Every finding on record at Western Convalescent Hospital

Based on observation, interview, and record review, the facility failed to ensure necessary measures were implemented to prevent falls for one of three sampled residents (Resident 1) by failing to:1. Follow Resident 1's Care Plan interventions, which indicated to conduct an Interdisciplinary Team [IDT - team members from different departments working together with a common purpose to set goals and make decisions that ensure residents receive the best care] meeting for falls, keep the call light within easy reach, and place the resident close to the nursing station for close observation, were implemented.2. Ensure a post-fall Rehab Fall Risk Assessment was conducted by a Physical Therapist (PT) after Resident 1's second fall (on 5/12/2026).3. Ensure an IDT meeting was conducted after Resident 1's first fall (on 4/22/2026) and second fall (on 5/12/2026).These failures resulted in Resident 1 sustaining a third fall (on 7/30/2026) and had the potential to cause physical injuries to the resident.Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including hemiplegia (total paralysis on of the arm, leg and trunk on the same side of the body) and hemiparesis (mild or partial weakness on one side of the body) following nontraumatic intracerebral hemorrhage (a sudden bleed inside the brain tissue caused by high blood pressure or a burst blood vessel, not by an accident or physical trauma) affecting the right dominant side, polyosteoarthritis (a degenerative joint disease where cartilage that cushions the joints gradually wears down), osteoporosis (weak and brittle bones due to lack of calcium and Vitamin D), and functional quadriplegia (the complete inability to move the limbs or walk due to severe physical frailty or disability from an underlying medical illness).During a review of Resident 1's COC (Change of Condition)/Interact Assessment Form, dated 4/22/2026, the COC /Interact Assessment Form indicated Resident 1 had an unwitnessed fall on 4/22/2026 and was found on the floor at the right of bed.During a review of Resident 1's COC/Interact Assessment Form, dated 5/20/2026, the COC /Interact Assessment Form indicated, Resident 1 had a fall on 5/12/2026 and was found during rounds sliding off the bed.During a review of Resident 1's COC/Interact Assessment Form, dated 7/30/2026, the COC /Interact Assessment Form indicated, Resident 1 had a fall on 7/30/2026 and was found lying on the floor mat on her right side next to her bed.During a review of Resident 1's History & Physical (H&P), dated 3/25/2026, the H&P indicated, Resident 1 did not have the capacity to understand and make decisions.During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 7/8/2026, the MDS indicated Resident 1's cognitive skills (ability to think, read, learn, remember, reason, and pay attention) for daily decision making were severely impaired. The MDS indicated Resident 1 was dependent (helper does all of the effort and the resident does none of the effort to complete the activity or the assistance of two or more helpers is required for the resident to complete the activity) on staff for personal hygiene and dressing. Walking was not attempted due to Resident 1's medical condition/safety concerns. The MDS also indicated Resident 1 had two or more falls since admission/entry or reentry to the facility. During an observation on 8/10/2026 at 1:32 p.m., in Resident 1's room, Resident 1 was observed lying in bed with the resident's call light dangling on the floor underneath the bed and right side rail.During an interview on 8/10/2026 at 1:49 p.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated, (on 7/30/2026) at approximately 11:30 a.m. - 12:00 p.m., Resident 1 fell from the bed. Resident 1 was confused, would become agitated and moved around a lot in bed. CNA 1 stated, Resident 1 had a history of falls and would typically slide out of bed.During an interview on 8/10/2026 at 2:01 p.m., with the Charge Nurse (CN 1), CN 1 stated, (on 7/30/2026) the Director of Rehabilitation (DOR) and the Speech Therapist (ST) found Resident 1 on the floor in Resident 1's room. CN 1 stated, Resident 1 had a history of agitation, falls and would try to get out of bed unassisted.During a concurrent interview and record review on 8/11/2026 at 9:19 a.m., with CNA 2, (3) pictures taken of Resident 1's call light on the floor dated 8/10/2026 were reviewed. CNA 2 stated Resident 1's call light should not be on the floor, and it should be within reach of the resident. CNA 2 stated, if the call light was not within the resident's reach, the resident was at risk for unmet needs and may not being able to call staff for help in the event of emergencies.During a concurrent interview and record review on 8/11/2026 at 10:50 a.m. with the DOR, Resident 1's Rehab Fall Risk Assessments, dated 4/22/2026 and 7/30/2026, were reviewed. the DOR stated (on 7/30/2026) he exited another resident's room and saw Resident 1 on the floor (in Resident 1's room) lying on her right-back side. He had seen Resident 1 restless, move around in bed, and would have her feet off the edge of the bed. The DOR stated a post-assessment (Rehab Fall Risk Assessment) should have been completed after a resident's fall. He was not aware of Resident 1's second fall on 5/12/2026 and a post-fall assessment was not completed. During a review of the facility's daily census, dated 6/18/2026, 6/19/2026, 6/20/2026, 7/29/2026, and 8/9/2026, the daily census indicated Resident 1 was assigned to the resident's current room.During a review of the facility's floor plan, the floor plan indicated Resident 1's current room was not close to the nursing station.During a concurrent interview and record review on 8/11/2026 at 12:22 p.m. with Registered Nurse Supervisor (RNS) 1, Resident 1's COC /Interact Assessment Forms, dated 4/22/2026, 5/20/2026, and 7/30/2026, Care Plan titled, Actual fall related to: cognitive impairment, dated 4/22/2026, Care Plan titled, Resident is at risk for falls/injury related to: CVA, impaired cognition, impaired vision, poor body/balance/control, poor safety awareness/judgement, dated 5/19/2026 and Care Plan titled, Falling Star Program. At risk for falls related to antihypertensive medications, balance deficit, cognitive impairment, decreased strength/endurance, history of fall, poor safety awareness/judgement, dated 5/19/2026 were reviewed. RNS 1 stated, the COC /Interact Assessment Forms indicated, Resident 1 had three falls in the facility on 4/22/2026, 5/12/2026, and 7/20/2026. Resident 1's Care Plan interventions indicated to conduct an IDT for falls. RNS 1 stated she was not sure if IDT meetings were conducted after a resident's fall. She and other licensed nurses did not participate in IDT meetings. RNS 1 Care Plan interventions indicated to keep the residents' call light within reach. The call light intervention was not followed because Resident 1's call light was on the floor and not within the resident's reach. RNS 1 stated, Resident 1's fall could have been prevented if the resident had access to the call light. RNS 1 stated Resident 1's Care Plan interventions indicated to place the resident close to the nursing station for close observation. Resident 1 was moved to Resident 1's current room on 6/18/2026, which was not close to the nursing station. If Resident 1 was near the nursing station, the Resident's fall (on 7/30/2026) could have been prevented.During a concurrent interview and record review on 8/11/2026 at 2:20 p.m., with the Director of Nursing (DON), Resident 1's Rehab Fall Risk Assessments, Care Plan, titled Falling Star Program. At risk for falls related to: antihypertensive medications, balance deficit, cognitive impairment, decreased strength/endurance, history of fall, poor safety awareness/judgement, dated 5/19/2026, IDT - Narrative - Other Concerns and (3) pictures taken of Resident 1's call light on the floor were reviewed. The DON stated the PT was supposed to do a post-fall assessment after the resident's fall. The Rehab Fall Risk Assessments did not indicate a Rehab Fall Risk Assessment was completed for Resident 1's second fall on 5/12/2026. The DON stated conducting PT's post-fall assessment was important because the findings could be implemented in Resident 1's Care Plan and used to revise the interventions to prevent further falls. The DON stated, Resident 1's Care Plans intervention indicated to place the resident close to nursing station for close observation. Resident 1 was previously in a room next to the nursing station and did not remember the reason why Resident 1 moved to her current room. The DON stated Resident 1's current room was not near the nursing station. The DON stated the IDT - Narrative - Other Concerns indicated, no IDT meeting was conducted after Resident 1's first fall (on 4/22/2026) and Resident 1 second fall (on 5/12/2026). An IDT meeting should have been conducted after Resident 1's first two falls. The DON stated, conducting an IDT meeting was important to allow the IDT to brainstorm and identify ways to revise the care plan and implement interventions to prevent further falls and potential injuries for Resident 1. The DON 1 stated also stated Resident 1's call light should not be on the ground, and the call light should be within the reach of the resident. Not having the call light readily accessible to the resident could result in delayed staff responses to the residents' needs or emergencies and placed the resident at risk for falls. During a review of the facility's Policy and Procedures (P&P) titled, Care Plans, Comprehensive Person-Centered, dated 3/2026, the P&P indicated, The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. The P&P indicated, The interdisciplinary team reviews and updates the care plan when there has been a significant change in the resident's condition.During a review of the facility's P&P, titled, Screening, undated, the P&P indicated, Post-fall screen should be completed timely (within 48 to 72 hours) after we (rehab) have been informed by the facility in which rehab can provide their feedback and if therapy intervention is recommended.During a review of the facility's in-service lesson plan titled, Accident-Prone Residents and Safety Measures, undated, the training plan indicated, accident-prone residents include residents who have limited mobility, cognitive impairment, history of falls, and poor awareness of surroundings. The training plain indicated, environmental safety measures and prevention strategies include position call lights, phones, and personal items within easy reach.During a review of the facility's in-service lesson plan titled, Falling Star: Fall Safety & Supervision, undated, the in-service lesson plan indicated, Follow the Care Plan - Know the resident's required level of assistance and fall precautions, Look for Hazards - Keep floors clear and dry, call lights within reach, and assistive devices available

Based on interview and record review, the facility did not meet professional standards of quality, for one of three residents (Resident 3), by failing to ensure acyclovir (medication to treat shingles [painful, blistering rash]) was administered on 6/19/2026, as ordered by the doctor. This deficient practice had the potential to delay Resident 3's healing and placed at risk for worsening condition and increased feeling of pain.Findings: During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE], with diagnoses including hypotension (low blood pressure) and alcohol abuse in remission (getting better). During a review of Resident 3's History and Physical (H&P) dated 2/18/2026, the H&P indicated Resident 3 did not have the capacity to understand and make decisions. During a review of Resident 3's care plan titled, Shingles resident is at risk for transmission of chicken pox (blistering rash) secondary to Shingles initiated 6/18/2026, the care plan interventions indicated to administer antiviral (medication that kills virus) ointment as ordered. During a review of Resident 3's Prescriber Order dated 6/18/2026 at 15:19 p.m., the order indicated to cleanse the left lateral (side) abdomen with normal saline (cleansing solution), pat dry, apply acyclovir external cream (topical) 5 percent (%), every day shift for shingles for 14 days, leave open to air. During a review of Resident 3's Treatment Administration Record (TAR) for the month of June 2026, the TAR for 6/19/2026 was blank. During a review of Resident 3's Minimum Data Set (MDS - a resident assessment tool) dated 7/15/2026, the MDS indicated Resident 3 had the ability to understand and be understood by others. The MDS Resident 3 required setup assistance (Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity) for eating, and oral hygiene. Resident 3 required moderate assistance (Helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) for toileting hygiene, shower/bathe self, lower dressing, and putting on/taking off footwear. Resident 3 required supervision (Helper provides verbal cues and/or touching/steadying, and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently.) for upper body dressing and personal hygiene. During an interview on 8/7/2026 at 10:55 a.m., with Resident 3, Resident 3 stated on 6/18/206, she was diagnosed with shingles and experienced pain and discomfort. Resident 3 stated she was told by the nurse (unknown name) she was going to receive medication (acyclovir) to treat her shingles. Resident 3 stated she did not get medication until 6/20/2026. During a concurrent record review and interview on 8/7/2026 at 12:38 p.m., with the Treatment Nurse (TN 2), Resident 1's acyclovir order dated 6/18/2026 and TAR for the month of 6/2026 were reviewed. The TN 2 stated the acyclovir was ordered on 6/18/2026 but was not administered on 6/19/2026, as indicated in the TAR. The TN 2 stated shingles are very painful rash, and it was important to administer Valtrex right away to not delay treatment and keep Resident 3 comfortable. During a review of the facility's Policy and Procedure (P&P) titled, Medication Administration - General Guidelines, dated 10/2017, the P&P indicated medications should be administered within 60 minutes of scheduled time (1 hour before and 1 hour after).

Based on observation, interview and record review, the facility failed to implement infection control measures before entering 2 of 3 resident (Residents 2 and 4) rooms on Enhance Barrier Precautions (EBP- infection control strategy that uses gown and gloves during high-contact resident care activities [e.g. cleaning, emptying urinary drainage bags, wound care] to reduce the spread of multidrug-resistant organisms in nursing homes) by failing to wear a gown (a personal protective equipment [PPE] to be worn during direct resident's care on EBP). This failure had the potential for cross-contamination (process by which bacteria or other microorganisms are unintentionally transferred from one object or person to another, with harmful effect) and spread infection, to another residents, visitors and staff in the facility.Findings: During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 2's diagnoses included dysphagia (difficulty or discomfort when swallowing food, liquids, or saliva) following a nontraumatic (not caused by injury) intracerebral (brain) hemorrhage (bleeding) and pressure ulcer (wound/ bedsore) of sacral region (tailbone), stage 4 (full thickness skin loss with extensive destruction; tissue necrosis; or damage to muscle, bones). During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool) dated 6/25/2026, the MDS indicated Resident 2 was rarely/never able to understand and be understood by others. Resident 2 was dependent (Helper does all of the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity) on staff for ADL such as oral hygiene, toileting hygiene, shower/bathe self, upper/lower body dressing, putting/taking off footwear and personal hygiene. Resident 2 was dependent on staff on rolling from left to right. During a review of Resident 2's Order Summary Report as of 8/1/2026, the order summary dated 4/6/2026, indicated Enhance Barrier Precautions (EBP)- Gastric Tube (Gtube- a flexible medical tube placed through the skin of the belly directly into the stomach to deliver food, liquids, and medications) /wounds. During observation on 8/7/2026 at 10:15 a.m., Certified Nurse Assistant (CNA 1) entered Resident 2's room and removed Resident 2's gown and diaper without a gown. During a concurrent observation and interview on 8/7/2026 at 12:07 p.m., with CNA 1, CNA 1 stated she was supposed to wear a gown, in addition to gloves when caring for Resident 2, as indicated in the EBP signage at the entrance of Resident 2's door, to prevent the transmission of germs to other residents and to herself. 2). During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 4's diagnoses included dysphagia following a cerebral infarction (the death of body tissue caused by a sudden lack of blood flow and oxygen) and hypertension (high blood pressure). During a review of Resident 4's MDS dated [DATE], the MDS indicated Resident 4 was able to understand and be understood by others. Resident 4 was dependent on staff for ADL such as oral hygiene, toileting hygiene, shower/bathe self, upper/lower body dressing, putting/taking off footwear and personal hygiene. Resident 2 was dependent on staff on rolling from left to right, from sitting to lying position, and lying to sitting on side of the bed. During a review of Resident 4's Order Summary Report, the order summary dated 7/12/2025, indicated EBP - indwelling (inside the body) medical device. During observation on 8/7/2026 at 10:55 a.m., CNA 2 entered Resident 4's room. Resident 4 had a roommate who was on a shower chair with a towel. CNA 2 was not wearing a gown, dried Resident 4's roommate and put on a new clothing. During interview on 8/7/2026 at 1:42 p.m., with CNA 2, CNA 2 stated she was supposed to wear a gown, in addition to gloves when caring for Resident 4, as indicated in the EBP signage at the entrance of Resident 4's door, to prevent the transmission of germs other residents and to herself. During a review of the facility's Policy and Procedure (P&P) titled, Enhanced Barrier Precautions, dated 2001, the P&P indicated EBPs are utilized to prevent the spread of multi-drug-resistant organisms (MDROs) to residents. The P&P indicated enhanced barrier precautions apply when a resident is not known to be infected or colonized with any MDRO, has a wound or indwelling medical devices, and does not have secretions or excretions that are unable to be covered or contained.

Based on observation, interview and record review, the facility failed to ensure one of three (3) sampled residents (Resident 2), who had a stage 4 pressure ulcer (full thickness skin loss with extensive destruction; tissue necrosis; or damage to muscle, bones), received care in accordance with the professional standards and the resident's care plan titled, Actual Pressure Sore (wound). Resident 2 noted with Sacrococcyx (tailbone). The facility failed to:1). Turn and reposition Resident 2 every two hours as indicated in the resident's care plan.2). Provide the Low Air Loss Mattress (special mattress that blows a tiny stream of air to stop bedsores and helps healing) for wound care management, as ordered by the physician.3). Ensure Resident 2's sacrococcyx wound was covered with dressing as ordered by the physician. These failures had the potential to delay wound healing and placed the resident's wound at risk for infection and development of other pressure ulcers (wounds). Findings: During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 2's diagnoses included dysphagia (difficulty or discomfort when swallowing food, liquids, or saliva) following a nontraumatic (not caused by injury) intracerebral (in the brain) hemorrhage (bleeding) and pressure ulcer (wound/ bedsore) of sacral region (lower back, sitting right above the crease of the buttocks) stage 4 (most severe type of bedsore). During a review of Resident 2's admission Reassessment dated 2/17/2024, the skin reassessment indicated Resident 2 had an ulcer on the sacrum with measurements of 4 by 2 by 0.2 centimeters (cm, unit of measurement [unspecified]). During a review of Resident 2's Care Plan titled Actual Pressure Sore. Resident 2 noted with Sacrococcyx Stage 4 Pressure Ulcer, dated 2/21/2024, the interventions indicated to use pressure relieving devices as needed, to turn and reposition every 2 hours and as needed when in bed or wheelchair. During a review of Resident 2's History and Physical (H&P) dated 4/6/2026, the H&P indicated Resident 2 did not have the capacity to understand and make medical decisions. During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool) dated 6/25/2026, the MDS indicated Resident 2 was rarely/never able to understand and be understood by others. The MDS indicated Resident 2 was dependent (Helper does all of the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity) on staff for ADL such as oral hygiene, toileting hygiene, shower/bathe self, upper/lower body dressing, putting/taking off footwear and personal hygiene. Resident 2 was dependent on staff on rolling from left to right. The MDS indicated Resident 2 was incontinent of urine and bowel. The MDS indicated Resident 2 was at risk for pressure ulcers and had an unhealed pressure ulcer stage 4. The MDS indicated skin and ulcer treatments included pressure reducing devices, turning/repositioning program, application of nonsurgical dressings and application of ointments/medications. During a review of Resident 2's Braden Scale (a standardized tool used by healthcare professionals to assess a patient's risk of developing pressure ulcers, or bedsores) dated 7/6/2026, the Braden scale indicated Resident 2 was at high risk for developing pressure ulcers. During a review of Resident 2's Wound Care dated 7/30/2026, the wound care note indicated Resident 2 had a sacral coccyx stage 4 with measurements of 2 by 2 by 0.9 cm. (unspecified). During a review of Resident 2's Order Summary Report dated 8/1/2026, the order dated 4/4/2026, indicated the following: Low Air Loss Mattress for wound care management.Monitor dressing integrity daily every day shift.Turning and repositioning program. During a review of Resident 2's Order Summary Report dated 8/1/2026, the order dated 7/17/2026, indicated to cleanse sacrococcyx wound with normal saline (NS- a cleansing solution), pat dry, apply santyl, collagen, pack loosely with calcium alginate (gel making material that stops bleeding and keeps wound moist to heal fast), cover with dry dressing every day shift for stage 4 pressure for 30 days. During a concurrent observation on 8/7/2026 at 8:00 a.m., with the Assistant Director of Nursing (ADON), Resident 2 was observed on her back position. During a concurrent observation and interview on 8/7/2026 at 10:15 a.m., with Certified Nurse Assistant (CNA 1), Resident 2 was observed on her back position. When CNA 1 removed Resident 2's diaper to check the resident, Resident 2's wound was not covered. CNA 1 stated usually Resident 2's wound was not covered and have not seen the wound with a dressing before. CNA 1 stated she believed that was how Resident 2's wound was supposed to be. During a concurrent observation and interview on 8/7/2026 at 12:07 p.m., with CNA 1, CNA 1 stated Resident 2 was contracted (muscle, tendons stiff and unable to move), CNA 1 stated Resident 2 did not need to be turned because it was too painful for the resident to be turned. CNA 1 stated Resident 2 could turn on her own. CNA 1 stated she had not turned Resident 2 since she started her shift at 7:00 a.m. CNA 1 stated there were no pillows to assist with turning because she had taken Resident 2's pillows to be washed and she did not get any more. During a concurrent interview and record review on 8/7/2026 at 12:38 p.m., with the Treatment Nurse (TN 2), Resident 2's care plan dated 2/21/2024 and the order summary dated 4/4/2026, were reviewed. The Orders dated 4/4/2026, indicated low air loss mattress, turning and repositioning program, monitor dressing daily, and Orders dated 7/17/2026 indicated Santyl External Ointment (Collagenase) 250 unit/gm apply to sacrococcyx topically every day shift for Stage 4 pressure for 30 Days Cleanse with NS, pat dry, apply Santyl, collagen, pack loosely with calcium alginate, cover with dry dressing. The TN 2 stated Resident 2 was not turned and repositioned as indicated in the care plan to turn and position as needed and to provide Resident 2 with pressure relieving device. Resident 2 could not keep herself turned without assistive devices. The TN 2 stated Resident 2 did not have any relieving devices in the room. The TN 2 stated all residents who are not mobile or had pressure ulcers should be turned every two hours or more depending on the severity of the wound. The TN 2 stated on 8/7/2026) at 10:59 a.m., Resident 2's sacral wound did not have wound dressing when she performed wound treatment for Resident 2. CNA 1 did not report to her. The TN 2 stated Resident 2's lack of turning and wound without the dressing with the wound medication, could lead to the worsening condition of the wound or infection. During an interview on 8/7/2026 at 1:10 p.m., with TN 2, TN 2 stated Resident 2 had no air loss mattress as indicated in the order summary dated 4/4/2026. The TN 2 stated she requested the air loss mattress a week ago (date not specified) and, but it had not been delivered yet. The TN 2 stated she requested the air loss mattress from ADON. During an interview on 8/7/2026 at 1:24 p.m., with ADON, ADON requested Resident 2's air loss bed this morning (8/7/2026) with the Maintenance (unidentified), but he did not follow up. The ADON stated it was important to provide an air loss mattress as ordered by the physician to aid in wound healing and so that Resident 2 could not develop more wounds. During an interview on 8/7/2026 at 1:32 p.m., with Maintenance, Maintenance stated the ADON requested the air loss mattress around 10:00 a.m. (8/7/2026). The Maintenance stated ADON was requested to assist Resident 2 be moved out of bed but failed to follow up. During a review of the facility's Policy and Procedure (P&P) titled, Prevention of Pressure Injuries, dated 3/2026, the P&P indicated to review the resident's care plan, reposition the resident as indicated on the care plan and to select appropriate support surfaces based the resident's risk factors, in accordance with current clinical practice.

Based on interview and record review, the facility failed to ensure the Family Member (FM 1) of one of three residents' (Resident 3), was notified of the resident's Change of Condition ([COC] a clinical deviation from a resident's baseline). This failure resulted in the resident's responsible party not being aware of the resident's changes/ current skin condition. Findings: During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 3's diagnoses included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness or partial paralysis affecting one side of the body) following cerebral infarction (stroke) affecting the left non-dominant side and dysphagia (difficulty swallowing). During a review of Resident 3's Minimum Data Set (MDS - a resident assessment tool) dated 5/6/2026, the MDS indicated Resident 3 was able to understand sometimes and be understood by others. The MDS indicated Resident 3 was dependent (Helper does all of the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity) on staff with ADLs, oral hygiene, toileting hygiene, shower/bathe, upper/lower body dressing, putting on/taking off footwear and personal hygiene. Resident 3 was dependent on staff on rolling from left to right. During a review of Resident 3's Order Summary Report dated 6/1/2026, the order summary report indicated Triamcinolone Miconazole Powder (topical medicine to treat infection while absorbing excess moisture and reducing chafing) topically (applying a treatment directly to the skin or a specific body part), to general body affected area (site not specified), every day shift for dermatitis (inflammation of the skin) for 30 days, leave open to air. During a review of Resident 3's History and Physical (H&P) dated 6/27/2026, the H&P indicated Resident 3 did not have the capacity to understand and make decisions. During a concurrent interview and record review on 7/10/2026 at 2:21 p.m., with the Registered Nurse (RN 1), RN 1 stated Resident 1's medical record did not indicate a COC was made on 6/1/2026, regarding Resident 1's rash/ skin inflammation (site not specified). RN 1 stated it was important to have a COC to ensure Resident 3 received uninterrupted care and the resident's doctor and family were made aware. During an interview on 7/9/2026 at 10:18 a.m., with FM 1, FM 1 stated he was not notified by the facility about Resident 3's body rash. During a review of the facility's Policy and Procedure (P&P) titled, Change in a Resident's Condition or Status, undated, the P&P indicated unless otherwise instructed by the resident, a nurse should notify the resident's representative when there was a significant change in the resident's physical, mental, or psychosocial status.

Based on interview and record review, the facility failed to:Ensure medications were administered as ordered for one of five sampled residents (Resident 40) when:Licensed Vocational Nurse (LVN) 4 administered hydralazine (a blood pressure medication) outside of the ordered parameters on 4/6/2026 and 5/12/2026.LVN 5 failed to administer insulin (a medication to control blood sugar) as ordered on 5/18/2026.Clarify medication orders with the physicians for two of five sampled residents (Resident 103 and 34), when the residents had advanced from intake via gastrostomy tube (G-tube, a flexible medical device inserted directly through the abdomen into the stomach) to being able to take medicine by mouth.Ensure two licensed nurses conducted and signed as witnesses in the destruction of non-controlled medications. Ensure discontinued controlled medications were accounted for and their disposition properly documented, for two of two sampled residents (Residents 109 and 120):Resident 109's 41 tablets of discontinued Norco (hydrocodone/acetaminophen, a narcotic, or controlled medication, pain medication) 5/325 milligrams (mg, unit to dose measurement) were not documented as destroyed, or accounted forResident 120's 2622 milliliters (mL, a unit of volume measurement) of discontinued phenobarbital 20 mg per (/) 5 mL solution (a controlled medication and a long-acting barbiturate that acts as a central nervous system depressant) was documented to have been destroyed as non-controlled medication.These deficient practices placed Resident 40 at risk for complications associated with low blood pressure, such as dizziness, falls, elevated heart rate, and at risk of untreated elevated blood sugar levels. These deficient practices also had the potential of medication errors, misuse of medications, and/or drug diversion.Findings: 1. During a review of Resident 40's Face Sheet, the Face Sheet indicated Resident 40 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 40's diagnoses included high blood pressure and type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 40's Minimum Data Set (MDS, a resident assessment tool), dated 4/21/2026, the MDS indicated Resident 40's cognition (ability to think and process) was severely impaired. The MDS indicated Resident 40 was dependent (helper does all of the effort) on staff for all attempted activities of daily living (activities such as bathing, dressing and toileting a person performs daily) and mobility. a. During a review of Resident 40's physician order, dated 1/14/2026, the order indicated staff were to administer hydralazine 100 milligrams (mg, a unit of dose measurement) twice a day for high blood pressure. The order indicated staff were not to administer the medication if Resident 40's systolic blood pressure (SBP) reading was less than 110 millimeters of mercury (mm HG, a unit of measuring blood pressure). During a review of Resident 40's Electronic Medication Administration Record (EMAR), dated 4/1/2026 to 4/31/2026, the EMAR indicated staff were to hold Resident 40's hydralazine for SBP less than 110 mm HG. The EMAR indicated on 4/6/2026, LVN 4 documented Resident 40's SBP was 103 mm HG and administered Resident 40's hydralazine. During a review of Resident 40's EMAR, dated 5/1/2026 to 5/31/2026, the EMAR indicated staff were to hold Resident 40's hydralazine for SBP less than 110 mm HG. The EMAR indicated on 5/12/2026, LVN 4 documented Resident 40's SBP was 103 mm HG and administered Resident 40's hydralazine. During an interview on 5/20/2026 at 2:29 p.m., with LVN 4, LVN 4 stated that when administering blood pressure medication, she typically assessed the resident's blood pressure first because there were parameters for not administering the medication if the blood pressure was too low. LVN 4 stated if blood pressure medication was administered when the resident's blood pressure was low, the medication could cause the blood pressure to decrease further, resulting in lethargy and possibly death. During a concurrent interview and record review, on 5/20/2026 at 2:34 p.m., with LVN 4, Resident 40's EMARs dated 4/1/2026 to 4/31/2026, and 5/1/2026 to 5/31/2026, were reviewed. LVN 4 stated that she should not have administered Resident 40's hydralazine on 4/6/2026 or 5/12/2026. b. During a review of Resident 40's physician order, dated 1/14/2026, the order indicated staff were to administer two (2) units (a unit of measuring insulin) of insulin for blood glucose readings between 121 and 150 milligrams per deciliter (mg/dL, a unit of measuring blood glucose levels). During a review of Resident 40's EMAR, dated 5/1/2026 to 5/31/2026, the EMAR indicated LVN 5 documented Resident 40's blood glucose level was 123 mg/dL. The EMAR indicated LVN 5 did not administer two (2) units of insulin as ordered. During an interview on 5/20/2026 at 2:41 p.m. with LVN 5, LVN 5 stated she should have administered two (2) units of insulin for Resident 40's blood glucose level of 123 mg/dL. LVN 5 stated that if insulin was indicated but not administered, it could lead to a further rise in the resident's blood glucose levels. LVN 5 stated medications should be administered as ordered. 2. During a review of Resident 34's Face Sheet, the Face Sheet indicated Resident 34 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 34's diagnoses including chronic kidney disease (CKD, a long-term condition where the kidneys are damaged and lose their ability to filter blood properly) and anemia (a condition where the body does not have enough healthy red blood cells). During a review of Resident 34's physician order, dated 6/28/2021, the physician order indicated to discontinue G-tube feeding and change medications to take by mouth. During a review of Resident 34's physician order, dated 5/28/2025, the physician order indicated to administer labetalol (a medication to treat high blood pressure) 200 mg, 1 tablet via G-tube two times a day. During a medication administration observation on 5/20/2026 at 10:25 a.m., Resident 34 took all medications by mouth. During an interview on 5/20/2026 at 2:37 PM with Registered Nurse 6 (RN 6), RN 6 stated the labetalol order was not updated when Resident 34's G-tube was removed. During a review of Resident 103's Face Sheet, the Face Sheet indicated Resident 103 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 103's diagnoses included peripheral vascular disease (PVD, a slow progressive narrowing of the blood flow to the arms and legs) and dysphagia (difficulty swallowing). During a review of Resident 103's dietary evaluation, dated 11/4/2022, the evaluation indicated to discontinue the G-tube. During a review of Resident 103's physician order, dated 10/20/2025, the physician order indicated to administer amlodipine (a medication to treat high blood pressure) 1 tablet via G-tube daily. During a medication administration observation on 5/20/2026 at 9:45 a.m., Resident 103 took all the medications by mouth. During an interview on 5/20/2026 at 3:20 p.m. with the Director of Nursing (DON), the DON stated licensed nurses should check before administration and clarify with the physicians if there was a discrepancy. The DON stated the nurses that perform monthly order summary should have caught the discrepancies as well and clarify the orders. 3. During a concurrent interview and record review on 5/20/2026 at 4:15 p.m. with RN 4, the medication destruction logs, dated 5/11/2026, were reviewed. RN 4 stated the night shift nurse performed the non-controlled medication destructions. RN 4 stated the initials on the column named witness #1 were the night nurse, however, the witness #2 column was empty, which indicated there was no documented witness to the destruction. There was a total of twelve medications destroyed on 5/11/2026 without the signatures of a witness. During an interview on 5/20/2026 at 4:19 p.m. with the DON, the DON reviewed the log and stated the instruction on the destruction log indicated for one RN to destroy the medication and one other licensed nurse would witness the destruction. 4. a. During a review of Resident 109's Face Sheet, the Face Sheet indicated Resident 109 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 109's diagnoses included chronic respiratory failure (a long-term condition where the lungs cannot adequately get enough oxygen into the blood) and seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness). During a review of Resident 109's physician order, dated 1/13/2026, the physician order indicated to administer Norco 5-325 mg 1 tablet via G-tube every four hours as needed for pain management for seven days. The physician order indicated the order was completed on 1/20/2026. b. During a review of Resident 120's Face Sheet, the Face Sheet indicated Resident 120 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 120's diagnoses included chronic respiratory failure and dysphagia. The Face Sheet indicated Resident 120 was discharged from the facility on 3/1/2026 to the hospital. During an interview on 5/21/2026 at 9:36 a.m. with the DON, the DON stated the assistant director of nursing (ADON) was the designated person for destroying controlled medications. During a concurrent interview and record review on 5/21/2026 at 9:36 a.m. with the DON and ADON, the controlled medications destruction logs, dated 5/11/2026, were reviewed. The logs indicated the process for destroying controlled medications consisted of an endorsement from the releasing nurse to the DON/designated RN and the destruction was conducted by the DON/designated nurse and a pharmacist. The log indicated there were nine discontinued controlled medications that were endorsed from the releasing nurse to the ADON, however, there was no signatures that indicated these 9 medications had been destroyed. The log indicated one of the nine controlled medications was Resident 109's Norco 5/325 mg with a quantity of 41 tablets, endorsed on 2/16/2026. However, there was no releasing nurse's signature for the endorsement and there were no signatures for the destruction of the drug. The log indicated the remaining eight medications were eight bottles of Resident 120's phenobarbital 20mg/5 ml solutions, with a total volume of 2622 ml, endorsed to ADON on 2/11/2026, 2/28/2026, and 3/3/2026, and there were no signatures for the destruction. During an interview on 5/21/2026 at 9:50 a.m. with the DON and ADON, the DON stated Resident 109 was a current resident and the ADON stated Resident 109 did not have active Norco order. The DON stated Resident 120 was discharged to a hospital on 2/22/2026 and did not return to the facility. The ADON stated there was no documentation of what happened to the controlled medications. The ADON and the DON could not find the controlled medications in the locked cabinets that stored endorsed controlled medications to be destroyed. During an interview on 5/21/2026 at 10 a.m. with the DON, the DON stated the lack of documentation of the medications could have the potential of diversion or misuse that may affect the safety of the residents and staff.During a phone interview on 5/21/2026 at 10:28 a.m. with the facility consultant pharmacist (RPh), the RPh stated he remembered there were many bottles of phenobarbital. The RPh stated at the time of the destruction with ADON, the bottles were not destroyed because the facility ran out of space in the destruction bin (pharmaceutical waste bin) that could hold the volume. The RPh stated he and ADON secured the bottles in a locked cabinet in DON's office. During an interview on 5/21/2026 at 2:11 p.m. with the ADON, the ADON stated he had searched everywhere but could not locate Resident 120's 8 bottles of phenobarbital or Resident 109's 41 tablets of Norco. During an interview on 5/21/2026 at 2:53 p.m. with the ADON, the ADON stated he remembered he had moved the phenobarbital bottles to nursing station 2 medication rooms and destroyed them as non-controlled medications with another nurse. The ADON stated he knew phenobarbital was a controlled medication, however, he could not explain why he destroyed phenobarbital using the disposition process for non-controlled medications. During a concurrent interview and record review on 5/21/2026 at 3:22 p.m. with the ADON, the multipurpose drug disposition record, undated, was reviewed. The record indicated there were 8 bottles of Resident 120's phenobarbital destroyed on 4/29/2026 (1x 52 ml, 1x 220 ml, 3x of 400 ml, 1x 250 ml, and 2x 450 ml). The ADON stated he destroyed the medication with another RN. During an interview on 5/21/2026 at 3:45 p.m. with the DON, the DON stated controlled medications should not be destroyed as non-controlled meds. During an interview on 5/22/2026 at 5:25 p.m. with the ADON, the ADON stated Resident 120's medication was not correctly disposed of. The ADON stated the correct process was to dispose of the phenobarbital in the narcotic waste bin with a pharmacist. The ADON stated narcotics were potent. At the time of the survey exit, the facility did not find the missing 41 tablets of Resident 109's discontinued Norco or the records for Resident 109's Norco and Resident 120's Phenobarbital. During a review of the facility's policy and procedure (P&P) titled Administering Medications, dated 2001, the P&P indicated vital signs were to be checked/verified, if necessary, prior to administering medications. During a review of the facility's P&P titled Administering Medications, dated 2001, the P&P indicated medications were to be administered in accordance with prescriber's orders. During a review of the facility's P&P titled Medication Destruction, revised 01/2025, the policy indicated controlled substances are retained in a securely locked area with restricted access until destroyed by the facility director of nursing or a registered nurse employed by the facility, and a consultant pharmacist. During a review of the facility's P&P titled Physician orders and Telephone orders, dated 1/2004, the P&P indicated all orders would be reviewed for accuracy, completeness, and clarity. During a review of the facility's P&P titled Medication Destruction, dated 1/2025, the P&P indicated non-controlled medication destruction would occur in the presence of two licensed nurses.

Based on observation, interview, and record review, the facility failed to ensure infection control practices were maintained for two of five sampled residents (Resident 86 and Resident 109).This deficient practice increased the potential for spread of infection among facility residents and staff. Findings: 1. During a review of Resident 86's Face Sheet, the Face Sheet indicated Resident 86 was admitted to the facility on [DATE]. Resident 86's diagnoses included need for assistance with personal care, generalized muscle weakness, and presence of a tracheostomy (a surgical procedure that creates an opening in the neck and directly into the windpipe) and gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems).During a review of Resident 86's Minimum Data Set (MDS, a resident assessment tool), dated 2/20/2026, the MDS indicated Resident 86's cognition (ability to think and process) was severely impaired. The MDS indicated Resident 86 was dependent (helper does all the effort) on staff for all attempted activities of daily living (activities such as bathing, dressing and toileting a person performs daily) and mobility.During a review of Resident 86's physician order, dated 3/3/2026, the order indicated staff were to implement contact isolation precautions (infection control measures used to prevent the spread of germs transmitted through direct or indirect contact) due to Carbapenem-Resistant Acinetobacter baumannii (CRAB, an aggressive, opportunistic bacterium, notorious for its resistance to multiple antibiotics) in Resident 86's sputum (a mixture of mucus and saliva that is coughed up from the lower respiratory tract).During a review of Resident 86's care plan titled Other contact isolation: CRAB Sputum, dated 3/3/2026, the care plan indicated goals of care included reducing the risk of complications and infections daily. The care plan indicated staff were to implement contact isolation precautions.During an observation on 5/19/2026 at 9:18 a.m., outside of Resident 86's room, signage was posted indicating staff and visitors were to implement contact isolation precautions. Signage was also posted with instructions for donning (put on) and doffing (take off) the required personal protective equipment (PPE, clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments). There were containers of hand sanitizer and required PPE (disposable gown and gloves) mounted on the wall next to the signage.During an observation on 05/19/2026 at 9:28 a.m., outside of Resident 86's room, Certified Nursing Assistant (CNA) 3 donned a disposable gown and mask prior to entering Resident 86's room. While in the room, CNA 3 placed a pile of clean linens on Resident 86's bed and pulled his privacy curtain closed. CNA 3 then exited the room while wearing the disposable gown and put on a pair of gloves taken from the wall-mounted container outside of the room. CNA 3 did not perform hand hygiene (the process of cleaning one's hands to prevent the spread of infectious diseases) prior to donning the gloves.During an observation on 5/19/2026 at 9:30 a.m., CNA 3 re-entered Resident 86's room. During an interview on 05/21/2026 at 4:35 p.m., with Registered Nurse (RN) 3, RN 3 stated it was not appropriate for CNA 3 to enter Resident 86's room without gloves on. RN 3 stated that after entering the room, if CNA 3 touched surfaces in the environment, she should stop right away, remove all PPE before exiting the room, perform hand hygiene upon exiting the room, and don the correct required PPE before re-entering the room. 2. During a review of Resident 109's Face Sheet, the Face Sheet indicated Resident 109 was originally admitted to the facility on [DATE], and readmitted on [DATE]. Resident 109's diagnoses included carrying carbapenem-resistant enterobacterales (CRE, a family of highly drug-resistant bacteria [such as E. coli and Klebsiella pneumoniae] that are immune to carbapenem antibiotics.During a review of Resident 109's MDS, dated [DATE], the MDS indicated Resident 109's cognition was severely impaired and was dependent on staff for all attempted activities of daily living and mobility.During a review of Resident 109's physician order, dated 10/2/2025, the order indicated staff were to implement contact isolation precautions due to CRE.During a review of Resident 109's care plan titled Contact isolation: CRE, dated 2/14/2023 and last revised 7/3/2023, the care plan indicated goals of care included reducing the risk of complications and infections daily. The care plan indicated staff were to implement contact isolation precautions.During an observation on 5/19/2026 at 2:22 p.m., in Resident 109's room, Medical Doctor (MD) 1 was observed at Resident 109's bedside wearing a mask. MD 1 was not wearing a protective gown or gloves. MD 1 was observed pressing his stethoscope directly to Resident 109's chest and hanging the stethoscope around his neck after he was done. MD 1 was observed touching Resident 109 on various parts of her trunk and limbs without gloves on.During a concurrent observation and interview, on 5/19/2026 at 2:24 p.m., with MD 1, MD was observed exiting Resident 109's room. MD 1 did not perform hand hygiene or disinfect his stethoscope. MD 1 stated Resident 109's sputum culture (a laboratory test that analyzes secretions coughed up from the lungs to identify bacteria, fungi, or other germs causing a respiratory infection) was positive.During an observation on 5/19/2026 at 2:25 p.m., MD 1 was observed walking directly from Resident 109's room to Nurse's Station 2. MD 1 did not perform hand hygiene prior to removing a resident chart from the shelf.During an interview on 5/21/2026 at 4:36 p.m., with RN 3, RN 3 stated it was not appropriate for MD 1 to enter Resident 109's room and come into direct physical contact with Resident 109 without the required PPE. RN 3 stated no staff were exempt from implementing contact isolation precautions. RN 3 stated MD 1 should have also disinfected his stethoscope and performed hand hygiene before touching other surfaces in the facility. During an interview on 5/21/2026 at 4:32 p.m., with RN 3, RN 3 stated she was serving at the facility's infection preventionist. RN 3 stated the purpose of contact isolation precautions was to contain the applicable infectious organism and prevent spread between facility residents. RN 3 stated contact isolation precautions required staff to don a disposable gown, gloves, and a mask. RN 3 stated staff were to don all required PPE prior to entering the room and doff all PPE prior to exiting the room. RN 3 stated staff were to perform hand hygiene upon exiting the room.During a review of the facility's policy and procedure (P&P) titled Isolation - Categories of Transmission-Based Precautions, revised 9/2022, the P&P indicated contact isolation precautions were implemented for residents known (or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident, or indirect contact with environmental surfaces or resident-care items in the resident's environment. The P&P indicated staff were to wear gloves and a disposable gown upon entering the room. The P&P indicated hand hygiene was to be performed before leaving the room. The P&P indicated staff were to avoid touching potentially contaminated environmental surfaces or items in the resident's room after gloves are removed.

Based on observation, interview, and record review, the facility failed to provide interventions for the prevention of pressure ulcers (localized damage to the skin and/or underlying tissue usually over a bony prominence) for four of eight sampled residents (Residents 40, 108, 10, and 65) when:Resident 40's and 108's low air loss mattresses (LALM, therapeutic support surfaces designed to prevent and treat pressure ulcers) were not functioning according to manufacturer's guidance.Resident 10's LALM did not have the correct setting.The facility failed to follow its policy and procedure (P&P) titled Wound Care to document Resident 65's wound assessment when doing wound care.These deficient practices placed Residents 40,108, 10, and 65 at risk of developing new pressure ulcers, or developing a worsening condition of their existing pressure ulcers. Findings: 1. During a review of Resident 40's Face Sheet, the Face Sheet indicated Resident 40 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 40's diagnoses included chronic respiratory failure (a long-term condition where the respiratory system cannot properly oxygenate the blood or remove excess carbon dioxide) with hypoxia (low oxygen levels in the blood), encephalopathy (a group of conditions that cause brain dysfunction), and sepsis (a serious condition in which the body responds improperly to an infection). During a review of Resident 40's Minimum Data Set (MDS, a resident assessment tool), dated 4/21/2026, the MDS indicated Resident 40's cognition (ability to think and process) was severely impaired. The MDS indicated Resident 40 was dependent (helper does all of the effort) on staff for all attempted activities of daily living (activities such as bathing, dressing and toileting a person performs daily) and mobility. The MDS indicated Resident 40 was at risk for developing pressure ulcers (PUs) and used a pressure-reducing device in his bed. During a review of Resident 40's physician order, dated 1/16/2026, the order indicated staff were to provide Resident 40 with a LALM for wound care and management. During a review of Resident 40's care plan titled Risk for further developing pressure sore, and other types of skin breakdown., dated 2/20/2025, the care plan indicated goals of care were minimization of the risk of skin breakdown and pressure sore development daily. The care plan indicated staff were to provide Resident 40 with a pressure relieving device. During a review of Resident 40's record titled, Braden Assessment, dated 4/15/2026, the assessment indicated Resident 40 was at very high risk for developing a PU. During an observation on 5/19/2026 at 10:57 a.m. at Resident 40's bedside, Resident 40 was lying in bed on a LALM. The pump attached to the LALM at the foot of Resident 40's bed had an orange flashing light with an audible beeping alarm. The pump indicated the alarm and flashing light was a low-pressure alarm. An unidentified Licensed Vocational Nurse was at the bedside and stated the maintenance department was notified of the malfunctioning LALM. During an observation on 5/20/2026 at 9:36 a.m., 2:25 p.m., and 3:00 p.m., at Resident 40's bedside, Resident 40 was lying in bed on a LALM. The pump attached to the LALM at the foot of Resident 40's bed had an orange flashing light indicating a low-pressure alarm. During an interview on 5/20/2026 at 2:26 p.m., with Certified Nursing Assistant (CNA) 5, CNA 5 stated she was Resident 40's one-to-one sitter (a dedicated caregiver or staff member assigned to constantly monitor a single individual) since 7:00 a.m. that morning. CNA 5 stated no staff from the maintenance department had come to check on Resident 40's LALM. During an observation on 5/21/2026 at 10:12 a.m. and 11:42 a.m., at Resident 40's bedside, Resident 40 was lying in bed on a LALM. The pump attached to the LALM at the foot of Resident 40's bed had an orange flashing light and audible beeping, indicating a low-pressure alarm. b. During a review of Resident 108's Face Sheet, the Face Sheet indicated Resident 108 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 108's diagnoses included chronic respiratory failure with hypoxia and dependence on a ventilator (a medical machine that completely takes over or assists breathing for a patient who cannot do so independently). During a review of Resident 108's MDS, dated [DATE], the MDS indicated Resident 108's cognition was severely impaired and was dependent on staff for all attempted activities of daily living and mobility. The MDS indicated Resident 40 was at risk for developing pressure ulcers (PUs) and used a pressure-reducing device in his bed. During a review of Resident 108's record titled Braden Scale for Predicting Pressure Sore Risk, dated 5/9/2026, the record indicated Resident 108 was at high risk for developing a PU. During a review of Resident 108's physician order, dated 5/10/2026, the order indicated staff were to provide Resident 108 with a LALM for wound care and management. During an observation on 5/20/2026 at 2:26 p.m. and 3:00 p.m., at Resident 108's bedside, Resident 108 was lying in bed on a LALM. The pump attached to the LALM at the foot of Resident 108's bed had an orange flashing light and audible beeping, indicating a low-pressure alarm. During an observation on 5/21/2026 at 10:12 a.m. and 11:42 a.m., at Resident 108's bedside, Resident 108 was lying in bed on a LALM. The pump attached to the LALM at the foot of Resident 108's bed had an orange flashing light and audible beeping, indicating a low-pressure alarm. During an interview on 5/21/2026 at 3:05 p.m., with the Maintenance Assistant (MA), the MA stated he had not received any report from nursing staff regarding malfunctioning LALMs. The MA stated that when the low pressure alarm was flashing and audible, it indicated there was an air leak somewhere in the system. The MA stated that the presence of an air leak prevented the mattress from working effectively. During an interview on 5/21/2026 at 3:37 p.m., with Treatment Nurse (TN) 1, TN 1 stated a low-pressure alarm meant there was an air leak somewhere in the LALM system, and the alarm alerts staff that something needed to be addressed. TN 1 stated a PU could develop as soon as two hours. TN 1 stated it was not appropriate for a LALM alarm to go unaddressed for multiple days because it increased the risk for development of PUs. 2. During a review of Resident 10's Face Sheet, the Face Sheet indicated Resident 10 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 10's diagnoses included dementia (a progressive state of decline in mental abilities), and pressure ulcer of the sacral region, left buttock, and other site, stage 4 (Full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone). During a review of Resident 10's H&P, dated 10/23/2025, the H&P indicated Resident 10 had fluctuating capacity to understand and make decisions. During a review of Resident 10's MDS, the MDS indicated Resident 10's cognition was severely impaired. The MDS indicated Resident 10 was dependent on staff for all activities of daily living and mobility. During a review of Resident 10's physician order, dated 10/22/2025, the physician order indicated Resident 10 was to receive a LALM for wound care and management. During a review of Resident 10's care plan titled, Multiple Stage Four Pressure Ulcers, dated 10/22/2025, the care plan intervention indicated to utilize pressure relieving devices including specialty mattress. During a review of Resident 10's Weight Summary dated 5/5/2026, the weight summary indicated Resident 10 weighed 107 pounds ([lbs.]- a unit of weight). During an observation on 5/19/2026 at 10:24 a.m. in Resident 10's room, Resident 10 was lying on a LALM with the setting at 200 lbs. During a concurrent observation and interview on 5/20/206 at 11:27 a.m. with the Assistant Director of Nursing (ADON) in Resident 10's room, the LALM was set at 160lbs. The ADON stated the LALM was set at 160 lbs. and the resident weighed (107 lbs.) less than 160 lbs. The ADON stated the LALM should be set at 120 lbs. The ADON stated the LALM should be at the correct setting to prevent injury. During a concurrent observation and interview on 5/20/2026 at 12:40 p.m., with Treatment Nurse (TN) 1), the LALM was set at 160 lbs., the TN 1 stated Resident 10 weighed less than 160 lbs. The TN 1stated the LALM protocol was to match the weight of the resident to the low air loss pressure of the mattress. TN 1 stated the LALM was to promote wound healing and skin management (frequent and thorough assessment, basic hygiene, and protecting skin areas at risk from harmful friction and shear). During a review of manufacture operational manual titled, Proactive Medical Products, unknown date, the operational manual indicated LAL mattress was for the prevention and treatment of all stage pressure ulcers. The operational manual indicated determining the patient's weight and set the control knob to that weight setting on the control unit. 3. During a review of Resident 65's Face Sheet, the Face Sheet indicated Resident 65 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 65's diagnoses included left leg above knee amputation (AKA, surgical removal of the leg above the knee joint), peripheral vascular disease (PVD, a slow progressive narrowing of the blood flow to the arms and legs), cerebral infarction (a type of ischemic stroke – occurs when a blood clot or fatty plaque blocks a blood vessel in the brain), and sepsis (a life-threatening blood infection). During a review of Resident 65's MDS, dated [DATE], the MDS indicated Resident 65's cognition was severely impaired. The MDS indicated Resident 65 was dependent (helper does all of the effort) from staff with oral hygiene, toileting hygiene, upper and lower body dressing, and personal hygiene. The MDS indicated Resident 65 was at risk of developing pressure ulcers. During a review of Resident 65's H&P, dated 4/21/2026, the H&P indicated Resident 65 did not have the capacity to understand and make decisions but was able to make decisions for activities of daily living. During a review of Resident 65's Treatment Administration Record (TAR, a daily documentation record used by a licensed nurse to document treatment given to a resident) dated 12/24/2025 to 3/23/2026, the TAR indicated Resident 65's wound care treatment on left foot gangrene was done daily and had the initials of the individual performing the wound care. During a concurrent phone interview and record review on 5/26/2026 at 9:48 a.m., with Registered Nurse 3 (RN 3), the facility's policy and procedure (P&P) titled, Wound Care, revised 3/2023, was reviewed. The P&P indicated the date and time the wound care was given, the position in which the resident was placed, the name and title of the individual performing the wound care, if there were any changes in the resident's condition, all assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound, how the resident tolerated the procedure, if there were any problem or complaints made by the resident related to the procedure, if the resident refused the treatment and the reason(s) why, and the signature and title of the person recording the data should be documented in the resident's medical record. RN 3 stated the facility's practice when doing wound care was to check and provide the wound care treatment as ordered by the physician to the residents and put the initials of the licensed nurse performing the wound care on the TAR. RN 3 stated the licensed nurse would document resident's wound assessment which includes the type, location, and size of the wound, and the wound description on a weekly basis. RN 3 stated the facility did not follow its P&P by not assessing the wound while doing wound care treatment. RN 3 stated it was important to assess and document the wound condition daily so the facility could identify any changes of the wound and notify and address by the physician promptly.

Based on observation, interview, and record review, the facility failed to ensure:Resident 103's food at the bedside was dated and properly stored.One container of baking powder, one container of peanut butter, and one container of beef base in the dry storage area were labeled and dated.Two cabbages with discolored and black markings on edges were not kept in the walk-in refrigerator. These failures had the potential to result in harmful bacteria growth and cross contamination (a transfer of harmful bacteria from one place to another or one object to another) that could lead to foodborne illness (an illness caused by food contaminated with bacteria, viruses, and other toxins) in all of the facility's residents. Findings: 1. During a review of Resident 103's Face Sheet, the Face Sheet indicated Resident 103 was originally admitted to the facility on [DATE] and was readmitted on [DATE]. Resident 103's diagnosis included peripheral vascular disease (PVD, a slow progressive narrowing of the blood flow to the arms and legs), chronic kidney disease (a disease characterized by progressive damage and loss of function in the kidneys), and polyneuropathy (a diffuse, bilateral disorder where multiple peripheral nerves are simultaneously damaged). During a review of Resident 103's History and Physical (H&P), dated 10/22/2025, the H&P indicated Resident 103 had the capacity to understand and make decisions. During a review of Resident 103's Minimum Data Sheet (MDS, a resident assessment tool), dated 4/28/2026, the MDS indicated Resident 103's cognition (ability to think and reason) was intact. The MDS indicated Resident 103 was dependent (helper does all the effort) on staff for toileting hygiene, showering, and dressing. During an observation on 5/19/2026 at 11:04 a.m., in Resident 103's room, Resident 103 had opened hot dog buns, bread rolls, and salad dressing that was not dated and labeled on her bedside table. During a review of Resident 103's, Interdisciplinary Team (IDT), dated 4/28/2026, the IDT indicated Resident 103 was storing perishables (goods with a limited shelf life that spoils, decay, and is stored under specific conditions) in her room. During an interview on 5/20/2026 at 9:34 a.m., with Resident 103, Resident 103 stated she would allow the staff to mark the dates on her food items, but the staff had not marked her food items. During an observation and interview on 5/20/2026 at 11:51 a.m., with the Assistant Director of Nursing (ADON) in Resident 103's room, Resident 103 had opened hot dog buns, bread rolls, and salad dressing with no open date on her bedside table. The ADON stated the food items in Resident 103's room were open and were not dated. The ADON stated the food items were required to have an open date and were considered perishable in 72 hours. The ADON stated if the food items are not dated, Resident 103 would be at risk of getting an upset stomach. During an interview on 5/20/2026 at 1:10 p.m. with Certified Nursing Assistant (CNA) 4, CNA 4 stated Resident 103 wanted to keep her food items at the bedside. CNA 4 stated the food items were not dated. CNA 4 stated Resident 103's food items were scattered around the room and was not sure when the food items were brought into the room. CNA 4 stated there was no system in place to keep track of her food items. CNA 4 stated the food items could spoil and put the resident at risk to become sick. 2. During a concurrent observation and interview on 5/19/2026 at 8:21 a.m., with Dietary Aide 1 (DA 1) in the dry food storage area, there were one unopened container of baking powder and one unopened container of peanut butter with no label and date and one open container of beef base with delivery date of 2/26/2026 with no best by date. DA 1 stated all food items in the dry storage should be labeled and dated with delivery date, open date, and best by date. DA 1 stated it was important to label and date all food items so the dietary staff would know the expiration date of the food items. 3. During a concurrent observation and interview on 5/19/2026 at 8:33 a.m., with DA 1 in the walk-in refrigerator, there were two discolored cabbages with black markings on the edges. DA 1 stated the cabbage should be good and kept in the refrigerator for only 3 days. DA 1 stated giving expired food items to residents could result in food poisoning that would jeopardize resident's health and safety. During a review of facility's policy and procedure (P&P) titled, Food from Outside Sources, unknown date, the P&P indicated facility staff will assist residents with food brought in to ensure safe and sanitary storage of outside food. The P&P indicated leftover food or unused portions of packaged foods should be discarded. The P&P indicated no food will be stored beyond 72 hours from received date. During a review of the facility's P&P, titled Dating and Labeling, undated, the P&P indicated all items should be properly covered, dated with delivery date, open date, thaw date, and labeled.

Based on interview and record review, the facility failed to ensure an interdisciplinary team ([IDT] - team members from different disciplines who come together to discuss resident care) or a Bioethics committee (multidisciplinary group designed to address, analyze, and advise on complex ethical challenges) meeting was conducted prior to initiation of a psychotropic drug (Any drug that affects brain activities associated with mental process and behavior) for one of one sampled resident (Resident 2) who had a diagnosis of Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities).This deficient practice placed Resident 2 at risk for sustaining adverse effects (undesired effect of a drug) from psychotropic medication.Findings:During a review of Resident 2's Face Sheet, the Face Sheet indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 2's diagnoses included Alzheimer's Disease, bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), and major depressive disorder (MDD, a mood disorder that causes a persistent feeling of sadness and loss of interest).During a review of Resident 2's History and Physical (H&P), dated 2/7/2026, the H&P indicated Resident 2 was unable to make decisions due to severe major neurocognitive disorder (a medical condition characterized by a significant, persistent decline in cognitive function).During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool), dated 2/11/2026, the MDS indicated Resident 2's cognition (ability to think and process) was severely impaired. The MDS indicated Resident 2 was dependent (helper does all of the effort) from staff with toileting hygiene, upper and lower body dressing, personal hygiene, and mobility.During a review of Resident 2's physician's order, dated 2/5/2026, the physician order indicated to administer Lexapro (drug used to treat depression) 20 milligrams (mg, metric unit of measurement) by mouth in the evening (5:00 p.m.) for depression manifested by persistent feelings of hopelessness and helplessness. Resident 2's physician's order, dated 4/23/2026, indicated to administer Seroquel (drug used to treat bipolar disorder) 50 mg by mouth at bedtime (9:00 p.m.) for bipolar disorder manifested by recurrent behavior fluctuations from depressed behaviors to manic behaviors.During a concurrent interview and record review on 5/21/2026 at 11:39 a.m. with Registered Nurse 5 (RN 5), Resident 2's Psychotherapeutic Informed Consent forms, dated 2/5/2026 and 4/23/2026, were reviewed. The consent form, dated 2/5/2026, indicated Resident 2 was receiving Lexapro 20 mg at night. The consent form, dated 4/23/2026, indicated Resident 2 was receiving Seroquel 50 mg at bedtime. The consent forms indicated the licensed nurse confirmed the resident or resident representative gave their consent to treatment with the psychotherapeutic drug. RN 5 stated the Psychotherapeutic Informed Consent was obtained by the physician from Resident 2. RN 5 stated the Psychotherapeutic Informed Consents were not valid because Resident 2 was unable to make decisions. RN 5 stated there were no prior IDT meetings to address and discuss Resident 2's use of psychotropic medications. RN 5 stated psychotropic medications had serious adverse effects that would put Resident 2 at risk for fall.During an interview on 5/21/2026 at 12:35 p.m., with the Social Service Director (SSD), the SSD stated Resident 2 should have been placed under the care of the IDT or the bioethics committee when the physician determined Resident 2 did not have the capacity to make medical decisions. The SSD stated there were no IDT or bioethics committee meetings prior to Resident 2's initiation of psychotropic medications. The SSD stated it was important to have an IDT meeting to determine if the psychotropic medications were appropriate to Resident 2.During a review of the facility's policy and procedure (P&P) titled, Lack of Capacity when Medical Interventions Requires Informed Consent, undated, the P&P indicated an IDT review of prescribed medical interventions would be provided when the resident lacked capacity and there was no person with legal authority to make health care decisions on behalf of the resident. The P&P indicated when the resident lacked capacity for informed consent and a psychoactive medication was ordered by the physician, a bioethics meeting would be held and would include the resident's primary physician, another physician, and the facility interdisciplinary team member.

Based on observation, interview, and record review, the facility failed to ensure one of five sampled residents (Resident 73) call light was within reach.This deficient practice of not having the call light within reach had the potential for Resident 73 not to be able to call for assistance. Findings:During a review of Resident 73's Face Sheet, the Face Sheet indicated Resident 73 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 73's diagnosis included epilepsy (a chronic neurological disorder characterized by recurrent, unprovoked seizures), stage 4 pressure ulcer (full thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone), and intracerebral hemorrhage (a life-threatening type of hemorrhagic stroke where blood ruptures directly into the brain tissue).During a review of Resident 73's Minimum Data Sheet (MDS, a resident assessment tool), dated 3/29/2026, the MDS indicated Resident 73 was rarely able to understand and be understood by others. The MDS indicated Resident 73's cognition (ability to think and process) was severely impaired. The MDS indicated Resident 73 was dependent (helper does all the effort) on staff for activities of daily living such as toileting hygiene and personal hygiene, and mobility. The MDS indicated Resident 73 was always incontinent.During a review of Resident 73's care plan titled, Alteration in Elimination Patterns related to Bowel Always Incontinent, dated 2/8/2024, the care plan intervention indicated to keep call light within reach and encourage to use for assistance.During a concurrent observation and interview on 5/20/2026 at 12:16 p.m., with the Assistant Director of Nursing (ADON), Resident 73's call light was on the floor to the left side of her bed and not within reach. The ADON stated the call light was not within reach and the call light was on the wrong side of the bed due to Resident 73's left hand contracture. The ADON stated the call light should be on the right side of the bed so Resident 73 could call in case of an emergency or for assistance so the staff could render care.During a review of the facility's policy and procedure (P&P) titled, Call System, Resident, dated 3/2023, the P&P indicated residents were provided with a means to call staff for assistance through a communication system that directly call a staff member or a centralized workstation.

Based on observation, interview, and record review, the facility failed to provide a safe and hazard-free environment for three of three sampled residents (Residents 76, 110, and 37) when:1. Staff did not provide padded side rails as indicated in Resident 76's and 110's respective care plans.2. Staff failed to provide fall mats, as ordered by the physician, for Resident 37.These deficient practices increased the potential for Residents 76 and 110 to sustain avoidable injuries and complications related to missing siderail padding in the event of a seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness) and increased the potential for Resident 37 to sustain fall-related injuries. Findings: 1. During a review of Resident 76's Face Sheet, the Face Sheet indicated Resident 76 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 76's diagnoses included seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness). During a review of Resident 76's Minimum Data Set (MDS, a resident assessment tool), dated 3/31/2026, the MDS indicated Resident 76's cognition (ability to think and process) was severely impaired. The MDS indicated Resident 76 was dependent (helper does all of the effort) on staff for all attempted activities of daily living (activities such as bathing, dressing and toileting a person performs daily) and mobility. During a review of Resident 76's physician order, dated 7/30/2024, the order indicated staff were to keep Resident 76's upper half side rails up while he was in bed. During a review of Resident 76's care plan titled History of Myoclonus (sudden, brief, involuntary jerking or twitching of a muscle or group of muscles), dated 10/31/2023, the care plan indicated Resident 76 was at risk for injury, and goals of care included Resident 76 sustaining no injuries. The care plan indicated staff were to provide Resident 76 with padded side rails. During an observation on 5/20/2026 at 9:26 a.m. and 2:54 p.m., and 5/21/2026 at 11:13 a.m., Resident 76 was observed lying in bed with side rails on both sides of his bed. The side rails were not padded. During a concurrent interview and record review, on 5/21/2026 at 11:37 a.m., with Licensed Vocational Nurse (LVN) 3, Resident 76's care plan titled History of Myoclonus, dated 10/31/2023, was reviewed. LVN 3 stated the care plan indicated Resident 76 was to have padded side rails. During a concurrent observation and interview, on 5/21/2026 at 11:38 a.m., LVN 3 stated Resident 76 did not have padding on his side rails. LVN 3 stated the purpose of the padding was to prevent Resident 76 from sustaining injuries if he hit his head during a seizure. During a review of Resident 110's Face Sheet, the Face Sheet indicated Resident 110 was originally admitted to the facility on [DATE], and most recently readmitted on [DATE]. Resident 110's diagnoses included anoxic brain damage (when the brain is completely deprived of oxygen, leading to widespread brain cell death), encephalopathy (a group of conditions that cause brain dysfunction), and seizures. During a review of Resident 110's MDS, dated [DATE], the MDS indicated Resident 110's cognition was severely impaired and was dependent on staff for all attempted activities of daily living and mobility. During a review of Resident 110's physician order, dated 5/18/2026, the order indicated staff were to keep Resident 110's upper half side rails up while she was in bed. During a review of Resident 110's care plan titled Seizure Disorder, dated 10/31/2023, the care plan indicated Resident 110 was at risk for injury, and goals of care included Resident 110 sustaining no injuries. The care plan indicated staff were to provide Resident 110 with padded side rails. During an observation on 5/19/2026 at 3:47 p.m., 5/20/2026 at 2:55 p.m., and 5/21/2026 at 11:13 a.m., Resident 110 was observed lying in bed with side rails on both sides of her bed. The side rails were not padded. During a concurrent interview and record review, on 5/21/2026 at 11:16 a.m., with LVN 4, Resident 110's care plan titled Seizure Disorder, dated 10/31/2023, was reviewed. LVN 4 stated the care plan indicated Resident 110 was to have padded side rails. During a concurrent observation and interview, on 5/21/2026 at 11:19 a.m., with LVN 4, LVN 4 stated Resident 110 did not have padding to any of her side rails. LVN 4 stated Resident 110 needed padding on the side rails to protect her from injury. 2. During a review of Resident 37's Face Sheet, the Face Sheet indicated Resident 37 was admitted to the facility on [DATE] with diagnoses including seizures and contracture (A stiffening/shortening at any joint that reduces range of motion) of left and right shoulders. During a review of Resident 37's MDS, dated [DATE], the MDS indicated Resident 37 was rarely able to understand and be understood by others. The MDS indicated Resident 37's cognition was severely impaired. The MDS indicated Resident 37 was dependent on a staff to do all of the effort for toileting, showering/bathing, dressing upper and lower body dressing, and for oral and personal hygiene. During a review of Resident 37's Change of Condition (COC)/Interact Assessment Form, dated 5/17/2026, the form indicated Resident 37 fell from her bed. During a review of Resident 37's physician order dated 5/17/2026, the order indicated staff were to add floor mats to decrease potential injury. During a concurrent observation and interview on 5/21/2026 at 4:30 p.m. in Resident 37's room with the Assistant Director of Nursing (ADON), Resident 37 was lying in bed but did not have floor mats on either side. The ADON stated the floor mats should be there as ordered in case she falls so she won't land on the hard floor. During a review of the facility's policy and procedure (P&P) titled Accident/Incident Prevention, undated, the P&P indicated it was the facility's policy to strive to prevent accidents and provide adequate care plans with procedures to prevent accidents. During a review of the facility's P&P titled, Safety and Supervision of Residents, Revised July 2017, the P&P indicated staff will ensure that interventions are implemented correctly and consistently.

Based on observation, interview, and record review, the facility failed to ensure two of five sampled residents (Resident 104 and Resident 120) received care in accordance with professional standards of practice when:1. Resident 104 was not monitored for 72 hours after a change of condition ([COC] -any sudden, clinically significant deviation from a patient's normal baseline in their physical, cognitive, behavioral, or functional health status).2. Resident 120's abnormal heart rate was not reported to the physician in a timely manner.These deficient practices had the potential for Resident 104's skin rash (a noticeable change in the color, texture, or appearance of your skin) to worsen due to not being monitored and delayed physician intervention for Resident 120. Findings: 1. During a review of Resident 104's Face Sheet, the Face Sheet indicated Resident 104 was admitted to the facility on [DATE]. Resident 104's diagnosis included chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing), osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), and anemia (a condition where the body does not have enough healthy red blood cells). During a review of Patient 104's History and Physical (H&P), dated 2/18/2026, the H&P indicated Resident 104 did not have the capacity to understand and make decisions. During a review of Resident 104's Minimum Data Sheet (MDS, a resident assessment tool), dated 2/18/2026, the MDS indicated Resident 104's cognition (ability to think and process) was intact. The MDS indicated Resident 104 required partial /moderate assistance (helper does less than half the effort) on staff for toileting hygiene, showering, and putting on footwear. The MDS indicated Resident 104 had skin treatment applications for ointment (a smooth, semisolid, oil-based preparation applied topically to the skin) medications. During an observation on 5/19/2026 at 10:45 a.m. in Resident 104 room, Resident 104 had a scattered itchy skin rash. During a review of Resident 104's COC, dated 5/14/2026, the COC indicated a sudden onset generalized rash throughout the body. The COC indicated Resident 104 reported itching and discomfort. During a concurrent interview and record review on 5/21/2026 at 4:20 p.m. with the Director of Nursing (DON), Resident 104's COC, dated 5/14/2026 was reviewed. The COC indicated a sudden onset generalized rash throughout the body. The COC indicated Resident 104 reported itching and discomfort. The DON stated the protocol was to do a COC by the licensed staff. The DON stated the licensed nurses were to do an assessment and monitor Resident 104 skin every shift for 72 hours. During a concurrent interview and record review on 5/21/2026 at 4:30 p.m. with the DON, Resident 104's Licensed Notes, dated 5/14/2026, was reviewed. The Licensed Notes indicated Resident 104 was being monitored for generalized rash. The DON stated there were no Licensed Notes assessments for the skin rash on 5/16/2026. The DON stated 72-hour monitoring was not completed after the COC. The DON stated when the 72-hour monitoring was not done, staff would not know if her skin was improving or worsening. 2. During a review of Resident 120's Face Sheet, the Face Sheet indicated Resident 120 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including hypotension (low blood pressure), heart disease, and anemia. During a review of Resident 120's H&P dated 2/14/2026, the H&P indicated Resident 120 did not have the capacity to understand and make decisions. During a review of Resident 120's MDS dated [DATE], the MDS indicated Resident 120 was never able to understand or be understood by others. The MDS indicated Resident 120's cognition was severely impaired. The MDS indicated Resident 120 was dependent (helper does all of the effort) on staff for all activities of daily living and mobility. During a review of Resident 120's physician order, dated 2/12/2026, the physician order indicated to administer Metoprolol Tartrate (medication used to treat high blood pressure by slowing the heart rate), oral tablet via G-Tube (a device that allows feedings to be administered directly to the stomach, common for people with swallowing problems), two times a day for hypertension (HTN, high blood pressure) and to hold if the systolic blood pressure (SBP, top number of blood pressure measurement) was less than 110 or heart rate (HR) was greater than 60. During a record review of Resident 120's Medication Administration Record (MAR, a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 2/1/2026 – 2/28/2026, the MAR indicated Resident 120's medication Metoprolol Tartrate, scheduled for 2/21/2026 at 5:00 pm was not given due to orders to hold if HR was less than 60. During a record review of Resident 120's Licensed Nurses Note, dated 2/21/2026 at 11:08 p.m., the note indicated Resident 120's Pulse (HR) was 38 on 2/21/2026 at 4:43 p.m. The note indicated Resident 120's vital signs were within normal range (normal limits for HR are 60-100.) During a record review of Resident 120's COC dated 2/22/2026 at 1:10 a.m., the COC indicated Resident 120's HR was 36. The COC indicated the physician was notified and ordered Resident 120 to be transferred to nearest hospital emergency room. During a concurrent record review and interview on 5/22/2026 at 3:35 pm with LVN 2, Resident 120's MAR dated 2/1/2026 – 2/28/2026 was reviewed. LVN 2 stated a HR under 60 should be reported to the Registered Nurse (RN) Supervisor and the resident's physician. LVN 2 stated she did not find documentation for reporting Resident 120's HR of 38 and did not remember which supervisor she told. During a review of facility's policy and procedure (P&P) titled, Acute Condition Changes-Clinical Protocol, dated 3/2024, the P&P indicated the staff would monitor and document the resident/patient's progress and responses to treatment. During a review of facility's P&P titled, Change in a Resident's Condition or Status, undated, the P&P indicated the facility would promptly notify the attending physician of changes in the resident's medical condition.

Based on interview and record review, the facility failed to ensure a physician order for gastrointestinal referral (formal request by a physician to send a patient to a gastroenterologist [a medical doctor who specializes in diagnosing, treating, and preventing disease of the digestive system] for testing and work-up) was completed for one of one sampled resident (Resident 98).This deficient practice had the potential to put Resident 98 at risk for worsened gastrointestinal symptoms and delayed diagnosis of underlying medical condition.Findings:During a review of Resident 98's Face Sheet, the Face Sheet indicated Resident 98 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 98's diagnoses included gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) tube placement, anemia (a condition where the body does not have enough healthy red blood cells), and Diabetes Mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing).During a review of Resident 98's Minimum Data Set (MDS, a resident assessment tool), dated 4/15/2026, the MDS indicated Resident 98's cognition (ability to think and process) was intact. The MDS indicated Resident 98 was dependent (helper does all of the effort) on staff with toileting hygiene, upper and lower body dressing, and personal hygiene.During a review of Resident 98's physician order, dated 4/29/2026, the physician order indicated to follow-up on a gastrointestinal referral for possible colonoscopy (a medical procedure where a doctor uses a flexible tube with a tiny camera to examine the inside of your rectum and colon) for rectal ulcer (an open sore, wound, or lesion that forms in the lining of the rectum).During a concurrent interview and record review on 5/20/2026 at 1:32 p.m. with Registered Nurse 4 (RN 4), Resident 98's physician order was reviewed. RN 4 stated Resident 98 had a physician order for gastrointestinal referral. RN 4 stated Resident 98's gastrointestinal referral had not been completed. RN 4 stated Resident 98 did not have a scheduled gastrointestinal appointment. RN 4 stated she communicated Resident 98's physician order for gastrointestinal referral to the social service department because they were responsible for following up with insurance and scheduling an appointment. RN 4 stated it was important for Resident 98 to be seen by a gastroenterologist and get a colonoscopy to find out the cause of the rectal ulcer and to rule out rectal cancer (a disease in which abnormal cells grow uncontrollably in the rectum). RN 4 stated Resident 98 was a high risk for bleeding and the risk for not having a gastrointestinal consult referral in a timely manner would result in delay of care and treatment.During a concurrent interview and record review on 5/20/2026 at 1:45 p.m. with the Social Service Director (SSD), Resident 98's Progress Notes, dated 4/29/2026 to 5/20/2026, were reviewed. The SSD stated there was no documentation indicating the social service staff requested an authorization from Resident 98's insurance for gastrointestinal referral. The SSD stated it was important to always follow the resident's physician's order.During a review of the facility's policy and procedure (P&P) titled, Quality of Care, dated 12/10/2022, the P&P indicated it was the policy of the facility to ensure that each resident received and the facility provided the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being, in accordance with the comprehensive assessment and plan of care, in accordance with State and Federal Regulations.Cross Reference F745

Based on interview and record review, the facility failed to ensure a care plan was developed for one of 23 sampled residents (Resident 40) when Resident 40 did not have a care plan in place for his as needed use of melatonin (an over the counter or prescription pill used to improve sleep issues).This deficient practice prevented staff from having resident-specific non-drug interventions to aid Resident 40's sleep and monitor the effectiveness of his of melatonin.Findings:During a review of Resident 40's Face Sheet, the Face Sheet indicated Resident 40 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 40's diagnoses included metabolic encephalopathy (a general term for altered brain function or structure caused by an underlying systemic condition).During a review of Resident 40's Minimum Data Set (MDS, a resident assessment tool), dated 4/21/2026, the MDS indicated Resident 40's cognition (ability to think and process) was severely impaired. The MDS indicated Resident 40 was dependent on staff for all activities of daily living (activities such as bathing, dressing and toileting a person performs daily) and mobility. During a review of Resident 40's physician order, dated 1/14/2026, the order indicated to administer melatonin five (5) milligrams (mg, a unit of dose measurement) at bedtime as needed for sleep aid.During an interview on 5/21/2026 at 12:51 p.m. with the Director of Nursing (DON), the DON stated staff administered melatonin to assist Resident 40 to sleep, but there were also non-pharmacological interventions that staff could have attempted to aid Resident 40's sleep. The DON stated these interventions would be documented in a care plan. The DON stated Resident 40 did not have a care plan for his sleeping difficulties or use of melatonin, but he should. The DON stated the care plan would ensure staff monitored the effectiveness of Resident 40's melatonin use. The DON stated the care plan would also encourage staff to attempt non-drug interventions to aid Resident 40's sleep. During a review of the facility's policy and procedure (P&P) titled Care Plans, Comprehensive Person-Centered, revised 3/2023, the P&P indicated a comprehensive, person-centered care plan that met the resident's physical, psychosocial and functional needs was to be developed and implemented for each resident.

Based on observation, interview, and record review, the facility failed to ensure Minimum Data Sets (MDS, a resident assessment tool) were coded accurately for two of 23 sampled residents (Resident 40 and Resident 65).Resident 40's MDS, dated [DATE], did not reflect his use of continuous oxygen therapy, and receipt of intermittent suctioning and tracheostomy care (the routine cleaning and maintenance of a surgically created opening in the neck (stoma) and the inserted breathing tube).Resident 65's MDS, dated [DATE], did not reflect his venous ulcer (slow healing open sore that typically develop on lower leg that is caused by poor blood circulation).These deficient practices resulted in the transmission of inaccurate data to the Centers for Medicare and Medicaid Services (CMS) regarding Resident 40's and 65's health status and increased the potential for these residents to not receive the care and services they needed. Findings: 1. During a review of Resident 40's Face Sheet, the Face Sheet indicated Resident 40 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 40's diagnoses included presence of a tracheostomy (a surgical procedure that creates an opening in the neck and directly into the windpipe) and chronic respiratory failure (a long-term condition where the respiratory system cannot properly oxygenate the blood or remove excess carbon dioxide) with hypoxia (low oxygen levels in the blood). During a review of Resident 40's Minimum Data Set (MDS, a resident assessment tool), dated 4/21/2026, the MDS indicated Resident 40's cognition (ability to think and process) was severely impaired. The MDS indicated Resident 40 was dependent (helper does all effort) on staff for all attempted activities of daily living (activities such as bathing, dressing and toileting a person performs daily) and mobility. The MDS indicated Resident 40 was not receiving continuous oxygen, tracheostomy care, or intermittent suctioning. During a review of Resident 40's physician order, dated 1/15/2026, the order indicated staff were to administer oxygen by T-piece (a T-shaped tubular connector primarily used in medicine to deliver oxygen or humidity to patients with breathing tubes) at five (5) L/min. During an observation on 5/19/2026 at 11:04 a.m., Resident 40 was receiving continuous oxygen through a T-piece. During an observation on 5/20/2026 at 2:56 p.m., Resident 40 was receiving continuous oxygen through a T-piece. During an interview on 5/21/2026 at 11:34 a.m., with Respiratory Therapist (RT) 2, RT 2 stated Resident 40 was receiving continuous oxygen at five (5) L/min and received suctioning of his respiratory secretions (fluids produced by the respiratory tract, including mucus, saliva, and phlegm) as needed. RT 2 stated Resident 40 received tracheostomy care every shift and as needed. During an interview on 5/21/2026 at 12:18 p.m., with Minimum Data Set Nurse (MDSN) 2, MDSN 2 stated Resident 40 had physician orders for continuous oxygen and was receiving tracheostomy care and intermittent suction of his respiratory secretions. During a concurrent interview and record review on 5/21/2026 at 12:20 p.m. with MDSN 2, Resident 40's MDS, dated [DATE], was reviewed. MDSN 2 stated Resident 40's MDS did not accurately reflect his use of continuous oxygen, intermittent suctioning, and receipt of tracheostomy care. MDSN 2 stated the purpose of the MDS was to assess the residents and to guide their plans of care. 2. During a review of Resident 65's Face Sheet, the Face Sheet indicated Resident 65 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 65's diagnoses included left leg above knee amputation (AKA, surgical removal of the leg above the knee joint), peripheral vascular disease (PVD, a slow progressive narrowing of the blood flow to the arms and legs), cerebral infarction (a type of ischemic stroke – occurs when a blood clot or fatty plaque blocks a blood vessel in the brain), and sepsis (a life-threatening blood infection). During a review of Resident 65's Wound Care Notes, dated 12/31/2025, the Wound Care Notes indicated Resident 65 had one vascular wound (kind of wound that occurs due to poor blood flow in the arteries and veins) on left anterior (toward the front) foot extending to the left great toe (big toe) to second toe gangrene (death of body tissue due to a lack of blood flow or a serious bacterial infection). During a review of Resident 65's History and Physical (H&P), dated 4/21/2026, the H&P indicated Resident 65 did not have the capacity to understand and make decisions but was able to make decisions for activities of daily living. During a concurrent interview and record review on 5/21/2026 at 7:57 a.m. with MDSN 1, Resident 65's MDS Significant Change in Status Assessment (SCSA, a comprehensive assessment that must be completed when the Interdisciplinary Team [IDT, team members from different disciplines who come together to discuss resident care] has determined that a resident meets the significant change guidelines for either improvement or decline), dated 1/6/2026, was reviewed. MDSN 1 stated Resident 65's MDS SCSA, Section M1030 (Number of Venous and Arterial Ulcers), was completed inaccurately. MDSN 1 stated there should be number 1 (one) not 0 (zero) on Resident 65's MDS SCSA, Section M1030, because Resident 65 had 1 vascular wound on left foot classified by wound specialist on 12/31/2025. MDSN 1 stated MDS accuracy of assessment was very important in order to reflect the actual condition of the resident and the interventions provided by facility staff. MDSN 1 stated there was a possibility that resident's plan of care would be affected by not completing the MDS accurately. During a review of the facility's policy and procedure (P&P) titled, Comprehensive Assessments, revised 3/2023, the P&P indicated comprehensive assessments were conducted to assist in developing person-centered care plans. During a review of the facility's P&P titled, Certifying Accuracy of the Resident Assessment, dated 11/2019, the P&P indicated any person completing a portion of the Minimum Data Set/MDS must sign and certify the accuracy of that portion of the assessment.

Based on observation, interview, and record review, the facility failed to implement their policy and procedure (P&P) titled Use of Restraints, revised 3/2023, for one of one sampled resident (Resident 40) when:Staff placed pillows under Resident 40's fitted bed sheet, on both sides of his body, without an order or consent.Staff failed to document that Resident 40 was assessed for potential physical injury or discomfort while hand mitten restraints (a padded, glove-like medical device used to enclose a patient's hands) were used.This deficient practice restricted Resident 40's movement within his bed and increased the potential for late identification of potential skin breakdown or circulatory issues. Findings:During a review of Resident 40's Face Sheet, the Face Sheet indicated Resident 40 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 40's diagnoses included presence of a gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) and encephalopathy (a broad term for any disease, damage, or malfunction that affects the brain's structure or function).During a review of Resident 40's History and Physical (H&P), dated 1/17/2026, the H&P indicated Resident 40 did not have the capacity to understand make decisions.During a review of Resident 40's Minimum Data Set (MDS, a resident assessment tool), dated 4/21/2026, the MDS indicated Resident 40 had severe cognitive impairment (a significant loss of intellectual and memory capacity that prevents independent living). The MDS indicated Resident 40 was dependent (helper does all of the effort) on staff for all activities of daily living (activities such as bathing, dressing and toileting a person performs daily) and mobility. The MDS indicated Resident 40 used limb restraints daily.During a review of Resident 40's physician order, dated 2/23/2026, the order indicated staff were to apply hand mitten restraints (a padded, glove-like medical device used to enclose a patient's hands) to both of Resident 40's hands. 1. During an observation on 5/19/2026 at 11:00 a.m. at Resident 40's bedside, Resident 40 was observed lying in bed with hand mitten restraints to both hands. Resident 40 was lying in the center of his bed, and rolled pillows were observed under the fitted bed sheet on both sides of the resident.During an interview on 5/21/2026 at 10:54 a.m., with the Assistant Director of Nursing (ADON), the ADON stated the facility used bolster restraints, which were cushions placed under the fitted bed sheet to prevent the resident from exiting the bed. The ADON stated the bolster restraints required informed consent and a physician order. The ADON stated that placement of pillows under the fitted bed sheet mimicked the action of bolster restraints and restricted the resident's movement. The ADON stated Resident 40 did not have orders for bolster restraints and stated there should not have been anything under the fitted sheet to restrict his movement.2. During an observation, on 5/19/2026 at 11:00 a.m., at Resident 40's bedside, Resident 40 was observed with hand mitten restraints on both hands. During an observation on 5/20/2026 at 2:55 p.m., at Resident 40's bedside, Resident 40 was observed with hand mitten restraints on both hands. During an observation on 5/21/2026 at 10:11 a.m., at Resident 40's bedside, Resident 40 was observed with hand mitten restraints on both hands.During an interview on 5/21/2026 at 10:47 a.m., with the ADON, the ADON stated the licensed nurse was to check Resident 40's skin and circulation every shift. The ADON stated ongoing monitoring of the resident's skin and circulation while restraints were used was important for timely identification of any complications and prompt intervention. The ADON stated he could not locate any documentation that these assessments were completed while Resident 40 has been in restraints. During an interview on 5/22/2026 at 11:03 a.m., with the Director of Nursing (DON), the DON stated interventions to remove the hand mitten restraints and assess Resident 40's skin and circulation was ordered on 5/21/2026. The DON stated Resident 40 had been in hand mitten restraints since 12/2025. The DON stated this intervention was important to identify skin breakdown and circulation issues. The DON could not locate any documentation that these assessments were completed while Resident 40 has been in restraints. During a review of the facility's policy and procedure (P&P) titled Use of Restraints, revised 3/2023, the P&P defined physical restraints as any manual method., material or equipment.adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts access to one's body. The P&P indicated practices that inappropriately utilize equipment to prevent resident mobility are considered restraints. The P&P indicated restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative. The P&P indicated restraints were to be used in such a way as to not cause physical injury to the resident, and to ensure the least possible discomfort to the resident.

Based on observation, interview, and record review the facility failed to ensure the belongings for one of five sampled residents (Resident 103) were inventoried and documented.This deficient practice of not keeping track of Resident 103's belongings had the potential to increase the risk of Resident 103 losing her personal items.Findings:During a review of Resident 103's Face Sheet, the Face Sheet indicated Resident 103 was originally admitted to the facility on [DATE] and readmitted [DATE]. Resident 103's diagnoses included peripheral vascular disease (PVD, a slow progressive narrowing of the blood flow to the arms and legs), chronic kidney disease (a disease characterized by progressive damage and loss of function in the kidneys), and polyneuropathy (a diffuse, bilateral disorder where multiple peripheral nerves are simultaneously damaged).During a review of Patient 103's History and Physical (H&P), dated 10/22/2025, the H&P indicated Resident 103 had the capacity to understand and make decisions.During a review of Resident 103's Minimum Data Sheet (MDS, a resident assessment tool), dated 4/28/2026, the MDS indicated Resident 103's cognition (ability to think and process) was intact. The MDS indicated Resident 103 was dependent (helper does all the effort) on staff for toileting hygiene, showering, and dressing.During an observation on 5/19/2026 at 11:02 a.m. in Resident 103's room, Resident 103 had an abundance (a large, plentiful quantity or an overflowing fullness of something) of personal belongings in her room.During an interview on 5/20/2026 at 9:34 a.m., in Resident 103's room, Resident 103 stated she had a lot of personal items in her room. Resident 103 stated she did not recall the last time her items were inventoried.During an interview on 5/21/2026 at 11:57 a.m., with Social Service Director (SSD), the SSD stated Resident 103 had a large number of personal items in her room. The SSD stated inventory was to be done upon admission and during Resident 103's stay at the facility. The SSD stated an inventory log was to be done to keep track of Resident 103's items and know the location of her belongings. The SSD stated not keeping track of Resident 103's belongings made Resident 103's room disorderly.During an interview on 5/21/2026 at 2:06 p.m., with Director of Nursing (DON), the DON stated staff were to document Resident 103's belongings when Resident 103 received personal items or something was brought by the family. The DON stated there was no documentation or tracking of Resident 103's items. The DON stated not keeping track of Resident 103's items placed Resident 103 at risk for losing her belongings.During a review of facility's policy and procedure (P&P) titled, Personal Property, dated 8/2022, the P&P indicated residents are encouraged to use personal belongings to maintain homelike environment. The P&P indicated the residents' personal belongings and clothing were to be inventoried, documented upon admission, and updated as necessary.

Based on interview and record review, the facility failed to ensure a written Notice of Proposed Transfer and Discharge Form was sent to local ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities) for one of five sampled residents (Resident 51).This deficient practice had the potential to compromise Resident 51's due process rights related to transfer.Findings:During a review of Resident 51's Face Sheet, the Face Sheet indicated Resident 51 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 51's diagnoses included Diabetes Mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), atherosclerosis (a buildup of fats, cholesterol and other substances in and on the artery walls), and hypertension (HTN, high blood pressure).During a review of Resident 51's History and Physical (H&P), dated 1/6/2026, the H&P indicated Resident 51 had fluctuating capacity to understand and make decisions.During a review of Resident 51's Minimum Data Set (MDS, a resident assessment tool), dated 3/18/2026, the MDS indicated Resident 51's cognition (ability to think and process) was intact. The MDS indicated Resident 51 required setup assistance (helper assists only prior to or following the activity) from staff with oral hygiene, toileting hygiene, and personal hygiene and was independent from staff with mobility.During a review of Resident 51's Situation, Background, Assessment, and Recommendation (SBAR, a communication tool used by healthcare workers when there is a change of condition among the residents), dated 12/28/2025, the SBAR indicated Resident 51 had a change of condition of headache, redness of the cheeks, and swelling of the nose. The SBAR indicated Resident 51 was transferred to General Acute Care Hospital (GACH) on 12/28/2025.During a concurrent interview and record review on 5/21/2026 at 9:43 a.m., with Registered Nurse 3 (RN 3), Resident 51's Notice of Proposed Transfer and Discharge, dated 12/28/2025, was reviewed. There was no evidence of the fax confirmation that the Notice was sent to the Ombudsman. RN 3 stated Resident 51's Notice of Proposed Transfer and Discharge form was not faxed to the local ombudsman. RN 3 stated the written Notice of Proposed Transfer and Discharge Form should be completed within 24 hours of resident's transfer or discharge date and a copy should be sent to the resident or his family representative and to the local ombudsman office. RN 3 stated it was important to notify and send a copy of the Notice of Proposed Transfer and Discharge Form to the local ombudsman for tracking purposes, transparency, and to identify if the transfer or discharge was appropriate.During a review of the facility's policy and procedure (P&P) titled, Transfer or Discharge Notice, dated 3/2021, the P&P indicated a copy of the notice would be sent to the Office of the State Long-Term Care Ombudsman at the same time the notice of transfer or discharge is provided to the resident and representative.

Based on interview and record review, the facility failed to ensure the physician obtained informed consent for restraint use for one of one sampled resident (Resident 40).This deficient practice had the potential for Resident 40's Responsible Party (RP 1), to not be fully informed of the risks and benefits associated with restraint use, or to have the opportunity to discuss alternatives to restraints. Findings:During a review of Resident 40's Face Sheet, the Face Sheet indicated Resident 40 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 40's diagnoses included presence of a gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) and encephalopathy (a broad term for any disease, damage, or malfunction that affects the brain's structure or function).During a review of Resident 40's History and Physical (H&P), dated 1/17/2026, the H&P indicated Resident 40 did not have the capacity to understand make decisions.During a review of Resident 40's Minimum Data Set (MDS, a resident assessment tool), dated 4/21/2026, the MDS indicated Resident 40 had severe cognitive impairment (a significant loss of intellectual and memory capacity that prevents independent living). The MDS indicated Resident 40 was dependent (helper does all of the effort) on staff for all activities of daily living (activities such as bathing, dressing and toileting a person performs daily) and mobility.During a review of Resident 40's physician order, dated 2/23/2026, the order indicated staff were to apply hand mitten restraints (a padded, glove-like medical device used to enclose a patient's hands) to both of Resident 40's hands. During a review of Resident 40's record titled Physical Restraint Informed Consent, dated 2/23/2026, the record indicated the Assistant Director of Nursing (ADON) verified informed consent for the use of hand mitten restraints was obtained. The record did not indicate the physician had confirmed they provided material information (any facts, risks, or details that a reasonable person would need to make an informed, voluntary decision about whether to) to Resident 40's RP, RP 1.During an interview on 5/21/2026 at 10:39 a.m., with the ADON, the ADON stated he contacted Resident 40's RP, RP 1, to obtain consent for the use of hand mitten restraints. The ADON stated that his name in the section of the record titled Verification of Informed Consent, indicated he called RP 1. The ADON stated the physician did not routinely obtain informed consent. The ADON stated he explained the risks and benefits of the restraints to RP 1 himself. The ADON stated the purpose of obtaining informed consent for restraints was to explain the treatment to verify that the RP knew the risks and benefits of the proposed treatment. The ADON stated there were risks associated with physical restraint use, including reduced mobility, skin breakdown, and circulation concerns.During an interview on 5/22/2026 at 11:25 a.m., with the Director of Nursing (DON), the DON stated the physician was responsible for obtaining informed consent. The DON stated the licensed nurse's responsibility was to verify that the physician spoke with the RP and obtained the consent. The DON stated it was not within the nurse's scope to obtain informed consent.During a review of the facility's policy and procedure (P&P) titled Use of Restraints, revised 3/2023, the P&P indicated restraints were only to be used after obtaining consent from the resident and/or Representative [RP].During a review of the facility's P&P titled Informed Consent, undated, the P&P indicated the attending physician was responsible for disclosing the risks of the proposed treatment or procedure. The P&P indicated an Informed Consent Form shall be prepared and acknowledged by the attending physician that indicates that the attending physician has disclosed the appropriate information prior to obtaining informed consent.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program for scabies (a contagious, intensely itchy skin condition caused by a tiny, burrowing mite) for eight of eight sampled residents (Resident 1, Resident 2, Resident 3, Resident 7, Resident 8, Resident 19, Resident 21 and Resident 26) afterfacility was informed Resident 1 (who was transferred from the facility to a general acute care hospital [GACH] on 3/25/2023 with rashes) was diagnosed and treated for scabies on 3/26/2023 and returned to the facility on [DATE]. The facility failed to: 1. Inform the dermatologist ( [Medical Doctor (MD) 2 ] a medical practitioner specializing in the diagnosis and treatment of skin disorders), to report Resident 1 was diagnosed and treated with scabies on 3/26/2023 at the GACH, to further investigate and treat other six Residents (Resident 1, Resident 3, Resident 7, Resident 8, Resident 19, and Resident 21) who were exhibiting symptoms of scabies. 2. Address the rashes noted for six of six sampled residents (Resident 1, Resident 3, Resident 7, Resident 8, Resident 19, and Resident 21) who were exhibiting symptoms of scabies. 3. Treat Resident 2 (Resident 1' s roommate) prophylactically (a medicine or course of action used to prevent disease), after being exposed to Resident 1, who was treated and diagnosed with scabies. 4. Ensure Certified Nurse Assistant (CNA) 1, (who did not receive prophylactic treatment after exposure to residents who were suspected of having scabies), wore personal protective equipment ([PPE] protective clothing or equipment worn to protect against infectious materials) when providing care to residents, Resident 1 and Resident 26, who were in a contact isolation (precautions taken when a patient has an infectious disease that may be spread by touching either the patient or other objects the patient has handled). CNA 1 placed Resident 1 and 26 at high risk for exposure to scabies. 5. Adhere to the facility's policy and procedure titled, Scabies Prevention and Control, which stipulates to identify possible cases of scabies infection as soon as possible, skin scrapings will be performed as ordered for suspected cases, place all residents and staff suspected of scabies in contact precaution, wear PPE when providing care to residents to prevent the potential spread of scabies. These deficient practices placed 109 Residents, all staff, vendors, and visitors at risk for scabies exposure. On 4/25/2023, at 4:30 p.m., the Department identified an Immediate Jeopardy ([IJ] a situation in which the facility's noncompliance with one or more requirements of participation has caused, or likely to cause, serious injury, harm, impairment, or death to a resident and the situation created a need for an immediate corrective action situation). The Administrator (ADM), the Director of Nursing (DON), and Clinical Manager (CM 1) were notified at this time of the immediate actions that needed to be taken and the seriousness of the residents ' health and safety threatened due to the facility's failure to ensure infection control practices were implemented during scabies outbreak. The facility failed to address the rashes of six residents (Residents 1, Resident 3, Resident 7, Resident 8, Resident 19, and Resident 21) who were exhibiting symptoms of scabies, ensure the facility ' s policy and procedure for scabies was followed, treat Resident 2 prophylactically, and ensure CNA 1 wore PPE while providing care. On 4/27/2023 at 3:05 p.m., the ADM provided an acceptable IJ removal plan. The IJ removal plan included the following: 1. On 4/17/2023, 21 residents with rashes were seen and evaluated by the Dermatologists. 2. On 4/18/2023, all 21 residents with rashes received treatment orders for Permethrin ([Elimite] an insecticide, used to treat scabies). 3. On 4/18/2023, the facility implemented monitoring of facility staff and resident for skin rashes/scabies. Any staff or resident with a new rash will be included in the scabies outbreak line list. 4. On 4/19/2023, Permethrin was applied for residents with rashes, and 8 roommates received prophylactic treatment. 5. On 4/19/2023, all 29 resident's responsible parties were notified of the new orders. 6. On 4/19/2023, all 29 residents were placed on contact precautions during the duration of initial Permethrin. 7. On 4/19/2023, and 4/20/2023 Staff utilized PPE (gowns, gloves, masks) when showering residents. 8. On 4/19/2023, belongings of 29 residents were bagged and kept sealed for seven days. 9. 16 rooms of resident's that received treatment were all deep cleaned, all linens were bagged and washed separately. All beds were disinfected. All curtains were replaced, and all bathrooms were terminally cleaned on 4/19/2023, and 4/20/2023. 10. 21 residents with rashes will continue to be treated with Permethrin once a week for 3 weeks to complete course of treatment. 11. On 4/21/2023, all 21 residents with skin rashes were skin scraped (a test to confirm or rule out scabies). 12. On 4/21/2023, Los Angeles Public Health conducted an on-site visit to the facility giving the facility verbal guidance on the Scabies Toolkit (contains materials to assist health care facilities in managing scabies outbreaks and educating health care workers on identification, transmission, signs and symptoms, and treatment of scabies) to manage rashes at the facility. 13. On 4/21/2023, Resident 2 was offered prophylaxis treatment, after being one of the residents exposed to scabies. 14. On 4/21/2023, CNA 1 was given one on one reeducation by the DON, about following the scabies prevention, control, and managing protocol, and the use of PPE. 15. On 4/18-4/19/2023, 4/21-4/22/2023, 4/25-4/26/2023, the DON, Director of Staff Development (DSD), and Infection Preventionist Nurse (IPN) gave in-services to staff about scabies prevention and management, which included good hand hygiene for residents, hand hygiene for staff, proper PPE use, and contact precaution protocol. PPE training included utilization of gowns, gloves, and masks. 16. On 4/25/2023, the housekeeping supervisor trained four (4) housekeepers about proper infection control, proper cleaning of isolation rooms, room cleaning process, bathroom cleansing process and deep clean process. 17. On 4/19/2023, staff were offered Permethrin cream as prophylaxis. 18. On 4/24/2023, all staff were notified and educated about the use of Permethrin cream as scabies prophylaxis. Permethrin was provided to all staff from 4/24-4/26/2023. 90 staff members received the Permethrin. In the event of refusal, the staff will be required to wear gowns when in the facility. 19. On 4/21/2023, the DON, DSD, IPN, and RN conducted rounds and observed staff donning (to put on) and doffing (to remove) PPE. 20. On 4/25/2023, the DSD, IPN, and RNs completed body check for all residents to ensure that there were no residents with new rashes. 21. On 4/25/2023, the Dermatologist agreed to conduct telehealth consults so residents with rashes will be evaluated timely, and dermatology to follow-up after completion of treatment as needed. 22. On 4/26/2023, monitoring started, the DON and/or designee will conduct clinical meetings daily, for 30 days to review and identify any resident with a new rash and conduct daily rounds to ensure staff adhere to infection prevention precautions and procedures, including hand washing and appropriate use of PPE. 23. On 4/28/2023, the medical records staff will start to conduct weekly audits for medication and treatment for any new residents with rashes for six (6) weeks. The audit will be reviewed by the DON and Clinical Manager weekly to ensure appropriate interventions were in place. 24. The DON and the DSD will present the recapitulation (summary) of the plan of action to the QA (Quality Assurance)/Utilization Group on 4/26/2023. Findings shall be reviewed and discussed monthly for three (3) months to ensure corrections were achieved and sustained during QA/Utilization Group quarterly meetings. The QA/Utilization Group shall thereby decide if further reviews/audits need to be extended for another quarter to ensure compliance. On 4/27/2023, at 3:05 p.m., after an onsite verification of the facility's IJRP implementation through observation, interview, and record review, IJRP was not found implemented, the IJ was not lifted and an exit was conducted for the investigation. The Facility was placed on a 23-day fast track (enforcement action when immediate jeopardy exists where the IJ must be removed no later than 23 days from the last day of the survey or the provider agreement will be terminated). On 4/28/2023, at 3:58 p.m., the IJ Removal Plan was verified as implemented through observation, interviews, and record review. The ADM was notified that the IJ was removed. Findings: 1. During a review of Resident 1's Admission Record (Face Sheet), dated 4/25/2023, the Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE], and readmitted on [DATE]. Resident 1's diagnoses included Raynaud ' s syndrome (a condition in which some areas of the body feel numb and cool in certain circumstances), alcoholic liver disease (liver damage caused by excess alcohol intake), chronic obstructive pulmonary disease ([COPD] a group of lung diseases that block airflow and make it difficult to breath) and anemia (a condition in which blood does not have enough healthy red blood cells). During a review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 2/3/2023, the MDS indicated the cognitive (the ability to think and process information) skills for daily decisions making was intact. Resident 1 required extensive assistance in dressing, limited assistance in personal hygiene, and limited assistance in bed mobility. During a review of Resident 1's document, titled Change of Condition ([COC] a clinical deviation from a resident's baseline) Assessment Form, dated 2/20/2023, at 9:30 p.m., indicated, Resident 1 expressed concerns over a new onset rash with redness, scabbing, and extreme itchiness on the trunk of her body, and upper extremities. COC indicated Resident 1 denied being exposed to any known allergens (iodine, and sea food). COC indicated Licensed Vocational Nurse (LVN) 1 notified Resident 1 ' s primary physician (MD) 1. MD 1 ordered Triamcinolone Acetonide Cream (used to treat the itching, redness, dryness, crusting, scaling, inflammation, and discomfort of various skin conditions) for generalized (all over the body) rash. During a review of Resident 1's Physician Order, dated 2/21/2023, indicated an order for Triamcinolone Acetonide Cream 0.1 % topically every morning and evening shift for 30 days for generalized body rash. During a review of Resident 1's Physician Order, dated 2/28/2023, indicated an order for Hydrocortisone External Gel (used to treat skin conditions by suppressing the immune response, relieving itch) every morning and evening shift for generalized body rash for 30 days. During a review of Resident 1's Physician Order, dated 2/28/2023, indicated, a dermatology consult was ordered eight days after onset of rash. During an interview on 4/20/2023, at 12:45 p.m., with Registered Nurse (RN) 2, RN 2 stated, Resident 1 originally had the rash on 2/20/2023, was readmitted to the facility on [DATE] from the GACH, and was treated for scabies (3/26/2023) during her hospitalization , prior to readmission on 4/4/2023. During a concurrent observation and interview on 4/21/2023, at 11:35 a.m., inside Resident 1 ' s room, Resident 1 was observed with a pimple like red rash and residual scarring on arms, legs, and chest. Resident 1 stated her rash started approximately on 2/20/2023, eight weeks before she was hospitalized on [DATE]. Resident 1 stated that the physician in the hospital told her she had scabies. Resident 1 stated she still felt itchy today (4/21/2023). During a review of Resident 1 ' s Physician Order, dated 4/4/2024, indicated an order for Benadryl (used to treat sneezing, runny nose, watery eyes, hives, skin rash, itching, and other cold or allergy symptoms) 25 mg ([milligram] unit of measurement) every 6 hours as needed for itchiness. During a concurrent interview and record review on 4/21/2023 at 2:15 p.m., with CM 1, Resident 1's Physician Orders, Dermatology Notes, and Nurses Notes from 2/20/2023 to 4/21/2023 were reviewed. CM 1 stated a dermatology consult was ordered for Resident 1 on 2/28/2023. CM 1 stated Resident 1's clinical record indicated she was only seen by MD 2 on 4/17/2023. CM 1 stated there was no dermatology notes from 2/20/2023 up until 4/17/2023 to address Resident 1 ' s new onset rash on 2/20/2023. CM 1 was unable to explain why a dermatology consult was not done for Resident 1 as ordered. During record review of Resident 1's documents from MD 2, Resident 1's dermatology records indicated MD 2 did a consult for Resident 1 was on 4/17/2023. Resident 1 ' s Dermatology Order, dated 4/17/2023, indicated the folowing orders: Permethrin 5% cream, apply one tube from neck to toes, leave for 12 hours then rinse. Repeat once a week times four weeks. Ivermectin (an anti-parasite medication used to treat parasitic diseases, and scabies) 12 mg once a week times four weeks. During a review of Resident 1's Medication Administration Record (MAR), dated 4/2023, the MAR indicated, Permethrin 5% cream was administered on 4/19/2023 to Resident 1, by RN 2. During a review of Resident 1's MAR, dated 4/2023, the MAR indicated, Ivermectin 12 mg was administered on 4/20/2023 to Resident 1, by LVN 2. During a review of Resident 1's Physician Order, dated 4/21/2023, indicated an order for a skin scraping (a definitive scabies test that identifies mites, eggs, or eggshell fragments embedded in the skin) for Resident 1. During an interview on 4/20/2023, at 10:50 a.m., with Treatment Nurse (TN) 1, TN 1 stated Resident 1 had a history of the generalized body rash since 2/20/2023. During a review of Resident 1's GACH record, titled Physian History and Physical, dated 3/26/2023, indicated Resident 1 was admitted on [DATE] at 10:54 p.m. Resident 1 ' s history of present illness / chief complaint included a scabies appearing rashes. The Infectious Disease note indicated a diagnosis of Ectoparasitic infestation (condition in which organisms live primarily on the surface of the host) scabies and Permethrin, Ivermectin and contact isolation were ordered. During a review of Resident 1's GACH record, titled, Physician ' s Progress Note Infectious Diseases, dated 3/30/2023, indicated Resident 1 was itching, had scattered diffused papules (a raised, pimple-like growth on the skin that does not produce pus) and burrows (a tunnel made in or under the skin) on upper extremities, chest, abdomen, lower extremities and skin excoriation (linear erosion of skin tissue resulting from mechanical means) of bilateral buttocks. The GACH record indicated Resident 1's diagnosis included Ectoparasitic Infestation, scabies . Resident 1 was treated with Permethrin, Ivermectin on 3/26/2023, and was placed on contact isolation. During a concurrent interview and record review on 4/21/2023, at 2:29 p.m., with CM 1, CM 1 reviewed Resident 1's GACH discharge summary record indicating Resident 1 was treated for scabies at the GACH on 3/26/2023. CM 1 stated she does not know if the hospital informed facility staff, upon readmission, that Resident 1 was treated for scabies during her hospitalization . During an interview on 4/25/2023, at 3:35 p.m., with the DON, the DON stated she screened all residents prior to admission, and reviews the GACH records for the residents ' diagnosis and what kind of treatment residents received from the GACH. The DON stated Resident 1 ' s GACH records indicated Resident 1 was treated for scabies on 3/26/2023. The facility should had initiated an investigation of other residents with skin rashes and scabies exposure upon knowledge of Resident 1's scabies treatment during hospitalization to prevent the potential spread of scabies. 2. During a review of Resident 2's Face Sheet, dated 4/25/2023, the Face Sheet indicated Resident 2 was admitted to the facility on [DATE]. Resident 2 ' s diagnoses included diabetes mellitus (body has high sugar levels for prolonged periods of time), hypertension (blood pressure that is higher than normal), and muscle weakness (lack of muscle strength that affects mobility). During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 ' s cognitive skills for daily decision making was intact, and Resident 2 required extensive assistance in dressing, toileting, personal hygiene and bed mobility. During an interview on 4/21/2023, at 10:50 a.m., with Resident 2, Resident 2 stated she and Resident 1 were roommates prior to Resident 1's transfer to the GACH on 3/25/2023. They (Resident 1 and Resident 2) were also roommates when Resident 1 returned to the facility on [DATE] until 4/15/2023. Resident 2 stated Resident 1 had told her the doctor in the hospital said she (Resident 1) had scabies. Resident 2 stated she suspected that scabies had been why all the showers have been taking place for other residents the past couple of days, but the facility staff have not communicated anything to her regarding the potential exposure to scabies. Resident 2 stated she did not receive or was offered any creams or treatments for scabies. During a concurrent interview and record review, on 4/21/2023, at 2:15 p.m., with CM 1, the Facility Census dated 3/25/2023 to 4/21/2023 was reviewed. CM 1 stated that Resident 1 and Resident 2 were roommate on 3/25/23, prior to Resident 1 ' s transfer to GACH, where Resident 1 was treated for scabies. CM 1 also stated Resident 1 and Resident 2 were roommates from 4/4/2023 to 4/15/2023. During a review of Resident 2's Dermatology Order, dated 4/17/2023, indicated an order for Permethrin 5% cream, apply one tube from neck to toes, leave for two hours then rinse for prophylactic treatment. During a review of Resident 2's Dermatology Progress note, dated 4/17/2023, MD 2 progress note indicated Resident 2 was seen by MD 2, who determined no skin pathology was seen on general body, and treatment plan was to administer Elimite prophylaxis (precautionary measure taken to prevent the onset of scabies). During review of document, titled, Scabies Outbreak Line List for Healthcare Facilities: Patients, dated 4/18/2023, indicated that Resident 2 who was exposed to Resident 1, was not on the line list. During an interview, on 4/21/2023, at 2:30 p.m., with the DON, the DON stated she was not sure why Resident 2 was not added to the line list and treated prophylactically for scabies. During a review of Resident 2's Change of Condition Assessment Form (COC), dated 4/21/2023, the COC indicated on 4/21/2023 at 4 p.m., RN 2 discussed recommendation from dermatologist with the primary physician (MD1) to treat Resident 2 for dermatitis [sic]prophylactically and obtained an order for prophylactic treatment on 4/21/2023. COC indicated Resident 2 was notified of a new order for prophylactic treatment but refused treatment. COC did not indicate the physician was notified Resident 2 was refusing treatment to determine what other orders could be done to mitigate potential spread of scabies. During a review of Resident 2's Physician Order, dated 4/21/2023, indicated, Permethrin External Cream was ordered on 4/21/2023 at 2:31 p.m., by MD 2. During a review on of Resident 2's MAR, dated 4/2023, indicated, Permethrin External Cream (5%) was administered on 4/24/2023 to Resident 2, by LVN 3. During an interview on 4/25/2023, at 12:57 p.m., with the DON, the DON stated the facility should have identified Resident 2 did not receive prophylactic treatment on 4/17/2023, and Resident 2 could have spread scabies to other staff or residents since she was exposed to Resident 1 on 4/15/2023. The DON was unable to explain why Resident 2 did not receive prophylaxis treatment for scabies when MD 2 ordered Elimite on 4/17/2023. 3. During a review of Resident 3, Resident 7, Resident 8, Resident 19, and Resident 21's clinical records, the records indicated the residents did not receive treatment for scabies when Resident 1 returned to the facility on [DATE], with a disgnosis of scabies. The records indicated the following: a. During a review of Resident 3's Face Sheet, dated 4/18/2023, the Face Sheet indicated Resident 3 was initially admitted to the facility on [DATE], and readmitted on [DATE]. Resident 3 ' s diagnoses included functional quadriplegia (complete immobility and inability to move due to severe physical disability), ventilator dependence (inability to breath independent of a machine device), and hypertension. During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3 ' s cognitive skills for daily decision making was severely impaired, and had total dependence (full staff performance) on personal hygiene and bathing. During an observation on 4/21/2023, at 11:40 a.m., inside Resident 3 ' s room, Resident 3 was observed lying in bed, unable to move, and nonverbal. Resident 3 had red skin lesions on her back and left lateral torso (side of trunk of the body), with red scarring, both raised and flat, some of which were greater than 1-centimeter ([cm] unit of measurement) in diameter, with surrounding skin showing darkened discolored, and eczematous (patches of skin become rough and inflamed with blisters that cause itching and bleeding) blotches (irregular patch or unsightly marks on surfaces). During a review of Resident 3's Physician Order dated 4/1/2023, indicated an order for Clobetasol Proprianate External Foam (used to treat the itching, redness, dryness, crusting, scaling, inflammation, and discomfort of various scalp and skin conditions) 0.05%, apply to affected areas topically every day shift for rash. During a review of Resident 3's Dermatology Progress Note, dated 4/17/2023, indicated Resident 3 had generalized body dermatitis. During a review of Resident 3's Dermatology Order, dated 4/17/2023, indicated the following orders: Permethrin 5 % cream, apply one tube from neck to toes, leave for 12 hours then rinse. Repeat once a week times four weeks. Ivermectin 12 mg via gastrostomy tube ([g-tube] a tube that allows nutrition and medication to bypass the mouth and go directly into the stomach) every week times four weeks. During a review of Resident 3's MAR, dated 4/2023, the MAR indicated, Permethrin Cream 5% was administered on 4/18/2023. During a review of Resident 3's MAR, dated 4/2023, the MAR indicated, Ivermectin 12 mg was administered on 4/20/2023 to Resident 3. During an interview on 4/20/2023, at 10:50 a.m., with TN 1, TN 1 stated Resident 3 had rashes since 3/13/2023, but was determined by MD 2 to be dermatitis (inflammation of skin), and was treated with topical corticosteroids (a topical immune suppressorant to reduce inflammation of skin). b. During a review of Resident 7's Face Sheet, dated 4/19/2023, the Face Sheet indicated Resident 7 was originally admitted to the facility on [DATE], and was readmitted to the facility on [DATE]. Resident 7's diagnoses included traumatic brain injury (a head injury causing damage to the brain by external force or mechanism)), quadraplegia (whole body paralysis), Urinary Tract Infection (an infection in any part of the urinary system), rash and other nonspecific eruption. During a review of Resident 7's MDS , dated 3/27/2023, the MDS indicated Resident 7 ' s cognitive skills for daily decisions was severely impaired. Resident 7 required total dependence with bed mobility, dressing, eating, toilet use and personal hygiene. During a review of Resident 7's Dermatology Progress note, dated 1/16/2023, indicated Resident 7 has prurigo nodularis (a chronic skin disorder characterized by the presence of hard, extremely itchy bumps known as nodules) on left arm, left flank and left trunk and was treated with topical steroids. During a review of Resident 7's Dermatology Progress Note, dated 2/13/2023 indicated Resident 7 had general body tinea corporis (a rash caused by a fungal infection) and was treated with topical steroids, oral steroids, and oral antifungal. During a review of Resident 7's GACH record, titled Physician H&P General, dated 2/24/2023 (admitted ) at 1:12 p.m., indicated physician was concerned about Resident 7 ' s widespread rash and suspecting scabies. The GACH records further indicate he was placed on contact isolation for scabies, and treated with Permethrin twice on 2/24/2023. During a review of Resident 7's Admission Reassessment note, dated 3/8/2023, indicated Resident 7 had a generalized body rash. During a review of Resident 7's Dermatology Progress Note, dated 4/17/2023, indicated Resident 7 had a generalized dermatitis. During a review of Resident 7's Dermatology Order, dated 4/17/2023, indicated the following orders: Permethrin 5 % cream, apply one tube from neck to toes, leave for 12 hours then rinse. Repeat once a week times four weeks. Ivermectin 12 mg by mouth every week times four weeks. During an interview on 4/20/2023, at 12:25 p.m., with TN 1, TN 1 stated Resident 7 was readmitted to the facility with the generalized body rash on 3/8/2023, and that dermatology visited him on 1/16/2023, 2/13/2023, 3/13/2023, and 4/17/2023. TN 1 stated that prior to 4/17/2023 when MD 2 suspected Resident 7 had scabies, his rash was diagnosed as prurigo (skin condition characterized by multiple nodules on the back of the arms and legs, and was extremely itchy) and tinea corpus. c. During a review of Resident 8's Face Sheet, dated 4/19/2023, the Face Sheet indicated Resident 8 was admitted to the facility on [DATE]. Resident 8 ' s diagnoses included ventilator dependence, dysphagia (difficulty swallowing), and traumatic brain injury. During a review of Resident 8's MDS, dated [DATE], the MDS indicated the cognitive skills for daily decisions was severely impaired, and Resident 8 required total dependence with personal hygiene and bathing. During a review of Resident 8's Physician Order dated 3/18/2023, indicated an order for Clotrimazole Cream 1%, apply to groin topically every morning and evening shift for Tinea Cruris ([Jock itch] a [NAME] infection that causes a red and itchy rash in warm and moist areas of the body). During a review of Resident 8's Physician order dated 4/3/2023, indicated an order for Triamcinolone Acetonide External Cream 0.1%, apply to general body topically every day shift for dermatitis unspecified for 30 days. During a review of Resident 8's Dermatology Progress Note, dated 4/17/2023, indicated Resident 8 had a generalized dermatitis. During a review of Resident 8's Dermatology Order, dated 4/17/2023, indicated the following orders: Permethrin 5 % cream, apply one tube from neck to toes, leave for 12 hours then rinse. Repeat once a week times four weeks. Ivermectin 12 mg via gastrostomy tube (g-tube) every week times four weeks. During an interview on 4/20/2023, at 10:51 a.m., with TN 1, TN 1 stated Resident 8 had a rash since 4/4/2023, and antifungal and antiinflammatory creams were ordered for the rash by MD 1. Resident 8 was seen by dermatologist, MD 2, on 4/17/2023 for the first time. During an observation on 4/21/2023, at 11:15 a.m., inside Resident 8 ' s room, Resident 8 was observed lying in bed, unable to move, and nonverbal. Resident 8 had a red rash of raised bumps on his back, abdomen, both arms, and legs. d. During a review of Resident 19's Face Sheet, dated 4/18/2023, the Face Sheet indicated Resident 19 was admitted to the facility on [DATE]. Resident 19 ' s diagnoses included diabetes mellitus, dysphagia, and left-sided hemiplegia (paralysis of the left side of the body). During a review of Resident 19's MDS, dated [DATE], the MDS indicated Resident 19's cognitive skills for daily decisions was intact. Resident 19 required extensive assistance with bed mobility, dressing eating, personal hygiene, and total dependence with toilet use. During an observation on 4/21/2023, at 10:30 a.m., inside Resident 19's room, Resident 19 was awake, alert, and refused observation of rash, and interview. During a review of Physician Order dated 11/9/2022, indicated an order for Triamcinolone Acetonide External Cream 0.1%, apply to left upper thigh topically every morning for dermatitis unspecified for 30 days. During an review of Resident 19's Physician Order dated 12/20/20222, indicated an order for Bethamethasone Diprolonate External Cream 0.05%, apply to general body topically every morning shift for dermatitis unspecified for 30 days. During a review of Dermatology Progress Note dated 1/16/2023, indicated Resident 19 was status post dermatitis unspecified general body and treat for topical steroids. During a review of Resident 19's Physician order dated 1/17/2023 indicated an order for Triamcinalone Acetonide External Cream 0.1%, apply to general body topically every morning shift for status post dermatitis unspecified for 30 days. During a review of Resident 19's progress note dated 2/13/2023 indicated Resident 19 has dermatitis unspecified general body topical steroids. During a review of Resident 19's Physician Order dated 2/16/2023, indicated an order for Clobetasol Propionate External Cream 0.05%, apply to generalized body topically two times a day for dermatitis unspecified for four weeks. During a review of Resident 19's Physician Order dated 3/16/2023, indicated an order for Clobetasol Proprionate External Cream 0.05%, apply to generalized body topically, two times a day for 4 weeks. During review of Resident 19's Treatment Administration Record (TAR), dated 4/2023, the TAR indicated Resident 19 was receiving Clobetasol Propionate 0.05% cream since 4/1/2023 for generalized body rash. During a review of Resident 19's Dermatology Progress Note, dated 4/17/2023, indicated Resident 19 had a generalized dermatitis. During a review of Resident 19's Dermatology Order, dated 4/17/2023, indicated the following orders: Permethrin 5 % cream, apply one tube from neck to toes, leave for 12 hours then rinse. Repeat once a week times four weeks. Ivermectin 12 mg by mouth every week times four weeks. f. During a review of Resident 21's Face Sheet, dated 4/18/2023, the Face Sheet indicated Resident 21 was admitted to the facility on [DATE]. Resident 21 ' s diagnoses included dementia (a group of symptoms that affects memory, thinking and interfers with daily life) COPD, and diabetes mellitus. During a review of Resident 21' s MDS, dated [DATE], the MDS indicated Resident 21 was cognitively impaired, and required extensive assistance for personal hygiene and toileting. The MDS indicated Resident 21 did not have any skin issues. During a review of Resident 21 ' s GACH record dated 3/10/2023, indicated, Resident 21 was admitted to the GACH on 3/6/2023 with complaints of itchy rash that she had for the last several months. Resident 21 ' s GACH assessment indicated Resident 21 had possible scabies and plan was to treat with Elimite and Ivermectin trial. Clinical summary indicated Resident 21 received Permethrin 5% topical on 3/7/2023 with discharge summary indicating to continue taking the following medications: Triamcinolone 0.1% topical cream, apply topically to affected area two times a day. Triamcinolone 0.5 % topical cream, apply topically to affected area once a day. During an interview on 4/20/2023, at 12:45 a.m., with RN 2, RN 2 stated Resident 21 had a new generalized rash discovered by MD 2 on 4/17/2023. During a review of Resident 21 ' s Dermatology Progress Note, dated 4/17/2023, indicated Resident 21 had a generalized dermatitis. During a review of Resident 21 ' s Dermatology Order, dated 4/17[TRUNCATED]

Based on interview, and record review, the facility failed to prevent one of three sampled residents (Resident 1), who was at risk for falls and had a history of involuntary movements from falling off the bed to the floor by failing to: 1. Ensure a Certified Nursing Assistant (CNA) 1, used a two-person assist while providing care to Resident 1 on 3/5/2023. 2. Follow Resident 1's care plan titled At risk for falling from Low Air Loss Mattress ([LAL], a mattress designed to prevent and treat pressure wounds) which indicated Resident 1 required a two-person assist with transfers, repositioning, and daily care. These deficient practices caused Resident 1 to fall and sustain a bump and laceration to the back of the head that required a visit to an General Acute Care Hospital (GACH) for evaluation and treatment. Findings: During a review of Resident 1's Face sheet (Admission Record) the face sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including contractures (A permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff) of the right and left knees, dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), seizures (a burst of uncontrolled electrical activity in the brain that causes temporary abnormalities such as stiffness, confusion and involuntary movements), tracheostomy (a small surgical opening that is made through the front of the neck into the windpipe to allow air to flow in and out of the windpipe), and dependence on respiratory ventilator (machine used to provide breathing assistance to patients who have lost the ability to breathe on their own). During a review of Resident 1's History and Physical (H&P), dated 1/20/2022, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1's Physician order summary dated 1/19/2022, the Physician order Summary indicated bilateral upper half side rails up when in bed for safety and protection secondary to involuntary movement. During a review of Resident 1's care plan titled, Side rail use as non-restraint, resident is at risk for movement from bed to floor due to head of bed elevated and gravity-related to involuntary movements and unresponsiveness, initiated on 4/20/2022, the care plan intervention indicated staff will reposition Resident 1 as indicated and use side rails. During a review of Resident 1's care plan, dated contracted 5/4/2022, titled, Resident has self-care deficits: in bed mobility, transfer, total assist, the care plan intervention indicated staff may provide 1-2 staff when performing turning, repositioning, and activities of daily living ([ADL] activities related to personal care such as dressing, and toilet use) care. During a review of Resident 1's care plan initiated on 5/4/2022 titled, At risk for falling from low air loss mattress due to involuntary movements, spontaneous movements, large heavy resident requiring total care, turning and repositioning, the care plan intervention indicated Resident 1 required a two-person assist with transfers, repositioning and daily care, and the use of side rails. During a review of Resident 1's Fall Risk assessment dated [DATE], the fall risk assessment indicated Resident 1 had a high risk for falls. During a review of Resident 1's Minimum Data Set ([MDS], a standardized assessment and care-screening tool), dated 1/17/2023, the MDS indicated Resident 1 was rarely/never able to understand or be understood by others. The MDS indicated Resident 1 required a one person assist for bed mobility, dressing, eating, toilet use, and personal hygiene. During a review of Resident 1's Change of Condition/Interact Assessment Form (COC), dated 3/5/2023 at 10:07a.m., the form indicated Resident 1 fell on [DATE] at 9 a.m., and sustained a head bump, skin abrasion and minimal bleeding. The COC indicated the back of Resident 1's head was cleaned with normal saline (a type of water used to clean wounds) and a pressure dressing applied. The COC indicated Resident 1 was transferred to a GACH. During a review of Resident 1's Physician order summary dated 3/6/2023, the Physician order Summary indicated Resident 1 returned to the facility after a fall with staples on the head. The order summary indicated to remove staples at the back of Resident 1's head in 7-10 day. During a review of the facility's follow up report dated 3/13/2023, the report indicated on 3/5/2023 at 9:43 a.m., during supervised care with a CNA, Resident had a witnessed fall when CNA 1 turned Resident 1 to her right side to finish cleaning Resident 1 while in bed. The report indicated Resident 1 was shaking and jerking, causing her to slide off the bed to the floor. The report indicated Resident 1 sustained a cut to the back of the head with minimal bleeding and was noted to have a spinal fracture (backbone fracture). The follow up report indicated Resident 1's fall was due to the resident's spontaneous movements evidenced by the shaking and jerky movement. During a review of Resident 1's GACH admission record, the admission record indicated Resident 1 was admitted to the GACH on 3/5/2023 and discharged on [DATE]. The record indicated Resident 1 was admitted for a closed head injury, scalp laceration (deep cut) and abrasion, after a fall. The report indicated Resident 1 had bilateral upper and lower extremities contractures. The record indicated staff was rolling Resident 1 over without the side rails up and Resident 1 rolled out of the bed and hit her head. The report indicated Resident 1 had a hematoma (a pool of clotted blood) to the occipital region (back of the head) of the scalp with 1.5-centimeter ([cm] unit of measurement) in length and 3 millimeters ([mm] unit of measurement) deep, and laceration that was bleeding in the center of the hematoma. The report also indicated Resident 1 had abrasions to the left hip and lower back. The report indicated two (2) staples were used to close the laceration. During a review of Resident 1's radiology ([Xray] process of taking pictures of body parts to diagnose and treat disorders such as features) of the anterior/posterior ([AP] front and back) and lateral aspects of the thoracic spine (the middle section of the spine, starting at the base of the neck to the bottom of the ribs.) dated 3/5/2023, the Xray report indicated Resident 1 had multiple compression fractures. During a review of Resident 1's readmission assessment dated [DATE] at 1:33 a.m., the admission assessment indicated Resident 1 was readmitted to the facility from the GACH on 3/6/2023. The admission assessment indicated Resident 1 had a laceration with two (2) staples at the back of the head from a fall. During an interview with Resident 1's Family (FM) 1, FM 1 stated on 3/5/2023, during morning care, Resident 1 slid off the bed to the floor. FM 1 stated there were supposed to be two staff assisting Resident 1 during care and not just one staff to prevent Resident 1 from falling and getting injured. FM 1 stated she had always seen two staff changing Resident 1 and did not understand why CNA 1 had to change Resident 1 alone. FM 1 stated, she was informed by the GACH that Resident 1 had two staples on the head to control the bleeding from the back of her head. FM 1 also stated Resident 1 sustained a fracture after the fall. During an interview with CNA 3, on 3/14/2023, at 3 p.m., CNA 3 stated Resident had spasms and jerky movements when repositioned. CNA 3 stated he always asked for help from other staff to reposition or bathe Resident 1. CNA 3 stated it usually required 3 staff members including a Restorative Nursing Assistant (RNA), and a Respiratory Therapist ([RT] certified medical professionals who treat problems with your lungs or breathing), because Resident 1 had a tracheostomy. During an interview with CNA 1, on 3/16/2023, at 11:30 a.m., CNA 1 stated on 3/5/2023 around 9 a.m., during morning care, Resident 1 who was laying on a low air loss mattress, suddenly started to jerk forcefully about two or three times but CNA 1 did not hold Resident 1 while the resident was jerking because she was on the opposite side of Resident 1's bed. CNA 1 stated she noticed Resident 1 was sliding off the bed to the floor. CNA 1 stated there were no floor mats on Resident 1's bedside. CNA 1 stated the side rails at the head of Resident 1's bed was up but there were no side rails at the foot of the bed to prevent Resident 1 from falling and getting injured. CNA 1 stated it was her first time assigned to care for Resident 1 and neither the Registered Nurse (RN) 1, Licensed Vocational Nurse (LVN) 1, nor outgoing CNA 2 gave her report on how to care for Resident 1. CNA 1 stated if she knew Resident 1 had sudden jerky movements, she would have asked for help from another CNA. During an interview with LVN 1, LVN 1 on 3/16/2023 at 11:50 a.m., stated she was not sure whether it was her responsibility to endorse residents' care to CNAs. LVN 1 stated she did not give CNA 1 any report on Resident 1 on 3/5/2023, before Resident 1 fell off the bed. LVN 1 stated if CNA 1 received a report, Resident 1's fall would have been avoided. During an interview with RN 1 on 3/16/2023, at 12:05 p.m., LVNs and RNs were supposed to endorse, update, and report any changes in residents' conditions to CNAs for care continuity. During an interview with the DON on 4/7/2023, at 10:12 a.m., the DON stated Resident 1 had a high risk for falls, was supposed to have a floor mat to ease the fall and prevent injuries in the event of a fall. The DON stated on 3/5/2023, when Resident 1 fell from the bed to the floor, there was no floor mat by the resident's bedside. The DON stated the Charge Nurse was supposed to update CNA 1 of Resident 1's care but the Charge Nurse did not. The DON stated Resident 1 was at risk for falls and require a two-persons assist with ADLs as needed. During an interview with the Clinical Manager (CM), on 3/16/2023, CM stated it was the responsibility of the LVN to orient all CNAs new to any assignment, so the CNAs were aware of how to take care of residents properly. During a review of the facility's undated Initial Fall Risk Assessment, the assessment indicated each resident will be assessed for falls, a plan of care developed, and its interventions implemented to prevent falls. The P&P indicated recommended interventions including the use of side rails, lower bed, and floor mats. During a review of the facility's undated policy and procedure (P&P) titled, Fall Policy and Procedures, the P&P indicated the facility will identify high risk residents for falls and minimize falls through appropriate interventions. The P&P indicated a comprehensive care plan will be developed to meet residents' specific needs. During a review of the facility's undated P&P titled Positioning/Repositioning Residents, the P&P indicated staff will provide repositioning as indicated. The P&P indicated staff will turn the resident onto the side, place the side rail up on one side as needed.

Based on interview, and record review, the facility failed to implement interventions to prevent the decline of residents who were confirmed with COVID-19 (a highly contagious virus that causes severe respiratory illness that affects the lungs and airways) in accordance with the facility's policies and procedures (P/P) and mitigation plan ((MP) a plan to prevent loss of life by failing to ensure the following: 1. Resident 1 had a change in condition (COC) of a decrease in oxygen (O2) saturations (amount of oxygen in the blood) and notify the family about the change in condition in a language that they understood to confirm their wishes for end of life. The facility did not honored Resident 1's Physician order [REDACTED]. stops beating and/or stops breathing, procedures are provided to keep them alive). 2. Follow the physician orders [REDACTED]. 3. Monitor Resident 3's COC's and vital signs (clinical measurements, specifically pulse rate (heart beats per minute), temperature, respiration rate (breaths per minute), and blood pressure (measures the force your heart exerts on the walls of your arteries each time it beats), every 4 hours as order by the physician after having a change in condition on [DATE]. Resident 3 had a second change in condition on [DATE] requiring a GACH transfer and expiring on [DATE] four (4) days after admission. 4. Physicians' orders and COVID care plans to monitor vital signs every 4 hours for COVID-19 confirm Residents 1, 2, 3, 4, 5, 6 and 7 were followed. 5. Ensure facility provided License Vocational Nurses (LVN) and Certified Nurses Assistants (CNA) to ensure coverage and continuity of care in the event of an emergency situation in the red zone (a designated area that restricts the movement of people who are confirmed with COVID-19) and COCs. These deficient practices resulted in the death of 3 of 12 residents (Residents 1, 2, and 3) who were confirmed with COVID-19 and had COCs and had the potential to lead to serious respiratory illness, hospitalization , and/or death of 78 residents, 24 in the green zone (area designated for people who do not have or have recovered from COVID-19), 45 residents in the yellow zone (an area that restricts the movement of people who might have COVID-19), and 9 residents in the red zone (separates and restricts the movement of people who are confirmed with a contagious disease). On [DATE] at 7 p.m., the administrator (ADM) and the Director of Staff Development (DSD), Director of Nursing (DON), and the Nursing Consultant (Consultant) were notified of the Immediate Jeopardy ((IJ) a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, a serious injury, harm, impairment, or death to a resident) was called for the facility's staff inability to follow and implement change of condition protocols to prevent the death of residents confirmed with COVID-19 in the facility. The facility ADM, DSD, DON, and Consultant were notified of the immediacy and serious non-compliance that threatened the 78 resident's health and safety by not following the facility's protocol. On [DATE] at 6 p.m., the ADM provided an acceptable plan of action (POA) as follows: 1. Residents 1, 2, 3, 4, 5, 6 and 7 are no longer at the facility. On [DATE] and [DATE], the DON notified the licensed nurses (Registered Nurses (RN) and LVNs) and the Respiratory Therapist ((RTs) a person trained to treat patients with lung diseases and condition) of the findings and gave in-services to the licensed nurses regarding following care plans and physician's orders [REDACTED]. During the in-service, the DON emphasized the importance of checking the vital signs as ordered by the physician and documenting the vital signs on the clinical records. On [DATE] and [DATE], the DON notified the licensed nurses (RNs and LVNs) and the RTs of the findings stated on the IJ template (document provided to the facility indicating the findings during the investigation to increase transparency and increase timeliness between providers, suppliers and laboratories) and gave an in-services to the licensed nurses and RTS regarding the COVID symptoms and vital signs monitoring as ordered by the physicians and as indicated on the care plans. During the in-service, the DON emphasized the importance of checking the vital signs as ordered by the physician and documenting the vital signs on the clinical records. On [DATE] the DON and the medical record designee checked all five residents in the red zone who have vital signs monitoring orders, to ensure that all the physician orders [REDACTED]. The DON and the RN supervisor will complete checking the vital sign monitoring for all current resident in two days starting [DATE] to ensure that no other residents will be affected by this deficient practice. The DSD and/or Infection Preventionist Nurse ((IPN) nurse in charge of infection prevention for the facility) will provide in-service to the registry staff (temporary staff provided by a contracted agency) prior to being assigned on any unit regarding following care plan and following physician's orders [REDACTED]. The RN supervisors for both the sub-acute unit (an area in the facility designated to the care for patients who require specialized and complex care) and Skill Nursing Facility (SNF) will check vital signs monitoring for all residents on each shift to ensure that all vital signs have been checked as ordered by the physicians and recorded timely daily for two months, and then weekly. The medical record audit vital signs monitoring daily for completion for 2 months, and then weekly, and present the findings to the DON for review and action as indicated. Effective [DATE], the DON/designee will check five residents' clinical records randomly daily for 2 months and then followed by ongoing weekly to ensure that the vital signs are checked as ordered. The DON will present the recapitulations of the findings to the monthly Quality Assurance ((QA) Quality management program) meeting for review and action as indicated until the problem has resolved. 2. On ,[DATE] and ,[DATE], the Administrator notified the licensed nurses (RNs and LVNs), the RTs and the social worker of the findings stated on the IJ template and gave an in-service regarding POLST policy and foreign language policy. During the in-service, the administrator explained the importance of: Honoring resident's wishes indicated on the POLSTs. Having staff who speaks resident's native language explain to the resident/responsible party to ensure that resident/responsible party understood their wishes. On [DATE], the administrator has made arrangement for an audio language services, to assist the facility as needed. The audio language instructions will be posted at each nursing station. On [DATE], the social worker identified a total of five residents/family members who do not speak English. The social worker and the activity director who speaks their native language contacted the five residents/family members to ensure that they understood their wishes as stated on the POLSTs. On [DATE] and [DATE], the administrator gave an in-service to the licensed nurses (RNs and LVNs), RTs and social worker regarding the policy and procedure for POLST and foreign language. During the in-service, the administrator educated the RNs, LVNs, RTs and social worker the importance of ensuring the resident/responsible part's wishes in the POLST are honored. Effective [DATE], the Minimum Data Set ((MDS) a standardized assessment and care screening tool) nurse will conduct interdisciplinary team ((IDT a group of health care professionals from diverse fields who work in a coordinated fashion toward a common goal for the resident) meeting for all residents upon admission, quarterly and as needed, to ensure that the POLSTs were updated and accurate based on the residents/responsible parties' wishes. The MDS nurse will present the recapitulations of the findings to the monthly QA meeting for review and action as indicated until the problem is resolved. 3. On [DATE] and [DATE], the DON notified the licensed nurses (RNs and LVNs) and RTs. of the findings stated in the IJ template and gave an in-service to them regarding the policy and procedure for change of condition. During the in-service, the DON explained the importance of following the physician's orders [REDACTED]. On [DATE], the DON has reviewed 5 hospital transfers that occurred in [DATE], to ensure that the nurses have followed the physician orders, managing the changes of condition properly including timely hospital transfer. Effective [DATE], the DON or designee will review acute changes of condition daily for 2 months and on-going to ensure the licensed nurses and the RTs will follow the physician orders, managing the acute changes of condition properly including hospital transfers. The DSD and Infection Control Preventionist will provide in-service education to the registry staff prior to utilization in any unit regarding following physician's orders [REDACTED]. The DON/designee will review clinical records for residents with acute changes of condition daily on an on-going basis to check if the condition was managed properly. Effective [DATE], the DON or designee will conduct daily clinical meeting with the RN on duty, to review residents with changes of condition on a daily basis, to ensure that the licensed nurses have followed the physician order, managed the change of condition properly including timely hospital transfers. The DON will present the recapitulations of the findings to the monthly QA meeting for review and action for 2 months or until the problem has resolved. 4. On [DATE] and [DATE], the DON notified the nurses (RNs, LVNs and RTs) of the findings stated in the IJ template and gave in-services regarding physician order [REDACTED]. During the in-service, the DON emphasized the importance of closely monitoring resident's change of condition and checking the vital signs as ordered by the physician and documenting the vital signs on the clinical records. On [DATE], the DON reviewed 5 clinical records of residents with changes of condition that occurred in [DATE], to ensure that no other resident will be affected by this deficient practice. On ,[DATE] and ,[DATE], the DON gave an in-service to the licensed nurses (RNs, LVNs and RTs) regarding physician order [REDACTED]. During the in-service, the DON emphasized the importance of closely monitoring resident's change of condition, checking the vital signs as ordered by the physician and documenting the vital signs on the clinical records promptly. Effective [DATE], the DON and/or designee will conduct daily clinical meeting with the RN on duty, review the change of condition management, to ensure that all vital signs ordered by physicians are completed and all changes of condition are managed properly. The DON will present the recapitulations of the findings to the monthly QA meeting for review and action as indicated until the problem is resolved. 5. On ,[DATE] and ,[DATE] the administrator and the DON notified the licensed nurses (RNs, IVNs and RTs) of the findings stated in the IJ template, and gave an in-service regarding staffing contingency plan including: use of registry, providing 12-hours shift, offering over time and meal break waiver program to ensure coverage and continuity of care in the event of emergency situation in the red zone. Such as overhead paging for code blue or related events in the red zone. On [DATE], the DON and DSD reviewed the nursing schedule for the month of January, to ensure enough staffing coverage and 24- hours licensed nurse coverage in the red zone always, always based on resident acuity. On [DATE], the Administrator will in-service the skilled nursing facility (SNF) staff about responding to the red zone call for assistance when needed. Post the medical director and DON cell numbers at each station for assistance. The DSD will provide orientation and education to the registry staff about their job description before utilizing them in the unit. Effective [DATE], the DON and the DSD will check the nursing schedule daily for two months to ensure enough staffing and 24- hour licensed nurse based on resident acuity. The DON and the DSD will present the recapitulations of the findings to the monthly QA meeting for review and action as indicated until the problem is resolved. On [DATE] at 12:10 p.m., the ADM, DON, DSD, RN Consultant, MR, SSD, were notified the IJ was lifted after the team conducted an onsite observation, interview and record review and verified and confirmed the POA was implemented as indicated. Findings: a) A review of Resident 1's Face Sheet (Admission Record) indicated Resident 1 was originally admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review for Resident 1's History and Physical (H/P), dated [DATE] indicated Resident 1 did not have the capacity to make decisions. The H/P indicated Resident 1 was a full code (if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provided to keep them alive). A review of Resident 1's document tittle, POLST, dated [DATE] indicated to attempt resuscitation in the event Resident 1 did not have a pulse or was not breathing. The POLST form indicated Resident 1 would receive full treatment to prolong life by all medically effective means. The form indicated only healthcare providers were able to make changes based on the resident's preferences and only the residents legally recognized decision maker, could request to modify the orders in collaboration with the physician, nurse practitioner, or physician assistant, based on the known desires of the resident. A review of Resident 1's Order Summary Report indicated an order started on [DATE] to monitor for symptoms of COVID-19 such as coughing, difficulty breathing, fatigue, chills, muscle or body ache, sore throat, new loss of taste or smell, headache, congestions or runny nose, diarrhea, nausea and vomiting. The order indicated to notify the physician and document on the nurses notes every shift if Resident 1 experienced any symptoms. A review of Resident 1's care plan titled, COVID-19 Pandemic, revised [DATE] indicated Resident 1 was at risk for shortness of breath ((SOB)-difficulty breathing), coughing, fever, nausea and sore throat. The goal was to keep Resident 1 free of any signs or symptoms of COVID-19. The care plan interventions included provide oxygen as needed and ordered, assess for SOB, irregular respiration, cough, weakness, activity intolerance, monitor oxygen saturations and respirations as needed and inform physician promptly. A review for Resident 1's care plan titled, COVID-19 Potential Exposure at Prior Setting, revised on [DATE] indicated to monitor and document vital signs every four hours including oxygen saturation (the amount of oxygen in the blood) and notify physician of any abnormal results. A review of Resident 1's Minimum Data Set ((MDS) dated [DATE] indicated Resident 1 had an order to attempt resuscitation/CPR, and full treatment to prolong/safe life. A review for Resident 1's Medication Administration Record (MAR) for the month of ,[DATE] indicated the following: On [DATE] at 8 a.m., and 12 p.m., no vital signs were documented. On [DATE] at 8 a.m.,12 p.m., and 8 p.m., no vital signs were documented. A review for Resident 1's document titled, Weights and Vitals Summary, indicated the following: On [DATE] at 7:28 a.m., decreased oxygen saturation (O2) of 88 percent (%) (normal reference range (NRR) ,[DATE]%) at room air (RA) and 24 breaths per minute ((bpm) NRR is ,[DATE]). On [DATE] at 12:40 a.m., O2 saturation of 88% on room air (RA), temperature of 93.7 degrees Fahrenheit ((F) unit of measurement (NRR- 98.6 F to 99 F)) and RR of 22 breaths per minute. On [DATE] at 12:18 a.m., O2 saturation of 90% on RA and RR of 2021 breaths per minute On [DATE] at 4:59 a.m., O2 saturation of 92% on RA and RR of 2021 breaths per minute On [DATE] at 7:17 p.m., O2 saturation of 92% on RA During a review for Resident 1's Change of Condition ((COC) internal communication tool), dated [DATE] at 10:16 p.m., indicated Resident 1 was lethargic (a condition marked by drowsiness and an unusual lack of energy and mental alertness), had a cough, and was on isolation precaution (precaution taken in health care to prevent the spread of an infectious agent from an infected patient) for COVID-19. The COC indicated on [DATE] at 9:30 a.m., Resident 1 was lethargic and had refused meals and medications, had an O2 sat at 91%, blood pressure at ,[DATE] millimeter of mercury ((mmHg) unit of measure), heart rate (number of times the heart beats in a minute)120 beats per minute and RR 26 breaths per minute. The COC indicated RN 1 notified Resident 1's Responsible Party (RP) of the COC and RP requested to place resident on comfort care, keep stable, and comfortable. During a review of Resident 1's Licensed Nurses' progress notes from [DATE] to [DATE] there was no documentation the facility staff monitored the resident's COC. During a review of Resident 1's COC, dated [DATE] at 7 a.m., indicated Resident 1 was noted to be lethargic with decreased O2 sat at 85%, respirations were labored, BP ,[DATE] mm/Hg, and temperature 96.8 F, RR 26 breaths per minute. The resident received five liters of oxygen via nasal cannula (a flexible plastic tube inserted into the nostrils of the nose to deliver oxygen). At 7:25 a.m. Resident 1 was found not breathing and pulseless. During an interview on [DATE] at 12:50 p.m., LVN 1 stated it was important to monitor and check vital signs as ordered by the physician to identify any changes in the residents' condition and provide prompt interventions for the care of the resident. During an interview on [DATE] at 2 p.m., the DON stated COCs included SOB, high temperature, and respiratory distress. The DON stated residents should have been monitored every hour or every 30 minutes during a COC and until the resident was stable. The DON stated the licensed nurses should monitor and document the resident's condition for 72 hours during the COC period in the progress notes. During an interview and concurrent record review on [DATE] at 2:33 p.m., the DON stated there was no other progress notes or a MAR for Resident 1 in [DATE]. The DON stated the documentation of the resident's vital signs were kept in the MAR. The DON stated when the residents had a change of condition the RN was responsible to assess the resident and notify the doctor. The DON stated residents were monitored for 72 hours when a COC was identified and every 30 minutes to an hour until the resident was stable. The DON also stated when Resident 1's oxygen level did not improve the facility staff should called 911 (a phone number used to call an emergency service) and document in the nurse's progress notes for 72 hours. The DON stated when the respiratory therapists help the residents in the SNF, the respiratory therapists have the nurses complete the documentation because the respiratory therapists do not have access to the SNF medical records. During an interview on [DATE], at 4:30 p.m., LVN 2 stated, We should monitor the vital signs and the signs and symptoms of COVID-19 in the red zone as ordered. We must also follow the physician orders [REDACTED]. During an interview on [DATE], at 4:34 p.m., LVN 7 stated when residents have a COC, the staff documented in the progress note and monitored the residents for 72 hours. LVN 7 stated the staff monitor residents for signs and symptoms of COVID-19 by checking the respirations, oxygen levels, checking for fever, chills, body aches, nausea, vomiting, diarrhea, cough, headache, and shortness of breath. LVN 7 stated the resident's vital signs were monitored every four hours. LVN 7 stated the supervisor, responsible party, and the physician are notified about the resident's change of condition During an interview on [DATE] at 12:26 p.m., the RP stated she spoke with a staff member on [DATE] who stated Resident 1 was fine, then on [DATE] at 7:30 a.m., she received a call from a nurse in the facility notifying her Resident 1 had died at 7:20 a.m. The RP stated she had told the facility staff and the physician she wanted Resident 1 to be resuscitated, intubated, and to provide with all the care needed if he was to be found pulseless. Resident 1's RP stated the facility did not provide translator services when she called Resident 1, even after asking on multiple occasions for a translator. During an interview on [DATE] at 12:12 p.m., LVN 6 stated she worked for a registry (an agency that provided temporary staff, by contract, to the skilled nursing facility). LVN 6 stated around 7 a.m., she was doing rounds in the red zone orienting an RN from the registry when they found Resident 1 lying in bed not breathing and immediately notified the RN supervisor. LVN 6 stated she did not know who was caring for Resident 1 prior to her shift. LVN 6 stated she did not know Resident 1's code status (the emergent treatment a person who heart stops beating and/or stops breathing will receive), but she thought it was not to resuscitate (save) because Resident 1 did not receive cardiopulmonary ((CPR) treatment measure to keep a person alive) resuscitation and 911 was not called. LVN 6 stated when residents are full code the facility staff call 911. LVN 6 stated when the residents have a change of condition, and she called for help, the facility staff took their time to respond to anybody in the red zone. During an interview on [DATE], at 12:34 p.m., the IPN stated the staff was not in-serviced about monitoring the residents' vital signs every four hours. During an interview on [DATE] at 12:42 p.m., Resident 1's physician 1 (Physician 1) stated he was not made aware Resident 1's RP changed the residents' resuscitation status. Physician 1 stated facility staff must communicate with the MD to ensure the changes to resident's code status, prior to making any changes. Physician 1 stated he was called by the facility after Resident 1 was found deceased . During an interview on [DATE] at 11:57 a.m., LVN 5 stated she talked to Resident 1's RP two days before Resident 1 was found unresponsive, RP requested to provide Resident 1 with pain medication to help him not suffer since he had COVID-19, but she never said to not provide CPR to the resident. LVN 5 stated Resident 1 was full code. LVN 5 stated she did not receive training prior to starting her assignment in the red zone and only receiving a check list for competency with minimal demonstration. LVN 5 stated she did not receive support by the facility's staff and was left in the red zone with no guidance, which made her job difficult. LVN 5 stated there was no clear instruction on what to do in case of an emergency and at times she was the only licensed nurse for 32 residents in the red zone and was unable to provide care to all the resident. LVN 5 stated she was sad to see no response for the resident's care from the in-house staff. During an interview on [DATE] at 10:22 a.m., LVN 11 stated the vital signs should be checked and COVID symptoms monitored as ordered and documented in the MAR. LVN 11 stated it was important to follow physician's orders [REDACTED]. LVN 11 stated COCs were monitored every ,[DATE] hours for ,[DATE] days depending on the condition of the resident. b) A review of Resident 2's Face Sheet indicated Resident 2 was admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 2's [DIAGNOSES REDACTED]. waste from the blood). During a review of Resident 2's MDS, dated [DATE] indicated Resident 2 was able to make himself understood and understand others. The MDS indicated Resident 2 was totally dependent on a one-person physical assist for bed mobility, transferring and personal hygiene. During a review of Resident 2's Order Summary Report indicated an order started on [DATE] to monitor for symptoms and signs of COVID-19 every four (4) hours and document temperatures above 99.6 F degrees, respiratory rate, and oxygen saturations. During a review of Resident 2's Order Summary Report indicated an order started on [DATE] to monitor for symptoms of COVID-19 such as cough, difficulty breathing, fatigue, chills, muscle or body ache, sore throat, new loss of taste or smell, headache, congestions or runny nose, diarrhea, nausea and vomiting. If any of the symptoms present, notify physician and document on the nurses notes every shift. During a review of Resident 2's Order Summary Report indicated an order started on [DATE] for [MEDICATION NAME] (medication use for relaxing muscles around the airways and open up the airways to make breathing easier) Nebulization (drug delivery device used to administer medication in the form of a mist inhaled into the lungs) Solution 2.5 milligrams/3 milliliters (a unit of measurement) one unit inhaled orally every four (4) hours as needed for SOB. During a review of Resident 2's MAR for [DATE] indicated Resident 2 did not received [MEDICATION NAME] when he experienced a COC of SOB on [DATE] at 9:20 a.m. During a review of Resident 2's care plan titled, COVID-19 Pandemic, dated [DATE] indicated Resident 2 was at risk for SOB, irregular respiration, cough, activity intolerance, fever, nausea and sore throat. The goal was to keep Resident 2 free of any signs or symptoms of COVID-19. The interventions indicated to apply oxygen as needed and ordered, assess for SOB, medication and breathing treatment as ordered, monitor oxygen saturations and respirations as needed and inform physician promptly. During a review of Resident 2's COC dated, [DATE] at 9:20 a.m., indicated Resident 2 had decreased oxygen saturation 85 % to 88% and was placed on three liters ((L) units of measurement) of oxygen via nasally. The COC indicated the plan of treatment was to monitor Resident 2's vital signs and transfer to the general acute care hospital (GACH) emergency room (ER). The COC indicated the following: At 9:20 a.m., Resident 2 complained of SOB, respirations 22 breaths per minute, and a non-breathable (non-rebreather mask is a medical device that helps deliver oxygen in emergency situations. It consists of a face mask connected to a reservoir bag that's filled with a high concentration of oxygen) oxygen mask administered 15 L. At 9:30 a.m., physician was notified and ordered to transfer Resident 2 to the GACHs ER for evaluation. At 9:40 a.m., Resident 2's oxygen saturation increased at ,[DATE] % an oxygen decreased to 10 L. At 10 a.m., RN 1 informed Resident 2 of physician 1 orders to transfer him to the GACHs ER for evaluation. At 10:22 a.m., Resident 2 was noted non-responsive, not breathing and unable to obtained vital signs and paramedics called. At 10:30 a.m., paramedics pronounced Resident 2 deceased . During an interview and review of Resident 2's COC, MAR and facility's policy and procedures (P/P), on [DATE] at 9:41 a.m., RN 1 stated Resident 2's primary physician ordered a transfer to the GACH on [DATE] at 9:30 a.m. for COC evaluation. RN 1 stated SOB was considered a COC requiring immediate attention. RN 1 stated not she did not call for Resident 2's transfer to the GACHs ER as ordered by the physician because she was preparing the transferring paperwork first. During an interview on [DATE] at 12:42 p.m., Resident 2's physician 1 stated he was notified on [DATE] of Resident 2's SOB. Physician 1 stated he gave an order to transfer the resident to the GACHs ER for further evaluation. Physician 1 stated the facility's licensed nurses were aware to transfer residents to the GACH via 911 (emergency number) when there is a critical change of condition such as the one Resident 2 experienced. During an interview on [DATE] at 12:56 p.m., RT 4 stated he was called to Residents 2's room. The RT 4 stated Resident 2 was complaining of SOB and not able to breathe. RT 4 stated he placed Resident 2 on a non-rebreather mask with 15 L to increase oxygen saturations from 85% to 100% and gave instructions to LVN 2 to monitor the resident closely due to desaturation (a decrease in oxygen levels in the blood). During an interview and review of the facility's P/P for COC, on [DATE] at 1:20 p.m., the DON stated based on the facility's P/P, COCs such as low oxygen, SOB, and unresponsiveness should be handled promptly. The DON stated RN 1 did not follow the facility's P/P and the physician orders [REDACTED]. During an interview on [DATE] at 2:2021 p.m., with CNAs 6 and 7 stated on [DATE] at approximately 9 a.m., Resident 2 was complaining of not being able to breathe. CNA 6 stated RN 1 went into the room and was cleaning Resident 2's wound instead of addressing his SOB. CNA 7 stated the facility staff did not care for the resident and ignore his call for help when Resident 2 was unable to breathe. During an interview on [DATE], at 3:15 p.m., LVN 2 stated Resident 2's oxygen level was low, and Resident 2 stated he could not breathe. LVN 2 stated RT 4 provided Resident 2 with oxygen and RN 1 notified the doctor. LVN 2 stated she did not document the monitoring conducted for Resident 1's COC. LVN 2 stated RN 1 waited to transfer Resident 2, but she was not sure why. LVN 2 stated Resident 2 was pale and stiff when the paramedics arrived at the facility. LVN 2 stated prior to the resident dying RN 1 clean Resident's 2 wounds and changed his bandage instead of taking care of the resident's SOB. During an interview on [DATE] at 6:30 a.m., LVN 2 stated CNAs 6 and 7 notified her of Resident 2 complaining of SOB. LVN 2 stated no breathing treatment was administered to Resident 2 as ordered by the physician 1 for SOB. During a review of RN 1's written declaration dated, [DATE] at 10:23 a.m. indicated the paramedics pronounced Resident 2 deceased . The RN 1 stated the paramedics did not performed resuscitation measures on Resident 2 beca (TRUNCATED)

Based on observation, interview, and record review, the facility failed to conduct an ongoing monitoring of the kitchen environment and maintain an effective ongoing pest control service to ensure the kitchen was free from cockroaches (small insects that cause a spread of bacterial infection) for 113 of 113 residents. This deficient practice placed the 113 residents at risk of vermin-borne diseases (diseases that result from an infection transmitted to human by pests, such as cockroaches, rats, and mice), such as gastroenteritis (an intestinal [an intestine is a long tube from the stomach to the anus] infection marked by watery diarrhea [feces or stool], stomach cramps, and nausea and vomiting). This deficient practice had the potential for the 113 residents to experience food infection from ingesting live bacteria, food intoxication from ingesting food containing toxins from bacteria, and disease transmission that can lead to life threatening complications and death. On 2/27/2020 at 5 p.m., the Department declared an Immediate Jeopardy (IJ, a situation in which the provider's non-compliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment or death of a resident) and notified the facility's Administrator and Director of Nutritional Services (DNS) of the findings. On 2/29/2020 at 6:49 p.m., the Department removed the IJ and notified the Administrator after verifying and confirming on-site that the facility had implemented the acceptable written plan of action as follows: 1. The facility enlisted a new pest control pest control service provider and initiated pest control services on 2/27/2020. 2. The Dietary Consultant provided an in-service on 2/27/2020 to dietary staff on importance of maintaining pest control program and sanitary meal preparation and will continue to educate dietary staff to maintain established standards a minimum of once a month or as needed that includes proper sanitary meal preparation and importance of maintaining pest control program. 3. The Maintenance Supervisor checked and sealed all visible wall and floor openings/cracks in the kitchen as needed for any entry points where the pest may penetrate, monitor pest control program, and provide the Administrator with a copy of the pest control report. 4. The Infection Control Preventionist will inspect the kitchen and facility surroundings and maintain a cleaning schedule to ensure a safe and sanitary food preparation and service by identifying any infection control issues and to report any negative findings immediately to the administrator. The facility will establish and maintain an effective pest control program by ensuring regular pest control services with a minimum of once a month or as needed. 5. The kitchen has been deemed non-operational, all personal items have been removed, pots and pans including all ware cleaned and sanitized, and all food items disposed while deep cleaning of the kitchen initiated immediately. 6. Temporary permitted meal service and vendor will be provided for the residents at the facility. 7. A new Dietary Supervisor has been in place effective immediately. 8. Facility residents have been notified of the facility kitchen's non-operation until further notice. Findings: A review of the facility's census report, dated 2/27/2020, indicated there were 113 residents residing in the facility. On 2/27/2020 at 12:52 p.m., the district office's Supervisor received an email notification from the Los Angeles County Department of Public Health (LAC DPH) Environmental Health Specialist (EHS, performs inspections of various facilities and properties to determine conformance with applicable State laws and County Ordinance Code sections). The EHS reported (in the notification), during the facility's kitchen inspection, on 2/27/2020 at 11:17 a.m., she found ten cockroaches in between shelves, pipes, and side panels of a steam table (in the dish washing area), and one dead cockroach on the floor next to the steam table. The report indicated there were six dead cockroaches inside the two cockroach glue traps/monitors on the steam table shelves and there was heavy (cockroach) fecal spotting around the steam table pipes. The EHS reported she closed the facility's kitchen at 12:52 p.m. On 2/27/2020 at 1:50 p.m., the surveyor and the EHS conducted a joint inspection of the facility's kitchen. During an observation, both the surveyor and the EHS, in the presence of the DNS found three live roaches underneath the kitchen steam table/sink (dishwashing area) near the pipes, one dead cockroach on the floor next to the sink, and three (3) dead cockroaches behind the kitchen's stove. A review of the EHS report titled, Retail Food Official Inspection Report, dated 2/27/2020 at 2:12 p.m., indicated the EHS conducted an inspection of the facility's kitchen, the EHS suspended the facility's kitchen's public health permit to operate, and the EHS directed the facility to discontinue operation of the kitchen at once (the kitchen was closed for operation). The EHS found the following during the inspection: a. 10 live cockroaches (8 brown banded and 2 German), all adults in between shelves, pipes and side panels of a steam table and one on the floor next to steam table. b. Two (2) dead adult cockroaches on the floor behind stove. c. Six (6) dead cockroaches inside two cockroach glue traps/monitors on steam table shelves, across the stove. g. Heavy (cockroach) fecal spotting around the steam table pipes On 2/27/2020 at 3:10 p.m., during an interview, the DNS stated a pest control company serviceman usually comes every month and had come to the facility last Tuesday 2/24/2020 and applied treatment (pesticides - any substance used to kill, repel, or control pests). On 2/27/2020 at 3:21 p.m., during an interview, the DNS stated new pest control is starting immediately to apply treatment. On 2/27/2020 at 3:55 p.m., during an interview, the Kitchen Staff (KS) stated she had been employed at the facility for [AGE] years and she was aware there were cockroaches in the kitchen. KS stated when she sees cockroaches, she will kill them (the cockroaches) and clean the area. KS staff stated she last saw a cockroach on 2/25/2020 near the kitchen doorway but she did not report it to anyone. KS stated although there is a schedule for the kitchen staff to follow and to know their assigned area to clean, she feels the problem is some of the staff do not follow the protocol of cleaning in the kitchen. On 2/27/2020 at 4:30 p.m., a review of the pest control company work order, dated 2/24/2020, indicated the pest control company provided treatments, on 2/24/2020 and 12/30/19. The target pests were ant, cockroach, and spider, silverfish, crickets, and earwigs. The instructions on the work order indicated to treat for control of cockroaches in the facility's kitchen and breakroom. On 2/27/2020 at 4:50 p.m., during a follow-up observation and inspection of the kitchen with the DNS and maintenance supervisor and a concurrent interview, the maintenance supervisor stated some open gaps (openings) around the pipes were found on the walls located underneath the steam table and on the walls behind the stove. The maintenance supervisor and pest control servicewoman were observed covering the gaps and other areas where cockroaches could possibly enter. A review of article from the Los Angeles County Department of Public Health titled, Effective Management of Cockroach Infestation, retrieved from publichealth.lacounty.gov/eh/docs/specializedvencor_managment, indicated the cockroaches may become pests in any structure that has food preparation or storage areas. They contaminate food and eating utensils, occasionally damage fabric and paper products, leave stains on surfaces, and produce unpleasant odors when present in high enough numbers. When cockroaches that live outdoors come into contact with human excrement [feces or stool] in sewers or with pet droppings, they have the potential to transmit bacteria that cause food poisoning if they enter into structures. A review of the Centers for Disease Control and Prevention, Guidelines for Environmental Infection Control in Health Care Facilities, updated on 7/2019 and retrieved from https://www.cdc.gov/infectioncontrol/guidelines/environmental/index.html, indicated the guidelines were recommendations for the prevention and control of infectious diseases that are associated with healthcare environments. Pest Control included cockroaches found in health-care facilities that can serve as agents for the mechanical transmission of microorganisms, or as active participants in the disease transmission process by serving as a vector (carrier that transfers an infectious organism from one host to another). A review of the facility's undated policy and procedure for Pest Control, in a joint effort to control the spread of pest (cockroaches) the nursing, housekeeping, dietary, and ancillary departments must work together to have an effective pest control management program. Chemical insecticides may be utilized for the control of small cockroaches, such as German or Brown Banded cockroaches, oriental cockroaches, or in any area where cockroaches are a problem.

Based on interview and record review, the facility failed to identify and evaluate accident risks and hazards and did not implement care plan interventions when necessary (monitor for adverse drug effects every shift, provide 1:1 visit as needed for behavioral management, and report to doctor any behavioral decompensation), for one of three sampled residents (Resident 1). For Resident 1, who was assessed as high risk for fall and injury due to disorientation, the facility did not provide supervision or promptly notify the physician for Resident 1's change in condition. This deficient practice resulted in Resident 1 exhibiting possible adverse reaction to medication and suffering a fall with injuries, which included a protrusion of bone (sticks outward from body) and a right displaced oblique fracture of the proximal femoral diaphysis (break in the thigh bone). Findings: A review of the Admission Face Sheet indicated Resident 1 was a [AGE] year old, admitted to the facility, on 8/5/15, at 4:30 p.m., with [DIAGNOSES REDACTED]., behavior, feelings and sense of well-being). A review of the Admission Assessment, dated 8/5/15, indicated Resident 1 was alert, required one-person assistance with transfers, walking, and personal hygiene. A review of the Fall Risk Assessment, dated 8/5/15, indicated Resident 1 was disoriented to person, place, and time at all times. This indicated a discrepancy when compared to the Admission Assessment. The Fall Risk Assessment indicated Resident 1 had a previous fall in the past 2 to 6 months and a total score of 8 or above represented a high risk for falls. Resident 1 scored 30. The fall risk assessment also indicated Resident 1 received 1 to 2 medications within the past seven days, but a review of the routine medication physician's orders [REDACTED]. A review of the Physician admission orders [REDACTED]. According to Drugs.com, 2016, for Remeron care givers should be alert to change in mood or symptoms, report any new or worsening symptoms to doctor, such as behavior changes, anxiety, hostility, aggressiveness or hyperactive (mentally or physically). Drugs.com indicated to call the doctor at once if you have racing thoughts, decreased need for sleep, unusual risk-taking behavior, agitation, or hallucinations. A review of the care plan, dated 8/5/15, indicated Resident 1 had a problem with psychotropic drug use (affecting mental activity, behavior, or perception, as a mood-altering drug) related to depression. The care plan indicated the resident would be free from adverse drug reactions and the nursing interventions included to monitor for adverse drug effects every shift, report to doctor any behavioral decompensation and adverse drug reactions timely. A review of the care plan, dated 8/5/15, indicated Resident 1 had potential for falls due to Alzheimer's disease / dementia, depression, and history of falls. The care plan included to monitor the resident's whereabouts so the resident remains safe and free from injuries such as falls. A review of the care plan, indicated Resident 1 had behavioral problems and to assess the potential cause or reason for her behavior, redirect the resident, provide safe environment, and monitor the resident to ensure safety. The care plan indicated Resident 1 had combative behavior and physical aggression due to Alzheimer's disease and the plan of care included utilizing alternative interventions such as redirection, providing 1:1 visit as needed for behavioral management, and notifying the physician for any behavioral decompensations. A review of the Psychotropic Assessment form, undated, indicated Resident 1 had [DIAGNOSES REDACTED]. The behavior problem, behavior exhibited, and behavior intervention remained blank. There were no team recommendations, no date of when physician notified, no documentation of the medications ordered, or if consent was obtained. During an interview, on 9/16/15, at 1:15 p.m., the certified nurse assistant (CNA 1) stated on 8/10/15, at the beginning of her shift at 11 p.m., she received Resident 1 in the wheelchair. CNA 1 stated Resident 1 remained in the wheelchair from 11 p.m. to 5 a.m., because there were unsuccessful attempts to put her back to bed. CNA 1 stated she had 16 residents that day and she was not Resident 1's one to one personal CNA. CNA 1 stated she was tired of telling the resident to sit back down and not get out from her wheelchair. Resident 1 was very agitated throughout the night and kept saying she needed the keys to her car. Resident 1 was very aggressive and tried to hit, scratch and swung her arms at CNA 1. CNA 1 stated Resident 1 would get a hold of the rails in the hallway and used it to get out of the wheelchair and move along the wall. CNA 1 stated she had to put the resident back into the wheelchair 4 times that night and asked the licensed vocational nurse (LVN 1) if he could give Resident 1 something for her agitation so they can put her back to bed. CNA 1 stated LVN 1 stated Resident 1 did not have anything for agitation and it was too late in the night to call the physician. At approximately 5 a.m., on 8/11/15, CNA 1 stated she was coming out of another resident's room when she saw Resident 1 getting out of her wheelchair again and ran to assist the resident, but it was too late. Resident 1 fell to the floor and as she was assisting the resident back into the wheelchair. Resident 1 continued to be very combative and aggressive towards her. A review of the Change of Condition / Interact Assessment Form, dated 8/11/15, indicated at around 5 a.m., Resident 1 was sitting in her wheelchair and stated she wanted to get her car keys to go home and check on her kids. Resident 1 then started to get out of her wheelchair and Certified Nurse Assistant 1 (CNA 1) assisted the resident to sit back down. The Change of Condition form indicated Resident 1 became aggressive, managed to get out of the wheelchair, attempted to walk, and fell on the floor. CNA 1 and licensed vocational nurse (LVN 1) assisted the resident back to the wheelchair while Registered Nurse 1 did a body assessment. Resident 1 was noted with protrusion of bone on right thigh and she was complaining of pain. A review of the CNA Assignment Sheet, dated 8/10/15 to 8/11/15 was conducted with the director of nursing (DON), which indicated CNA 1 was assigned 16 residents and she was not Resident 1's one on one personal CNA. During an interview, on 9/16/15, at 2 p.m., LVN 1 stated at the start of his shift at 11 p.m., Resident 1 was already restless and screaming. He stated, It was like she was hallucinating and saying she needed her keys to drive home, and that she needed to be home to take care of her little kids. LVN 1 stated he tried to get Resident 1 to go back to bed, but it only made her more angry. Throughout the night, Resident 1 continued to scream and shout, and he made more than 3 to 4 attempts to put her back to bed. LVN 1 stated Resident 1 kept getting up from her wheelchair. LVN 1 stated he wished CNA 1 was the resident's one to one, but she had 16 other residents to take care for that night. During an interview, on 9/16/15, at 2:30 p.m., with LVN 1, he stated it was late at night and he did not want to call the physician regarding Resident 1's behavior. He stated he was the medication nurse and he was busy, so he could not always observe Resident 1. During an interview, on 9/16/15, at 3 p.m., registered nurse 1 (RN 1) stated she was aware Resident 1 was agitated and being aggressive towards staff, but she did not call the physician because it was late at night. A review of the facility's undated policy and procedure titled, Change of Condition, indicated when a resident condition changes for any reason the facility would implement proper care and follow-up by using a monitoring system using a Nursing 24 Hour Report Form. The licensed nurses would ensure proper assessment and documentation changes by notifying the physician and the family. The physician must be called promptly when the resident's condition changes such as agitation, anxiety, or refusing care. During an interview with the director of nursing (DON), on 9/16/15, at 1:55 p.m., she stated she could not provide any documentation the facility staff implemented the above policy. A review of the care plan, dated 8/6/15 (five days prior to the fall) indicated Resident 1 was at risk for spontaneous pathological fracture related to osteoporosis (bones become increasingly brittle and subject to fracture) and osteopenia (a condition of bone in which decreased density, or reduced mass occurs). The plan of care included providing a safe and hazard free environment, assist with transfers and ambulation, and medicate as needed. A review of the Licensed Nurses Notes, dated 8/11/15, indicated Resident 1 was transferred to the general acute care hospital (GACH), on 8/11/15, at 7:25 a.m., via ambulance where upon an x-ray on the right hip at 9:54 a.m. disclosed a displaced oblique fracture of the proximal femoral diaphysis (break in the right thigh). During an interview with the DON, on 9/16/15, at 3:55 p.m., she stated the facility staff should have notified the physician of Resident 1's agitation and aggressive behavior, and to obtain appropriate intervention such as medication if indicated. The DON stated the facility staff should have closely monitored Resident 1 during this time for her safety. A review of the facility's policy and procedure, dated 2/13/13, titled Job Description, indicated it was the responsibility of the licensed nurse to assess a resident's change in condition, make ongoing assessment and interventions related to the change of condition, monitor and document the resident's behavioral change and provide interventions and documentation as indicated.