Every finding on record at Westwood Post Acute Care

Based on observation, interview, and record review, the facility failed to provide adequate supervision in accordance with the resident's assessed needs and individualized care plans (CP- a document outlining a detailed approach customized to an individual resident's need and care) for one of three sampled residents, Resident 3. This deficient practice resulted in Resident 3 walking out of the room unsupervised and sustain a fall with injury requiring a surgical intervention on 6/17/2026. During a review of Resident 3's admission Records, Resident 3 was originally admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis including muscle weakness, mild cognitive impairment (ability to acquire and understand knowledge to make decisions), bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), unspecified dementia (a brain disorder that affects a person's ability to carry out daily activities and that may cause changes in mood and personality), history of falling. During a review of Resident 3's History and Physical (H&P) dated 6/22/2026, the H&P indicated, Resident 3 had a history of neurocognitive (disorder in mental abilities caused by a physical brain issue, such as an injury, a stroke, or a disease) disorder due to Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements). The H&P indicated Resident 3 was sent to General Acute Care Hospital (GACH) after an accidental fall onto his left shoulder resulting in a left humeral neck fracture (a broken upper arm bone near the shoulder joint) and underwent open reduction internal fixation (ORIF- a two-step surgery when a surgeon opens the skin and put displaced bone pieces back by attaching metal plates and screws or rods to hold the bone) on 6/17/2026. Resident 3 has the capacity to make medical decision making. During a review of Resident 3's Minimum Data Set (MDS- a standardized resident assessment tool), dated 6/25/26, Resident 3 had moderately impaired cognitive skills (mental action or process of acquiring knowledge and understanding) to make decisions on selfcare activities. The MDS indicated Resident 3 was dependent on staff for mobility, uses a walker and wheelchair for ambulation. During a review of Resident 3's CP, titled Resident had an actual witnessed fall with poor balance, unsteady gait related to Parkinson's, non-compliant with assistance from staff, dated 6/15/2026, the CP goal indicated, Resident 3 to ambulate safely with assistive devices and will agree with supervision and will remain fall free during stay through review date. The CP intervention indicated, reinforce use of assistive device during ambulation, supervise or provide standby assistance during outdoor ambulation as indicated, constant supervision. During a review of Resident 3's Fall Risk Evaluation dated 6/16/2026, Resident 3 had two or more falls in the past three months, intermittent confusion, balance problem while walking, requires use of assistive devices (cane, wheelchair, walker, furniture). During an observation on 7/7/2026 at 11:47 AM, Resident 3 was observed accompanied by a medical sitter (companion, patient observer, or safety attendant) in the resident's room. During an interview on 7/7/2026 at 11:47 AM Resident 3, Resident 3 reported, he had a fall and injured the left shoulder. Resident 3 was sitting at the patio, has not been observed by staff, and does not recall fall incident and details. During an interview on 7/7/2026 at 12:02 PM with Certified Nursing Assistant (CNA) 1, CNA 1 stated, Resident 3 requires a one-to-one observation and close monitoring for fall risk. CNA 1 state, Resident 3 is not observed by a medical sitter when sitting at the facility's patio. During an interview on 7/7/2026 at 12:37 PM, with Licensed Vocational Nurse (LVN) 2, LVN 2 stated, Resident 3 is a fall risk and unable to keep balance during ambulation. Resident 3 can benefit from constant supervision to prevent falls. During an interview on 7/7/2026 at 1:36 PM with assistant director of nursing (ADON), the ADON stated, Resident 3 had a fall on 6/15/2026 around 8 PM while sitting at the patio and injured shoulder. ADON stated, Resident 3 was not supervised by staff while sitting at the patio. ADON acknowledged Resident 3 was supposed to be supervised for fall while sitting at the patio due to a known history of fall risk. During an interview on 7/9/2026 at 2:33 PM with the director of nursing (DON), the DON stated, Resident 3 is a fall risk and is on continuous staff supervision. The DON stated, a licensed staff could not locate Resident 3 in his room between 7:45 to 8 PM on 6/15/2026. Resident 3's sitter did not report to licensed staff Resident 3 left his room. Resident 3 sustained a fall and shoulder injury. The DON further stated, We did not educate the sitter to notify charge nurses when the resident leaves the room. During a review of the facility's Policy and Procedures (P&P) titled Fall Prevention and Management Program revised on 6/10/2026, the P&P indicated, A resident who sustains multiple falls as defined as more than one fall in a day, week or month, will be considered a high risk to fall and as a result may sustain a major injury. These residents may require more frequent observation of activities and whereabouts, may require a structured environment or routine.

Based on observation, interview and record review, the facility's failed to:1. Implement standard precautions (a set of infection control practices used to prevent the transmission of diseases) in the provision of care for one out of one sampled resident (Resident 96).2. Check and the temperatures for two of two facility laundry dryers (Dryer 1 and Dryer 2) to ensure the dryers temperature was at 180 degrees according to the facility's policy and procedures (P&P) titled, Laundry - Sorting, Washing & Drying. The facility's census was 84 residents.3. Ensure one of one sampled resident (Resident 82's) nasal cannula (NC- flexible plastic tubing used to deliver oxygen directly through the nose) was not left on the floor. Resident 82 was dependent on oxygen therapy.These deficient practices placed residents at increased risk of acquiring and transmitting infections/pathogens (a virus or bacteria that enters your body and causes illness or disease) to residents, staff and visitors. Findings: 1. A review of Resident 96's admission record indicated the resident was admitted to the facility on [DATE] with diagnoses that included traumatic subarachnoid hemorrhage (bleeding into the subarachnoid space—the area between the brain and the tissues that cover it—caused by physical head trauma), fracture of the base of skull (break in one or more of the bones forming the floor of the enclosed cranial cavity), type 2 diabetes mellitus (a disease that occurs when your blood glucose, also called blood sugar, is too high), hypertension (high blood pressure), hyperlipidemia (excess of lipids, circulating in your blood.), muscle weakness and history of falling. A review of Resident 96's history and physical (H&P) dated 6/14/2026 indicated Resident 96 has the capacity for medical decision making. During a facility tour observation on 6/15/2026 at 9:03am, a urinal (a portable, handheld vessel used by bedridden patients to collect urine) with 500 milliliters of urine like liquid was observed on Resident 96's bedside table next to Resident 96's fast food from El [NAME] loco. During an interview on 6/15/2026 at 9:08am, Licensed Vocational Nurse (LVN) 2 stated the urinal had urine and should not be placed next to Resident 96 food because of potential exposure to infection from (harmful microorganisms (such as bacteria, viruses, fungi, or parasites) in the body). During an interview on 6/18/2026 at 5:45pm, Director of Nursing (DON) stated urinal placed by Resident 96's food puts the resident at risk for possible cross contamination and infection. A review of the facility's policy and procedures (P&P) titled Infection Control-Policies & Procedures dated 6/10/2026 indicated, The facility's infection control policies and procedures are intended to facilitate maintaining a safe sanitary and comfortable environment and to help prevent. transmission of diseases and infections. 2. During a concurrent observation and interview on 6/16/2026 at 12:24 P.M. with the Maintenance Supervisor (MS) in the laundry room, the manufacturer thermometer indicated below 40 degrees Fahrenheit (a unit of measurement for temperature) for Dryer 1 and Dryer 2. The MS confirmed and stated, both dryer thermometers are broken (not functional). The MS stated he did not know when the thermometers broke. During a review of the facility's Laundry Temperature Schedule (LTS) log for Dryer 1 and Dryer 2, dated June 2026, the laundry temperature log indicated a handwritten temperature of 180 degrees was documented every hour from 6am to 8pm from 6/1/2026 to 6/14/2026 for Dryer 1 and Dryer 2. During a concurrent interview and record review on 6/16/2026 at 12:31 P.M. with the MS, Laundry Staff (LS), and Laundry Technician (LT), the facility's LTS log, dated June 2026 was reviewed. The MS, LS, and LT all confirmed and stated, 180 degrees for the laundry Dryers 1 and 2 is not correct because the thermometers for the dryers are showing below 40 degrees Fahrenheit. The MS stated, if the temperature is too hot, this can cause a fire and place the residents' safety at risk. If the temperature is too low, this can grow bacteria or viruses and make the residents sick. During an interview on 6/18/2026 at 9:56 A.M. with the Registered Nurse Supervisor (RNS) 1, RNS 1 stated, the facility laundry temperatures for the washer and dryer need to be hot enough to eradicate (eliminate) bacteria (a microscopic living organism that exists everywhere) and viruses (a tiny germ that causes illness). RNS 1 stated if the temperature is not hot enough, this can potentially cause further infection and result in more residents becoming sick. During an interview on 6/18/2026 at 4:56 P.M. with the DON, the DON stated, it is important for the facility laundry temperatures for the dryer and washer to stay hot to decrease the risk of contamination (presence of a harmful or unwanted substance). The DON stated this can potentially result in the residents becoming sick. During a review of the facility's P&P titled, Laundry – Sorting, Washing & Drying, dated 1/1/2012, indicated, When drying the laundry, the machine is set for the correct temperature and drying time for the load. During a review of the facility's manufacturer's dryer manual titled, Tumble Dryers, dated 12/2025, indicated the following: Ensure all guards and panels are properly installed. Medium setting is Temperature 180 degrees Fahrenheit. Ensure temperature sensors are free of lint. To ensure proper operation, the fire suppression system must be tested every month. If the fire suppression system failed the maintenance test, do not operate the tumble dryer. 3. During a review of Resident 82's admission Record (AR), the AR indicated the facility admitted Resident 82 on 5/28/2026 with diagnoses that included but not limited to chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing) and congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling). During a review of Resident 82's Minimum Data Set (MDS – a resident assessment tool) dated 6/4/2026, the MDS indicated Resident 82 had moderate cognitive (the mental ability to make decisions of daily living) impairment. The MDS indicated Resident 82 needed supervision/touching staff assistance with eating and oral hygiene, partial/moderate staff assistance with activities of daily living (ADL- toileting hygiene, upper body dressing, personal hygiene, sit/stand, toilet transfer, chair/shower and chair/bed transfer) and maximum staff assistance with shower/bath, lower body dressing and walking 10 feet. During an observation on 06/16/2026 at 8:43 am to 8:55 am, in Resident 82's room, Resident 82's nasal cannula (NC- flexible plastic tubing used to deliver oxygen directly through the nose) was observed on the floor. During an interview on 06/16/2026 on 8:47 AM, with Licensed Vocational Nurse (LVN) 3, LVN 3 stated, Nasal Cannula on the floor can be an infection issue. During an interview on 06/17/2026 on 1:52 pm, with the DON, DON stated, Anything can happen, there are many potentials in this situation. DON refused to say anything else regarding the situation. During the review of Resident 82's care plan (CP) untitled dated 5/28/2026, indicated that Resident 82 is dependent on supplemental oxygen (medical treatment that delivers concentrated oxygen to lungs when body can't get enough naturally) r/t (related to) chronic respiratory and/or cardiopulmonary (relating to the heart and lungs) condition, resulting in risk for hypoxia (a medical condition where your body, or a specific part of your body, does not get enough oxygen to function properly), decreased activity tolerance and respiratory compromise. The CP interventions indicated to ensure oxygen equipment is properly functioning and secure and positioned correctly. During a review of the facility's policy and procedures (P&P) titled, Infection Control – Policies and Procedure dated 6/10/2026, the P&P indicated, Purpose: To provide infection control policies and procedures required for a safe and sanitary environment. Policy: The Facility's Infection Control policies and procedures are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections.

Based on observation and interview, the facility failed to ensure staff completely closed the bedside privacy/dignity curtain during care that fully closed provide privacy and maintain the a resident's dignity (basic right to be valued, respected, and treated as a human being) during activities of daily living care (ADL - activities such as bathing, dressing and toileting a person performs daily) for one of one sampled resident (Resident 41) according to the facility's policy and procedures (P&P) tiled Resident Rights -Quality of Life, reviewed and approved 6/10/2026. A a result, Resident 41's private parts were visible from the hallway violating Resident 41's rights to be treated with privacy and dignity with the potential for the resident to suffer lowered self esteem and feel undignified.Findings: A review of Resident 41's admission Record indicated the facility admitted Resident 41 on 11/4/2025 with diagnoses including stroke (loss of blood flow to a part of the brain), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and hypertension (HTN - high blood pressure). A review of Resident 41's Minimum Data Set (MDS - resident assessment tool) dated 5/30/2026, indicated Resident 41 is cognitively intact (when a person has no trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 41 is dependent on staff with ADL care. During an observation on 6/15/2026, at 9:16 A.M., in Resident 41's room, Certified Nursing Assistant (CNA) 1)was seen providing ADL care to Resident 41 and the residents private parts were exposed and visible from the hallway. On further observation, the privacy/dignity curtain at the foot of the bed was missing, During an interview on 6/15/2026, at 9:17 A.M., with CNA 1, CNA 1 stated that CNA 1 was providing care to Resident 41 while the bed privacy/dignity curtain at the foot of the resident's bed was open and because there is no curtain provision to cover that part (foot of the bed). CNA 1 stated that the resident's privacy/dignity curtain only covers alongside the bed and does not cover the foot side of the bed. CNA 1 stated that there should be a curtain covering along the foot side of the bed to provide the resident with privacy. During an interview on 6/18/2026, at 1:53 P.M., with the Director of Nursing (DON), the DON stated that facility expectation is to provide and maintain Resident 41's dignity at the bedside during ADL care by making sure that the privacy/dignity curtain in closed all the way and that no part of the resident's body is exposed. The DON stated that the facility needs to make sure that the privacy/dignity curtains are provided and are fully functional, provide the resident with full coverage from wall to wall. The DON stated that, if the dignity curtain does not fully cover the resident's bed, resident's body parts may be exposed and making the resident feel undignified. A review of the facility's P&P titled tiled Resident Rights -Quality of Life, reviewed and approved 6/10/2026 indicated that,PurposeTo ensure that each resident receives the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care.PolicyEach resident shall be cared for in a manner that promotes and enhances the quality of life, dignity, respect, individuality and receives services un a person-centered manner, as well as those that support the resident in attaining or maintaining his/her highest practicable well-being.Procedure. X. Facility Staff promotes, maintains, and protects resident privacy, Including body privacy, whenassisting with personal care and during treatment procedures.XI. Demeaning practices and standards of care that compromise dignity are prohibited. Facility Staffpromote dignity and assist residents as needed by:.XII. Facility Staff treats cognitively Impaired residents with dignity and sensitivity.

Based on observation, interview, and record review, facility failed to ensure the residents and/or responsible party (RP) had the ability to consent to use of psychoactive medication (a drug that changes brain function and results in alterations in perception, mood, consciousness or behavior) treatment prior to initiating treatment for two of three sampled residents (Resident 7 and 9). This deficient practice violated the residents' right to make an informed decision regarding the use of psychoactive medications for Residents 7 and 9.Findings: A review of Resident 7's admission Record indicated the resident was admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses that include but are not limited to Major depressive disorder (MDD-a persistently depressed mood or loss of interest in activities, lasting at least two weeks), schizophrenia (a severe and serious ongoing brain disorder that disrupts a person's ability to think logically, manage emotions, relate to others, and perceive reality), difficulty walking, heart failure (a chronic clinical syndrome where the heart cannot pump enough oxygen-rich blood to meet the body's needs.), chronic obstructive pulmonary disease (COPD- progressive lung disease characterized by persistent and often worsening airflow limitation, which makes it hard to breathe), anemia (blood disorder in which the blood has a reduced ability to carry oxygen to the rest of the body), anxiety disorder (health condition characterized by persistent, excessive, and disproportionate fear or worry in response to everyday situations), and repeated falls. A review of Resident 7's History and Physical (H&P) dated 11/30/2025 indicated Resident 7 has the capacity to make medical decisions. A review of Resident 7's Minimum Data Set (MDS - a resident assessment tool, and care-screening tool) dated 3/15/2026, indicated Resident 7 had moderate cognitive (the mental ability to make decisions of daily living) impairment. The MDS indicated Resident 7 required substantial /maximal assistance with eating, required staff assistance with oral hygiene, toileting hygiene, upper body dressing and personal hygiene, shower/bathe self, lower body dressing, and for putting on/taking off footwear. A review Resident 7's Physician Order Summary Report dated 6/18/2026, indicated a medication order to give Resident 9 Haloperidol (medication to treat mental illness) oral tablet 10mg by mouth two times a day for schizoaffective disorder manifested by (m/b) visual hallucinations (is a false perception of objects or events involving your senses: sight, sound, smell, touch and taste), seeing bugs crawling all over the resident's body, give at 9 am (morning) and HS (hour of sleep) at 9 pm effective 6/10/2026 at 9 pm. A review of Resident 7's Psychotherapeutic Drug Informed Consent (PDIC), indicated that a physician obtained a informed consent for Haloperidol on 3/31/2026. The same PDIC indicated that two (2) licensed nurses with their names and signatures, signed the PDIC on 3/8/2026. The PDIC sections for Resident 7's name and signature section was hand written, unable to sign. During a telephone interview on 6/8/2026 at 11:27am with Resident 7's responsible party (RP)/emergency contact, RP stated that RP had never received a call from the facility requesting for consent authorization for Resident 7 due to Resident 7's inability to give consent. A review of Resident 9's admission Record indicated the resident was admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses that include but are not limited to encephalopathy(disturbance, damage, or malfunction of the brain that alters its function or structure), type 2 diabetes (metabolic disorder leading to persistently high blood sugar (glucose) levels), difficulty walking, schizophrenia, polymyalgia rheumatica (inflammatory condition affecting the joints, muscles, bones, and connective tissues), COPD, and muscle weakness. The same admission record indicated that Resident 9 was self-responsible and did not have a next of kin and/or power of attorney listed. A review of Resident 9's H&P dated 5/22/2026, indicated Resident 9 can make needs known but cannot make medical decisions. A review of Resident 9's MDS dated [DATE], indicated Resident 9's cognition was severely impaired. The MDS indicated Resident 9 required setup or clean-up for eating and oral hygiene, required supervision for toileting hygiene, upper body dressing and personal hygiene, required partial/moderate assistance for shower/bathe self, lower body dressing and putting on and/or taking off footwear. A review of the Resident 53 Physician Order Summary Report dated 6/18/2026, indicated to give Resident 53 Escitalopram Oxalate (medication to treat depression) oral tablet 5mg, give 1 tablet by mouth one time a day for depression (m/b) verbalization of worriedness about health verbalization about health condition as evidenced by frequently expressing fear of worsening health. A review of Resident 53's informed consent dated 5/6/2026, indicated a physician obtained informed consent for Escitalopram Oxalate, The same PDIC indicated that two (2) licensed nurses with their names and signatures, signed the PDIC on 5/6/2026. The PDIC sections for Resident 9's name and signature was hand written, gave verbal consent. During an interview on 6/18/2026 at 5:45 pm with the Director of Nursing (DON), the DON stated, It is important to obtain psychotherapeutic drug informed consent because it (psychotherapeutic drug) is a chemical restraint. The DON stated that if a resident is unable to sign/give consent, then the consent can be obtained from the resident's family representative. Additionally, the DON sated that, if a resident is self-responsible and has no family representative and/or power of attorney (POA), the facility will form a bioethics committee (is an advisory body within healthcare institutions that navigate and offer assistance in addressing ethical issues that arise in patient care and facilitate sound decision) to protect patient rights, and mediate conflicts between medical teams and surrogates (to act on behalf). A review of the undated facility policy and procedures (P&P) titled Informed Consent dated 6/10/2026, indicated, It was the policy of the facility to involve residents in their care decisions by facilitating information and obtaining consent for the use of psychotropic drugs .The attending physician determines the capacity of the resident to make decisions and give informed consent on his/her history & physical. If the Resident is determined to not have the capacity to make informed decisions, a surrogate decision-maker is identified.

Based on observation and interview, the facility failed to ensure one of one sampled residents (Resident 88) room was free of clutter, safe, clean, comfortable, homelike environment according to the facility's policy and procedure (P&P) titled Resident Rooms and Environment reviewed and approved 6/10/2026. Resident 88's room floor was cluttered with multiple several clothing and stuffed animal on the floor. This deficient practice resulted in an environment that was unsafe, unclean, uncomfortable, not homelike and had the potential for infection.Findings: A review of Resident 88's admission Record indicated the facility admitted Resident 88 on 11/28/2023 with diagnoses including epilepsy (a brain disorder that causes a person to have repeated, unprovoked seizures), atrial fibrillation (Afib - a condition where the heart's natural electrical signals get confused. out of control instead of beating smoothly), and fracture (a broken bone) of the femur (thighbone). A review of Resident 88's Minimum Data Set (MDS - a resident assessment tool) dated 3/3/2026, indicated Resident 88 is cognitively intact (when a person has no trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life) and was independent with Activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily) care. During a concurrent observation and interview with Resident 88 on 6/15/2026, at 9:34 A.M., Resident 88's room was observed with multiple cluttered clothing and a big stuffed [NAME] mouse doll approximately 3 feet tall on the floor and on the nightstand. Resident 88 stated that she has asked multiple facility staff to give her containers to store her belongings that are on the floor by her bedside for months and nothing has happened. During a concurrent interview and record review on 6/16/2026, at 11:06 A.M., with Registered Nurse Supervisor (RNS) 1, a picture of Resident 88's room with the multiple cluttered items that included clothing and a stuffed big [NAME] mouse doll about 3 feet tall that were seen on the floor and on the nightstand was reviewed. RNS 1 stated that Resident 88's clothing and/or items need to be in the resident's closet or the nightstand and should not be left on the floor or cluttered. RNS 1 stated leaving the residents belonging on the floor is a fire hazard, the clutter may cause the resident to fall, trip over, injury themselves and a risk for infection. The residents room/facility need to maintain a home-like environment and hazard free. During an interview, on 6/18/2025, at 2:14 P.M., with the Director of Nursing (DON), the DON stated resident's clothing/belongings need to be stored in the residents' closet, not on the floor for infection control and to maintain a homelike environment for the residents. A review of the facility's P&P, titled Resident Rooms and Environment reviewed and approved 6/10/2026, indicated that:PurposeTo provide residents with a safe, clean, comfortable and homelike environment.PolicyThe Facility provides residents with a safe, clean, comfortable, and homelike environment. Facility Staff will provide residents with a pleasant environment and person-centered care that emphasizes the residents' comfort, Independence, and personal needs and preferences. To this end, the Facility encourages residents to use their personal belongings to the extent possible.ProcedureI. Facility Staff aim to create a personalized, homelike atmosphere, paying close attention to thefollowing:A. Cleanliness and order

Based on observation, interview, and record review, for three of eight sampled residents (Residents 72, 74, and 78), the facility failed to implement its policy and procedures (P&P) titled, Grievances and Complaints, with a review date of 6/10/2026. Inform/educate the residents that the Administrator (Admin) is the facility's appointed Grievance Officer (GO - a resident advocate who handles residents/complaints, ensures the residents rights are respected, and investigates the residents' concerns without fear of retaliation) to oversee the facility grievance process (a formal complaint that is investigated by the facility). Address Residents 72, 74, and 78's concerns and grievances. This failure resulted in: Resident 72 felt scared of backlash (a strong, usually negative reaction by a large group of people to a change, event, or decision) if the resident made a complaint. Resident 74 waiting all day/several hours for staff to answer the call light. Resident 78 having difficulty moving in and out of his bathroom with the wheelchair (WC). Findings: During a review of Resident 72's admission record, dated 4/26/2026, indicated Resident 72 was admitted to the facility on [DATE] with diagnoses but not limited to hemiplegia (severe or complete loss of voluntary movement on one side of body), diabetes (a disorder characterized by difficulty in blood sugar control), and end stage renal disease (ESRD- irreversible kidney failure). During a review of Resident 72's Minimum Data Set (MDS- a resident assessment tool), dated 6/5/2026, indicated Resident 38 was cognitively intact (mental ability to make decisions). During a review of Resident 78's admission record, dated 4/30/2026, indicated Resident 78 was admitted to the facility on [DATE] with diagnoses but not limited to fracture of right femur (thigh bone), polyneuropathy (multiple nerves outside brain and spinal cord are damaged), and depression (a serious mood disorder that causes persistent sadness). During a review of Resident 78's MDS, dated [DATE], indicated Resident 78 was cognitively intact. During a review of Resident 74's admission record, dated 2/19/2026, indicated Resident 74 was admitted to the facility on [DATE] with diagnoses but not limited to fracture of vertebrae (one of the bones of spinal column), depression, and hypertension (high blood pressure). During a review of Resident 74's MDS, dated [DATE], indicated Resident 74 was cognitively intact. During an interview on 6/17/2026 at 10:44 A.M. with Resident 72, Resident 72 stated, I am scared of backlash (a strong, usually negative reaction by a large group of people to a change, event, or decision) if I make a complaint. During an interview on 6/17/2026 at 10:44 A.M. with Resident 74, Resident 74 stated, I have waited all day for staff to answer the call light, sometimes for hours. During an interview on 6/18/2026 at 10:58 A.M. with Resident 78, Resident 78 stated, I have difficulty moving in and out of the bathroom with my wheelchair. I told a couple of nurses (unable to recall names), and they (facility) didn't offer to change the room. During the Residents Council Meeting interview on 6/18/2026 at 10:13 A.M. with Residents 72, 74, and 78 at the Resident Council Meeting, all three residents stated that they do not know what a grievance is and would have filed a grievance if they had known the grievance process, this is frustrating. During an interview on 6/18/2026 at 9:08 A.M. with the Assistant Director of Nursing (ADON), the ADON stated if a resident is not aware of the facility's grievance process, then the residents can feel frustrated and their needs unmet. During an interview on 6/18/2026 at 9:56 A.M. with the Registered Nurse Supervisor (RNS) 1, RNS 1 stated the Social Services Director (SSD) is the facility's GO. During an interview on 6/18/2026 at 10:08 A.M. with SSD, SSD stated if the facility was not aware of a resident's grievance, this can potentially cause the resident to feel unheard and frustrated. SSD stated the facility's Admin is the GO. During an interview on 6/18/2026 at 12:45 P.M. with the Admin, the Admin stated the SSD is the facility's GO. The Admin stated, It is the Grievance Officer's responsibility to resolve grievances appropriately. The Admin stated if residents are not aware of the grievance process, then the facility will have no knowledge of resident complaints, and this can potentially result in the residents feeling unheard and frustrated. During a review of the facility's policy and procedures (P&P) titled, Grievances and Complaints, with a review date of 6/10/2026, indicated, the facility Administrator is the Grievance Official responsible for overseeing the grievance process. The Grievance Official or designee provides a copy of the grievance/complaint report to the appropriate department manager to begin the investigation, and subsequent resolution. If follow-up is required, the Grievance Official is responsible for ensuring that the follow-up action is taken in a timely manner. During a review of the facility's P&P titled, Grievances and Complaints with a review date of 6/10/2026, indicated: To ensure that residents, family members, and representatives know about the procedure for filing grievances and complaints to the facility or other agency or entity that hears grievances. The facility Administrator is the Grievance Official responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusion, maintaining the confidentiality of information associated with the grievance as necessary and assuring written grievance decisions are provided to the residents upon request. Any resident, representative, family member, or appointed advocate may file a grievance or complaint concerning treatment, medical care, behavior of other residents, facility staff, etc., without fear of threat or reprisal in any form.When a Facility Staff member overhears of receives a grievance/complaint from a resident, a resident's representative, or another interested family member of a resident concerning the resident's medical care, treatment, food, clothing, or behavior of other residents, etc., the Facility Staff member is encouraged to advise the resident that the resident may file a complaint or grievance without fear of reprisal or discrimination, and will assist the resident, or person acting on the resident's behalf, in filing a written complaint with the Facility. During a review of the facility's P&P titled, Resident Rights - Quality of Life, dated 3/2017, indicated, Each resident shall be cared for in a manner that promotes and enhances the quality of life, dignity, respect, individuality and receives services in a person-centered manner, as well as those that support the resident in attaining or maintaining his/her highest practicable well-being. During a review of the facility's job description titled, Social Service Coordinator, not dated, indicated, that the Social Service Coordinator will Assist with the Grievance protocol.

Based on observation, interview, and record review, the facility failed to:1. Ensure staff did not store a black pouch with seven credits cards inside Medication cart [NAME] (MC-W) drawer for to one of one sampled resident (Resident 105).2. Returned the credit cards and black pouch to Resident 105 when the facility discharged Resident 105 on 4/10/2026 according to the facility's policy and procedures (P&P) titled, admission and Discharge - Personal Property dated 10/2/2025. This deficient practice increased the risk for unauthorized access and use of Resident 105's credit cards resulted in exposing Resident 105 to the risk of financial abuse.Findings: During a review of Resident 105's admission Record (AR), the AR indicated the facility admitted Resident 105 on 3/27/2026 with diagnoses that included but not limited to essential hypertension (high blood pressure) and depression (ongoing sadness, emptiness, irritability, or numbness,. extreme fatigue, or changes in weight and appetite, difficulty concentrating, memory issues, or negative thinking). AR indicated that Resident 105 was discharged from the facility on 4/10/2026 at 7:15 pm. During a review of Resident 105's Minimum Data Set (MDS - a resident assessment tool) dated 6/4/2026, the MDS indicated Resident 105 had moderate cognitive (the mental ability to make decisions of daily living) impairment. The MDS indicated Resident 105 needed set up/cleaning assistance with eating, supervision/touching assistance with activities of daily living (ADL-oral hygiene, personal hygiene, sitting/laying, and partial/moderate assistance with toileting hygiene, shower/bath, upper and lower body dressing, personal hygiene, sit/stand, toilet transfer, sit/stand and walking 50 feet). During a review of Resident 105's History and Physical (H&P - medical document which include resident's background, physical exam and assessment) by resident's physician and signed by the same physician, dated 3/28/2026, H&P indicated, The resident has the capacity to make medical decisions. During a review of Resident 105's Personal Effects Inventory Form (PIF - a formal document signed by a facility staff and the resident/resident representative with the list of all of resident's valuables and belongings, resident had upon admission and discharge), dated 3/27/2026 (upon admission), PIF indicated, Zero belongings and valuables. There was no documented evidence that Resident 105's PIF was reviewed and signed upon Resident 105's discharge on [DATE]. During a concurrent observation and interview on 06/17/2026 at 9:58 am, with Registered Nurse (RN) - 1, a black pouch with 7 credits cards found in a locked drawer of Med Cart [NAME] (MC-W). RN 1 stated, Facility should have returned the credit cards to the resident upon resident's discharge. During an interview on 06/17/2026 at 10:24 am, with Business Office Manager (BM), BM stated, Once resident is getting discharged , the facility should not keep any of the resident's cash or credit card. The facility should give those (black pouch and all credit cards) back to the resident. During an interview on 06/17/2026 at 1:58 pm, with Director of Nursing (DON), DON stated, All charge nurses have access to that locked drawer (of MC-W). It is not appropriate for multiple staff members to have access to a discharged resident's credit cards. Facility has the responsibility to give back the credit cards back to the resident (Resident 105) upon discharge. During an interview on 06/17/2026 at 2:20 pm, with Social Services Director (SSD), SSD stated, (Residents) credit cards do not belong in the medication cart. The facility should have returned all the credit cards to the resident (Resident 105) when the resident was discharged . I do not see any documentation that we (facility) contacted the resident after discharge. During a review of the facility's policy and procedures (P&P) titled, admission and Discharge - Personal Property dated 10/2/2025, the P&P indicated, Upon admission, the Certified Nursing Assistant (CNA/designee) will conduct a personal inventory of the resident's property. Money and other valuables should be taken to business office for safekeeping. Upon discharge home, if the resident/resident representative does not take his/her belongings at the time of discharge, Social Service Staff/Designee will contact the resident/resident representative to explain the belongings can only be stored at the facility for 30 days.

Based on interview and record review, the facility failed to ensure that resident specific information for payment and quality measures were electronically transmitted to the Internet Quality Improvement Evaluation System (IQIES - digital filing cabinet and grading system that allows healthcare facilities like nursing homes and home health agencies to report patient data to the government) Assessment Submission and Processing (ASAP) System, an minimum data set (MDS - a standardized health checklist used by Medicare- or Medicaid-certified nursing homes) record that passes Centers for Medicare and Medicaid Services (CMS - a United States of America federal government agency that oversees public health insurance programs) standard edits and is accepted into the system, within 14 days of the final completion date, or event date in the case of Entry and Death in Facility situations, of the record for two of two sampled residents (Residents 17 and 87). The facility admitted Residents 17 on 10/29/2025, and admitted Resident 87 on 1/8/2026 and discharged Resident 87 on 2/11/2026. This deficient practice resulted in delayed notification to Center of Medicare and Medicaid services (CMS - It is the federal agency that provides health coverage through administers and Children Health Insurance Program [CHIP]) of Resident 17 admission assessment and Resident 87's discharge assessments. Findings: A review of Resident 17's admission Record indicated the facility admitted Resident 17 on 10/29/2025 with diagnoses including dementia (progressive state of decline in mental abilities), osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), and hypertension (HTN - high blood pressure). A review of Resident 17's Minimum Data Set (MDS - resident assessment tool) dated 5/27/2026, indicated Resident 17 was cognitively impaired (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 17 was dependent on staff with activities of daily living (ADL -routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) care. A review of Resident 87's admission Record indicated the facility admitted Resident 87 on 1/8/2026 and the facility readmitted residents 87 on 2/6/2026 with diagnoses including neoplasm of head of pancreas (a new, abnormal growth of tissue, better known as a tumor. It can be benign [non-cancerous] or malignant cancerous]), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and hypertension (HTN - high blood pressure). A review of Resident 87's MDS dated [DATE], indicated Resident 87 is cognitively intact (when a person has no trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 87 is dependent on staff with activities of daily living (ADL -routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) care. During a concurrent interview and record review, on 6/18/2025, at 11:36 A.M., with the Minimal Data Set Nurse (MDSN), Resident 17 and Resident 87's electronic charts were reviewed. The MDSN stated residents MDS assessments are done on admission, quarterly, annually, and when there is a significant change of condition. The MDSN stated that the resident assessments are then submitted in IQIES within 14 days of the assessment being completed. The MDSN stated that MDS assessments are done to accurately reflect the resident's clinical status and for facility compliance with CMS regulations and care planning. The MDSN stated that Residents 17 was admitted to the facility on [DATE], the most recent MDS assessment done was the quarterly assessment which was due for submission to CMS on 6/9/2026 however, was not submitted to CMS until 6/16/2026 which was late and out of compliance. The MDSN stated that Resident 87 was discharged from the facility on 2/11/2026 and Resident 87 needed a discharge MDS assessment done on the same day, 2/11/2026, however, Resident 87's MDS for discharge was done and submitted on 3/3/2026 which was late and out of regulatory compliance. During an interview, on 6/18/2025, at 2:17 P.M., with the Director of Nursing (DON), the DON stated MDS assessments are a comprehensive residents assessment used to guide in the resident's care in the facility and for billing purposes. The DON stated that MDS assessments need to be submitted within 14 days of their due date and if not done may not accurately communicate the resident's picture of care and lead to noncompliance. A review of the facility's policy and procedure (P&P) titled RAI process reviewed and approved 6/10/2026, indicated thatPurposeTo provide resident -assessments that accurately depict and identify residents specific issues and objectives as required, while meeting state and federal guidelines and data submission.PolicyThe facility will utilize the Resident Assessment Instrument (RAI) process as the basis for the accurate assessment of each resident's functional capacity and health status, as outlined in the CMS RAI MDS 3.0 Manual.Procedure1.The facility uses CMS's RAI Version 3.0 Manual as a reference tool.V. Data ProcessingA. The facility will transmit MDS assessments in accordance with the transmission dates outline in AP-30-Form A-RAI OBRA Required Assessment Summary and AP -30 -Form B -Medicare Assessment Reporting Schedule. A review of the facility provided CMS's Resident Assessment Instrument (RAI) Version 3.0 Manual dated 10/2024, the Manual indicated, .5.1 Transmitting MDS DataAll Medicare and/or Medicaid certified nursing homes and swing beds, or agent's pf those facilities, must transmit required MDS data records to CMS Internet Quality Improvement and Evaluation System (IQIES).Completion Timing:-For all non-admissions Omnibus Budget Reconciliation Act (OBRA-a series of Congress acts) and post-postscript (PPS -a payment system used by Medicare) assessment, the MDS completion date must be no later than 14 days after the assessment references date (ARD).

Based on interview and record review, the facility failed to ensure one (1) out of three sampled residents (Residents 9) preadmission screening and annual resident review (PASARR 1- a federally mandated assessment process ensuring that individuals with mental illnesses, are not inappropriately placed in Medicaid-certified nursing facilities and receive the specialized care they need) assessment screening was accurately completed to determine the facility's ability to provide the necessary care and appropriate services for the resident. This deficient practice placed Resident 9 at risk to not receive the necessary care and appropriate services necessary for the resident to reach the highest practicable physical, mental and psychological well-being.Findings: A review of Resident 9's admission Record indicated the resident was admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses that include but are not limited to encephalopathy(damage, or malfunction of the brain that alters its function or structure) difficulty walking chronic obstructive pulmonary disease (COPD- progressive lung disease characterized by persistent and often worsening airflow limitation, which makes it hard to breathe), type 2 diabetes (metabolic disorder leading to persistently high blood sugar (glucose) levels), difficulty walking, schizophrenia (a severe, chronic brain disorder that disrupts a person's ability to think logically, manage emotions, relate to others, and perceive reality), polymyalgia rheumatica (inflammatory condition affecting the joints, muscles, bones, and connective tissues), and muscle weakness A review of Resident 9's History and Physical (H&P) dated 5/22/2026 indicated Resident 9 can make needs known but cannot make medical decisions. A review of Resident 9's Minimum Data Set (MDS - a resident assessment tool) dated 4/9/2026, indicated Resident 9's cognition was severely (the mental ability to make decisions of daily living) impaired. Resident 9 required setup or clean-up for eating and oral hygiene, supervision for toileting hygiene, upper body dressing and personal hygiene, Resident 9 required partial/moderate assistance for shower/bathe self, lower body dressing and putting on and/or taking off footwear. A review of Resident 9 order listing report dated 6/18/2026 Escitalopram oxalate (medication to treat depression) oral tablet 5 milligrams (mg-unit of measurement) to be given by mouth one time a day for depression manifested by verbalization of worriedness about health condition as evidenced by frequently expressing fear of worsening of health. A review of Resident 9's PASRR dated 5/4/26, the facility documented NO for question 9 under Section III-Serious Mental Illness, if Resident 9 has been Diagnosed serious mental illness-Does the individual have a serious diagnosed mental disorder NO for question 10 if Resident 9, is Suspected Mental Illness-After observing the individual or reviewing their records, do you believe the individual may be experiencing serious depressing.ated NO for question 11 if Resident 9 is on Psychotropic Medication. Has the individual been prescribed psychotropic medications for serious mental illness . A review of Resident 9's Psychiatrist Notes dated of service 6/10/2026 indicated Resident 9 has a diagnosis of Major depressive disorder (MDD). During an interview on 6/18/2026 at 5:45 pm Director of Nurses (DON) failing to accurately complete a Level l PASRR's result in inaccurate assessment and recommendations that could result in improper placement, denial of necessary specialized services, and delayed medical care. A review of the facility's undated policy and procedures titled Preadmission Screening and Annual Resident Review (PASRR), dated 6/10/2026 indicated facility will ensure that a PASRR will be completed and placed in the resident's medical record. A review of the facility's Registered Nurse (RN) job description indicated, general duties and responsibilities:. Records care information accurately, timely and concisely.including Resident assessments. In the medical record in accordance with policy.

Based on interview and record review, the facility failed to ensure that a pre-admission screening Resident Review (PASRR -a detailed assessment that determines if someone with a mental illness [like serious mental illness, intellectual disability, or related conditions] needs specialized services and the most appropriate place to receive them) level I assessment for residents identified with mental disorder was accurately completed for one of one sampled resident (Resident 2), in accordance with the facility's policy and procedures (P&P) titled admission Screening Resident Review (PASRR) with review and approval date of 6/10/2026. This deficient practice had the potential to negatively affect the appropriate care and services rendered to Resident 2.Findings: A review of Resident 2's admission Record indicated the facility admitted Resident on 5/3/2019 and readmitted Resident 2 on 4/30/2026 with diagnoses including bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), Parkinson's (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), and mild cognitive impairment (the stage between the expected cognitive decline of normal aging and the more serious decline of dementia [a progressive state of decline in mental abilities]) of unknown etiology (the cause). A review of Resident 2's Minimum Data set (MDS - a resident assessment tool) dated 3/29/2026, indicated Resident 2 was cognitively intact (when a person has no trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 2 required staff assistance with activities of daily living (ADL -routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) care. A review of resident 2's PASARR level I ( is a mandatory federal screening used to identify if an individual being admitted to a Medicaid certified nursing facility has a suspected serious mental illness (SMI - a mental health condition that significantly disrupts a person's ability to function in daily life, impacting their thoughts, feelings, and behaviors), intellectual disability (ID) or related condition) dated 5/17/2025, the PASARR level 1 indicated the assessment was negative for a SMI - and that level II mental health evaluation was not required for SMI. During a concurrent interview and record review, on 6/18/2026, at 7:46 A.M., Registered Nurse Supervisor (RNS) 1, Resident 2's PASARR level I, face sheet and history and physical (H&P - formal and complete assessment of the patient and the problem) were reviewed. The RNS 1 stated that Resident 2 has a diagnosis is bipolar disorder which is a serious mental illness, and that Resident 2's PASARR level 1 that was completed on 5/17/2025 question number 9 indicated No that Resident 2 did not have a SMI. RNS 1 stated the PASAR level I was inaccurate based on Resident 2's diagnosis of bipolar disorder. RNS 1 stated that if the resident's assessment for PASARR level I is not done accurately, the facility may not be able to determine if the resident is being provided/receiving the proper care. During an interview on 6/18/2026, at 1:58 P.M., with the Director of Nursing (DON), the DON stated that the completion of PASRR level I allows the facility to determine if the resident needs to have a PASARR level II (an in depth, federally mandated evaluation triggered if a PASSAR Level I screen indicates a likeliwood os SMI, ID, or a related condition) assessment done, the appropriateness of the care in the facility. The DON stated that bipolar disorder is a definitely a SMI and that the answer to question nine No of the PASARR for Resident 2 that was done 5/17/2025 is inaccurate and appropriate answer should have been a yes. The DON stated that an inaccurately completed level I PASARR may not guide the facility to provide proper/appropriate care to the resident. A review of the facility's P&P titled, completion and correction effective date 3/25/2026, indicated, .Ill. Entries will be recorded in a timely manner and will be complete, legible, and accurate.IV. Documentation will reflect medically relevant information concerning the Resident and will be documented in a professional manner. A review of the facility's P&P titled, admission Screening Resident Review (PASRR) with review and approval date of 6/10/2026, indicated,1. The facility staff will ensure that a PASRR level I ls completed for each resident prior toadmission. A copy of the PASRR will be printed and placed In the resident's medicalrecord.5. The Facility MDS Coordinator will be responsible for accessing and ensuring updates to the PASRR are completed per MDS guidelines.

Based on interview and record review, the facility failed to develop a baseline care plan for one of one sampled resident (Resident 2) in accordance with the facility's policy and procedures (P&P) titled Person-Centered Care Planning with review and approval date of 6/10/2026, by failing ensure that resident 2 had a person-centered care plan. This deficient practice had the potential to negatively affect the delivery of necessary care and services needed for Resident 2.Findings: A review of Resident 2's admission Record indicated the facility admitted Resident on 5/3/2019 and readmitted Resident 2 on 4/30/2026 with diagnoses including bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), Parkinson's (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), and mild cognitive impairment (the stage between the expected cognitive decline of normal aging and the more serious decline of dementia [a progressive state of decline in mental abilities]) of unknown etiology (the cause). A review of Resident 2's MDS dated [DATE], indicated Resident 2 is cognitively intact (when a person has no trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 2 required staff assistance with activities of daily living (ADL -routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) care. During a concurrent interview and record review, on 6/18/2026, at 7:46 A.M., with Registered Nurse Supervisor (RNS) 1, Resident 2's medical chart was reviewed. RNS 1 stated that Resident 2 has a diagnosis of bipolar disorder however, the resident did not have a care plan on bipolar disorder. RNS 1 stated that the resident needs to have a care plan for bipolar disorder so that the facility can know how to manage the resident in terms of his psychiatric condition in this care bipolar disorder. RNS 1 stated that Resident 2 should have had a baseline care plan initiated within three days of admission for bipolar disorder. RNS 1 stated that if a resident does not have a care plan, the facility may not have a guide on how to care for the resident which may lead to worsening or escalating behaviors. During an interview, on 6/18/2026, at 2:14 P.M., with the Director of Nursing (DON), the DON stated that a baseline care plan should be initiated within 48 hours of the resident's admission. The DON stated that for Resident 2 with diagnosis of bipolar disorder should have a care plan so the facility staff may know how to manage the psychosocial/emotional aspect of the resident and there if there no care plan for it, then the facility may not know how to manage the residents psychosocial/emotional care. A review of the facility's P&P, titled Person-Centered Care Planning with review and approval date of 6/10/2026, indicated,1. Definitiona. Person-centered care plan means that the facility focuses on the resident as thecenter of control and support each resident in making his or her own choices.Person-centered care includes making an effort to understand what is important toeach resident with regard to daily routines and preferred activities and having anunderstanding of the resident's life before coming to reside in nursing facility.2. Baseline Care [NAME]. The baseline care plan must include the minimum healthcare information necessaryto properly care for each resident immediately upon their admission. It shouldaddress resident-specific health and safety concerns to prevent decline or injury, andwould identify needs for supervision, behavioral interventions, and assistance withactivities of daily living, as necessary.b. The Baseline Care Plan will be developed and implemented, using the necessarycombination of problem specific care plans to promote continuity of care andcommunication among facility staff, increase resident safety and safeguard againstadverse events, within 48 hours of the resident's admission. It will include, at minimum, the following information necessary on each care plan to properly care fora resident:i. Initial goals based on the admission ordersii. Physician ordersiii. Dietary ordersiv. Therapy Servicesv. Social Servicesvi. PASRR recommendations, if applicablec. The baseline care plan must reflect the resident's stated goals and objectives andinclude interventions that address his or her needs.3. Baseline Care Plan Summarya. The baseline care plan summary will be developed within 48 hours of admission.

Based on interview and record review, the facility failed to ensure that professional standards of practice met resident care and needs for one of one sampled resident (Resident 38) in accordance with the facility's policy and procedures (P&P) titled Physician Orders with review and approval date of 6/10/2026 when physicians orders were not carried out as instructed for resident follow up with the Orthopedic (a medical specialty that emphasizes the treatment of injuries and diseases of the musculoskeletal system) doctor and a Computed tomography (CT - a diagnostic imaging procedure that uses a combination of X-rays and computer technology to produce images of the inside of the body showing detailed images of any part of the body) scan post antibiotic therapy was ordered or scheduled. This deficient practice had the potential to negatively affect the appropriate care and services rendered to Resident 38.Findings: A review of Resident 38's admission Record indicated the facility admitted Resident on 5/29/2026 with diagnoses including infection following a procedure, spinal stenosis (narrowing of one or more spaces within your spinal canal), and diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing). A review for the history and physical (H&P - formal and complete assessment of the patient and the problem) dated, 5/29/2026, indicated . post operation surgical (period immediately following a surgical procedure [how surgeons fix or explore problems inside your body]) site infection/possible abscess (enclosed collection of pus in tissues) . Continue Vancomycin (antibiotic/medication used to treat infections) 1 gram (gm -unit of measure in weight) intravenously (within a vein) every 12 hours for post operative wound infection. A review of Resident 38's Discharge instructions dated, 5/29/2026 indicated . please schedule cervical spine CT after completion of antibiotics . A review of Resident 38's Physician Orders dated, 6/1/2026 indicated Resident 38 for orthopedic follow up . A review of Resident 38's MDS dated [DATE], indicated Resident 38 is cognitively intact (when a person has no trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 38 required staff setup or clean up assistance with activities of daily living (ADL -routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) care. During an interview, on 6/15/2026, at 10:01 A.M., with Residents 38, Residents 38 stated that he had a spinal cord fracture with surgery. Resident 38 stated, I spoke to multiple facility staff regarding following up with the surgeon, but the facility staff have not done anything about it. During a concurrent interview and record review, on 6/18/2026, at 7:06 A.M., Registered Nurse Supervisor (RNS) 1, Resident 38's general acute care hospital (GACH) records and physician orders dated 6/1/2026 were reviewed. The RNS 1 stated that Resident 38 had neck surgery on 5/6/2026 and had a physician's order to follow up with orthopedics and to order a CT scan after Resident 38 had completed the antibiotics (Vancomycin). RNS 1 stated that the facility had not scheduled Resident 38 with orthopedics follow up nor a CT scan after Resident 3d has completed the antibiotics. RNS 1 stated that physicians orders should be carried out as soon as they are received. RNS 1 stated that a follow up with orthopedics is important to determine if Resident 38's surgical procedure was healing well and if resident is not seen by an expert in the field, facility may not know if the resident is healing properly. RNS 1 stated that a CT scan post antibiotics is important to see if the abscess/infection has resolved and that if the CT is not done, may lead to possible sepsis (the body's extreme life threatening response to an infection) and death. RNS 1 stated all physicians orders should to be carried out. During an interview on 6/18/2026, at 1:33 P.M., with the Director of Nursing (DON), the DON stated that physicians' orders should to be carried out, right away, once the order is received. The DON stated that if an orthopedic appointment follow up is not scheduled for a resident after a cervical surgery with abscess, the resident may suffer complications such as infection, further resistance to antibiotics and potential hospitalizations. The DON stated that if a CT scan follow up for abscess treatment, it may lead to possible reinfection. A review of the facility's P&P titled, completion and correction effective date 3/25/2026, indicated, .Ill. Entries will be recorded in a timely manner and will be complete, legible, and accurate.IV. Documentation will reflect medically relevant information concerning the Resident and will be documented in a professional manner. A review of the facility's P&P titled, Physician Orders with review and approval date of 6/10/2026, indicated, .PolicyThe licensed nurse will confirm that physician orders are clear, complete and accurate as needed.PURPOSETo have a process to verify that all physician orders are complete and accurate. A review of facility's Registered Nurse (RN) Job Description undated, indicated . the following: .Position DescriptionA licensed professional nurse directly under the supervision of the Director of Nursing Services that providescare and services to residents in a long-term care setting .Clinical Records care information accurately, timely and concisely, Completes all required documentationIncluding resident assessments, interventions, and patient response(s) in the medical record inaccordance with policy. Receive and transcribe orders accurately from attending/alternate physician.

Based on observation, interview and record review, for one out of two sampled residents (Resident 95), the facility failed to clearly label the enteral feeding (a medical process that delivers a specialized liquid nutrient formula directly into the stomach or small intestine) bottle with the date and time staff started/hanged the enteral feeding, and label the hydration infusion (water flush) bag with the flow rate, and with the date and time the hydration infusion (water flush) bag was started/hang and the correct infusion rate for the enteral feeding. This deficient practice had the potential for the resident not receive desirable nutritional and hydration needs/goals and for the facility staff not to know when to next change the enteral feeding bottle for Resident 95.Findings: A review of Resident 95's admission record indicated the resident was admitted to the facility on [DATE] with diagnoses that include but are not limited to hemiplegia (is the complete or partial paralysis of one entire side of the body caused by injury to the brain or spinal cord) and hemiparesis (severe paralysis and partial weakness or reduced muscle strength) following cerebral infarction (the death of brain tissue caused by a lack of adequate blood flow and oxygen) affecting the right dominant side , dysphagia (difficulty swallowing) following cerebral infarction, chronic obstructive pulmonary disease (COPD- progressive lung disease characterized by persistent and often worsening airflow limitation, which makes it hard to breathe), cognitive communication deficit (difficulty with communication caused by disruptions in brain function and thinking skills), hypertension (high blood pressure), gastrostomy status (long-term presence of an artificial opening into the stomach used to receive vital nutrition, fluids, and medications directly into the stomach, bypassing the mouth and esophagus), history of mental and behavioral disorders, and hyperlipidemia (high levels of fats, or lipids, in the blood). A review of Resident 95's history and physical (H&P) dated 6/12/2026, indicated Resident 95 is non-verbal and does not have capacity for medical decision making due to cerebral vascular accident (CVA-stroke). During a facility tour observation on 6/15/2026 at 8:17am, Resident 95's enteral hydration bag was not labelled to indicate the date and or time the hydration was hung and the flow rate. Additionally Resident 95's enteral feeding formula bottle label start time was illegible and the flow rate (infusion) indicated 48ml/hr. However, the enteral feeding was infusing at 60 ml/hr. into Resident 95.A review of Resident 95's order listing report dated 6/18/2026 indicated enteral feed order every shift continuous water flush @ 40cc/hr. x20hours., and enteral feed order every shift . at 60ml/hr. x20hours .During an interview on 6/18/2026 at 8:35am, Licensed Vocational Nurse (LVN) 1 stated she did not hang the hydration and the enteral feeding formula, LVN 1 was unable to state the importance and risks of failing to and/or mislabeling hydration and/or enteral feeding formula.During an interview on 6/18/2026 at 5:45pm, Director of Nursing (DON) stated the importance of labeling hydration and enteral feeding formulas is to ensure the Residents consumption of enteral feeding is accurately tracked and documented based on the rate and time ordered by the physician.A review of the facility's policy and procedures (P&P) titled Enteral Feeding dated 6/10/2026, indicated, label bag and tubing with date and time hang.

Based on observation, interview, and record review, the facility failed to follow its policy and procedures (P&P) titled, Medication Storage in the Facility reviewed 2024 and Medication ordering and receiving from pharmacy reviewed 2024 for two of three Medication Carts (MC-E and MC-W), by failing to dispose:1) One unlabeled/unidentified orange oval shaped pill found in one drawer of MC-E2) Three unlabeled/unidentified (a pink oval shaped pill, a small yellow round pill and a yellow capsule) were found in one drawer of MC-W.This failure had the potential to cause medication errors and harm to the residents.Findings; During a concurrent observation and interview with Registered Nurse (RN) 1 on 6/17/2026 at 9:19 am, in the facility hallway, one drawer in MC-E had an unlabeled/unidentified one orange oval shaped pill. RN 1 stated that, It was difficult to tell what that pill is or which resident the pill belongs to._ RN-1 stated, It's not ok. We don't know what type of medication it is. It should be in bubble pack (A method of organizing medicines in an individual plastic compartment or bubble sealed with a foil). We should have discarded this pill in the appropriate bin since it doesn't have resident name or name of the medication or dosage. During a concurrent observation and interview with RN 1 on 6/17/2026 at 9:58 am, in the facility hallway, three unlabeled pills were found in a drawer of MC-W. RN 1 stated that facility should ensure that all medication in any of the facility's medication carts are labelled appropriately. RN-1 stated, Anything could happen due to these unlabeled pills. Residents might have missed their dose. During an interview on 06/17/2026 at 1:58 pm, with Director of nursing (DON), DON stated, It's not the right practice to have unlabeled tablets in the med cart. It (unlabeled medications) should have been disposed of. All medications in the medication carts should be labeled with the resident's name and the medication name and dosage. During a review of the facility's policy and procedures (P&P) titled, Medication Storage in the Facility reviewed on 2024, the P&P indicated, All medications dispensed by the pharmacy are stored in the container with the pharmacy label. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soil, or without secure closure or immediately removed from inventory, disposed of according to procedures for medication disposal. During a review of the facility's policy and procedures (P&P) titled, Medication ordering and receiving from pharmacy reviewed on 2024, the P&P indicated, Medications are labeled in accordance with the facility requirements and state and federal laws. Each prescription medication label includes: 1)Residents name2)Facility Name3)Medication name4)Strength of medication

Based on observation, interview, and record review the facility failed to label and date food items in the patient refrigerator for 81 of 86 medically compromised residents who receive nutrition orally in the facility according to the facility's policy and procedures (P&P) titled Food brought in by Visitors dated 05/22/2025. This deficient practice had the potential to result in harmful bacterial growth that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or toxins) in 81 medically compromised residents who receive nutrition orally in the facility.Findings: During an observation on 06/15/2026 at 9:15 AM at the [NAME] Nursing Station, the resident refrigerator contained a half-full bottle of kefir (a drinkable fermented dairy beverage similar in consistency to a thin yogurt) lying on its side in the middle rack of the refrigerator. During continued observation, no labeling, date, or room number was visible on the bottle. Posted on the refrigerator door is a sign printed in large font that indicates the refrigerator is for resident use only, items should be labeled with name, room number, date, and that all items will be removed after 48 hours. Also posted on the refrigerator is a policy titled Food brought in by Visitors which indicated that, nursing home is responsible for labeling and discarding within 48 hours. During an interview on 06/16/2026 at 11:29 AM with the Director of Nursing (DON), DON stated that nursing at the station where the resident refrigerator is located is responsible for labeling and dating food items. Upon review of findings DON could not confirm whether the food item belonged to a resident or employee. DON stated that food items without labeling and date presents variables in holding times that risks spoiled food being consumed by residents which may cause foodborne illness. During a document review of the facility's policy and procedures titled Food brought in by Visitors dated 05/22/2025, the policy indicates that food should be clearly labeled with the resident's name and date received and should be discarded after 48 hours if not consumed.

Based on interview and record review, the facility failed to ensure that the facility staff performed Restorative Nursing Session (RNS - guided practice with a nurse or nursing assistant to help a patient maintain or regain their ability to do everyday tasks) services according to physician orders, dated 1/27/2026 and the facility's policy and procedure (P&P) tiled Resident Restorative Nursing Program Guidelines, effective date 5/26/2026 for one of one sampled resident (Resident 4). This deficient practice had the potential to result in ineffective RNA services, development of contractures (is a permanent or prolonged shortening of muscles, tendons, ligaments or skin to become stiff and rigid) and further decline in Resident 4's ability to perform everyday tasks. Findings: A review of Resident 4's admission Record indicated the facility admitted Resident 4 on 1/23/2025 and readmitted Resident 4 on 10/16/2025 with diagnoses including quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and chronic obstructive pulmonary disease (COPD - a chronic lung disease causing difficulty in breathing). A review of Residents 4's Physician Orders, dated 1/27/2026, the physician orders indicated RNA program for left lower extremity (LLE - entire left leg) passive range of motion (PROM -how far a joint can move when an external force does all the work while the muscles stay completely relaxed) exercises four times a week as tolerated. A review of Residents 4's Physician Orders, dated 1/27/2026, the physician orders indicated RNA program for right lower extremity (RLE - entire right leg) passive range of motion (PROM -how far a joint can move when an external force does all the work while the muscles stay completely relaxed) exercises four times a week as tolerated. A review of Residents 4's Physician Orders dated 1/27/2026, the physician orders indicated RNA program for left upper extremity (LUE - left arm) passive range of motion (PROM -how far a joint can move when an external force does all the work while the muscles stay completely relaxed) exercises four times a week as tolerated. A review of Residents 4's Physician Orders, dated 1/27/2026, the physician orders indicated RNA program for right upper extremity (RUE - right arm) passive range of motion (PROM -how far a joint can move when an external force does all the work while the muscles stay completely relaxed) exercises four times a week as tolerated. A review of Resident 4's Minimum Data Set (MDS - resident assessment tool) dated 3/24/2026, indicated Resident 4 is cognitively intact (when a person has no trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 4 is dependent on staff with activities of daily living care (ADL - activities such as bathing, dressing and toileting a person performs daily) care. During an interview on 6/15/2026, at 11:09 A.M., with Resident 4, Resident 4 stated that he is unable to get out of bed, has limited mobility and gets RNA to help maintain movement that he still has and not to get worse. During a concurrent interview and record review, on 6/18/2026, at 11:02 A.M., with RNA 1, Resident 4's Restorative Program documentation for 3/2026, 4/2026, 5/2026 and 6/2026 were reviewed. The RNA documentations indicated that on:3/2026: Nursing rehab/Restorative: Passive ROM program # 3:3/1/2026 to 3/3/2026 indicated blank3/4/2026 indicated 15, (RE - resident participated with encouragement), (97 -Not applicable)3/5/2026 to 3/10/2026 indicated blank3/11/2026 indicated 15 RE, 973/12/2026 to 3/16/2026 indicated blank3/17/2026 to 3/19/2026 indicated blank3/20/2026 indicated 15 RE, (0 -Numeric response [s])3/21/2026 indicated blank3/22/2026 indicated 15 RE, 03/23/2026 to 3/25/2026 indicated blank3/26/2026 indicated 15 RE, 03/27/2026 to 3/30/2026 indicated blank3/31/2026 indicated 15 RE, 0 4/2026 Nursing rehab/Restorative: Passive ROM program # 3:4/1/2026 to 4/5/2026 indicated blank4/6/2026 indicated 15 RE, 04/7/2026 to 4/9/2026 indicated blank4/10/2026 indicated 15 RE, 04/11/2026 to 4/15/2026 indicated blank4/16/2026 indicated 15 RE, 04/17/2026 indicated 15 RE, 0 4/18/2026 to 4/22/2026 indicated blank4/23/2026 indicated 15 RE, 04/24/2026 to 4/26/2026 indicated blank4/27/2026 indicated 15 RE, 04/28/2026 to 4/29/2026 indicated blank4/30/2026 indicated 15 RE, 0 5/2026 Nursing rehab/Restorative: Passive ROM program # 3:5/1/2026 to 5/2/2026 indicated blank5/3/2026 indicated 15 RO, 05/5/2026 to 5/7/2026 indicated 15 RE, 05/8/2026 to 5/9/2026 indicated blank5/10/2026 to 5/12/2026 indicated 15 RE, 05/13/2026 indicated 15 RO, 05/14/2026 to 5/16/2026 indicated blank5/17/2026 indicated 15 RO (R0 -resident was a passive participant), 05/18/2026 indicated blank5/19/2026 indicated 15 RO, 05/20/2026 indicated blank5/21/2026 indicated 15 RO, 05/22/2026 to 5/23/2026 indicated blank5/24/2026 indicated 15 RO, 05/25/2026 indicated 15 RO, 05/26/2026 indicated blank5/27/2026 indicated 15 RO, 05/28/2026 indicated 15 RO, 05/29/2026 to 5/31/2026 indicated blank 6/2026 Nursing rehab/Restorative: Passive ROM program # 3:6/1/2026 indicated 15 RE, 06/2/2026 to 6/3/2026 indicated blank 6/4/2026 indicated 15 RE, 06/5/2026 to 6/7/2026 indicated blank 6/8/2026 indicated 98 (98 -Residents refused), 986/9/2026 to 6/11/2026 indicated 15 RE, 06/12/2026 to 6/3/2026 indicated blank 6/13/2026 indicated 15 RE, 06/14/2026 to 6/3/2026 indicated blank During the same interview and record review, RNA 1 stated, that once RNA services are provided to a resident or if the resident refuses, it is immediately documented in the resident's chart in point click care (PCC -digital medical record and management platform built specifically for senior care and rehabilitation centers) in the point of care section. RNA 1 stated that she was familiar with Resident 4, who is on the RNA program for ROM exercises and receives services 4 times a week, for every two weeks there should be documentation of refusal or provision of RNA services of eight times. RNA 1 stated that RNA week starts on Monday and ends on Sunday and facility has RNA coverage in the facility from Monday to Sunday. RNA 1 stated that if a resident's documentation is blank then it means nothing was done, 15 in the documentation means 15 minutes was spent with the resident, RE means resident encouragement and RO means resident was a passive participant. RNA 1 stated that in 3/2026, residents should have documentation done 16 times however, resident only had documentation of either refusal or provision of services six times, for 4/2026 documentation was done eight out of 16 times, 5/2026 documentation was done 15 out of 16 times and 6/2026 documentation was done seven out of eight times. RNA 1 stated that every encounter with the residents whether services were provided or not should be documented in the resident's chart, if it was not documented, then it was not done. During an interview on 6/18/2026, at 1:29 P.M., with the Director of Nursing (DON), the DON stated that facility expectations are for RNAs to document in the resident's chart when services have been provided or not. The DON stated documentation should be done as soon as able during the RNA's shift. The DON stated that documentation is done to validate the service has been done with the resident. The DON stated that a blank in the documentation or lack of a progress notes indicates that a task was not done. The DON stated, There is a reason for the RNA services order, which is to maintain the residents' potential to prevent a decline which may lead to a contracture, which may lead to a decline in the quality of life if not done as ordered. A review of the facility's P&P titled tiled Resident Restorative Nursing Program Guidelines, effective date 5/26/2026 indicated that,I. Implementation of a restorative nursing program:A. Referral and admission to the Restorative Nursing Program1. Residents may be referred to the Restorative Nursing Program based on:a. Therapy recommendationi. Physical, Occupational, or Speech Therapyb. Nursing assessmenti. admission Assessment; ORii. A change in functional statusc. Provider orderd. Interdisciplinary Team (IDT} recommendationB. Measurable objectives and Interventions are documented in the Care Plan. TheInterdisciplinary Care Plan will reflect the written plan of care for meeting the restorativeneeds of each Resident including problems/needs, measurable goals and individualizedapproaches.IV. DocumentationA. Licensed Nurses reflect participation in and progress of Residents in the Restorative NursingProgram and update the care plan weekly and as needed.B. The RNA will document each session:1. Type of activity performed2. Frequency/duration3. Level of assistance provided4. Resident response and tolerance.

Based on observation, interview and record review, the facility failed to protect and safeguard the residents personal and medical records for one of one sampled residents (Resident 38) according to the facility's policy and procedure (P&P), titled, Storage and Destruction of the Designated Record Set, reviewed and approved 6/10/2026. Resident 38's intravenous (IV -within a vein) Vancomycin (antibiotic/medication used to treat infections) bag with a label intact containing Resident 38's protected health information (PHI - information maintained in the same data set that could identify the individual). This deficient practice violated health insurance portability and accountability (HIPPA - strict standards for managing, transmitting, and storing protected health information) and right to privacy for Resident 38.Findings; A review of Resident 38's admission Record indicated the facility admitted Resident on 5/29/2026 with diagnoses including infection following a procedure, spinal stenosis (narrowing of one or more spaces within your spinal canal), and diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing). A review of Resident 38's MDS dated [DATE], indicated Resident 38 is cognitively intact (when a person has no trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 38 required staff setup or clean up assistance with activities of daily living (ADL -routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) care. During an initial tour of the facility on 6/15/2026, at 10:01 A.M., in Resident 38's room, a bag of intravenous (IV-within a vein) Vancomycin (antibiotic used to treat infections) was seen inside a trash can in Resident 38's room. The IV bag of Vancomycin had an intact label containing Resident 38 protected health information (PHI - information maintained in the same data set that could identify the individual). During a concurrent observation and interview on 6/15/2026, at 10:10 A.M, with Licensed Vocational Nurse (LVN) 1, a bag of IV Vancomycin was seen inside the trash can in Resident 38's room. The IV bag of Vancomycin had an intact label containing Resident 38 PHI. LVN 1 stated that the IV Vancomycin bag was in Resident 38's trash can and should not be in the trash can because it contained Residents 38's information attached to it. LVN 1 stated that Resident 38's PHI should be removed because of HIPPA reasons. LVN 1 stated that the Resident 38's information in the trash can be used in the wrong way and for possible identify theft. During an interview, on 6/16/2025, at 11:14 A.M., with Registered Nurse Supervisor (RNS) 1, RNS 1 stated Resident 38's information needs to be removed from the IV bag prior to disposing it because of HIPAA reasons, to protect the resident's medical health information and for privacy. During an interview, on 6/18/2025, at 1:51 P.M., with the Director of Nursing (DON), the DON stated that facility staff are expected to remove the label on the IV antibiotic (Vancomycin) bag which contains Resident 38's information before disposing of it. The DON stated, this is done for HIPPA reasons; to keep resident medical record confidential and the residents trash can is definitely not appropriate for disposal of resident health information. A review of the facility's P&P, titled, Storage and Destruction of the Designated Record Set, reviewed and approved 6/10/2026, indicatedPurposeTo describe the elements of the Designated Record Set and the procedure for approving the content, creation and maintenance of data sources that contains Protected Health Information.IV. Destruction of the Designated Record SetA. Records that have satisfied their legal, fiscal, administrative, and archival requirements may be destroyed In accordance with MR-15-Record Retention Guidelines.B. The Facility records must be destroyed In a manner that ensure the confidentiality of the records and renders the information unrecognizable.I. For PHI In paper records, proper disposal methods may Include shredding, burning, pulping, or pulverizing the records so that the PHI Is rendered essentially unreadable, Indecipherable, and otherwise cannot be reconstructed.Ill. The Facility may not dispose of resident PHI by throwing whole documents In the trash can because this Is not a method of destruction which ensures the resident information will be unrecognizable. A review of the facility's P&P titled tiled Resident Rights -Quality of Life, reviewed and approved 6/10/2026 indicated,PurposeTo ensure that each resident receives the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care.PolicyEach resident shall be care for in a manner that promotes and enhances the quality of life, dignity, respect, individuality and receives services in a person-centered manner, as well as those that support the resident in attaining or maintaining his/her highest practicable well-being.IX. Facility Staff shall maintain an environment in which confidential clinical information Is protected,for example:B. the resident's clinical status or care needs are not to be openly posted In the resident's room unless.XI. Demeaning practices and standards of care that compromise dignity are prohibited.

Based on observations, interview, and record review, the facility staff failed to develop a base line individualized care plan addressing identified resident's behavior and refusal of wound care for one of four sampled residents, Resident 2. This deficient practice had the potential for delayed assessment and provision of necessary care and services for Resident 2. Findings: During a review of Resident 2's admission records, Resident 2 was admitted to the facility on [DATE] with a diagnoses including chronic obstructive pulmonary disease (COPD - a lung disease characterized by long term poor airflow), depression, (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily activities of living), unspecified dementia (loss of memory, thinking and reasoning). A review of Resident 2's Minimum Data Set (MDS- a comprehensive resident assessment and screening tool) dated 3/17/2026, indicated Resident 2's cognitive skills (mental ability or process of acquiring knowledge and understanding for daily decision-making) were intact. During a review of Resident 2's Social Services (SS) notes dated 4/3/2026, the SS note indicated, the resident refused wound care, informed SS he will skip the wound care for the day, and have it done next day. The note further indicated, physician notified and aware of episodes of refusal. During a review of Resident 2's Order Summary Report dated 4/10/2026, the Order Summary Report indicated, right shin venous stasis ulcer (a condition where blood flow slows down or pools in the veins, usually in the lower legs) cleanse with normal saline (a water and salt fluid used to clean wounds), pat dry, apply xeroform (medicated nonstick gauze dressing used to cover wounds) cover with dry dressings every day shift. During a review of Resident 2's baseline care plans (CP- a step-by-step roadmap created by licensed staff to manage specific health needs), the care plan did not address Resident 2's identified episodes of wound care refusals. During a review of Resident 2's February and March 2026 Treatment Administration Records (TAR), the TAR indicated, Resident 2 refused right shin wound care on February 17, 21, 28, March 3, and March 9, 20226. During an interview on 4/9/2026 at 9:30 AM with Resident 2, Resident 2 stated, he likes his wound be changed and treated at the General Acute Care Hospital (GACH) where he goes frequently for appointments. During an interview on 4/9/2026 at 10:37 AM with the licensed vocational nurse (LVN) 1, LVN 1 stated, Resident 2 is known to refuse care. LVN 1 also stated, resident care plans are important because it is a tool to know residents' baseline care needs. During a concurrent interview and record review on 4/9/2026 at 12:35 PM with the treatment nurse (TN), Resident 2's TAR and CP were reviewed. Resident 2's baseline CP does not indicate CP for refusal of wound care. TN stated Resident 2 refuses wound care treatments occasionally, this morning he refused wound care, I called and notified the charge nurse and nurse practitioner (NP). TN stated, wound treatment nurses are responsible for initiating and updating wound care. CP is important because it guides staff on how to care for residents. During an interview on 4/9/2026 at 12:49 PM with registered nurse supervisor (RN), RN stated care plans are needed for residents, care plans are the heart of nursing, it is where we do our plans for nursing care. RN further stated, CP shows residents are assessed appropriately and all their issues are addressed. RN acknowledged Resident 2's baseline care plan does not include Resident 2's refusal of wound care, services, and refusing to provide his clinic appointments to staff. During an interview on 4/8/2026 at 1:35 PM with the assistant director of nursing (ADON), DON stated, CP is resident specific, goal oriented, focused on specific interventions of residents' area of care needs. CP must be implemented for all areas of care. During a review of the facility's policy and procedures (P&P) titled Person-Centered Care Planning reviewed 4/24/225, the P&P indicated, Person-centered care plan means that the facility focuses on the resident as the center of control and supports each resident in making his or her own choices. Person-centered care includes making an effort to understand what is important to teach resident with regard to daily routines and preferred activities and having an understanding of the resident's life before coming to reside in the nursing facility. The Baseline Care Plan will be developed and implemented, using the necessary combination of problem specific care plans to promote continuity of care and communication among facility staff, increase resident safety and safeguard against adverse events, within 48 hours of the resident's admission.

Based on observation, interview, and record review the facility failed to ensure a resident's request for a lateral transfer to another skilled nursing facility closer to the resident's family was assisted and facilitated. The facility staff failed to assist a resident with required insurance changes to allow accepting facilities to process admission for one of four sampled residents Resident 2. This failure had resulted in an unreasonable delay and impeded Resident 2's right to transfer to the facility of choice. During a review of Resident 2's admission Records, the Records indicated Resident 2 was admitted to the facility on 529/2025 with a diagnoses including, hemiplegia and hemiparesis ( severe or complete loss of strength or paralysis on one side of the body), type two diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy, hemiparesis (mild or partial weakness or loss of strength on one side of the body ) essential primary hypertension (when the pressure in your blood vessels is too high ). During a review of Resident 2's Minimum Data Set (MDS- resident assessment tool), dated 12/2/2025, the MDS indicated, Resident 2 had a moderate cognitive impairment (mental action or process of acquiring knowledge and understanding). Resident 2 is dependent on staff moderately (Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort), shower/bathing, upper dressing, and dependent with maximal assistance (Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) with toilet transfer (the ability to get on and off a toilet or commode). During an interview on 1/21/2026 at 10:35 AM with Resident 2, Resident 2 stated I want to be close to my sons in Bakersfield, it has been a while since I wanted to do that. Resident 2's was not informed about the transfer process, unaware of what was happening. Resident 2 further stated, his son is the responsible party and is the one who is handling the transfer process. During an interview on 1/26/2026 at 10:21 AM with Resident 2's responsible party, the responsible party stated it has been almost three months since desire expressed and request made to the facility to transfer Resident 2 to Bakersfield, close to where his family lives. Responsible party stated, We were not given a list of available facilities in Bakersfield. The responsible party further stated, he did not get a chance to speak to the facility administrator (ADM) despite his requests, he was provided with conflicting and inconsistent information about reasons Resident 2 cannot be transferred. He did not get assistance from the facility to change Resident 2's insurance so that facilities in Bakersfield can accept Resident 2. During an interview on 1/26/2026 at 10 :55 AM with the social services director (SS), SS stated Resident 2's family has asked to transfer the resident to Bakersfield. It has been two to three months since the desire to discharge home and more than one month ago to transfer to another facility expressed. SS further stated the contacted facility at Bakersfield did not accept Resident 2's insurance. Changing insurance is the responsibility of residents or the responsible parties. A review of Resident 2's Progress Notes dated 1/27/2026 indicated, on 1/21/2026 at 1:51 PM SS spoke with admissions director for Bakersfield facility, the facility does not take Resident 2's insurance, SS will inform Resident 2's responsible party and will send out referrals to more facilities. Records do not indicate referrals and transfer plans prior complaint investigation date 1/21/2026. A review of Resident 2's Discharge Care Plan initiated on 6/4/2025 and revised on 1/27/2026, the Care Plan goal indicated Resident 2 will have a safe transition to home. And support when he gets home. The same care plan interventions indicated, discussed placement options as needed or as requested, review insurance verification and authorization as needed. During a review of the facility's policy and procedures (P&P) titled Resident Rights reviewed on 3/21/2025 indicated, Residents of skilled nursing facilities have rights under state and federal law. The facility will promote and protect those rights. Residents have freedom of choice, as much as possible, about how they wish to live their everyday lives and receive care, subject to the Facility's rules and regulations and applicable state and federal laws governing the protection of resident health and safety.

Based on observation, record review and interview the facility failed to remove expired food from refrigerator as per their policy.This deficient practice had the potential to cause food borne illness.During an observation on 12/15/2025 at 1:46 p.m., in the refrigerator, there was a bin of tomatoes with a use by date of 12/12/2025 and a bin of wilted (limp) celery with no date.During a review of the produce storage guidelines, the guidelines indicated tomatoes can be stored for 1 week at room temperature and celery can be stored in the refrigerator for one week.During an interview on 12/15/2025 at 1:48 p.m. with the dietary supervisor (DS), the DS stated all deliveries are labeled upon receipt and should be disposed of past the use by date.During a review of the facility policy and procedure (P&P) titled, Food Storage and Handling, revised 2/2024, the P&P indicated {.}Fresh vegetable storagea. Fresh vegetables should be checked and sorted for ripenessb. Store at a room temperature of 41 degrees or lessc. Unwashed produce should not be placed in the refrigerator near prepared foodsd. Fresh vegetables should be ordered and delivered frequently to ensure freshnesse. Label and date all food itemsf. Rotate vegetables so that the oldest produce is used first.

Based on interview and record review, the facility failed to immediately initiate cardiopulmonary resuscitation (CPR - an emergency treatment that's done when someone's breathing or heartbeat has stopped) in accordance with the American Heart Association (AHA - organization dedicated to fighting heart disease and stroke) guideline for one of three sampled residents (Resident 1). On [DATE] at 4:08 P.M., Resident 1 was found unresponsive (when a person is not reacting to shaking, touch, sound, or verbal commands and may or may not continue breathing) in the patio, facility staff transferred Resident 1 to his room to start the CPR. As a result, Los Angeles Fire Department (LAFD) paramedics (healthcare professional/s trained to provide advanced emergency medical care, often in pre-hospital settings) pronounced Resident 1 dead in the facility on [DATE] at 4:34 P.M. Findings: During a review of Resident 1’s admission Record, the admission record indicated the facility admitted Resident 1 on [DATE] and readmitted Resident 1 on [DATE] with diagnoses including chronic (on going) systolic heart failure (a specific type of heart failure that occurs in the heart's left ventricle [chamber which are responsible for pumping blood out of the heart]), generalized muscle weakness (when muscles aren't as strong as they should be), and acute embolism (a blockage of a pulmonary [lung] artery). During a review of Resident 1’s Physician Orders for Life -Sustaining Treatment (POLST - is a medical order that helps give people with serious illness more control over their care during a medical emergency) dated and signed by Resident 1 on [DATE], indicated Resident 1 wanted the facility to attempt resuscitation (bring back to life)/CPR and provide full treatment with the primary goal of prolonging life by all medically effective means. During a review of Resident 1’s Minimum Data Set (MDS - a resident assessment tool) dated [DATE], indicated Resident 1 was cognitive intact (when a person has no trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 1 required partial/moderate to substantial/maximal assistance from staff with activities of daily living (ADL - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) During a review of Resident 1’s Advance Healthcare Directive (AHCD -is a legal document that outlines a person's wishes for medical treatment, especially in situations where they can no longer make their own decisions) dated and signed by Resident 1 on [DATE] indicated that Resident 1 did not have AHCD and did not want AHCD information. During a review of Resident 1’s Change of Condition (COC - a sudden, clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains) dated [DATE] at 4:31 P.M., indicated Registered Nurse Supervisor (RNS) 1 documented that Resident 1 was seen unresponsive on the patio on [DATE] at 4:08 P.M. During a review of Resident 1’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 [DATE] at 4:31 P.M., indicated that RNS 1 indicated that on [DATE] at around 4:08 P.M., Resident 1 was seated in a wheelchair (WC) in the patio and was unresponsive … Resident 1’s vital (not limited to blood pressure [BP], Pulse [HR-heart rate], respirations (RR-breathing], temperature (temp-T), oxygen saturation [O2-amount of oxygen present in the blood) signs were unappreciated (not able to record). The SBAR further indicated Resident 1 … was wheeled back to Resident 1’s room … and another nurse called 911 (telephone number used to reach emergency medical, fire, and police services) on [DATE] at around 4:09 P.M. The SBAR further indicated multiple staff (unidentified) help transfer Resident 1 back to bed and that Resident 1 did not have a BP, pulse, or respirations … During a review of Resident 1’s LAFD Patient Care Report dated [DATE], the LAFD Patient Care Report indicated the facility contacted LAFD on [DATE] at 4:07 P.M., that Resident 1 was unconscious and had suffered a cardiac arrest (a sudden and unexpected cessation of the heart's pumping action, leading to a complete or near-complete loss of blood flow to the vital organs, including the brain). The LAFD Patient Care Report indicated that paramedics were dispatched to the facility on [DATE] at 4:08 P.M., paramedics were at the scene (facility) on [DATE] at 4:11 P.M., and by Resident 1 on [DATE] at 4:12 P.M. The LAFD Patient Care Report indicated that on [DATE] at 4:18 P.M., upon arrival, Resident 1 was found in bed in the facility, pulseless (no heart beat), was unresponsive, had apnea (cessation of breathing), was pale (pallor - refers to an abnormal loss of color in the skin or mucous membranes, often indicating reduced blood flow), and both pupils (eyes) were fixed and dilated (a condition where the pupils of the eyes are enlarged and unresponsive to changes in light or focus), and Resident 1’s downtime (collapse) was unknown. The LAFD Patient Care Report indicated CPR was initiated prior to arrival, and that upon the paramedics arrival, Resident 1’s initial rhythm (the sequence and regularity of the heart's electrical activity and contractions) was Pulseless Electrical Activity (PEA - is a type of cardiac arrest where the heart muscle exhibits electrical activity but is unable to contract effectively enough to produce a palpable pulse, meaning no blood is being pumped to the body). Resident 1 remained in asystole (when your heart's electrical system fails, causing your heart to stop pumping) for 20 minutes. The LAFD team pronounced Resident 1 dead in the facility on [DATE] at 4:34 P.M. During a review of Resident 4’s admission Record, the admission record indicated the facility admitted Resident 4 on [DATE] with diagnoses that included diabetes mellitus (DM- inappropriately elevated blood glucose levels). During a review of Resident 4’s History and Physical (H&P- a term used to describe a physician's examination of a patient) dated [DATE], the H&P indicated Resident 4 did not have memory loss and had the capacity to make medical decisions. During a review of Resident 4’s MDS dated [DATE], the MDS indicated Resident cognition was intact. During an interview on [DATE], at 2:22 P.M., with Certified Nursing Assistant (CNA) 1, CNA 1 stated that a few minutes before or maybe after 4 P.M., on [DATE], she (CNA 1) saw facility staff (unknown) wheeling Resident 1 in a WC. CNA 1 stated Resident 1’s head was leaning on the left side and resting on the resident’s left shoulder, the resident’s eyes were closed, and the resident was unconscious. CNA 1 stated she was in a resident’s room across from Resident 1’s room and was providing care/changing incontinent brief (an absorbent garments worn to manage urinary or fecal incontinence [inability to control the passage of urine and or feces was done providing care to the resident, resident she (CNA 1) went to Resident 1’s room and found Resident 1 still sitting in the WC. CNA 1 stated she then assisted the facility staff (unknown staff were already at Resident 1’s bedside) to transfer Resident 1 back to bed and then the staff started performing CPR on Resident 1. CNA 1 was able to recall how long she took to provide care to the resident before going to assist with Resident 1. During interview on [DATE], at 2:50 P.M., with RNS 1, RNS 1 stated that while making rounds on [DATE] at around 4 P.M., an unknown CNA told him that there was a patient that was not well on the patio. RNS 1 stated he immediately went to the patio area and saw Resident 1 and Resident 4. RNS 1 stated he saw Resident 4 asking Resident 1 if Resident 1 was okay, however, Resident 1 did not respond. RNS 1 stated that he also tapped Resident 1 on the shoulder, called the resident by name, but Resident 1 did not respond. RNS 1 stated Resident 1 was sitting in a WC, saliva was drooling (the excessive flow of saliva from the mouth) from the mouth and onto the chin. RNS 1 stated that Resident 1’s vital signs were checked and none were appreciated. RNS 1 stated that he asked the facility staff around him to assist place Resident 1 in bed. RNS 1 stated he and the facility staff then opened the emergency doors to another resident's room and wheeled Resident 1 through that room and then wheeled Resident 1 to Resident 1’s room. RNS 1 stated that it took six to seven people (facility staff) to place Resident 1 in bed so as to begin CPR. RNS 1 stated CPR should be started immediately (right away) on an unresponsive resident because the heart is not pumping, the heart needs to be pumped to help the blood flow. RNS 1 stated if CPR is not done immediately, there is a big chance that the patient will die. During an interview on [DATE], at 3:39 P.M., Resident 4 stated that she was wheeling herself in front of Resident 1 and when she and Resident 1 got to the patio, Resident 4 noticed that Resident 1 was lagging way behind Resident 4, “and when I looked back he (Resident 4) had stopped, had his head slumped down, so I rolled my wheelchair backwards to where he was. I called his name, I rubbed his head, you know he had a bald head to stimulate him but he did not wake up, I yelled I need help here that’s when all the staff came right away and took him to his room.” Resident 4 stated the paramedics came right after, they did not take time they were here and that the facility staff did not start the CPR on the patio. During an interview on [DATE], at 11A.M., with the medical doctor (MD), the MD stated, “We are not sure why staff moved him [Resident 1] to the room.” MD stated CPR should be started immediately on an unresponsive patient. MD stated that in order for chest compressions to be adequate, residents need to have a board placed underneath them. MD stated When they find a resident unresponsive they need to get him flat as well because from what I understand I think he was he wasn't like he was leaning up against this other resident’s shoulder so obviously they had to lay him flat anyways and then start CPR. MD stated that the patio floor is a flat surface and appropriate to start CPR. MD stated that when a person is pulseless, the heart is not contracting therefore blood floor and perfusion to organs are not occurring so the process of CPR is to put in place that function of the heart, you are literally pumping the chest to pump the heart, to pump the blood to try and perfuse the tissues. MD stated that the sooner CPR is started the better the outcome for the resident/person not performing CPR may lead to end organ damage, because tissue without oxygenation and perfusion can start to die. During a review of the facility Part 3: Adult Basic and Advanced Life Support 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care indicates, “1. On recognition of a cardiac arrest event, a layperson should simultaneously and promptly activate the emergency response system and initiate cardiopul­monary resuscitation (CPR)”. During a review of the facility policy and procedures (P&P) titled Cardiopulmonary Resuscitation revised on [DATE], indicated, “Policy: 1. The facility shall ensure that properly trained personnel (and certified in CPR for Healthcare Providers) are available immediately (24 hours per day) to provide basic life support, including cardiopulmonary resuscitation (CPR). a. The facility’s procedure for administering CPR shall incorporate the guidance from the current standards established by the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care or facility Basic Life Support (BLS) training material. 2. If an individual is found unresponsive and not breathing normally, a staff member who is certified in CPR/BLS shall initiate CPR. PURPOSE: To provide basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident’s advance directives/expressed wishes. Based on interview and record review, the facility failed to immediately initiate cardiopulmonary resuscitation (CPR - an emergency treatment that's done when someone's breathing or heartbeat has stopped) in accordance with the American Heart Association (AHA - organization dedicated to fighting heart disease and stroke) guideline for one of three sampled residents (Resident 1). On [DATE] at 4:08 P.M., Resident 1 was found unresponsive (when a person is not reacting to shaking, touch, sound, or verbal commands and may or may not continue breathing) in the patio, facility staff transferred Resident 1 to his room to start the CPR. As a result, Los Angeles Fire Department (LAFD) paramedics (healthcare professional/s trained to provide advanced emergency medical care, often in pre-hospital settings) pronounced Resident 1 dead in the facility on [DATE] at 4:34 P.M. Findings: During a review of Resident 1’s admission Record, the admission record indicated the facility admitted Resident 1 on [DATE] and readmitted Resident 1 on [DATE] with diagnoses including chronic (on going) systolic heart failure (a specific type of heart failure that occurs in the heart's left ventricle [chamber which are responsible for pumping blood out of the heart]), generalized muscle weakness (when muscles aren't as strong as they should be), and acute embolism (a blockage of a pulmonary [lung] artery). During a review of Resident 1’s Physician Orders for Life -Sustaining Treatment (POLST - is a medical order that helps give people with serious illness more control over their care during a medical emergency) dated and signed by Resident 1 on [DATE], indicated Resident 1 wanted the facility to attempt resuscitation (bring back to life)/CPR and provide full treatment with the primary goal of prolonging life by all medically effective means. During a review of Resident 1’s Minimum Data Set (MDS - a resident assessment tool) dated [DATE], indicated Resident 1 was cognitive intact (when a person has no trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 1 required partial/moderate to substantial/maximal assistance from staff with activities of daily living (ADL - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) During a review of Resident 1’s Advance Healthcare Directive (AHCD -is a legal document that outlines a person's wishes for medical treatment, especially in situations where they can no longer make their own decisions) dated and signed by Resident 1 on [DATE] indicated that Resident 1 did not have AHCD and did not want AHCD information. During a review of Resident 1’s Change of Condition (COC - a sudden, clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains) dated [DATE] at 4:31 P.M., indicated Registered Nurse Supervisor (RNS) 1 documented that Resident 1 was seen unresponsive on the patio on [DATE] at 4:08 P.M. During a review of Resident 1’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 [DATE] at 4:31 P.M., indicated that RNS 1 indicated that on [DATE] at around 4:08 P.M., Resident 1 was seated in a wheelchair (WC) in the patio and was unresponsive … Resident 1’s vital (not limited to blood pressure [BP], Pulse [HR-heart rate], respirations (RR-breathing], temperature (temp-T), oxygen saturation [O2-amount of oxygen present in the blood) signs were unappreciated (not able to record). The SBAR further indicated Resident 1 … was wheeled back to Resident 1’s room … and another nurse called 911 (telephone number used to reach emergency medical, fire, and police services) on [DATE] at around 4:09 P.M. The SBAR further indicated multiple staff (unidentified) help transfer Resident 1 back to bed and that Resident 1 did not have a BP, pulse, or respirations … During a review of Resident 1’s LAFD Patient Care Report dated [DATE], the LAFD Patient Care Report indicated the facility contacted LAFD on [DATE] at 4:07 P.M., that Resident 1 was unconscious and had suffered a cardiac arrest (a sudden and unexpected cessation of the heart's pumping action, leading to a complete or near-complete loss of blood flow to the vital organs, including the brain). The LAFD Patient Care Report indicated that paramedics were dispatched to the facility on [DATE] at 4:08 P.M., paramedics were at the scene (facility) on [DATE] at 4:11 P.M., and by Resident 1 on [DATE] at 4:12 P.M. The LAFD Patient Care Report indicated that on [DATE] at 4:18 P.M., upon arrival, Resident 1 was found in bed in the facility, pulseless (no heart beat), was unresponsive, had apnea (cessation of breathing), was pale (pallor - refers to an abnormal loss of color in the skin or mucous membranes, often indicating reduced blood flow), and both pupils (eyes) were fixed and dilated (a condition where the pupils of the eyes are enlarged and unresponsive to changes in light or focus), and Resident 1’s downtime (collapse) was unknown. The LAFD Patient Care Report indicated CPR was initiated prior to arrival (time not indicated), and that upon the paramedics arrival, Resident 1’s initial rhythm (the sequence and regularity of the heart's electrical activity and contractions) was Pulseless Electrical Activity (PEA - is a type of cardiac arrest where the heart muscle exhibits electrical activity but is unable to contract effectively enough to produce a palpable pulse, meaning no blood is being pumped to the body). Resident 1 remained in asystole (when your heart's electrical system fails, causing your heart to stop pumping) for 20 minutes. The LAFD team pronounced Resident 1 dead in the facility on [DATE] at 4:34 P.M. During a review of Resident 4’s admission Record, the admission record indicated the facility admitted Resident 4 on [DATE] with diagnoses that included diabetes mellitus (DM- inappropriately elevated blood glucose levels). During a review of Resident 4’s History and Physical (H&P- a term used to describe a physician's examination of a patient) dated [DATE], the H&P indicated Resident 4 did not have memory loss and had the capacity to make medical decisions. During a review of Resident 4’s MDS dated [DATE], the MDS indicated Resident cognition was intact. During an interview on [DATE], at 2:22 P.M., with Certified Nursing Assistant (CNA) 1, CNA 1 stated that a few minutes before or maybe after 4 P.M., on [DATE], she (CNA 1) saw facility staff (unknown) wheeling Resident 1 in a WC. CNA 1 stated Resident 1’s head was leaning on the left side and resting on the resident’s left shoulder, the resident’s eyes were closed, and the resident was unconscious. CNA 1 stated she was in a resident’s room across from Resident 1’s room and was providing care to another resident and then went to Resident 1’s room and found Resident 1 still sitting in the WC. CNA 1 stated she then assisted the facility staff (unknown staff were already at Resident 1’s bedside) to transfer Resident 1 back to bed and then the staff started performing CPR on Resident 1. CNA 1 was able to recall when the staff started CPR on Resident 1. During interview on [DATE], at 2:50 P.M., with RNS 1, RNS 1 stated that while making rounds on [DATE] at around 4 P.M., an unknown CNA told him that there was a patient that was not well on the patio. RNS 1 stated he immediately went to the patio area and saw Resident 1 and Resident 4. RNS 1 stated he saw Resident 4 asking Resident 1 if Resident 1 was okay, however, Resident 1 did not respond. RNS 1 stated that he also tapped Resident 1 on the shoulder, called the resident by name, but Resident 1 did not respond. RNS 1 stated Resident 1 was sitting in a WC, saliva was drooling (the excessive flow of saliva from the mouth) from the mouth and onto the chin. RNS 1 stated that Resident 1’s vital signs were checked and none were appreciated (no pulse, no blood pressure, and no breaths). RNS 1 stated that he asked the facility staff around him to assist place Resident 1 in bed. RNS 1 stated he and the facility staff then opened the emergency doors to resident room [ROOM NUMBER] and wheeled Resident 1 through room [ROOM NUMBER] and then to Resident 1’s room. RNS 1 stated that it took six to seven people (facility staff) to place Resident 1 in bed so as to begin CPR. RNS 1 did not state how long it took to place Resident 1 in bed before starting CPR. RNS 1 stated CPR should be started immediately (right away) on an unresponsive resident because the heart is not pumping, the heart needs to be pumped to help the blood flow. RNS 1 stated if CPR is not done immediately, there is a big chance that the patient will die. During an interview on [DATE], at 3:39 P.M., Resident 4 stated that she was wheeling herself in front of Resident 1 and when she and Resident 1 got to the patio, Resident 4 noticed that Resident 1 was lagging way behind Resident 4, “and when I looked back he (Resident 1) had stopped, had his head slumped down, so I rolled my wheelchair backwards to where he was. I called his name, I rubbed his head, you know he had a bald head to stimulate him but he did not wake up, I yelled I need help here that’s when all the staff came right away and took him to his room.” Resident 4 stated the paramedics came right after, they did not take time they were here and that the facility staff did not start the CPR on the patio. During an interview on [DATE], at 11A.M., with the medical doctor (MD), the MD stated, “We are not sure why staff moved him [Resident 1] to the room.” MD stated CPR should be started immediately on an unresponsive patient. MD stated that in order for chest compressions to be adequate, residents need to have a board placed underneath them. MD stated When they find a resident unresponsive they need to get him flat as well because from what I understand I think he was he was leaning up against this other resident’s shoulder so obviously they had to lay him flat anyways and then start CPR. MD stated that the patio floor is a flat surface and appropriate to start CPR. MD stated that when a person is pulseless, the heart is not contracting therefore blood floor and perfusion to organs are not occurring so the process of CPR is to put in place that function of the heart, you are literally pumping the chest to pump the heart, to pump the blood to try and perfuse the tissues. MD stated that the sooner CPR is started the better the outcome for the resident/person not performing CPR may lead to end organ damage, because tissue without oxygenation and perfusion can start to die. During a review of the facility Part 3: Adult Basic and Advanced Life Support 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care indicates, “1. On recognition of a cardiac arrest event, a layperson should simultaneously and promptly activate the emergency response system and initiate cardiopulmonary resuscitation (CPR)”. During a review of the facility policy and procedures (P&P) titled Cardiopulmonary Resuscitation revised on [DATE], indicated, “Policy: 1. The facility shall ensure that properly trained personnel (and certified in CPR for Healthcare Providers) are available immediately (24 hours per day) to provide basic life support, including cardiopulmonary resuscitation (CPR). a. The facility’s procedure for administering CPR shall incorporate the guidance from the current standards established by the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care or facility Basic Life Support (BLS) training material. 2. If an individual is found unresponsive and not breathing normally, a staff member who is certified in CPR/BLS shall initiate CPR. PURPOSE: To provide basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident’s advance directives/expressed wishes.

Based on interview and record review, the facility failed to ensure, the resident who was assessed as high risk for falls, did not fall four times and sustained injuries for one of three sampled residents (Resident 1). The facility failed to: 1. Provide Resident 1 with a full-time 1:1 sitter (one to one staff that is immediately at hand to help prevent a fall or redirect a patient from engaging in a harmful act) per a care plan titled, High Risk for Injury/Accidents and Falls, dated 11/24/23, to prevent the resident from falling on 1/25/2024, 4/11/24, 4/28/24, and 5/7/2024 and sustain injuries. Resident 1 was provided with the 1:1 sitter only after Resident fall on 5/7/2024. 2. Ensure after Resident 1's first fall on 1/25/2024, the resident's care plan titled High Risk for Injury/Accidents and Falls, interventions for the prevention of falls, were evaluated for effectiveness and other effective interventions were considered to prevent Resident 1 from future falls on 4/11/2024, 4/28/24, and 5/7/2024. 3. Ensure staff provided Resident 1 with 1:1 sitter to assist the resident with supervision in accordance with the facility policy and procedure (P&P) titled, Sitters. These deficient practices resulted in Resident 1 sustaining a fall on 1/25/2024 with dislocated (a separation of two bones where they meet at a joint) left hand 5th finger and left arm ulna (a bone in the forearm (the region of the upper limb between the elbow and the wrist) shaft (a long structure) fracture (brake in bone), and subsequent falls on 4/11/24, 4/28/24 without the injuries, and another fall on 5/7/2024 when the resident sustained a hematoma on the right eyebrow requiring transfer to the acute care hospital (GACH) for evaluation and treatment. Findings: A review of Resident 1's Admission Record (Face Sheet) indicated Resident 1 was admitted to the facility, on 8/29/23, with diagnoses including an unspecified injury of the head, repeated falls, and an unspecified psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with external reality). A review of Resident 1's Care Plan (CP) titled High Risk for Injury/Accidents and Falls, dated 9/18/23, indicated Resident 1 was a high risk for falls and injuries, with a history of falls and an actual fall on 9/18/23.The CP goals included resident 1 would have no injury/accidents or falls in the next three months. The CP interventions (specific care and services facility staff needed to provide a resident to promote healing and prevent a worsening of a condition) included the following interventions for Resident 1: 1. Maintain the resident's environment safe and hazard free. 2. Monitor residents' whereabouts often. 3. Keep the resident's bed in the lowest position. 4. Place a floor mat at the resident's bed. 5. Keep the resident's call light in reach. A review of Resident 1's Fall Risk Evaluation dated 9/28/23 at 6:36 AM, indicated Resident 1 had one to two falls (actual number falls not specified) in the past three months. Fall Risk Evaluation indicated Resident 1 was transferred to a general acute care hospital (GACH) on 9/28/23 for evaluation due to fall on 9/28/23 and suffered a laceration on the forehead. The Fall Risk Evaluation did not indicate if a physician was notified about the fall with injury. A review of Resident 1's CP titled, High Risk for Injury/Accidents and Falls, dated 11/24/23, indicated Resident 1 was a high risk for falls and injuries, with a history of falls. The CP goal indicated Resident 1 would not have injury/accidents or falls in the next three months. The CP interventions included the following interventions to prevent repeated falls for Resident 1: 1. Provide Resident 1 with 1:1 sitter as necessary for safety. 2. Frequent visual checks. 3. Keep the resident's bed in lowest position. 4. Keep floor mat at the resident's bed side. 5. Keep a call light in resident's reach. 6. Maintain environment safe and hazard free A review of Resident 1's Progress Notes for the months of 4/2023, 5/2023, and 6/2023, indicated there was no documentation Resident 1 was provided with a 1:1 sitter for safety and to prevent Resident 1 from falls. A review of Resident 1's Progress Notes dated 1/25/24 and timed at 10:10 AM indicated, Resident 1 was found by staff on the floor mat by her bed on 1/25/24 at around 9 AM. Resident 1 complained of mild (pain level not documented) left hand and right hip pain. A review of Resident 1's Progress Notes dated 1/25/24 at 2:13 PM indicated, Resident 1 had swelling of the left hand and right hip pain. A review of Resident 1's Progress Notes dated 1/25/24 at 9:42 PM, indicated, Resident 1 was noted to have left hand swelling. A review of Resident 1's untitled CP , initiated on 1/25/24, indicated Resident 1 was noted with swelling on the left hand and pain and right hip pain. Medical doctor (MD) was present and assessed with order. The CP indicated Resident 1 had a dislocated (a separation of two bones where they meet at a joint) left 5th digit as evidenced by x-ray of left hand (date not indicated). The CP goal for Resident 1 was to have no further decline and increase in pain level for the next three months. The CP interventions included: 1. Provide Resident 1 with sitter 1:1 around the clock (initiated on 1/28/24). 2. Inform MD and responsible party that Resident 1's left 5th finger was dislocated. 3. Resident 1 was sent to emergency room (ER) for further evaluation. The same CP indicated that on 1/27/2024, Resident 1 returned to the facility from ER with a splint ( a medical device to support and immobilize a joint/body part). The CP did not indicate if Resident 1 was provided with a sitter. A review of Resident 1's Progress Notes dated 1/27/24 at 4:30 PM, indicated, Resident 1 was readmitted from a GACH and that at the GACH it was confirmed Resident 1 had a dislocated left 5th finger. Resident 1's Progress Notes indicated the GACH's physician (MD) was unable to put Resident 1's finger back in place and a splint (a medical device that stabilizes a part of your body and holds it in place) was applied. A review of Resident 1's Progress Notes dated 1/29/24 at 5:41 PM, indicated, the facility's social worker discussed with Resident 1's conservator (a court appointed person or organization to be legally responsible for someone who cannot manage alone) regarding the conservator providing a 1:1 siter for Resident 1. The progress notes indicated the conservator could only provide a 1:1 sitter for Resident 1 from 10 AM to 1 PM. The progress notes did not indicate Resident 1 was provided a 1:1 sitter for safety to prevent repeated falls. A review of Resident 1's Progress Notes dated 1/30/24 at 1:13 PM, indicated, Resident 1 was arguing with staff, trying to kick and bite them. A review of Resident 1's Progress Notes dated 1/30/24 at 3:52 PM, indicated, Resident 1 was trying to throw herself on to the floor and was scratching and trying to hit staff. Resident 1 was also twisting her (Resident 1's) body and arms while in bed. A review of Resident 1's Progress Notes dated 1/30/24 at 4:10 PM, indicated Resident 1 was getting out of bed to her wheelchair all night and staff had to prevent Resident 1 from falling. The progress notes indicated staff tried to redirect Resident 1 to stay in bed, but Resident 1 was kicking, biting, and moving upside down in bed. A review of Resident 1's untitled CP dated 1/30/24, indicated Resident 1 was physically aggressive toward staff and was trying to throw self on the floor. The CP goals indicated Resident 1 would not harm self or others through review date of 4/30/24. The CP included the following interventions: 1. Continue 1:1 sitter at the bedside. 2. Give the resident choices about care. 3. Assess the resident sensory (relating to sensation or to the senses) deficits. 4. Redirect resident. The same CP did not indicate if a sitter was provided to Resident 1. A review of Resident 1's History and Physical (H&P) from a general acute care hospital (GACH) dated 1/31/24 at 11:17 AM, indicated, Resident 1 was in the emergency department to be evaluated for aggressive behavior at the facility. The H&P indicated Resident 1 was observed to be combative, agitated, and aggressive both physically and verbally with lashing out at staff. A review of Resident 1's Physician's Progress Notes from the GACH dated 2/11/24 at 1:48 PM, indicated Resident 1 was noted to be confused and was trying to get out of bed. The Physician's Progress Note's indicated Resident 1 was on fall precaution and that Resident 1 was noted to have significant swelling of a left-hand 5th digit. The physician progress notes indicated GACH admitted Resident 1 for dehydration (excessive loss of body water), metabolic encephalopathy (a group of conditions that cause brain dysfunction), urinary tract infection ([UTI] - infection of any part of the urinary system), and impaired balance (unsteadiness), strength, and mobility. Resident remained at GACH from 2/11/24 and was discharged back to the facility on [DATE]. A review of Resident 1's Physician's Progress Notes from the GACH dated 2/12/24 at 4 PM, indicated Resident 1's assessment included left ulna shaft fracture and dislocated left 5th finger with an open wound. A review of Resident 1's H&P from the facility dated 2/14/24, indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1's CP titled, Resident is high risk for fall related to (r/t) repeated falls, revised 3/15/24, indicated the goal for Resident 1 was to be free of falls and injuries through the review date of 8/28/24. The CP interventions included the following: 1. Evaluate the resident for the risk for falls on admission and as necessary (PRN). 2. Provide 1:1 sitter as deemed necessary for safety. 3. Initiate fall risk precautions. 4. Review information on past falls and attempt to determine the cause of falls and record possible root causes. A review of Resident 1's CP titled The Resident had an actual fall. Fall Risk score:13, dated 1/25/24, indicated the resident had an assisted fall on 4/11/24 with no injury or pain. The CP did not indicate where the resident fell from or the circumstances of the fall. The same CP indicated Resident 1 had a witnessed fall on 5/7/24 and was transferred to a GACH via 911 for further evaluation. The CP interventions indicated Resident 1 to have 1:1 sitter at all times and to conduct frequent room visit. A review of Resident 1's Progress Notes dated 4/11/24 at 5:46 AM, indicated Resident 1 slid to the floor from her wheelchair in the hallway. A review of Resident 1's CP (untitled) dated 4/15/24, indicated Resident 1 was at risk for falls with the following interventions to achieve a goal for Resident 1 to be free of falls: 1. 1:1 Sitter (initiated on 5/7/24). 2. Assist with ambulation and transfers. 3. Evaluate fall risk as needed. A review of Resident 1's CP dated 4/28/24, indicated Resident 1 had a witnessed/assisted fall on 4/28/24. The CP interventions included to determine and address causative factors of fall. A review of Resident 1's Progress Notes dated 4/28/24 at 6:22 AM, indicated Resident 1 was trying to get out of bed and a Certified Nursing Assistant (CNA) helped her to slide to the floor in an assisted fall. A review of Resident 1's Progress Notes dated 4/30/24 at 10:58 AM, indicated Resident 1 stood up and tried to walk. Resident 1 bit CNA that tried to assist Resident 1 back to bed. A review of Resident 1's Progress Notes dated 5/7/24 at 9:50 AM, indicated that during an interview with Resident 1, the resident stated she rolled out of bed and fell on her face. The Progress Notes indicated Resident 1's roommate stated the resident's roommate heard a loud thump and saw Resident 1 on the floor face down. The Progress Notes indicated Resident 1 developed a bump on her forehead and complained of pain, 911 was called, and Resident 1 was transferred to a hospital for further evaluations. A review of Resident 1's Progress Notes dated 5/7/24 at 10:23 AM indicated, Resident 1 was observed with hematoma (when an injury causes blood to collect and pool under the skin) on her right eyebrow and was transferred to the GACH 1 for evaluation. A review of Resident 1's Progress Notes dated 5/7/24 at 3:44 PM indicated, Resident 1 was treated at a GACH 1's Emergency Department (ED) after falling from bed and sustaining an injury to the head. The Progress Notes indicated Resident 1's ED's evaluation included a physical exam, laboratory tests and diagnostic imaging of head and face. The Progress Notes indicated Resident 1 had a Computed Tomography ([CT] a computerized x-ray imaging procedure) exam on 5/7/24 of the spine, face, and brain. The CT of the resident's brain results dated 5/7/24 indicated a small anterior (front) midline (middle) scalp (the skin on top of the head) hematoma. A review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 6/1/24 indicated Resident 1 had sever impairment of cognitive (capable of remembering, learning new things, concentrating, or making decisions that affect everyday life) skills for daily decision making and required maximal assistance form staff with oral hygiene, toileting, showering, dressing and personal hygiene. During an interview on 6/21/24 at 10:50 AM a Certified Nursing Assistant (CNA 3) stated Resident 1 gets violent when staff try to get her back in bed. CNA 3 stated Resident 1 tries to kick and slap her (CNA 3). During a concurrent interview and record review on 6/21/24 at 11:01 AM with the Licensed Vocational Nurse (LVN 2) Resident 1's CPs history was reviewed. The CP history indicated the resident had to be provided with 1:1 sitter at all times in accordance with the CP dated 11/24/23, 1/25/24, 1/30/24, 3/15/24, and 4/15/24. LVN 2 stated, Resident 1 did not have a full-time sitter before Resident 1's most recent fall on 5/7/24. LVN 2 stated, the CP interventions after Resident 1's first fall on 1/25/24 were not effective because Resident 1 was continuing falling. During a concurrent interview and record review on 6/21/24 at 11:57 AM the Director of Nursing (DON), Resident 1's Fall Incidents were reviewed on the Facility Fall Incidents List. Resident 1's Fall Incidents indicated Resident 1 experienced four falls on the following dates 1/25/24, 4/11/24, 4/28/24, and 5/07/24. The DON stated Resident 1 was transferred to the hospital after sustaining an injury to the hand from the first fall on 1/25/24. The DON stated Resident 1 was transferred back to this facility. The DON stated Resident 1 was sent on a 5150 (danger to others) hold after biting a staff member. The DON stated this facility is not appropriate for Resident 1 but we had to readmit the resident back from the hospital because no other facility will accept her. The DON stated Resident 1 did not have a full-time sitter before the resident's most recent fall (on 5/7/24). The DON stated the facility could have prevented further falls if Resident 1 had a full-time sitter. A review of the facility's policy and procedures (P&P) titled, Sitters dated 1/1/12, indicated, Purpose: to assist residents who need additional supervision. Sitter responsibilities: 1. Notifying facility staff if and/or when resident attempts to get out of bed unassisted. 2. Notifying facility staff of any resident needs. A review of the facility's P&P titled, Fall Prevention and Management Program dated 8/1/14, indicated, residents will be provided with a safe environment that minimizes complications associated with falls. The facility will provide an environment free from the hazards that the facility has control over. The interdisciplinary team ([IDT] - a group of health care professionals with various areas of expertise who work together toward the goals of their clients) will initiate, review and update resident fall risks and plan of care upon significant change of condition and post fall.

Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1) received between 1620-1890 Milliliters Per Day (mL/d- a unit of measurement) of fluid needed to maintain proper hydration and health. As a result, on 4/10/2021, Resident 1 developed increased confusion, low blood pressure (hypotension) 100/40 millimeters of mercury (mmHg - normal range between 90/60 and 120/80 mmHg), and low heart rate (bradycardia) 48 beats per minute. Resident 1's baseline was unknown. (normal 60-100 beats per minute [bpm]). Resident 1 required transfer to General Acute Care Hospital 2 (GACH 2), where she was diagnosed with severe dehydration (a dangerous loss of body fluid caused by illness, sweating, or inadequate intake of fluid which could result in confusion and weakness as the brain and other body organs receive less blood flow.) and urinary tract infection (UTI- an infection in any part of the urinary system: kidneys, bladder, or urethra), Findings: A review of Resident 1's Admission Record (Face Sheet) indicated the facility admitted Resident 1, an [AGE] year old female on 3/9/2018 with a readmitted d 4/15/2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Foods are mechanically altered by whipping, blending, grinding, chopping, or mashing so that they are easy to chew and swallow) and thin liquids consistency. A review of Resident 1's Risk for Nutritional Problem Care Plan, developed on 11/20/2020 (with no revision date), due to poor oral intake, had a goal for Resident 1 to maintain adequate nutritional status. A review of Resident 1's Risk for Dehydration Care Plan developed on 11/20/2020 (with no revision date), due to medications side effects and poor oral intake, had a goal for Resident 1 to be free of symptoms of dehydration. The interventions included providing cold water, thickened apple sauce, invite resident to activities that promote additional fluid intake, monitor and document intake and output, monitor vital signs (measurements of the body's most basic functions such as body temperature, heart and respiration rate, and blood pressure), and monitor, document, and report to the physician, signs and symptoms of dehydration: decreased or no urine, concentrated urine, strong other tenting skin, cracked lips, furrowed tongue, new onset of confusion, dizziness on increased pulse, headache, fatigue, weakness, dizziness, fever, thirst, recent/sudden weight loss, and dry/sunken eyes. The facility was unable to provide documentation the care Plan intervention were implemented, and Resident 1 was assessed for signs and symptoms of dehydration. A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 3/30/2021, indicated Resident 1 was unable to remember, make decisions, or make needs known. Resident 1 required extensive assistance with eating (needed to be assisted by one staff to eat), toilet use, personal hygiene, and bathing. Resident 1 had dysphagia at the oropharyngeal phase (swallowing problems occurring in the mouth and/or the throat) and was on a mechanically altered therapeutic diet. A review of Resident 1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Dietary Nutritional Progress Note, dated 4/1/2021, Registered Dietician (RD) indicated the last [MEDICATION(S)] test was dated 2/17/2021 which was low, 3.2 g/dl. The RD documented Resident 1's estimated fluid needs were between 1620-1890 ml per day; however, the RD did not evaluate Resident 1's daily fluid intake to determine if Resident 1 was consuming sufficient fluids. A review of Resident 1's Health Status Note (Nursing Note) dated 4/10/2021, timed at 9:03 a.m., indicated at approximately 8:15 a.m., the resident had three episodes of vomiting, increased confusion, blood pressure 100/40 mmHg (low), and heart rate of 48 bpm (low). The attending physician was notified and ordered a non-emergency transfer to GACH 1 for further evaluation. Resident 1 desaturated (developed a sudden low oxygen saturation - oxygen carried by the red blood cells to all the body organs and tissues, the normal oxygen saturation over 95%) with oxygen saturation reading of 81%, the heart rate increased to 110 bpm, and the blood pressure was 140/60 mmHg. Paramedics (health care professionals whose primary role is to provide advanced emergency medical care for critical and emergent patients) were called (911 call) and arrived at 9:20 a.m. Paramedics transferred Resident 1 at 9:37 a.m. to GACH 2 (closer to the facility). A review of Resident 1's GACH 2's Intensive Care Unit (ICU) Consultation Note, dated 04/10/2021, at 1:38 p.m. indicated Resident 1 was admitted to GACH for [CONDITION(S)]. Resident 1 presented to GACH 2 with low oxygen saturation and was found to have severe [CONDITION(S)] with a sodium (Na) level of 172 milliequivalents per liter (mEq/L - unit of measure, normal blood sodium level is between 135 and 145 mEq/L). Resident 1 had dehydration, acute renal failure, [MEDICATION(S)] tachycardia (rapid heartbeat), UTI (urinary tract infection) per lab test, and [CONDITION(S)] (low oxygen in the blood). Resident 1's BUN (blood, urea, [MEDICATION(S)], a measure of how much waste product is in blood and can indicate dehydration) was elevated at 41 mg/dL (normal range is 6 to 23 mg/dL), [MEDICATION(S)] was 2.8 gm/dL (normal range is 3.4 to 5.0 g/dL). On 6/14/2021, at 8:47 a.m., during an interview, the Dietary Manager (DM) stated fluids provided with a meal tray included water, milk, and juice, coffee, hot cocoa. The DM stated a bedside water pitcher may contain varied amounts of water, with capacity to hold approximately 900 ml when full. The DM states it was the responsibility of the nurses to fill up the water pitchers and provide fluid to the residents. On 6/15/2021 at 10:59 a.m., during an interview with the Assistant Director of Nursing (ADON) and concurrent review of Resident 1's average fluid daily intake from 3/1/2021 to 4/10/2021 was between 240 to 720 ml/day, below Resident 1's estimated fluid needs of 1620-1890 ml/day recommended by Registered Dietitian. ADON could not explain why no new interventions were implemented to address the low fluid intake. On 6/18/2021, at 2:26 a.m. during an interview with ADON and concurrent record review of Resident 1's medical record, the ADON stated neither the RD or the attending physician ordered laboratory tests for Resident 1, after 2/17/2021, to evaluate the resident's nutritional or hydration status. A review of the facility's policy and procedures titled, Nutritional Assessment, revised date 8/21/2020, indicated to reassess a resident's dietary needs. The Registered Dietitian is responsible for completing .laboratory data estimated nutritional needs .In the resident's medical record, the registered dietitian will provide the recommendations in narrative and identify any risk factors for weight loss or dehydration. This process will be repeated each time a nutritional assessment is required. A review of the facility's policy and procedures titled, Resident's Rights - Quality of Life, revised date 3/2017, indicated to ensure that each resident receives the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care. Each resident shall be cared for in a manner that promotes and enhances the quality of life . and receives services in a person-centered manner, as well as those that support the resident in attaining or maintain his/her highest practicable well-being.

Based on observation, interview, and record review, the facility failed to ensure pharmaceutical services were provided accurately and safely for 10 of 11 sampled residents (Residents 10, 11, 13, 15, 23, 31, 45, 56, 61, and 269). The facility failed to: 1. Verify the residents' identity prior to administering medications to Residents 10, 11, 13 and 269 2. Ensure residents' medications ordered by the physician were available in the medication cart for administration to Residents 10, 11, 13, and 269, and the physician was notified timely if the medication was unavailable or the resident refused to take it. 3. Ensure medication administration for Residents 15, 23, 31, 45, 56, and 61 was documented per facility's policy on medication administration when medication was administered more than one hour before or after the scheduled medication administration time on the Medication Administration Record (MAR) and the nursing progress notes. The facility did not notify promptly the attending physician of Residents 15, 23, 31, 45, 56, and 61 for late or missed medication administration and did not document the notification in the residents' medical records. 4. Ensure Residents 15, 23, 31, 45, 56, and 61 received their medications as prescribed by the physician. There was no documentation (licensed nurses initials) on the MAR the medications were administered, the initials of the licensed nursing staff on the MAR. 5. Ensure medications removed from the emergency medication kit (E-kit) stored in the Medication Cart (MedCart) of the Yellow Zone (an area designated for resident with Coronavirus Disease 2019 [COVID-19 a highly contagious [CONDITION(S)] infection that affects the respiratory system] status not determined yet waiting for laboratory results) were accurately accounted for and were documented including the name of the resident, name of the medication removed, and date of the medication removal from the E-kit for resident administration. The licensed nurses did not document the removal of [MEDICATION(S)] (water pill) from the E-kit, the date of the medication removal and the name of the resident. These deficient practices increased the risk for adverse effects due to the residents not receiving medications necessary to treat and/or control potentially life-threatening medical conditions, including, high blood pressure for Residents 10, 11, 15, 23, 31, 45, 61, and 269; heart disease including [CONDITION(S)] (an irregular heartbeat) or heart failure for Residents 10 and 269; diabetes (A chronic condition that affects the way the body processes blood sugar [glucose]) for Residents 10, 31, and 15; prevention of blood clots including pulmonary embolism (a blood clot that travels to the lungs) for Residents 23 and 269; sleep disorders for Residents 11 and 23; and pain for Residents 11, 45, 61, and 269; [CONDITION(S)] deficiency (a condition in which the [CONDITION(S)] gland does not produce enough [CONDITION(S)] hormone) for Residents 10, 13, 15, 45, and 56; dementia (is a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) for Residents 13 and 61; and urinary tract infection prevention for Residents 10, 11, and 13. These deficient practices could result in Residents 10,11, 13, 15, 23, 31, 45, 56, 61, and 269 not maintaining therapeutic range levels (the amount of drug levels in the blood in which a drug has the desired effects upon the body) for medications including but not limited to [MEDICATION(S)] (medication used to treat heart failure) for Resident 10, and had the potential to result in residents experiencing an increased in anxiety, depression, unnecessary pain, shortness of breath, uncontrolled blood pressure and blood sugar, heart attack, stroke or death. On 5/26/2021, at 5:57 p.m., the Director of Nurses (DON), Assistant Director of Nursing (ADON), and the Administrator (ADM) were verbally notified of an Immediate Jeopardy (IJ: a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death of a resident) situation. The IJ situation was declared due to facility not identifying residents prior to medication administration, not administering resident medications as ordered by the physician for, high blood pressure, heart disease, heart failure, diabetes, blood clots, [CONDITION(S)] deficiency, dementia, pain, anxiety, depression, and [CONDITION(S)] (a serious mental illness that affects how a person thinks, feels, and behaves). The facility failed to provide documentation to verify residents' physicians were notified prior to late medication administration and timely for refused medication administrations or concerns related to missing initials on the MAR, medication error over 5%, medication not given within time frame, no documentation supporting held medication, medication signed in MAR but observed not administered, incomplete documentation, instructions of medication administration not followed, and no pain assessment. On 5/28/2021 at 2:20 p.m., the facility provided a complete POA, which was accepted after an onsite validation through observations, interviews, and record reviews. The IJ was lifted in the presence of DON and ADM. The POA included the following: 1. Assessed the 10 residents affected for any adverse effects related to the missed or late medication administration. All medications administered late were documented and physicians were notified. 2. Residents involved assessed for pain and pain assessment documented in the resident's medical record. 3. DON and Regional Nurse Consultant (RNC), and Pharmacy Nurse Consultants (PNC), provided in-service to licensed nurses regarding facility's policy and procedures on medication administration followed by medication administration competency validation. DON and Director of Staff Development (DSD) provided skilled competency validation, observation, and return demonstration for medication administration for current licensed nursing staff. 4. DON, ADON, and PNC reviewed the remaining 72 residents for timely medication administration. 5. ADM and Assistant Administrator (AADM) conducted rounds on all current residents with a facility census of 82 for identification bands (bracelets). Residents that refused to wear bands, photos were taken and placed in the MAR as mean of identification. 6. Pharmacy Consultant/Licensed Nurse Designee will continue to conduct Medication Pass Observations with return demonstration for Licensed Nursing staff. Findings: 1a. During a medication pass observation on 5/25/2021 at 9:38 a.m., on West Nursing Station with Licensed Vocational Nurse (LVN 6), LVN 6 prepared and administered morning medications for Resident 11. LVN 6 failed to verify Resident 11's identity prior to administering the morning medications. 1b. During a medication pass observation on 5/25/2021 at 9:58 a.m., on West Nursing Station with LVN 6, LVN 6 prepared morning medication and offered the medications to Resident 269. LVN 6 failed to verify Resident 269's identity prior to offering the morning medications. Resident 269 requested Tylenol for a headache and did not take the morning medications when she did not see Tylenol among the medications offered. During an interview on 5/25/2021 at 10:04 a.m., with LVN 6, LVN 6 stated for Residents 11 and 269, I did not look at the residents (Residents 11 and 269) armbands or ask the residents to state their names. I did not look at them because I know the residents (Residents 11 and 269) by face because I have worked with them for some time. For new admission I will verify identity by looking at the resident identification (ID) on the armband, asking the resident to state their name or have another staff verify the resident's identity. LVN 6 further stated I should have verified the residents' (Residents 11 and 269) identity before administering medication to (Resident 11) or offering to administer the medications to (Resident 269). LVN 6 further stated had to administer medications to 37 residents. 1c. During a medication pass observation on 5/25/2021 at 10:25 a.m., on East Nursing Station with LVN 3, LVN 3 entered the shared residents' room and stated, Which resident is asking for pain medication? The resident (Resident 10) next to the window raised her hand. LVN 3 called Resident 10 by her roommate's name (Resident 13). LVN 3 did not verify Resident 10's identity, ask the resident to state her name, or ask what her pain level was. LVN 3 went back to the medication cart to look for pain medication for Resident 13. Resident 13 whose bed was next to the door observed sleeping in her bed. LVN 3 stated the incorrect resident's (Resident 13) name again stating she (Resident 13, the incorrect resident) has an order for [MEDICATION(S)] (medication for pain) for pain. LVN 3 was unable to locate the pain medication in the West MedCart or the refrigerator in the medication storage room. During an interview with LVN 3 and Director of Staff Development/ Infection Preventionist (DSD/IP), on 5/25/2021 at 10:50 a.m., LVN 3 asked the DSD/IP to assist him in looking for the pain medication for the incorrect resident (Resident 13). DSD/IP and LVN 3 were both unable to locate the pain medication [MEDICATION(S)]. DSD/IP realized LVN 3 was reviewing the incorrect resident's clinical record and stated Resident 10's bed was close to the window and Resident 13's bed was next to the door. DSD/IP found Resident 10 had an order for the controlled pain medication [MEDICATION(S)] and not an order for [MEDICATION(S)]. During an interview with the DSD/IP, on 5/25/2021 at 10:55 a.m., the DSD/IP stated, I think he (LVN 3) got confused with the beds. The A bed is listed first and then the B, middle bed, and C, the bed next to the window. 1d. During a medication pass observation on 5/25/2021 at 11:20 a.m., on East Nursing Station with LVN 3, LVN 3 prepared morning medications for Resident 13. During an observation on 5/25/2021 at 11:27 a.m., LVN 3 entered Resident 13's room and awaken her to administer the morning medications. LVN 3 failed to use any identifiers to verify the resident's identity. LVN 3 did not look for an ID armband ask the resident to state her name, and there was no resident picture observed on Resident 13's MAR. During an interview with LVN 3, on 5/25/2021 at 11:30 a.m., LVN 3 stated, I called Resident 10 by another resident's name (Resident 13). I did not ask the resident (Resident 10 or Resident 13) to state their names. I thought Resident 13 was Resident 10. I did not know which resident was in which bed. I should have asked another staff that knew the resident to identify the resident when the resident is not wearing an identifying armband or have a picture on file. LVN 3 stated he was still passing medication that had a morning administration time of 9 a.m. and had five more residents' rooms to go to complete the morning medication pass. A review of the facility's policy and procedures (P&P) titled, Medication Administration, revision dated 1/2012, indicated, No medication will be used for any patient other than the patient for whom it was prescribed .The Licensed Nurse will verify the resident's identity before administering the medication .Nursing Staff will keep in mind the seven rights of medication when administering medication. The seven rights of medication are. The right resident. The right time . 2a. During a concurrent observation and interview on 5/25/2021, at 9:38 a.m., with LVN 6, of the West Nursing Station Medication Cart (West MedCart), LVN 6 prepared and administered morning medications to Resident 11. LVN 6 stated he prepared all but one of Resident 11 morning medication that total seven and it should have been eight medications. LVN 6 stated Resident 11 was supposed to receive an antibiotic medication [MEDICATION(S)] (used to treat urinary tract infection) which was unavailable. LVN 6 stated the [MEDICATION(S)] (medications to treat infections) was unavailable and not administered to Resident 11. LVN 6 did not document the antibiotic was not given at the back of the MAR sheet. LVN 6 did not give Resident 11 [MEDICATION(S)] (for paint) and Pro-Stat liquid (protein supplement). A review of Resident 11's Admission Record indicated Resident 11 was readmitted to the facility on [DATE] with diagnoses including hypertension, history of urinary tract infections, [CONDITION(S)] (difficulty falling or staying asleep), and depression. A review of Resident 11's History and Physical (H&P) Examination (the initial clinical evaluation and examination of the resident) dated 4/25/2021 indicated Resident 11 had the capacity to understand and make decisions. A review of Resident 11's clinical records were inconsistent to determine if the resident had an active order for the antibiotic [MEDICATION(S)]. A review of Resident 11's Physician's Order indicated to give [MEDICATION(S)] 500 milligrams (mg), one tablet by mouth one time a day for UTI (urinary tract infection) with an order date of 4/24/2021. A review of Resident 11's Care Plan indicated under Focus: The resident is on antibiotic therapy for UTI, date created 5/26/2021 and a target date of 4/14/2021, a date in the past. A review of the MAR for the month of May 2021 indicated [MEDICATION(S)] 500 mg, one tablet by mouth one time a day for UTI, with an order date of 4/25/2021 and a scheduled administration time of 9:00 a.m. daily. LVN 6 initialed the MAR on 5/25/2021 and [MEDICATION(S)] was marked as administered to Resident 11 at 9 a.m. On 5/26/2021 at 4:07 p.m., Medical Records Supervisor (MRS) provided the original written physician's order for Resident 11 which indicated [MEDICATION(S)] 500 mg, one tablet by mouth daily for seven days, dated 3/17/2021 and signed by the prescriber on 3/17/2021. MRS stated there was no other [MEDICATION(S)] order found for Resident 11. A review of the MAR for Resident 11 on 5/25/2021 for medications scheduled for 9 a.m. medication administration indicated LVN 6 documented with his initial the administration of [MEDICATION(S)] and was not administered Pro-Stat a liquid on 5/25/2021 at 9 a.m. During an interview with Resident 11, on 5/27/2021 at 3:54 p.m., Resident 11 stated she was not administered an antibiotic [MEDICATION(S)], [MEDICATION(S)], or Pro-Stat on 5/25/2021. Resident 11 stated the morning medications received on 5/25/2021 from LVN 6 were the medications administered while observed by the surveyor and LVN 6 did not return to give additional morning medications. During a review of the facility's policy and procedures titled, Medication - Verification,' revision date 1/2012, indicated, Medications are administered safely and appropriately as ordered. A review of the facility's policy and procedures titled, Medication Administration, revision date 1/2012, indicated, Medications and treatments will be administered as prescribed to ensure compliance with dose guidelines. The Licensed Nurse will prepare medications within one hour of administration. Medications may be administered one hour before or after the scheduled medication administration time. 2b. A review of Resident 269's Admission Record indicated Resident 269 was admitted to the facility on [DATE] with diagnoses including heart failure, hypertension, [CONDITION(S)], pulmonary embolism, depression, [CONDITION(S)] (A disorder that affects a person's ability to think, feel, and behave clearly), and mild cognitive impairment. A review of Resident 269's H&P, dated 4/24/2021, indicated, resident did not have the capacity to understand and make decisions. During a concurrent observation and interview on 5/25/2021, at 9:43 a.m., with LVN 6, of the West Nursing Station Medication Cart (West MedCart), LVN 6 took Resident 269's blood pressure and stated it measured 160 millimeters of mercury (mmHg) (SBP, systolic blood pressure, the pressure of the blood in the arteries when the heart pumps) over 89 mmHg (DBP, diastolic blood pressure, the pressure between heartbeats). According to the American Heart Association website Hypertension Stage 2 is when blood pressure consistently ranges at 140/90 mm Hg or higher. At this stage of high blood pressure, doctors are likely to prescribe a combination of blood pressure medications and lifestyle changes. During a continued observation and interview with LVN 6, on 5/25/2021, at 10:04 a.m., LVN 6 stated Resident 269 was asking for Tylenol, but does not have an order for Tylenol in the MAR. LVN 6 was not observed assessing Resident 269 for pain or asking for resident's pain level. LVN 6 stated Resident 269 refused all the morning medications because the Tylenol she requested was not added. LVN 6 stated Resident 269 always refuse medications and he will change the MAR to resident refused and will waste the seven prepared medications. LVN 6 stated he would circle his initial, which means the resident did not take the medications. LVN 6 was observed placing Resident 269's medications in a sharps container for disposal that was in the bottom of his medication cart. LVN 6 stated Resident 269's blood pressure was high (160/89) and acknowledged the medications disposed included blood pressure medications and blood thinners to prevent clots. LVN 6 stated Resident 269 physician was not notified resident frequently refuses morning medications and that he would call the doctor later today to regarding the Resident 269's request for Tylenol for pain. LVN 6 further stated Resident 269's was supposed to receive one more morning medication, but the medication was unavailable in the West MedCart. LVN 6 showed an empty bubble pack (a medication pack with each tablet or capsule individually sealed and labeled with date) labeled for Resident 269 that indicated the order was for [MEDICATION(S)] 125 mg capsule. During a review of the facility's policies and procedures titled, Medication - Verification,' revision date 1/2012, indicated, Medications are administered safely and appropriately as ordered. During a review of the facility's policies and procedures titled, Medication Administration, revision date 1/2012, indicated, If resident is refusing to take medication, time of refusal must be circled in the Medication Administration Record (MAR) and initialed by the Licensed Nurse who is passing meds (medications) and documentation will be entered on the back of the MAR stating the reason for the refusal. The Licensed Nurse will attempt to give the medications several times, but if resident continues to refuse after one hour, the refused medications will be destroyed. Licensed Nurse will notify M.D. (physician) and document in the medical record. 2c. A review of Resident 10's Admission Record indicated Resident 10 was readmitted on [DATE] with diagnoses including heart failure, hypertension, [CONDITION(S)], diabetes, depression, muscle weakness, and dysphagia (difficulty swallowing). A review of Resident 10's H&P, dated 5/19/2021, indicated, resident has the capacity to understand and make decisions. During concurrent interview and record review on 5/26/2021, at 2:29 p.m., with LVN 3, Resident 10's MAR, dated May 2021 was reviewed. The MAR indicated, on 5/25/2021, for the 9 a.m. administration time, there were no licensed staff initials in the boxes for Resident 10's [MEDICATION(S)] KwikPen (insulin pen to control blood sugar) Solution Pen-injector 100 units per milliliter (units/ml), Pro-Stat Sugar Free Liquid (supplement), [MEDICATION(S)] (medication to treat nerve pain) tablet 600 mg, to demonstrate the medications were administered and Pain Assessment Flow Sheet was missing documentation for Resident 10's [MEDICATION(S)] administration on 5/25/2021 at 11:00 a.m. LVN 3 stated, there was no documentation on the MAR for 5/2021 indicating Resident 10 received [MEDICATION(S)] KwikPen, [MEDICATION(S)] and the Pro-stat was unavailable for administration on 5/25/2021 and again on 5/26/2021. LVN 3 stated, I did not document anywhere the medicines were not given. [MEDICATION(S)] was not given yesterday (5/25/2021). The medicine was not in the MedCart. If I did not sign the MAR, the medicine was not given. I did not document, notify the physician or let anyone know the resident (Resident 10) did not receive the medications ([MEDICATION(S)], [MEDICATION(S)] KwikPen, or Pro-stat). [MEDICATION(S)] is for pain. Yesterday (5/25/2021) the resident (Resident 10) was complaining about pain that is why I gave her the [MEDICATION(S)]. The [MEDICATION(S)] may have helped reduce her pain. LVN 3 stated he forgot to document on the Pain Assessment Flowsheet, and he should have documented on the Pain Assessment Flow Sheet as well as on the back of the MAR for the administration of [MEDICATION(S)] to Resident 10 on 5/25/2021. The back of Resident 10's MAR for [MEDICATION(S)] was blank, missing documentation to indicate Resident 10 was assessed and reassessed to determine the effectiveness of the pain medication of [MEDICATION(S)], after administration. A review of the facility's P&P titled, Medication Ordering and Receiving - Ordering and Receiving Medications from the Dispensing Pharmacy, effective date 2/2015, indicated, Reorder medications three days in advance of need to assure an adequate supply is on hand. 2d. During concurrent interview and record review on 5/26/2021, at 2:41 p.m., with LVN 3, Resident 13's MAR, dated May 2021 was reviewed. The MAR indicated, on 5/25/2021, for the 9 a.m. administration time, there were no licensed staff initials in the boxes for Resident 13's [MEDICATION(S)] (Brinzolamide 1 % [percentage]-[MEDICATION(S)] 0.2%, medication to treat primary open-angle [CONDITION(S)] [POAG] a leading cause of blindness) Suspension 1-0.2%, eye drop, to demonstrate the medication was administered. LVN 3 stated, The eye drop was not offered to the resident (Resident 13). I should have documented an attempt to offer the eye drop to the resident. I did not notify the physician or another nurse that the medication was not administered. LVN 3's initial was observed on the MAR to demonstrate the medication was administered to Resident 13 on 5/25/2021, for the 9 a.m. administration time. LVN 3 stated Resident 13 refused medications on 5/25/2021 for the 9 a.m. administration time and he should have circled his initial to indicate the resident refused the medications and the documentation of the medication administration was incorrect. LVN 3 stated the following medications was offered, and Resident 13 refused on 5/25/2021 for the 9 a.m.: i. Cranberry Supplement 450 mg, one tablet (to assist with prevention of UTI) ii. [MEDICATION(S)] (Miralax - a [MEDICATION(S)] to treat constipation) one capful 17 grams (gm) in 4 ounces (oz) water iii Multiple Vitamins (supplement), one tablet iv. Vitamin D 25 (supplement) micrograms (mcg) one tablet v. [MEDICATION(S)] Sodium (stool softener) 100 mg, one capsule During concurrent interview and record review on 5/26/2021, at 4:07 p.m., with Medical Records Supervisor (MRS), Nursing Progress Notes were reviewed for Residents 10, 11, 13, and 269 for 5/2021. MRS stated there was no documentation the physician was notified of the refused medications for Resident 269 and Resident 13. MRS stated there was no documentation to clarify the discrepancy on Resident 11's antibiotic medication [MEDICATION(S)], the omitted morning medications for Residents 10 and 13, or the request for Tylenol pain medication for Resident 269 on 5/25/2021 during the 9 a.m. morning medication pass. A review of the facility's P&P titled, Medication Ordering and Receiving: Ordering and Receiving Medications from the Dispensing Pharmacy, effective date 2/2015, indicated, Reorder medication three days in advance of need to ensure adequate supply is on hand. A review of the facility's P&P titled, Medication Administration, revision date 1/2012, indicated, Medications and treatments will be administered as prescribed to ensure compliance with dose guidelines. The Licensed Nurse will chart the drug, time administered and initial his/her name with each medication administered and sign full name and title on each page of the Medication Administration Record (MAR). Whenever a medication is held for any reason, the hour it was held must be initialed and circled in the Medication Administration Record (MAR) by the responsible Licensed Nurse. The Licensed Nurse will document on the back of the MAR, noting the time and reason the medication was held. If the PRN (as needed) is for complaint of pain, the Nurse will document the pain score prior to giving the medication and after administration of the pain medication. If resident is refusing to take medication, time of refusal must be circled in the Medication Administration Record (MAR) and initialed by the Licensed Nurse who is passing meds (medications) and documentation will be entered on the back of the MAR stating the reason for the refusal. The Licensed Nurse will attempt to give the medications several times, but if resident continues to refuse after one hour, the refused medications will be destroyed. Licensed Nurse will notify M.D. (physician) and document in the medical record. 3. During an observation and concurrent interview on 5/26/2021, at 12:17 p.m., with DON, on the East Nursing Station, the DON stated licensed nurses are supposed to pass medication to residents within one hour of the scheduled medication administration time. DON stated if the administration time is 9 a.m. the Licensed Nurse may pass medications starting at 8 a.m. until 10 a.m., DON stated if medications are passed outside that time frame, the responsible nurse must notify the physician before administering a late medication to get prior approval from the physician. DON stated if a blood pressure medication is late for administration the resident's vital signs (reflect essential body functions, including heartbeat, breathing rate, temperature, and blood pressure) may need to be taken and documented on a change of condition (COC) form. DON stated the Licensed Nurse must document the date and time of the late administration on the resident's MAR, notify the physician and document in the nursing progress notes that the physician was made aware including details related to the late administration and physician orders. While interviewing the DON LVN 3 was observed in the hallway passing medications. Upon interview, LVN 3 stated he was passing medications for Resident 61 which were scheduled for 9 a.m. with the medications scheduled at 12 p.m. DON asked LVN 3 if he had notified the physician and received approval to administer the medications late. DON stated she was not notified by the licensed nurses that residents' medications were being administered late, outside the one hour before or one hour after scheduled administration time. DON stated residents not receiving their medications as ordered could experience a change of condition, loss of control of blood pressure, blood sugar, potential to experience more anxiety or depression depending on which medication is not administered timely and could lead to resident harm, hospitalization or death. During an interview with the DSD/IP, on 5/26/2021, at 2:22 p.m., the DSD/IP stated after 10 a.m. Residents 15, 23, 31, 45, 56, and 61 were identified to have been administered the 9 a.m. medications late on the East Nursing Station. A review of the facility's policies and procedures titled, Medication Administration, revision date 1/2012, indicated, Medications and treatments will be administered as prescribed to ensure compliance with dose guidelines. The Licensed Nurse will prepare medications within one hour of administration. Medications may be administered one hour before or after the scheduled medication administration time. 4. During a Medication Cart Inspection on the Middle Nursing Station, MedCart 1, on 5/27/2021, at 10:48 a.m., with LVN 2, LVN 2 stated the Middle MedCart is shared with another nurse that has residents on the East Nursing Station. LVN 2 stated they each have a key to the shared Middle MedCart. LVN 2 stated she had completed her morning medication pass before 10 a.m. but did not know if the other nurse who shared her MedCart had completed her morning medication administrations for the 9 a.m., administration time. During a concurrent interview and record review, on 5/27/2021, at 10:55 a.m., with LVN 2, Residents (56, 15, 45, 61, 31, and 23) Medication Administration Record (MAR), dated May 2021 was reviewed. 4a. The MAR indicated, on 5/26/2021 and 5/27/2021, for the 9 a.m. administration time, there were no licensed staff initials in the box for Resident 56's Aspirin 81 mg, [MEDICATION(S)] (supplement) Tablet 400 mg, Artificial Tears (treat dry eyes) Solution 1.4%, [MEDICATION(S)] Sodium (stool softener) 100 mg capsule, and [MEDICATION(S)] 500mg/ 200 mg Vitamin D (supplement) Tablet to demonstrate the medications were administered. LVN 2 stated there was no documentation on the MAR for 5/2021, that indicated Resident 56 received the Aspirin, [MEDICATION(S)], Artificial Tears, [MEDICATION(S)] Sodium, or [MEDICATION(S)] with Vitamin D on 5/26/2021 and on 5/27/2021 at 9 a.m. A review of Resident 56's Admission Record indicated Resident 56 was admitted to the facility on [DATE] with diagnoses including dementia. A review of Resident 56's H&P, dated 4/27/2021, indicated, resident can make needs know but cannot make medical decisions. A review of the facility's P&P titled, Medication - Verification,' revision date 1/2012, indicated, Medications are administered safely and appropriately as ordered. 4b. A review of the MAR indicated, on 5/27/2021, for the 9 a.m. administration time, there were no licensed staff initials in the box for Resident 15's Aspirin 81 mg, [MEDICATION(S)] (medication used to treat high blood pressure) 20 mg, [MEDICATION(S)] Sodium 200 mg, [MEDICATION(S)] (medication used to treat high cholesterol) 160 mg, Vitamin B-12 (supplement) 1000 micrograms (mcg), Vitamin D3 (supplement) 25 mcg, to demonstrate the medications were administered on 5/27/2021 at 9 a.m. LVN 2 stated, there was no documentation on the MAR for 5/2021 that indicated Resident 15 received the above medications on 5/26/2021 and on 5/27/2021 at 9 a.m. A review of Resident 15's Admission Record indicated Resident 15 was admitted to the facility on [DATE] with diagnoses including history of falling, diabetes, [CONDITION(S)], hypertension, and muscle weakness. A review of Resident 15's H&P, dated 5/19/2021, indicated, resident can make needs known but cannot make medical decisions. A review of the facility's P&P titled, Medication -Verification,' revision date 1/2012, indicated, Medications are administered safely and appropriately as ordered. 4c. A review of Resident 45's Admission Record indicated Resident 45 was readmitted to the facility on [DATE] with diagnoses including chronic pain, muscle weakness, cognitive communication deficit, hypertension, neuralgia (chronic nerve pain) and neuritis (Inflammation of nerves). A review of Resident 45's H&P, dated 11/16/2020, indicated, resident can make needs known but cannot make medical decisions. On 5/27/2021 at 10:55 a.m., during an interview with LVN 2 and concurrent review of Resident 45' MAR for 5/26/2021 and 5/27/2021, indicated that a total of 12 medication scheduled for 9 a.m., did not have documentation (licensed nurses' initials) to indicate the medications were given as order. The medication were: Aspirin 81 mg, [MEDICATION(S)] (Vitamin D3 supplement) 3000 units, [MEDICATION(S)] (treatment for depression) 90 mg, capsule, [MEDICATION(S)] (treatment for dementia) 10 mg, [MEDICATION(S)] (treatment for high blood pressure) 50 mg, [MEDICATION(S)] Solution (treatment for [CONDITION(S)], an eye conditions that can cause blindness) 0.01 %, Artificial Tears Solution (for dry eyes) 1 %, [MEDICATION(S)] (treatment for mental disorder), 250 mg, [MEDICATION(S)] Sodium 100 mg, [MEDICATION(S)]-Salmeterol Aerosol (treatment for difficulty breathing) 100-50 mcg/dose, [MEDICATION(S)] [MEDICATION(S)] (vitamin supplement to support vision health), and [MEDICATION(S)] (treatment for high blood pressure) 0.1 mg., LVN 2 stated, there was no documentation on the

Based on observation, interview, and record review, the facility failed to ensure three of five sampled residents' medication regimen was free from significant medication errors (Residents 10, 11, and 269). This deficient practice jeopardized Residents 10, 11, and 269's health and safety by failing to administer necessary medications in accordance with the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/26/2021, at 5:57 p.m., the Director of Nurses (DON), Assistant Director of Nursing (ADON), and the Administrator (ADM) were verbally notified of an Immediate Jeopardy (IJ: a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death of a resident) situation. The IJ situation was declared due to facility not administering resident medications as ordered by the physician for, high blood pressure, [CONDITION(S)], heart failure, diabetes mellitus (A group of diseases that result in too much sugar in the blood), blood clots, [CONDITION(S)] deficiency (A condition in which the [CONDITION(S)] gland doesn't produce enough [CONDITION(S)] hormone), dementia (A group of thinking and social symptoms that interferes with daily functioning), pain, anxiety, depression (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily functioning), and [CONDITION(S)] (A mental disorder that affects a person's ability to think, feel, and behave clearly). The facility failed to provide documentation to verify residents' physicians were notified prior to late medication administration and timely for refused medication administrations or concerns related to missing initials on the Medication Administration Record (MAR- a legal record of drug administered to a resident), medication error over 5%, medication not given within time frame, no documentation supporting held medication, medication signed in MAR but observed not administered, incomplete documentation, instructions of medication administration not followed, and no pain assessment. On 5/28/2021 at 2:20 p.m., the third Plan of Action (POA) was accepted after an onsite validation of the POA through observations, interviews, and record reviews, the IJ lifted in the presence of DON and ADM notified the IJ was lifted. The POA included the following: 1. Assessed all the three residents involved for any adverse effects related to the missed or late medication administration. All medications administered late were documented and physicians were notified. 2. Residents involved assessed for pain and pain assessment documented in the resident's medical record. 3. DON and Regional Nurse Consultant (RNC), and Pharmacy Nurse Consultants (PNC), provided in-service to licensed nurses regarding facility's policy and procedures on medication administration followed by medication administration competency validation. DON and Director of Staff Development (DSD) provided skilled competency validation, observation, and return demonstration for medication administration for current licensed nursing staff. 4. DON, ADON, and PNC reviewed the remaining80 residents for timely medication administration. 5. Pharmacy Consultant/Licensed Nurse Designee will continue to conduct Medication Pass Observations with return demonstration for Licensed Nursing staff. Findings: 1. During a concurrent observation on 5/25/2021, at 9:21 a.m., with Licensed Vocational Nurse (LVN 6), at the West Nursing Station Medication Cart, LVN 6 prepared and administered seven morning medications on 5/25/201, scheduled for 9:00 a.m. administration time to Resident 11 including: i. Vitamin C (supplement) 500 milligrams (mg- unit of measure), one tablet ii. [MEDICATION(S)] (medication used to treat low blood cells) 1 mg - one tablet iii. [MEDICATION(S)] (used to reduce extra fluid in the body (edema) caused by conditions such as heart failure) 20 mg, one-half tablet (10 mg) iv [MEDICATION(S)] (supplement) 400 mg, two tablets (800 mg) v. [MEDICATION(S)] (HCL) sustained release (SR) (medication used to treat depression) 150 mg, one tablet vi. [MEDICATION(S)] (supplement) 220 mg, one tablet vii. [MEDICATION(S)] (medication to treat nerve pain and seizures [sudden episodes of uncontrollable muscle tone or movements that includes stiffness, twitching or limpness]) 300 mg, three capsules (900 mg). During an interview with LVN 6, on 5/25/2021, at 9:38 a.m., LVN 6 stated he administered seven morning medications for Resident 11. LVN 6 stated Resident 11 was scheduled to have an antibiotic, [MEDICATION(S)] (Medication used to treat a variety of bacterial infections), but it was unavailable. A review of Resident 11's Admission Record indicated an original admitted d 11/6/2020 and a readmission on 2/15/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 11's Health and Physical (H&P) Examination (the initial clinical evaluation and examination of the resident) dated 4/25/2021 indicated Resident 11 had the capacity to understand and make decisions. A review of Resident 11's May 2021 MAR was conducted. The MAR for Resident 11 was initialed by a licensed nurse to indicated Resident 11 was administered [MEDICATION(S)] and [MEDICATION(S)] (medication to treat moderate pain) on 5/25/2021, at 9 a.m. administration time. During a concurrent interview and record review, on 5/26/2021, at 4:09 p.m., with Medical Records Supervisor (MRS), MRS provided Resident 11's prescription order for [MEDICATION(S)] (Medication used to treat a variety of bacterial infections) 500 mg, one tablet by mouth daily for seven days, dated 3/17/2021. The MRS stated she had reviewed Resident 11's clinical records and nursing notes and this was the last [MEDICATION(S)] order she could locate for Resident 11. The MRS further stated there were no nursing notes to indicate Resident 11's physician was called to clarify the [MEDICATION(S)] order or determined if the medication was still needed for the resident. During an interview with Resident 11, on 5/27/2021 at 3:54 p.m., Resident 11 stated she was not administered an antibiotic [MEDICATION(S)] or [MEDICATION(S)] on 5/25/2021, at 9:00 a.m. administration time. Resident 11 further stated the morning medications received on 5/25/2021 at 9:38 a.m., from LVN 6 were the medications administered while observed by the surveyor and LVN 6 did not return to give additional morning medications. Resident 11 further stated her antibiotic therapy had ended in 4/2021. 2. During Medication Pass (MedPass) observation on 5/25/2021, at 11:06 a.m., with LVN 3 at the East Nursing Station, LVN 3 was observed preparing and administering the following medications for Resident 10: i. Aspirin (Medication used to treat pain, fever, headache, and inflammation. It can also reduce the risk of heart attack) low dose [MEDICATION(S)] coated 81 mg, one tablet ii. [MEDICATION(S)] (Medication used to treat heart failure and heart rhythm problems) 0.125 mg one tablet iii. [MEDICATION(S)] (Medication used to treat [CONDITION(S)] [chest pain] and high blood pressure) Extended Release (ER) 50 mg one tablet iv. Multiple Vitamin One Daily one tablet (red tablet) v. Vitamin C 500 mg one tablet vi. [MEDICATION(S)] (It is used as a dietary supplement to treat [MEDICATION(S)] deficiency) 220 mg one tablet vii. [MEDICATION(S)] (Zoloft) (Medication used to treat depression, social anxiety disorder, and panic disorder) 50 mg one tablet viii. [MEDICATION(S)] (Pepcid) (Medication that can be used to treat ulcers, gastroesophageal reflux disease [GERD- A digestive disease in which stomach acid or bile irritates the food pipe lining], and conditions that cause excess stomach acid) 20 mg one tablet During an interview with LVN 3, on 5/25/2021, at 11:18 a.m., LVN 3 stated Resident 10 was administered eight medications, which was all her scheduled 9:00 a.m., morning medications for 5/25/2021. During a review of Resident 10's MAR dated May 2021, the MAR including, not limited to the following prescribed orders was not observed administered to Resident 10 on 5/25/2021, for 9 a.m. administration time: i. Ordered start date 2/19/2021 - [MEDICATION(S)] 600 mg one tablet by mouth three times a day for [CONDITION(S)] (Weakness, numbness, and pain from nerve damage, usually in the hands and feet), scheduled administration time 9:00 a.m., 1:00 p.m., and 5:00 p.m. [MEDICATION(S)] 600 mg was not observed administered during morning medication pass observation to Resident 10 on 5/25/2021, for the 9 a.m. administration time. ii. Ordered start date 5/14/2021 - [MEDICATION(S)] (insulin, to control blood sugar) KwikPen Pen Injector 100 units per milliliter (units/ml- unit of measure), Inject 40 units subcutaneously (just under the skin) two times a day for Diabetes Mellitus. Hold if blood sugar less than 100. Rotate site, scheduled administration times 9:00 a.m. and 5:00 p.m. [MEDICATION(S)] KwikPen Pen Injector 40 units was not observed administered during morning medication pass observation to Resident 10 on 5/25/2021, for the 9 a.m. administration time. During concurrent interview and record review on 5/26/2021, at 2:29 p.m., with LVN 3, Resident 10's May 2021 MAR was reviewed. The May 2021 MAR indicated, on 5/25/2021, for the 9 a.m. administration time, there were no licensed staff initials in the boxes for Resident 10's [MEDICATION(S)] KwikPen Pen-injector 100 units/ml or [MEDICATION(S)] 600 mg tablet, to demonstrate the medications were administered to Resident 10. LVN 3 stated Resident 10's [MEDICATION(S)] was unavailable for administration on 5/25/2021 and on 5/26/2021. LVN 3 further stated he had not administered Resident 10's [MEDICATION(S)] KwikPen on 5/25/2021 at 9:00 a.m. administration time. LVN 3 further stated, he did not document anywhere the medicines were not give to Resident 10. LVN 3 further stated he did not sign the MAR and the medicines was not given. LVN 3 stated he did not document, notify the physician or let anyone know Resident 10 did not receive the medications ([MEDICATION(S)] or [MEDICATION(S)]). LVN 3 stated the [MEDICATION(S)] was for pain and Resident 10 complained about pain and the medication might have helped reduced her pain. During a review of Resident 10's 5/2021 MAR, blood sugar reading between 5/20/2021 through 5/25/2021, indicated Resident 10's blood sugar levels were high and not well controlled with the following blood sugar (BS) readings: On 5/20/2021 at 9:00 a.m., BS 212 and at 5:00 p.m., BS 319 On 5/21/2021 at 9:00 a.m., BS unclear documentation and at 5:00 p.m., BS 362 On 5/22/2021 at 9:00 a.m., BS 240 and at 5:00 p.m., BS 300 On 5/23/2021 at 9:00 a.m., BS 200 and at 5:00 p.m., BS 299 On 5/24/2021 at 9:00 a.m., BS 250 and at 5:00 p.m., BS 375 On 5/25/2021 at 9:00 a.m., BS not documented According to the World Health Organization, [CONDITION(S)], the term for expressing high blood sugar, has been defined as the blood glucose (blood sugar) levels greater than 126 milligram/deciliter (mg/dl- unit of measurement) when fasting (on an empty stomach); and blood glucose levels greater than 200 mg/dl, two hours after meals. 3. A review of Resident 269's Admission Record indicated Resident 269 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 269's H&P, dated 4/24/2021, indicated, Resident 269 did not have the capacity to understand and make decisions. During a medication pass observation on 5/25/2021 at 9:43 a.m., LVN 6 took Resident 269's blood pressure and stated it measured 160 millimeters of mercury (mmHg- unit of measurement) (SBP, systolic blood pressure, the pressure of the blood in the arteries when the heart pumps) over 89 mmHg (DBP, diastolic blood pressure, the pressure between heat beats). According to the American Heart Association Hypertension Stage 2 is when blood pressure consistently ranges at 140/90 mm Hg or higher. At this stage of high blood pressure, doctors are likely to prescribe a combination of blood pressure medications and lifestyle changes. During a concurrent observation and interview with LVN 6, on 5/25/2021, at 10:04 a.m., LVN 6 stated Resident 269 refused all the morning medications because the Tylenol she requested was not added. LVN 6 further stated Resident 269 always refuse medications and he will change the MAR to resident refused and will waste the seven prepared medications. LVN 6 stated he would circle his initial, which means the resident did not take the medications. LVN 6 was observed placing Resident 269's medications in a sharps container for disposal was in the bottom of his medication cart. LVN 6 stated Resident 269's blood pressure was high (160/89) and acknowledged the medications disposed included blood pressure medications and blood thinners to prevent clots. LVN 6 further stated another medication ([MEDICATION(S)] Sodium [Medication is used to treat certain types of seizures (uncontrollable movement)] 125 mg) scheduled for 9:00 a.m. administration for Resident 269 was unavailable. LVN 6 stated Resident 269 physician was not notified Resident 269 frequently refused morning medications or [MEDICATION(S)] was unavailable for administration to Resident 269. LVN 6 further stated Resident 269's was supposed to receive one more morning medication, however, the medication was unavailable in the medication cart. LVN 6 showed an empty bubble pack (a medication pack with each tablet or capsule individually sealed and labeled with date) labeled for Resident 269 indicated the order was for [MEDICATION(S)] Sodium 125 mg capsule. Medications observed prepared for Resident 269 and wasted by LVN 6 included: i. [MEDICATION(S)] (Medication used to treat fluid retention (edema) and swelling) 20 mg, one tablet ii. [MEDICATION(S)] (medication to control high blood pressure) 20 mg, one tablet iii. Multiple vitamins (supplement) - One Daily, one tablet iv. Sennosides (used to treat constipation) 8.6 mg, one tablet v. [MEDICATION(S)] (Apixaban, indicated for the prevention of [CONDITION(S)] [DVT, blood clot in the leg], which may lead to pulmonary embolism [PE]) 5 mg, one tablet vi. [MEDICATION(S)] (medication to control high blood pressure) 25 mg, one tablet vii. Tums (Calcium [MEDICATION(S)], use to treat heartburn or upset stomach) 750 mg, one tablet chewable. A review of Resident 269's 5/2021 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 269's 5/2021 MAR indicated LVN 6 initialed and circled his initial to indicate Resident 269 had refused the [MEDICATION(S)] Sodium medication administration on 5/25/2021, for 9:00 a.m. administration time. During an interview with LVN 6 on 5/25/2021, at 10:04 a.m., LVN 6 stated [MEDICATION(S)] medication was unavailable during 9 a.m., administration time. During an interview with the DON, on 5/26/2021, at 12:36 p.m., the DON stated she was not notified by the LVN that residents' medications were being administered late, outside the one hour before or one hour after scheduled administration time. The DON further stated residents not receiving their medications as ordered could experience a change of condition, loss of control of blood pressure, blood sugar, potential to experience more anxiety or depression depending on which medication is not administered timely and could lead to resident harm, hospitalization or death. A review of the facility's policy and procedures (P&P) titled, Medication Administration - Refusing Medication, with revised of 1/2012, indicated, The Licensed Nurse will attempt to give the medications several times, but if resident continues to refuse after one hour, the refused medications will be destroyed. Licensed Nurse will notify M.D. (physician) and document in the medical record. A review of the facility's P&P titled, Medication-Verification,' with revision date of 1/2012, indicated, Medications are administered safely and appropriately as ordered. A review of the facility's P&P titled, Medication Administration, with revision date of 1/2012, indicated, Medications and treatments will be administered as prescribed to ensure compliance with dose guidelines. The Licensed Nurse will prepare medications within one hour of administration. Medications may be administered one hour before or after the scheduled medication administration time. A review of the facility's P&P titled, Medication Ordering and Receiving - Ordering and Receiving Medications from the Dispensing Pharmacy, effective date 2/2015, indicated, Reorder medications three days in advance of need to assure an adequate supply is on hand.

Based on observation, interview, and record review, the facility failed to ensure its medication error rate was less than five percent (5%). During the medication pass observation on 5/27/2021, eight medication errors were observed of a total of 30 opportunities for error (a total of 30 medications were observed administered or missed [omitted] for one of four sampled residents (Residents 10). Eight medications were not given within one hour from the scheduled 9 a.m. time (considered medication error), and two medications were omitted ([MEDICATION(S)] [Neurontin] medication to treat nerve pain and [MEDICATION(S)] KwikPen Pen Injector [Insulin pen to control blood sugar]) for a total of 10 medication errors. This deficient practice resulted in an overall medication error rate of 33.33% placing Resident 10 at risk of complications including not maintaining therapeutic range levels (the amount of drug levels in the blood in which a drug has the desired effects upon the body) and had the potential to result in Resident 10 experiencing increase in anxiety, depression, uncontrolled blood pressure and elevated blood sugar, and [CONDITION(S)], or death. On 5/26/2021, at 5:57 p.m., the Director of Nurses (DON), Assistant Director of Nursing (ADON), and the Administrator (ADM) were verbally notified of an Immediate Jeopardy (IJ: a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death of a resident) situation. The IJ situation was declared due to delayed in administering the medication as per scheduled time and omitting two medications, placing the resident at risk for high blood pressure, heart disease, pain, and high or low blood sugar levels. On 5/28/2021 at 2:20 p.m., the facility's Plan of Action (POA) was accepted after an onsite validation through observations, interviews, and record reviews and the IJ was lifted in the presence of DON and ADM. The POA included the following: 1. Assessed Resident 10 for any adverse effects related to the missed or late medication administration. All medications administered late were documented and physicians were notified. 2. DON and Regional Nurse Consultant (RNC), and Pharmacy Nurse Consultants (PNC), provided in-service to licensed nurses regarding facility's policy and procedures on medication administration followed by medication administration competency validation. DON and Director of Staff Development (DSD) provided skilled competency validation, observation, and return demonstration for medication administration for current licensed nursing staff. 3. DON, ADON, and PNC reviewed the remaining 72 residents for timely medication administration. 4. Pharmacy Consultant/Licensed Nurse Designee will continue to conduct Medication Pass Observations with return demonstration for Licensed Nursing staff. Findings: A review of the Admission Record indicated the facility originally admitted the resident on 4/2/2013 and readmitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/25/2021, at 11:06 a.m., a Medication Pass (MedPass) observation of Licensed Vocational Nurse 3 (LVN 3) at the East Nursing Station was initiated. LVN 3 was preparing and administering the following medications for Resident 10 orally (by mouth): 1. Aspirin low dose [MEDICATION(S)] coated 81 mg (milligrams - unit of measure) one tablet (for prevention of [CONDITION(S)]). 2. [MEDICATION(S)] 0.125 mg one tablet (for irregular heartbeat). 3. [MEDICATION(S)] 50 mg one tablet (white round tablet with drug imprint 565 [pill imprint code is used to uniquely identify all solid oral dosage forms such as tablets, capsules, and pills]) for hypertension. 4. Multiple Vitamin One Daily one tablet (red tablet) as supplement. 5. Vitamin C 500 mg one tablet as supplement. 6. [MEDICATION(S)] 220 mg one tablet as supplement. 7. [MEDICATION(S)] (Zoloft) 50 mg one tablet for depression(a common and serious medical illness that negatively affects how the person feels, the way they think and how they act). 8. [MEDICATION(S)] (Pepcid) 20 mg one tablet for GERD (gastroesophageal reflux disease - a digestive disorder, occurs when stomach acid flows back into the tube [esophagus] connecting the mouth and stomach). On 5/25/2021, at 11:18 a.m., during interview and concurrent review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 10's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] 1. Ordered start date 2/19/2021 - Aspirin 81 one time a day by mouth for. Take with food, scheduled administration time 9:00 a.m. However, Aspirin 81 mg medication was observed administered on 5/25/2021, at 11:06 a.m., two hours after scheduled administration time of 9 a.m. and not observed administered with food as ordered. 2. Ordered start date 3/28/2021 - [MEDICATION(S)] 0.125 mg one time a day by mouth for [CONDITION(S)] (irregular heartbeat) related to heart failure. Hold if apical pulse (pulse taken on the left side of the chest over the heart) is less than 60 heartbeats per minute, scheduled administration time 9:00 a.m. However, [MEDICATION(S)] 0.125 mg medication was observed administered on 5/25/2021, at 11:06 a.m., two hours after scheduled administration time of 9 a.m. 3. Ordered start date 2/19/2021 - [MEDICATION(S)]-[MEDICATION(S)] (combined antihypertensive medications [MEDICATION(S)] and [MEDICATION(S)] [diuretic, water pill]) ER (Extended Release) 24 Hour 50 mg/12.5 mg one tablet by mouth one time a day, scheduled administration time 9:00 a.m. [MEDICATION(S)] 50 mg ER without [MEDICATION(S)] 12.5 mg (wrong medication) was administered on 5/25/2021, at 11:06 a.m., two hours after scheduled administration time of 9 a.m. 4. Ordered start date 2/19/2021- multi-vitamin with minerals one tablet by mouth one time a day for supplement, scheduled administration time 9:00 a.m. Multivitamin without minerals (wrong medication) was observed administered on 5/25/2021, at 11:06 a.m., two hours after scheduled administration time of 9 a.m. 5. Ordered start date 2/28/2021 - Vitamin C 500 mg one tablet by mouth in the morning for supplement, scheduled administration time 9:00 a.m. Vitamin C 500 mg was observed administered on 5/25/2021, at 11:06 a.m., two hours after scheduled administration time of 9 a.m. 6. Ordered start date 2/28/2021 - [MEDICATION(S)] 220 mg one tablet by mouth in the morning for supplement, scheduled administration time 9:00 a.m. [MEDICATION(S)] 220 mg medication was observed administered on 5/25/2021, at 11:06 a.m., two hours after scheduled administration time of 9 a.m. 7. Ordered start date 2/19/2021 - [MEDICATION(S)] (Zoloft) 50 mg one tablet by mouth one time a day for depression manifested by verbalization of sadness, scheduled administration time 9:00 a.m. [MEDICATION(S)] 50 mg medication was observed administered on 5/25/2021, at 11:06 a.m., two hours after scheduled administration time of 9 a.m. 8. Ordered start date 2/19/2021 - [MEDICATION(S)] (Pepcid) 20 mg one tablet by mouth two times a day for GERD, scheduled administration times 9:00 a.m. and 9 p.m. However, [MEDICATION(S)] 20 mg medication was observed administered on 5/25/2021, at 11:06 a.m., two hours after scheduled administration time of 9 a.m. 9. Ordered start date 2/19/2021 - [MEDICATION(S)] (Neurontin) 600 mg one tablet by mouth three times a day for [CONDITION(S)] (weakness, numbness, and pain from nerve damage, usually in the hands and feet) scheduled administration time 9:00 a.m., 1:00 p.m., and 5:00 p.m. [MEDICATION(S)] 600 mg was not observed administered during morning medication pass observation to Resident 10 on 5/25/2021, for the 9 a.m. administration time. 10. Ordered start date 5/14/2021 - [MEDICATION(S)] KwikPen Pen Injector 100 units per ml, Inject 40 units subcutaneously (just under the skin) two times a day for diabetes. Hold if blood sugar less than 100 mg per deciliters (mg/Dl). Rotate site, scheduled administration times 9:00 a.m. and 5:00 p.m. [MEDICATION(S)] Kwikpen Pen Injector 40 units was not observed administered during morning medication pass observation to Resident 10 on 5/25/2021, for the 9 a.m. administration time. On 5/25/2021, at 11:30 a.m., during an interview, LVN 3 stated, the eight medications (Aspirin 81 mg, [MEDICATION(S)] 0.125 mg, [MEDICATION(S)] 50 mg [imprint on tablet 565, white round tablet], Multiple Vitamin One Daily, one tablet [red tablet], Vitamin C 500 mg, [MEDICATION(S)] 220 mg, [MEDICATION(S)] (Zoloft) 50 mg, and [MEDICATION(S)] (Pepcid) 20 mg) administered to Resident 10 starting at 11:06 a.m. on 5/25/2021, were the resident's morning medications scheduled for 9 a.m. administration. LVN 3 stated, he was late passing medications to Resident 10, and he had five more residents' rooms to go to complete the 9 a.m. scheduled medication administrations. On 5/26/2021, at 2:29 p.m., during an interview with LVN 3 and concurrent MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . LVN 3 stated Resident 10's [MEDICATION(S)] was unavailable for administration on 5/25/2021 and again on 5/26/2021. LVN 3 confirmed he had not administered resident's [MEDICATION(S)] Kwikpen injection. On 5/26/2021 at 12:17 p.m., during an interview, DON stated the facility's licensed nurses were supposed to pass medication to the residents within one hour before or within one hour after the scheduled time for medication administration. DON stated medication scheduled for administration to a resident at 9 a.m., the nurse may pass medications starting at 8 a.m. until 10 a.m. A review of the facility's policy and procedures titled, Medication - Verification, revision date 1/2012, indicated, Medications are administered safely and appropriately as ordered. A review of the facility's P&P titled, Medication Administration, revision date 1/2012, indicated, To ensure accurate administration of medications for residents in the Facility. Medications and treatments will be administered as prescribed to ensure compliance with dose guidelines. The Licensed Nurse will prepare medications within one hour of administration. Medications may be administered one hour before or after the scheduled medication administration time. The seven rights of medication are: i. The right medication ii. The right amount iii. The right resident iv. The right time v. The right route vi. Resident has right to know what the medication does .

Based on observation, interview, and record review, the facility failed to provide a safe and sanitary environment to help prevent the development and transmission of COVID-19 (Coronavirus disease, a severe respiratory illness caused by virus and spread from person to person) for five of five residents (Residents 1, 2, 3, 4, 5), out of a total of 82 residents in the facility, had available PPE for staff use, in accordance to the facility's infection control policies and the Mitigation Plan (MP, a plan a reduce loss of life and impact of COVID-19 in the facility). The facility also failed to provide a safe environment for seven of 23 facility staff (RN 1, LVN1, Receptionist, Activity Assistant, CNA1, CNA 2, Housekeeper 1), who did not donn or doff appropriate PPE when required. The facility failed to: a.Ensure there were available isolation gowns in the personal protective equipment (PPE - protective clothing, goggles, head/shoe covers, mask, gown, gloves, or other garments or equipment to protect the wearers body from infection) carts, located outside of Resident 1's, Resident 2's, and Resident 3's yellow zone rooms who were potentially COVID-19 positive and were persons under investigation (PUI - quarantined (period or place of isolation in which people have arrived from elsewhere or been exposed to infectious or contagious disease are placed) for 14 days due to a possible exposure to rule out COVID-19). b.Ensure Registered Nurse 1, (RN1), Licensed Vocational Nurse 1, (LVN 1), Receptionist 1, Activity Assistant (AA) have been mask fit tested (a respirator fit test checks whether a respirator properly fits the face of someone who wears it. It tests the seal between the respirator face piece and the face (around nose and mouth) to prevent air leak) for an N95 (a particulate-filtering face piece, respirator that meets the U.S. National Institute for Occupational Safety and Health (NIOSH) and filters at least 95% of airborne particles). c.Ensure Certified Nursing Assistant 1 (CNA 1) entered Resident 4's room in the yellow zone with PPE (isolation gown, gloves, and face shield). d.Ensure CNA 2 doffs (remove) PPE (isolation gown and gloves) properly upon exiting Resident 5's yellow zone room. CNA 2 exits Resident 5's room and doffs gowns/gloves outside of room and reenters room and washes hands in Resident 5's bathroom. e.Ensure Housekeeper 1 (HK 1) wore a face shield or face protection in the yellow zone. These deficient practices had the potential to result in the spread of COVID-19 placing 79 residents in the facility's yellow zone and the staff at risk to be infected with COVID-19 and becoming seriously ill, leading to hospitalization and/or death. On 12/19/2020 at 4:53 p.m., an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified in the presence of the facility's Administrator and Director of Nursing (DON) for the facility's failure to implement measures to prevent the transmission of COVID-19 infection which threatened the health and safety of the residents and staff. On 12/22/2020 at 5 p.m., the IJ was lifted after the facility submitted an acceptable Plan of Action (POA). The survey team verified and confirmed on-site the implementation of the POA through observation, interview, and record review. The IJ situation was removed in the presence of the Administrator, DON, and Director of Staff Development (DSD). The accepted POA included the following actions: a.Isolation carts with sufficient PPE, such as isolation gowns, face shields, surgical masks, N95 mask, gloves and Alcohol Rub Hand Sanitizers were placed outside PUI yellow zone rooms. b.N95 fit testing was provided by the DON/designee to the nursing staff on-going fit testing will be continued to all staff by 12/24/2020. All staff in the yellow zone were in-serviced regarding wearing face shield and N95 mask in the yellow zone. Signs were posted on the front door to inform all persons entering the facility to wear N95 and face shield while in facility and N95 and face shield provided by the receptionist upon entry to the facility. c.One-to-one in-service provided to CNA 1 on wearing face shield, N95 mask, and gloves before entering yellow zone rooms. d.One-to-one in-service was provided to CNA 2 regarding proper doffing of PPE and handwashing prior to exiting yellow zone rooms. e.One-to-one in-service was provided to Housekeeper 1 (HK 1) regarding wearing face shield and N95 mask in the yellow zone. Findings: A review of the facility's census during onsite visits conducted on 12/19/2020 indicated the facility had 82 residents in-house. a.A review of Resident 1's Face Sheet, indicated the facility initially admitted Resident 1 on 6/1/2018 and readmitted Resident 1 on 10/13/2020 with [DIAGNOSES REDACTED]. A review of Resident 2's Face Sheet, indicated the facility admitted Resident 2 on 10/19/2020 with [DIAGNOSES REDACTED]. A review of Resident 3's Face Sheet, indicated the facility admitted Resident 3 on 10/7/2020 with [DIAGNOSES REDACTED]. On 12/19/2020 at 10:55 a.m., during an observation in the yellow zone, PPE carts located outside of Resident 1's, Resident 2's, and Resident 3's yellow zone rooms were observed to be empty. During the observation, HK 2 began stocking the empty PPE carts located outside of the yellow zone rooms with isolation gowns. On 12/19/2020 at 10:55 a.m., during an interview, HK 2 stated the PPE carts located outside of yellow zone rooms were empty and should be stocked with isolation gowns. HK 2 stated the laundry department was responsible for stocking the isolation carts with gowns. We are short staffed today, because someone in laundry called off. During an observation, on 12/20/2020 at 2:18 p.m., HK 2 retrieved a box of isolation gowns from the basement conference room. During a concurrent interview, HK 2 stated facility staff were using the disposable isolation gowns while the reusable isolation gowns were being washed. On 12/20/2020 at 2:45 p.m., during an interview, the DON stated, We have been placing isolation carts outside of every yellow zone room and ensuring they are stocked with isolation gowns. On 12/20/2020 at 2:50 p.m., during an interview, Administrator, DON and DSD stated and confirmed Resident 1, Resident 2 and Resident 3 did not have stocked PPE carts on 12/19/20. b.On 12/19/2020, at 11 a.m. during an observation in the yellow zone, RN 1 was wearing a N95 mask, model Dasheng DTC 3X NIOSH. During a concurrent interview, RN 1 stated she had not been N95 mask fit-tested for the N95 mask respirator she was currently wearing. On 12/19/2020 at 11:01 a.m., during an observation in the yellow zone, LVN 2 was wearing the N95 mask below her nose. During a concurrent interview, LVN 2 stated, It keeps slipping of my nose. On 12/19/2020 at 11:12 a.m., during an observation, Receptionist 1 was wearing N95 mask, model Dasheng DTC 3X NIOSH. During a concurrent interview, Receptionist 1 stated he had not been mask fit tested for the N95 mask respirator he was currently wearing. Receptionist 1 stated, The facility only has one size of N95 masks. On 12/19/2020 at 11:18 a.m., the Activity Assistant (AA) was observed wearing an N95 mask. During a concurrent interview, the AA stated he had not been N95 mask fit tested . I am doing in-room activities with the residents in the yellow zone. During an observation in the yellow zone, on 12/19/2020 at 12:14 p.m., LVN 1 was wearing a N95 mask, model Dasheng DTC 3X NIOSH with a surgical mask covering the N95 mask. During a concurrent interview, LVN 1 stated she was N95 mask fit tested for the mask she was wearing. LVN 1 further stated she was wearing a surgical mask over the N95 mask because the N95 mask kept slipping off her face. LVN 1 stated the surgical mask kept the N95 mask in place. On 12/19/2020 at 12:38 p.m., during an observation in the yellow zone, with DON and DSD, RN 1's Medication Cart on the East Unit, had one model of N95 mask available, model Dasheng DTC 3X NIOSH. On 12/19/2020 at 12:39 p.m., during an observation in the yellow zone, with DON and DSD, LVN 2's Medication Cart, on the Middle West Unit, had one model N95 mask available, model Dasheng DTC 3X NIOSH. On 12/19/2020 at 12:40 p.m., during an interview, the DON and DSD stated and acknowledged the facility had one type of N95 mask, model Dasheng DTC 3X NIOSH readily available for all staff. During an observation in the yellow zone, on 12/19/2020 at 12:42 p.m., with the DON, DSD, and the Administrator, the Medication Room had one N95 masks, model Dasheng DTC 3X NIOSH available. A review of the Respirator Fit Test Records, dated 7/16, 7/17, and 7/23/2020 indicated, RN 1, LVN 1, LVN 2, AA, Receptionist 1, and HK 1 had not been N95 mask fit-tested . During a concurrent interview, on 12/19/2020 at 1:03 p.m., the DSD stated RN 1, LVN 1, LVN 2, Receptionist 1, AA, and HK 1 had not been N95 mask fit tested to date. During an observation in the red zone, on 12/19/2020 from 2:10 p.m. - 2:19 p.m., the ADON, LVN 3, and CNA3 were observed wearing NIOSH approved N95 TC 84A 4329 mask, NIOSH N95 TC 84A 4329 mask, and N95 mask Model TC-84A-4329. respectively. A review of the Respirator Fit Test Record, dated 7/16/2020, indicated CNA 3 was fit-tested for the N95 3M 1870 mask. The Respirator Fit Test Records, dated 7/16, 7/17, and 7/23/2020 indicated the ADON had not been N95 mask fit tested . During a concurrent interview, on 12/19/2020 at 2:25 p.m., the ADON stated and confirmed, The Respirator Fit Test Records do not indicate I was N95 mask fit tested . On 12/20/2020 at 3:20 p.m. during an interview, the DSD stated, We expect registry staff to be N95 mask fit tested and to wear the appropriate N95 mask they were fit-tested for. A review of the Respirator Fit Test Record, dated 12/19/2020, indicated LVN 3 was fit tested for the N95 mask, model Dasheng DTC 3X NIOSH and dated 12/20/2020, indicated CNA 3 was mask fit tested for the N95 mask, model 3M N95 1860 S. c.A review of Resident 4's Face Sheet, indicated Resident 4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 12/19/2020 at 11:04 a.m., during an observation in the yellow zone, CNA 1 entered Resident 4's room with an N95 mask. During a concurrent interview, CNA 1 stated, he should have donned a gown, gloves and face shield when he entered Resident 4's room. CNA 1 stated he did not perform patient care, so he did not put on PPE. CNA 1 stated, I should be wearing an N95 mask and face shield at all times in the yellow zone. On 12/19/2020 at 12:30 p.m., the DON stated staff should don PPE, wearing an N95 mask and face shield at all times in the yellow zone. The DON stated CNA 1 was not wearing an N95 mask and face shield in the yellow zone and this was not proper procedure. d.A review of Resident 5's Face Sheet, indicated Resident 5 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 12/19/2020 at 11:24 a.m., during an observation in the yellow zone, CNA 2 exited Resident 5's room, and removed gown and gloves outside of Resident 5's room. CNA 2 reentered Resident 5's room and washed her hands in the bathroom. On 12/19/2020 at 11:24 a.m., during an interview, CNA 2 stated the gown and gloves should have been thrown away inside Resident 5's room before exiting. CNA 2 stated the gown and gloves should have been thrown away in the trash can near the exit door of Resident 5's room. On 12/19/2020 at 12:30 p.m., the DON stated staff should doff PPE (isolation gown, gloves) prior to exiting a resident's room. e.On 12/19/2020 at 12:06 p.m., during an observation in the yellow zone, HK 1 was wearing an N95 mask model NIOSH TC 84A-4329, but no face shield. On 12/19/2020 at 12:30 p.m., the DON stated staff should be wearing an N95 mask and face shield at all times while in the yellow zone. A review of the Respirator Fit Test Record, dated 7/16, 7/17, and 7/23/2020 indicated HK 1 had not been N95 mask fit tested . On 12/19/2020 at 1:03 p.m., during a concurrent interview, the DSD stated HK 1 had not been N95 mask fit-tested to date. A review of the facility's Respiratory Protection Infection Control Manual, revised, 7/14/2017, (Page 1) the Respiratory Protection Infection Control Manual indicated the purpose was to reduce employee exposure to infectious agents in the workplace through the proper use of respirators during an influenza pandemic or other infectious respiratory disease emergency. The Manual indicated the procedure: II. Respiratory Protection Program Administrator (RPPA). The Respiratory Protection Program Administrator with the Infection Preventionist is responsible for administering the respiratory protection program. Duties of the RPPA/IP include arrange for and/or conduct training and fit testing, and annually review the implementation of the program in consultation with employees and their representatives. The facility's Manual also indicated the procedure: V. Program Scope and Applications. This program applies to all employees who could potentially be exposed to airborne respiratory illnesses during routine work operations in the event of an influenza pandemic or other infectious respiratory disease emergency. Some of the types of work activities required to wear respirators are: Work Process, Location, Type of Respirator, Direct Patient Care, Patient Care Areas, N95 - Disposable PAPR, Housekeeping/Cleaning, Patient Care areas where pandemic/respiratory patients have stayed, N95 - Disposable PAPR A review of the facility's Respiratory Protection Infection Control Manual, revised 07/14/2017, the Respiratory Protection Infection Control Manual indicated procedure: IX. Respirator fit testing. After the initial fit test, fit tested must be completed at least annually, or more frequently if there is a change in status of the wearer or if the employer changes model or type of respiratory protection .Fit tests are conducted to determine that the respirator fits the user adequately and that a good seal can be obtained. Respirators that do not seal do not offer adequate protection. Fit testing is required for tight fitting respirators. Fit tests will be conducted prior to being allowed to wear any respirator. A review of the facility's Hand Hygiene, Infection Control Manual, date revised 9/1/2020, indicated the purpose was to establish the use of appropriate hand hygiene for all facility staff, healthcare personnel (HCP), residents, volunteers and visitors while at the facility. Facility staff follow the hand hygiene procedures to help prevent the spread of infections to other staff, residents, volunteers and visitors. The following situations require appropriate hand hygiene before donning and after doffing Personal Protective Equipment (PPE) and immediately upon entering and exiting a resident room A review of the facility's Mitigation Plan, updated 12/14/2020 indicated, residents will be cohorted in one of three distinct areas of the facility; green, yellow or red. Residents who test negative for COVID-19 and have no signs or symptoms of the illness are kept in the Green area. Residents who are under investigation for COVID-19 are kept in the Yellow area and those who are positive for COVID-19 are kept in the Red area. The facility's Mitigation Plan, updated 12/14/2020, indicated, in addition to standard precautions, additional PPE for transmission-based precautions should be used when caring for residents among the color coded areas of the facility. Red Area: Contact and Droplet Precautions, N95 respirator and eye protection. Yellow Area: Contact and Droplet Precautions, N95 respirator and eye protection. An N95 respirator should be worn for the duration of the shift and doffed when contaminated-do not reuse. Wear goggles or a face shield when providing care within six feet of a resident. Gowns should be worn and changed between resident encounters. Do not reuse gowns. Gloves are worn and changed between every resident encounter with adherence to hand hygiene. Green Area: Standard Precautions with surgical mask and eye protection. Wear surgical masks (or an N95 respirator if required). Use goggle or a face shield when providing care within six feet of a resident. Gowns should be worn and changed between resident encounters. Do no reuse gown. Gloves are worn and changed between every resident encounter with adherence to hand hygiene.

Based on observation, interview, and record review, the facility failed to ensure adequate supervision to prevent avoidable accidents and did not provide a safe environment, per the plan of care for one of two sampled residents (Resident 1). For Resident 1, who was a high fall risk and had impaired cognitive skills, the facility did not provide one to one (1:1) supervision (a sitter, continuous observation by a staff whose role it is to provide direct observation to an individual resident for a determined period), per physician's orders [REDACTED].>This deficient practice caused repeated falls for Resident 1, on [DATE] sustaining a laceration and bruise. Resident 1 fell on [DATE], resulting in transfer to the General Acute Care Hospital (GACH) where Resident 1 was diagnosed with [REDACTED]. Findings: A review of the Admission Record indicated Resident 1 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. of removing waste and excess water from the body). A review of the Fall Risk assessment, dated [DATE], indicated Resident 1 was a high risk for potential falls, unable to independently come to a standing position, and exhibited loss of balance while standing. A review of the Falls Care Plan created [DATE] and revised on [DATE] indicated Resident 1 would be free of falls through the review date of [DATE]. The care plan included interventions of ensuring resident's call light was within reach, anticipate and meet the resident's needs, and a safe environment. According to a review of the Quarterly Minimum Data Set (MDS- a standardized assessment and screening tool) dated [DATE], Resident 1 had severely impaired cognitive skills for decision making. The MDS indicated Resident 1 required total dependence with activities of daily living with one person assist, including but not limited to bed mobility, transfer, toilet use, and personal hygiene. A review of Resident 1's Change of Condition (COC) Documentation and Nursing Progress Notes, dated [DATE], indicated Resident 1 had two unwitnessed falls on the same day, at 12:30 PM (found beside the bed) and at around 2:30 PM, sustaining a small laceration on left neck and discoloration noted on left side of the face. The COC documentation indicated Resident 1 was not transferred to a hospital for the sustained injuries. During an observation on [DATE] at 2:20 PM, Resident 1 was noted with a bruise on her left eye and lacerations on her left neck. A review of Resident 1's neuro-check documentation from ,[DATE] - [DATE] indicated no abnormal findings. A review of Resident 1's Change of Condition (COC) Documentation and Nursing Progress Notes, dated [DATE], indicated Resident 1 sustained another unwitnessed fall with a small cut on top of the head, noted with minimal blood and slight swelling. The COC form indicated Resident 1 was grimacing upon contact and was transferred to a hospital for the sustained injuries at 9:30 AM. A review of Resident 1's Emergency Transfer Communication form dated [DATE], indicated a transfer time of 9:40 AM, via paramedics (911, emergency medical rescue). The resident had bruising to the left side of the face and a 1.5 centimeters (cm) [MEDICAL CONDITION]. According to a review of GACH 1 Emergency Department (ED) Provider Notes dated [DATE], Resident 1 had a Computed Tomography scan (CT - is a medical imaging procedure that uses computer-processed combinations of many x-rays to see inside the body) of the brain and showed chronic subdural hematomas. Resident 1 was discharged back to the facility on the same day ([DATE]). A review of Resident 1's Change of Condition Documentation and Nursing Progress notes, dated [DATE] (the day after returning from the hospital with a hematoma), indicated Resident 1 was found with her upper body touching the floor while lower body still hanging on the bed. The documentation indicated no signs of injury noted. A review of the physician's orders [REDACTED]. A review of the Nursing Progress Notes dated [DATE], timed at 11:55 AM indicated Resident 1 returned to the facility from the [MEDICAL TREATMENT] treatment, was placed in bed which was on the lowest position with floor mats present. Resident 1 requested to eat cereal and started feeding herself. A review of Resident 1's COC Documentation and Nursing Progress notes, dated [DATE], at 12:20 PM indicated Resident 1 sustained an unwitnessed fall (5). She was found by a CNA on the floor, on her right side, facing the window. No injuries were noted at the time of the incident. Resident 1 was not transferred out to the hospital for further evaluation. A review Resident 1's Falls Care Plan, revised [DATE], indicated Resident 1 will be free of falls. The care plan included interventions of ensuring resident's call light was within reach, anticipate and meet the resident's needs, and a safe environment. A review of Resident 1's Nursing Progress Note dated [DATE], timed at 1:01 AM documented by Licensed Vocational Nurse 3 (LVN 3), indicated Certified Nursing Assistant (CNA 2) informed the Charge Nurse (RN 1) at 12 midnight Resident 1 did not look well and was unresponsive. Resident 1 was unconscious (not alert or aware) and unresponsive (not reacting to touch or verbal commands), pale, and pupils dilated (indicating brain damage), with no vital signs (no blood pressure reading, no heart beats and no respiration). Staff initiated CPR, paramedics were called, arrived, and took over the CPR. A review of Resident 1's COC Documentation and Nursing Progress Notes, dated [DATE], indicated Resident 1 was found unconscious and unresponsive, pale, pupils dilated, and unresponsive to any stimuli. According to a review of the Paramedics Log dated [DATE], the paramedics arrived at 12:14 AM. The log disposition indicated Resident 1 was dead on arrival, Resident 1 dead at scene, and resuscitation attempted without transport. The log indicated time of death at 12:34 AM. A review of Resident 1's Certificate of Death, indicated Resident 1 expired on [DATE] at 12:33 AM with [MEDICAL CONDITION] as the immediate cause of death and the underlying cause was [MEDICAL CONDITION] ([MEDICAL CONDITION] - heart muscle is weakened and cannot pump enough blood to meet the body's needs for blood and oxygen). During an interview with Director of Nursing (DON) on [DATE] at 3:25 PM, the DON stated Resident 1 was on a 1:1 sitter starting on [DATE], 24 hours a day. She stated one to one means resident was supposed to be constantly watched by staff to prevent further falls. The DON stated no staff was with Resident 1 when she fell on [DATE]. During an interview with Director of Staff Development (DSD) on [DATE] at 3:45 PM, the DSD stated physician ordered a one to one sitter by Resident 1's bedside. The DSD stated due to previous multiple falls, 1:1 sitter should have been on every shift. The DSD stated she was responsible for scheduling a 1:1 sitter. The DSD stated she did not have a sitter on [DATE] morning shift 7 AM to 3 PM. The DSD further stated she did not have enough staff to provide a 1:1 sitter. She stated a sitter was there to ensure prevention of fall and not following physician's orders [REDACTED]. On [DATE] at 7:34 AM during an interview, LVN 3 stated she worked the 11 PM to 7 AM shift on the night of [DATE]. At around 11:05 PM she conducted rounds and Resident 1 was doing well. She stated Resident 1 was not in distress, and not complaining of pain upon initial assessment at 11:05 PM. LVN 3 stated Resident 1 had a sitter assigned, CNA 2. LVN 3 stated CNA 2 notified another nurse (RN 1) Resident 1 was not doing well. LVN 3 went to Resident 1's room at around 12 AM and the resident was pale, cold, had no pulse, and the pupils were dilated, and she did CPR. Paramedics took over and pronounced Resident 1 dead. During an interview with Certified Nursing Assistant 2 (CNA 2) on [DATE] at 7:51 AM, CNA 2 stated she was the assigned sitter for Resident 1 on night shift from 11 PM to 7 AM on [DATE]. CNA2 stated she found Resident 1 on the floor when she arrived at 11:05 PM, and informed Registered Nurse 1 (RN 1). CNA2 stated Resident 1 was put back in bed and her incontinent brief was very wet. She stated when she was changing Resident 1's diaper, she noticed her breathing had stopped around 11:15 PM and called for RN 1. During an interview on [DATE] at 8:03 AM, RN 1 stated around 11 PM CNA 2 told him Resident 1 was on the floor. RN 1 stated he checked on Resident 1 around 11:30 PM, at end of his shift, found Resident 1 on the floor and assisted her back to bed. RN 1 stated there was a gap between the sitters. During an interview on [DATE] at 8:43 AM, the DON stated Resident 1 had an unwitnessed fall on [DATE] at 12:50 PM. The DON stated Resident 1 was supposed to have a 1:1 sitter for that shift but did not have a sitter. The DON stated if the 1:1 sitter was present the fall could have been prevented. On [DATE], at 11:19 AM during an interview, the Assistant DON (ADON) stated the care plan interventions for Resident 1's fall risk and actual falls was not revised to include specific interventions to prevent falls. A review of the facility's policy and procedure titled, Fall Management Program, revised [DATE], indicated a resident who sustains multiple falls as defined as more than one fall in a day, week, or month, will be considered a high risk and as a result may sustain a major injury. These residents may require more frequent observation of activities and whereabouts.

Based on observation, interview, and record review, the facility failed to afford one of two sampled residents (Resident 1) the right to be free from physical restraints (any device attached or adjacent to the body that cannot be easily removed and restricts freedom of movement). Licensed Vocational Nurse 1 (LVN 1) tied Resident 1 to her wheelchair with an oxygen tank holder for wheelchairs. As a result, Resident 1's freedom of movement was inhibited and caused Resident 1 to call out for help and to feel scared. This deficient practice violated Resident 1's right causing a loss of dignity. Findings: A review of the Admission Record indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. of removing waste and excess water from the body). A review of Resident 1's Quarterly Minimum Data Set (MDS - a standardized assessment and screening tool) dated 6/5/2020 indicated Resident 1 had memory problems, was unable to make decisions, required total assistance with one-person physical assistance with all activities of daily living (ADLs - such as bed mobility, transfer, toilet use, and personal hygiene). A review of Resident 1's Change of Condition (COC) form, dated 6/18/2020, indicated staff reported Resident 1 was in a wheelchair with an oxygen strap around her. During an interview on 6/19/2020 at 1:15 p.m., Physical Therapist Assistant 1 (PTA 1) stated that on 6/18/2020 at around 1 p.m. or 2 p.m., she found Resident 1 in the room sitting in the wheelchair asking for help to go to the bathroom. PTA 1 stated she and Occupational Therapist Assistant 1 (OTA 1) moved Resident 1 into bathroom and observed Resident 1 tied to the wheelchair with a black oxygen tank holder/bag. Resident 1 was unable to get out of wheelchair. PTA 1 stated she with OTA 1 untied Resident 1 and assisted her onto the commode and then to the bed. PTA 1 and OTA 1 notified the Charge Nurse. On 6/19/2020 at 2:20 p.m., during an observation and concurrent interview, Resident 1 stated a woman had tied her onto her wheelchair; she was scared and could not get out of the wheelchair. Resident 1 stated she was calling for help to go to the bathroom and staff came and helped her. A review of the Corrective Action Memo, dated 6/25/2020, indicated Licensed Vocational Nurse 1 (LVN 1) was in charge, when Resident 1 was found restrained against her will and it was apparent LVN 1 failed to provide Resident 1 safety and was the primary suspect for placing the restraint on Resident 1. The facility terminated LVN 1. On 7/2/2020 at 9:35 a.m., during an interview, OTA 1 stated on 6/18/2020 she observed Resident 1 sitting in the wheelchair asking for help to go to the restroom. OTA 1 stated she took Resident 1 to the restroom and asked her to stand up but Resident 1 kept saying, Take it off. OTA 1 stated she removed the blanket off Resident 1 and noticed the resident tied to the wheelchair with an oxygen tank bag. OTA 1 stated she and PTA 1 removed the physical restraint. On 7/2/2020 at 10:35 a.m., a review of Resident 1's clinical record with the Director of Nursing (DON), indicated there was no documented physician's orders [REDACTED]. During an interview on 7/6/2020 at 8:43 AM the DON stated Resident 1 was found physically restrained to her wheelchair on 6/18/2020 by OTA and PTA. The DON stated the use of physical restraint was a last resort requiring physician order, IDT meeting for risk and benefits, and consent. She stated this process for the use of physical restraint was not conducted for Resident 1 physical restraint to wheelchair. She stated Resident 1's physical restraint is a form of physical abuse. She stated the potential outcomes of this type of physical restraint are bruising, fracture, hematoma, and potentially death. During an interview, on 7/6/2020 at 8:50 a.m., the Administrator stated the it was the facility's policy to get a physician's orders [REDACTED]. During an interview, on 7/6/2020 at 8:59 AM with Admin stated through the investigation he determined the most likely staff with access to Resident 1 to place her in physical restraint was Licensed Vocational Nurse 1 (LVN 1). The Admin stated LVN 1 was let go from the facility and he reported her to the nursing board. A review of the facility's policies and procedures titled, Restraints, revised 1/2012 indicated restraints require a physician's orders [REDACTED].

Based on observation, interview, and record review, the facility failed to ensure one of five sampled residents (Resident 1) environment was free of accident hazards, including, but not limited to: 1. Failure to follow Resident 1's care plan for moderate risk for falls, by not educating the caregivers about safety reminders, after the side rails were removed on [DATE], and changed to a grab bars. 2. Failure to conduct an interdisciplinary team (IDT, allows the members of the treatment team to coordinate care and to document the communication among all members of the team related to resident's plan of care and treatment goals) conference with Resident 1's responsible party before the removal of side rails as indicated in facility's Restraints policy and procedure revised [DATE]. 3. Failure to implement the facility's Performance Improvement Project to become side rail free by failing to provide an in-service to nursing assistants, and evaluating and monitoring the effectiveness of the removal of resident's side rails. These deficient practices resulted to Resident 1 slipping out of bed, hitting her head on a bedside dresser and sustained a bump on her right side of the head on [DATE]. Resident 1 was transferred to the General Acute Care Hospital (GACH), and admitted to intensive care unit (ICU, a designated area of a hospital facility that is dedicated to the care of residents who are seriously ill) with [DIAGNOSES REDACTED]. Finding: On [DATE] at 11:30 a.m., an unannounced visit was made to the facility to investigate a complaint regarding Quality of Care/Treatment. A review of Resident 1's admission record indicated Resident 1 was [AGE] year old female, re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS, an assessment and care-planning tool), dated [DATE], indicated Resident 1 had clear speech, difficulty communicating some words or finishing thoughts but able if prompted or given time, and usually understands most conversation. The MDS assessed Resident 1 as total dependence on full staff performance with bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed), dressing, and toilet use. A review of Resident 1's care plan for at moderate risk for falls, revised on [DATE], related to generalized weakness, cardiac artery disease, hypertension and dementia, indicated the goal is for Resident 1 will be free of falls through review date. The interventions included anticipate and meet resident's needs, educate the resident/family/caregivers about safety reminders, what to do if a fall occurs, and follow the facility protocol. A review of Resident 1's Side Rail Notification, dated [DATE] indicated Resident 1's FM was notified due to state regulations and restrictions side rails are now considered a restraint. The side rail notification further indicated the facility has a plan in place to become a restraint free facility by (MONTH) 1, (YEAR). All side rails are to be removed from all beds by this date. The comment section indicated Resident 1's FM paid $500.00 and wants to be reimbursed for the side rails. A review of Resident 1's physician order [REDACTED]. A review of Resident 1's Physical therapy Evaluation and Plan of Treatment dated [DATE], indicated Resident 1; a [AGE] year old female and long-term care resident was referred by nursing for assessment for mobility bars. The Physical therapy evaluation further indicated the facility is restraint free and resident's side rails have been removed. Per caregivers, Resident 1 previously rolled side-to-side using side rails as an enabler during care. Physical therapy recommendation for left and right mobility bars to enable resident to assist with turning during care. A review of Resident 1's side rail evaluation dated [DATE] indicated the risks/ benefits of side rails have been explained to the resident/surrogate which includes the risk of entrapment from the side rails which may result in the possibility of serious injury including death. The note indicated the family member (FM) who is the power of attorney wants mobility bar for the resident. A review of Resident 1's Situation-Background-Assessment-Recommendation (SBAR, technique provides a framework for communication between members of the health care team about a resident's condition) dated [DATE], at 9:00 p.m., indicated Resident 1 has a bump on the right side of the head. A review of Resident 1's physician order [REDACTED]. A review of Resident 1's Nursing Progress note dated [DATE], at 11:55 p.m., indicated the certified nursing assistant (CNA 1) was changing the bed and turned around to reach for a diaper and noticed Resident 1 sliding down the front of bed and the resident's head bumped bed side dresser corner. When Resident 1 lifted her head, CNA 1 noticed her right side of the head begin to swell. An ice pack was applied to bump; the physician and Resident 1's son were notified. The physician ordered to transfer Resident 1 to GACH. A review of Resident 1's GACH intensive care summary dated [DATE] indicated Resident 1 endured abnormal heart rhythms, mechanical ventilation (artificial ventilation where mechanical means is used to assist or replace spontaneous breathing), and several medications to sustain life, until passing on [DATE] at 7:40 a.m. A review of Resident 1's GACH Neuro Critical Care Intensive Care Unit Discharge Summary dated [DATE] indicated the admission [DIAGNOSES REDACTED]. Resident 1 presented to the GACH for evaluation of head injury sustained on [DATE] at 8:00 p.m. Resident 1 hit head against nightstand, and has associated head pain and swelling. The computed axial tomography (scan can reveal anatomic details of internal organs that cannot be seen in conventional X-rays) indicated subarachnoid hemorrhage (bleeding in the area between the brain and the thin tissues that cover the brain). A review of Resident 1's Death Certificate dated (MONTH) 31, (YEAR), indicated Resident 1 died on [DATE] at 7:40 a.m. The death certificate indicated the immediate cause of death was [MEDICAL CONDITION] (is a type of bleeding that occurs inside the skull (cranium) caused by fall. On [DATE] at 11:40 a.m., during a tour of the facility the Director of Nursing (DON) stated the facility is side rail free. On [DATE] at 3:10 p.m., during an interview with the DON, the DON stated the resident was evaluated for the use of grab bars by physical therapy. On [DATE] at 3:30 p.m., during an interview with the Director of Rehabilitation, the director of rehabilitation stated the residents were evaluated for the use of grab bars/mobility bars, and certified nursing assistants were educated (in-service) on how to use grab bars. During an interview with Resident 1's responsible party (FM) on [DATE], at 8:12 a.m., FM stated Resident 1 was a resident at the facility for [AGE] years and had three (3) previous falls. FM stated he told the facility's social service director (SSD) and staff he wanted side rails because Resident 1 has a history of falls, dementia (a broad category of brain diseases that cause a long-term and often gradual decrease in the ability to think and remember that is great enough to affect a person's daily functioning), and [MEDICAL CONDITION] (an irreversible, progressive disorder in which brain cells (neurons) deteriorate, resulting in the loss of cognitive functions, primarily memory, judgment and reasoning, movement coordination and pattern recognition). On [DATE] at 1:50 p.m., during an interview with the DON, the DON stated a quality assurance improvement plan (QAPI, a systematic, comprehensive, and data-driven approach to maintain and improve safety and quality in nursing homes while involving all nursing home caregivers in practical and creative problem solving) was used to implement removing side rails from resident's beds. The DON further stated side rails are not used for turning a resident unless the resident is able to assist by grabbing. On [DATE] at 3:27 p.m., during an interview with the Certified Nursing Assistant (CNA 1), CNA 1 stated Resident 1 was in bed with clothes on [DATE] around 9:00 p.m. CNA 1 put supplies at the edge of the bed and pulled the sheets back, which covered the supplies. CNA 1 stated that Resident 1 was on low air loss mattress and the bed was at waist level. CNA 1 stated Resident 1 raised her upper body and tilted, and her head went in between the bedside table and the bed. CNA 1 stated, the grab bar did not help. CNA 1 stated she did not receive an in-service related to working with residents with no side rails prior to the side rails removal. On [DATE] at 12:00 p.m., during an interview with CNA 2, CNA 2 stated she did not receive an in-service about working with residents without side rails before the removal of the side rails. CNA 2 further stated residents started to complaint and staff was in serviced about safety of working side rail free. On [DATE] at 9:20 a.m., during an interview with the SSD, SSD confirmed that Resident 1's FM (complainant) did not want the side rails removed. SSD stated, FM had the side rails placed on the bed and stated he had a receipt for the side rails. The report was given to the DON. On [DATE] at 12:05 p.m., during a follow up interview with CNA 2, CNA 2 stated again she did not receive an in-service related to the removal of side rails. When shown the facility sign in sheet with her signature titled Removal of side rails: to ensure safety and accident prevention upon removal of side rails frequent monitoring, reduce anxiety, and fear. CNA 2 explained the Director of Staff Development encourages employees to sign blank (no title) in service sheets during the morning huddle. During an interview with CNA 3 on [DATE] at 12:25 p.m., CNA 3 stated she did not receive an in-service related to working with resident's side rail free. CNA 3 further stated residents families were asking why the side rails were removed. CNA 3 confirmed she signed several blank in-service sheets during huddle because she was too busy to question why or what in-service. During a record review with the Administrator [DATE] at 1:40 p.m., the Administrator was unable to locate the Interdisciplinary Team conference record indicating Resident 1's FM participated in a conference related to Resident 1's safety with side rails. The Administrator stated he was unable to locate data related to the monitoring and effectiveness of the performance improvement project side -rail free. A review of the facility's Performance improvement project (PIP) guide dated [DATE] indicated the facility would study and act to be side rail free by [DATE]. The PIP further indicated the plan is to involve family, provide education, plan each side rail removal, in-service staff, and audit side rails. The facility policy titled Restraints revised dated (MONTH) 1, 2012, indicated if the resident or their representative refuses to consent, the interdisciplinary team will meet with the administrator, Ombudsman, attending physician, and the resident's surrogate decision maker to determine if the resident's physical or behavioral issues jeopardize the facility's ability to provide for the safety of the resident and/or others. The facility policy titled Quality Assessment & Assurance Program dated (MONTH) 1, 2012, indicated the facility implements and maintains an ongoing, facility wide quality assessment & assurance program designed to monitor and evaluate the quality of resident care, pursue methods to improve care quality, and resolve identified problems. The goal is to provide a means to identify and resolve present and potential negative outcomes related to resident care and safety.

Based on observation, interview and record reviews, the facility failed to prevent elopement (leaving without authorization) for one of two sampled residents (Resident 1). Resident 1 who had history of unspecified dementia (disease that cause memory loss) with elopement behaviors (leaves without permission) left the facility at night without being noticed due to the facility's door alarm was turned off. This deficient practice resulted in Resident 1 eloping from the facility, sustaining a fall outside of the facility, which resulted in a right [MEDICAL CONDITION]. Findings: A review of Resident 1's admission records indicated the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 1's Wandering Risk Assessment, dated [DATE], indicated Licensed Vocational Nurse 1(LVN 1) assessed the resident at high risk for wandering with a wandering risk score of 18 (high risk). The assessment indicated Resident 1 had history of wandering/a known wanderer. The assessment indicated Resident 1 was forgetful with short attention span. The assessment indicated Resident 1 was able to ambulate independently, but unable to understand his surroundings or what was being said to him due to language barrier and cognitive impairment. A review of Resident 1's Nursing Care Plan, dated [DATE], indicated there was no care plan developed to address the resident's high risks for elopement. Resident 1 had a care plan to address the resident's risks for falls related to confusion, gait/balance problems, psychoactive drug use, and unaware of safety needs. The goal was for the resident to be free from falls. The care plan interventions were for staff to anticipate and meet the resident's needs. A review of Resident 1's history and physical examination [REDACTED]. A review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care-screening tool, dated [DATE], indicated Resident 1 had impairment in cognition with a brief interview for mental status (BIMS) score of six (cognitive impairment). The MDS indicated Resident 1 required limited to extensive assistance from staff for bed mobility, transfers, dressing, walking, and personal hygiene. The MDS indicated Resident 1 had no functional limitation in range of motion (the full movement potential of joints) and the resident used walker and wheelchair for mobility. A review of Resident 1's Progress Notes, dated [DATE], timed at 5:20 a.m., entered by the night shift Registered Nurse Supervisor (RN 1), indicated on [DATE], at 1:10 a.m., LVN 1 noted the resident was walking toward the west station. At 1:15 a.m., LVN 1 noted Resident 1 had not came back to his room and she started to search for the resident in and outside of the facility. The progress notes indicated the front and back exit doors were locked at the start of the night shift and the door alarms did not go off. At 1:55 a.m., LVN 1 called the police department and filed a missing person report. A review of Resident 1's progress notes, dated [DATE] indicated on [DATE], at 9:30 a.m., a police officer called the facility and informed RN 2 that Resident 1 was transferred to a general acute care hospital (GACH 1) via emergency paramedic (911) after the resident fell on the street. A review of Resident 1's Wandering Risk Assessment, dated [DATE], indicated RN 1 assessed the resident at high risk for wandering with a score of 16 (high risk). The assessment indicated Resident 1 was a known wanderer with a history of wandering and able to ambulate independently without the use of assistive device. On [DATE], at 11 a.m., during an observation, facility's staff opened and closed the door at the ambulance entrance exit (the east exit, across from room [ROOM NUMBER], five rooms from Resident 1's room/room [ROOM NUMBER]), and the exit door alarm did not go off. Facility's staff entered and exited the building thru this exit door multiple times to put trash bags, and linen hampers outside of the facility. On [DATE], at 11:45 a.m., during an interview with LVN 2, she stated Resident 1 wandered everywhere. LVN 2 stated Resident 1 was able to walk by himself with a short distance. LVN 2 stated Resident 1 had short-term memory loss. LVN 2 stated sometimes, the resident asked her Where is my room? LVN 2 stated the resident did not have a wander guard (tracking application designed to prevent persons at risk from leaving a facility), and there was no wander guard detector at the exit doors. On [DATE], at 12:00 p.m., during an interview with Certified Nurse Assistant 1 (CNA1), she stated Resident 1 spoke Spanish and was able to understand some English. CNA 1 stated Resident 1 wandered and wanted to get out of the facility. CNA 1 stated Resident tried to go out of the facility thru the back exit door. CNA 1 stated she redirected Resident 1 back to his room when she saw the resident put his hands on the exit door handle. On [DATE], at 12:20 p.m., during an interview with the Maintenance Supervisor (MS), he stated the facility has five exit doors, four exit doors had alarms, and the front door had no alarm. The MS stated the evening shift supervisor locks the front door daily at 8:30 p.m. The MS stated one of four exit doors with the alarms had an alarm that was turned off. The MS stated the exit door alarm, across from room [ROOM NUMBER] was turned off due to the residents complained of the noise, and CNAs used that exit door to go out of the building. The MS stated the alarm was turned off 24 hours a day because day shift and night shift staff used the exit door to get in and out the building to put trash bags and linen hampers outside. The MS stated the laundry personnel collected the linen hampers from outside of the building. On [DATE], at 12:35 p.m., during an interview with the Director of Admission (DA), she stated on [DATE], Resident 1 eloped from the facility. On [DATE], Resident 1's family member asked her to re-admit the resident from the hospital, but the hospital transferred the resident to another facility (SNF 2), and asked the resident's family member to make a complaint against the facility regarding Resident 1's elopement. The DA stated on [DATE], she called SNF 2, and a staff from SNF 2 informed her that Resident 1 was transferred to GACH 2 via 911. The DA stated when she spoke to Resident 1's family member gain; the resident's family member informed her that the resident expired on [DATE]. On [DATE], at 1:10 p.m., during an interview with the Director of Staff Development (DSD), she stated LVN 1 told her that at the beginning of her shift (11p.m. to 7 a.m.), she saw Resident 1 walking toward the west station. The DSD stated LVN 1 and LVN 3 could not find Resident 1 and they notified the police. The DSD stated the police found Resident 1 on the street. On [DATE], at 3:00 p.m., during a telephone interview with LVN 1, she stated on [DATE], when she passed medication at 12:45 a.m., she saw Resident 1 walking around room [ROOM NUMBER] (the same hallway with the exit that had the alarm that was turned off). LVN 1 stated after 15 minutes, she passed medication at the east station and she saw Resident 1 near the elevator and the dining room. LVN 1 stated at 1:10 a.m., she could not find Resident 1. LVN 1 stated she reported the incident to the police department. LNV 1 stated the police officers had a community search with the helicopter and underground search but they could not find Resident 1. LVN 1 stated the exit door alarm should sound and she should hear the alarm when Resident 1 left the building. LVN 1 stated when she ended her shift at 7 a.m., Resident 1 was still not found. On [DATE] at 3:35 p.m., during an interview, the Registered Nurse Supervisor (RN 3) who worked on [DATE] from 3 p.m. to 11 p.m. shift stated on [DATE], she locked the front door around 9:00 p.m. RN 3 stated the front door had no alarm. RN 3 stated when she locked the front door, visitors could not enter the building but staff and residents from inside the building could open the door and go outside without the alarm. RN 3 stated the back east exit door at the east station across from room [ROOM NUMBER] was not locked and the alarm was not on. RN 3 stated she did not have the key for that back exit door. RN 3 stated staff used the east exit door to throw trash bags and bring linen hampers outside of the building. RN 3 stated the east exit door never have the alarm on. A review of Resident 1's emergency room (ER) Report from GACH 1, dated [DATE], at 6: 40 a.m., indicated the police officers brought the resident in the ER after they found him on the street. The report indicated Resident 1 sustained an unwitnessed fall and was conscious when found but unable to provide any history due to the resident had dementia. The ER report indicated Resident 1 wandered from SNF 1, had a fall and complained of right hip pain. The ER report indicated per Resident 1's family member, the resident has been living at SNF 1 for 20 days and the resident's condition is at his baseline, typically disoriented and at time becomes agitated. The ER report indicated per Resident 1's family member the resident has a history of wandering. A review of Resident 1's X-ray (imaging creates pictures of the inside of the body) report, dated [DATE], indicated there was an impacted fracture (when a bone is broken into several parts) through the neck of the right femur (the bone of the thigh, articulating at the hip and the knee). A review of Resident 1's Operating Room (OR) notes from GACH 1, dated [DATE], at 10:08 a.m., indicated Resident 1 was diagnosed with [REDACTED]. The OR report indicated Resident 1 had a right intertrochanteric [MEDICAL CONDITION] intramedullary nail (a metal rod forced into the medullary cavity of a bone). The OR report indicated Resident 1's wounds were irrigated and closed with 0 and ,[DATE] [MEDICATION NAME] (an absorbable, synthetic, usually braided suture) in the deep layer and staples superficially. The OR report indicated Resident 1 was placed in a sterile dressing and transferred to the post-anesthesia care unit (PACU). A review of the facility's policy and procedures titled Wandering & Elopement, dated (MONTH) 11, (YEAR), indicated to enhance the safety of residents of the facility; the facility will identify residents at risk for elopement and minimize any possible injury as a result of elopement. The licensed nurse, in collaboration with the interdisciplinary team (IDT, a team of professionals who work together to help the residents achieve their goals), will assess residents upon admission, readmission, quarterly, and upon identification of significant change in condition according to the Resident Assessment Instrument (RAI) guidelines to determine their risk of wandering/elopement. The resident's risk for elopement or wandering and preventative interventions will be documented in the resident's medical record, and will be reviewed and re-evaluated by the IDT upon admission, and upon change in condition according to the RAI guidelines. On [DATE], at 9:43 a.m., during an interview, the Licensed Vocational Nurse who helped with the admission paper work (LNV 4) stated when Resident 1 was assessed at high risk for wandering; the facility's staff need to put the resident on wandering monitoring. LVN 4 stated staff should notify Resident 1's physician regarding the resident's at high risks for wandering, and obtain an order from the physician for an alarm. LVN 4 stated staff should develop nursing care plan with staff interventions to address Resident 1's risks for wandering. On [DATE], at 10:10 a.m., during an interview, RN 4 stated Resident 1 had behavior of wandering, and he liked to talk about going home. RN 4 stated Resident 1's family members informed the facility's staff that they could not let the resident stay at home because the resident would find a way to elope from their house. RN 4 stated staff should develop a care plan to address the risks of wandering and the IDT should meet with Resident 1's family members to come up with interventions such as 1 to 1 sister, frequent rounding and monitoring to keep the resident safe in the facility. On [DATE], at 11:02 a.m., during an interview, CNA 2 stated Resident 1 was confused and oriented only to his name. CNA 2 stated the key to the east exit door was at the nursing station. CNA 2 stated any staff could get the key from the nursing station and lock the east exit door. CNA 2 stated the alarm did not go off when Resident 1 left the building due to staff did not turn the alarm on.

Based on interview and record review, the facility failed to have systems in place to ensure body slings (works like a hammock by supporting the body), attached to the lift (mechanical lift device used to move immobile residents) used during resident transfers were in good working condition to prevent serious fall to one of three sampled residents (Resident 1). On (MONTH) 14, (YEAR), during a transfer of Resident 1 from the bed to a wheelchair using a mechanical lift device two of the sling straps broke off, one of the sling straps broke off then another sling strap broke, causing Resident 1 to fall. Restorative Nurse Aide 1 (RNA 1) and Central Supply Staff 1 (CSS 1) both stated the sling used for Resident 1 was old. This deficient practice resulted in Resident 1 complaining of severe pain, 9 out of 10 (pain rating scale from zero, being no pain to 10, being excruciating pain), medicated for pain, transferred to the General Acute Care Hospital (GACH) and was diagnosed with [REDACTED]. Findings: According to the facility's admission records indicated Resident 1 was admitted to the facility on (MONTH) 3, 2008. The [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care-screening tool, dated (MONTH) 23, (YEAR), indicated Resident 1 was alert and oriented, and needed two-plus-persons physical assistance with transfers. A review of Resident 1's care plan, dated (MONTH) 27, (YEAR), for activities of daily living (routine activities that residents perform every day like eating, bathing, and dressing) indicated Resident 1 had self-care performance deficit related to spinal bifida (part of the spinal cord is exposed through a gap in the backbone), and general weakness. The care plan indicated Resident 1 was at moderate risk for falls related to paralysis and gait/balance problems. The intervention was to follow facility's fall protocol. A review of Resident 1's Progress notes, dated (MONTH) 14, (YEAR), at 12:44 p.m., indicated the resident was on the floor with a pillow underneath her head. Certified Nursing Assistant (CNA 1) and RNA 1 replaced the ripped body sling with a different one. The notes indicated Resident 1 was transferred back to bed, but denied having pain. On the same day at 11:03 p.m., (late entry) the notes indicated Resident 1 complained of right shoulder pain at around 5:50 p.m., (after the fall incident) and was medicated with Oxycodone (pain medication) 10 milligram (mg) for the pain. The notes, dated (MONTH) 15, (YEAR), at 3:36 a.m., indicated Resident 1 complained of 9 out of 10 pain and was medicated with Oxycodone Hydrochloride (pain medication for moderate to severe pain) 10 milligrams (mg) for breakthrough pain. Resident 1's blood oxygen saturation level (amount of oxygen in the blood) registered at 86 percent (normal ranges are from 90 percent to 100 percent). Resident 1 was administered oxygen, and blood oxygen saturation level registered at 95 percent. The primary physician was notified and ordered a transfer of Resident 1 to the GACH emergency department for further evaluation. A review of the GACH computerized tomography ((CT scan) combines a series of x-ray images taken from different angels), dated (MONTH) 15, (YEAR), indicated the CT scan of the pelvis (the large bony structure near the base of the spine (back bone) to which legs are attached) without intravenous contrast (medications injected in the vein to enhance the images) indicated an acute (sudden) fracture involving the superior (above) left anterior (towards the front of the body) sacrum (tailbone). The bones were demineralized (thinning of the bone). Resident 1 was medicated with Hydromorphone Hydrochloride (pain medication for moderate to severe pain) 1 mg injection, Morphine Sulfate (pain medication) 4 mg injection, along with Ondansetron (medication used to prevent nausea and vomiting) 4 mg disintegrating (dissolving) tablet orally (by mouth). A review of the undated Incident Report Progress notes documented by the 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) indicated on (MONTH) 14, (YEAR) at 10:30 a.m., while using a mechanical lift to transfer Resident 1, the resident had an assisted fall. The notes indicated RNA 1 was by the head of Resident 1, and CNA 1 was holding the legs when they noticed the resident shifting to the left side. RNA 1 then wrapped her arms around the Resident 1's body while CNA 1 obtained the remote for the lift and started to lower the resident. Once Resident 1 reached approximately half a foot from the floor, they again noticed the resident's body shifting, when both staff assisted the resident to the floor. RNA 1 was left holding the upper body and supporting the head of Resident 1, while CNA 1 called the charge nurse. Resident 1 was assessed but denied having pain. The sling was then changed so Resident 1 could be transferred back to the bed. The notes indicated around 3 a.m. (March 15, (YEAR)), Resident 1 complained of 9 out of 10 pain rating scale in which she was medicated with Oxycodone 10 mg for pain. Resident 1's blood oxygen saturation level registered at 86 percent. Resident 1 was administered oxygen and blood oxygen saturation level registered at 95 percent. The physician was notified and at 7 a.m., Resident 1 was transferred to GACH for further evaluation. The IDT notes indicated Resident 1 was at risk for fracture, and the staff were in-serviced regarding proper handling and transferring, especially for residents that were compromised. Further review of the IDT notes failed to address the type and age of the full body sling used for Resident 1 to prevent further falls and injuries. On (MONTH) 5, (YEAR), at 1:52 p.m., during a phone interview, CNA 1 stated as RNA 1 was helping her transfer Resident 1, one sling strap broke off, the resident dropped down, then another sling strap broke off, which made the resident fall even further. CNA 1 stated the sling used on Resident 1 was old because it has been in used for a while. CNA 1 did not know when the sling used on Resident 1 was last purchased or changed. On (MONTH) 5, (YEAR) at 5 p.m., during a phone interview, RNA 1 stated upon transferring Resident 1, the sling strap broke and the resident dropped down. RNA 1 stated as they were lowering Resident 1 to the floor, the second sling strap broke. On (MONTH) 7, (YEAR), at 9:41 a.m., during a phone interview, the Director of Nursing (DON) stated the sling used during Resident 1's transfer may have been old. On (MONTH) 7, (YEAR), at 9:50 a.m., during a phone interview, CSS 1 stated he had been employed in the facility for about a year and was in charge of ordering slings. CSS 1 stated sometime in (MONTH) (YEAR), the facility changed slings because they were old. He stated the sling used during Resident 1's transfer was called Proactive, which was one of the old ones that should have been removed. When asked why an old sling was used to transfer Resident 1, CSS 1 stated he was not sure why that particular sling was still being used. On (MONTH) 8, (YEAR) at 11:18 a.m., during a phone interview, the Administrator stated they no longer have the sling used during Resident 1's transfer because the facility threw it away. The Administrator was not sure what type of sling was used, when it was last ordered, and what was the facility's time frame for removing an old sling from being used. A review of facility's invoices for slings purchased, dated (MONTH) 12, and (MONTH) 10, (YEAR), indicated some slings were removed, and or replaced. However, the invoices did not mention about Proactive sling. According to the Proactive medical product instructions for full-body sling indicated to use only slings that are in good condition and to discard and destroy unusable slings. A review of facility's policy and procedures titled, Fall Management Program, revised (MONTH) 1, (YEAR), indicated the purpose was to prevent the resident fall and to minimize complications associated with falls through the development of a fall management program. The policy indicated the facility developed a fall management program that strive to prevent the resident falls through a meaningful assessments, interventions, education, and re-evaluation. The universal fall prevention measures that can be used in the prevention of falls included the environmental assessment. The policy indicated following the post-fall assessment, the IDT-fall committee will meet within 72 hours of a fall. The IDT-fall committee will review and document the root cause analysis, and interventions to prevent further falls.

Based on interview and record review, the facility failed to follow its policy/procedure regarding abuse, the residents' plan of care, and the physician's orders [REDACTED]. These deficient practices resulted in Resident 1 verbally abusing, bullying and threatening Residents 2, 3, 4, 5 and other residents who resided in the facility, which resulted in the residents crying, verbalizing fear, anxiety, and had limited freedom of movement in the facility for at least six months. Findings: a. A review of Resident 1's Admission Face Sheet indicated the resident was initially admitted to the facility on [DATE], and re-admitted on [DATE]. Resident 1 [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 4/27/17, indicated Resident 1's cognition was fully intact and was independent in activities of daily living, such as bed mobility, transferring, walking, eating, and personal hygiene. A review of Resident 1's plan of care, dated 12/28/16 and titled, Resident with identified Needs and Behaviors which may lead to Increase Risk for Conflict with Other Peers/Residents/Staff, related to Resident 1 entering other resident's rooms and accusing other residents of touching or invading his personal belongings. The staff's listed interventions included identifying the resident's increasing or escalating behaviors that required re-evaluation. The plan of care also indicated the staff would monitor the behaviors daily and investigate and report any identified behavior noted. A review of another plan of care for Resident 1, dated 3/3/17, and titled, Problem Behavior related to Socially Inappropriate/Disruptive Behavior, indicated the resident behaviors included screaming, yelling, and bullying residents. The staff's interventions included to attempt to point out the inappropriate behaviors; refocus the attention to something positive to avoid further escalations and report to the physician accordingly. A review of Resident 1's physician's orders [REDACTED]. There was no record of monitoring for resident's behavior by the staff. A review of a nurse' notes, dated 5/25/17 at 10:56 p.m., indicated Resident 1 had an argument with Resident 2. A review of the facility's investigative report, dated 5/26/17, indicated at approximately 4:30 p.m., a resident (Resident 2) reported to the Administrator that he and some other residents were being threatened by Resident 1. The report indicated Resident 2 stated Resident 1 was being very aggressive, banging tables, screaming at the visitors, and other residents. The investigative report indicated after an in depth investigation including interviews with the facility's staff, residents and family members, the investigation concluded Resident 1's aggressive behavior resulted in other residents feeling threatened. The investigation indicated that the police had to be called on several occasions due to Resident 1's behavior toward residents and was transferred to an assisted living facility on 6/1/17. A review of Resident 2's Admission Face Sheet indicated the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 2's MDS, dated [DATE], indicated the resident's cognition was intact and had no memory problems. On 6/1/17 at 1:10 p.m., during an interview, the Administrator stated that many of the residents stopped attending activities due to Resident 1's behavior. The Administrator stated he, some residents and family members feared for their lives, due to Resident 1 behavior. At 2:05 p.m., on 6/1/17, during an interview, Resident 1 stated on 5/31/17, the facility told him to leave and called the police on him, because he was accused of threatening to murder someone. b. On 6/1/17 at 2:50 p.m., Resident 3 stated, The resident (Resident 1) was a loud mouth, who takes other resident's food or belongings. Resident 3 stated a few days prior, while in the dining room, Resident 1 entered the dining room and began knocking over the residents' food trays. A review of Resident 3's Admission Face Sheet indicated the resident was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 3's MDS, dated [DATE], indicated the resident's cognition was intact and had no memory problems. On 6/1/17 at 3 p.m., during an interview, Resident 3's family member (FM 1) stated Resident 1 had stolen food from Resident 3's refrigerator and would yell loudly, and used bad language toward other residents. c. At 3:50 p.m., on 6/1/17, Resident 4 stated two weeks prior, he was sitting in the patio and Resident 1 came into the patio area and stated, Go. Resident 4 stated it made him upset and afraid to be spoken to like that and it made him cry. Resident 4 stated the Administrator was made aware but nothing was done, because the following day Resident 1 repeated the same behaviors toward him. There was no documented evidence of this incident. A review of Resident 4's Admission Face Sheet indicated the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 4's MDS, dated [DATE], indicated the resident's cognition and memory were intact. d. During an interview on 6/1/17 4:05 p.m., Resident 5 stated there have been several incidents with Resident 1. Resident 5 stated Resident 1 would walk back and forth in front of the television (TV) in the dining room and no one wanted to argue with him. Resident 5 stated once an older resident asked Resident 1 to move from in front of the TV and Resident 1 flipped his middle finger at her. Resident 5 stated during an activity outing Resident 1 stood up and began swearing/cursing at another resident, which made her feel embarrassed. Resident 5 stated Resident 1 would sit by her room and watch her, which made her afraid. Resident 5 stated the Administrator was made aware on several occasions of Resident 1's inappropriate behavior, but nothing was ever done. A review of Resident 5's Admission Face Sheet indicated the resident was last readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 5's MDS, dated [DATE], indicated the resident's cognition and memory were intact. During an interview on 6/1/17 at 4:13 p.m., the Activities Director (AD) stated she was aware of Resident 1's abusive behavior towards other residents. The AD stated approximately the third week of (MONTH) (YEAR), Resident 1 was arguing with another resident and gestured as if he wanted to hit the other resident. During a concurrent interview and record review on 6/1/17 at 4:45 p.m., the RNS 1 stated there was no documented evidence that the staff monitored Resident 1's behavior for screaming, yelling and bullying other residents, staff and family members. RNS1 further stated that there was no documented evidence for incidents involving Resident 1 and 3. A review of the facility's policy titled Abuse-Prevention Program, with a revised date of (MONTH) (YEAR), indicated the facility's purpose was to ensure the health, safety, and comfort of residents by preventing abuse and mistreatment. The policy also stipulated that the facility would not condone any form of resident abuse, neglect, misappropriation of resident property, exploitation and/or mistreatment, and develops facility policies, procedures, training programs, and systems in order to promote an environment free from abuse and mistreatment. The policy indicated that the administrator, who was the abuse prevention coordinator, was responsible for the coordination and implementation of the facility's abuse prevention policies and training.

Based on interview and record review, the facility failed to follow its policy/procedure regarding abuse, the residents' plan of care, and the physician's orders [REDACTED]. These deficient practices resulted in Resident 1 verbally abusing, bullying and threatening Residents 2, 3, 4, 5 and other residents who resided in the facility, which resulted in the residents crying, verbalizing fear, anxiety, and had limited freedom of movement in the facility for at least six months. Findings: a. A review of Resident 1's Admission Face Sheet indicated the resident was initially admitted to the facility on [DATE], and re-admitted on [DATE]. Resident 1 [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 4/27/17, indicated Resident 1's cognition was fully intact and was independent in activities of daily living, such as bed mobility, transferring, walking, eating, and personal hygiene. A review of Resident 1's plan of care, dated 12/28/16 and titled, Resident with identified Needs and Behaviors which may lead to Increase Risk for Conflict with Other Peers/Residents/Staff, related to Resident 1 entering other resident's rooms and accusing other residents of touching or invading his personal belongings. The staff's listed interventions included identifying the resident's increasing or escalating behaviors that required re-evaluation. The plan of care also indicated the staff would monitor the behaviors daily and investigate and report any identified behavior noted. A review of another plan of care for Resident 1, dated 3/3/17, and titled, Problem Behavior related to Socially Inappropriate/Disruptive Behavior, indicated the resident behaviors included screaming, yelling, and bullying residents. The staff's interventions included to attempt to point out the inappropriate behaviors; refocus the attention to something positive to avoid further escalations and report to the physician accordingly. A review of Resident 1's physician's orders [REDACTED]. There was no record of monitoring for resident's behavior by the staff. A review of a nurse' notes, dated 5/25/17 at 10:56 p.m., indicated Resident 1 had an argument with Resident 2. A review of the facility's investigative report, dated 5/26/17, indicated at approximately 4:30 p.m., a resident (Resident 2) reported to the Administrator that he and some other residents were being threatened by Resident 1. The report indicated Resident 2 stated Resident 1 was being very aggressive, banging tables, screaming at the visitors, and other residents. The investigative report indicated after an in depth investigation including interviews with the facility's staff, residents and family members, the investigation concluded Resident 1's aggressive behavior resulted in other residents feeling threatened. The investigation indicated that the police had to be called on several occasions due to Resident 1's behavior toward residents and was transferred to an assisted living facility on 6/1/17. A review of Resident 2's Admission Face Sheet indicated the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 2's MDS, dated [DATE], indicated the resident's cognition was intact and had no memory problems. On 6/1/17 at 1:10 p.m., during an interview, the Administrator stated that many of the residents stopped attending activities due to Resident 1's behavior. The Administrator stated he, some residents and family members feared for their lives, due to Resident 1 behavior. At 2:05 p.m., on 6/1/17, during an interview, Resident 1 stated on 5/31/17, the facility told him to leave and called the police on him, because he was accused of threatening to murder someone. b. On 6/1/17 at 2:50 p.m., Resident 3 stated, The resident (Resident 1) was a loud mouth, who takes other resident's food or belongings. Resident 3 stated a few days prior, while in the dining room, Resident 1 entered the dining room and began knocking over the residents' food trays. A review of Resident 3's Admission Face Sheet indicated the resident was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 3's MDS, dated [DATE], indicated the resident's cognition was intact and had no memory problems. On 6/1/17 at 3 p.m., during an interview, Resident 3's family member (FM 1) stated Resident 1 had stolen food from Resident 3's refrigerator and would yell loudly, and used bad language toward other residents. c. At 3:50 p.m., on 6/1/17, Resident 4 stated two weeks prior, he was sitting in the patio and Resident 1 came into the patio area and stated, Go. Resident 4 stated it made him upset and afraid to be spoken to like that and it made him cry. Resident 4 stated the Administrator was made aware but nothing was done, because the following day Resident 1 repeated the same behaviors toward him. There was no documented evidence of this incident. A review of Resident 4's Admission Face Sheet indicated the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 4's MDS, dated [DATE], indicated the resident's cognition and memory were intact. d. During an interview on 6/1/17 4:05 p.m., Resident 5 stated there have been several incidents with Resident 1. Resident 5 stated Resident 1 would walk back and forth in front of the television (TV) in the dining room and no one wanted to argue with him. Resident 5 stated once an older resident asked Resident 1 to move from in front of the TV and Resident 1 flipped his middle finger at her. Resident 5 stated during an activity outing Resident 1 stood up and began swearing/cursing at another resident, which made her feel embarrassed. Resident 5 stated Resident 1 would sit by her room and watch her, which made her afraid. Resident 5 stated the Administrator was made aware on several occasions of Resident 1's inappropriate behavior, but nothing was ever done. A review of Resident 5's Admission Face Sheet indicated the resident was last readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 5's MDS, dated [DATE], indicated the resident's cognition and memory were intact. During an interview on 6/1/17 at 4:13 p.m., the Activities Director (AD) stated she was aware of Resident 1's abusive behavior towards other residents. The AD stated approximately the third week of May 2017, Resident 1 was arguing with another resident and gestured as if he wanted to hit the other resident. During a concurrent interview and record review on 6/1/17 at 4:45 p.m., the RNS 1 stated there was no documented evidence that the staff monitored Resident 1's behavior for screaming, yelling and bullying other residents, staff and family members. RNS1 further stated that there was no documented evidence for incidents involving Resident 1 and 3. A review of the facility's policy titled Abuse-Prevention Program, with a revised date of November 2016, indicated the facility's purpose was to ensure the health, safety, and comfort of residents by preventing abuse and mistreatment. The policy also stipulated that the facility would not condone any form of resident abuse, neglect, misappropriation of resident property, exploitation and/or mistreatment, and develops facility policies, procedures, training programs, and systems in order to promote an environment free from abuse and mistreatment. The policy indicated that the administrator, who was the abuse prevention coordinator, was responsible for the coordination and implementation of the facility's abuse prevention policies and training.

Based on observation, interview, and record review, the facility failed to ensure one of 17 sampled residents (Resident 2) who was admitted to the facility with a stage IV pressure sore) was provided treatment and services to promote healing of an existing pressure sore by failing to: 1. Implement the care plan intervention to turn and reposition Resident 2 every two hours. 2. Ensure alternative nutritional supplements or interventions were assessed for effectiveness to increase Resident 2's low [MEDICATION NAME] level [MEDICATION NAME] (measures the amount of protein clear liquid portion of the blood (occur when the body does not get or absorb enough nutrients)), when the resident refused to take Prostat (protein supplement) as ordered by the physician. 3. Ensure Resident 2's low air loss mattress (LALM, a mattress that maintains proper pressure redistribution to prevent pressure sore) was set according to manufacturer's recommendation. As a result, these deficient practices resulted in non-healing of the resident's pressure sore, an increase in the size of the existing stage IV pressure, and presented a potential for the development of new pressure sores. Cross refer F325 Findings: During an initial tour of the facility on February 9, 2016, at 8:18 a.m., Resident 2 was observed lying in bed in a supine (lying on the back) position. At 11:30 a.m., and 1:00 p.m., Resident 2 was lying in bed in the same position on her back. Licensed vocational nurse (LVN 3) confirmed the resident had been lying on her back since 8:18 a.m. During interview with Resident 2 on February 9, 2016 at 11:30 a.m., during an inquiry about her activities, Resident 2 stated they do not allow me to get up from bed every day. On February 10, 2016, at 8:55 a.m., and 11:45 p.m., and on February 11, 2016, at 8:15 a.m., and 11:00 a.m., Resident 2 was observed lying on her back while in bed. A review of Resident 2's admission record indicated the resident was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The annual Minimum Data Set (MDS, a standardized resident assessment and care screening tool) dated October 18, 2015 indicated Resident 2's cognitive skills for daily decision-making were moderately impaired, and required extensive physical assistance with two staff for bed mobility, transfers and toilet use and was totally dependent for bathing. The MDS indicated the resident was frequently incontinent (inability to hold urine in the bladder or to keep feces in the rectum) of urine and bowel, and was assessed as being at risk of developing pressure sores and had two unstageable pressure sores (full thickness tissue loss in which the base of the ulcer is covered by slough ((a mass of dead tissue, yellow or white in color). A review of the quarterly MDS dated [DATE] indicated Resident 2 had an indwelling catheter (tube inserted into the bladder to drain urine), and was always incontinent of bowel. The MDS further indicated the resident had one stage I pressure sore (skin redness), and two stage IV pressure sores which measured seven (7) centimeter's (cm) in length x (by) 6 cm width x 2 cm depth. The pressure sore treatments included the use of a pressure reducing device for the chair and bed, a turning and repositioning program, nutrition or hydration intervention and pressure sore care. A review of Resident 2's sacral pressure sore weekly Skin Breakdown Progress Report indicated the following measurements: 1. On December 21, 2015, the sacral pressure sore measured 1.3 cm in length x 5.7 cm in width x by 1.7 in depth and was described as 90 granulation (tissue made up of granulations that temporarily replaces lost tissue in a wound), and 10 % slough. 2. On December 30, 2015, the sacral pressure sore measured 1.5 cm in length x 5 cm in width x 1 cm. in depth, and was described as 80 percent (%) granulation and 20 % slough. 3. On January 4, 2016, the sacral pressure sore measured 1.5 cm in length x 4.5 cm in width x 1 cm in depth and was described as 90 % granulating tissue and 10 % slough. 4. On January 15, 2016, 4 cm in length x 5.5 cm in width x 1 cm in depth with a note stating regression of ulcer and was described as 60 % granulating tissue, 20 % necrotic (death tissue), and 20 % slough. 5. On January 22, 2016, there was no documented measurement or description of the pressure sore. 6. On January 29, 2016, there was no documented measurement or description of the pressure sore. 7. On February 4, 2016, the sacral pressure sore was debrided (a process of removing dead tissue from pressure sore), and measured 8 cm in length x 8 cm in width x 2 cm. in depth and was described as 80 % granulating tissue, 20 % slough. 8. On February 11, 2016, the sacral pressure sore measured 8 cm in length x 8 cm in width x 2 cm. in depth and was described as 80 % granulating tissue, 20 % slough. During a wound treatment observation on February 11, 2016, at 9:50 a.m., in the presence of LVN 4, Resident 2 was observed with an irregular shaped stage IV pressure sore on her sacrum. The wound bed was beefy read, with redness on the surrounding skin and had serosanguinous (clear fluid and blood) drainage. During a subsequent interview with LVN 4, he stated that the wound doctor had seen the resident earlier that morning and stated that there was no improvement in pressure ulcer size. An undated care plan for the pressure sore on the sacral area and left medial buttock indicated the pressure sore was now one site and was described as a sacral pressure sore extending to the left medial buttock stage IV pressure sore. The care plan indicated Resident 2 was at a high risk for wound deterioration secondary to weight loss, bowel and bladder incontinence, low [MEDICATION NAME], left [MEDICAL CONDITION] and [MEDICAL CONDITION] (paralysis of the lower part of the body). The interventions included to provide diet as ordered and turn and reposition the resident every 2 hours. A review of Resident 2's nutritional and vitamins supplement recapitulated physician's orders [REDACTED]. 1. On August 8, 2015, the physician ordered to administer Vitamin C 500 milligrams (mg) daily, and [MEDICATION NAME] (Iron supplement) 325 mg daily. 1. On August 11, 2015, the physician ordered to provide a house supplement four (4) ounces (oz.) two times a day with meals. 2. On September 29, 2015, the physician ordered to provide a fortified diet (food [MEDICATION NAME] or fortified with vitamins and minerals). with regular texture. 3. On November 5, 2015, the physician order [REDACTED]. 4. On November 18, 2015, the physician ordered to administer MED PLUS 2.0 (calorie/protein supplements) four (4) oz. three times a day. 5. On November 29, 2015, the physician ordered to administer Zinc Sulfate 220 mg daily for supplement. A review of Weights and Vitals Summary indicated Resident 2's re-admission weight was 150 pounds (lbs), and on February 8, 2016, the resident weight was 134 lbs, a 10.7 percent (%) weight loss in 6 months. A Review of Resident 2's [MEDICATION NAME] level indicated on August 28, 2015, the resident's [MEDICATION NAME] level was 3.3 grams per deciliter (g/dL) (Normal therapeutic range is 3.5 to 5.7 g/dL). On October 5, 2015, the resident's [MEDICATION NAME] level decreased to 3.2 g/dL. On November 5, 2015, the [MEDICATION NAME] level had dropped to 3.0 g/dL. On November 9, 2015, the [MEDICATION NAME] level dropped to 2.6 g/dL. On December 10, 2015, the [MEDICATION NAME] level was 2.9 g/dL, on December 22, 2015, the [MEDICATION NAME] level was 3.4 g/dL and on February 3, 2016, the resident's [MEDICATION NAME] level was to 2.9 g/dL. A review of the registered dietician notes dated January 19, 2016 indicated the resident was refusing to take Prostat at times, as it makes her feel sick. There was no documented evidence other nutritional supplements or interventions were attempted to increase Resident 2's [MEDICATION NAME] level to promote wound healing. During an observation of Resident 2's low air loss mattress setting on February 11, 2016, at 9:50 a.m., accompanied by LVN 3, a permanent charge nurse, the low air loss mattress was set at six (6) corresponding to 245 lbs. The low air loss mattress setting indicated the higher the number, the firmness the low air loss mattress was. On February 8, 2016, the weight of Resident 2 was noted as 134 lbs. During a subsequent, interview with LVN 3 while in the resident's room, LVN 3 stated he was not aware of the low air loss mattress was to be set using resident's weight for firmness, and alternating pressure redistribution to promote wound healing. On February 11, 2016, at 10 a.m., during an interview with the director of staff development (DSD), she stated the low air loss mattress was a new mattress for the facility, and was not aware that the low air loss mattress had to be set based on the resident's weight, and the alternating pressure redistribution settings also had to be set. A review of In-service Education Attendance Record/Sign in Sheet dated October 30, 2015 for low air loss mattress indicated there was four licensed nurse attended the in-service. According to a list of active employees, there were 74 direct caregiver and licensed nurses working in the facility that should have been educated with the purpose and benefits of the low air loss mattress to the residents. A review of the undated Owner's Operator and Maintenance Manual indicated the comfort control level LED displays the resident comfort pressure levels from 0 to 9 and provides a guide to the caregiver to set approximate comfort pressure level depending on the resident's weight.

Based on observation, interview, and record review, the facility failed to ensure a resident who consistently eats less than 75 percent (%), had low protein level was offered with meal substitute, assessed and evaluated the effectiveness of nutritional interventions for one of 17 sampled residents (Resident 2). This deficient practice resulted in resident significant weight loss of 10.7 percent (%) in 6 months, and non-wound healing for a sacral stage IV pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle). Cross refer F314 Findings: During breakfast observation on February 11, 2016, at 7:40 a.m., Resident 2 was observed with an English muffin, a hard-boiled egg, a bowl of dry rice crispies, and a banana on her tray, untouched. Resident 2 stated she ate two graham crackers, one slice of bacon and 1/2 cup of tea. She stated she loves tea, raisin bran cereal and white bread and she did not like English muffin or toasted bread because they were too hard to chew. She stated that she likes pancakes but the facility did not serve pancakes every day. The diet slip was observed on resident tray indicated food preferences included pancakes. During an interview with the dietary supervisor (DS) on February 11, 2016, at 7:50 a.m., she stated when the resident eats less than 75 percent (%), the certified nursing assistant (CNA) would ask for substitutes. DS stated she talks to Resident 2 every day about her food preferences. A room observation on February 11, 2016, at 8:00 a.m., with Resident 2 in the presence of the DS, resident expressed her like for raisin bran every day, DS stated she was unaware of this food preference. According to Resident 2's admission record indicated the resident was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident admission weight was 150 pounds (lbs), 62 inches (in) tall. The annual Minimum Data Set (MDS, a standardized resident assessment and care screening tool) dated October 18, 2015 indicated Resident 2's cognitive skills for daily decision-making were moderately impaired, required extensive physical assistance for bed mobility, transfers and toilet use and was totally dependent with bathing. The MDS assessed the resident at a high risk for developing pressure ulcers, and had two unstageable pressure ulcers (full thickness tissue loss in which the base of the ulcer is covered by slough (yellow or white tissue). The MDS indicated the resident was on a therapeutic diet and was not on a physician-prescribed weight loss regimen. Mood behavior indicated no symptoms of behaviors including feeling down, depressed or hopeless or having poor appetite. The resident's weight was 145 pounds (lbs). A review of the quarterly MDS dated [DATE] indicated the resident was at risk for developing pressure ulcers and had one stage 1 pressure ulcer and two stage 4 pressure ulcers. The skin treatments included nutrition or hydration intervention to manage skin problems. The MDS indicated Resident 2 had no signs and symptoms of swallowing disorder, was on a therapeutic diet and on a physician-prescribed weight loss regimen. Mood behavior indicated no symptoms or frequency of behaviors including feeling down, depressed or hopeless or having poor appetite. The resident's weight was 134 lbs. The care plan (no date) for nutritional problem or potential nutritional problem related to variable intake and disease process, the goals indicated for Resident 2 to have meal and supplement intake greater than 75 percent (%) for 90 days. The interventions included calorie count for 3 days, change to fortified regular diet, give high protein nourishment (HPN) four (4) ounces (oz) two times a day with meals, Med plus 2.0 (high calorie, high protein supplement) three (3) oz two times a day with medications and Prostat (protein supplement) sugar free two (2) oz two times a day, and [MEDICATION NAME] (appetite stimulant) 400 milligrams (mg) for 30 days, and maintain blood test at acceptable range. Review of Resident 2's nutritional recapitulated physician's orders [REDACTED]. 1. August 11, 2015, a house supplements four (4) ounces (oz) two times a day with meals. 2. September 29, 2015, a fortified diet with regular texture 3. November 5, 2015, Pro-stat sugar free liquid 60 cubic centimeter (cc) by mouth two times a day for protein supplement. 4. November 18, 2015, MED PLUS 2.0 supplements four (4) oz three times a day. A review of the Certified Nursing Assistants (CNAs) resident's meal intake record from November 2015 to February 10, 2016 indicated Resident 2's meal intake consumption ranges from zero (0) to 50 percent (%). There was no documentation evidence that a meal substitutes were offered to the resident for meal intake less than 75 percent (%). During an interview with director of staff development (DSD) on February 10, 2016 at 5 p.m., stated the CNAs records the amount the resident ate by the percentage on the computer. DSD stated that residents are offered snacks and beverages on a hydration cart that goes from residents' room at 10 a.m. and at 3 p.m. DSD stated that there was no documentation of how much the resident had taken from the hydration cart. A review of CNAs resident's snack record intake from November 2015 to February 10, 2016 indicated the resident snack consumption ranges from zero (0) to 25 percent (%). There was no documentation evidence what type of snacks were given to the resident, to identify the nutritional value of the snacks consumed. A review of the Medication Administration Record [REDACTED]. Review of the MAR from November 2015, December 2015, January 2016 and February 11, 2016 indicated that the Med plus 2.0 supplements reflects the licensed nurses' initials. There was no documentation of how much the resident consumed. Review of the MAR for the month of February 2016 indicated for Pro-stat sugar free liquid (protein supplement) reflects the licensed nurses' initials. There was no documentation of how much the resident consumed. Resident 2's Weights and Vitals Summary indicated the following weights: 1. August 10, 2015, 150 lbs 2. September 7, 2015, 147 lbs 3. October 4, 2015, 143 lbs 4. November 2, 2015, 140 lbs 5. December 7, 2015, 134 lbs 6. January 4, 2016, 135 lbs 7. February 8, 2016, 134 lbs A significant weight loss of 16 pounds (lbs) (10.7% in six (6) months). A review of [MEDICATION NAME] (test to measure the amount of protein in the blood), and pre-[MEDICATION NAME] (marker for nutritional status, helps detect calorie-protein malnutrition) indicated the following: 1. November 5, 2015, [MEDICATION NAME] 3.0 grams per deciliters (g/dL) (therapeutic range 3.5 to 5.7 g/dL, and pre-[MEDICATION NAME] 10 milligrams per deciliter (mg/dL)(therapeutic range 17 to 34 mg/dL). 4. November 9, 2015, [MEDICATION NAME] 2.6 g/dL 5. December 10, 2015, [MEDICATION NAME] 2.9 g/dL 6. December 22, 2015, [MEDICATION NAME] 3.4 g/dL 7. February 3, 2016, [MEDICATION NAME] 2.9 g/dL Resident 2's sacral pressure ulcer (any lesion caused by skin pressure) Skin Breakdown Progress Report indicated on November 12, 2015 the pressure ulcer measurement was length 1.5 (centimeter) cm x (by) width 5 cm x depth 1 cm, and on February 4, 2016 length 8 cm x width 8 cm x depth 2 cm. There was an increase in size of pressure ulcer. During an interview, and records review with the registered dietician (RD) on February 11, 2016, at 11:30 a.m., she stated she was aware of Resident 2's continued weight loss, poor meal intake and [MEDICATION NAME] and pre-[MEDICATION NAME] not in therapeutic ranges. The RD stated Resident 2 did not like the taste of the protein supplement; RD agreed resident's nutritional interventions were not re-evaluated for effectiveness. The RD was not able to provide documented evidence that other nutritional interventions were attempted to prevent further weight loss and aid resident wound healing. She confirmed that the last nutritional interventions were last evaluated in November 2015. During an interview, and record review with registered nurse 2 (RN 2), a weight variance coordinator on February 10, 2016, at 5:30 p.m., she stated there was no evaluation for effectiveness of resident's nutritional consumption to prevent further weight loss. RN 2 stated there should have been an assessment and re-evaluation of nutritional intake. RN 2 was unable to provide specific documentation that other nutritional interventions were attempted to prevent further weight loss. The facility's policy and procedures titled Nutrition/Hydration Management dated December 1, 2015 indicated the nutrition management program addressed the factors contributing to actual or potential causes for inadequate nutrition status, and specific modification should be done in the resident's meal plan.