collapsed lungs, due to improper placement of [MEDICAL CONDITION], with tracheal and [MEDICAL CONDITION] perforation.

Based on observation, interview and record review the facility failed to ensure four of four sampled residents (Residents 1, 2, 3 and 4) received necessary services to prevent pressure ulcers (breakdown of skin or deeper tissues due to pressure). 1. This failure resulted in Resident 1 getting a Stage 3 pressure ulcer (full thickness skin loss) from lack of ulcer preventive services. 2. Resident 2, 3, and 4 were not repositioned every two hours as needed. This failure resulted in the potential for worsening of existing pressure ulcers and acquiring additional pressure ulcers for Residents 2 and 3. This failure also resulted in the potential for Resident 4 to acquire a pressure ulcer.(full thickness skin loss An investigation was done in response to a report that Resident 1 was discharged from the (skilled) facility and admitted to an assisted living (AL) home. The AL staff discovered a patch on Resident 1's coccyx (tailbone area) that was covering a pressure ulcer. According to the report Resident 1 did not have a pressure ulcer upon entering the facility. Findings: 1. Review of the clinical record showed Resident 1 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident 1's Minimal Data Set (MDS-assessment tool used to direct resident care), Section M (Skin Conditions), dated 5/20/15, Resident 1 did not have a pressure ulcer. Review of Resident 1's Progress Notes dated 5/13/15 showed Resident 1 needed one person extensive assistance in repositioning and movement. In a telephone interview on 6/5/15 at 12:55 p.m., the assisted living nurse (ALN) confirmed Resident 1 had a pressure ulcer and redness on her coccyx when assessed on 5/20/15, after Resident 1 was discharged from the facility. In an interview on 6/5/15 at 3:15 p.m., Certified Nurse Assistant (CNA) 2 stated Resident 1 had a patch located on Resident 1's coccyx area when she had took care of her during Resident 1's stay at the skilled facility. In an interview on 6/8/15 at 1:00 p.m., the Director of Nursing (DON) stated residents who were at moderate risk for skin breakdown should not be in a wheelchair for more than two hours. The DON stated residents could get a pressure ulcer if they sat in the wheelchair all day and if they were not repositioned in bed. The DON stated nurses should document when a resident was repositioned or if they refused to be repositioned. The DON stated documentation of repositioning should be done every shift. In a telephone interview on 7/15/15 at 11:05 a.m., Home Health Nurse (HHN) 1 confirmed Resident 1 had a Stage 3 wound with slough (dead tissue) when Resident 1 was assessed on 5/22/15 at the AL home. HHN 1 stated Resident 1 should have been repositioned every two hours to prevent pressure ulcers. Record review of Resident 1's, Visit Note Report, dated 5/22/15, showed, Coccyx pressure ulcer Stage 3, measures 3 x 4 x 0.2 (centimeters), wound bed pink, slough, surrounding pink, no undermining, tunneling, odor, scant serosanguinous (fluid composed of blood and serum) drainage. Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitoring. Record review of Resident 1's Care Home Admission Assessment, dated 5/20/15, showed, Positive skin breakdown. Open sore and positive redness on coccyx. Review of Resident 1's Braden Assessment (assessment tool to predict skin breakdown), dated on 5/9/15, showed, Mobility: Very limited. Friction & Shear: Potential problem. Other skin risk factors: Bed/Chair bound. Skin Inspection: Skin normal, supple and free from open areas. Review of Resident 1's Treatment Record, dated 5/9/15 showed, Skin inspection every day for 72 hours and Pressure ulcer risk assessment tool every Monday for four weeks upon admission. No documentation was entered. Review of Resident 1's Progress Notes,dated 5/12/15 and 5/15/15, showed, Resident 1 slept most of time today in wheelchair. Review of Resident 1's care plan showed there was no documentation of interventions to address and prevent skin breakdown. Review of the facility's Policy and Procedure, titled Positioning a patient with or without pressure ulcers, revised 6/5/15, showed Repositioning without a pressure ulcer: Reposition resident at least every two hours whether the resident is in bed or in a chair. According to the Wound, Ostomy, and Continence Nurses Society (2015), an avoidable pressure ulcer, Means that the resident developed a pressure ulcer and that the facility did not do one or more of the following: define and implement interventions that are consistent with resident needs, resident goals, and recognized standards of practice. (Reference: <http://c.ymcdn.com/sites/www.wocn.org/resource/resmgr/Publications/PS_Avoidable_vs_Unavoidable_.pdf>) According to the National Pressure Ulcer Advisory Panel (2015), Documentation provides a written record of care delivery and, as such, serves as evidence that repositioning has occurred. (Reference: <http://www.npuap.org/wp-content/uploads/2014/08/Updated-10-16-14-Quick-Reference-Guide-DIGITAL-NPUAP-EPUAP-PPPIA-16Oct2014.pdf>) 2. Review of the record showed Resident 2 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident 2 was dependent on one person for bed mobility. Resident 2 had two Stage 2 (partial thickness loss of the skin), one Stage 4 (full thickness tissue loss with exposed bone, tendon or muscle), and two unstageable pressure ulcers (full thickness tissue loss with slough). Observations on 6/5/15: 9:40 a.m. Resident 2 was in bed positioned on his back with the head of the bed up. Resident 2 stated he had paralysis and should be turned every two hours, but does not get turned every two hours. 11:00 a.m. Resident 2 was on his back with the head of the bed up. 12:00 p.m. Resident 2 was in bed on his back with the head of the bed up. 1:10 p.m. Resident 2 was in bed on his back with the head of the bed up. In an interview on 6/5/15 at 2:45 p.m., CNA 1 stated the last time Resident 2 was repositioned was at 12:00 p.m. CNA 1 confirmed Resident 2 was positioned on his back with the head of the bed up. In an interview on 6/5/15 at 3:35 p.m., Registered Nurse (RN 1) confirmed Resident 2 needed assistance to be repositioned every two hours to prevent further pressure ulcers. In an interview and concurrent record review on 6/8/15 at 1:00 p.m., the DON stated CNAs and Nurses had a card titled,Sample Turning Schedule, on their badges, which they should follow and carry at all times. The DON stated the instructions on the Sample Turing Schedule card showed which position a resident should be in at the times listed on the card. Review of the Sample Turning Card in the presence of the DON showed, 6 and 12 - on your back for a snack, 8 and 4 - face the door, and 10 and 2 - face the view (window). The DON stated CNAs and Nurses should follow what was written on the turning card to ensure residents were repositioned. Review of Resident 2's care plan titled Actual alteration in skin integrity secondary to [MEDICAL CONDITION], dated 3/26/15, showed, Turn and reposition as needed. Review of Resident 2's Braden Scale for Predicting Pressure Sore Risk, dated 4/23/15 showed, Degree of physical activity: Confined to bed. Ability to change and control body position: Very Limited-makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently. Review of the facility's Policy and Procedure, titled Positioning a Patient with or without pressure ulcers, revised 6/5/15, showed Repositioning without a pressure ulcer: Reposition resident at least every two hours whether the resident is in bed or in a chair. 3. Review of the clinical record showed Resident 3 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident 3's MDS section G (Functional Status), dated 5/22/15, showed Resident 3 required extensive one-person assistance for Bed mobility, and had one-sided impairment of both arms and legs. Section M (Skin conditions), dated on 5/22/15, showed Resident 3 was at risk of developing pressure ulcers, and had one existing unstageable pressure ulcer with slough (dead tissue). Observations on 6/5/15 9:52 a.m., Resident 3 was positioned on his back in bed. 11:00 a.m., Resident 3 was on his back in bed. 12:00 p.m., Resident 3 was in bed on his back. 1:10 p.m., Resident 3 was in bed on his back. In an interview on 6/5/15 at 2:45 p.m., CNA 1 confirmed Resident 3 needed assist to reposition every two hours. CNA 1 confirmed Resident 3 was positioned on his back and was last repositioned at 1:30 p.m. In an interview on 6/5/15 at 3:35 p.m., RN 1 stated Resident 3 needed assistance to be repositioned every two hours to prevent further pressure ulcers. Review of Resident 3's Braden Scale for Predicting Pressure Sore Risk dated 3/18/14 showed, Degree to which skin is exposed to moisture: Very Moist-skin is often, but not always, moist. Friction: Requires moderate to maximum assistance in moving. Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance. Review of Resident 3's care plan titled Open area to sacrum (lower back bone area) dated 4/14/15 indicated to, Turn and reposition every 2 hours and as needed. Review of the clinical record of Resident 3 showed, 5/14/15 Pressure ulcer risk assessment tool (Braden scale) every Monday for 4 weeks upon admission 4. Review of the clinical record showed Resident 4 was admitted on [DATE] with a [DIAGNOSES REDACTED]. Review of the MDS, dated [DATE], Section G (Functional status) showed Resident 4 required two-person physical assist and was totally dependent for her activities of daily living, and section M (Skin conditions) showed Resident 4 was at risk for developing a pressure ulcer. In an observation and concurrent interview on 6/5/15 at 8:40 a.m., Resident 4 was observed positioned on her back in bed. Resident 4 stated she was not repositioned every two hours. Resident 4 stated she was last turned at 5:00 a.m. on 6/5/15. Resident 4 stated she needed assistance to help reposition. Resident 4 attempted to reposition herself, but could not. LVN 1 was informed of the situation at 9:00 a.m. Review of Resident 4's Braden Scale for Predicting Sore Risk dated 6/4/15 showed, Ability to change and control body position: Very limited - Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently. Friction- Requires moderate to maximum assistance in moving. Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance.

Based on observation, interview and record review, the facility failed to provide adequate supervision and a safe environment for one of one sampled resident. (Resident 1). During incontinent care, on 6/11/14, Resident 1 was left alone with the bed in the high position. This failure resulted in Resident 1 falling to the floor and sustaining hip and knee fractures. The hip fracture required surgery under anesthesia. Findings: See also F 279 Review of the medical record, on 7/1/14, showed Resident 1's [DIAGNOSES REDACTED]. She was receiving rehabilitation therapy for strengthening. Resident 1 used a wheelchair to get around. Assessments done on admission included a Bed Safety/Rails Assessment, dated 5/26/14. It showed Resident 1 was confused, required a 1/4 bed rail to enable movement, the bed should be in a low position, a tab alarm (sensor pad alerts staff if patient attempts to get up) should be used and fall precautions established. The previous Functional Assessment, dated 5/27/14, showed Resident 1 had a fall within the previous three months and she used a walker. The physical therapy treatment record, dated 6/8/14, showed Resident 1 required minimum to moderate assist with bed mobility, had full range of motion and had poor judgment with safety. In an interview, 7/3/14 at 11:25 a.m., Certified Nurse Assistant (CNA) 1 stated while in the process of doing incontinent care for Resident 1, on 6/11/14, he raised the bed to the high position so he could more easily do the care. The bed linens were soiled and needed to be changed. There were no fresh linens in the room. CNA 1 stated he left Resident 1 lying on her back, with the bed in high position, to go to the hallway linen cart and found it did not have the linens required. He proceeded down the hall, around the corner and down the next hall to the laundry room. When he returned, Resident 1 was side ways on the floor between the room's two beds. He stated side rails were not in use. CNA 1 stated Resident 1, "Wasn't agitated and was very calm" prior to leaving the room, or "I wouldn't have left her in that position." "I should have just put the bed down totally flat to the floor, in the lowest position. She would have been closer to the floor." Resident 1 sustained a fracture of the hip that required surgery under anesthesia, and a fracture of the knee. In an interview, 7/1/14 at 11:10 a.m., a family member of Resident 1 stated that sometimes he had to remind staff to return the bed to the low position after care. Review of the Managing Fall Risk policy and procedure, released 2/28/14, showed that the environment was to be maintained to promote patient safety. A component of this was was to be accomplished by keeping "The bed in its lowest position," initiation of a fall risk program with weekly interdisciplinary team meetings, falling star magnet placed on door frame, a care plan addressing falls and individual interventions that is revised as needed. Resident 1 had a care plan, dated 5/27/14, showing she was at risk for falls related to confusion and incontinence. There was one intervention documented on the care plan; to anticipate and meet Resident 1's needs.

Based on observation, interview and record review, the facility failed to ensure that one of 3 sampled residents were monitored appropriately when Respiratory Therapist (RT 1) placed a Passy Muir Valve (PMV) on her [MEDICAL CONDITION] and left her room. Resident 1 had a history of [REDACTED]. Resident 1 had a history of [REDACTED]. Passy Muir Valve (PMV)=A Passy-Muir valve is a one-way valve that attaches to the outside opening of the [MEDICAL CONDITION] (tube inserted into airway of resident to allow breathing) and allows air to pass into the trachesotomy but no out. The valve opens when patient breathes in and closes when patient exhales, allowing the exhaled air to flow around the trachesotomy tube and up through the vocal cords and out the mouth and nose. The patient breathes out through the mouth and nose instead of the [MEDICAL CONDITION]. [MEDICATION NAME] [DIAGNOSES REDACTED] is a neurological disorder caused by inflammation across both sides of one level, or segment, of the spinal cord which can cause nervous system scars that interrupt communications between the nerves in the spinal cord and the rest of the body. Subdural hematoma is bleeding under the lining of the brain. [DIAGNOSES REDACTED] is a life-threatening single prolonged [MEDICAL CONDITION] or a series of [MEDICAL CONDITION] without intervening full recovery of consciousness. [MEDICAL CONDITION] is a surgical procedure to create an opening through the neck into the trachea (windpipe), so patient can breath and have secretions removed. Pulse oxymeter is a device that measures the oxygen saturation of arterial blood in a subject by utilizing a sensor attached typically to a finger, toe, or ear to determine the percentage of oxyhemoglobin in blood pulsating through a network of capillaries. Findings: Resident 1 was an [AGE] year old female who was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Medical Doctor (MD 1) wrote in a progress note on [DATE] that Resident 1 had [MEDICATION NAME] [DIAGNOSES REDACTED], subdural hematoma, a frontal [DIAGNOSES REDACTED] ([DIAGNOSES REDACTED]) and a [MEDICAL CONDITION] disorder. Resident 1's had a history of [REDACTED]. On [DATE] the [MEDICAL CONDITION] was removed but the next day she had acute respiratory distress and was sent to the hospital and again a [MEDICAL CONDITION] was inserted. According to her initial minimum data set (MDS) assessment dated [DATE], she required [MEDICAL CONDITION] care, suctioning and oxygen therapy. She had no speech but was sometimes understood, and had the ability to sometimes understand others as demonstrated by responds adequately to simple direct communication only. She had short term memory problems and was moderately impaired for daily decision making. She was totally dependent of staff to care for her activities of daily living. She could not swallow and was fed by a gastrostomy tube (a tube inserted into the stomach to administer a liquid diet and give medications and water.) The quarterly MDS assessment dated [DATE] revealed the resident was unchanged. She was receiving respiratory therapy seven days a week, and had received 85 hours of speech and language therapy. The physician's orders [REDACTED]. According to the Speech Pathology Evaluation, dysphagia (difficulty in swallowing) and communication record dated [DATE] the use of PMV trials with speech therapist and respiratory therapist as tolerated was planned to improve communication effectiveness, and swallowing function with the goal to increase her quality of life. Review of the speech therapist progress note dated [DATE] , showed that Resident 1 poorly tolerated the PMV trials and experienced stridorous breathing (an abnormal, high-pitched, musical breathing sound caused by a blockage in the throat or voice box. It is usually heard when taking in a breath.) In an interview with on [DATE] at 12:10 p.m. the Speech Therapist stated that Resident 1 had a history of [REDACTED]. She fluctuated between 60 to 80 percent with one step directions, and needed moderate to maximum cues. She discontinued the resident from therapy on [DATE] and discontinued the goal for PMV because she was not tolerating the valve based on stridorous breathing sounds; therefore, the use of PMV was not indicated. She communicated that to the respiratory therapist on [DATE]. MD 1 wrote in a progress note on [DATE], [DATE] and [DATE] that the resident was not tolerating the PMV and on [DATE] gave an order to schedule an ear, nose throat consult to rule out any obstructive mass or pathology of her airway. During an interview on [DATE] at 1:50 p.m. Medical Doctor (MD 2), who was the partner of MD 1 and familiar with Resident 1's care said he thought the PMV trials should have been discontinued after learning the resident was not tolerating. Additionally, he stated that MD 1's note on [DATE] indicated that the resident was not tolerating the PMV trials. A review of the "Respiratory Daily Notes," Resident 1 had not been trialed with the PMV after the [DATE] documentation by the Speech Therapist, until [DATE]. According to the Respiratory Daily Notes on [DATE] at 10 a.m., Respiratory Therapist (RT) 1 wrote at 10 a.m., "Placed PMV..." He recorded her heart rate at 125 beats per minute. Her heat rate at 5:15 a.m. was recorded as 95 beats per minute. At 10:20 a.m. RT 1 wrote "Does not tolerate...O (no) PMV at this time." On [DATE] at 11:05 a.m. RT 1 documented on a "Respiratory Therapy Summary Form" that Resident 1 was biting off the cuff balloon (inflated cuff balloon keeps [MEDICAL CONDITION] in place) on her Shiley [MEDICAL CONDITION]. The note revealed that he removed [MEDICAL CONDITION] due to a "cuff balloon breach." There was a small amount of bleeding...with no complications. Later on [DATE] at 9:20 p.m., the Respiratory Daily Notes revealed that the resident was stable on room air, aerated [MEDICAL CONDITION] (oxygen given though a mask covering the [MEDICAL CONDITION] opening), resting comfortably with no distress noted, and her heart rate was 106 beats per minute. The next day, [DATE], RT 1 documented on the Respiratory Daily Notes at 9:25 a.m. that the resident was stable on room air ...Placed on PMV." Her heart rate was 100 beats per minute. At 9:50 a.m. RT 1 documented, "Peeked in room - remains stable." At 10:45 a.m. RT 1 documented, "Code blue" and cardiopulmonary resuscitation (CPR) with a bag and mask was performed for 30 minutes, and Resident expired. A review of the "Code Event Minutes" dated [DATE] revealed that Resident 1 was found at 10:45 a.m. by two certified nursing assistants (CNA) 1 and CNA 2 to be non-responsive, not breathing and with no pulse. 911 and code blue was called. The PMV was removed. At 10:46 CPR was started, RT was "bagging" (aerating with ambu-bag) and AED (automated external defibrillator which is a portable device that checks the heart rhythm and If needed, it can send an electric shock to the heart to try to restore a normal rhythm.) was in place. At 10:58 the note revealed there was no "shock." The paramedic arrived at 11:02. At 11:03 the Paramedic called (off) the code and pronounced (dead). During an interview on [DATE] at 11:50 a.m., the sub-acute unit nursing supervisor RN 1 stated that she was present in Resident 1's room and wrote the "Code Event Minutes" dated [DATE]. She stated that RT 1 should have stayed with the resident during the trial of PMV, especially in light of not tolerating the PMV the day before. She stated that she did not know what he meant in his note, "Peeked in room," and that was not an acceptable way to assess a resident's condition. MD 2 documented in a physician's progress note on [DATE] at 12:25 p.m. titled, "physician CPR note," that he was called to evaluate the resident when the code blue was called. He noted that in addition to CPR, an automatic defibrillator was connected to the resident's chest, and the resident did not "require defibrillation." In an interview on [DATE] at 1:30 p.m. MD 2 stated that the AED machine is simple and that anyone can use it. The machine is turned on and you follow the instructions. The pads are attached but will give a "shock" if the resident is in ventricle fibrillation (lower chamber of the heart beating very fast and irregular) or [MEDICAL CONDITION]-ventricle fibrillation (both upper and lower chambers of the heart beating fast and irregular). He stated that the AED machine did not give resident 1 a "shock" because her heart was not beating. In an interview on [DATE] at 11:50 a.m. Respiratory Therapist 2 (RT 2) stated that she was working on both [DATE] and [DATE] along with RT 1. She stated that Resident 1 had a Shiley #[MEDICAL CONDITION] a cuff and outside pilot balloon. The outside pilot balloon will be inflated if the inside cuff is inflated. [MEDICAL CONDITION] was inflated using a 10 cc (cubic centimeters) syringe of air. To deflate the cuff she would draw out the air until the pilot balloon collapses. She stated that on [DATE], Resident 1 bit off her pilot balloon and [MEDICAL CONDITION] needed to be changed so she assisted RT 1 in changing the tube. On [DATE] she heard a code blue and went with RT 1 to Resident 1's room, she grabbed the ambu-bag and passed it to RT 1 and he gave her a syringe and she inflated the cuff. She was able to put in 6 or 7 ccs of air only. RT 1 ventilated the resident and RT 2 started chest compressions. They continued until the emergency medical technicians (EMT) arrived and took over. In a follow-up telephone interview on [DATE] at 11 a.m. RT 2 stated that she remembered that Resident 1 had a pulse oxymeter attached to her toe. That was where they placed it on residents who have behaviors that cause the oxymeter to fall off the finger which was where it would commonly be placed. She did not know why it took so long to discover that the resident was not breathing and she wasn't sure if the pulse oxymeter was working or why the alarm did not sound. In an interview on [DATE] at 11:05 a.m., the charge nurse (LVN 1) stated that she had given medications to Resident 1 that morning [DATE], and the resident was "doing o.k." She was writing her notes at the nurses station when CNA 2 came to her and said that Resident 1 was not breathing. She went to the room with CNA 2 and CNA 1 was there with RN supervisor, and RT 1. LVN 1 stated that nurses can place PMVs on residents who are stable, but not on residents who are not tolerating or being trialed with the PMV, stating that only RTs can put on the PMVs in those cases and the RTs need to stay with the Resident. When asked if RT 1 had informed her that morning that he had placed the PMV on Resident 1 and was leaving the room, so that she could monitor, she stated "no, he didn't tell me anything." In a telephone interview on [DATE] at 7:40 a.m. RT 2 said he remembered placing the PMV on Resident 1 the day she died . He sat with her for about 20 to 25 minutes, she had a pulse oxymeter on either her finger or toe, but he couldn't remember for sure. He said she was tolerating it and her heart rate was steady, her breathing was steady. She was not really a talker so when he asked if she was o.k. she "nodded." He left her to do check on other residents on the unit. He looked into Resident 1's room from the hallway and her monitor (pulse oxymeter monitor) was on, she "looked good." He stated that he couldn't actually see the pulse oxymeter monitor because it was next to her bed on the bed side stand next to the wall and behind the privacy curtain, but he didn't hear the alarm. He stated that he was following the doctor's orders when placing the PMV and the reasons she was being trialed was not documented, but heard that the family was pushing for her to have the PMV. He stated that he usually will trial a PMV for three days and if not tolerated, after that would consult with the doctor, and it had not been three days yet. He said he had worked at the facility for one and a half years and was the lead therapist. He assisted the sub-acute manager (RN1), writing policies, procedures and providing staff education, and hiring. According to RT 1's personnel file reviewed on [DATE], he resigned from his position of lead respiratory Therapist on [DATE], and no longer works for the facility.

Based on interview and record review, the facility failed to ensure that the one of one sampled residents (1) was not treated roughly during care. For Resident 1 the facility failed to ensure that Resident 1 was not handled roughly during care. This created a incident where Resident 1 was exposed to rough handling and verbal abuse after Resident 1 had refused care and requested additional assistance. Findings: On 5/31/12 at 1:00 p.m. during an interview, Resident 1 said, "The nurses are good here, but CNA 1 who works the night shift, is very rough and mean. The first night she pulled hard on my body and on my clothes. When I reminded her to move my position in bed every 2 hours, she said 'I know how to do my job.' On the 2nd night she was rough with me. I don't like her. She moves me up in bed by herself. It hurts me when she does it by herself. When I asked her to stop and get help, she said she can do it, and continued to move me by herself. I asked CNA 1 to put on my oxygen, she put on the nasal cannula but did not turn on the oxygen or tell the nurse to turn it on. Thirty minutes later, I noticed that the oxygen was not turned on. I had to use the call light to get my oxygen turned on. She said she told the nurse, but she lied. I had to use the call light so the nurse could turn it on. She no longer takes care of me. I feel safe here." During an interview on 6/8/12 at 3:00 p.m. LVN 1 (Charge Nurse who works the night shift) said, "Resident 1 doesn't want CNA I. When I asked the resident what was wrong with CNA 1, she said she (CNA 1) does not answer the call light. I was off work for a couple of days and when I came back to work, Resident 1 said CNA 1 was rough with her. She said CNA 1 repositioned her and she was feeling dizzy and nauseated, then she lifted her by herself. I did hear CNA 1 say, when I asked her to change a resident, she said "What does she want now, I just changed her." One night the call light was on and CNA 1 did not answer the light. I asked her to answer the light, but she just kept folding laundry." During an interview on 6/8/12 at 3:40 p.m. CNA 2 said, "I heard CNA 1 talk back to other patients, I had (Resident 1) a couple of night after this incident and she said that CNA 1 was rude and very rough with her. She said CNA 1 was talking to her, like scolding her. She said the CNA 1 was turning her, and CNA 1 kept on moving her even after the resident told her she was hurting her. I heard a resident tell CNA 1 to just leave her alone. I remember hearing another family member say that CNA 1 was rough too, and another resident had a bruise. This one time I heard CNA 1 talking to this resident like the resident was a kid. CNA 1 is good with residents that don't require much care, she can be real nice, but if they use the call light to much she gets angry." During an interview on 6/8/12 at 2:30 p.m. when asked about the incident involving Resident 1 CNA 1 said that, "I don't recall this incident. That day was the 1st time I ever had her as a patient. When I went in to introduce myself and ask if there was anything she needed she said she wanted 2 of the other CNA's that took care of her before, so I went to the charge nurse (LVN 1), and told her that the patient wanted one of the other CNA's to take care of her. I have never taken care of her before that day. So (LVN 1) went in the room and talked to her. (Resident 1) agreed to have me provide her care. Nothing went wrong that night. No complaints or yelling, nothing. I was not rough with her physically or verbally. (Resident 1) does harass the staff, she is very grouchy. Nothing happened that night." During an interview on 5/31/12 at 1:30 p.m. the Administrator said that the claims of abuse were substantiated, and that the employee will be terminated from employment on 6/1/12. During record review on 5/31/12 at approximately 3:15 p.m., the "Resident Progress Notes" indicated that the social worker visited Resident 1 and documented the following. "Resident 1 claims on 5/29/12, that CNA 1 was rough. Resident 1 was allowed to express her feeling and vent. Resident 1 stated that she feels safe and that CNA 1 no longer works with her." Record review on 5/31/12 at 4:00 p.m. of the "Abuse" policy dated 10/26/11 indicated, "Verbal, sexual, physical, and mental abuse, corpal punishment, involuntary seclusion, and neglect of the patient as well as mistreatment, neglect, and misappropriation of patient property are strictly prohibited.