Chestnut Ridge Post Acute Llc

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to identify interventions related to one (1) of three sampled residents (Resident 1's) specific risks and causes to try to prevent the resident from falling by failing to: Ensure that Resident 1 was frequently monitored and checked for safety and not to leave frequently used items unreachable for Resident 1;Ensure that IDT (Interdisciplinary Team- a collaborative group of health professionals working together to manage patient care) identified and evaluated specific factors and causes after Resident 1 fell on [DATE] and 1/21/2026;Ensure that staff obtained physician's order for floor mat and applied as recommended by IDT and as in the Care Plan. As a result, Resident 1 sustained a four (4)-centimeter laceration on the right forehead on 11/11/2025 requiring suture, and a second fall on 1/21/2026 during similar timeframe. These deficient practices also had potential risks to place other residents at risk for falls. Findings: During a review of Resident 1's admission Record (AR) the AR indicated that Resident 1 was originally admitted to the facility on [DATE] and discharged on 2/11/2026 with diagnoses including Pressure Ulcer (localized damage to the skin and/or underlying tissue usually over a bony prominence) of Sacral Region(shield-shaped bony structure at the base of spine), Stage 4 (Full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone), Parkinson's Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), and hypertension (high blood pressure). During a review of Resident 1's Minimal Data Set (MDS- a federally mandated resident assessment tool) dated 12/8/2025, the MDS indicated that Resident 1 was moderately cognitively impaired (decisions poor, supervision required). The MDS also indicated that Resident 1 required substantial/maximal assistance (helper does more than half the effort) on toileting hygiene, and partial/moderate assistance (helper does less than half the effort) on sit to stand, chair/bed-to-chair transfer, and walking 10 (ten) feet. During a review of Resident 1's Nursing Progress Notes (NPN) dated 11/11/2025, the NPN indicated Resident 1 was found on his right side on the floor at 4:05 AM and noted to have right forehead laceration (a tear or ragged cut in skin or flesh). The NPN also indicated that 911 was called at 4:11 AM, and Resident 1 was transferred to the general acute care hospital (GACH) 1 via 911 paramedics at 4:30 AM. During a review of Resident 1's GACH 1 Emergency Department (ED) Discharge Instruction Document dated 11/11/2025, the Discharge Instructions indicated that Resident 1 had a laceration to the forehead and would require suture removal. During a review of Resident 1's IDT Conference Record - Fall Management Follow-Up (IDTCR) dated 11/11/2025, the record indicated interventions that included Medication Regimen Review (MMR a comprehensive evaluation of a patient's medication list), bed in lowest position, landing floor mat, and applying bed alarm (a safety device to detect when a person attempts to leave their bed). There was no documented evidence that indicated the cause of Resident 1's fall. During a review of Resident 1's NPN dated 1/21/2026, the NPN indicated Resident 1 was found on the floor next to the left side of the bed at 4:10 AM. Resident 1 was lying on the floor and had a snack bag in her hand. The NPN indicated that Resident 1 was alert but forgetful and stated that she was trying to reach the snack bag from the bedside table and slide down from bed. The NPN indicated Resident 1 was observed with skin redness on left side of the forehead and that Resident 1 stated she hit bedside table. During a review of Resident 1's IDT Conference Record - Fall Management Follow-Up (IDTCR) dated 1/21/2026, the IDTCR was incomplete since there were no checkmarks by the IDT that indicated suggestive appropriate interventions. During a review of Resident 1's Physician's Orders dated from 9/10/2025 to 1/29/2026, the Physician Orders did not indicate an order for floor mats. During a review of Resident 1's Care Plan Resident presents with deficits in strength, safety awareness. dated 12/19/2025, the Care Plan did not indicate to provide supervision for safety when Resident 1 had poor safety awareness and not remembering to use call light. During a review of Resident 1's Care Plan Resident had an actual fall with minor injury dated 11/11/2025 and 1/21/2026, the Care Plan did not indicate to ensure bed alarm was functioning. During a concurrent interview and record review on 3/31/2025 at 10:30 AM with the MDS Nurse (MDSN 1), Resident 1's clinical records were reviewed. MDSN 1 stated Resident 1 fell on [DATE] and 1/21/2026 around the same time between 4 AM and 4:30 AM. MDSN stated Resident 1's IDTCR should have been completed and thorough, and should indicate the cause of Resident 1's fall. MDSN stated Resident 1's Care Plan interventions for fall precautions should have included frequent monitoring even though there was a bed alarm to alert the staff about resident's movement in bed. MDSN stated that finding the causes of a resident's fall was important because it was the first step to develop a resident-centered care plan and apply appropriate interventions tailored to Resident 1's specific needs. During an interview on 3/31/2026 at 2:45 PM with the Director of Nursing (DON), the DON stated that Resident 1 had Parkinson's Disease and was cognitively impaired. The DON stated Resident 1 did not have a care plan for supervision after Resident 1 sustained her first fall on 11/11/2025. The DON stated she was not sure why floor mat was recommended by the IDT but never ordered or applied to Resident 1. The DON also stated the staff failed to try to identify and document specific factors and causes of resident's fall and failed to implement a resident-centered Care Plan interventions. The DON stated since the cause of the fall was not identified and specific needs were not implemented for Resident 1, the DON stated Resident 1 could likely sustain another fall. During a review of the facility's policy and procedures (P&P) Assessing Falls and Their Causes reviewed in 6/2025, the P&P indicated the following: Within 24 hours of a fall, try to identify possible or likely causes of the incident, Evaluate chains of event or circumstance preceding a recent fall, Continue to collect and evaluate information until the cause of falling is identified or it is determined that the cause cannot be found,Consult with the attending physician or medical director to confirm specific causes from among multiple possibilities. During a review of the facility's policy and procedures (P&P) Care Plans, Comprehensive Person-Centered reviewed in 6/2025, the P&P indicated that care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. The P&P also indicated that assessment of residents are ongoing and care plans are revised as information about the residents and residents' condition change.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1), who had a stage 4 (Full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone), pressure injury (PI localized damage to the skin and/or underlying tissue usually over a bony prominence) was provided care and services to prevent wound deterioration in accordance with the facility's policy and procedures titled Prevention of Pressure Injuries. This deficient practice placed Resident 1 at risk for delayed wound healing, infection, and negative outcome of Resident 1's prognosis.Findings: During a review of Resident 1's admission Record (AR) the AR indicated that Resident 1 was originally admitted to the facility on [DATE] and discharged on 2/11/2026 with diagnoses including PI of sacral region (shield-shaped bony structure at the base of spine) Stage 4 (Full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone), Parkinson's Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), and hypertension (high blood pressure). During a review of Resident 1's Minimal Data Set (MDS- a federally mandated resident assessment tool) dated 12/8/2025, the MDS indicated that Resident 1 was moderately cognitively impaired (decisions poor, supervision required). The MDS also indicated that Resident 1 required substantial/maximal assistance (helper does more than half the effort) on toileting hygiene, rolling left and right, and chair/bed-to-chair transfer. During a review of Resident 1's Braden Scale for Predicting Pressure Injury Risk dated 9/11/2025, indicated the total score was 16 (scale range 15 to 18 at risk for pressure injury). During a review of Resident 1's Skilled Evaluation Nurse Note (SEN) dated 9/11/2025, the SEN indicated pressure-reducing device for bed was checked off. The SEN did not indicate a checkmark to indicate that Resident 1 was turned and repositioned every two (2) hours. During a review of Resident 1's Care Plan Resident has sacrococcyx pressure injury Stage 4 dated 9/13/2025, the Care Plan indicated interventions included to cleanse with normal saline, pat dry, apply Santyl ointment (a topical medicine used to debride (remove) dead, necrotic tissue from chronic skin ulcers and severe burns to promote healing), cover with dry dressing then foam dressing daily. The Care Plan indicated to provide pressure relief and low air loss mattress (LAL-a mattress designed to prevent and treat pressure wounds), and to support good body alignment and position. The Care Plan did not indicate an individualized repositioning schedule, educate and remind residents of the importance of repositioning. During a review of Resident 1's Documentation Survey Report (DSR) dated from 11/1/2025 to 11/30/2025, the DSR indicated that Resident 1 was assisted to roll left and right every shift. The DSR did not indicate that Resident 1 was turned and repositioned every two (2) hours while in bed. The DSR did not indicate the frequency Resident 1's incontinence brief was checked and changed after each episode. During a review of Resident 1's Nursing Progress Notes (NPN) dated from 11/25/2025 to 11/27/2025, the NPN indicated that despite explaining to Resident 1 the purpose of a foley catheter (thin, flexible, indwelling tube inserted through the urethra into the bladder to drain urine into a collection bag) for a Stage four (4) Sacral PI wound healing, Resident 1 refused reinsertion of foley catheter. During a review of Resident 1's IDT (Interdisciplinary Team- a collaborative group of health professionals working together to manage patient care) Conference Record (IDTCR)- Wound Management dated 12/5/2025, the IDTCR indicated the following interventions utilized: Treatment per Physician's OrderMedication/Mineral/Vitamin SupplementsVitamin CLAL MattressPressure Reducing MattressLAL Mattress. There was no documentation in the IDTCR indicating that IDT identified incontinence (involuntary loss of bladder control, causing leakage) as one risk factor that could inhibit the healing process for Resident 1's stage 4 PI. There was no documentation in the IDTCR that indicated any new recommendations after Resident 1 refused reinsertion of foley catheter since 11/25/2025. During a review of Resident 1's Care Plan Resident has potential for injury, worsening in condition related to non-compliance as evidence by refusing to reinsert foley catheter dated 12/9/2025, the Care Plan did not include any wound protective measures or moisture preventive interventions. During a concurrent interview and a record review on 3/27/2026 at 3 PM with the Treatment Nurse (TXN), Resident 1's clinical records were reviewed. TXN stated since 11/25/2025 Resident 1 refused reinsertion of foley catheter the resident did not have a foley catheter prior to discharge. TXN stated she was not sure how often Resident 1 was turned/repositioned by staff. TXN stated she was not sure how frequent staff checked or changed Resident 1's incontinence brief. TXN stated that the facility did not develop or indicate on the Care Plan to ensure that Resident 1 was turned or repositioned at least every two hours. TXN also stated that the Care Plan regarding Resident 1 refusal of a foley catheter did not have effective measures to protect Resident 1's sacrococcyx PI. During an interview on 3/27/25 at 4PM with the Director of Nursing (DON), the DON stated that the staff were supposed to ensure that Resident 1 was turned at least every two hours and that Resident 1's wound dressing was protected from soiling by incontinence. The DON stated preventative measures like repositioning and moisture reduction were very important for Resident 1 to lower the risks for PI wound infection and deterioration, however IDT did not address this risk, therefore the Care Plan was not revised. During a review of the facility's Policy and Procedures (P&P) Prevention of Pressure Injuries reviewed in 6/2025, the P&P indicated the following: Keep the skin clean and hydrated,Clean promptly after episodes of incontinence,Use a barrier product to protect skin from moisture,Reposition all residents with or at risk of pressure injuries on an individualized schedule, Teach residents who can change positions independently the importance of repositioning. Provide support devices and assistance as needed. Remind and encourage residents to change positions.Review the interventions and strategies for effectiveness on an ongoing basis.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed notify the physician after a change in condition for one of three sampled residents (Resident 1) who was a diabetic (someone whose body cannot properly manage blood sugar levels) and had an episode of hypoglycemia (a condition where blood sugar drops below normal levels, typically under 70 mg/dL( unit of measurement used to show the concentration of a substance) on 3/6/2026 This deficient practice had the potential for Resident 1's hypoglycemic episode to recur resulting in weakness, confusion or even coma (unconsciousness) that could negatively affect Resident 1's quality of life.FINDINGS: During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 3/4/2026 with diagnoses that included type1 diabetes (a chronic autoimmune condition where the immune system destroys insulin-producing beta cells in the pancreas, leading to little or no insulin production), duodenal ulcer (ulcer that appears in the first part of the small intestine, called the duodenum), and muscle weakness. During a review of Resident 1's History and Physical Examination (H&P), dated 3/6/2026, the H&P indicated Resident 1 was alert and oriented to person and place. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 3/6/2026, the MDS indicated Resident 1's cognitive status (the mental process of thinking and understanding) was intact. The MDS indicated Resident 1 required set-up or clean-up assistance (helper sets up and clean up) with eating, and partial/moderate assistance (helper does less than half the effort) with toileting, bathing and dressing. During a review of Resident 1's facility document titled Order Summary Report (a physician order), dated 3/6/2026 -active orders, indicated the following orders:call provider immediately if resident is hypoglycemic (less than 70 mg/dl), call provider as soon as possible when blood glucose values are regularly 70- 100 mg/dl ( for possible regimen adjustment).Inject Insulin Glargine (long-acting insulin) subcutaneously (SC) (under the skin) 30 units (dose strength) at bedtime.Inject Insulin Lispro (rapid acting insulin) 11 units SC before breakfast and before dinner.Inject Insulin Lispro 14 units SC before lunch. During a review of Resident 1's Care Plan (CP) for Resident 1's diabetes, dated 3/5/2026, the CP intervention indicated to call provider immediately if resident was hypoglycemic (less than 70 mg/dl), call provider as soon as possible when blood glucose values are regularly 70- 100 mg/dl (for possible regimen adjustment). During a review of Resident 1's facility document titled Progress Notes (PN) dated 3/6/2026 timed at 3:49 PM, the PN indicated Resident 1's blood sugar before lunch was 371 mg/dL, and insulin was administered. The PN indicated after lunch Residents blood sugar was checked again and it was 60 mg/dL, then Resident 1 was given juice and a parfait. Resident 1s blood sugar was reassessed and the blood sugar increased to 72 mg/dL. Resident 1 was monitored with no signs of distress. The PN did not indicate that the medical doctor (MD) was notified regarding Resident 1's hypoglycemic episode. During an interview on 3/17/2026 at 11:30 AM with Licensed Vocational Nurse (LVN) 1, LVN 1 stated on 3/6/2026 around 11:30 AM, prior to lunch, Resident 1's blood sugar was 371mg/dL, so LVN 1 administered 14 units of insulin to Resident 1's as ordered, then LVN 1 rechecked Resident 1's blood sugar around 1 PM after lunch, and Resident 1's blood sugar was 60mg/dL. LVN 1 stated she gave Resident 1 some juice and a parfait as part of her nursing measure to increase Resident 1's blood sugar. LVN 1 stated Resident 1 was asymptomatic. LVN 1 stated she rechecked Resident 1's blood sugar and was 72mg/dL. LVN 1 continued to monitor Resident 1 for any distress. LVN 1 stated, she forgot to notify the MD of Resident 1's change of condition (COC). LVN 2 stated by not notifying the MD of Resident 1's COC, Resident 1 could potentially remain hypoglycemic. LVN 1 stated, if MD was made aware of the COC, MD could have made changes on Resident 1's insulin regimen to prevent another hypoglycemic episode. During a concurrent interview and record review, on 3/17/2026 at 12:30 PM with the Director of Nurses (DON), Quality Assurance nurse (QA) and medical record director (MRD), Resident 1's electronic health record (EHR) from admission on [DATE] until discharge on [DATE] was reviewed. The EHR did not indicate that MD was made aware of Resident 1's COC on 3/6/2026. MRD stated, she did not see any COC, and she did not see any documentation that MD was notified of Resident 1's COC. QA stated the MD should have been notified immediately regarding Resident 1 being hypoglycemic as ordered by the physician when Resident 1's blood sugar was less than 70mg/dL. QA stated there was no documentation in Resident 1's EHR that the MD was made aware of the hypoglycemic episode. DON stated, even though Resident 1 had a planned discharge later that day, MD still should have been notified that Resident 1 was hypoglycemic, so MD could make adjustments, if needed, to Resident 1's insulin regimen and to prevent the potential of the hypoglycemic episode to reoccur, which could lead to weakness, confusion or even coma. A review of the facility's policy and procedure (P&P) titled, Management of Hypoglycemia, dated 10/2025 indicated; a) classification of level 1 hypoglycemia : blood glucose less than 70 mg/dl, but greater than 54 mg/dl, b) for level 1 hypoglycemia give resident an oral form of rapidly absorbed glucose and notify the provider immediately. A review of the facility's policy and procedure (P&P) titled, Change in a Resident's Condition or Status, dated 5/2017, indicated: a) the facility shall promptly notify his or her attending physician of changes in the resident's medical condition, b) the nurse will notify the resident's attending physician or physician on call when there has been a specific instruction to notify Physician of changes in the resident's condition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide care and services to ensure one of three sample residents (Resident 1) with blisters (a painful skin condition filled with fluid fills a space between layers of skin) due to shingles (an infection caused painful rash) was assessed, monitored and documented weekly for two weeks the skin condition in accordance with the facility's policy and procedures (P&P) titled, Wound Care. This deficient practice had the potential for Resident 1's to receive delayed care or no care when the resident's skin condition with blisters due to shingles to worsen, become infected, and could also spread to other vulnerable residents in the facility. Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility originally admitted Resident 1 on 5/20/2025 and readmitted on [DATE] with diagnoses that included anxiety disorder (a normal feeling of worry or fear in response to stress) and hypertension (high blood pressure). During a review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care planning screening tool), dated 12/24/2025, the MDS indicated Resident 1 had moderately impaired cognitive (ability to understand and make decisions) skills for daily decision making. The MDS indicated Resident 1 required partial/moderate assistance with eating, oral hygiene, personal hygiene and chair/bed-to-chair transfer, and substantial/maximal assistance with toileting hygiene and shower/bathe self. During a review Resident 1's Physician Order, dated 12/24/2025, the order indicated the physician ordered to cleanse the shingles rash on bilateral buttocks in the morning with normal saline, pat dry, and cover with foam dressing daily for 14 days. During an interview on 1/8/2026 at 1:02 PM with Certified Nursing Assistant (CNA) 1, CNA 1 stated she assisted the Treatment Nurse (TXN) to assess Resident 1's skin when the resident was admitted to the facility on [DATE]. CNA 1 stated she saw Resident 1 had some red closed dots on her low back area and Resident 1 complained it was painful in that area. During a concurrent interview and record review on 1/8/2026 at 2:55 PM with the TXN, Resident 1's medical record was reviewed. The TXN stated Resident 1 had shingles and she saw red blisters on Resident'1 lower back area when she assessed Resident 1 on 12/19/2025. The TXN stated the Registered Nurse (RN) supervisor was responsible with documenting Resident 1's skin condition related to blisters, but the RN supervisor did not document the condition of the blisters in the resident's clinical record. The TXN stated the there was no documentation in Residen1's clinical record that indicated the resident's blisters was assessed, documented and monitored for two weeks since 12/19/2025 The TXN stated she was off for the past two weeks and the covering nurses did not assess and complete the Weekly Skin Check for Resident 1 from 12/26/2025 and 1/2/2026. The TXN stated it was important to assess the skin and document the assessment on the admission and weekly afterwards, so they could monitor the healing progress of the shingles and evaluate the effectiveness of the current treatment. The TXN stated if Resident 1's blisters condition worsens compared to the previous assessment; they could intervene immediately to prevent the wound and the infection from getting worse. During a concurrent interview and record review on 1/8/2026 at 3:15 PM with the Infection Preventionist (IP), Resident 1's medical record was reviewed. The IP stated she was aware Resident 1 had shingles and blisters upon admission on [DATE]. The IP stated there was no documentation indicated Resident 1's skin condition due to shingles were assessed, documented and monitored since her admission on [DATE]. The IP stated the nurses should assess and document Resident 1's skin condition due to shingles upon admission and weekly afterwards, so she could monitor the healing status of Resident 1's shingles and prevent potential spread of shingles virus to other vulnerable residents in the facility. During an interview on 1/8/2026 at 3:33 PM with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she was covering for the TXN to provide wound care to Resident 1 for past two weeks, but she did not know and was not endorsed to assess and complete the Weekly Skin Check for Resident 1 for the past two weeks. During a concurrent interview and record review on 1/9/2026 at 3:00 PM with the Director of Nursing (DON), the facility's policy and procedures (P&P) titled, Wound Care, dated 10/ 2010, and admission Assessment and Follow Up: Role of the Nurse, dated 9/2012, were reviewed. The DON stated the RN supervisor did not assess and document Resident 1's shingles blisters condition on Skin Check upon admission on [DATE] and the nurses did not assess and document the Weekly Skin Check for Resident 1's blisters on 12/26/2025 and 1/2/2026. The DON stated it was important to assess and document Resident 1's shingles blisters upon admission, so they would know the baseline condition. The DON stated the facility's P&P did not indicate the frequency of follow up skin assessment, but as the facility's practice, the nurses should reassess and document the shingles blisters condition weekly so they could monitor the healing process of the blisters and determine when and how to intervene timely to promote wound healing and prevent the spread of shingles to other residents. During a review of the facility's P&P titled, Wound Care, dated 10/2010, the P&P indicated the nurse should record all assessment data obtained when inspecting the wound and any change in the resident's condition in the resident's medical record. During a review of the facility's P&P titled, admission Assessment and Follow Up: Role of the Nurse, dated 9/2012, the P&P indicated the nurse should conduct physical assessments, including skin assessment, and record all relevant assessment data obtained during the admission assessment in the resident's medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that a physician's order for a resident's code status preference that included the resident's Provider Orders for Life-sustaining Treatment (POLST-a set of portable medical orders that communicate a patient's wishes for end-of-life intervention to health care facilities and providers) was readily retrievable and placed in the residents' current medical chart for 11 out of 100 sampled residents (Resident 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 and 11), in case of an emergency and in accordance to the facility's Policy and Procedure (P&P) titled, Advance Directive. This deficient practice had the potential to delay life sustaining measures during a medical emergency. Findings: During a review of Resident 1's admission Record, (AR) the AR indicated the resident was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD, [a progressive lung condition making breathing difficult), chronic bronchitis (inflamed airways), emphysema (damaged air sacs), and respiratory failure (condition where the lungs can't adequately oxygenate the blood or remove carbon dioxide). During a review of Resident 1's History and Physical (H&P), dated [DATE], the H&P indicated the resident does not have the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (a resident assessment tool), dated [DATE], the MDS indicated that Resident 1 has severely impaired cognition (the ability to process thoughts and emotions). The MDS also indicated that the resident did not have a life expectancy of less than 6 months at the time of assessment. The MDS further indicated that the resident did not have a POLST in the resident's medical chart. During a review of Resident 2's admission Record indicated the resident was admitted on [DATE] with diagnoses that included metabolic encephalopathy (when the brain has trouble working because of a chemical, or metabolic, problem in the body), hypertension (high blood pressure), and hyperlipidemia (high cholesterol level). During a review of Resident 2's History and Physical (H&P), dated [DATE], indicated the resident does not have the capacity to understand and make decisions. During a review of Resident 2's MDS dated [DATE], the MDS indicated that the resident has severely impaired cognition. The MDS also indicated that the resident had a POLST in the resident's medical chart. During a review of Resident 3's admission Record indicated the resident was originally admitted on [DATE], and readmitted on [DATE], with diagnoses that included chronic kidney disease (CKD, a disease characterized by progressive damage and loss of function in the kidneys), cardiomegaly (an enlarged heart), and dementia (progressive loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). During a review of Resident 3's History and Physical (H&P), dated [DATE], indicated that the resident has fluctuating capacity to understand and make decisions. During a review of Resident 3's MDS, dated [DATE], the MDS indicated the resident has severely impaired cognition. The MDS also indicated that the resident did not have a POLST in the resident's medical chart. During a review of Resident 4's admission Record indicated the resident was admitted on [DATE] with diagnoses that included pneumonia (a lung infection), muscle weakness, and dysphagia (difficulty swallowing). During a review of Resident 4's H&P, dated [DATE], the H&P indicated that the resident does not have the capacity to understand and make decisions. During a review of Resident 4's MDS, dated [DATE] the MDS, indicated that the resident has moderately impaired cognition. The MDS also indicated that the resident had a POLST in the resident's medical chart. During a review of Resident 5's admission Record indicated the resident was originally admitted on [DATE], and readmitted on [DATE], with diagnoses that included COPD, muscle weakness, and hypertension. During a review of Resident 5's H&P, dated [DATE], indicated that the resident does have the capacity to understand and make decisions. During a review of Resident 5's MDS, dated [DATE], the MDS, indicated that the resident has moderately impaired cognition. The MDS also indicated that the resident had a POLST in the resident's medical chart. During a review of Resident 6's admission Record indicated the resident was admitted on [DATE] with diagnoses that included osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and CKD. During a review of Resident 6's H&P, dated [DATE], the H&P indicated that the resident has fluctuating capacity to understand and make decisions. During a review of Resident 6's MDS, dated [DATE], the MDS indicated that the resident has moderately impaired cognition. The MDS also indicated that the resident had a POLST in the resident's medical chart. During a review of Resident 7's admission Record indicated the resident was admitted on [DATE] with diagnoses that included quadriplegia (paralysis affecting all four limbs and the torso, usually from a spinal cord injury in the neck but also from brain trauma or disease), muscle weakness, and hypertension. During a review of Resident 7's H&P, dated [DATE], the H&P indicated that the resident does have the capacity to understand and make decisions. During a review of Resident 7's MDS, dated [DATE], the MDS indicated that the resident has moderately impaired cognition. The MDS also indicated that the resident had a POLST in the resident's medical chart. During a review of Resident 8's admission Record indicated the resident was admitted on [DATE] with diagnoses that included COPD, bipolar disorder (a mental health condition causing extreme mood swings), and depression (a serious mood disorder causing persistent sadness, loss of interest, and impacting thoughts, feelings, and daily life). During a review of Resident 8's H&P, dated [DATE], the H&P indicated that the resident does have the capacity to understand and make decisions. During a review of Resident 8's MDS, dated [DATE], the MDS indicated that the resident has intact cognition. The MDS also indicated that the resident had a POLST in the resident's medical chart. During a review of Resident 9's admission Record indicated the resident was admitted on [DATE] with diagnoses that included CKD, dementia, and hypothyroidism (a condition where the thyroid gland doesn't make enough thyroid hormone). During a review of Resident 9's H&P, dated [DATE], the H&P indicated that the resident does not have the capacity to understand and make decisions. During a review of Resident 9's MDS, dated [DATE], the MDS indicated that the resident has moderately impaired cognition. The MDS also indicated that the resident had a POLST in the resident's medical chart. During a review of Resident 10's admission Record indicated the resident was admitted on [DATE] with diagnoses that included diabetes mellitus, muscle weakness, and endocarditis (a serious inflammation of the heart's inner lining and valves). During a review of Resident 10's H&P, dated [DATE], the H&P indicated that the resident does have the capacity to understand and make decisions. During a review of Resident 10's MDS, dated [DATE], the MDS indicated that the resident has severely impaired cognition. The MDS also indicated that the resident did not have a POLST in the resident's medical records. During a review of Resident 11's admission Record indicated the resident was admitted on [DATE] with diagnoses that included diabetes mellitus, intracerebral hemorrhage (bleeding in the brain), and hypertension. During a review of Resident 11's H&P, dated [DATE], the H&P indicated that the resident does have the capacity to understand and make decisions. During a review of Resident 11's MDS, dated [DATE], the MDS indicated that the resident MDS indicated that the resident has moderately impaired cognition. The MDS also indicated that the resident had a POLST in the resident's medical chart. During an interview on [DATE] at 11:47 AM with licensed vocational nurse (LVN) 1, LVN 1 stated that on [DATE] at around 3 PM to 3:15 PM, Registered Nurse (RN) 1 went into Nursing Station (NS) 3 to check Resident 1's medical chart and identify what Resident 1's code status was. LVN 1 stated that RN 1 could not locate Resident 1's POLST. LVN 1 stated that after not being able to find the resident's POLST, RN 1 instructed the nurses to initiate CPR. LVN 1 stated when a POLST or a code status order was not found, the resident was treated as full code (a patient wants all possible life-saving measures, including CPR [chest compressions, defibrillation], intubation [breathing tube], and mechanical ventilation, if their heart stops or they stop breathing). During a telephone interview on [DATE] at 1:18 PM with RN 1, RN 1 stated that on [DATE] at around 3 PM, LVN 2 informed her in NS 1 that Resident 1 was unresponsive and pulseless. RN 1 stated that she went from NS 1 to NS 3 to look for Resident 1's code status. RN 1 stated that she could not find Resident 1's POLST or code status in Resident 1's current medical chart. RN 1 stated that she instructed the nurses to initiate CPR since there was no POLST or code status, therefore Resident 1 was treated as full code. During an interview on [DATE] at 4:53 PM with the Director of Nursing (DON), the DON stated that the facility could not find Resident 1's POLST or Advance Directive (AD a written statement of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) in the current medical chart. DON stated that the POLST or AD might be in the resident's old chart, since the POLST or AD was not in Resident 1's current medical chart. During a concurrent interview and record review on [DATE] at 8:47 AM with the DON, Resident 1's POLST, dated [DATE], was reviewed. The DON stated that she had found Resident 1's POLST in the resident's previous medical chart. The DON stated that the document was still valid on [DATE] when Resident 1 was found unresponsive. The DON stated that the POLST was part of the resident's AD and the AD should have been placed in the resident's current chart since the nurses look for the POLST when a resident was found unresponsive to determine if CPR should be performed. The DON further stated that not having the POLST or AD in the chart could cause a delay in performing CPR during a medical emergency. During a concurrent interview and record review on [DATE] at 11:38 PM with RN 3, the electronic and current medical charts of the facility's 100 residents were reviewed for their completeness, including the presence of a POLST and AD. During the record review, the records of Resident 2, Resident 3, Resident 4, Resident 5, Resident 6, Resident 7, Resident 8, Resident 9, Resident 10, and Resident 11 did not include a POLST or AD. RN 3 stated that she could not find the residents' POLST or AD. RN 3 stated that the POLST or AD must be in the charts because the nurses need the POLST or AD during a medical emergency to ensure the residents wishes were performed and that facility staff follow the residents wishes. The RN 3 stated a medical emergency example was when a resident was found unresponsive and pulseless. During a concurrent interview and record review on [DATE] at 3:35 PM with Social Worker (SW) 1, Resident 2's records were reviewed. SW 1 stated Resident 2's POLST was on SW 1's email and not placed in Resident 2's medical chart. SW 1 stated that the POLST must be printed and in the resident's physical chart. During a concurrent interview and record review on [DATE] at 3:35 PM with SW 1, Resident 3's records were reviewed. SW 1 stated that Resident 3's POLST was not in the resident's records because the resident was transferred to a different facility prior to the most recent admission. SW 1 stated Resident 3's POLST was found in Resident 3's previous medical records and not placed in Resident 3's current medical chart. During a concurrent interview and record review on [DATE] at 3:35 PM with SW 1, Resident 4's records were reviewed. There was not POLST for Resident 4 found. SW 1 stated she did not know if Resident 4 has a POLST. During another concurrent interview and record review on [DATE] at 3:35 PM with SW 1, Resident 5's records were reviewed. Resident 5's POLST could not be found. SW 1 stated Resident 5's POLST might be in the resident's old records. During another concurrent interview and record review on [DATE] at 3:35 PM with SW 1, Resident 6's records were reviewed. Resident 6's POLST could not be found. SW 1 stated that she is not sure if Resident 6 had a POLST. During another concurrent interview and record review on [DATE] at 3:35 PM with SW 1, Resident 7's records were reviewed. SW 1 could not locate Resident 7's POLST and stated that Resident 7 was able to make decisions. During another concurrent interview and record review on [DATE] at 3:35 PM with SW 1, Resident 8's records were reviewed. SW 1 stated that Resident 8 was new to the facility and did not know if Resident 8 had a POLST. SW 1 stated that it was SW 1's responsibility to obtain the POLST for newly admitted residents. During another concurrent interview and record review on [DATE] at 3:35 PM with SW 1, Resident 9's records were reviewed. SW 1 stated that Resident 9 was new to the facility. Resident 9's POLST was not found in Resident 9's current medical chart. SW 1 stated she was unsure if Resident 9 was offered a POLST. During another concurrent interview and record review on [DATE] at 3:35 PM with SW 1, Resident 10's records were reviewed. Resident 10's POLST was not found in Resident 10's current medical chart. During another concurrent interview and record review on [DATE] at 3:35 PM with SW 1, Resident 11's records were reviewed. SW 1 stated Resident 11's POLST and AD were not in Resident 11's current medical chart. SW 1 stated that the POLST should be in the resident's chart and not in her office. During another concurrent interview record review on [DATE] at 3:56 PM with SW 1, the facility's policy and procedures (P&P) titled, Advance Directives, dated 9/2022, was reviewed. SW 1 stated that the P&P indicated that upon admission, the social workers must inquire about the resident's POLST or AD. SW 1 stated that the term upon admission means within 48 to 72 hours upon the resident's admission. SW 1 stated that the P&P indicated that if the resident has an AD or a POLST, the documents must be in the resident's medical records and is accessible to any facility staff, and not in her office. During an interview on [DATE] at 11:41 AM with the DON, the DON stated that it is the responsibility of SW 1 to obtain the residents' AD and POLST within 48 hours of admission to the facility. The DON stated that if there was a POLST, the POLST must be in the resident's current medical chart. The DON stated that facility staff use the POLST to identify if residents are full code, especially in an emergency such as when a resident is found unresponsive. During a review of the facility Job Description (JD) for a social worker titled, Social Services Designee, undated, the JD indicated that the SW works with residents to complete advance directive documentation. During a record review of the facility's P&P titled, Advance Directive, dated 9/2022, the P&P indicated that if the resident or representative has not established an advance directive for the resident, the facility staff will offer assistance in establishing advance directive. The P&P also indicated that information about whether or not the resident has executed an advance directive is displayed prominently in the medical record in a section that is retrievable by any staff. The P&P also indicated that if the resident has an advance directive, copies of these documents are obtained and maintained in the same section of the residents medical record and are readily retrievable by any facility staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure proper and effective Basic Life Support (BLS-the level of care provided to victims of life-threatening illnesses or injuries until full medical care is available, including recognition of cardiac arrest and activation of the emergency response system), that included cardiopulmonary resuscitation (CPR, an emergency procedure combining chest compressions and rescue breaths to circulate blood and oxygen when the heart stops or breathing ceases). The facility did not continuously perform BLS for one of 66 identified full code (a resident who wants all possible life-saving measures used if their heart stops or they stop breathing, including CPR residents) (Resident 1) during a code blue (a life-threatening medical emergency requiring an immediate trained response for CPR) when Resident 1 was found unresponsive, pulseless, and not breathing by failing to ensure: 1. Certified Nursing Assistant (CNA) 1, Registered Nurse Supervisor (RN) 1, Licensed Vocational Nurse (LVN) 1, LVN 2, and LVN 5 immediately called a code blue when Resident 1 was found unresponsive on [DATE] between 3:05 PM to 3:10 PM, so that CPR could be initiated without delay. 2. CNA 1, RN 1, LVN 1, LVN 2, and LVN 5 were aware of Resident 1's code status (a medical order indicating the type of emergency treatment a person would or would not receive if their heart or breathing stopped) and were able to locate this information in the resident's medical record. LVN 1 stated that CPR was initiated by a licensed nurse on the resident's bed at 3:22 PM on [DATE], approximately 12 minutes after the resident was found unresponsive. 3. LVN 1 and CNA 2 placed Resident 1 on a firm, flat surface while performing CPR on the resident's bed and utilized a backboard available at the facility, designed to provide a rigid surface under the resident's back to prevent mattress compression and improve the depth and effectiveness of chest compressions during CPR. 4. LVN 1 and CNA 2 performed continuous and uninterrupted CPR on the resident's bed until emergency medical services (EMS- ambulance services or emergency services that provide treatment and stabilization for the patient) assumed care. As a result, Resident 1 was pronounced deceased (dead) on [DATE] at 3:48 PM by EMS crew after 20 minutes of CPR were performed on the floor. These failures placed the facility's identified 66 full code residents at risk to not receive adequate and proper life-saving measures during a code blue, potentially leading to greater harm and/or death to other residents residing in the facility. On [DATE] at 2:34 PM, 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 (ADM) and the Director of Nursing (DON) regarding the facility's failure to ensure Resident 1 adequately and continuously received BLS, including CPR, resulting in Resident 1's death on [DATE]. On [DATE] at 4:13 PM, the Administrator (ADM) provided an acceptable IJ Removal Plan (a detailed plan to address the IJ findings). On [DATE] at 6:13 PM, while onsite and after the surveyor verified/confirmed the facility's full implementation of the IJ Removal Plan through observation, interview, record review, and determined that the IJ situation was no longer present, the IJ was removed onsite on [DATE] at 6:13 PM, in the presence of the ADM and the Director of Nursing (DON). After the IJ was removed, the surveyor verified that the facility's non-compliance remained at a lower scope of isolated (when one or a very limited number of residents are affected and/or one or a very limited number of staff are involved) and lower severity of Level 2 (noncompliance with the requirements for participation that results in the potential for no more than minimal physical, mental, and/or psychosocial harm to the resident, but has the potential to result in more than minimal harm that is not immediate jeopardy). On [DATE] at 6:13 PM, the IJ was removed, in the presence of the ADM and the DON after the facility submitted an acceptable IJ Removal Plan. The surveyor verified and confirmed the implementation of the IJ Removal Plan while onsite through observation, interview, and record review. The acceptable IJ Removal Plan included the following: On [DATE], Quality Assurance Nurse (QA) and the RN on duty initiated a review of the current residents' care profile in the facility's electronic health record (EHR) system, Code Status. The QA and the RN verified the residents' Code Status via Physician Orders for Life-Sustaining Treatment (POLST -a portable medical order form that helps seriously ill or frail individuals specify their end-of-life care wishes, such as CPR) forms and/or physician's orders for Code Status and input the data accordingly in the residents' care profile under Code Status so that the information is readily available for facility staff, including such events as a Code Blue to ensure all residents who have a full code status receive effective BLS, including CPR. Out of 100 current residents, 66 residents have Full Code status. On [DATE], a copy of the list of these Full Code residents was readily available to staff at the nurse's station for reference and will be updated by the Social Services Director (SW) 1/designee on every admission/readmission and as needed. On [DATE] and ongoing, the DON/Designee provided in-service education to nursing staff regarding the availability of the list of residents who are Full Code. On [DATE], the DON checked the EC and ensured that CPR backboard is available. The RN and/or Designated Licensed Nurse conducted inventory on the EC utilizing the Emergency Cart Checklist and ensure that CPR backboard is readily available. This was validated by the DON and/or Designee. The RN and/or Designated Licensed Nurse will conduct inventory of the EC utilizing the Emergency Cart Checklist every shift to ensure that all necessary items listed are readily available, including, but not limited to, the CPR backboard. On [DATE] and ongoing, the DON initiated immediate in-service to RNs, LVNs, and CNAs regarding ensuring a CPR backboard is readily available and used accordingly. On [DATE], the DON initiated immediate in-service to RNs, LVNs, and CNAs regarding providing rescue breathing (a type of first aid that's given to people who have stopped breathing), not placement of a non-rebreather mask (medical device that delivers high concentrations of oxygen to individuals who can breathe independently but have low blood oxygen). The DON will provide continued in-services for all of the facility's RNs, LVNs, and CNAs. On [DATE], the DON initiated immediate in-service to RNs, LVNs, and CNAs regarding effective and appropriate procedure for CPR, including performing adequate and appropriate chest compressions and rescue breathing, effective and continuous CPR, and ensuring a CPR backboard is readily available and used accordingly. The DON will provide continued in-services for all facility's Licensed Nurses and CNAs. On [DATE], the Director of Staff Development (DSD) reviewed employee files for all current Licensed Nurses and CNAs, specifically to validate that all CPR cards are up to date. There are currently 102 active Direct Care Staff employed at the facility with a total of 16 RNs, 25 LVNs, and 61 CNAs are currently employed at the facility. One LVN (LVN 2) and one CNA do not have a current CPR/BLS certification. On [DATE], the identified CNA attended the CPR certification training. The CNA will be put on temporary suspension until CPR certification is received as part of Direct Care Staff competency. The identified LVN that did not have a current CPR/BLS certification has been placed on suspension and will not be permitted to return to work without an active certification for CPR/BLS. Multiple attempts have been made to contact the LVN with no response at this time. Clinical Nurse Consultant provided 1:1 in-service education to the DSD regarding the importance and significance of monitoring and validating direct staff's BLS/CPR competencies and filing of CPR cards. On [DATE], the DON/Designee provided in-service to CNA 1, CNA 2, LVN 2, and RN 1 regarding the facility's policy and procedure titled Emergency Procedures - Cardiopulmonary Resuscitation with emphasis on immediate code activation and calling for help, hard surface/backboard placement before compression, BVM rescue breathing with appropriate rate/volume, and high-quality compressions including the rate, depth, recoil (allowing the chest to completely return to its normal, resting position between compressions) and minimal interruptions. DON/Designee will provide in-service to LVN 2 upon returning to work. LVN 2 will not be on the schedule until education/reeducation was provided regarding the facility's policy and procedure titled, Emergency Procedures - Cardiopulmonary Resuscitation. On [DATE], the DON/Designee provided in-service to LVN 5 regarding the facility's policy and procedure titled Emergency Procedures - Cardiopulmonary Resuscitation with the emphasize on immediate code activation and calling for help, hard surface/backboard placement before compression, BVM rescue breathing with appropriate rate/volume, and high-quality compressions including the rate, depth, recoil and minimal interruptions. On [DATE], a Certified CPR instructor came to the facility and provided mandatory re-education and training for all Licensed Nurses and CNAs which was also attended by the DON and DSD with return demonstration conducted. A series of ongoing CPR Certification Training sessions will be provided by a Certified CPR instructor until all current Licensed Nurses and CNAs have been provided re-education and training to ensure all residents who have a full code status receive effective BLS, including CPR when the needs arise and prevent greater harm and/or death. Additionally, a Code Blue drill (training) was initiated on [DATE] and will continue weekly, once per shift for 3 months and monthly thereafter for the purpose of Skills Check Validation through return demonstration of Licensed Nurses and CNAs response to Code Blue situations and providing effective BLS, including CPR. An RN is designated as the team leader for Code Blue emergencies. On [DATE], additional CPR training will be provided by a Certified CPR Instructor to provide mandatory (required) re-education and training for all Licensed Nurses and CNAs with return demonstration. Any Licensed Nurses or CNAs will not be permitted to work directly with patients if they do not complete the Certified CPR refresher course. Quality Assurance and Performance Improvement (QAPI, a mandatory facility program to systematically monitor and enhance the quality of care and life for residents) Monitoring Plan Effective [DATE]: The DSD/Designee will maintain a log for all Direct Care Staff of their active Certification for BLS/CPR. DSD/Designee will notify staff with BLS/CPR certification expiring within a month. DSD/Designee will present to the QAA Committee the monthly log for all Direct Care Staff Certification for monitoring and compliance on BLS/CPR certification. As part of QAPI and Compliance on BLS/CPR, no Direct Care Staff will be permitted to work directly with patients without an active BLS/CPR certification. QAA Committee, on a monthly basis, will review audit findings from the DSD/Designee on BLS/CPR Certification monitoring for further needed corrective actions. Cross referenced to F659 Findings: During a review of Resident 1's admission Record, (AR) the AR indicated the resident was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD, [a progressive lung condition making breathing difficult), chronic bronchitis (inflamed airways), emphysema (damaged air sacs), and respiratory failure (a serious condition when not enough oxygen passes from a person's lungs to the blood). During a review of Resident 1's POLST, dated [DATE], and signed by Resident 1, the POLST instructed staff to attempt CPR if Resident 1 had no pulse and is not breathing. During a review of Resident 1's History and Physical (H&P), dated [DATE], the H&P indicated the resident does not have the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (a resident assessment tool), dated [DATE], the MDS indicated that Resident 1 has severely impaired cognition (the ability to process thoughts and emotions). The MDS also indicated that the resident did not have a life expectancy of less than 6 months at the time of assessment. The MDS further indicated that the resident did not have a POLST in the resident's chart. During a review of Resident 1's Interdisciplinary Team (IDT) Conference Record Notes, dated [DATE], the IDT indicated that Resident 1's code status was Full code and that staff should attempt CPR when necessary. During a review of Resident 1's Physician Progress Notes, dated [DATE], the Notes indicated that Resident 1 had a code status of Full Code- Attempt CPR. The Notes also indicated a plan to continue regular breathing treatments as scheduled. During a review of Resident 1's Progress Notes for the month of [DATE], the Progress Notes indicated the following information: 1. On [DATE], timed at 4:10 PM, and signed by RN 1, the note indicated that at 3:15 PM, the charge nurse reported to [RN 1] that she saw [Resident 1] unresponsive during rounds (scheduled nurse visits to patient's bedside to assess, monitor and address patient needs). The note further indicated that RN 1 went to the resident's room to assess Resident 1 and could not obtain the resident's blood pressure. The note also indicated that RN 1 instructed one of the team members to start CPR right away. The note indicated that CPR was continued until the Emergency Medical Services crew from the local Fire Department (FD) arrived at 3:29 PM. The note further indicated that the resident was pronounced deceased at 3:48 PM. 2. On [DATE], timed at 4:47 PM, and signed by LVN 1, the note indicated that at 3:05 PM, the CNA [CNA1] reported [to LVN 1] that resident was unresponsive. The note indicated that Resident 1 did not have a pulse or blood pressure. The note also indicated chest compressions were performed until the EMS crew came and took over. The note further indicated that Resident 1's time of death was on [[DATE]] at 3:48 PM. During a review of a Statement of Declaration (SOD) titled, Declaration, signed by LVN 1, dated [DATE], the SOD indicated that at 3:17 PM, [CNA 1] told [LVN 1] that [Resident 1] is unresponsive. The SOD indicated LVN 1, RN 1, and RN 2 reported to the resident's room. The SOD stated that chest compressions started at 3:22 PM initially. The SOD also indicated that RN 2, LVN 1, and CNA 2 were performing chest compressions until the EMS crew arrived. The SOD indicated that compressions were performed [at] 30 [per minute]. The SOD indicated RN 1 and RN 2 went into the Nurse's Station to check for Resident 1's POLST. The SOD further indicated that Resident 1's POLST could not be found and [RN 1 and RN 2] stated to initiate CPR. The SOD indicated that when a resident is found to be unresponsive, the resident's POLST is checked, and after that, CPR is initiated. During a review of the SOD titled, Declaration, signed by RN 3, dated [DATE], the SOD indicated that before doing CPR [staff] [has] to check [the] code status of the resident. During a review of the facility's staffing schedule titled, Monthly Work Schedule, the staffing schedule indicated the following information: 1.For CNA 3, for the month of [DATE], the schedule indicated that CNA 3 started working at the facility on [DATE]. The facility staffing schedule indicated CNA 3 performed work and assigned to residents at the facility on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE],[DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and[DATE]. 2. For CNA 3, for the month of [DATE], the schedule indicated that CNA 3 performed work and assigned to residents at the facility on [DATE], [DATE], [DATE], [DATE], [DATE],[DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. 3. For LVN 2, for the month of [DATE], the schedule indicated that LVN 2 performed work and assigned to residents at the facility on [DATE], [DATE], [DATE], [DATE], [DATE],[DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. 4. For LVN 2, for the month of [DATE], the schedule indicated LVN 2 performed work at the facility on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. During a review of a facility document titled, Emergency Cart Checklist, dated for the month of [DATE], the document indicated a list of equipment and medication contents required to be included in the facility's EC. The checklist indicated that all the contents of the EC were marked off as present and the daily inventory for [DATE] was completed, which included an Adult Ambu-bag with connective tubing (a thin plastic tubing that attaches to an oxygen source). During a concurrent interview and record review of the facility's [DATE] Emergency Cart Checklist on [DATE] at 9:46 AM with RN 3, RN 3 stated that the check marks in the checklist indicated that the item was checked and available in the EC. RN 3 further stated that she completed the inventory of the EC and checked off the EC checklist for [DATE]. During a follow up observation of the EC on [DATE] at 9:46 AM, in the presence of RN 3, the EC contents were inspected for completeness. During the observation, the EC did not contain an Ambu-bag. During a concurrent interview on [DATE] at 9:46 AM with RN 3, RN 3 stated Ambu-bags are used for CPR during a code blue. RN 3 stated it was her responsibility to inspect the EC at the beginning of the shift at 7:30 AM. RN 3 stated she completed and signed the EC checklist but did not actually inspect the entire contents of the EC because she was busy. During a follow-up interview on [DATE] at 11:11 AM with RN 3, RN 3 stated the correct procedure when inspecting the EC is to go over the EC contents one-by-one to make sure everything is there. RN 3 further stated that the Ambu-bag is important because in order to perform an effective CPR, an Ambu-bag is used to give rescue breaths to the resident. RN 3 also stated that the Ambu-bag might have been taken out of the EC during the code blue on [DATE]. RN 3 stated the Ambu-bag was probably not replaced when it was taken out on [DATE] during the code blue situation. RN 3 further stated that the EC contents must be re-stocked by the licensed nurses when the contents are used, as soon as possible. During a follow-up interview with RN 3 on [DATE] at 11:11 AM, RN 3 stated that the rate of compression during a CPR is 30 compressions per minute. During an interview on [DATE] at 11:47 AM with LVN 1, LVN 1 stated he worked on [DATE] when Resident 1 was found unresponsive. LVN 1 stated that on [DATE], at around 3:15 PM, CNA 1 informed him that Resident 1 was unresponsive. LVN 1 stated that he and other nurses, including RN 1 and RN 2, assessed the resident and found that the resident was not breathing and did not have a pulse. LVN 1 stated that RN 1 and RN 2 went into the nurse's station to check Resident 1's records and locate Resident 1's code status. LVN 1 stated that RN 1 was the one who instructed staff (LVN 1 and CNA 2) to start CPR on Resident 1. LVN 1 stated he could not recall who first initiated chest compressions to Resident 1 and if anyone was giving rescue breaths. LVN 1 also stated he could not recall if a backboard was used during Resident 1's CPR while the resident was on the bed. During a phone interview on [DATE] at 12:27 PM, CNA 1 stated that on [DATE], at approximately 3:10 PM to 3:15 PM, she entered Resident 1's room and found Resident 1 sitting up in bed and unresponsive. CNA 1 reported that she attempted to shake Resident 1, but the resident remained unresponsive. CNA 1 further stated that she did not initiate CPR immediately; instead, she left the room to inform LVN 2, followed by LVN 1. During a phone interview on [DATE] at 12:43 PM with LVN 2, LVN 2 stated that on [DATE] at around 3:10 PM, she went inside Resident 1's room and observed that Resident 1 was pale and not breathing. LVN 2 stated she assessed Resident 1 by checking the pulses in both arms and neck and found that the resident did not have a pulse. LVN 2 stated that she went out of Resident 1's room and went to Nursing Station 1 to notify RN 1. LVN 2 stated she did not initiate CPR right away and could not remember who initiated chest compressions to Resident 1. LVN 2 stated she went back to Resident 1's room. LVN 2 added she could not remember if anyone put the backboard under Resident 1 and if the Ambu-bag was used to give Resident 1 rescue breaths. During a phone interview on [DATE] at 1:18 PM with RN 1, RN 1 stated that on [DATE], between the hours of 3:00 PM to 3:15 PM, she was at Nursing Station 1 when LVN 2 informed her that Resident 1 was unresponsive and had no pulse. RN 1 stated that she went to Nursing Station 3 to check Resident 1's records and look for Resident 1's code status. RN 1 stated that when she found out Resident 1 was full code, that was when she informed the other nurses (CNA 1, CNA 2, RN 1, LVN 1, LVN 2, and LVN 5) in the room to initiate CPR on Resident 1. RN 1 stated that the nurses that were inside Resident 1's room were waiting for her to check Resident 1's code status. RN 1 stated that she could not recall who initiated CPR on Resident 1, could not recall if the Ambu-bag was used, or if the backboard was placed under Resident 1. During another interview on [DATE] at 1:36 PM with LVN 1, LVN 1 stated that on [DATE] at around 3:15 PM, RN 1 and RN 2 searched for Resident 1's code status in Nursing Station 3. LVN 1 stated that when RN 1 and RN 2 could not find the code status, RN 1 and RN 2 instructed facility staff (CNA 1, CNA 2, RN 1, LVN 1, LVN 2, and LVN 5) to initiate CPR on Resident 1. During another phone interview on [DATE] at 2:38 PM with LVN 2, LVN 2 stated that on [DATE] when she found Resident 1 unresponsive, she activated code blue by going to Nursing Station 1 to notify RN 1. LVN 2 stated she did not stay with the resident to initiate CPR. During a phone interview on [DATE] at 2:51 PM with RN 2, RN 2 stated that on [DATE] at around 3:20 PM, she entered Resident 1's room and found LVN 1 and LVN 5 assessing Resident 1. RN 2 stated that LVN 1 and LVN 5 informed her that Resident 1 did not have a pulse. RN 2 stated that RN 1 instructed them to start and initiate CPR on Resident 1. RN 2 stated that CPR was started after RN 1 instructed them to initiate CPR (after RN 2's arrival in Resident 1's room at 3:20 PM). RN 2 stated she could not remember who provided rescue breaths to Resident 1. RN 2 stated she could not remember if a backboard was placed under Resident 1 because when the EMS crew arrived, the EMS crew placed Resident 1 on the floor and continued CPR on the floor. During another phone interview on [DATE] at 3:35 PM with RN 1, RN 1 stated that on [DATE] when Resident 1 was found unresponsive, she searched for Resident 1's code status and could not find it. RN 1 stated that when there is a resident that's unresponsive and pulseless, the facility staff must first search for the resident's code status because if the resident's code status is a DNR (Do not Resuscitate, allow natural death), they would not have to initiate code blue. During another phone interview on [DATE] at 3:44 PM with CNA 1, CNA 1 stated that when she found Resident 1 unresponsive on [DATE] at around 3:, she did not check Resident 1's pulse or respirations. CNA 1 stated she did not call for help by shouting code blue. CNA 1 added she did not initiate CPR. During a phone interview on [DATE] at 4:16 PM with EMS Crew, Paramedic (PC) 1, PC 1 stated that on [DATE], PC 1 and PC 2 responded to the facility's call to 911 (a phone number used to contact the emergency services) emergency services for a resident that was unresponsive. PC 1 stated that on [DATE] upon arriving in Resident 1's room, PC 1 stated the he observed Resident 1 on the bed and two facility staff members (unable to state the names and titles) were next to Resident 1, and one of the facility staff members (unable to state name and title) was performing CPR. PC 1 stated Resident 1 was wearing a non-rebreather mask and staff were not using an Ambu-bag. PC 1 stated that an oxygen mask like the non-rebreather mask was not an appropriate equipment to use while conducting a CPR. PC 1 stated that the Ambu-bag was observed right next to Resident 1's head of the bed but was not being used by the facility staff because PC 1 observed that it was not inflated (be filled or expanded with air) and not connected to an oxygen source. PC 1 also stated that the EMS crew had to move Resident 1 from the bed to the floor because Resident 1 was not placed under a backboard while on the bed. PC 1 stated that the EMS crew continued to perform CPR on Resident 1 for about 15 more minutes. During a phone interview on [DATE] at 4:43 PM with another EMS Crew, PC 2, PC 2 stated that on [DATE] when the EMS crew responded to the facility's 911 call, PC 2 observed one facility staff member (unable to state the name and title) perform CPR on Resident 1. PC 2 stated that the facility staff member was not performing adequate CPR because the rate was inconsistent and slow and described the facility staff's compressions as it would stop and go and stop. PC 2 further stated that during his observation, the facility staff member performing the CPR was only using one hand, instead of two hands during chest compressions. PC 2 stated that the facility staff performing the CPR was not using the Ambu-bag to provide rescue breaths because Resident 1 was placed on a non-breather mask. PC 2 further stated that the facility staff did not place Resident 1 on a backboard and performed CPR on the bed. During a review of an SOD titled, Declaration, signed by LVN 5, dated [DATE], the SOD indicated that on [DATE] at around 3:15 PM, LVN 5 heard CNA 1 informing LVN 2 that Resident 1 was unresponsive. The SOD indicated that LVN 5 observed LVN 2 ran towards [Nursing] Station 1. The SOD indicated that LVN 5 assessed Resident 1 and the resident looked pale, unresponsive, and pulseless. The SOD indicated that LVN 5 recalled how LVN 2 searched for Resident 1's code status in the resident's electronic records and could not find Resident 1's code status. The SOD indicated that LVN 5 recalled that LVN 2 asked the facility's Social Worker (SW 2) regarding Resident 1's code status, and SW 2 stated that Resident 1's code status was full code and started CPR. During an interview on [DATE] at 9:37 AM, LVN 5 stated that on [DATE] at around 3 PM, she heard CNA 1 informed LVN 2 that Resident 1 was unresponsive. LVN 5 stated she instructed LVN 2 to get the EC, however, LVN 2 went to Nursing Station 1. LVN 5 stated she assessed Resident 1 and the resident was unresponsive, pale, and pulseless. LVN 5 stated that LVN 1, RN 2, and SW 2 were inside Resident 1's room. LVN 5 stated she went out of Resident 1's room to search for Resident 1's code status in the resident's physical chart. LVN 5 stated she needed to know Resident 1's code status before starting CPR. During an interview on [DATE] at 10:24 AM with LVN 5, LVN 5 stated that if a resident is unresponsive and pulseless, staff must make sure that the resident is a full code before initiating CPR. LVN 5 added that the chest compression rate for an effective CPR is 30 compressions per minute. LVN 5 also added that a non-rebreather mask may also be used during CPR. During a phone interview on [DATE] at 10:29 AM with CNA 2, CNA 2 stated that on [DATE], he participated in performing CPR on Resident 1. CNA 2 stated he performed CPR at 80 compressions per minute because Resident 1 was fragile. CNA 2 stated that when the EMS arrived, CNA 2 and another LVN (LVN 2) were performing CPR on Resident 1 while the resident was on the bed. CNA 2 stated that he could not remember if an Ambu-bag was used on Resident 1. CNA 2 also stated that he could not recall if a backboard was placed under Resident 1. During an interview on [DATE] at 10:45 AM with LVN 4, LVN 4 stated that on [DATE], she was in Nursing Station 1 when LVN 2 informed her that Resident 1 was unresponsive. LVN 4 stated that she brought the EC into Resident 1's room. LVN 4 stated that RN 1 instructed the nurses to perform CPR on Resident 1. During an interview on [DATE] at 11:08 AM with RN 5, RN 5 stated that if a resident is found unresponsive and pulseless, she would initially check the resident's code status. RN 5 then stated that after confirming that the resident is full code, the emergency cart will be brought inside the resident's room and CPR will be initiated. During an interview on [DATE] at 11:47 AM with LVN 7, LVN 7 stated that if a resident is found unresponsive and pulseless, she would check the resident's code status first. LVN 7 stated that if the resident is full code, she will start CPR. LVN 7 stated that the rate of compression during a CPR is 30 compressions per minute. During a concurrent interview and record review on [DATE] at 2:00 PM with the DSD, the entire facility's direct care employee records were reviewed, including each staff member's BLS/CPR certification. The DSD stated that CNA 3 and LVN 2 do not have a BLS/CPR certification on file. The DSD stated that she was aware that CNA 3 and LVN 2 have not submitted their BLS/CPR certification During an interview on [DATE] at 3:07 PM with the DON, the DON stated that when a staff member finds that a resident is unresponsive, the staff member should check the resident's vital signs (are measurements of the body's most basic functions-temperature, pulse rate, respiration rate, and blood pressure), such as the pulse, blood pressure, and respirations. The DON stated that if the resident was found to be pulseless, not breathing, and unresponsive, the staff member should initiate Code Blue by shouting Code Blue to alert other staff members into the room then initiate CPR right away. The DON added that when CPR has been initiated, other staff members may call for 911 and verify the resident's code status. During the same interview on [DATE] at 3:07 PM with the DON, the DON stated that in order to deliver quality CPR, staff members must use a backboard and the Ambu-bag. The DON stated that the backboard is placed under the resident when performing CPR. The DON added that an Ambu-bag is used to provide the resident two rescue breaths after 30 compressions. The DON also added that CPR must be performed at a rate of 100 to 120 compressions per minute. During an interview on [DATE] at 3:15 PM with CNA 3, CNA 3 stated that she was hired by the facility in [DATE]. CNA 3 stated that she has not provided a copy of her CPR Certificate to the facility. CNA 3 stated that if she finds a resident who is unresponsive, she will put the resident's chin up and perform CPR at the rate of 15 compressions per minute. During an interview on [DATE] at 4:05 PM with the DSD, the DSD stated that it is her responsibility to ensure that all the facility's nursing staff have updated and non-expired licenses and certifications. The DSD confirmed that since [DATE], CNA 3 has[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that direct care staff were qualified to respond and perform cardiopulmonary resuscitation (CPR) for one out of 66 identified full code (a resident who wants all possible life-saving measures used if their heart stops or they stop breathing, including CPR residents) (Resident 1). After further investigation, it was determined the facility failed to ensure that: 1.On [DATE], CNA 1, Registered Nurse (RN) 1, LVN 1, LVN 2, and LVN 5 did not call a code blue immediately when Resident 1 was found unresponsive on [DATE] between 3:05 PM to 3:10 PM. 2. On [DATE], LVN 1 and CNA 2 did not place Resident 1 on a firm, flat surface while performing CPR. LVN 1 and CNA 2 did not use the backboard (a rigid board inserted under a patient's back to create a firm surface, preventing soft surfaces [like mattresses] from absorbing compression force, thereby improving the depth and effectiveness of chest compressions) that was available at the facility. 3. On [DATE], LVN 1 and CNA 2 did not perform rescue breaths on Resident 1 while performing CPR on [DATE], in accordance with professional standard of practice and the 2025 American Heart Association (AHA) Guidelines for CPR. 4.On [DATE], LVN 1 and CNA 2 did not perform continuous and appropriate chest compressions with the required depth on Resident 1, in accordance with professional standard of practice and the 2025 AHA Guidelines for CPR. As a result, Resident 1 was pronounced deceased (dead) on [DATE] at 3:48 PM by EMS crew after 20 minutes of CPR. As a result of these deficiencies, the facility placed 66 full code (a patient wants all possible life-saving measures if their heart or breathing stops, including CPR) residents at risk to not receive adequate and proper life-saving measures during a code blue, potentially leading to greater harm and/or death to other residents residing in the facility. Cross referenced to F678 Findings: During a review of Resident 1's admission Record, (AR) the AR indicated the resident was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD, [a progressive lung condition making breathing difficult), chronic bronchitis (inflamed airways), emphysema (damaged air sacs), and respiratory failure (condition where the lungs can't adequately oxygenate the blood or remove carbon dioxide). During a review of Resident 1's POLST (Physician Orders for Life-Sustaining Treatment, a portable medical order form that helps seriously ill or frail individuals specify their end-of-life care wishes, such as CPR), dated [DATE], and signed by Resident 1, the POLST instructed staff to attempt CPR if Resident 1 has no pulse and is not breathing. During a review of Resident 1's History and Physical (H&P), dated [DATE], the H&P indicated the resident does not have the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (a resident assessment tool), dated [DATE], the MDS indicated that Resident 1 has severely impaired cognition (the ability to process thoughts and emotions). The MDS also indicated that the resident did not have a life expectancy of less than 6 months at the time of assessment. The MDS further indicated that the resident did not have a POLST (---) in the resident's chart. During a review of Resident 1's Interdisciplinary Team (IDT) Conference Record Notes, dated [DATE], the IDT indicated that Resident 1's code status was Full code and that staff should attempt CPR when necessary. During a review of Resident 1's Physician Progress Notes, dated [DATE], the Notes indicated that Resident 1 had a code status of Full Code- Attempt CPR. During a review of Resident 1's Progress Notes for the month of [DATE], the Progress Notes indicated the following information: 1. On [DATE], timed at 4:10 PM, and signed by RN 1, the note indicated that at 3:15 PM, the charge nurse reported to [RN 1] that she saw [Resident 1] unresponsive during rounds (scheduled nurse visits to patient's bedside to assess, monitor and address patient needs). The note further indicated that RN 1 went to the resident's room to assess Resident 1 and could not obtain the resident's blood pressure. The note also indicated that RN 1 instructed one of the team members to start CPR right away. The note indicated that CPR was continued until the Emergency Medical Services crew from the local Fire Department (FD) arrived at 3:29 PM. The note further indicated that the resident was pronounced deceased at 3:48 PM. 2. On [DATE], timed at 4:47 PM, and signed by LVN 1, the note indicated that at 3:05 PM, the CNA [CNA1] reported [to LVN 1 that resident was unresponsive. The note indicated that Resident 1 did not have a pulse or blood pressure. The note also indicated chest compressions were performed until the EMS crew came and took over. The note further indicated that Resident 1's time of death was on [[DATE]] at 3:48 PM. During a review of a Statement of Declaration (SOD) titled, Declaration, signed by LVN 1, dated [DATE], the SOD indicated that at 3:17 PM, [CNA 1] told [LVN 1] that [Resident 1] is unresponsive. The SOD indicated LVN 1, RN 1, and RN 2 reported to the resident's room. The SOD stated that chest compressions started at 3:22 PM initially. The SOD also indicated that RN 2, LVN 1, and CNA 2 were performing chest compressions until the EMS crew arrived. The SOD indicated that compressions were performed [at] 30 [per minute]. The SOD indicated RN 1 and RN 2 went into the Nurse's Station to check for Resident 1's POLST. The SOD further indicated that Resident 1's POLST could not be found and [RN 1 and RN 2] stated to initiate CPR. The SOD indicated that when a resident is found to be unresponsive, the resident's POLST is checked, and after that, CPR is initiated. During a review of a Statement of Declaration (SOD) titled, Declaration, signed by RN 3, dated [DATE], the SOD indicated that before doing CPR [staff] [has] to check [the] code status of the resident. During a follow-up interview on [DATE] at 11:11 AM with RN 3, RN 3 stated that the rate of compression during a CPR is 30 compressions per minute. During an interview on [DATE] at 11:38 AM with LVN 1, LVN 1 stated that when a resident is found unresponsive, the responding staff should go straight for airway. LVN 1 stated the next step is to assess the resident's circulation by checking the resident's pulse. LVN 1 stated that chest compressions should be initiated if the resident is determined to be pulseless at a rate of 30 compressions per minute. During another interview on [DATE] at 11:47 AM with LVN 1, LVN 1 stated he worked on [DATE] when Resident 1 was found unresponsive. LVN 1 stated that on [DATE], at around 3:15 PM, CNA 1 informed him that Resident 1 was unresponsive. LVN 1 stated that he and other nurses, including RN 1 and RN 2, assessed the resident and found that the resident was not breathing and did not have a pulse. LVN 1 stated that RN 1 and RN 2 went into the nurse's station to check Resident 1's records and locate Resident 1's code status. LVN 1 stated that RN 1 was the one who instructed staff (LVN 1 and CNA 2) to start CPR on Resident 1. LVN 1 stated he could not recall who first initiated chest compressions to Resident 1 and who administered rescue breaths. LVN 1 also stated he could not recall if a backboard was used during Resident 1's CPR. During a phone interview on [DATE] at 12:27 PM with CNA 1, CNA 1 stated she went into Resident 1's room on [DATE] at around 3:10 PM to 3:15 PM and found Resident 1 sitting up in bed and unresponsive. CNA 1 stated that she shook Resident 1 and still unresponsive. CNA 1 stated she did not initiated CPR right away on Resident 1 but instead went out of the resident's room to inform LVN 2 then LVN 1. During a phone interview on [DATE] at 12:43 PM with LVN 2, LVN 2 stated that on [DATE] at around 3:10 PM, she went inside Resident 1's room and observed that Resident 1 was pale and not breathing. LVN 2 stated she assessed Resident 1 by checking the pulses in both arms and neck and found that the resident did not have a pulse. LVN 2 stated that she went out of Resident 1's room and went to Nursing Station 1 to notify RN 1. LVN 2 stated she did not initiate CPR right away and could not remember who initiated chest compressions to Resident 1. LVN 2 stated she went back to Resident 1's room. LVN 2 added she could not remember if anyone put the backboard under Resident 1 and if the Ambu-bag was used to give Resident 1 rescue breaths. During a phone interview on [DATE] at 1:18 PM with RN 1, RN 1 stated that on [DATE], at around 3:00 PM to 3:15 PM, she was at Nursing Station 1 when LVN 2 informed her that Resident 1 was unresponsive and had no pulse. RN 1 stated that she went to Nursing Station 3 to check Resident 1's records and look for Resident 1's code status. RN 1 stated that when she found out Resident 1 was full code, that was when she informed the other nurses (CNA 1, CNA 2, RN 1, LVN 1, LVN 2, and LVN 5) in the room to initiate CPR on Resident 1. RN 1 stated that the nurses that were inside Resident 1's room was waiting for her to check Resident 1's code status. RN 1 stated that she could not recall who initiated CPR on Resident 1, could not recall if the Ambu-bag was used, or if the backboard was placed under Resident 1. During another interview on [DATE] at 1:36 PM with LVN 1, LVN 1 stated that on [DATE] at around 3:15 PM, RN 1 and RN 2 searched for Resident 1's code status in Nursing Station 3. LVN 1 stated that when RN 1 and RN 2 could not find the code status, RN 1 and RN 2 instructed facility staff (CNA 1, CNA 2, RN 1, LVN 1, LVN 2, and LVN 5) to initiate CPR on Resident 1. During another phone interview on [DATE] at 2:38 PM with LVN 2, LVN 2 stated that on [DATE] when she found Resident 1 unresponsive, she activated code blue by going to Nursing Station 1 to notify RN 1. LVN 2 stated she did not stay with the resident to initiate CPR. During a phone interview on [DATE] at 2:51 PM with RN 2, RN 2 stated that on [DATE] at around 3:20 PM, she entered Resident 1's room and found LVN 1 and LVN 5 assessing Resident 1. RN 2 stated that LVN 1 and LVN 5 informed her that Resident 1 did not have a pulse. RN 2 stated that RN 1 instructed them to start and initiate CPR on Resident 1. RN 2 stated that CPR was started after RN 1 instructed them to initiate CPR (after RN 2's arrival in Resident 1's room at 3:20 PM). RN 2 stated she could not remember who provided rescue breaths to Resident 1. RN 2 stated she could not remember if a backboard was placed under Resident 1. RN 2 further stated that when the EMS crew arrived, the EMS crew placed Resident 1 on the floor and continued CPR on the floor. During another phone interview on [DATE] at 3:44 PM with CNA 1, CNA 1 stated that when she found Resident 1 unresponsive on [DATE] at around 3:, she did not check Resident 1's pulse or respirations. CNA 1 stated she did not call for help by shouting code blue. CNA 1 added she did not initiate CPR. During a phone interview on [DATE] at 4:16 PM with EMS Crew, Paramedic (PC) 1, PC 1 stated that on [DATE], PC 1 and PC 2 responded to the facility's 911 call for a resident that was unresponsive. PC 1 stated that on [DATE] upon arriving in Resident 1's room, PC 1 stated he observed two facility staff members were next to Resident 1, and one more facility staff member was performing CPR. PC 1 stated Resident 1 was wearing a non-rebreather mask and staff was not using an Ambu-bag. PC 1 stated that an oxygen mask like the non-rebreather mask was not an appropriate equipment to use while conducting a CPR. PC 1 stated that the Ambu-bag was observed right next to Resident 1's head of the bed but was not being used by the facility staff because it was not inflated and not connected to an oxygen source. PC 1 also stated that the EMS crew had to move Resident 1 from the bed to the floor because Resident 1 was not placed under a backboard while on the bed. PC 1 stated that the EMS crew continued to perform CPR on Resident 1 for about 15 more minutes. During a phone interview on [DATE] at 4:43 PM with another EMS Crew, PC 2, PC 2 stated that on [DATE] when the EMS crew responded to the facility's 911 call, PC 2 observed one facility staff member perform CPR on Resident 1. PC 2 stated that the facility staff member was not performing adequate CPR because the rate was inconsistent and slow and the facility staff's compressions would stop and go and stop. PC 2 further stated that during his observation, the facility staff member performing the CPR was only using one hand, instead of two hands during chest compressions. PC 2 stated that the facility staff performing the CPR were not using the Ambu-bag to provide rescue breaths because Resident 1 was placed on a non-breather mask. PC 2 further stated that the facility staff did not place Resident 1 on a backboard and performed CPR on the bed. During a review of a Statement of Declaration (SOD) titled, Declaration, signed by LVN 5, dated [DATE], the SOD indicated that on [DATE] at around 3:15 PM, LVN 5 heard CNA 1 informing LVN 2 that Resident 1 was unresponsive. The SOD indicated that LVN 5 observed LVN 2 ran towards [Nursing] Station 1. The SOD indicated that LVN 5 assessed Resident 1 and the resident looked pale, unresponsive, and pulseless. The SOD indicated that LVN 5 recalled how LVN 2 searched for Resident 1's code status in the resident's electronic records and could not find Resident 1's code status. The SOD indicated that LVN 5 recalled that LVN 2 asked the facility's Social Worker (SW 2) regarding Resident 1's code status, and SW 2 stated that Resident 1's code status was full code and started CPR. During an interview on [DATE] at 9:37 AM, LVN 5 stated that on [DATE] at around 3 PM, she heard CNA 1 informed LVN 2 that Resident 1 was unresponsive. LVN 5 stated she instructed LVN 2 to get the Emergency Cart, however, LVN 2 went to Nursing Station 1. LVN 5 stated she assessed Resident 1 and the resident was unresponsive, pale, and pulseless. LVN 5 stated that LVN 1, RN 2, and SW 2 were inside Resident 1's room. LVN 5 stated she went out of Resident 1's room to search for Resident 1's code status in the resident's physical chart. LVN 5 stated she needed to know Resident 1's code status before starting CPR. During an interview on [DATE] at 10:24 AM with LVN 5, LVN 5 stated that if a resident is unresponsive and pulseless, staff must make sure that the resident is a full code before initiating CPR. LVN 5 added that the chest compression rate for an effective CPR is 30 compressions per minute. LVN 5 also added that a non-rebreather mask may also be used during CPR. During a phone interview on [DATE] at 10:29 AM with CNA 2, CNA 2 stated that on [DATE], he participated in performing CPR on Resident 1. CNA 2 stated he performed CPR at 80 compressions per minute because Resident 1 was fragile. CNA 2 stated that when the EMS arrived, CNA 2 and another LVN (LVN 2) was performing CPR on Resident 1. CNA 2 stated that he could not remember if an Ambu-bag was used on Resident 1. CNA 2 also stated that he could not recall if a backboard was placed under Resident 1. During an interview on [DATE] at 10:45 AM with LVN 4, LVN 4 stated that on [DATE], she was in Nursing Station 1 when LVN 2 informed her that Resident 1 was unresponsive. LVN 4 stated that she brought the Emergency Cart into Resident 1's room. LVN 4 stated that RN 1 instructed the nurses to perform CPR on Resident 1. LVN 4 stated she could not remember who used the Ambu-bag. LVN 4 stated she could not recall who put the backboard under Resident 1. During an interview on [DATE] at 10:48 AM with LVN 6, LVN 6 stated that if a resident is found unresponsive and pulseless, she would call an RN. LVN 6 stated that after calling for an RN, call 911 and check for the resident's code status. LVN 6 stated that after those steps, she would initiate CPR by laying the resident flat and starting chest compressions. During an interview on [DATE] at 3:07 PM with the Director of Nursing (DON), the DON stated that when a staff member finds that a resident is unresponsive, the staff member should check the resident's vitals signs, such as the pulse, blood pressure, and respirations. The DON stated that if the resident was found to be pulseless, not breathing, and unresponsive, the staff member should initiate Code Blue by shouting Code Blue to alert other staff members into the room then initiate CPR right away. The DON added that when CPR has been initiated, other staff members may call for 911 and verify the resident's code status. During the same interview on [DATE] at 3:07 PM with the DON, the DON stated that in order to deliver quality CPR, staff members must use a backboard and Ambu-bag. The DON stated that the backboard is placed under the resident when performing CPR. The DON added that an Ambu-bag is used to provide the resident 2 rescue breathing in between 30 compressions. The DON also added that CPR must be performed at a rate of 100 to 120 compressions per minute. During a phone interview on [DATE] at 4:31 PM with Medical Doctor (MD) 1, MD 1 stated that when a resident is found to be unresponsive, facility staff are expected to initiate CPR right away. MD 1 stated that staff should not prioritize looking for the resident's code status because if CPR is not initiated immediately, the resident could suffer prolonged cardiac arrest and, eventually, death. During a concurrent interview and record review on [DATE] at 11:41 AM with the DON, Resident 1's medical records were reviewed, including the progress notes. The DON stated the progress notes indicated that on [DATE] at 3:05 PM, a CNA reported to LVN 1 that Resident 1 was unresponsive. The DON stated that at 3:15 PM, another nurse informed RN 1. The DON stated that RN 1 instructed staff to perform CPR. The DON stated that CPR was delayed and it should have been initiated right away. During the same concurrent interview and record review on [DATE] at 11:41 AM with the DON, the facility's policy and procedures (P&P) titled, Emergency Procedure- Cardiopulmonary Resuscitation, dated 2/2018, was reviewed. The DON stated that the P&P indicates that CPR must be initiated until the resident is determined to be DNR. The DON stated that the P&P indicates that CPR compressions must be at a rate of at least 100 compressions per minute. The DON stated that the P&P also indicates that supplies necessary for CPR must always be readily available. The DON added that the EC must contain a backboard and Ambu-bag. During a phone interview on [DATE] at 3:49 PM with MD 2, MD 2 stated that facility staff must follow the facility's P&P in the event of a code blue. MD 2 added that during a code blue, CPR must be initiated right away. During a review of the facility's job description (JD) for a CNA titled, Certified Nursing Assistant, undated, the JD indicated that a CNA's job function includes initiating CPR and assisting with code procedures. During a review of the facility's job description (JD) for an LVN titled, Charge nurse- LVN, undated, the JD indicated that a LVN's job function includes responding and directing care in emergency situations using good judgement and established policies and procedures. The JD also indicated that the LVN initiates CPR and directs code procedures. During a review of the American Heart Association's guidelines published on [DATE], titled, 2025 American Heart Association Guidelines for CPR and ECC, https://cpr.heart.org/en/resuscitation-science/cpr-and-ecc-guidelines/adult-basic-life-support, [site accessed on [DATE]], the guidelines indicated the following: 1.If a resident is found unconscious/unresponsive, with absent or abnormal breathing (ie, only gasping), the health care professional should check for a pulse for no more than 10 seconds and, if no definite pulse is felt, should assume the person is in cardiac arrest. 2. After identifying an adult in cardiac arrest, a lone responder should activate the emergency response system first, then immediately begin CPR, beginning with chest compressions. 3. In adult cardiac arrest, it is preferred to perform CPR on a firm surface and with the person in the supine position, when feasible and does not delay chest compressions. 4. During manual CPR, rescuers should perform chest compressions to a depth of at least 2 inches. 5. For adults in cardiac arrest, it is reasonable for rescuers to perform chest compressions at a rate of 100 to 120 [per minute]. 6. It is reasonable for lay rescuers and health care professionals to perform CPR with cycles of 30 compressions followed by 2 breaths before placement of an advanced airway. 7. Bag-mask ventilation is most effective when provided by 2 trained and experienced rescuers; 1 rescuer opens the airway and seals the mask to the face with both hands while the other rescuer (who might also be the chest compressor) squeezes the bag during the pauses in chest compression. During a review of the facility's P&P titled, Emergency Procedure- Cardiopulmonary Resuscitation, dated 2/2018, the P&P indicated that the following: 1.The chances of a resident surviving a cardiac arrest may be increased if CPR is initiated immediately. 2. If a resident is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR. 3. The facility's procedure for administering CPR shall incorporate the steps covered in the 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care or facility BLS training material. 4. Maintain equipment and supplies necessary for CPR/BLS in the facility at all times. 5. If an individual is found unresponsive, briefly assess for abnormal or absence of breathing. If sudden cardiac arrest is likely, begin CPR. 6. The BLS sequence of events is referred to as C-A-B (chest compressions, airway, breathing). 7. Chest compressions: Following initial assessment, begin CPR with chest compressions; Push hard to a depth of at least 2 inches (5 cm [centimeters, a unit of measuring length]) at a rate of at least 100 compressions per minute; Allow full chest recoil after each compressions; and Minimize interruptions in chest compressions. Airway: Tilt head back and lift chin to clear airway. Breathing: After 30 chest compressions provide 2 breaths via Ambu-bag or manually (with CPR shield). All rescuers, trained or note, should provide chest compressions to victims of cardiac arrest. Trained rescuers should also provide ventilations with a compression-ventilation ratio of 30:2. Continue with CPR/BLS until emergency medical personnel arrive.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Findings: During a review of Resident 1's admission Record, the record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing), emphysema (a lung disease where the air sacs [alveoli] in the lungs are damaged, making breathing difficult), respiratory failure (a condition where the lungs cannot supply enough oxygen or remove carbon dioxide from the blood) with hypoxia (a condition in which body tissues do not receive enough oxygen to function properly), and recurrent pneumonia (an infection/inflammation in the lungs). During a review of Residents 1's Minimum Data Sheet (MDS- a resident assessment tool) dated 10/6/2025, the MDS indicated Resident 1 had significantly impaired cognition (the ability to process thoughts) and was dependent on staff for all cares such as eating, bathing, and rolling left and right in bed. During a review of Resident 1's care plan (CP) initiated on 4/11/2025 at revised on 11/18/2025, the CP indicated Resident 1 had an impaired gas exchange related to ineffective airway clearance, dyspnea (difficulty breathing), shortness of breath (SOB), COPD, and emphysema. The CP indicated goal for appropriate interventions that will improve airway function, maintain a patent airway, optimal oxygenation/ventilation, oxygen saturation (O2 sat- the percentage of oxygen in the blood) maintained greater than 92% (normal range for COPD: 88% - 92%), and mobilize secretions. The CP indicated interventions to administer medications as ordered. During a review of Resident 1's Medication Administration Record (MAR) for December 2025, the MAR indicated the following orders: 1. Order start dated 9/30/2025, the order indicated to administer Acetylcysteine (a medication used to thin mucus in the lungs) Inhalation Solution 20% three mL (milliliter- a unit measure of volume) inhale orally two times a day for COPD, 2. Order start dated 3/3/2025, the order indicated to administer Budenoside (a medication inhaled to reduce swelling in the airways) Inhalation Suspension 0.25 milligram (mg- a unit of measurement)/2 mL, inhale two mL orally every morning and at bedtime for COPD. 3. Order start dated 6/16/2025, the order indicated to administer Ipratropium-Albuterol (a medication used in a nebulizer that combines two drugs to relax and open the airways) Inhalation Solution 0.5-2.5 mg (3 mg)/3 mL, inhale three mL orally four times a day for congestion/breathing treatment. During a review of Resident 1's Medication Admin Audit Report dated December 2025, the report indicated the following: 1. Administration of Acetylcysteine Inhalation Solution 20% for COPD a. Schedule date: 12/5/2025 at 6 PM. Administration time: 12/5/2025 at 3:29 PM. Documented time in Resident 1's electronic records: 1/1/2026 at 3:30 PM by LVN 9. b. Schedule date: 12/6/2025 at 6 PM. Administration time: 12/6/2025 at 3:36 PM. Documented time in Resident 1's electronic records: 1/1/2026 at 3:37 PM by LVN 9. c. Schedule date: 12/11/2025 at 6 PM. Administration time: 12/10/2025 at 4:05 PM. Documented time in Resident 1's electronic records: 1/1/2026 at 4:06 PM by LVN 3 d. Schedule date: 12/12/2025 at 6 PM. Administration time: 12/12/2025 at 5:25 PM. Documented time in Resident 1's electronic records: 12/30/2025 at 5:26 PM by LVN 9 e. Schedule date: 12/13/2025 at 6 PM. Administration time: 12/13/2025 at 4 PM. Documented time in Resident 1's electronic records: 1/1/2026 at 4:07 PM by LVN 3 f. Schedule date: 12/19/2025 at 6 PM. Administration time: 12/19/2025 at 4:09 PM. Documented time in Resident 1's electronic records: 1/1/2026 at 4:09 PM by LVN 3 g. Schedule date: 12/23/2025 at 6 PM. Administration time: 12/23/2025 at 4:11 PM. Documented time in Resident 1's electronic records: 1/1/2026 at 4:12 PM by LVN 3 2. Administration of Budenoside Inhalation Suspension for COPD a. Schedule date: 12/4/2025 at 9 PM. Administration time: 12/4/2025 at 5:27 PM. Documented time in Resident 1's electronic records: 1/1/2026 at 3:27 PM by LVN 9 b. Schedule date: 12/5/2025 at 9 PM. Administration time: 12/5/2025 at 5:33 PM. Documented time in Resident 1's electronic records: 1/1/2026 at 3:34 PM by LVN 9 c. Schedule date: 12/6/2025 at 9 PM. Administration time: 12/6/2025 at 5:36 PM. Documented time in Resident 1's electronic records: 1/1/2026 at 3:37 PM by LVN 9 d. Schedule date: 12/10/2025 at 9 PM. Administration time: 12/10/2025 at 4 PM. Documented time in Resident 1's electronic records: 1/1/2026 at 4:05 PM by LVN 3 e. Schedule date: 12/11/2025 at 9 PM. Administration time: 12/11/2025 at 4 PM. Documented time in Resident 1's electronic records: 1/1/2026 at 4:06 PM by LVN 3 f. Schedule date: 12/12/2025 at 9 PM. Administration time: 12/10/2025 at 5:26 PM. Documented time in Resident 1's electronic records: 12/30/2025 at 5:26 PM by LVN 9 g. Schedule date: 12/13/2025 at 9 PM. Administration time: 12/13/2025 at 4 PM. Documented time in Resident 1's electronic records: 1/1/2026 at 4:07 PM by LVN 3 h. Schedule date: 12/18/2025 at 9 PM. Administration time: 12/18/2025 at 4:08 PM. Documented time in Resident 1's electronic records: 1/1/2026 at 4:08 PM by LVN 3 i. Schedule date: 12/19/2025 at 9 PM. Administration time: 12/19/2025 at 4:09 PM. Documented time in Resident 1's electronic records: 1/1/2026 at 4:10 PM by LVN 3 j. Schedule date: 12/23/2025 at 9 PM. Administration time: 12/23/2025 at 4:12 PM. Documented time in Resident 1's electronic records: 1/1/2026 at 4:12 PM by LVN 3 3. Ipratropium-Albuterol Inhalation Solution a. Schedule date: 12/4/2025 at 9 PM. Administration time: 12/4/2025 at 3:27 PM. Documented time in Resident 1's electronic records in Resident 1's electronic records: 1/1/2026 at 3:27 PM by LVN 9 b. Schedule date: 12/5/2025 at 5 PM. Administration time: 12/5/2025 at 3:29 PM. Documented time in Resident 1's electronic records: 1/1/2026 at 3:30 PM by LVN 9 c. Schedule date: 12/5/2025 at 9 PM. Administration time: 12/5/2025 at 3:34 PM. Documented time in Resident 1's electronic records: 1/1/2026 at 3:34 PM by LVN 9 d. Schedule date: 12/6/2025 at 5 PM. Administration time: 12/6/2025 at 5:36 PM. Documented time in Resident 1's electronic records: 1/1/2026 at 3:37 PM by LVN 9 e. Schedule date: 12/6/2025 at 9 PM. Administration time: 12/6/2025 at 3:36 PM. Documented time in Resident 1's electronic records: 1/1/2026 at 3:37 PM by LVN 9 f. Schedule date: 12/10/2025 at 9 PM. Administration time: 12/10/2025 at 4 PM. Documented time in Resident 1's electronic records: 1/1/2026 at 4:05 PM by LVN 3 g. Schedule date: 12/11/2025 at 5 PM. Administration time: 12/10/2025 at 4:05 PM. Documented time in Resident 1's electronic records: 1/1/2026 at 4:06 PM by LVN 3 h. Schedule date: 12/11/2025 at 9 PM. Administration time: 12/11/2025 at 4 PM. Documented time in Resident 1's electronic records: 1/1/2026 at 4:06 PM by LVN 3 i. Schedule date: 12/12/2025 at 5 PM. Administration time: 12/12/2025 at 5:25 PM. Documented time in Resident 1's electronic records: 12/30/2025 at 5:26 PM by LVN 9 j. Schedule date: 12/12/2025 at 9 PM. Administration time: 12/12/2025 at 5:26 PM. Documented time in Resident 1's electronic records: 12/30/2025 at 5:26 PM by LVN 9 k. Schedule date: 12/13/2025 at 5 PM. Administration time: 12/13/2025 at 4 PM. Documented time in Resident 1's electronic records in Resident 1's electronic records: 1/1/2026 at 4:07 PM by LVN 3 l. Schedule date: 12/13/2025 at 9 PM. Administration time: 12/13/2025 at 4 PM. Documented time in Resident 1's electronic records: 1/1/2026 at 4:07 PM by LVN 3 m. Schedule date: 12/18/2025 at 9 PM. Administration time: 12/13/2025 at 4:09 PM. Documented time in Resident 1's electronic records: 1/1/2026 at 4:09 PM by LVN 3 n. Schedule date: 12/19/2025 at 5 PM. Administration time: 12/19/2025 at 4:09 PM. Documented time in Resident 1's electronic records: 1/1/2026 at 4:09 PM by LVN 3 o. Schedule date: 12/19/2025 at 9 PM. Administration time: 12/19/2025 at 4:10 PM. Documented time in Resident 1's electronic records: 1/1/2026 at 4:10 PM by LVN 3 p. Schedule date: 12/23/2025 at 5 PM. Administration time: 12/23/2025 at 4:11 PM. Documented time in Resident 1's electronic records: 1/1/2026 at 4:12 PM by LVN 3 q. Schedule date: 12/23/2025 at 9 PM. Administration time: 12/23/2025 at 4:12 PM. Documented time in Resident 1's electronic records: 1/1/2026 at 4:12 PM by LVN 3 During an interview with LVN 9 on 1/2/2026 at 5:18 PM, LVN 9 stated she could not recall what days she worked for the month of December 2025 or what medications Resident 1 received. LVN 9 stated she could only remember that Resident 1 received Albuterol breathing treatments, but stated she could not remember if the resident also received Budenoside or Acetylcysteine. LVN 9 also stated she could not recall what time she gave Resident 1's medications on 12/4/2025 or if any of the resident's medications were withheld for the month of December 2025. LVN 9 further stated that she was responsible for administering medications to many residents and therefore could not remember what medications she gave in the past, specifically for December 2025, or what time she administered them to Resident 1. During the same interview with LVN 9 on 1/2/2026 at 5:18 PM, LVN 9 stated the reason she documented Resident 1's acetylcysteine, budenoside, and ipratropium-albuterol administrations on 12/30/2025 and 1/1/2026 was because Medical Records Assistant (MRA) 1 audited Resident 1's MAR and discovered missing administration documentation. LVN 9 stated that when Medical Records notified her of the missing administration documentation, she then documented that she administered the medications in order to complete the audit. LVN 9 explained that this was her usual practice of completing medical record audits for medication administrations. LVN 9 further stated she knew she was supposed to document medication administrations immediately after administering the medication, but stated she forgot about it until MRA 1 audited her documentation. During an interview with the Director of Nursing (DON) on 1/2/2026 at 5:57 PM, the DON stated that LVN 3 and LVN 9 should have documented Resident 1's medication administrations in a timely manner. If there were issues with the MAR, they were required to document why medications were documented at a later time in Resident 1's progress notes. The DON stated that physicians and nurses use documentation to monitor effectiveness and adverse reactions to medications, and if the records were inaccurate, providers may delay adjusting medications or initiating new treatments. During a phone interview with MRA 1 on 1/13/2026 at 1:51 PM, MRA 1 stated he did MAR audits every day with a lookback period of up to 30 days. MRA 1 stated that the audit specifically searched for missing documentation in a resident's MAR. After finding missing documentation, MRA 1 stated he submitted the audit report to the DON and the DON would tell the licensed nurses to complete the documentation. MRA 1 stated that the audit would be considered resolved if the nurse documented that the medication was administered or a reason the medication was not administered. During a review of the facility's policy and procedure (P&P) titled Administering Medications revised April 2019, the P&P indicated, The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next one.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to verify received or follow up with the attending physician (Medical Doctor [MD] 1) and/or the Nurse Practitioner (NP) 1 of the abnormal laboratory and diagnostic results for one of two sampled residents (Resident 1) with abnormal laboratory and diagnostic results. Resident 1 had an elevated white blood cell (WBC - a blood cell that helps attack infection or injury in the body) count of 16.85 x10*3/ul (thousands of cells per microliter- a unit of measurement [Normal range 4.0-11.0 x10*3/ul]) and abnormal chest x-ray (a type of imaging that uses electromagnetic radiation to view internal structures of the body) results indicating mild patchy opacity (an area that appears white or dense on an x-ray) in the left lower lung which represented a potential indicator of lung infection. This failure resulted in Resident 1 not to receive necessary medical intervention such as prescribing antibiotics (medication used to treat infection) which placed Resident 1 at risk for worsening infection, respiratory distress, sepsis (a life-threatening blood infection), hospitalization, and death. Cross referenced to F695 and F678 Findings: During a review of Resident 1's admission Record, the record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty breathing), emphysema (a lung disease where the air sacs [alveoli] in the lungs are damaged, making breathing difficult), respiratory failure (a condition where the lungs cannot supply enough oxygen or remove carbon dioxide from the blood) with hypoxia (a condition in which body tissues do not receive enough oxygen to function properly), recurrent pneumonia (an infection/inflammation in the lungs) and aneurysm of specified arteries (localized bulge on the wall of the blood vessels which pose a risk for rupture). During a review of Residents 1's Minimum Data Sheet (MDS- a resident assessment tool) dated [DATE], the MDS indicated Resident 1 had significantly impaired cognition (the ability to process thoughts) and was dependent on staff for all cares such as eating, bathing, and rolling left and right in bed. During a review of Resident 21's Care Plan, initiated on [DATE] and revised [DATE], indicated Resident 1 had impaired gas exchange. The intervention included to monitor and report any respiratory distress to the MD. During a review of Resident 1's MD Progress Notes (PN) dated [DATE], the notes indicated Resident 1 was assessed by Nurse Practitioner (NP) 1. The PN indicated Resident 1's lung exam exhibited rales (abnormal crackling sounds in the lungs when breathing) with respiratory distress, coughing and with oxygen saturation of 93% (normal range 90-100%) while receiving 3 L/min (liters per minute- a unit measuring the flow rate of oxygen through a delivery device). The PN indicated to continue regular breathing treatments as scheduled, physical therapy, chest percussion therapy (CPT- a technique that uses rhythmic clapping on the chest and back to loosen and clear mucus from the lungs) two times a day with administration of Mucomyst (acetylcysteine- a medication used to thin or loosen up mucus in the lungs), wean off of oxygen, obtain chest x-ray, and labs that included CBC (complete blood count) and CMP (comprehensive metabolic panel) to rule out possible cause of infection. During a review of Resident 1's Orders Report (a physician's order by MD 1) dated [DATE] indicated to obtain CBC and CMP, and Chest X-ray due to congestion and cough. During a review of Resident 1's lab results collected on [DATE] at 8:10 AM and resulted on[DATE] at 12:59 PM, faxed to the facility on [DATE] at 1:10 PM, indicated an (elevated) WBC 16.85 x10*3/ul (Normal range 4.0-11.0 x10*3/ul). During a review of Resident 1's Final chest X-ray report dated [DATE], the report indicated mild patchy opacity in left lower lung represent infectious process and a suggestion for radiographic follow-up examination to look for resolution, faxed to the facility on [DATE] at 11:13 PM. During a review of RN 5's text thread to NP 1 on (RN 5) [DATE] from the facility's RN Supervisor (RN5) phone, the text thread indicated pictures of Resident 1's faxed lab results for the CBC and CMP drawn on [DATE] and the faxed chest x-ray results from [DATE]. The text thread did not indicate a confirmation of delivery or a response from NP 1. During a review of Resident 1's Progress Notes for the month of [DATE], the Progress Notes indicated the following information: -On [DATE] timed at 10:36 PM, NP 1 came to see Resident 1 and ordered chest x-ray for congestion and cough, CBC and CMP for congestion and cough, and CPT two times a day with Acetylcysteine Inhalation Solution 20% in 3mL inhale orally two times a day -On [DATE], timed at 4:10 PM, and signed by RN 1, the note indicated that at 3:15 PM, the Charge Nurse reported to [RN 1] that she saw the resident during rounds unresponsive, RN 1 assessed the resident and could not obtain the resident's blood pressure, RN 1 instructed one of the team members to start CPR right away which was continued until the Emergency Medical Services (EMS - a system that provides emergency medical care) crew from the local Fire Department (FD) arrived at 3:29 PM. The PN indicated Resident 1 was pronounced deceased at 3:48 PM. A review of Resident 1's PN indicated no evidence that a physician or NP were notified of Resident 1's abnormal lab or x-ray results and the abnormal WBC. The progress notes also did have a documented change in condition (CIC/SBAR- a communication tool used by healthcare workers when there is a change of condition among the residents) report or assessment related to Resident 1's WBC 16.85 x10*3/ul or chest x-ray with left lung opacity. During an interview with RN 5 on [DATE] at 11:08 AM, RN 5 stated lab and diagnostic results were faxed to the facility, and the results were reviewed by the RN on shift. The RN was responsible for sending lab and diagnostic results to the MD and obtaining new orders. RN 5 further explained that important results to send to the MD included opacities in a chest x-ray. During another interview with RN 5 on [DATE] at 4:54 PM, RN 5 stated that she sent Resident 1's lab and diagnostic results by text messages to NP 1 but did receive responses back from NP 1. RN 5 further stated that she also faxed Resident 1's results to MD 1's office but she did not verify or followed up with the physician if the lab results were received. RN 5 stated that elevated WBCs of 16.85 x10*3/ul and a chest x-ray with left lung opacities indicated an infectious process and not relaying the results delayed the providers from treating Resident 1's infection. During an interview with MD 1 on [DATE] at 11:23 AM, MD 1 stated that Resident 1's WBC of 16.85 x10*3/ul and chest x-ray results with left lung opacities were never received by faxed or text by her practice. MD 1 also stated that the facility did not have NP 1 or MD 1's cellphone numbers. thereby making it impossible for any residents' results to be received by text. MD 1 further stated the facility's nurses had a practice of documenting lab and diagnostic results were faxed to her practice, but the results were never received. MD 1 elaborated that the facility's nurses would document physician notified without actual notification. MD 1 stated that the facility's nurses should have called her practice to verify receipt of lab and diagnostic results. During an interview with RN 3 on [DATE] at 12:51 PM, RN 3 stated the text messages to NP 1 would not work because the number used was actually the direct line to MD 1's operator and could not receive text messages. RN 3 stated that lab and diagnostic results should have been faxed to MD 1's practice, with verbal confirmation of receipt by phone. During an interview with the Director of Nursing (DON) on [DATE] at 11:41 AM, the DON stated that faxing residents' results to an MD was not enough; nurses were expected to call the MD and verify receipt of the results then document notification in a progress note with who the nurse spoke to, what results were discussed, and if any new orders were placed related to the results received. The DON further explained that Resident 1's WBC 16.85 x10*3/ul and chest x-ray with left lung opacity warranted a Change in Condition (CIC/SBAR- a communication tool used by healthcare workers when there is a change of condition among the residents) and therefore MD 1 should have been notified of the resident's change in status. During an interview with MD 2 on [DATE] at 3:45 PM, MD 2 stated if the facility's staff cannot get a hold of a resident's primary MD regarding abnormal lab/diagnostic results or change in condition, they were informed to call the medical director. During another interview with MD 1 on [DATE] at 2:30 PM, MD 1 stated that NP 1 ordered CPT with Acetylcysteine to help with Resident 1's new chest congestion while waiting for the lab and chest x-ray results. MD 1 further stated that if she was made aware of Resident 1's chest x-ray with left lung opacity and WBC 16.85 x10*3/ul, she would have ordered antibiotics for the resident. MD 1 stated that Resident 1 could have become septic if the infection was left untreated. During a review of the facility's Policy and Procedure (P&P) titled Lab and Diagnostic Test Results - Clinical Protocol, revised [DATE], the P&P indicated the following: 1. When test results are reported to the facility, a nurse will first review the results 2. Before contacting the physician, the person who is to communicate results to a physician will gather, review, and organize the information and be prepared to discuss the individual's current condition and details of any recent changes in status such as major diagnoses and any recent pertinent lab work. 3. A nurse will identify the urgency of communicating with the Attending Physician, the seriousness of any abnormality, and the individual's current condition. 4. Nursing staff will consider whether the resident's clinical status is unclear or he/she has signs and symptoms of acute illness or condition change and is not stable or improving to identify situations requiring prompt physician notification concerning lab or diagnostic test results. 5. A physician can be notified by phone, fax, voicemail, e-mail, mail, pager or a telephone message to another person acting as the physician's agent (for example, office staff). a. Facility staff should document information about when, how, and to whom the information was provided and the response. This should be done in the Progress Notes section of the medical record. b. Direct voice communication with the physician is the preferred means for presenting any results requiring immediate notification, especially when the resident's clinical status is unstable or current treatment needs review or clarification. 6. Physicians or nurses who have concerns about how test results have been handled or reported should communicate such concerns to the DON and/or Medical Director. Such concerns or disagreements should not prevent timely, clinically appropriate management of a current result or clinical situation. During a review of the facility's P&P titled Change in a Resident's Condition or Status, revised February 20121, the P&P indicated the following: 1. The nurse will notify the resident's attending physician or physician on call when there has been a significant change in the resident's physical/emotional/mental condition. 2. A significant change of condition is a major decline or improvement in the resident's status that will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions 3. Except in medical emergencies, notification will be made within 24 hours of a change occurring in the resident's medical/mental condition or status.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents were free from significant medication errors for one of two sampled residents (Resident 1). Licensed nurses did not administer prescribed respiratory medications to Resident 1, who had chronic obstructive pulmonary disease (COPD-a chronic lung disease causing breathing difficulty) and was oxygen-dependent. Missed doses included: Acetylcysteine Inhalation Solution 20% (used to thin mucus in the lungs): 25 scheduled doses between September and November 2025 Budesonide Inhalation Suspension (reduces airway inflammation): 31 scheduled doses between September and November 2025 Ipratropium-Albuterol Inhalation Solution (relaxes and opens airways): 60 scheduled doses between September and November 2025 This failure placed Resident 1 at risk for respiratory compromise and deterioration related to COPD exacerbation, potentially resulting in further complications and hospitalization. Cross referenced to F678 Findings: During a review of Resident 1's admission Record, the record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including COPD, emphysema, respiratory failure (a condition where the lungs cannot supply enough oxygen or remove carbon dioxide from the blood) with hypoxia (a condition in which body tissues do not receive enough oxygen to function properly), recurrent pneumonia (an infection/inflammation in the lungs) and vascular dementia (changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain). During a review of Residents 1's Minimum Data Sheet (MDS- a resident assessment tool) dated 10/6/2025, the MDS indicated Resident 1 had significantly impaired cognition (the ability to process thoughts) and was dependent on staff for all cares such as eating, bathing, and rolling left and right in bed. During a review of Resident 1's Care Plan (CP) initiated on 4/11/2025 at revised 11/18/2025, the CP indicated Resident 1 had impaired gas exchange related to ineffective airway clearance, dyspnea (difficulty breathing)/ shortness of breath (SOB), COPD, and emphysema. The CP further indicated interventions to administer medications as ordered. During a review of Resident 1's Medication Administration Record (MAR) for the months of September, October, and November 2025, the MAR indicated the following orders: 1. Acetylcysteine Inhalation Solution 20% three mL (milliliter- a unit measure of volume) inhale orally two times a day for COPD, start date 9/30/2025. 2. Budenoside Inhalation Suspension 0.25 milligram (mg- a unit of measurement)/2 mL, inhale two mL orally every morning and at bedtime for COPD, start date 3/3/2025. 3. Ipratropium-Albuterol Inhalation Solution 0.5-2.5 mg (3 mg)/3 mL, inhale three mL orally four times a day for congestion/breathing treatment, start date 6/16/2025. During a continued review of resident 1's MAR for the months of September, October, and November 2025 indicated no documentation on the following days and times for Resident 1's Acetylcysteine Inhalation Solution: 9/30/2025 at 6 PM, 10/1/2025 at 6 PM, 10/2/2025 at 6 PM, 10/3/2025 at 6 PM, 10/4/2025 at 6 PM, 10/5/2025 at 6 PM, 10/6/2025 at 6 PM, 10/7/2025 at 9AM and 6 PM, 10/8/2025 at 6 PM, 10/9/2025 at 6 PM, 10/11/2025 at 6 PM,10/12/2025 at 6 PM, 10/17/2025 at 6 PM, 10/18/2025 at 6 PM, 10/20/2025 at 6 PM, 10/23/2025 at 6 PM, 10/24/2025 at 6 PM, 10/25/2025 at 6 PM, 10/28/2025 at 9AM and 6 PM, 10/31/2025 at 6 PM, 11/1/2025 at 6 PM, 11/15/2025 at 6 PM, and 11/22/2025 at 9 AM. The MAR for September, October, and November 2025 indicated a total of 25 undocumented administrations for Acetylcysteine between September and November 2025. During a continued review of Resident 1's MAR for the months of September to November 2025 indicated no documentation on the following days and time for Resident 1's Budenoside Inhalation Suspension: 9/5/2025 at 9 PM, 9/30/2025 at 9 PM, 10/1/2025 at 9 PM, 10/2/2025 at 9 PM, 10/3/2025 at 9 PM, 10/4/2025 at 9 PM, 10/5/2025 at 9 PM, 10/6/20258 at 9 PM, 10/7/2025 at 9AM and 9 PM, 10/8/2025 at 9 PM, 10/9/2025 at 9 PM, 10/11/2025 at 9 PM, 10/12/2025 at 9 PM, 10/15/2025 at 9 PM, 10/17/2025 at 9 PM, 10/18/2025 at 9 PM, 10/20/2025 at 9 PM, 10/22/2025 at 9 PM, 10/23/2025 at 9 PM, 10/24/2025 at 9 PM, 10/25/2025 at 9 PM, 10/28/2025 at 9AM and 9 PM, 10/31/2025 at 9 PM, 11/1/2025 at 9 PM, 11/6/2025 at 9 PM, 11/13/2025 at 9 PM, 11/14/2025 at 9 PM, 11/15/2025 at 9 PM, and 11/22/2025 at 9 AM. The MAR for September to November 2025 indicated a total of 31 undocumented administrations for Budenoside between September and November 2025. During a continued review of Resident 1's MAR for the months of September to November 2025 indicated no documentation on the following days and time for Resident 1's Ipratropium-Albuterol Inhalation Solution: 9/5/2025 at 5 PM and 9 PM, 9/30/2025 at 5 PM and 9 PM, 10/1/2025 at 5 PM and 9 PM, 10/2/2025 at 5 PM and 9 PM, 10/3/2025 at 5 PM and 9 PM, 10/4/2025 at 5 PM and 9 PM, 10/5/2025 at 5 PM and 9 PM, 10/6/2025 at 5 PM and 9 PM; 10/7/2025 at 9 AM, 12 PM, 5 PM and 9 PM; 10/8/2025 at 5 PM and 9 PM; 10/9/2025 at 5 PM and 9 PM, 10/11/2025 at 5 PM and 9 PM, 10/12/2025 at 5 PM and 9 PM, 10/15/2025 at 9PM, 10/17/2025 at 5 PM and 9 PM, 10/18/2025 at 5 PM and 9 PM, 10/20/2025 at 5 PM and 9 PM, 10/22/2025 at 9 PM, 10/23/2025 at 5 PM and 9 PM, 10/24/2025 at 5 PM and 9 PM; 10/25/2025 at 12 PM, 5 PM, and 9 PM; 10/28/2025 at 9 AM, 12 PM, 5 PM, and 9 PM; 10/31/2025 at 5 PM and 9 PM, 11/1/2025 at 5 PM and 9 PM, 11/6/2025 at 9 PM, 11/13/2025 at 9 PM, 11/14/2025 at 9 PM, 11/15/2025 at 5 PM and 9 PM, 11/19/2025 at 12 PM, 11/22/2025 at 9 AM and 12 PM, and 11/30/2025 at 12 PM. The MAR for September to November 2025 indicated a total of 60 undocumented administrations for Resident 1's Ipratropium-Albuterol between September and November 2025. During a review of Resident 1's physician PN dated 9/29/202, authored by Nurse Practitioner (NP) 1, the PN indicated Resident 1 had diminished breath sounds, was on three liters of oxygen, no respiratory distress, and with a nonproductive cough at the time of the exam. Rales (crackling sounds in the lungs caused by air moving through fluid) and rhonchi (low, snoring-like lung sounds caused by air moving through mucus in larger airways) noted on respiratory exam. The PN further indicated, Plan is to continue regular breathing treatments as scheduled. During another review of Resident 1's physician PN dated 10/10/2025 and authored by NP 1, the PN indicated Resident 1 was on three liters of oxygen with no respiratory distress noted. Plan was to continue regular breathing treatments as scheduled. During another review of Resident 1's PN dated 10/11/2025, authored by Licensed Vocational Nurse (LVN) 8, the PN indicated, shortness of breath noted. Nurse observed shortness of breath (upon exertion). Right lung clear. Left lung clear. Oxygen via nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) During a review of Resident 1's physician PN dated 10/31/2025 and authored by NP 1, the PN indicated Resident 1 was on three liters of oxygen with no respiratory distress noted. Plan was to continue regular breathing treatments as scheduled. During a review of Resident 1's physician PN dated 11/8/2025 and authored by Medical Doctor (MD) 3, the PN indicated, Rhonchi present, diminished lung sounds. During another review of Resident 1's PN dated 11/9/2025, authored by Registered Nurse (RN) 5, the PN indicated, shortness of breath noted. Resident [1] reported shortness of breath (while lying flat). Nurse observed shortness of breath (while lying flat). Right lung clear, left lung clear. Oxygen via nasal cannula. During another review of Resident 1's PN dated 11/15/2025, authored by RN 5, the PN indicated, shortness of breath noted. Resident [1] reported shortness of breath (while lying flat). Nurse observed shortness of breath (while lying flat). Right lung clear, left lung clear. Oxygen via nasal cannula. During another review of Resident 1's PN dated 11/17/2025, authored by RN 5, the PN indicated, shortness of breath noted. Resident [1] reported shortness of breath (while lying flat). Nurse observed shortness of breath (while lying flat). Right lung clear, left lung clear. Oxygen via nasal cannula. During a review of Resident 1's physician PN dated 11/30/2025 and authored by NP 1, the PN indicated Resident 1 was on three liters of oxygen with no respiratory distress noted. Plan was to continue regular breathing treatments as scheduled. During a concurrent interview and record review with the Director of Nursing (DON) on 1/2/2026 at 5:57 PM, Resident 1's MAR for September to December 2026 was reviewed. The DON stated she could not find documented evidence that the Acetylcysteine, Budenoside, and Ipratropium-Albuterol respiratory medications were administered Resident 1. The DON further stated that by not receiving the respiratory medications as ordered, Resident 1 was placed at risk of COPD exacerbation (a sudden worsening of breathing symptoms, such as increased shortness of breath, cough, or sputum), which could lead to hospitalization or death. During an interview with MD 1 on 1/5/2026 at 2:30 PM, MD 1 stated that Acetylcystiene, Budenoside, and Ipratropium-Albuterol respiratory medications were ordered specifically to help with Resident 1's COPD and missing several doses, especially consecutively, could trigger Resident 1 to experience a COPD exacerbation, further explaining that this could have led to Resident 1 experiencing a medical emergency from COPD exacerbation. During a review of the facility policy and procedure (P&P) titled Administering Medications dated April 2019, the P&P indicated, Medications are administered in accordance with prescriber orders, including any required timeframe.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure four out of five facility staff members, Registered Nurses (RNs) 1 and 2, and Certified Nursing Assistants (CNAs) 1 and 2, demonstrated competencies and skill sets necessary to provide emergency response and perform cardiopulmonary resuscitation (CPR-CPR is an emergency, life saving procedure performed when the heart stops beating and involves chest compressions at a rate of 100-120 beats per minute (bpm) and rescue breaths to maintain blood flow and oxygenation) as indicated in the facilities policy and procedure (PP) for Emergency Procedure - Cardiopulmonary Resuscitation and the American Red Cross CPR guidance as evidence by: 1. CNA 1 stated it took two (2) minutes to check for an unresponsive resident's pulse and breathing prior to performing CPR. 2.CNA 2 stated it took thirty (30) seconds to check for an unresponsive resident's pulse and breathing prior to performing CPR. 3.CNA 1 and CNA 2 failed to indicate the correct chest compressions at a rate of 100 - 120 bpm. 4. Registered Nurse (RN) 1 failed to demonstrate how to set up, turn it on, and check if the portable suction device (machine used to pull liquids away from the mouth or throat) and emergency oxygen tank (portable metal cylinder containing compressed oxygen) was operable as part of the emergency equipment in accordance with the facility's PP titled Disposable Suction Canister. 5. Registered Nurse (RN) 1 and RN 2 failed to identify the location of the emergency supplies in the emergency crash cart such as the adult oxygen masks (medical device that fits over the nose and mouth to deliver oxygen from the oxygen tank to the lungs), suction catheters (thin flexible tube connected to a portable suction device to remove fluids from the resident's mouth or throat), short and long connective tubing for the suction machine, and the CPR mask/shield (small plastic barrier to deliver safe recuse breaths to an unresponsive resident) in accordance with the facility's PP Suctioning the Upper Airway, 6. RN 1 failed to state the correct chest compression rate of 100-120 bpm and the depth of compressions at 2 inches or 5 centimeters. 7. Director of Staff Development (DSD) failed to demonstrate proficient chest compressions at a rate of 100 - 120 bpm. 8. The facility failed to evaluate the competency and skills set of RNs 1 and 2 and CNs 1 and 2 to determine the understanding and compliance of the Licensed Nurses (LNs) or CNAs with CPR to training provided during these Mock Code Blue (life threatening emergencies that require immediate CPR) Drills. These deficient practices had the potential to result in ineffective and poor-quality CPR and emergency response, which may lead to rib fractures (broken bone), irreversible brain damage due to prolonged lack of oxygen, and ultimately preventable death. Findings: During a concurrent observation and interview on [DATE] at 3:36 PM, CNA 1was asked to demonstration CPR skills as instructed during the Mock Code Blue Drill held on [DATE]. CNA 1 stated, if a resident was found unresponsive, he would check the resident's chest rise and pulse on the neck for two (2) minutes before initiating chest compressions. CNA 1 stated, he did not know the correct rate of the chest compressions, but he sings happy birthday slowly while performing chest compressions. During a concurrent observation and interview on [DATE] at 4PM with CNA 2, CNA 2 was asked to demonstrate how to perform CPR as instructed during the Mock Code Blue Drill held in [DATE]. CNA 2 was observed pressing two fingers to check the carotid pulse on the right side of her neck and then performed chest compressions. CNA 2 stated, if a resident was found unresponsive, she needed to check if the resident had chest rise and a pulse for thirty (30) seconds. CNA 2 stated, she was not sure how fast the compressions should be, but she just needed to count fast. During a concurrent observation and interview on [DATE] at 4:32 PM with RN 1 in front of the emergency crash cart, RN 1 was observed checking the emergency crash cart using the Emergency Cart Checklist document. RN 1 stated, she has not checked the emergency crash cart for today. RN 1 was asked to demonstrate how to operate the suction machine and oxygen tank and the emergency equipment in the emergency cart. During the interview, RN 1 stated: 1.She he did not know where the adult oxygen masks, suction catheters, short and long connective tubing for the suction catheters, and the CPR mask/shield were located. 2. She did not know where the personal protective equipment (PPE) was located in the emergency cart. 3. She did not know how to connect, turn on, and check if the suction machine was operable and found the [NAME] suction tip (a rigid plastic medical device used to clear fluids from the mouth or throat) not connected to the machine. 4. She did not know how to check if the oxygen tank was operable or contained oxygen. During the same observation and interview on [DATE] at 4:40 PM with RN 1 in front of the emergency crash cart, RN 1 stated she did not know what pressure the suction machine should be set at. RN 1 stated, it was important to be familiar with the emergency crash cart to ensure all equipment was operable in case of emergency because it can make a difference in a life-or-death situation. During an observation and interview on [DATE] at 4:50 PM with RN 1 was asked to demonstrate how to perform CPR as instructed during the in-service and the Mock Code Blue Drill held on [DATE]. RN 1 stated the rate of compressions for CPR was 100 - 110 bpm and the compression depth was 1/3 of the chest. RN 1 stated, the facility conducts weekly mock Code Blue Drills where all the LNs and CNAs were required to participate by demonstrating how to perform chest compressions, verbally answer knowledge- based and scenario-based questions related to CPR, and signing the in-service sign-in sheet. RN 1 stated, there was no documentation to indicate the staffs were evaluated for competencies, understanding and the effectiveness of the mock Code Blue Drills for the LNs and CNAs. During an interview on [DATE] at 9:30 AM, with the Director of Staff Development (DSD), the DSD stated that during the facility's Mock Code Blue Drills, each licensed nurse (LN) and CNA demonstrated CPR by performing thirty (30) chest compressions to two (2) breaths using an ambu-bag (a handheld portable device used to manually deliver oxygen into the lungs) for two (2) minutes. During the same observation and interview on [DATE] at 9:45 AM with the DSD, the DSD was asked to demonstrate how to perform CPR as instructed during the in-service and Mock Code Blue Drill held in [DATE]. The DSD was observed with her bilateral arms straight, elbows locked, and hands on top of each other and interacted together performing chest compressions on top of the overbed side table. The DSD stated the chest compression count rate per beat was 1 one thousand, 2 one thousand, 3 one thousand, 4 one thousand until 30 one thousand. During the same interview on [DATE] at 10 AM with the DSD, the Director of Staff Development (DSD) stated that Registered Nurses (RNs) are the primary point of contact during any Code Blue situation and they are expected to know the location of emergency supplies in the crash cart and ensure that all emergency equipment is operable at each shift. During a concurrent observation and interview on [DATE] at 11:56 AM, in front of the emergency crash cart, RN 2 was observed checking the crash cart using the facility's Emergency Cart Checklist document. RN 2 did not know the location of the suction catheters and CPR masks/shields within the crash cart. During the interview, RN 2 stated it was important to check if the equipment was operable and to know the location of emergency equipment because it can be time-consuming looking for equipment. RN 2 further stated that the portable suction device should be set at a negative pressure of 200-300 millimeters of mercury (mmHg). During a concurrent interview and record review on [DATE] at 4:30 PM, during an interview with the Director of Staff Development (DSD) and review of the facility's ETP Attendance Roster (Single Day) dated [DATE], the DSD stated she monitored the effectiveness of the mock Code Blue Drills through staff verbal responses, return demonstrations, and participation as evidenced by the in-service sign-in roster. The DSD further stated there was no documented evidence the competencies and understanding of the Licensed Nurses (LNs) and CNAs were evaluated for the training provided during these Mock Code Blue Drills as of [DATE]. During a review of the facility's P&P titled Suctioning the Upper Airway, dated [DATE], the P&P indicated that the portable suction device should have a negative pressure set at 10-15mmHg. During a review of the instruction manual for Disposable Suction Canister, date unknown, the manual indicated to attach the suction cannister's short vacuum tubing to the suction machine to one open port, attach the long vacuuming tubing to the second open port, and ensure all seals are intact by turning on the vacuum pump. During a review of the facility's policy and procedures (P&P) titled Emergency Procedure - Cardiopulmonary Resuscitation, dated February 2018, the P&P indicated chest compressions are performed by pushing hard to a depth of at least 2 inches (5 centimeters) at a rate of at least 100 compressions per minute. During a review of the facility's P&P title Competency of Nursing Staff, dated [DATE], the P&P indicated: 1. All the licensed nurses and nursing assistants employed by the facility will demonstrate specific competencies and skill sets deemed necessary to care for the needs of residents, as identified through resident assessment. 2. The factors considered in the creation of the competency-based staff development and training program include a method to track, assess, plan, implement, and evaluate the effectiveness of training. 3. The competency demonstrations will be evaluated based on the staff member's ability to use and integrate knowledge and skills obtained in training, which will be evaluated by the staff already deemed competent in that skill or knowledge. During a review of the American Red Cross skill sheet CPR for Adults, dated 2019, the skill sheet indicated to compress the chest at a depth of at least 2 inches and to provide smooth compressions at a rate of 100 to 120 per minute.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide the necessary respiratory care and interventions in accordance with the resident's respiratory care needs, care plan, facility policy and professional standards of practice, the physician's order and facility's policy and procedure for one of two sampled residents (Resident 1) diagnosed of respiratory failure (a condition where the lungs cannot supply enough oxygen or remove carbon dioxide from the blood) with hypoxia (a life-threatening condition where the lungs fail to deliver enough oxygen to the blood, leading to dangerously low oxygen levels in the body), chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty breathing), emphysema (a lung disease where the air sacs [alveoli] in the lungs are damaged, making breathing difficult) and recurrent pneumonia (an infection/inflammation in the lungs) by failing to: 1. Administer respiratory medications consistently as ordered for Resident 1 for COPD, chest congestion and shortness of breath. The Medication Administration Record (MAR) indicated the following missed respiratory treatments: -Acetylcysteine Inhalation Solution 20% (a medication used to thin mucus in the lungs) 25 (twenty-five) scheduled times between [DATE] to [DATE]. -Budenoside Inhalation Suspension (a medication inhaled to reduce swelling in the airways) 31 (thirty-one) scheduled times between [DATE] to [DATE]. -Ipratropium-albuterol Inhalation Solution (a medication used in a nebulizer that combines two drugs to relax and open the airways) 60 (sixty) scheduled times between [DATE] to [DATE]. 2. Monitor Resident 1 for respiratory distress (life-threatening condition that causes severe difficulty breathing. It occurs when the lungs become inflamed and damaged, making it difficult for oxygen to reach the bloodstream) and change in respiratory condition, in accordance with the resident's care plan for COPD and emphysema when Nurse Practitioner (NP) 1 identified Resident 1 on [DATE] as having cough, congestion, abnormal lung sounds and respiratory distress with oxygen saturation of 93% at 3 liter of oxygen and Registered Nurse (RN) 5 received abnormal laboratory (lab) and chest Xray (CXR - (a type of imaging that uses electromagnetic radiation to view internal structures of the body) results on [DATE]. 3. Revise and implement Resident 1's care plan to assess or monitor Resident 1's respiratory status that included assessment of lung sounds and monitoring Resident 1's worsening cough and congestion to initiate nursing interventions, after receiving Resident 1's abnormal laboratory (lab) and CXR results on [DATE]. 4. Notify Medical Doctor (MD) 1 of Resident 1's elevated white blood cell (WBC - a blood cell that helps attack infection or injury in the body) count and abnormal chest x-ray results indicating mild patchy opacity (an area that appears white or dense on an x-ray) in the left lower lung which represented a potential indicator of lung infection. This deficient practice had the potential to result to medical and respiratory complications which included severe respiratory distress/failure, collapsed lungs, septicemia that may lead to hospitalization and/or death. Furthermore, these deficient practices delayed necessary medical evaluation and treatment of Resident 1's respiratory condition from [DATE] to [DATE]. On [DATE], Resident 1 was found unresponsive and pulseless at 3:05 PM. Cardiopulmonary Resuscitation (CPR) was performed and Resident 1 was later pronounced dead on [DATE] at 3:48 PM by Emergency Medical Services (EMS). Cross referenced to F678Findings: During a review of Resident 1's admission Record, the record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including COPD, emphysema, respiratory failure (a condition where the lungs cannot supply enough oxygen or remove carbon dioxide from the blood) with hypoxia (a condition in which body tissues do not receive enough oxygen to function properly), recurrent pneumonia (an infection/inflammation in the lungs) and vascular dementia (changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain). During a review of Residents 1's Minimum Data Sheet (MDS- a resident assessment tool) dated [DATE], the MDS indicated Resident 1 had significantly impaired cognition (the ability to process thoughts) and was dependent on staff for all cares such as eating, bathing, and rolling left and right in bed. During a review of Resident 1's Medication Administration Record (MAR) for the months of [DATE], [DATE], and [DATE], the MAR indicated the following orders: 1. Acetylcysteine Inhalation Solution 20% three mL (milliliter- a unit measure of volume) inhale orally two times a day for COPD, start date [DATE]. 2. Budenoside Inhalation Suspension 0.25 milligram (mg- a unit of measurement)/2 mL, inhale two mL orally every morning and at bedtime for COPD, start date [DATE]. 3. Ipratropium-Albuterol Inhalation Solution 0.5-2.5 mg (3 mg)/3 mL, inhale three mL orally four times a day for congestion/breathing treatment, start date [DATE]. During a continued review of resident 1's MAR for the months of [DATE], [DATE], and [DATE] indicated no documentation on the following days and times for Resident 1's Acetylcysteine Inhalation Solution: [DATE] at 6 PM, [DATE] at 6 PM, [DATE] at 6 PM, [DATE] at 6 PM, [DATE] at 6 PM, [DATE] at 6 PM, [DATE] at 6 PM, [DATE] at 9AM and 6 PM, [DATE] at 6 PM, [DATE] at 6 PM, [DATE] at 6 PM,[DATE] at 6 PM, [DATE] at 6 PM, [DATE] at 6 PM, [DATE] at 6 PM, [DATE] at 6 PM, [DATE] at 6 PM, [DATE] at 6 PM, [DATE] at 9AM and 6 PM, [DATE] at 6 PM, [DATE] at 6 PM, [DATE] at 6 PM, and [DATE] at 9 AM. The MAR for [DATE], [DATE], and [DATE] indicated a total of 25 undocumented administrations for Acetylcysteine between [DATE] and [DATE]. During a continued review of Resident 1's MAR for the months of [DATE] to [DATE] indicated no documentation on the following days and time for Resident 1's Budenoside Inhalation Suspension: [DATE] at 9 PM, [DATE] at 9 PM, [DATE] at 9 PM, [DATE] at 9 PM, [DATE] at 9 PM, [DATE] at 9 PM, [DATE] at 9 PM, [DATE] at 9 PM, [DATE] at 9AM and 9 PM, [DATE] at 9 PM, [DATE] at 9 PM, [DATE] at 9 PM, [DATE] at 9 PM, [DATE] at 9 PM, [DATE] at 9 PM, [DATE] at 9 PM, [DATE] at 9 PM, [DATE] at 9 PM, [DATE] at 9 PM, [DATE] at 9 PM, [DATE] at 9 PM, [DATE] at 9AM and 9 PM, [DATE] at 9 PM, [DATE] at 9 PM, [DATE] at 9 PM, [DATE] at 9 PM, [DATE] at 9 PM, [DATE] at 9 PM, and [DATE] at 9 AM . The MAR for [DATE] to [DATE] indicated a total of 31 undocumented administrations for Budenoside between [DATE] and [DATE]. During a continued review of Resident 1's MAR for the months of [DATE] to [DATE] indicated no documentation on the following days and time for Resident 1's Ipratropium-Albuterol Inhalation Solution: [DATE] at 5 PM and 9 PM, [DATE] at 5 PM and 9 PM, [DATE] at 5 PM and 9 PM, [DATE] at 5 PM and 9 PM, [DATE] at 5 PM and 9 PM, [DATE] at 5 PM and 9 PM, [DATE] at 5 PM and 9 PM, [DATE] at 5 PM and 9 PM; [DATE] at 9 AM, 12 PM, 5 PM and 9 PM; [DATE] at 5 PM and 9 PM; [DATE] at 5 PM and 9 PM, [DATE] at 5 PM and 9 PM, [DATE] at 5 PM and 9 PM, [DATE] at 9PM, [DATE] at 5 PM and 9 PM, [DATE] at 5 PM and 9 PM, [DATE] at 5 PM and 9 PM, [DATE] at 9 PM, [DATE] at 5 PM and 9 PM, [DATE] at 5 PM and 9 PM; [DATE] at 12 PM, 5 PM, and 9 PM; [DATE] at 9 AM, 12 PM, 5 PM, and 9 PM; [DATE] at 5 PM and 9 PM, [DATE] at 5 PM and 9 PM, [DATE] at 9 PM, [DATE] at 9 PM, [DATE] at 9 PM, [DATE] at 5 PM and 9 PM, [DATE] at 12 PM, [DATE] at 9 AM and 12 PM, and [DATE] at 12 PM. The MAR for [DATE] to [DATE] indicated a total of 60 undocumented administrations for Resident 1's Ipratropium-Albuterol between September and [DATE]. During a review of Resident 1's physician Progress Notes (PN) dated [DATE], authored by Nurse Practitioner (NP) 1, the PN indicated Resident 1 had diminished breath sounds, was on three liters of oxygen, no respiratory distress, and with a nonproductive cough at the time of the exam. Rales (crackling sounds in the lungs caused by air moving through fluid) and rhonchi (low, snoring-like lung sounds caused by air moving through mucus in larger airways) noted on respiratory exam. The PN further indicated, Plan is to continue regular breathing treatments as scheduled. During another review of Resident 1's PN dated [DATE], authored by Licensed Vocational Nurse (LVN) 8, the PN indicated, shortness of breath noted. Nurse observed shortness of breath (upon exertion). Right lung clear. Left lung clear. Oxygen via nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen). During a review of Resident 1's physician PN dated [DATE] and authored by Medical Doctor (MD) 3, the PN indicated, Rhonchi present, diminished lung sounds. During another review of Resident 1's PN dated [DATE], authored by Registered Nurse (RN) 5, the PN indicated, shortness of breath noted. Resident [1] reported shortness of breath (while lying flat). Nurse observed shortness of breath (while lying flat). Right lung clear, left lung clear. Oxygen via nasal cannula. During another review of Resident 1's PN dated [DATE], authored by RN 5, the PN indicated, shortness of breath noted. Resident [1] reported shortness of breath (while lying flat). Nurse observed shortness of breath (while lying flat). Right lung clear, left lung clear. Oxygen via nasal cannula. During another review of Resident 1's PN dated [DATE], authored by RN 5, the PN indicated, shortness of breath noted. Resident [1] reported shortness of breath (while lying flat). Nurse observed shortness of breath (while lying flat). Right lung clear, left lung clear. Oxygen via nasal cannula. During a review of Resident 1's physician PN dated [DATE] and authored by NP 1, the PN indicated Resident 1 was on three liters of oxygen with no respiratory distress noted. Plan was to continue regular breathing treatments as scheduled. During a review of Resident 1's physician Progress Notes dated [DATE], authored by NP 1, the note indicated NP 1 assessed Resident 1's medical condition at the facility. The note further indicated Resident 1's lung exam exhibited rales (abnormal crackling sounds in the lungs when breathing). The note indicated Resident 1 was on oxygen at 3 liters per minute (LPM- a unit measuring the flow rate of oxygen through a delivery device) with an oxygen saturation (O2 sat- a measurement of how much oxygen the blood is carrying as a percentage [normal for COPD is 88% to 92%]) level of 93%, with respiratory distress noted, and coughing. The note indicated to continue regular breathing treatments as scheduled, chest percussion therapy (CPT- a technique that uses rhythmic clapping on the chest and back to loosen and clear mucus from the lungs) two times a day with Mucomyst (Acetylcysteine- a medication used to thin mucus in the lungs), wean off of oxygen, chest x-ray, and labs that included CBC (complete blood count) and CMP (comprehensive metabolic panel) to rule out infection etiology. During a review of Resident 1's Orders Report for [DATE], the Report indicated the following physician orders: 1. Chest x-ray 2 view due to congestion and cough, ordered on [DATE] by MD 1 at 3:50 PM as confirmed by RN 5 2. CBC and CMP due to congestion and cough, ordered on [DATE] by MD 1 at 4:01 PM as confirmed by RN 5 3. Acetylcysteine Inhalation Solution 20% 3 mL (milliliter- a measure of volume) inhale orally two times a day for cough, CPT with [Acetylcysteine] 3 mL 20% solution, ordered on [DATE] by MD 1 at 4:17 PM as confirmed by RN 5 During a review of Resident 1's lab results dated [DATE], the results indicated WBC of 16.85 x10*3/ul (Normal range 4.0-11.0 x10*3/ul). The lab results indicated a collected date of [DATE] at 8:10 AM and a result date of [DATE] at 12:59 PM, faxed to the facility on [DATE] at 1:10 PM. During a review of Resident 1's Final X-ray report dated [DATE], the report indicated mild patchy opacity (an area that appears white or dense on an x-ray) in left lower lung represent infectious process and a suggestion for radiographic follow-up examination to look for resolution, faxed to the facility on [DATE] at 11:13 PM. During a review of RN 5's text messages (a standard for sending short, text-only messages between mobile phones) thread to NP 1 on [DATE] at 1:52 PM from the facility's cellular phone, the text thread indicated pictures of Resident 1's faxed lab results for the CBC and CMP drawn on [DATE] and the faxed chest x-ray results from [DATE]. The text messages did not indicate a confirmation of text message delivery or a text response from NP 1. During a review of Resident 1's Progress Notes for the month of [DATE], the Progress Notes indicated the following information: 1. On [DATE] timed at 10:36 PM, and signed by RN 5, the note indicated NP 1 came to see Resident 1 and ordered chest x-ray for congestion and cough, CBC and CMP for congestion and cough, and Acetylcysteine Inhalation Solution 20% 3mL inhale orally two times a day for cough, and CPT two times a day with Acetylcysteine. 2. On [DATE], timed at 4:10 PM, and signed by RN 1, the note indicated that at 3:15 PM, the charge nurse reported to [RN 1] that she saw [Resident 1] during rounds unresponsive. The note further indicated that RN 1 went to the room to assess Resident 1 and could not obtain the resident's blood pressure. The note also indicated that RN 1 instructed one of the team members to start CPR right away. The note indicated that CPR was continued until the Emergency Medical Services (EMS - a system that provides emergency medical care) crew from the local Fire Department (FD) arrived at 3:29 PM. The entry further indicated that the resident was pronounced deceased at 3:48 PM. The progress notes did not indicate MD 1 or NP 1 verbally confirmed receipt of Resident 1's abnormal and chest x-ray with left lung opacity, or that the results were discussed with Resident 1's providers by any licensed nurses. The progress notes also did not indicate a change in condition (CIC/SBAR- a communication tool used by healthcare workers when there is a change of condition among the residents) or assessment and monitoring by licensed nurses for cough and congestion after NP 1 ordered CBC, CMP, chest x-ray, and CPT with Acetylcysteine for Resident 1's cough and congestion. The PN also did not indicate a CIC/SBAR with assessment and monitoring for Resident 1's WBC 16.85 x10*3/ul and chest x-ray with left lung opacity. During a review of Resident 1's CP initiated on [DATE] and revised [DATE], the CP indicated Resident 1 had impaired gas exchange related to COPD. The CP indicated a goal for Resident 1 to maintain O2 sat within personal goal range. The CP indicated interventions to evaluate capillary refill, evaluate for change in level of consciousness, evaluate for restlessness, evaluate for use of accessory muscles while breathing, evaluate mental status, evaluate respiratory rate and effort, evaluate skin color, temperature and characteristics, monitor for changes in respiratory rate or shallow breathing, and monitor for use of accessory muscles. During another review of Resident 1's CP initiated on [DATE] and revised [DATE], the CP indicated Resident 1 had oxygen therapy related to respiratory illness. The CP indicated goals for Resident 1 not to have signs and symptoms of poor oxygen absorption. The CP also indicated to monitor for signs and symptoms of respiratory distress and report to the MD as needed: respirations, O2 sat, increased heart rate, restlessness, sweating, headaches, lethargy, confusion, atelectasis (partial or complete lung collapse), hemoptysis (coughing blood), cough, painful breathing, accessory muscle usage, and skin color. During further review of Resident 1's current care plans, the CPs did not include a revised/updated care plan for Resident 1's new onset or worsening cough and congestion that included at risk for infection related to the abnormally high WBC lab results and abnormal chest x-ray received on [DATE]. During an interview with RN 5 on [DATE] at 11:08 AM, RN 5 stated that Resident 1's lab and diagnostic results were faxed to the facility on [DATE], and the results were reviewed by the RN on shift. The RN was responsible for sending lab and diagnostic results to the MD and obtaining new orders. During the same interview with RN 5, RN 5 stated she was aware NP 1 came to facility on [DATE] and placed new orders for Resident 1 that included CBC, CMP, chest x-ray, and CPT with Acetylcysteine for Resident 1's worsening cough and congestion. RN 5 further stated that these new orders should have triggered her to initiate a CIC/SBAR and assess Resident 1's respiratory condition because it was a change in the resident's condition, but RN 5 stated that she did not initiate a CIC/SBAR to assess/monitor Resident 1's respiratory condition such as lung sounds or breathing to ensure Resident 1 was not in respiratory distress or experiencing shortness of breath. During another interview with RN 5 on [DATE] at 4:54 PM, RN 5 stated that when she received Resident 1's lab and x-ray results on [DATE] at 1:52 PM, RN 5 sent pictures of the lab and CXR result to NP 1's cellular phone but never received text message responses back from NP 1. RN 5 further stated that she also faxed Resident 1's lab and CXR results to MD 1's office on [DATE], but did not verify the lab results were received by MD 1's office. RN 5 stated she did not call MD1's office or NP 1's cellular phone to confirm receipt of Resident 1's lab and CXR results. RN 5 stated that she should have called MD 1's office or NP 1 to verify the receipt of Resident 1's lab and CXR results. RN 5 stated that elevated WBCs of 16.85 x10*3/ul and a chest x-ray with left lung opacities indicated an infectious process and not relaying the results to MD 1 or NP 1 delayed the provider's from providing orders to treat Resident 1's respiratory infection. During the same interview with RN 5 [DATE] at 4:54 PM, RN 5 stated that she should have also initiated a CIC/SBAR on [DATE] for Resident 1's elevated WBCs of 16.85 x10*3/ul and a chest x-ray with left lung opacities and assessed Resident 1 for signs of respiratory distress or shortness of breath, but she did not. During a concurrent record review and interview with RN 5 on [DATE] at 4:54 PM, Resident 1's Progress Notes for [DATE] was reviewed. RN 5 stated she did not document that she notified MD 1 or NP 1 of Resident 1's abnormal lab results indicating elevated WBC and abnormal CXR. RN 5 stated that there was no documentation in the progress notes of any licensed nurses discussing the WBC or chest x-ray results with NP 1 or MD 1. RN 5 also stated there was no documentation of a CIC/SBAR or assessment and monitoring by licensed nurses for cough and congestion after [DATE] after NP 1 ordered CBC, CMP, CXR, and CPT with Acetylcysteine for Resident 1's cough and congestion in the progress notes. RN 5 also stated the progress notes did not contain documentation of a CIC/SBAR with assessment and monitoring for Resident 1's WBC of 16.85 x10*3/ul and CXR with left lung opacity. During an interview with MD 1 on [DATE] at 11:23 AM, MD 1 stated that Resident 1's WBC of 16.85 x10*3/ul and chest x-ray results with left lung opacities were not received by her office. MD 1 also stated that the facility did not have NP 1 or MD 1's direct cellphone numbers, thereby making it impossible for any residents' results to be received via text message. MD 1 further stated the facility's nurses had a practice of documenting lab and diagnostic results were faxed to her office, even if the lab and diagnostic results were not confirmed as received. MD 1 elaborated that the facility's nurses would document physician notified without actual notification. MD 1 stated that the facility's nurses should have called her practice to verify receipt of lab and diagnostic results. During an interview with RN 3 on [DATE] at 12:51 PM, RN 3 stated she was familiar with Resident 1. RN 3 stated the text messages to NP 1 would not work because the number used was actually the direct line to MD 1's operator and would not be able to receive text messages. RN 3 stated that Resident 1's lab and CXR results should have been faxed to MD 1's office, with verbal confirmation from MD1's office staff by phone. During the same interview with RN 3 on [DATE] at 12:51 PM, RN 3 stated that abnormal lab results were considered a change in a resident's condition. RN 3 further explained that there were two missed opportunities for RN 5 to initiate a CIC/SBAR and conduct an assessment of Resident 1: 1. When RN 5 received NP 1's orders of labs, chest-x-ray and new respiratory treatments for Resident 1's chest congestion and cough 2. When RN 5 received Resident 1's results indicating elevated WBCs of 16.85 x10*3/ul and chest x-ray with left lung opacities, RN 3 stated Resident 1 should have been assessed for shortness of breath or difficulty breathing so that staff can properly intervene if the resident was in respiratory distress. By not doing so, Resident 1 could die from respiratory complications. During an interview with the Director of Nursing (DON) on [DATE] at 11:41 AM, the DON further stated that nurses were expected to perform a full head-to-toe assessment when residents experience a change in condition. The DON stated this was important to fully understand the resident's clinical status and what interventions needed to be done. The DON stated that, by failing to properly assess Resident 1 and initiate a CIC/SBAR for continued assessment and monitoring of Resident 1's respiratory status, the resident was at risk for further decline. During an interview with MD 2 on [DATE] at 3:45 PM, MD 2 stated if the facility's staff could not get ahold of a resident's primary MD regarding abnormal lab/diagnostic results or change in condition, they were directed to call the medical director. During a concurrent interview and record review with the Director of Nursing (DON) on [DATE] at 5:57 PM, Resident 1's MAR for September to [DATE] was reviewed. The DON stated she could not find documented evidence that the Acetylcysteine, Budenoside, and Ipratropium-Albuterol respiratory medications were administered Resident 1. The DON further stated that by not receiving the respiratory medications as ordered, Resident 1 was placed at risk of COPD exacerbation (a sudden worsening of breathing symptoms, such as increased shortness of breath, cough, or sputum), which could lead to hospitalization or death. During another interview with MD 1 on [DATE] at 2:30 PM, MD 1 stated that NP 1 ordered CPT with Acetylcysteine to help with Resident 1's worsening chest congestion while waiting for the lab and chest x-ray results. MD 1 further stated that if she was made aware of Resident 1's abnormal chest x-ray with left lung opacity and elevated WBC of 16.85 x10*3/ul, she would have ordered antibiotics for Resident 1. MD 1 stated that Resident 1 could have become septic if the infection was left untreated. During the same interview with MD 1, MD 1 stated that Acetylcystiene, Budenoside, and Ipratropium-Albuterol respiratory medications were ordered specifically to help with Resident 1's COPD and missing several doses, especially consecutively, could trigger Resident 1 to experience a COPD exacerbation, further explaining that this could have led to Resident 1 experiencing a medical emergency from COPD exacerbation. During a review of the facility's P&P titled Change in a Resident's Condition or Status, revised February 20121, the P&P indicated the following: 1. The nurse will notify the resident's attending physician or physician on call when there has been a significant change in the resident's physical/emotional/mental condition. 2. A significant change of condition is a major decline or improvement in the resident's status that will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions 3. Except in medical emergencies, notification will be made within 24 hours of a change occurring in the resident's medical/mental condition or status. 4. Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR Communication Form. 5. The nurse will record in the resident' s medical record information relative to changes in the resident's medical/mental condition or status. During a review of the facility's P&P titled Resident Examination and Assessment, the P&P indicated the purpose of this procedure is to examine and assess the resident for any abnormalities in health status, which provides a basis for the care plan. The P&P further indicated how to perform a full head-to-toe assessment and indicated to notify the physician of any abnormalities such as labored breathing; breath sounds that are not clear; or cough, productive or nonproductive. During a review of the facility policy and procedure (P&P) titled Administering Medications dated [DATE], the P&P indicated, Medications are administered in accordance with prescriber orders, including any required timeframe.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to protect the resident's rights to be free from physical abuse for two of three sampled residents (Resident 2 and 3) by failing to protect Residents 2 and 3 from physical abuse. On 11/24/25, Resident 1 was observed by facility staff to be agitated, pacing back and forth in the room and swinging two metal wheelchair footrests in the air. Facility staff (Certified Nurse Assistant 1) failed to redirect and remove Resident 1 from the room leaving two other residents (Residents 2 and 3) in the room with Resident 1. As a result, Resident 1 hit Resident 2 several times in the head with the metal wheelchair footrests while Resident 2 was in bed. Resident 2 sustained severe, multiple lacerations (a jagged or irregular tear in the skin, often with edges that do not line up, caused by blunt force or tearing), bruising and severe pain to the face. Resident 3 verbalized fear and frightened for her life as she witnessed Resident 1 attempt to strike her with the metal footrests. The facility called 9-1-1 emergency services on 11/24/2025 at 12:08 AM, and Resident 2 was transferred to General Acute Care Hospital (GACH) 3. In GACH 3, Resident 2 was found to have sustained forehead soft tissue hematoma (collection of blood outside the blood vessel that forms a swollen area under the skin after an injury) as well as a right periorbital (around the eye socket) laceration. Resident 2's Computerized Tomography scan (CT scan - imaging using x-ray [a photographic or digital image of the internal composition of a part of the body] technique to create detailed images of the body) indicated there was partial mild irregularity of the right nasal (internal part of the nose) bone and a questionable right anterior (front) nasal bone fracture (broken bone). Resident 2 was readmitted back to the facility on [DATE] at 8:15 AM with derma bond (surgical glue) and steri-strips (sterile, adhesive, porous strips used to close small cuts, lacerations, and surgical incisions) applied to Resident 2's facial injuries. Findings: During a review of Resident 1's General Acute Care Hospital Records (GACH) 1 dated 5/21/2025, prior to admission to the facility, the GACH 1 record indicated Resident 1 was previously admitted to the GACH 1 Emergency Department (ED) due to an altercation with Family Member (FM) 1, threatening FM 1 with a knife. The GACH 1 ED record indicated Resident 1 was placed on a 5150 hold (involuntary psychiatric detention) at the GACH 1 for danger to others During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted the resident to the facility on 5/22/2025, with diagnoses including dementia (a general term for a decline in thinking, memory, and reasoning skills severe enough to interfere with daily life) with behavioral disturbance (loss of memory and thinking ability with agitation and physical aggression), psychosis ( loses of touch with reality, experiencing symptoms like hallucinations (seeing/hearing things not there) and delusions (false beliefs), along with confused thinking and speech. During a review of Resident 1's care plan initiated on 5/23/2025 indicated Resident [1] has a behavioral symptom manifested by delusions as evidenced by resident saying the resident hears God's voices all the time, the care plan indicated the care plan goals for the resident's behavior is to not result in harm or injury to self or others. The care plan interventions included for facility staff to provide behavioral management or modification as needed, such as providing redirection when exhibiting inappropriate behavior. During a review of Resident 1's History and Physical (H&P) dated 5/24/2025, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. The H&P indicated Resident 1 came from GACH 1 for altered mentation (confusion, not acting right, altered behavior), metabolic encephalopathy (brain dysfunction caused by illness) and dementia. During a review of a care plan developed for Resident 1 and initiated on 6/14/2025, the care plan indicated the resident has a behavioral problem of being physically aggressive related to pushing staff and throwing trash when entering her room. The care plan indicated that staff must intervene to protect the rights and safety of others, divert attention and remove Resident 1 from the situation and/or take to an alternate location. During a review of Resident 1's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 8/26/2025, the MDS indicated the resident had severe cognitive impairment (problems with a person's ability to think, learn, remember, use judgement, and make decisions). The MDS indicated Resident 1 was assessed requiring partial/moderate assistance for activities of daily living (basic self-care tasks). The MDS further indicated Resident 1 was assessed walking with partial/moderate staff assistance. The MDS further indicated Resident 1 manifested wandering behavior (a disturbance of motor activity that involves directionless, disoriented movement) and behavioral symptoms not directed towards (MDS examples indicated physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes or verbal/vocal symptoms like screaming, disruptive sounds). During a review of Resident 1's previous Change of Condition (COC) form dated 9/10/2025, authored by Registered Nurse (RN) 2, the COC indicated Resident 1's previous history of agitation observed by staff with escalating agitation. The COC further indicated that at 5:09 PM Resident 1 was yelling profanities (offensive language) at staff when staff enters her room. The COC indicated that Resident 1 throws water at the CNA and other staff passing her doorway. The COC indicated that Resident 1 was medicated with Haldol (a medication used to treat aggressive behavior) 5 milligrams (mg - unit of measure) intramuscularly (IM - injection under the muscle) and Benadryl (medication used to cause drowsiness) 25 mg IM one time. During a review of Resident 1's Nursing Progress Notes dated 11/13/2025 timed at 4:31 PM, the Note indicated another previous episode of agitation that indicated how Resident 1 was in an agitated state, had thrown water at staff and attempted to elope (a patient leaving a facility or designated safe area without authorization, often due to confusion). The Note indicated that the staff left her alone pacing up and down the hallway as to not trigger her anger. During a review of Resident 1's psychology (the scientific study of the human mind and its functions, especially those affecting behavior) note titled Behavioral Health documented on 11/24/2025 at 5:31 PM, the note indicated that Resident 1 reported to the psychologist that the resident was experiencing anxiety, frustration, and negative thinking patterns. The Note did not provide details regarding the specific situations or triggers that contributed to these symptoms. In addition, the Note did not include any recommendations or modifications to the treatment plan to address these concerns.The psychology note documented the following statements: Were there any treatment modifications needed in today's session due to cognitive impairment? No cognitive impairment noted. Medical Necessity for Ongoing Treatment: Symptoms Require More Attention, Risk of Significant Decline. During a review of Resident 1's Progress Notes dated 11/24/2025 documented at 10:40 PM, the Note indicated an incident happened around 10:30 PM when the [CNA 1] informed [Registered Nurse (RN) 1] that Resident 1 was playing with a wheelchair's metal footrests. The Notes indicated [CNA 1] tried to calm [Resident 1] down and get the wheelchair footrests from [Resident 1], but the resident was swinging it [at] CNA 1. The Note indicated CNA 1 went to ask help from RN 1 but while walking back to Resident 1's room, a scream was heard from the roommate, [Resident 2]. The Note indicated that Resident 1's physician (MD 1) was notified and ordered to administer Haldol 5 mg and Benadryl 25 mg IM to [Resident 1]. The Note indicated that RN 1 entered [Resident 1's] room and the roommate, [Resident 2] was observed with multiple lacerations to her face. The Note indicated the Police Department was notified and a police report was filed with the local police department. During a review of Resident 1's physician's telephone order dated 11/25/2025 the order indicated to transfer Resident 1 to GACH 2 to rule out (r/t) agitation. During a review of Resident 1's Nursing Progress Note dated 11/25/2025 documented at 2:35 AM, the Note indicated that Resident 1 was taken to GACH 2 on 11/25/2025 at 12:52 AM for further behavioral evaluations related to agitation. During a review of Resident 1's Change of Condition (COC) dated 11/25/2025, the COC indicated that an incident occurred around 10:30 PM when [CNA 1] informed [RN 1] that Resident 1 was playing [with] the footrest of the wheelchair. She [CNA 1] tried to calm her (Resident 1) down but get the footrests from her, but she was swinging it [at] her. The Note indicated CNA 1 left the room and went to ask for help from RN 1, but while walking back to Resident 1's room, a scream was heard from the roommate, Resident 1. 2. During a review of Resident 2's AR, the AR indicated the facility admitted the resident on 9/15/2023, with a diagnosis of dementia with behavioral disturbance and anxiety disorder (experiencing excessive worry and fear). During a review of Resident 2's H&P dated 11/27/2025, the H&P indicated Resident 2 did not have the capacity to understand and make decisions. During a review of Resident 2's MDS dated [DATE], the MDS indicated that Resident 2 had severe cognitive impairment. The MDS indicated that Resident 2 required partial/moderate assistance for activities of daily living. The MDS further indicated that Resident 2 required partial/moderate assistance to move from sitting on her side of the bed to lying flat on the bed, to come to a standing position from sitting in a chair, wheelchair or on the side of the bed, and the ability to transfer to and from the bed to a chair. During a review of Resident 2's Nursing Progress Notes Type: Situation Background Assessment Recommendations [SBAR] dated 11/24/2025 timed at 11:14 PM, the Note indicated an incident occurred around 10:30 PM when [CNA 1] informed [RN 1] that Resident 1 was playing the footrest of the wheelchair. The Note indicated [CNA 1] tried to calm her (Resident 1) down and get the footrests from her, but [Resident 1] was swinging it [at] [CNA 1]. The Note indicated CNA 1 went to ask help from RN 1 but while walking back to Resident 1's room, a scream was heard from the roommate, [Resident 1]. The Note indicated that [Resident 2] was found with lacerations on her face and treatment was applied. During a review of Resident 2's Nursing Progress Notes dated 11/24/2025 timed at 11:14 PM, the Note indicated that Resident 2 was medicated with Acetaminophen (pain medication) 325 mg two tablets for 7 out of 10 (a severe level of pain on the standard 0 to 10 pain rating scale used by medical professionals to quantify subjective pain experiences) facial pain. During a review of Resident 1's Police Report dated 11/24/2025, documented by Police Officer (PO) 1 on 11/24/20925 at 11:58 PM, the report indicated that at approximately 11:57 PM, PO 1 responded to a call at the facility regarding a resident who struck another resident with a wheelchair footrest. The report indicated that Resident 1 was the individual who struck Resident 2. RN 1 stated that the incident occurred at approximately 10:40 PM, when CNA 1 was in Resident 1's shared bedroom and observed Resident 1 swinging wheelchair footrests she had removed from her wheelchair, attempting to strike CNA 1. PO 1 further indicated in the report that CNA 1 left the room to seek assistance, and shortly afterward, nursing staff heard screams coming from the shared bedroom. Staff entered the room and observed Resident 2 with severe laceration on her forehead. According to the report, LVN 1 called 911, and Resident 2 was transported to GACH 3 for treatment. During a review of Resident 2's COC Evaluation dated 11/25/2025, the COC indicated Resident 2 manifested acute pain (pain that comes on suddenly and is caused by something specific) to the face. The Pain Status Evaluation indicated Resident 2 was unable to rate the pain but noted with facial grimacing (distorted facial expression) with body language noted as rigid, fists clenched, knees pulled up. During a review of Resident 2's Nursing Progress Notes at the facility dated 11/25/2025, the Note indicated Resident 2 was transferred to GACH 3 on 11/25/2025 at 12:08 AM via ambulance assisted by two emergency medical technicians (EMT) for further evaluation of facial lacerations. During a review of Resident 2's GACH 3 records titled 'emergency room (ER) Documentation dated 11/25/2025 timed at 12:35 AM, the GACH 3 record indicated Resident 2 was admitted to the ER for facial injuries. The GACH 3 record indicated that Resident 2 presented to the ER with altered mental status and had a number of lacerations on the face. The GACH 3 record indicated Resident 2 was assaulted by another resident [Resident 1] and she [Resident 2] was hit several times to the head, bleeding was controlled with steri-strips. The Record indicated that it was unknown if Resident 2 had lost consciousness after the assault. During a review of Resident 2's GACH 3 record titled Computerized Tomography of the head for moderate-severe head trauma, dated 11/25/2025 timed at 1:33 AM, the CT scan indicated Resident 2's forehead had a soft tissue hematoma (a medical condition characterized by the presence of localized bleeding and blood clot formation in the soft tissues of the bod), and there was no acute intracranial (within the skull) hemorrhage (bleeding) or fluid collection. During a review of Resident 2's GACH 3 records titled CT of the maxillofacial (jawbone and face) for facial trauma dated 11/25/2025 timed at 1:34 AM, the CT indicated Resident 2 had a forehead soft tissue hematoma as well as a right periorbital (around the eye socket) laceration. The CT indicated there was partial mild irregularity of the right nasal bone and there was a questionable right anterior nasal bone fracture. During a review of Resident's 2 Nursing Progress Note dated 11/25/2025 timed at 7:40 AM, the Note indicated the facility received a report from GACH 3 that Resident 2 had no intracranial injury noted and derma bond (surgical glue) was applied to the facial lacerations. The Note indicated Resident 2 was cleared by GACH 3 to return back to the facility. During a review of Resident 2's Nursing Progress Note dated 11/25/2025 at 8:15 AM, the progress note indicated that Resident 2 was readmitted back to the facility from GACH 3. During a review of Resident 2's MD Progress Note dated 11/26/25, the progress note indicated Resident 2 was attacked by another resident [Resident 1] without provocation on 11/24/2025 with the footrest of a wheelchair. The progress note indicated that Resident 2 did not remember what happened to her face and is full of cuts and bruises. During a concurrent observation and interview on 12/9/2025 at 10:25 AM with Resident 2 in her room, Resident 2 was noted to have visible facial injuries, including swelling, laceration and bruising to the center of the forehead, two scabbed lacerations above the right eyebrow, a scabbed laceration on the right cheek, and another scabbed laceration beneath the right nostril. Resident 2 was able to respond verbally to her name, however, Resident 2 could not state or recall how the facial injuries occurred. During an interview on 12/9/2025 at 11 AM with the Director of Nursing (DON), the DON stated that on 11/24/2025, Resident 1 was in an agitated state and was swinging two metal wheelchair footrests inside their (Residents 1, 2, and 3) room. According to the DON, CNA 1 witnessed Resident 1 swinging the dangerous metal object but was unable to remove the wheelchair footrests from Resident 1's hands. CNA 1 left the room to go to Nursing Station 1 to seek assistance. The DON stated that RN 1 and Licensed Vocational Nurse (LVN) 1 were on their way to Resident 1's room when they heard residents screaming. The DON stated while other staff (CNAs 2 and 3) tried to get Resident 1 under control, and when Resident 1 eventually calmed down, RN 1 entered the room and observed that Resident 2 had sustained facial injuries after being struck by the metal wheelchair footrests that Resident 1 had been swinging in the air inside their shared room. During an interview on 12/9/2025 at 11:34 AM with RN 1, RN 1 stated that on 11/24/2025 at approximately 10:30 PM, she was at Nursing Station 1 when CNA 1 approached after leaving Resident 1's room. CNA 1 reported that Resident 1 was inside her room swinging two metal wheelchair footrests in an aggressive manner. CNA 1 stated she attempted to calm Resident 1 and remove the footrests but was unsuccessful. Feeling frightened, CNA 1 left the room to seek assistance, leaving Resident 1 unattended with her roommates, Residents 2 and 3. During the same interview on 12/9/2025 at 11:34 AM with RN 1, RN 1 stated that RN 1, Licensed Vocational Nurse (LVN) 1, and CNA 1 left the Nursing Station to respond to Resident 1's room and heard a loud scream. Upon arrival, RN 1 observed Resident 1 actively swinging the metal wheelchair footrests in front of her bed in an agitated state, preventing staff from safely entering the room to assess Resident 2. RN 1 stated that CNA 2 and CNA 3 removed Resident 1 from the room and restrained her against the hallway wall using a linen cart. RN 1 instructed LVN 1 to call the attending physician, who ordered Haldol 5 mg IM and Benadryl 25 mg IM for agitation. RN 1 stated that it took approximately 30 to 40 minutes for Resident 1 to calm down. During that time, Resident 1 remained agitated, pinned against the wall, and eventually slid to the floor. Once seated, Resident 1 released both metal wheelchair footrests. During another interview on 12/9/2025 at 12 PM with RN 1, RN 1 stated that when she was finally able to enter Resident 1's room at approximately 11:10 to 11:20 PM on 11/24/2025, Resident 2 was observed lying in bed with her face covered in blood. RN 1 stated that Resident 2 sustained a deep, open laceration to the center of the forehead, two open lacerations above the right eyebrow, an injury to the right cheek, and a small laceration beneath the right nostril. RN 1 stated she cleaned the wounds and applied steri-strips to the lacerations on the forehead, above the right eyebrow, the right cheek, and under the right nostril. RN 1 stated she applied a cold compress to the right side of Resident 2's face due to redness and swelling, administered Tylenol for severe pain, and initiated neurological checks (a quick, systematic way nurses assess a patient's brain function after a head injury). RN 1 stated Resident 1 was placed on one-to-one observation (assigning a dedicated staff member to continuously monitor a patient for safety ensuring they are constantly within sight) at Nursing Station 1. During the same interview on 12/9/2025 at 12:00 PM with RN 1, RN 1 further stated that CNA 1 should have remained in Resident 1's room, utilized diversion techniques (a non-pharmacological method used to temporarily shift a patient's focus away from pain, anxiety, or discomfort by engaging them in other activities), and called out for assistance rather than leaving Resident 1 unattended with her roommates, Residents 2 and 3, still inside the shared room. RN 1 stated that CNA 1 leaving the room while Resident 1 was agitated and holding two metal footrests, with Residents 2 and 3 still present, resulted in Resident 2 being struck by the metal wheelchair footrests and sustaining multiple facial lacerations. During an interview on 12/9/2025 at 12:48 PM, CNA 4 stated she had been previously assigned to care for Residents 1, 2 and 3. CNA 4 stated that Resident 1 was ambulatory (able to walk), while Residents 2 and 3 were bedbound (unable to leave their beds to walk independently). CNA 4 stated that Resident 2 had severe dementia and limited ability to verbally communicate needs, whereas Resident 3 was alert and oriented and able to verbally communicate needs, but required moderate assistance with activities of daily living. CNA 4 reported frequently observing Resident 1 sitting up in bed talking to herself. CNA 4 further stated that Resident 3 reported witnessing Resident 1 strike Resident 2 with the metal wheelchair footrests on 11/24/2025, prompting Resident 3 to scream for help. During an interview on 12/9/2025 at 1:30 PM with Resident 3, Resident 3 stated that on the night of 11/24/2025, Resident 1 was in an agitated state and threw a cup of water from her bedside table. Resident 3 reported witnessing Resident 1 grab two metal wheelchair footrests, wave them around the room, and pace (walk at a steady and consistent speed, especially back and forth and as an expression of one's anxiety) back and forth from the doorway to the back of the room. Resident 3 stated that CNA 1 entered the room and attempted to remove the metal footrests from Resident 1's hands but was unsuccessful and then left the room. Resident 3 stated that after CNA 1 left the room, Resident 1 turned and approached Resident 3, who was lying in bed, and came within approximately four feet, and attempted to strike her (Resident 3) with the metal footrests. Resident 3 stated she was able to yell at Resident 1 to leave her alone. Resident 3 stated that Resident 1 then turned toward Resident 2's bed, who was also in bed. Resident 3 stated she heard the sound of the metal footrests as Resident 1 struck Resident 2 and screamed for help. Although a privacy curtain obstructed her view of Resident 2's upper body, Resident 3 observed Resident 1's body movements consistent with striking Resident 2 and heard the impact. Resident 3 stated she was frightened and feared for her life. Resident 3 stated that Resident 2 was unable to defend herself due to being bedbound. Resident 3 stated that after the physical assault against Resident 1, a nurse (RN 1) arrived and assisted Resident 2 with her injuries. During an interview on 12/9/2025 at 2:22 PM with CNA 1, CNA 1 stated that at the start of her shift on 11/24/2025 at approximately 3:30 PM, Resident 1 was observed sitting up in bed and talking to herself. CNA 1 stated that at approximately 10:30 PM, she observed Resident 1 standing at the entrance of her shared room, swinging two metal wheelchair footrests-one in each hand-in a crosswise back-and-forth motion. CNA 1 stated she approached Resident 1 and attempted verbal redirection, however, Resident 1 was not redirectable and swung the footrests toward CNA 1, nearly striking her. CNA 1 stated Resident 1 appeared highly agitated and had an intense facial expression. CNA 1 stated she left Resident 1's room and walked to Nursing Station 1, located down the hallway and notified RN 1 and LVN 1. CNA 1 stated that other CNAs (CNA 2 and CNA 3) responded and were able to remove Resident 1 from the room and restrain her against the hallway wall until Resident 1 slid to a seated position on the floor and released the wheelchair footrests from her hands. During the same interview on 12/9/2025 at 2:22 PM with CNA 1, CNA 1 stated that she entered Resident 1's room with RN 1 at approximately 11:30 PM (after Resident 1 calmed down) and observed Resident 2 lying in bed with her face covered in blood. CNA 1 stated that Resident 1 was then taken to Nursing Station 1 for observation. CNA 1 acknowledged that she should have remained in the room, called out for assistance, and maintained oversight of Resident 1. CNA 1 stated she left Resident 1 in the room due to fear of being struck by the metal wheelchair footrests. CNA 1 further stated that when she left the room, Residents 2 and 3 were left alone at-risk form harm due to Resident 1's agitated state and possession of a dangerous object. CNA 1 stated that she should have remained in the room and yelled for help instead. CNA 1 also stated that licensed nursing staff typically overhead page for assistance when incidents like these (agitated resident in possession of a dangerous object) happens, which did not occur in this situation. During an interview on 12/9/2025 at 3:15 PM with the Director of Staff Development (DSD), the DSD stated that staff had received education regarding abuse, including physical abuse and resident-to-resident altercations. During a concurrent review of the facility's Abuse Policy with the DSD, the DSD stated that the policy required staff to understand resident behaviors and symptoms that increase the risk for abuse and how to respond. However, the DSD stated that the facility's Abuse Policy did not provide specific guidance on how staff should respond to an agitated resident in possession of a dangerous object or how to prevent harm to residents and staff. The DSD stated that the facility did not have a designated code alert for an agitated resident with a dangerous object, although staff could use overhead paging to request assistance. The DSD stated that CNA 1 should have remained with Resident 1, who was agitated and holding two metal wheelchair footrests, and that by leaving the room to obtain assistance, CNA 1 left Residents 2 and 3 unattended. During a phone interview on 12/12/2025 at 2 PM with PO 1, PO 1 stated he arrived at the facility at approximately 11:57 PM on 11/24/2025. PO 1 stated upon arrival into the facility, RN 1 informed him that Resident 1 had struck Resident 2 in the head and described the incident as an alleged accident. PO 1 further stated that [CNA 1] left Resident 1's room to seek assistance, and shortly afterward, nursing staff heard screams coming from Resident 1, 2, and 3's shared bedroom. PO 1 stated that when the staff [RN 1] entered the room, the staff observed Resident 2 with severe laceration on her forehead. During a review of the facility's policy and procedure (P&P) titled Abuse Prevention/Prohibition revised on 11/2018, the P&P indicated the facility does not condone any form of resident abuse, neglect . and develops facility policies, procedures, training programs, and systems in order to promote an environment free from abuse and mistreatment. During a review of the facility P&P titled Resident to Resident Altercation revised on 9/2022, the P&P indicated that behaviors that may provoke a reaction by residents or others included verbally aggressive behavior, such as screaming, cursing, bossing around/demanding, insulting to race or ethnic group, intimidating, physically aggressive behavior, such as hitting, kicking, grabbing, scratching, pushing/shoving, biting, spitting, threatening gestures, throwing objects. During a review of the facility P&P titled Resident Safety revised on 7/2017, the P&P indicated that resident safety and supervision and assistance to prevent accidents are facility-wide priorities. The P&P indicated that implementing interventions to reduce accident risks and hazards shall include the following: communicating specific interventions to all relevant staff, assigning responsibility for carrying out interventions, providing training, as necessary, ensuring that interventions are implemented. The P&P indicated that monitoring the effectiveness of interventions shall include the following: ensuring that interventions are implemented correctly and consistently, evaluating the effectiveness of interventions, modifying or replacing interventions as needed and evaluating the effectiveness of new or revised interventions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide medically related social services for one of three sampled residents (Resident 3) by not ensuring the resident attained or maintained his/her highest practicable physical, mental, or psychosocial well-being. Specifically, facility staff did not identify or address factors negatively affecting Resident 3's psychosocial functioning after the resident witnessed and was exposed to a violent incident (physical abuse) involving another resident (Residents 1 and 2). No nursing or facility staff checked or followed up on Resident 3 following the incident. This deficient practice had the potential to result in long-term psychosocial harm as resident 3 verbalized experiencing fear, anxiety, and emotional distress after witnessing and being threatened during a violent incident. These deficiencies may further lead to depression and/or post-traumatic stress disorder (PTSD) symptoms, thereby reducing Resident 3's sense of security and quality of life. Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted the resident to the facility on 5/22/2025, with diagnoses including dementia (a general term for a decline in thinking, memory, and reasoning skills severe enough to interfere with daily life) with behavioral disturbance (loss of memory and thinking ability with agitation and physical aggression), psychosis ( loses of touch with reality, experiencing symptoms like hallucinations (seeing/hearing things not there) and delusions (false beliefs), along with confused thinking and speech. During a review of Resident 1's History and Physical (H&P) dated 5/24/2025, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. The H&P indicated Resident 1 came from GACH 1 for altered mentation, metabolic encephalopathy and dementia. During a review of Resident 1's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 8/26/2025, the MDS indicated the resident had severe cognitive impairment (problems with a person's ability to think, learn, remember, use judgement, and make decisions). MDS indicated that Resident 1 was partial/moderate assistance for activities of daily living (basic self-care tasks). The MDS further indicated that Resident 1 was able to walk 50 feet with two turns with partial/moderate assistance. The MDS further indicated Resident 1 manifested wandering behavior and behavioral symptoms not directed towards (MDS examples indicated physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes or verbal/vocal symptoms like screaming, disruptive sounds). During a review of Resident 3's AR, the AR indicated the facility admitted the resident on 6/3/2024, with a diagnosis of type 2 diabetes (high blood sugar levels) and anxiety disorder (experiencing excessive worry and fear). During a review of Resident 3's H&P dated 11/27/2025, the H&P indicated Resident 3 did not have the capacity to understand and make decisions. During a review of Resident 3's MDS dated [DATE], the MDS indicated the Resident 3 cognition was moderately impaired. The MDS indicated that Resident 3 toileting hygiene required substantial/maximal assistance. The MDS indicated that Resident 3 was partial/moderate assistance for lying and sitting on the side of the bed, sit to stand and chair/bed to chair transfer. During a review of Resident 1's Progress Notes dated 11/24/2025 documented at 10:40 PM, the Note indicated an incident happened around 10:30 PM when the [CNA 1] informed [Registered Nurse (RN) 1] that Resident 1 was playing with a wheelchair's metal footrests. The Notes indicated [CNA 1] tried to calm [Resident 1] down and get the wheelchair footrests from [Resident 1], but the resident was swinging it [at] CNA 1. The Note indicated CNA 1 went to ask help from RN 1 but while walking back to Resident 1's room, a scream was heard from the roommate, [Resident 2]. The Note indicated that Resident 1's physician (MD 1) was notified and ordered to administer Haldol 5 mg and Benadryl 25 mg IM to [Resident 1]. The Note indicated that RN 1 entered [Resident 1's] room and the roommate, [Resident 2] was observed with multiple lacerations to her face. The Note indicated the Police Department was notified and a police report was filed with the local police department. During a review of Resident 1's physician's telephone order dated 11/25/2025 the order indicated to transfer Resident 1 to GACH 2 to rule out (r/t) agitation. During a review of Resident 1's Nursing Progress Note dated 11/25/2025 documented at 2:35 AM, the Note indicated that Resident 1 was taken to GACH 2 on 11/25/2025 at 12:52 AM for further behavioral evaluations related to agitation. During a review of Resident 1's Change of Condition (COC) dated 11/25/2025, the COC indicated that an incident occurred around 10:30 PM when [CNA 1] informed [RN 1] that Resident 1 was playing [with] the footrest of the wheelchair. She [CNA 1] tried to calm her (Resident 1) down but get the footrests from her, but she was swinging it [at] her. The Note indicated CNA 1 left the room and went to ask for help from RN 1, but while walking back to Resident 1's room, a scream was heard from the roommate, Resident 1. During a review of Resident 1's Police Report dated 11/24/2025, documented by Police Officer (PO) 1 on 11/24/20925 at 11:58 PM, the report indicated that at approximately 11:57 PM, PO 1 responded to a call at the facility regarding a resident who struck another resident with a wheelchair footrest. The report indicated that Resident 1 was the individual who struck Resident 2. RN 1 stated that the incident occurred at approximately 10:40 PM, when CNA 1 was in Resident 1's shared bedroom and observed Resident 1 swinging wheelchair footrests she had removed from her wheelchair, attempting to strike CNA 1. PO 1 further indicated in the report that CNA 1 left the room to seek assistance, and shortly afterward, nursing staff heard screams coming from the shared bedroom. Staff entered the room and observed Resident 2 with severe laceration on her forehead. According to the report, LVN 1 called 911, and Resident 2 was transported to GACH 3 for treatment. During an interview on 12/9/2025 at 11 AM with the Director of Nursing (DON), the DON stated that on 11/24/2025, Resident 1 was in an agitated state and was swinging two metal wheelchair footrests inside their (Residents 1, 2, and 3) room. According to the DON, CNA 1 witnessed Resident 1 swinging the dangerous metal object but was unable to remove the wheelchair footrests from Resident 1's hands. CNA 1 left the room to go to Nursing Station 1 to seek assistance. The DON stated that RN 1 and Licensed Vocational Nurse (LVN) 1 were on their way to Resident 1's room when they heard residents screaming. The DON stated while other staff (CNAs 2 and 3) tried to get Resident 1 under control, and when Resident 1 eventually calmed down, RN 1 entered the room and observed that Resident 2 had sustained facial injuries after being struck by the metal wheelchair footrests that Resident 1 had been swinging in the air inside their shared room. During an interview on 12/9/2025 at 11:34 AM with RN 1, RN 1 stated that on 11/24/2025 at approximately 10:30 PM, she was at Nursing Station 1 when CNA 1 approached after leaving Resident 1's room. CNA 1 reported that Resident 1 was inside her room swinging two metal wheelchair footrests in an aggressive manner. CNA 1 stated she attempted to calm Resident 1 and remove the footrests but was unsuccessful. Feeling frightened, CNA 1 left the room to seek assistance, leaving Resident 1 unattended with her roommates, Residents 2 and 3. During the same interview on 12/9/2025 at 11:34 AM with RN 1, RN 1 stated that RN 1, Licensed Vocational Nurse (LVN) 1, and CNA 1 left the Nursing Station to respond to Resident 1's room and heard a loud scream. Upon arrival, RN 1 observed Resident 1 actively swinging the metal wheelchair footrests in front of her bed in an agitated state, preventing staff from safely entering the room to assess Resident 2. RN 1 stated that CNA 2 and CNA 3 removed Resident 1 from the room and restrained her against the hallway wall using a linen cart. During another interview on 12/9/2025 at 12 PM with RN 1, RN 1 stated that when she was finally able to enter Resident 1's room at approximately 11:10 to 11:20 PM on 11/24/2025, Resident 2 was observed lying in bed with her face covered in blood. During an interview on 12/9/2025 at 12:48 PM with Certified Nursing Assistant (CNA 4), CNA 4 stated that Resident 1 was ambulatory and that her roommate Resident 3 was a bedbound resident and that was vulnerable. CNA 4 stated that Resident 3 was alert, orientated and required full assistance for Activities of Daily Living care (helping residents with essential self-care tasks they can't do alone, like eating, bathing, dressing, using the toilet, grooming, and moving around). CNA 4 stated that she had observed Resident 1 sitting up in bed and having a conversation with herself on 11/24/2025 at the start of her shift at 3:30 PM. CNA 4 stated that Resident 1 had thrown a cup of water at staff a few times when she got upset. CNA 4 stated that Resident 3 had told her she had witnessed Resident 1 in an agitated state and was pacing back and forth inside their room. During an interview on 12/9/2025 at 1:30 PM with Resident 3, Resident 3 stated that on the night of 11/24/2025, Resident 1 was in an agitated state and threw a cup of water from her bedside table. Resident 3 reported witnessing Resident 1 grab two metal wheelchair footrests, wave them around the room, and pace (walk at a steady and consistent speed, especially back and forth and as an expression of one's anxiety) back and forth from the doorway to the back of the room. Resident 3 stated that CNA 1 entered the room and attempted to remove the metal footrests from Resident 1's hands but was unsuccessful and then left the room. Resident 3 stated that after CNA 1 left the room, Resident 1 turned and approached Resident 3, who was lying in bed, and came within approximately four feet, and attempted to strike her (Resident 3) with the metal footrests. Resident 3 stated she was able to yell at Resident 1 to leave her alone. Resident 3 stated that Resident 1 then turned toward Resident 2's bed, who was also in bed. Resident 3 stated she heard the sound of the metal footrests as Resident 1 struck Resident 2 and screamed for help. Although a privacy curtain obstructed her view of Resident 2's upper body, Resident 3 observed Resident 1's body movements consistent with striking Resident 2 and heard the impact. Resident 3 stated she was frightened and feared for her life because she did not want to get hit with the wheelchair footrests. Resident 3 stated that Resident 2 was unable to defend herself due to being bedbound. Resident 3 stated that after the physical assault against Resident 2, a nurse (RN 1) arrived and assisted Resident 2 with her injuries. Resident 3 stated that none of nurses or facility staff came to check up on her. Resident 3 stated that she was afraid that Resident 1 would return back to their room. During an interview on 12/9/2025 at 4:00 PM with Registered Nurse (RN 1), RN 1 stated she was unaware that Resident 3 had also been confronted by Resident 1. RN 1 reported she did not know Resident 3 had been threatened by Resident 1 on 11/24/2025 with the metal wheelchair footrests. RN 1 acknowledged she had forgotten to check on Resident 3's well-being. RN 1 further stated she should have assessed Resident 3 for emotional trauma or distress resulting from witnessing the violent incident and fearing injury from Resident 1. RN 1 also stated she should have notified the facility's Social Services Designee (SSD) to follow up and check on Resident 3. During an interview on 12/9/2025 at 4:10 PM with the Director of Nursing (DON), the DON stated she was unaware that Resident 3 had been emotionally traumatized by Resident 1's aggressive behavior when attempting to attack her with the metal wheelchair footrests. The DON stated that RN 1 should have assessed Resident 3's psychosocial well-being. The DON further stated that Resident 3 might be experiencing post-traumatic stress disorder (PTSD) and anxiety. The DON acknowledged that the Social Services Designee (SSD) should have assessed Resident 3 for psychosocial distress. During a review of the facility P&P titled Social Services revised on 9/2021, the P&P indicated that the facility provides medically related social services to assure that each resident can attain or maintain his/her highest practicable physical, mental, or psychosocial well-being. The P&P indicated that the facility staff is able to identify and address factors that have a potentially negative effect on psychosocial functioning of a resident for example: skills, and/or resident to resident altercations, abuse of any kind, and behavioral problems (i.e., confusion, anxiety, loneliness, depressed mood, anger, fear, wandering, psychotic episodes). The P&P indicated that the social worker/social services staff are responsible for providing or arranging for mental and psychosocial counseling services, as needed and identifying and seeking ways to support resident needs through the assessment and care planning process.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to provide a safe and hazard free environment to ensure electrical and extension cord devices were safely used for one of 1 of 8 sampled residents (Resident 75). This deficient practice has the potential to result in fire at the facility, electrical shock, and burns that could lead to residents' hospitalization and deaths. During a review of Resident 75's admission Record (AR), the AR indicated the resident was admitted on [DATE] with diagnoses including intervertebral disc degeneration( the cushions between the discs in your spine wear out and become thinner causing pain and irritation to nearby nerves) , urinary tract infection and dependence on supplemental oxygen (extra oxygen given to person when their body isn't getting enough on its own helping them breath better and keeps their oxygen levels in a safe range). During a review of Resident 75's Minimum Set Data (MDS- a resident assessment tool) dated 07/8/2025, the MDS indicated Resident 75 had a brief interview for mental status (BIMS) score of 15 indicating resident's cognition (thinking) is intact. The MDS indicated that the resident requires partial to moderate assistance ( the helper dose less than half the effort , lifting, holding, or supporting the trunk or limbs) when performing tasks such as toileting hygiene, shower/ bathe self, upper body dressing, lower body dressing, putting on / taking off footwear and personal hygiene. During an observation on 09/29/2025 at 12:05 PM in Resident 75's room, Resident 75 was observed sitting on the bed. An electrical extension cord and power strip (an electrical device with a cord that has multiple outlets on one end, used to increase the number of devices that can be plugged into a single wall socket) was observed placed directly on Resident 75's bed. The outlets on the extension cord were all in use. The power strip was positioned on Resident 75's bed, directly by Resident 75's oxygen machine and nebulizer (a machine that turns liquid medication into a fine mist or aerosol for inhalation, allowing it to go deep into the lungs). During a concurrent observation and interview on 09/29/2025 at 12:10 PM with Registered Nurse (RN) 3 in Resident 75's room, RN 1 observed Resident 1's extension cord and power strip placed directly on Resident 75's bed, close to Resident 75's oxygen and nebulizer treatment. RN 1 stated the extension cord and power strip should not be placed on Resident 75's bed, and that it was dangerous, since it was a fire hazard. During a concurrent observation and interview on 09/29/2025 at 12:17PM with Maintenance Supervisor (MS) in Resident 75's room, a power strip with multiple electrical devices plugged into it was observed. The power strip was positioned on the Resident 75's bed. MS stated the cords should not be placed on the bed and must be on the floor. MS further stated we do not keep electrical outlets or power strips on the bed, because it was dangerous since it was a fire hazard. During a review of the facility's policy and procedure (P&P) Titled, Electrical Safety for Residents, with a revision date of January 2011, the P&P indicated the resident will be protected from injury associated with the use of electrical devices, including electrocution, burns and fire. When extension cords are in use precautions must be taken to secure extension cords ensuring they cannot cause trips, falls or overheat.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to complete an informed consent (a process of communication between a person and the health care provider that often leads to agreement or permission for care, treatment, or services) for psychotropic/psychotherapeutic (any drug that affects behavior, mood, thoughts, or perception) drug for one of two sampled resident (Resident 101) who was prescribed Ativan (a psychotropic medication used for anxiety). This deficient practice had the potential for Resident 101's rights to be violated by not being providing a complete and accurate explanation of care and treatment provided to Resident 101, in which Resident 101 fully understood the risk, benefits, and expected outcomes. During a review of Resident 101's admission Record [AR], the AR indicated Resident 101 was originally admitted to the facility on [DATE], with diagnoses that included degenerative disease of the nervous system (a progressive brain and spinal cord disease that cause cell death and lose their functions) and major depressive disorder (a feeling of constant sadness and loss of interest). During a review of Resident 101's History and Physical Examination (HP, a comprehensive physician's note regarding the assessment of the patient's health status) signed by the attending physician on 11/25/2025, the HP indicated Resident 101 did not have the capacity to understand and make decisions. During a review of Resident 101's Minimum Data Set (MDS, a resident assessment tool), dated 5/24/2025, the MDS indicated the Resident 101's cognition (thought process) was severely impaired. During a review of Resident 101's Order Summary Report dated 11/8/2024, the Report indicated Resident 101 had a physician order for Ativan Oral Tablet 0.5 mg (unit of measurement) to give 0.5 mg by mouth as needed every 6 hours for anxiety manifested by irritability and easily agitated. During a review of Resident 101's Informed Consent for Psychotropic Medication, the inform consent did not indicate the licensed nurse's (LN) signature and the date the informed consent was presented to Resident 101. During a concurrent interview and record review on 11/18/2025 at 12:30 PM with the Medical Records Assistant (MRA), Resident 101's medical chart under the consent section, and electronic health record (EHR, an electronic/digital collection of medical information about a person that is stored on a computer) was reviewed. The MRA stated the informed consent form for the use of Ativan was not signed or dated by the (LN). During a concurrent interview and record review on 11/18/2025 at 1:34 PM with Registered Nurse Supervisor (RN 1), Resident 101's medical paper chart under the consent section and EHR were reviewed. RN 1 stated that the informed consent for form for Resident 101 did not have a LN's signature and the date from the licensed nurse who admitted the resident. RN 1 stated the informed consent required a licensed nurse signature to indicate that the consent information was received, and the power of attorney (POA) understood the content of the consent. RN 1 stated since the consent form did not have a date, it was difficult to verify if the information was present to the POA regarding Resident 101's medication treatment for agitation. During an interview on 11/18/2025 at 1:47 PM with the Director of Nursing (DON), the DON stated he reviewed Resident 101's medical record (paper chart and EHR) and that the informed consent for psychotropic medication did not have the LN's signature and date. The DON stated consent forms required a LN's signature and date to verify the information was acknowledged by the POA. The DON stated ensuring a LN's had signed and dated the informed consent was based on facility's policy. The DON stated that it was important for the informed consent to be completed since the consent form validated the risks and benefits while taking the psychotropic medication, Ativan, and that other alternative treatments had been provided. The DON stated, not having an informed consent for psychotropic medications violated resident rights. During a review of the facility's policy and procedure (P&P) titled Psychoactive Medication Informed Consent, dated 3/2024, the P&P indicated that prior to the administration of any psychoactive medications initiated, a quick assessment and non-pharmacological interventions that have been attempted and found ineffective, an informed consent for the specific medication will be obtained by the physician and verified by the nurse. The P&P indicated if the resident or resident's representative cannot sign the form, a licensed nurse can sign the form and document the name of the person who gave consent and the date. The P&P indicated the signed written consent must be recorded in the resident's medical record and before initiating treatment with psychotherapeutic drugs, facility staff shall verify that the resident's health record contains written informed consent with the required signatures.

Based on interviews and record reviews, the facility failed to ensure one of four sampled resident (Resident 65) and her representative was assisted to formulate an Advance Directives (AD-a written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) upon admission and to complete an Advance Directive Acknowledgement (ADA a document where a person confirms they have received information about their right to create an advance directive and understand their options for future medical decisions) form timely. This deficient practice had the potential to cause conflict with Resident 65's wishes regarding health care treatment especially in an event of emergency. During a review of Resident 65's admission Record (AR), the AR indicated the facility admitted Resident 65 on 9/10/2025 with diagnoses that included Parkinson's disease (a progressive brain disorder that affects movement and can lead to symptoms like tremors, balance problems, and stiffness) and hypertension (high blood pressure). During a review of Resident 65's Minimum Data Set (MDS, a assessment tool), dated 9/13/2025, the MDS indicated Resident 65 had moderately impaired cognition (ability to understand and make decisions) and memory. The MDS indicated Resident 65 was dependent on eating, oral hygiene, toileting hygiene, personal hygiene and shower/bathe self. During a review of Resident 65's ADA form, dated 9/15/2025, the ADA was incomplete since the ADA did not indicate Resident 65's name, attending physician, date of admission, medical records number, and the name of facility. The ADA also indicated Resident 65's Responsible Party (RP) did not initial on the following statements indicated on the ADA form: 1. I have been given written material and informed about my right to accept or refuse medical treatment. 2. I have been informed of my rights to formulate Advance Directives. 3. I understand that I am not required to have an Advance Directive in order to receive medical treatment at this health care facility. 4. I understand that the terms of any Advanced Directives that I executed will be followed by the health care facility and my caregivers to the extent permitted by law. The ADA indicated Resident 65's RP did not checkmark on the form that he decline to execute an Advance Directive or wish to execute an Advance Directive. During a concurrent interview and record review on 9/29/2025 at 3:57 PM with the Social Service Director (SSD), Resident 65's ADA, dated 9/15/2025, was reviewed. The SSD stated she was responsible for explaining and assisting the residents with their AD. The SSD stated although RP signed and marked Resident 65 have not executed an Advance Directive on the ADA form, the ADA form was uncomplete since, Resident 65's information acknowledging he was informed about their rights, and his decision on the AD was not indicated by a checkmark. The SSD stated the facility had the interdisciplinary team (IDT, a group of professionals from different fields who collaborate to work on a common goal by integrating their knowledge and methods) meeting Resident 65's RP on 9/15/2025, but SSD could not state whether staff explained to the RP about the resident's right to accept or refuse medical treatment and to formulate an AD during the IDT meeting. SSD stated not knowing if a follow up with Resident 65's RP was required to execute Resident 65's AD. The SSD stated it was important to complete the ADA forms in its entirety with Resident 65's information to ensure everyone would know the ADA form belonged to that specific resident, and to prevent confusion of care. The SSD stated it was also important to inform the residents and the RP about their rights to formulate an AD and complete the ADA form to ensure the facility staff follow the residents' wishes at the time of emergency. The SSD stated because Resident 65's ADA was incomplete; she must contact the RP to make sure he was informed about their rights and decision on the AD. During an interview on 11/18/2025 at 3:15 PM with the SSD, the SSD stated she called and spoke with the RP and explained to Resident 65's RP about the right to formulate and execute an Advance Directive. SSD stated Resident 65's ADA form was completed on 9/29/2025. The SSD stated it is important to inform the residents and the RP about their rights and complete the ADA form timely and accurately. During a review of the facility's policies and procedures (P&P) titled Advance Directives, dated 9/2022, the P&P indicated: I. If the resident or representative indicates that he or she has not established advance directives, the facility staff will offer assistance in establishing advance directives. a. The resident or representative is given the option to accept or decline assistance, and care will not be contingent on either decision. b. Nursing staff will document in the medical record the offer to assist and the residents decision to accept or decline assistance. 2. Information about whether or not the resident has executed an advance directive is displayed prominently in the medical record in a section of the record that is retrievable by any staff. During a review of the facility's P&P titled Charting and Documentation, dated 7/2017, the P&P indicated documentation in the medical record will be objective, complete and accurate.

Based on observation, interview, and record review, the facility failed to develop a base line comprehensive person-centered care plan for one of three residents (Resident 61), who was identified as having dental problems and required change in texture of to be able to chew food effectively. This deficient practice had the potential to delay care and services to Resident 61 and could negatively impact Resident 61's health and lead to nutritional problems. Cross reference to F791 Findings: During a review of Resident 61's admission record (AR), the AR indicated that the facility originally admitted Resident 61 on 9/21/2021 and recently readmitted her on 8/23/2025, with diagnoses including hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time), anemia (a condition where the body does not have enough healthy red blood cells), and chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing.) During a review of Resident 61's Minimum Data Sheet (MDS- a Federally mandated resident assessment tool) dated 10/3/2025, the MDS indicated Resident 61 as having moderately impaired cognition (decision poor; cues/supervision required) that required supervision or touching assistance (helper provides verbal cues and/or contact guard assistance as resident completes activity) on oral hygiene and personal hygiene. The MDS also indicated that Resident 1 required change in texture of food or liquids while being a resident of the facility. During a review of Resident 61's Dental Progress Notes (DPN) dated 9/25/2025, the DPN indicated to resubmit treatment authorization request (TAR) for proposed/ recommended treatment plan. The DPN also acknowledged that Resident 61 requested dentures to replace missing teeth for mastication (the process of chewing food). During a review of Resident 61's History and Physical (H&P) dated 10/22/2025, the H&P indicated that Resident 1 had fluctuating capacity to understand and make decisions. During a review of Resident 61's DPN dated 10/23/2025, the DPN indicated the following: Recommend 3PA's (three periapical [PA] X-rays) and 2BW's (two-film bitewing X-ray) dental x-rays for definitive diagnosis. Recommend oral prophylaxis for oral hygiene and for periodontal health. Recommend composite filling (a dental restorative material that comprises a mixture of plastic resin and powdered glass filler) on tooth #22 due to decay beyond dentine-enamel junction (a natural junction that unites two mechanically dissimilar calcified tissues of the tooth) Recommend full upper and partial dentures lower for mastication. Recommend extraction of root fragments #20&21 on emergency basis or if dentures are to be fabricated. During a review of Resident 61's Comprehensive Care Plan, there was no documented evidence indicating a care plan was developed to address Resident 61's need for dentures and concerns with chewing food. During an observation and concurrent interview on 11/18/2025 at 10:50 AM, Resident 61 was observed with missing teeth on the upper and lower. Resident 61 stated that she has been asking he social worker and the dentist that she needed dentures. Resident 61 stated it's been a long time (she referred months) since she asked and dentist had come but she never got an update as to the progress about her dentures. Resident 61 stated she felt forgotten. During a concurrent record review and an interview on 11/18/2025 at 11:20 AM with the Licensed Vocational Nurse (LVN) 2, LVN 2 stated that she could not find a care plan developed for Resident 61's issues about teeth or dentures. During a concurrent record review and an interview on 11/18/2025 at 12 PM with the Social Service Director (SSD), SSD stated she could not find a care plan in relation to Resident 61's problems about her teeth or needing a denture. , and IDT (Interdisciplinary teams- a group of professional and direct care staff for program, planning, and coordinating care) did not ask her to assist with developing a care plan. During a concurrent record review and an interview on 11/18/2025 at 3:20 PM with RN 1, RN 1 stated that she could not find a care plan developed for Resident 61's issues about teeth or dentures. RN 1 stated any staff who identified Resident 61's dental issues should have developed a care plan so interventions for Resident 61's needs would have been implemented and kept up to date. During an interview on 11/19/2025 at 11:50 AM with the Director of Nursing (DON), the DON stated a comprehensive care plan was necessary to reflect a resident's needs being identified, person-centered care plan being developed, and the interventions being carried out and followed up timely. The DON stated the IDT team should have developed a care plan so they could communicate better and work together to address Resident 61's denture issues. During a review of the facility's policy and procedures (P&P) titled Care Plans, Comprehensive Person-Centered revised in 3/2022, the P&P indicated that a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The P&P also indicated that the comprehensive, person-centered care plan will be: a. Measurable objectives and timeframes. b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. c. Include the resident's stated goals upon admission and desired outcomes. d. Build on the resident's strengths; and e. Reflect currently recognized standards of practice for problem areas and conditions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and record reviews, the facility failed to ensure timely implementation of physician-ordered Passive Range of Motion (PROM) services and splint application for 1 of 2 sampled resident (Resident 88) reviewed for Restorative Nursing Assistant (RNA) services. This deficient practice resulted in a 22-day delay in PROM exercises and splint use, which placed Resident 88 at risk for increased joint stiffness, reduced mobility, and progression of contractures (the permanent shortening of a muscle or a joint, leading to a deformity and restricted range of motion). During a review of Resident 88's admission Record [AR], the AR indicated Resident 88 was originally admitted to the facility on [DATE], with diagnoses that included contracture right elbow and contracture right hand. During a review of Resident 88's History and Physical Examination (HPE, a comprehensive physician's note regarding the assessment of the patient's health status) signed by the attending physician on 8/29/2025, the HPE indicated Resident 88 had the capacity to understand and make decisions. During a review of Resident 88's Minimum Data Set (MDS, a resident assessment tool), dated 5/24/2025, the MDS indicated the Resident 88's cognition (thought process) was intact. During a review of Resident 88's Telephone Orders dated 9/2/2025, the order indicated restorative nursing assistant (RNA) to provide passive range of motion (PROM - joint movement by a person or device) exercises on right upper extremity every day 5 times a week during the day shift. The order further indicated that RNA was to apply right elbow splint and right resting hand splint for 4 to 6 hours with skin check every 2 hours every day 5 times a week during the day shift. During a review of Resident 88's Care plan titled Resident was at risk for decline in joint mobility and further contracture development on right upper extremity dated 9/2/2025, indicated interventions for RNA to provide PROM to Resident 88's right upper extremity (RUE), apply right elbow extension splint and right resting hand splint for 4 to 6 hours. During a review of Resident 88's RNA Documentation Survey Report dated September 2025, the report indicated that RNA services PROM to RUE, right elbow splint and right resting hand splint for Resident 88 started on 9/25/2025. During a concurrent interview and record review on 10/1/2025 at 10:13 AM with the Director of Rehab Services/Occupational Therapist (OTD), Resident 88's Electronic Health Record (EHR) under order summary report and RNA Documentation report were reviewed. OTD stated that there was an order 9/2/2025 for PROM to Resident 88's right upper extremity, right elbow splint and right resting hand splint should have started on 9/3/2025. OTD stated that the RNA Documentation report indicated RNA services started on 9/25/2025 which reflected a 22-day delay in ROM services. The OTD stated she was not informed of the delay during weekly meetings with the RNA. The OTD stated the delay placed Resident 88 at risk for joint stiffness, decreased mobility, and potential progression of contractures. During a concurrent interview and record review on 10/1/2025 at 10:36 AM with RNA 1, Resident 88's Electronic Health Record (EHR) under order summary report and RNA Documentation report were reviewed. RNA 1 stated that Resident 88 had an order for RNA to provide PROM, right elbow splint and right resting hand splint on 9/2/2025. RNA 1 stated that treatment should have begun on 9/3/2025 and stated that there was a 22-day delay and reported being unable to recall why services were not initiated. RNA 1 stated that licensed nurses and rehabilitation staff typically notify RNA 1 of new orders. RNA 1 stated the delay could limit or worsen Resident 88's mobility and contractures. During a concurrent interview and record review on 11/18/2025 at 2:47 PM with the Director of Nursing (DON), Resident 88's Electronic Health Record (EHR) under order summary report and RNA Documentation report were reviewed. DON stated that the order summary report indicated for the RNA provide PROM exercises right elbow splint and right resting hand splint on 9/2/2025. DON stated that the RNA documentation indicated that the services were initiated on 9/25/2025. The DON stated the nurse receiving the order should have notified the RNA. The DON stated the 22-day delay could result in decreased mobility of Resident 88's right arm and hand, joint stiffness, and negatively impact Resident 88's ability to perform ADLs. During a review of the facility's policy and procedure (P&P) titled Restorative Nursing Services revised 7/2017, the P&P indicated that residents would receive restorative nursing care as needed to help promote optimal safety and independence. The P&P indicated that residents may be started on a restorative nursing program upon admission, during the course of stay or when discharged from rehabilitative care. During a review of the facility's P&P titled Resident Mobility and Range of Motion revised 7/2017, the P&P indicated that residents will not experience an avoidable reduction in range of motion (ROM), residents with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in ROM and residents with limited mobility will receive appropriate services, equipment and assistance to maintain or improve mobility unless reduction in mobility is unavoidable.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide medically-related social service in accordance with the facility's policy and procedure titled Social Services for one of three sampled residents (Resident 61), who had missing teeth and had requested new dentures (removable oral appliances that replace missing teeth). The Social Service Designee (SSD) failed to follow up with the dentist's recommendation to have a dental hygiene prior to obtaining new dentures for Resident 61. As a result of this deficient practice, Resident 61 did not receive new dentures and leaving Resident 61 to remain with difficulty chewing with the remaining teeth. Cross reference to F791 Findings: During a review of Resident 61's admission record (AR), the AR indicated that the facility originally admitted Resident 61 on 9/21/2021 and recently readmitted her on 8/23/2025, with diagnoses including hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time), anemia (a condition where the body does not have enough healthy red blood cells), and chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing). During a review of Resident 61's Social Service History and Initial Assessment (SSHIA) dated 8/26/2025, the SSHIA indicated that Resident 61 having dental problems with broken teeth and needing to see a dentist were acknowledged by the social service director (SSD). During a review of Resident 61's hand-written Dental Progress Notes (DPN) dated 9/25/2025, the DPN indicated to resubmit treatment authorization request (TAR) for proposed/ recommended treatment plan. The DPN also acknowledged that Resident 61 requested dentures to replace missing teeth for mastication (the process of chewing food). During a review of Resident 61's Minimum Data Sheet (MDS- a Federally mandated resident assessment tool) dated 10/3/2025, the MDS indicated Resident 61 as having moderately impaired cognition (decision poor; cues/supervision required). The MDS indicated that Resident 61 required supervision or touching assistance (helper provides verbal cues and/or contact guard assistance as resident completes activity) on oral hygiene and personal hygiene. The MDS also indicated that Resident 1 required change in texture of food or liquids while being a resident of the facility. During a review of Resident 61's hand-written DPN dated 10/23/2025, the DPN indicated Annual Exam and the following: 1.Recommend 3PA's (three periapical [PA] X-rays) and 2BW's (two-film bitewing X-ray) dental x-rays for definitive diagnosis. 2. Recommend oral prophylaxis for oral hygiene and for periodontal health. 3.Recommend composite filling (a dental restorative material that comprises a mixture of plastic resin and powdered glass filler) on tooth #(Number) 22 due to decay (damage to a tooth's surface) beyond [NAME]-enamel junction (a natural junction that unites two mechanically dissimilar calcified tissues of the tooth). 4.Recommend full upper and partial dentures lower for mastication. 5.Recommend extraction of root fragments #20&21 on emergency basis or if dentures are to be fabricated (made). During a review of Resident 61's Social Service Progress Notes (SSPN) dated from 8/23/2025 to 11/17/2025, there was no documented evidence in the SSPN indicating any follow up regarding resubmission of TAR or the recommendations (listing above) indicated in the DPN. There was no documented evidence in the SSPN indicated any conversation with Resident 61 regarding concerns or updates about dentures. During an observation and a concurrent interview on 11/18/2025 at 11:20 AM, Resident 61 was observed to have several missing teeth on both upper and lower gums. Resident 61 stated that she needed new dentures to chew food and spoke to social services as well as the dentist many times but never got response. Resident 61 stated she felt forgotten. During an interview on 11/18/2025 at 1:25 PM with the SSD, SSD stated she was aware that Resident 61 asked for new dentures. SSD stated nurses are responsible for reading dentist notes but she was responsible for follow-ups with nurses. SSD stated she did not check with Resident 61 if Resident 61 was informed about dentist's recommendations. SSD stated she did not refer any X-ray exams or schedule treatment for Resident 61's tooth decay as recommended in the DPN. SSD stated she could not provide documents indicating her follow-up call with the dentist's clinic about the update of dental insurance application for Resident 61. SSD stated she did not schedule any future appointment with the dentist for Resident 61 since after 10/23/2025. SSD also stated she did not have any plan for Resident 61 to have dentures fabricated and she had not developed a care plan in regard to Resident 61's dental issues. During an interview on 11/18/2025 at 2:10 PM with Registered Nurse (RN) 1, RN 1 stated SSD did not inform her when they placed the hand-written DPN in the resident's chart. RN 1 stated she and the social services were responsible for following up on the DPN's recommendations and follow up with the dentist for ordering exams or treatments. RN 1 stated resident's oral hygiene was important for each individual and the facility should provide care and referral to protect resident's oral health. During a review of the facility's policy and procedures (P&P) titled Social Services revised in 9/2021, the P&P indicated the following: 1.The director of social services is a qualified social worker and is responsible for meeting or assisting with the medically-related social service needs of residents. 2. Medically-related social services are provided to maintain or improve each resident's ability to control everyday physical needs (e.g. appropriate adaptive equipment for eating) and mental and psychosocial needs. 3. Obtaining or attempting to obtain medically-related social services on behalf of a resident are not contingent upon Medicaid coverage of needed services. During a review of the facility's Job Description (JD) titled Social Service Director, the JD indicated duties and responsibilities including: 1.Develops and maintains plan of care in conjunction with facility interdisciplinary team. 2. Ensures ongoing evaluations for dental, vision, and mental health exams and follow up. 3.Works with facility consultants as necessary and implements recommended changes as required. Ensures outside services are properly supervised and completed in accordance with contracts/ work orders. 4. Ensures documentation is accurate informative and descriptive of the care provided and the resident's response to the care. 5. Keep abreast of current federal and state regulations, as well as professional standards.

Based on observation, interview, and record review, the facility failed to provide necessary dental care services to one of one sampled resident (Resident 61) who was not assisted to receive dental care as recommended by the dentist due to missing teeth and dental cavities and difficulty chewing food. As a result of these deficient practices Resident 61 had the potential for nutrition deficit, weight loss, choking due to difficulty chewing and pain due to untreated dental cavities. Findings: During a review of Resident 61's admission record (AR), the AR indicated that the facility originally admitted Resident 61 on 9/21/2021 and recently readmitted her on 8/23/2025, with diagnoses including hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time), anemia (a condition where the body does not have enough healthy red blood cells), and chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing.) During a review of Resident 61's Minimum Data Sheet (MDS- a Federally mandated resident assessment tool) dated 10/3/2025, the MDS indicated Resident 61 as having moderately impaired cognition (decision poor; cues/supervision required) that required supervision or touching assistance (helper provides verbal cues and/or contact guard assistance as resident completes activity) on oral hygiene and personal hygiene. The MDS also indicated that Resident 1 required change in texture of food or liquids while being a resident of the facility. During a review of Resident 61's Dental Progress Notes (DPN) dated 9/25/2025, the DPN indicated to resubmit treatment authorization request (TAR) for proposed/ recommended treatment plan. The DPN also acknowledged that Resident 61 requested dentures to replace missing teeth for mastication (the process of chewing food). During a review of Resident 61's History and Physical (H&P) dated 10/22/2025, the H&P indicated that Resident 1 had fluctuating capacity to understand and make decisions. During a review of Resident 61's DPN dated 10/23/2025, the DPN indicated the following: Recommend 3PA's (three periapical [PA] X-rays) and 2BW's (two-film bitewing X-ray) dental x-rays for definitive diagnosis. Recommend oral prophylaxis for oral hygiene and for periodontal health. Recommend composite filling (a dental restorative material that comprises a mixture of plastic resin and powdered glass filler) on tooth #22 due to decay beyond dentine-enamel junction (a natural junction that unites two mechanically dissimilar calcified tissues of the tooth) Recommend full upper and partial dentures lower for mastication. Recommend extraction of root fragments #20&21 on emergency basis or if dentures are to be fabricated. During a review of Resident 61's Social Service Progress Notes (SSPN) dated from 8/23/2025 to 11/17/2025, there was no documented evidence in the SSPN indicating any follow up regarding dentures and/or dentist's recommendations indicated in DPN. During an observation and concurrent interview on 11/18/2025 at 10:50 AM, Resident 61 was observed with missing teeth on the upper and lower. Resident 61 stated that she has been asking he social worker and the dentist that she needed dentures. Resident 61 stated it's been a long time (she referred months) since she asked and dentist had come but she never got an update as to the progress about her dentures. Resident 61 stated she felt forgotten. During a concurrent record review and an interview on 11/18/2025 at 11:20 AM with the Licensed Vocational Nurse (LVN) 2, LVN 2 stated that Resident 61 never wore a denture, and LVN 2 stated never heard from social worker that Resident 61 asked for dentures. During an interview on 11/19/2025 at 11:50 AM with the Director of Nursing (DON), the DON stated she and the IDT team should have could have communicated better and work together to address Resident 61's denture issues.

Based on observations, interviews, and record review, the facility failed to implement the facility's policies and procedures, titled storage of Food and Supplies, Procedures for Refrigerated Storage, and Preventing Foodborne illness- Employee Hygiene and Sanitary Practices, professional standards of practice on food storage, food service safety, sanitation and handling practices to prevent the outbreak of foodborne illness (food poisoning) by failing to ensure: 1.Discard one jar of turmeric powder, two (2) jars of curry powder, one jar of ground cumin, two (2) jars of ground Italian seasoning, one jar of ground paprika, one jar of steak sauce, one jar of dry basil leaves, one jar of chili powder, two bags of dried shredded coconut, one bag of pancake mix, one bag of brown rice; a bag of cornflakes, one bag of pepperoni slices when expired. 2. Label and store food that indicate the use-by-date or expiration date, including: a bag of scalloped potatoes, a 64-fluid-ounce bottle of pineapple juice, instant lemon pudding out of original box, individually-wrapped graham pie crust in a opened box, three unopened bags of frozen broccoli florets out of original package, one opened bag of frozen ravioli, one bag of frozen cauliflower, one five-pound bag of frozen ground pork out of original package, and several loose individual packets of cane sugar in a bin; 3. The Kitchen staff follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness. These deficient practices had the potential to result food contamination (transfer of harmful bacteria or other germs to food, surfaces, or utensils) that placed residents at risk for foodborne illness and lead to other serious medical complications and hospitalization. Findings: During an initial kitchen tour and a concurrent interview on 9/29/2025 from 8:20 AM to 9 AM with the Dietary Service Supervisor (DSS), the following were observed: In the freezer: Three unopened bags of broccoli florets out of original packaging with no expiration date. One opened bag of ravioli with no expiration date. One unopened bag of cauliflower with no received-date or use-by-date. The following jars of spices were observed on wall shelf above the sink For Veggies: Turmeric powder expired on 4/10/2025 Curry powder expired on 6/14/2025 Ground cumin expired on 4/2/2025 Another curry powder expired on 6/14/2025 Ground Italian Seasoning expired on 5/17/2025 Ground ginger expired on 6/20/2025 Ground paprika with unclear expiration date The following were observed in dry storage room: An opened bag of Pancake mix expired on 6/25/2025 An opened bag of brown rice expired on 9/25/2025 In a concurrent interview on 9/29/2025 at 9 AM, the DSS stated that dry stored, frozen foods without label lacking expiration or use-by-date were considered unsafe for resident's consumption. DSS stated according to facility policy, the kitchen staff are required to label and date foods when storing food and supply be stored properly and in a safe manner. During an observation and concurrent interview on 9/29/2025 at 9:02 AM with the Kitchen Staff (KS) 1, KS 1 was observed wearing gloves rinsing dirty dishes, then with the same gloved hands KS 1unloaded clean dishes from sanitizing dishwasher machine without changing gloves and performing hand hygiene between tasks. KS 1 stated she should have performed hand washing and replaced with new gloves after rinsing dirty dishes and before pulling out sanitized clean dishes from dishwasher. KS 1 stated without appropriate hand hygiene residents could get sick. During an interview on 9/29/2025 at 9:05 AM with the DSS, DSS stated cross contamination (transfer of harmful substances or disease-causing microorganisms to food by hands, food contact surfaces, sponges, cloth towels, or utensils which are not cleaned after touching raw food, and then touch ready-to-eat foods) could occur and residents could get sick from using those dishes handled by KS 1 who did not change gloves and preform hand hygiene between tasks. During a review of the facility's Policy and Procedures (P&P) titled Storage of Food and Supplies dated in 2023, the P&P indicated the procedures for dry storage: Dry bulk foods (flour, sugar, dry beans, food thickener, spices, etc) should be stored in seamless metal or plastic containers with tight covers, or in bins which are easily sanitized. Bins/ containers are to be labeled, covered, and dated. Food stores should be arranged in food groups to facilitate storing, locating, and taking inventories. Labels should be visible, and the arrangement should permit rotation of supplies so that oldest items will be used first. All food will be dated- month, day, year. No food will be kept longer than the expiration date on the product. Dry food items which have been opened, such as pudding, gelatin, biscuit mix, pancake mix, dry cereal, spices, coffee, noodles, etc., will be tightly closed, labeled, and dated. During a review of the facility's P&P titled Procedures for Refrigerated Storage dated in 2023, the P&P indicated that individual packages of refrigerated or frozen food taken from the original packing box need to be labeled and dated. During a review of the facility's P&P titled Procedures for Freezer Storage dated in 2023, the P&P indicated that all frozen food should be labeled and dated. During a review of the facility's P&P titled Preventing Foodborne Illness- Employee Hygiene and Sanitary Practices revised in 10/2017, the P&P indicated that employees must wash their hands after handling soiled equipment or utensils.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to implement infection control measures for two of eight sampled residents (Resident 75 and Resident 83) by failing to: 1.Ensure Resident 75's respiratory equipment was properly labeled and stored in a plastic bag with the resident's name and the date the tubing was changed. 2. Ensure Resident 83's Peripherally inserted Central Catheter ICC a long, thin tube inserted into a vein in the upper arm that extends to a large vein near the heart.)) site was labeled with the date of the last dressing (typically a transparent, secure, and often antimicrobial dressing that protects the insertion site from infection) change. These deficient practices had the potential to place Resident 75 and Resident 83 at risk for infection. During a review of Resident's 75's admission Record (AR), the AR indicated Resident 75 was admitted to facility on 01/26/2024, with a diagnosis of intervertebral disc degeneration ( a condition where the discs between your spine's bones begin to wear down over time) , urinary tract infection ( when bacteria gets into the urinary tract and starts to multiply) , chronic obstructive pulmonary disease (a group of lung conditions where air has trouble getting out of the lungs). During a review of Resident 75's Order Summary Report dated 09/25/2025, the Report indicated Albuterol Sulfate (medication used to relax muscles around the airways and improve breathing for individuals with lung conditions) inhalation Nebulization Solution 0.63 milligrams (mg a unit of measurement) per 3 milliliter (ml- A unit of measurement) 1 vial inhale orally via nebulizer (a small machine that turns liquid medicine into a mist that can be easily inhaled) every 2 hours as needed for Shortness of breath. A review of Resident 75's Minimum Data Set ( MDS -a resident assessment tool) dated 07/08/ 2025, the MDS indicated the resident has no significant cognitive impairment ( can understand, remember and make decisions appropriately) and requires partial assistance meaning the helper does less than half the effort with lift, hold or supports trunk or limbs for most activities such as toileting hygiene, showering, and dressing. During a review of Resident 83's AR, the AR indicated Resident 83 was admitted readmitted to facility on 09/24/2025 with a diagnosis of metabolic encephalopathy ( a change in mental status due to a medical issue like infection, dehydration, low oxygen) , type 2 diabetes mellitus (chronic condition where the body does not use insulin properly) , epilepsy ( when brain has moments where its electrical signals misfire, causing a seizure) , and heart failure (when the heart is not pumping blood as well as it should). During a review of Resident 83's H&P dated 6/6/2025, H&P indicated the resident does not have the capacity to understand and make decisions. During a review of Resident 83's MDS dated [DATE], MDS indicated the resident has moderate to severe cognitive impairment with decreased memory and impaired decision making requiring increased supervision and assistance with daily activities such as personal hygiene, dressing, and toileting. During an observation on 09/29/2025 at 10:15 AM in Resident 83's room, Resident 83 was observed with a PICC on the right forearm. The PICC line was covered with a dressing, and the dressing was not dated. During a concurrent observation and interview on 9/29/2025 at 10:35 AM with Registered Nurse (RN) 2 in Resident 83's room, Resident 83's PICC line dressing was observed. RN1 stated the PICC line site should have a date and time indicated on the dressing to determine when the next dressing change should be done. RN 1 stated changing the PICC line dressing was important to prevent possible infections. During an observation on 9/29/2025 at 12:05 PM in Resident 75's room, Resident 75's breathing treatment mask (a medical device that covers a patient's nose and mouth to facilitate the delivery of various respiratory therapies, such as medication in the form of a mist (aerosol therapy) or concentrated oxygen) was observed without a date or name, to indicated who the mask belonged to or when the mask needed to be changed. During a concurrent observation and interview on 9/29/2025 at 12:10 PM with Registered Nurse (RN) 3 in resident 75's room, a breathing treatment mask and tubing were observed. RN2 stated Resident 75's breathing mask should be dated to ensure staff know when the equipment needs to be changed. RN 2 stated not labeling Resident 75's mask with the name and date was an infection control issue. During a concurrent observation and interview on 11/19/2025 at 2:20 PM with the Director of Nursing (DON), an observation of a photograph of Resident 83's PICC line site was made. The photograph showed no date or staff initials on the PICC line dressing. The DON stated the PICC line dressing should include the date to indicate when the last dressing change occurred. The DON further state that at the time of admission, it is the RN's responsibility to obtain or request information regarding the resident's most recent PICC line dressing change. DON stated Resident 83's undated PICC line dressing was an infection control issue. A review of the facility's policy and procedure dated 2010, titled Administering medications through a Small Volume (Handheld) Nebulizer, indicated the purpose of the procedure is to safely and aseptically administer aerosolized particle of medication into the resident's airway. Steps in the procedure shall include storing the equipment in a plastic bag with the resident's name and the date on it. To change the equipment and tubing every seven days. A review of the facility's policy and procedure titled Peripheral and Midline IV Dressing Changes, revised March 2022, indicated the purpose of this procedure is to prevent complications associated with intravenous therapy, including catheter related infections associated with contaminated, loosened or soiled catheter - site dressings. The P&P indicated to maintain sterile dressing (transparent semi-permeable membrane [TSM] dressing or sterile gauze) for all peripheral catheter sites. The P&P indicated to changes the dressing at least every 7 days for TSM dressing and at least every two days for sterile gauze dressing. The P&P indicate to check expiration dates of dressing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to maintain a safe and sanitary environment for one of three sampled residents (Resident 74); by failing to ensure Resident 74's room was clean and free from stains and dust. 1. Resident 74's room was observed with more than one brown stains on the wall in 2. Resident 74's exhaust vent (a mechanical device designed to pull stale or polluted indoor air out of a room and expel it outdoors) was observed covered in dust. These deficient practices had the potential to result in Residents' discomfort. During a review of Resident 74's admission Record (AR), the AR indicated the facility originally admitted Resident 74 on 9/1/2023 and readmitted on [DATE] with diagnoses that included dementia (an overall term for a decline in mental ability that affects memory, thinking, and daily activities, not a specific disease itself) and type II diabetes mellites (a condition that happens when your blood sugar is too high). During a review of Resident 74's Minimum Data Set (MDS, a resident assessment tool), dated 8/19/2025, the MDS indicated Resident 74 had moderately impaired cognition (ability to understand and make decisions) and memory. The MDS indicated Resident 74 required setup or clean-up assistance with eating, oral hygiene, toileting hygiene, personal hygiene and chair/bed-to-chair transfer, and supervision or touching assistance with shower/bathe self. During a concurrent observation and interview on 9/29/2025 at 9:53 AM with Resident 74, Resident 74's room was observed with dry brown stains on the wall and dust was covering the exhaust vent in Resident 74's room. Resident 74 stated the brown stains were already on the wall when Resident 74 moved into the room. Resident 74 stated she has not seen anyone clean the vent on the wall that was covered in dust. Resident 74 stated the room was not clean and she did not feel comfortable. During a concurrent observation and interview on 9/29/2025 at 9:56 AM with Maintenance Assistant (MA) 1, MA 1 stated the multiple dry brown stains on the wall were coffee stains. MA 1 stated the exhaust vent in Resident 74's room was dusty. MA 1 stated housekeeping staff were supposed to remove the stains on the wall and clean the exhaust vent cover. During a concurrent observation and interview on 9/29/2025 at 10 AM with Housekeeper (HK) 1, HK 1 stated the HK did not clean the wall to remove the stains on Resident 74's wall and did not clean the dusty vent. HK 1 stated he was not sure for how long the stains had been on the wall and when was the last time they cleaned the exhaust vent cover in Resident 74's room. During an interview on 9/29/2025 at 11:36 AM with the Housekeeper Supervisor (HKS), the HKS stated the housekeepers did not clean the wall and the exhaust vent cover in Resident 74's room. The HKS stated the housekeepers should clean every room every day and check if the wall and the vent cover was clean. HKS stated it was important to keep each resident and to provide a sanitary environment for all the residents at the facility. During a review of the facility' policy and procedures (P&P) titled, Homelike Environment, dated 2/2021, the P&P indicated Residents are provided with a safe, clean, comfortable and homelike environment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident who displayed behaviors of refusing medications received treatment and services to correct the assessed problem, was provided behavioral health services for one of three sampled residents ( Resident 1) whose primary diagnosis was schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly) and bipolar disorder (a brain disorder that causes changes in a person's mood, energy, and ability to function) by failing to: 1.Notify the physician when Resident 1 refused Haloperidol (a medicine used to treat and manage various mental health and behavioral condition, including schizophrenia and bipolar disorder) 10 milligram (MG, a unit of measurement) one tablet by mouth two times a day for a total of 35 doses. 2. Notify the physician when Resident 1 refused Valproic Acid (a medicine used to treat bipolar disorder) 250 MG three capsules by mouth as two times a day for a total of 14 doses and partial administration of Valproic Acid for 4 doses. 3. Notify the physician when Resident 1 refused one dose of Venlafaxine (a medicine used to treat depression [a mood disorder that causes a persistent feeling of sadness and loss of interest] and anxiety [a common emotion characterized by feelings of unease, worry, or fear, which can range from mild to severe])5 MG one tablet by mouth two times a day. 4. Conduct an interdisciplinary team (IDT) meeting when Resident 1 continued to refuse psychotropic medications. 5. Assess and document the reason for Resident 1's constant refusal of psychotropic medications. These deficient practices resulted in Resident 1 pushing Resident 2 during a resident-to resident altercation on 6/20/2025. Subsequently, Resident 1 was transferred to a General Acute Care Hospital (GACH) and placed on a 5150 (the California Welfare and Institutions Code, which allows a qualified professional to place someone in an involuntary 72-hour psychiatric hold if they are a danger to themselves or others or are gravely disabled). During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 5/26/2025 with diagnoses that included schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly) and bipolar disorder (a brain disorder that causes changes in a person's mood, energy, and ability to function). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 5/30/2025, the MDS indicated Resident 1 had moderately impaired cognition (ability to understand and make decisions) and memory. The MDS indicated Resident 1 exhibited little interest or pleasure in doing things and trouble failing or staying asleep, or sleeping too much nearly every day, feeling down, depressed, or hopeless, feeling tired or having little energy, poor appetite or overeating several days over the last two weeks. The MDS also indicated Resident 1 required supervision or touching assistance with eating, and partial/moderate assistance with oral hygiene, toileting hygiene, shower/bathe self, personal hygiene, and chair/bed-to-chair transfer. During a review of Resident 1's Order Summary Report, dated 6/20/2025, the Report indicated the physician ordered to administer the following medications: 1.Haloperidol (a medicine used to treat and manage various mental health and behavioral condition, including schizophrenia and bipolar disorder) 10 milligram (MG, a unit of measurement) one tablet by mouth two times a day for bipolar manifested by striking out at staff, starting on 5/27/2025. 2.Valproic Acid (a medicine used to treat bipolar disorder) 250 MG three capsules by mouth as two times a day for bipolar disorder manifested by inconsolable screaming, starting on 5/27/2025. 3.Venlafaxine (a medicine used to treat depression [a mood disorder that causes a persistent feeling of sadness and loss of interest] and anxiety [a common emotion characterized by feelings of unease, worry, or fear, which can range from mild to severe])5 MG one tablet by mouth two times a day for restlessness, starting on 5/27/2025. During a review of Resident 1's Medication Administration Record (MAR), dated 5/2025, the MAR indicated Resident 1 refused to take Haloperidol 10 MG one tablet on 5/27/2025 at 6 PM, 5/28/2025 at 9 AM at 6 PM, 5/29/2025 at 9 AM and 6 PM, 5/30/2025 at 9 AM. The MAR also indicated Resident 1 refused to take Valproic Acid 250 MG three capsules on 5/28/2025 9 AM and 5/29/2025 9 AM. During a review Resident 1's MAR, dated 6/2025, the MAR indicated Resident 1 refused to take Haloperidol 10 MG one tablet on: a. 6/1/2025 at 9 AM and 6 PM b. 6/2/2025 at 9 AM and 6 PM c. 6/3/2025 at 9 AM and 6 PM d. 6/4/2025 at 9 AM e. 6/5/2025 at 9 AM and 6 PM f. 6/6/2025 at 9 AM and 6 PM g. 6/7/2025 at 9 AM h. 6/8/2025 at 9 AM and 6 PM i. 6/10/2025 at 9 AM and 6 PM j. 6/11/2025 at 9 AM and 6 PM k. 6/12/2025 at 6 PM l. 6/13/2025 at 9 AM and 6 PM m. 6/14/2025 at 9 AM n. 6/15/2025 at 9 AM and 6 PM o. 6/16/2025 at 9 AM p. 6/17/2025 at 6 PM q. 6/19/2025 at 6 PM r. 6/20/2025 at 9 AM and 6 PM During a review of Resident 1's MAR, dated 6/2025, the MAR indicated Resident 1 refused to take Valproic Acid 250 MG three capsules on: a. 6/3/2025 at 9 AM b. 6/6/2025 at 6 PM c. 6/12/2025 at 6 PM d. 6/13/2025 at 9 AM and 6 PM e. 6/14/2025 at 9 AM f. 6/15/2025 at 9 AM and 6 PM g. 6/17/2025 at 6 PM h. 6/19/2025 at 6 PM i. 6/20/2025 at 9 AM and 6 PM The MAR indicated Resident 1 received only a partial administration of Valproic Acid 250 MG three capsules on 6/8/2025 at 6 PM, 6/9/2025 at 6 PM, 6/10/2025 at 6 PM and 6/11/2025 at 6 PM. The MAR indicated Resident 1 did not receive the entire dose of Valproic Acid 250 MG three capsules on 6/5/2025 at 6 PM and was only administered one tablet. During a review of Resident 1's MAR, dated 6/2025, the MAR indicated Resident 1 refused to take Venlafaxine 75 MG one tablet on 6/6/2025 at 6 PM. During a review of Resident 1's Progress Notes (PN), dated 6/8/2025 at 5:34 PM, the PN indicated Resident only took one capsule of Valproic Acid 250 MG. During a review of Resident 1's Change in Condition Evaluation (COC), dated 6/12/2025 at 10:22 AM, the COC indicated Registered Nurse (RN) 1 reported to the physician that Resident 1 was non complaint with medication administration since Resident 1 kept refusing to take the medication, valproic acid. During a review of Resident 1's PN, dated 6/12/2025 at 10:22 AM, the PN indicated RN 1 reported to the physician that Resident 1 kept on refusing medications but there was no documentation for recommendations, new testing orders and new intervention ordered by the physician. During a review of Resident 1's PN, dated 6/20/2025 at 3:14 PM, the PN indicated that at 12:25 PM, Resident 1 allegedly approached Resident 2 in the smoking patio and asked Resident 2 for a cigarette, but Resident 2 stated he did not have a cigarette, so Resident 1 pushed Resident 2 and continued a verbal altercation. During a review of Resident 1's PN, dated 6/20/2025 at 8:04 PM, the PN indicated that the facility called 911 and transferred Resident 1 to the General Acute Care Hospital (GACH) at 7:10 PM for 5150. During an interview on 7/9/2025 at 11:25 AM with Restorative Nursing Assistant (RNA) 1, RNA 1, RNA 1 stated on 6/20/2025 after lunch, he was doing something in the hallway and he heard Resident 1 and Resident 2 arguing in the smoking patio, then, he tried to separate the residents. RNA 1 stated Resident 2 said Resident 1 was asking for a cigarette from him, but Resident 2 said he did not have a cigarette, then, Resident 1 pushed Resident 2. During an interview on 7/9/2025 at 12:17 PM with RN 2, RN 2 stated Resident 1 would become verbally aggressively toward staff when the staff did not attend to his request immediately. RN 2 stated the charge nurses reported that Resident 1 would refuse to take medications, then, the nurse would educate the resident about the risk of refusing medication, informed the responsible party (RP) to convince the resident, and notify the physician. RN 2 stated she did not know how often and how many medications Resident 1 had refused since his admission, and she did not know if any interventions were developed and implemented to address Resident 1's behavior of refusing medications frequently. During an interview on 7/9/2025 at 1:40 PM with Licensed Vocational Nursing (LVN) 2, LVN 2 stated Resident 1 had refused his medication since the first day he was admitted into the facility. LVN 2 stated Resident 1's refusal of medications increased before Resident 1 was transferred to the GACH. LVN 2 stated she reported Resident 1's refusal of medication to the RN supervisor and the RN supervisor was responsible for assessing Resident 1 and reporting to and following up with the physician. During a telephone interview on 7/9/2025 at 3:50 PM with RN 1, RN 1 stated on 6/12/2025, the charged nurse informed her that Resident 1 refused to take medications, such as metformin, haloperidol and valproic acid, so RN 1completed the COC, and reported Resident 1's refusals of medications to the nurse practitioner (NP) of Resident 1's psychiatrist. RN 1 stated the NP stated she would come to the facility and visit with Resident 1, however RN 1 did not document NP's response or COC onto Resident 1's medical record. RN 1 stated she did not know if the NP or the psychiatrist came to see Resident 1 after informing NP of Resident 1 refusing medications. RN 1 stated she had not followed up with Resident 1's COC nor did RN 1 know if Resident 1's refusal of meds was followed up. RN 1 stated she did not know Resident 1 refused the prescribed medication haloperidol almost every day and RN 1 did not know how often Resident 1 refused another prescribed medication valproic Acid. During an interview on 7/9/2025 at 4:01 PM with LVN 3, LVN 3 stated Resident 1 often refused medications, and she remembered she called Resident 1's primary physician about it Resident 1's refusal of medications, however did not inform Resident 1's psychiatrist since Resident 1's primary provided stated they would reach out to the psychiatrist. LVN 3 could not state whether Resident 1's psychiatrist knew Resident 1 refused the prescribed psychotropic medications or if Resident 1 had been reevaluated by the psychiatrist. LVN 3 stated it was not her responsibility to follow up with the physician for further orders, instead, it was the RN supervisors' responsibility to do that. LVN 3 stated she did not know if the RN supervisors follow up with it. During a concurrent interview and record review on 7/9/2025 at 4:20 PM with the Director of Nursing (DON), Resident 1's MAR, dated 5/2025 and 6/2025 were reviewed. The DON stated Resident 1, who had the diagnosis of schizophrenia and bipolar disorder, exhibited behaviors of refusing the prescribed psychotropic medications, which was a COC for Resident 1. The DON stated she was unaware that Resident 1 was refusing medications. The DON stated Resident 1 had refused Haloperidol since the first day of his admission on [DATE], but there was no COC was done until 6/12/2025. The DON stated the licensed nurses did not follow up with Resident 1's COC for further instruction from the physician, and did not inform the DON about Resident 1's COC. The DON stated the facility did not conduct an IDT and did not develop a care plan to address Resident 1's COC of refusing medications. The DON stated it was important for the licensed nurses to monitor Resident 1's behavior of refusing psychotropic medication closely, and report Resident 1 refusal of medications to the physician, to manage and intervened Resident 1's mental condition timely and effectively. The DON stated the facility did not monitor, communicate, address and intervene regarding Resident 1's behavior of frequent refusal of psychotropic medications, which had resulted in Resident 1 not receiving medications as ordered by the physician. The DON stated since Resident 1 was not receiving the prescribed medications, this could have resulted in why Resident 1 allegedly pushed Resident 2, and Resident 1 being transferred to the GACH for 5150 on 6/20/25. During a review of the facility's policy and procedure (P&P) titled, Behavioral Assessment, Intervention and Monitoring, dated 3/2019, the P&P indicated the facility will provide and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance. The P&P indicated the staff will assess, evaluate and identify, document, and inform the physician and RP about changes in an individual's mental status, behavior and cognition, then, IDT will evaluate and identify the cause of the changes, and intervene and manage the condition. During a review of the facility's policy and procedure (P&P) titled, Requesting, Refusing and/or Discontinuing Care or Treatment, dated 2/2021, the P&P indicated If a resident/representative requests, discontinues or refuses care or treatment, an appropriate member of the interdisciplinary team (IDT) will meet with the resident/representative to a. determine why he or she is requesting, refusing or discontinuing care or treatment; b. try to address his or her concerns and discuss alternative options; and c. discuss the potential outcomes or consequences (positive and negative) of the decision, If the decision to refuse or discontinue treatment results in a significant change of condition, a reassessment will occur and appropriate changes will be made to the resident's care plan. The P&P indicated detailed information relating to the refusal of treatment are documented in the resident's medical record, including the practitioner's response. The P&P indicated the practitioner must be notified of refusal of treatment, in a time frame determined by the resident's condition and potential serious consequences of the request.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that a comprehensive, person-centered care plan was developed for one of two sampled resident (Resident 1) who was assessed to be at risk of elopement (the act of leaving a facility unsupervised and without prior authorization) and wandering.
This deficient practice had the potential for Resident 1 to not receive care that would prevent the resident from wandering into other resident ' s rooms, which could be a violation of other resident ' s privacy and rights, and/or elope from the facility.
Findings:
During a review of Resident 1 ' s admission Record (AR), the AR indicated the resident was admitted on [DATE] with diagnoses that included Alzheimer ' s disease (a disease characterized by a progressive decline in mental abilities) and dementia (a progressive state of decline in mental abilities), and cognitive communication disease.
During a review of Resident 1 ' s History and Physical (H&P), dated 4/25/2025, the H&Pindicated the resident does not have the capacity to understand and make decisions.
During a review of Resident 1 ' s Minimum Data Set (MDS – a resident assessment tool), dated 4/25/2025, the MDSindicated the resident has severe impaired cognition (the ability to process thoughts). The MDS also indicated the resident requires moderate assistance (helper does less than half the effort) on activities such as walking up to 50 feet and sitting to standing. The MDS also indicated the resident requires substantial assistance (helper does more than half the effort) for self-care activities such as putting on/taking off footwear, toileting, and personal hygiene.
During a review of Resident 1 ' s Elopement Evaluation (EE), dated 4/21/2025, the EE indicated Resident 1 wandered aimlessly or non-goal-directed. The EE indicated the resident was at risk for wandering or elopement.
During a review of Resident 1 ' s active care plans, there were no care plans for Resident 1 initiated to address Resident 1 ' s behavior of wandering or elopement.
During an interview on 5/28/2025 at 12:39 PM with Registered Nurse (RN) 1, RN 1 stated Resident 1 wandered around the facility and was at risk for elopement. RN 1 stated Resident 1 could walk by himself and wandered around the facility.
During a concurrent interview and record review on 5/28/2025 at 2:32 PM with Director of Nursing (DON), Resident 1 ' s active care plans and EE, dated 4/21/2025, were reviewed. DON stated Resident 1 did not have a care plan that addressed Resident 1 ' s behaviors of wandering and for being at risk for elopement. DON stated there should be a care plan for the resident ' s behavior since the care plan wasused to inform all staff on which specific interventions to implement for Resident 1. DON stated the care plan for the resident ' s behavior of wandering and risk of elopement should include interventions such as close monitoring or moving the resident to a room closer to the nurses ' station.
During a record review of the facility ' s policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, revised 3/2022, indicated the care plan interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers. The P&P also indicated the comprehensive, person-centered care plan:
1. Includes measurable objectives and timeframes;
2. Describe the services that are to be furnished to attain or maintain the resident ' s highest practicable, mental, and psychosocial well-being, including:
a. services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including to refuse treatment;
3. builds on the resident ' s strengths; and
4. reflects currently recognized standards of practice for problem areas and conditions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to report immediately and/or no later than two hours if the alleged allegation involves abuse, the verbal and physical altercation that happened with two of two sampled residents (Resident 1 and Resident 6) on 5/3/2025. Resident 6 reported that on 5/3/2025 around 9AM, Resident 1 stopped him in the hallway in his wheelchair, and yelled profanity (offensive or vulgar language, often considered impolite, rude, or disrespectful) at him and while in his wheelchair, he was pushed fast, spun around and grabbed his shirt prior to the staff separating them.
As a result, Resident 6 verbalized feeling upset, sad and discouraged, which negatively affected his quality of life. Also, it had the potential for a recurrence resulting in harm to other residents and staff in the facility.
On the same day, 5/3/2025, approximately four hours after the altercation with Resident 6, the facility failed to report an incident of Resident 1 choking Certified Nurse Assistant (CNA) 1 on 5/3/2025, while CNA 1 was inside another resident ' s room (Resident 5).
Resident 1 was transferred to the General Acute Care Hospital (GACH 1) on 5/3/2025 via 5150 (temporary, involuntary psychiatric commitment of individuals who present a danger to themselves or others due to signs of mental illness).
Findings:
A review of Resident 1 ' s admission record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included cognitive communication deficit (communication difficulties stemming from underlying cognitive impairments, rather than from speech or language deficits), schizoaffective disorder- bipolar type (a mental illness that combines symptoms of schizophrenia [like hallucinations and delusions) with those of bipolar disorder (like mania and depression)], and psychotic disorder (when you see reality very differently to people around you).
A review of Resident 1 ' s History and Physical Examination (HPE), dated 4/18/2024, indicated Resident 1 was alert to time, person and situation.
A review of Resident 1 ' s Minimum Data Set (MDS – a resident assessment screening tool), dated 4/18/2025, indicated the Resident 1 ' s cognitively status (ability to think, remember, and reason) moderately impaired impaired. The MDS indicated Resident 1 required supervision or touching assistance (Helper provides verbal cues and or touching steadying) with eating, partial/moderate assistance (helper does less than half the effort) with personal hygiene, dressing, toileting and bathing.
A review of Resident 6 ' s admission record indicated the resident was admitted to the facility on [DATE] with diagnoses that included osteoarthritis (a degenerative joint disease where the cartilage cushioning the bones in your joints wears away over time) of both shoulders and both knees, diabetes mellitus (disease of inadequate control of blood levels of glucose), and hypertension (high blood pressure).
A review of Resident 6 ' s History and Physical Examination (HPE), dated 10/11/2024, indicated Resident 6 has the capacity to understand and make decisions.
A review of Resident 6 ' s Minimum Data Set (MDS – a resident assessment screening tool), dated 4/18/2025, indicated the Resident 6 ' s cognitively status (ability to think, remember, and reason) was intact. The MDS indicated Resident 6 required Setup and clean-up assistance (helper sets up and cleans up; resident completes activity) with eating and oral hygiene, substantial/maximal assistance (helper does more than half the effort) with dressing and personal hygiene, and dependent (helper does all the effort) with bathing and toileting.
A review of Resident 5 ' s admission record indicated the resident was admitted to the facility on [DATE] with diagnoses that included Alzheimer ' s disease (a progressive brain disorder that primarily affects memory and thinking skills, eventually leading to difficulty with everyday tasks and behavior changes), aortic aneurysm (a bulge that occurs in the wall of the body's main artery, called the aorta) and palliative care (focuses on improving the quality of life for people with serious illnesses by providing comfort and support, even when a cure isn't possible).
A review of Resident 5 ' s History and Physical Examination (HPE), dated 5/1/2024, indicated Resident 5 does not have the capacity to understand and make decisions.
A review of Resident 5 ' S Minimum Data Set (MDS – a resident assessment screening tool), dated 4/14/2025, indicated Resident 5 dependent with eating, oral hygiene, toileting, bathing, dressing and personal hygiene.
A review of Resident 1 ' s facility document titled, Progress Notes (PN), dated 5/3/2025 timed at 1:45 PM, indicated Resident 1 was aggressive and hurt Certified Nurse Assistant (CNA) 1 by putting his hands around CNA ' s 1 neck, and the police came and took Resident 1 to GACH 1 for physical aggression via 5150 (California law code for the temporary, involuntary psychiatric commitment of individuals who present a danger to themselves or others due to signs of mental illness).
During an interview on 5/7/2025 at 3:30 PM with Family 2 (Family of Resident 5), Fam 2 stated, on 5/3/2025 around 1 PM, while inside Resident 5 ' s room (which was adjacent to Resident 1 ' s room), she was talking to CNA 1, when Resident 1 came to Resident 5 ' s room and without warning attacked and started choking CNA 1. Fam 2 stated she helped CNA 1 and had to remove Resident 1 ' s hand around CNA 1 ' s neck. Fam 2 stated, the police came and took Resident 1 away. Fam 2 stated, she was concerned for Resident 5 ' s safety since Resident 5 is cognitively impaired, and other residents who cannot protect themselves from Resident 1. Fam 2 stated, she informed the Director of Social Services (DSS) and the facility leadership about her concern that same day.
During an interview on 5/7/2025 at 3:50 PM with CNA 1, CNA 1 stated, on 5/3/2025 around 1 PM she was talking to FAM 2 inside Resident 5 ' s room, when Resident 1 came inside Resident 5 ' s room and grabbed her neck and started choking her without warning. CNA 1 stated the staff came to help, and the police took Resident 1 away on 5/7/2025.
During a concurrent observation and interview on 5/7/2025 at 4:30 PM with Resident 6, in Resident 6 ' s room, Resident 6 was sitting at the side of the bed, next to his wheelchair, face was flushed, eyebrows drawn together, clenched teeth with teary eyes and would look up and down while being interviewed. Resident 6 stated, the incident with Resident 1 started with him, on 5/3/2025 around 9AM, he was in the hallway going towards the smoking area, when Resident 1 blocked his way and started yelling profanity, grabbed his wheelchair and pushed him in the hallway so fast, even touching his back and he almost fell. Resident 6 stated, he struggled, then Resident 1 turned his wheelchair around and grabbed his jacket, that ' s when the facility staff separated them. Resident 6 stated he reported the incident to the charge nurse, and there were other nurses there, but he does not remember their names. Resident 6 stated, he felt discouraged and sad and what upsets him the most was no one talked to him about the incident, and he felt he was nobody and no one cares for him.
During an interview on 5/8/2025 at 9:30 AM with Housekeeper (HSK) 1, HSK 1 stated., she worked on 5/3/2025, and around 9AM she saw Resident 6 wheeling himself in the hallway, when Resident 1 stopped him, and they yelled at each other. HSK 1 stated, Resident 1 then grabbed Resident 6 ' s wheelchair, pushed him hard and turned Resident 6 ' s wheelchair around. HSK 1 stated there were other people around and stopped the altercation, and she did not report it because she thought someone else would tell the administrator.
During an interview on 5/8/2025 at 9:45 AM with CNA 1, CNA 1 stated, on 5/3/2025 around 9 AM Resident 1 and Resident 6 were yelling at each other, then Resident 1 grabbed Resident 6 ' s wheelchair and pushed Resident 6 ' s wheelchair and turned him around and grabbed Resident 6 ' s jacket. CNA 1 stated, she does not know why it was not reported, since there were other staff there. CNA 1 stated, the incident should have been reported, and maybe the incident with her would not have happened.
During an interview on 5/8/2025 at 10:10 AM with CNA 4, CNA 4 stated, on 5/3/2025 around 9AM Resident 1 and Resident 6 were yelling at each other using profanity, Resident 1 yelled mother_____ to Resident 6. CNA 4 stated, he separated Resident 1 and resident 6 and escorted Resident 1 to his room while Resident 6 went to the nurse ' s station. CNA 4 stated, he did not see the physical abuse but saw the verbal abuse and it should have been reported to the abuse coordinator.
During an interview on 5/8/2025 at 10:20 AM with LVN (license Vocational Nurse) 4, LVN 4 stated, on May 3 she heard to commotion around 9 am, the staff was already separating Resident 1 and Resident 6. LVN 4 stated, Resident 6 told her that Resident 1 pushed him in his wheelchair and yelled at him profanity, and Resident 6 was concerned that he might get hurt. LVN 4 stated that the incident should have been reported because of verbal abuse and possible physical abuse, for patient safety and prevent recurrence. LVN stated the incident was not in the progress notes or change of condition (COC) documentation. LVN 4 stated, she reported it to RN (Registered Nurse) 3.
During an interview on 5/8/2025 at 10:35 AM with RN 3, RN 3 stated, no one told her about the incident between resident 1 and Resident 6. RN 3 stated, on 5/3/2025 in the morning, Resident 6 came to her very upset and told her Resident 1 yelled profanity at him and push his wheelchair while he was in it. RN 3 stated, she was unable to interview Resident 1 because he was still agitated. RN 3 stated, the incident should have been reported to the abuse coordinator, the ombudsman, police and California Department of Public Health (CDPH) as per policy. RN 3 stated that not reporting the incident had resulted in upsetting Resident 3 and had the potential for abuse to recur or escalate and could affect the safety of the other patients in the facility.
During an interview on 5/8/2025 at 11:00 AM with DON (Director of Nurses), the DON stated, any suspicion of abuse should be reported within 2 hours as indicated in the facility policy. The DON stated, any type of verbal or physical altercation should be reported, and should be investigated thoroughly, so the incident would be addressed and prevent from potential recurrence or harm to other residents. DON stated, yelling profanity to another Resident is considered abuse, grabbing a resident or pushing someone on a wheelchair against his will, is considered abuse and should be reported to PD, Ombudsman and CDPH. DON stated, not reporting the incident between Resident 1 and Resident 6 had the potential for recurrence and escalation of the problem that could potentially affect the safety of the residents in the facility.
A review of the facility ' s policy and procedure (P&P) titled, Abuse Prevention/ Prohibition, revised 11/2018, the P&P indicated; a) the facility does not condone any form of Resident abuse and/or mistreatment and develops a system in order to promote an environment free from abuse and mistreatment, b)Abuse is defined as a willful infliction of injury, involuntary seclusion, intimidation with resulting physical harm pain or mental anguish.
A review of the facility ' s policy and procedure (P&P) titled, Abuse Investigation and Reporting, revised 7/2017, the P&P indicated; a) all reports of residents abuse, mistreatment shall be promptly reported to local , state and federal agencies and thoroughly investigated by facility management, b) under reporting, all alleged violations of abuse or mistreatment will be reported by the facility administrator or his/her designee to the state licensing /certification agency, ombudsman, and law enforcement, c) an alleged abuse or mistreatment will reported immediately, but no later than two hours if the alleged allegation involves abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the facility have sufficient and competent nursing staff to address, and provide necessary services (behavior monitoring and management) and implement person centered care plans for the behavioral healthcare needs of one of three sampled residents (Resident 1) diagnosed with schizoaffective disorder- bipolar type (a mental illness that combines symptoms of schizophrenia [a serious mental health condition that affects how people think, feel and behave] with those of bipolar disorder (a mood disorder characterized by extreme mood swings)], and psychotic disorder (severe mental disorders that cause abnormal thinking and perceptions), in accordance with the facility ' s policy and procedures on Behavioral Assessment, Intervention and Monitoring and Care Planning – Interdisciplinary Team. The facility failed to:
1. Ensure Resident 1 ' s aggressive behavior was addressed, monitored and managed after an incident of choking Certified Nurse Assistant (CNA) 1 on 5/3/2025 while CNA 1 was inside another resident ' s room (Resident 5). Resident 1 transferred to the General Acute Care Hospital (GACH 1) on 5/3/2025 via 5150 (temporary, involuntary psychiatric commitment of individuals who present a danger to themselves or others due to signs of mental illness). Resident 1 was readmitted back to the facility on 5/8/2025.
2. Ensure Resident 1 ' s behavioral aggressiveness was thoroughly evaluated and licensed staff develop individualized comprehensive care plan interventions and approaches that were communicated with all facility staff upon readmission to the facility on 5/8/2025 due to the resident ' s history of aggressive and violent behaviors with a recent choking incident on 5/3/2025.
As a result, Resident 1 displayed physically aggressive and violent behaviors when Resident 1 ran after the facility staff with a bread knife at the facility lobby while pointing the bread knife at the facility receptionist and made a gesture of slitting Registered Nurse (RN) 5 ' s neck with the same bread knife on 5/16/2025 at 3 AM, during the night shift (11 PM to 7 AM). Resident 1 was taken by the Police via another 5150-hold, 5/16/2025 and was taken to GACH 2 Psychiatric facility.
These deficient practices had the potential to result in facility staff getting physically hurt and injured, including other vulnerable residents that included Resident 1 ' s roommate (Resident 12) who is cognitively impaired and assistance with activities of daily living, and Resident 5 who is also cognitively impaired and resides adjacent to Resident 1 ' s room.
Findings:
During a review of Resident 1 ' s admission Record (AR), the AR indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included cognitive communication deficit (communication difficulties stemming from underlying cognitive impairments, rather than from speech or language deficits), schizoaffective disorder- bipolar type (a mental illness that combines symptoms of schizophrenia [like hallucinations and delusions) with those of bipolar disorder (like mania and depression)], and psychotic disorder (when you see reality very differently to people around you).
During a review of Resident 1 ' s History and Physical Examination (HPE), dated 4/18/2024, the HPE indicated Resident 1 was alert to time, person and situation.
During a review of Resident 1 ' S Minimum Data Set (MDS – a resident assessment screening tool), dated 5/12/2025, the MDS indicated the Resident 1 ' s cognitively status (ability to think, remember, and reason) moderately impaired. The MDS indicated Resident 1 required supervision or touching assistance (Helper provides verbal cues and or touching steadying) with eating, partial/moderate assistance (helper does less than half the effort) with personal hygiene, dressing, toileting and bathing.
During a review of Resident 12 ' s AR, the AR indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included cognitive communication deficit, schizophrenia, bipolar disorder, unsteadiness on feet and muscle weakness.
During a review of Resident 12 ' s History and Physical Examination (HPE), dated 5/15/2025, the HPE indicated Resident 12 does not have the capacity to understand and make decisions.
During a review of Resident 12 ' s MDS, dated [DATE], the MDS indicated the Resident 12 ' s cognitively status was severely impaired. The MDS indicated Resident 12 required Setup and clean-up assistance (helper sets up and cleans up; resident completes activity) with eating and oral hygiene, supervision or touching assistance with dressing, personal hygiene and walking, and partial/moderate assistance (helper does less than half the effort) with toileting and bathing.
During a review of Resident 5 ' s AR, the AR indicated the resident was admitted to the facility on [DATE] with diagnoses that included Alzheimer ' s disease (a progressive brain disorder that primarily affects memory and thinking skills, eventually leading to difficulty with everyday tasks and behavior changes), aortic aneurysm (a bulge that occurs in the wall of the body's main artery, called the aorta) and palliative care (focuses on improving the quality of life for people with serious illnesses by providing comfort and support, even when a cure isn't possible).
During a review of Resident 5 ' s HPE, dated 5/1/2024, the HPE indicated Resident 5 does not have the capacity to understand and make decisions.
During a review of Resident 5 ' s MDS, dated [DATE], the MDS indicated Resident 5 dependent with eating, oral hygiene, toileting, bathing, dressing and personal hygiene.
During a review of Resident 1 ' s facility document titled, Progress Notes (PN), dated 5/3/2025 timed at 1:45 PM, the PN indicated Resident 1 was aggressive and hurt Certified Nurse Assistant (CNA) 1 by putting his hands around CNA 1 ' s neck, and the police came and took Resident 1 to GACH 1 for physical aggression via 5150.
During a review of Resident 1 ' s GACH 1 record titled Transfer of Summary dated 5/8/2025, the GACH 1 record indicated Resident 1 ' s Reason for admission or Evaluation was due to involuntary hold for DTO (danger to others) initiated on 5/3/2025 through 5/6/2025 . The record further indicated Resident 1 was at risk for danger to others.
During a review of Resident 1 ' s facility document titled, Progress Notes (PN), dated 5/8/2025 at 9:06 PM, indicated Resident 1 was readmitted to the facility from GACH 1 at 3:40 PM.
During a review of Resident 1 ' s GACH 1 document titled Transfer of Care Summary dated 5/8/2025, indicated diagnosis was at risk for danger to others.
During a review of Resident 1 ' s IDT Conference Record dated 5/9/2025 (one day after facility readmission), the IDT Record attended by the Activity Assistant, Social Services Director (SSD), Dietary Services Director (DSS), Director of Rehabilitation (DOR), and RN MDS Coordinator, indicated the IDT met with Resident 1 ' s representative via telephone and discussed the resident ' s plan of care [NAME] included medical diagnosis, nursing care/services, medication management, health teachings, training therapy needs, dietary/activity preferences, discharge process, and code status. The IDT Record, including IDT interventions indicated in the IDT Record did not include recommendations for developing individualized comprehensive care plan interventions and approaches that were communicated with all facility staff upon Resident 1 ' s readmission to the facility on 5/8/2025 due to the resident ' s history of aggressive and violent behaviors and with a recent choking incident with CNA 1 on 5/3/2025 that resulted to a 5150 transfer to GACH 1.
During a review of Resident 1 ' s facility document titled, Progress Notes (PN), dated 5/12/2025 at 12:00 AM, the PN indicated Resident 1 had a sudden outburst of anger towards a CNA, and refuse to take PRN medication, the PN indicated the resident ' s physician was made aware and monitored. The PN did not indicate any other individualized behavioral interventions developed or implemented to prevent physical aggression towards others and protect other staff and residents from Resident 1.
During a review of Resident 1 ' s Progress Notes (PN), dated 5/12/2025 at 6:44 AM, the PN indicated Resident 1 noted with verbal and aggressive behavior towards staff and residents, yelling and screaming. The PN did not indicate any other individualized behavioral interventions developed or implemented to prevent physical aggression towards others and protect other staff and residents from Resident 1.
During a review of Resident 1 ' s Progress Notes (PN), dated 5/16/2025 at 5:11 PM, the PN indicated at around 3:07 AM, Resident 1 went out of his room towards the lobby and turned to the RN (RN 5) sitting at the Nurse Station and showed a silver knife in his hand. The PN indicated He (Resident 1) moved it towards his neck, acted like slitting it. The PN indicated [Resident 1] run towards RN 5 and other nurses in Station 1 pointing the knife towards them acted as if he will stab one. RN hurriedly called 911 for police assistance. The PN further indicated [Resident 1] went to the front desk area and pointed the knife at the receptionist. [Resident 1] got a folded metal chair, went to Station 1 and tried to slam it to a nurse who is trying to calm him down. When he [Resident 1] wasn ' t able to, he went inside his room with the bread knife and foldable chair. He [Resident 1] closed the door and locked it most probably with another chair. 2 police officers came and went inside his room, a banged (sic) was heard inside the room like a heavy object hitting the floor, one office was able to open the door. [Resident 1] was inside by his bed, while his roommate was inside too (Resident 12) on his own bed and was not hurt at all . The PN further indicated Resident 1 was taken via 5150 hold and GACH 2 psychiatric facility was notified.
During a review of a facility document (untitled) dated 5/17/2025 at 12 AM, the document indicated Resident [1] had a bread knife in his hand, and while in the [facility] lobby he moved the bread knife in his neck and acted like slitting it. He [Resident 1] also run after the nurses with a bread knife, he pointed a bread knife to the receptionist and almost hit a nurse with a folded metal chair. The document indicated law enforcement (police department) was notified and that there were no residents present in the facility hallway during that time.
During an interview on 5/7/2025 at 3:30 PM with Family 2 (Family of Resident 5), Fam 2 stated, on 5/3/2025 around 1 PM, while inside Resident 5 ' s room (which was adjacent to Resident 1 ' s room), she was talking to CNA 1, when Resident 1 came to Resident 5 ' s room and without warning attacked and started choking CNA 1. Fam 2 stated she helped CNA 1 and had to remove Resident 1 ' s hand around CNA 1 ' s neck. Fam 2 stated, the police came and took Resident 1 away. Fam 2 stated, she was concerned for Resident 5 ' s safety since Resident 5 is cognitively impaired, and other residents who cannot protect themselves from Resident 1. Fam 2 stated, she informed the Director of Social Services (DSS) and the facility leadership about her concern that same day.
During an interview on 5/7/2025 at 3:50 PM with CNA 1, CNA 1 stated, on 5/3/2025 around 1 PM she was talking to FAM 2 inside Resident 5 ' s room, when Resident 1 came inside Resident 5 ' s room and grabbed her neck and started choking her without warning. CNA 1 stated the staff came to help, and the police took Resident 1 away on 5/7/2025.
During an interview and record review on 5/20/2025 at 11:40 AM with the Medical Record Director (MRD) and the Director of Nurses (DON), Resident 1 ' s Electronic Health Records (EHR) dated 5/8/2025 (Resident 1 ' s admission date) until 5/20/2025 were reviewed. The EHR indicated the facility did not have an active care plan developed for Resident 1 ' s behavior or a behavior monitoring for Resident 1 ' s history of aggressive behavior/s, history of violence nor specific interventions for managing Resident 1 ' s behavior and protecting others against Resident 1 ' s aggressive/violent behaviors. During the concurrent record review, Resident 1 ' s IDT (Interdisciplinary Team - a group of professionals from different fields who work together to provide comprehensive care for a patient or resident) notes dated 5/9/2025 (day after readmission) did not indicate Resident 1 ' s aggressive behavior, history of violence nor specific plan for facility staff to manage/address Resident 1 ' s behavior was discussed during the IDT meeting. The MRD stated, Resident 1 should have a current/active care plan that addressed Resident 1 ' s behavior history with this current facility readmission. The MRD stated the previous care plans prior to the readmission cannot be used. The DON stated, Resident 1 ' s active care plans should include behavior monitoring and specific interventions regarding the resident ' s aggressive
behavior and history of violence, The DON stated the IDT notes did not indicate Resident 1 ' s aggressive behavior nor history of violence was discussed and there was no specific interventions to address Resident 1 ' s behavior history.
During an interview on 5/20/2025 at 1:40 PM with LVN (license Vocational Nurse) 6, LVN 6 stated she started her shift on 5/16/2025 around 3 AM and heard a commotion by the facility lobby. LVN 6 stated she saw Resident 1 yelling while at the facility lobby. LVN 6 stated Resident 1 was holding something but not sure what it was. LVN 6 stated, when she called for help from the other facility staff, Resident 1 started to chase the staff away and so the staff had to ran. LVN 6 stated, Resident 1 went back to his room while his roommate (Resident 12) was inside the same room, sleeping and closed the door.
During an interview on 5/20/2025 at 1:50 PM with RN (Registered Nurse) 5, RN 5 stated on 5/16/2025 around 3AM, she saw Resident 1 come out of his room, went to the facility lobby then looked at RN 5 while Resident 1 was holding a bread knife and made a gesture of slitting his neck. RN 5 stated she felt threatened and scared, and she does not know where Resident 1 got the bread knife. RN 1 stated, when she asked Resident 1 to put the knife down, Resident 1 pointed the knife at her while RN 1 remained about 15 feet away from Resident 1 ' s location. RN 1 stated, she ran away from Resident 1 and called the police, so as the sitter. RN 1 stated, Resident 1 ran back to his room, still holding on to the bread knife, closed the door of the room, while Resident 12 remained inside the same room, sleeping. RN 5 stated, she was not aware Resident 1 did not have a specific care plan for his aggressive behavior and history of violence. RN 5 was asked if the CNAs assigned to provide one to one monitoring to Resident 1 was provided with Resident 1 ' s behavior care plan or how to manage Resident 1 ' s specific behaviors and how to protect others against Resident 1. RN 5 stated, she just instructed the CNAs/sitter to ensure Resident 1 do not hurt himself or others.
During an interview on 5/20/2025 at 3:00 PM with CNA 6, CNA 6 stated, she sometimes works as a sitter for Resident 1. CNA 6 stated the instruction from the licensed nurses and RN supervisors when she was assigned as a sitter for Resident 1 was just to keep Resident 1 safe and does not get into fight with others. CNA 6 there was specific reason and care plan provided to her when she was assigned to supervise Resident 1 one-on-one.
During an interview on 5/20/2025 at 3:10 PM with CNA 7, CNA 7 stated, was assigned as a sitter for Resident 1 before and recalled the RN supervisor ' s instructions were to make sure if Resident 1 gets agitated to make sure he does not hurt himself or other residents. CNA 7 stated, he was not provided a specific plan of care of how to ensure Resident 1 does not hurt others.
During an interview and record review on 5/20/2025 at 3:15 PM with the Director of Social Services (DSS), Resident 1 ' s IDT notes dated 5/9/2025 (day after admission) was reviewed. the DSS stated, she is part of the IDT and the IDT notes did not have documented evidence that Resident 1 ' s specific aggressive behavior and history of violence was discussed, and there was no specific care plan interventions indicated in the IDT notes to prevent potential for abuse or harm to residents or staff.
During an interview on 5/20/2025 at 3:30 PM with CNA 8, CNA 8 stated on 5/16/2025 around 3AM, she saw Resident 1 in the lobby with a bread knife, he was screaming at RN 5, then he ran to his room with the bread knife and close the door, Resident 12 was in there sleeping. CNA 8 stated, everyone felt threatened and scared.
During an interview on 5/20/2025 at 3:55 PM with DON, DON stated, Resident 1 did not have a specific care plan nor intervention for his aggressive behavior and history of violence. DON stated, the care plan Resident 1 had was general and not specific enough. DON stated the IDT notes on 5/9/2025 had no documentation regarding the plan of care for Resident 1 ' s history of violent behavior. DON stated, not having a specific care plan for Resident 1 ' s aggressive behavior and history of violence and not having documentation on the plan of care on the IDT notes upon admission for Resident 1 ' s aggressive behavior and history of violence, had potentially led to an escalation of Resident 1 ' s behavior that could have resulted in abuse to residents and staff.
During a review of the facility ' s policy and procedure (P&P) titled, Abuse Prevention/ Prohibition, revised 11/2018, the P&P indicated; a) the facility does not condone any form of Resident abuse and/or mistreatment and develops a system in order to promote an environment free from abuse and mistreatment, b)Abuse is defined as a willful infliction of injury, involuntary seclusion, intimidation with resulting physical harm pain or mental anguish.
During a review of the facility ' s policy and procedure (P&P) titled, Care Planning – Interdisciplinary Team, revised 3/2022, the P&P indicated; a) the interdisciplinary team is responsible for the development of resident care plans, and b) comprehensive, person centered care plans are based of resident assessments and developed by an IDT.
During a review of the facility ' s policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, revised 3/2022, the P&P indicated; a) A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet resident's physical, psychosocial and functional needs is developed and implemented for each resident, b) The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment, and c) The comprehensive, person-centered care plan includes measurable objectives and timeframes and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.
During a review of the facility ' s policy and procedure (P&P) titled, Behavioral Assessment, Intervention and Monitoring, revised 3/2019, the P&P indicated; a) The interdisciplinary team will thoroughly evaluate new or changing behavioral symptoms in order to identify underlying causes and address any modifiable factors that may have contributed to the resident's change in condition, including: worsening of or complications related to other conditions and emotional, psychiatric and/or psychological stressors. b) Interventions and approaches will be based on a detailed assessment of physical, psychological and behavioral symptoms and their underlying causes, as well as the potential situational and environmental reasons for their behavior. The care plan will include, as a minimum, a description of the behavioral symptoms, including frequency, intensity, duration, outcomes, and precipitating factors or situations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide sufficient nursing staff who have the knowledge, training, and skills sets to address behavioral healthcare needs for one of four sampled residents (Resident 1), who was diagnosed with dementia and assessed at high risk for elopement, in accordance with the resident ' s care plan, the facility ' s policy and procedure on Behavioral Health Services, Dementia Care, and the Facility Assessment.
The facility staff failed to intervene when Resident 1, who was visibly agitated and refused to come back inside the facility upon returning from an out-on-pass with the family [FM 1] on 11/27/2024. Registered Nurse [RN] 1 failed to implement Resident 1 ' s care plan on Behavioral Problem. RN 1 did not address Resident 1 ' s agitated behavior and allowed Resident 1 to wander out of the facility and instructed FM 1 to follow the resident and for FM 1 to call law enforcement.
As a result of this deficient practice Resident 1 could not be found for two and half hours on 11/27/2024. On 11/27/2024, at around 8:10 PM, local law enforcement found Resident 1 and transferred to the general acute care hospital [GACH] and was placed on Welfare and Institutions Code 5150 hold (the code allows an adult who is experiencing a mental health crisis to be involuntarily detained for a 72- hour when evaluated to be a danger to others, or to himself or herself, or gravely disabled).
Findings:
During a review of Resident 1 ' s admission Record indicated the facility admitted Resident 1 on 6/20/2024 with diagnoses that included encephalopathy (a general term for a group of brain disorders or diseases that cause brain dysfunction) and unsteadiness on feet.
During a review of Resident 1 ' s Elopement Risk Assessment (ERA), dated 6/21/2024, indicated Resident 1 had elopement risk total score of 12 which indicated Resident 1 had a history of elopement and was at high risk for elopement. The ERA indicated Resident 1 had wander behavior and wander aimlessly. The potential interventions for elopement indicated frequent monitoring-check every two hours, identification bracelet, and staff aware of resident ' s wander risk.
During a review of Resident 1 ' s Care Plan, dated 6/21/2024, the Care Plan indicated Resident 1 was at risk for elopement and the interventions were to assist in re-orientation to room/facility, monitor resident location with visual check, monitor behavior and mood patterns, anticipate resident needs based upon wandering behavior.
During a review of Resident 1 ' s History and Physical Examination (H&P), dated 6/22/2024, indicated Resident 1 had a diagnosis of dementia (a term used to describe a group of symptoms affecting memory, thinking and social abilities) and Resident 1 does not have the capacity to understand and make decisions.
During a review of Resident 1 ' s Psychiatric Examination, dated 6/27/2024, indicated Resident ' s chief complaint and psychiatric history was anxiety (a feeling of fear, dread, and uneasiness that can be a normal reaction to stress).
During a review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 9/24/2024, indicated Resident 1 required supervision or touching assistance for eating, and partial/moderate assistance with oral hygiene, toileting hygiene, shower/bathe self, and personal hygiene, and chair/bed-to-chair transfer.
During a review of Resident ' s Care Plan, dated 10/8/2024, the Care Plan indicated Resident 1 has a behavior problem and the intervention was to intervene as necessary by approach/speak in a calm manner, divert attention, and remove from situation and take to alternate location as needed.
During a review of Resident 1 ' s Elopement Evaluation (EE), with effective date 11/26/2024 and timed at 12:18 PM, indicated Resident 1 had a history of elopement and was the risk for elopement and she had a pattern of wandering behavior. The EE indicated the intervention included notify staff of wandering and elopement risk and monitor location frequently.
During a review of Resident 1 ' s Change in Condition Evaluation (COC), dated 11/26/24 at 5:09 PM, the COC evaluation indicated Resident 1 attempted to leave the facility on 11/26/2024 [prior to the resident ' s out on pass with the family member on the same day].
During a review of Resident 1 ' s Progress Notes (PN), dated 11/27/2024, was reviewed. The PN indicated the Family Member (FM) took Resident 1 home out on pass on 11/26/2024 at 6 PM [an hour prior to Resident 1 ' s attempt to elope the facility on 11/26/2024 timed at 5:09 PM] and planned to bring Resident 1 back to the facility after the holiday celebration, but Resident 1 was showing aggressive behavior at home. Then, on 11/27/2024 at 6:30 PM, the FM came inside the facility and asked for help because she brought Resident 1 to the outside of the facility but Resident 1 refused to come inside and walked away. The PN indicated FM 1 did not want to force Resident 1 getting inside the facility. The facility staff followed up with the FM over the phone twice and asked about Resident 1 ' s whereabouts, then, the FM stated she did not know where Resident 1 was. The facility staff advised the FM to report to local police. On 11/27/2024 around 9:30 PM, Resident 1 was found by police.
During a review of the Police Report (PR), dated 11/27/2024, the PR indicated that on 11/27/2024, at approximately 8:10 PM assisted with a missing person report. The PR indicated Resident 1 walked away from the facility after she was dropped off by the FM. The PR indicated Resident 1 was located sitting on a bus bench, subsequently. The PR indicated that based on Resident 1 ' s conflicting statements and wanting to wander the streets of another city, Resident 1 was transported to the GACH and was placed on Welfare and Institutions Code 5150 hold by the GACH. The PR indicated Resident 1 was gravely disabled and a danger to herself.
During a review of Resident 1 ' s Order Summary Report, for December 2024, the Order Summary Report indicated physician order dated 6/21/2024, to monitor the resident ' s whereabouts every two hours, visual check due to high risk for elopement. The Order Summary Report also indicated another physician order dated 11/26/204, that Resident 1 may go out on pass with the FM for 48 hours.
During an interview on 12/3/2024 at 10:53 AM, with Certified Nursing Assistant (CNA) 1, CNA 1 stated she was assigned to take care of Resident 1 regularly in the morning shift and she was familiar with Resident 1 ' s care. CNA 1 stated Resident 1 was confused, and she would get mad sometimes by yelling and screaming at the staff. CNA 1 stated she was not aware that Resident 1 was on the watch for elopement risk before the incident on 11/27/2024.
During an interview on 12/3/2024 at 11:15 AM, with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 1 was delusional sometimes and she could be aggressive sometimes by yelling and screaming at the staff. LVN 1 stated the facility identified Resident 1 was at risk for elopement before [could not recall date]. LVN 1 stated Resident 1 tried to go out the facility without the staff ' s supervision two times before [unable to recall dates], but the facility staff caught the resident before she could go out the facility.
During an interview on 12/3/2024 at 11:30 AM, with the Director of Nursing (DON), the DON stated the receptionist reported to her that Resident 1 was holding a bag and had the tendency of going out the facility on 11/26/2024 [prior to leaving out on pass with the FM], so the facility notified Resident 1 ' s physician and obtained an order to put a wander guard on the resident, and completed the COC. The DON stated Resident 1 was often out on pass with the family members and returns to the facility on the same day without any issue in the past. The DON stated Resident 1 did not have any history of an actual elopement from the facility, so the FM ' s request to take Resident 1 home for 48 hours for the holiday was approved even though it was the first time for Resident 1 to be out of the facility overnight. The DON stated the FM took Resident 1 home out on pass for 48 hours on 11/26/24 at 6 PM, but the FM decided to bring Resident 1 back to the facility on [DATE], because Resident 1 was showing aggressive behavior, and she could not control the resident at home. The DON stated the FM informed the staff that Resident 1 did not want to come inside the facility and Registered Nurse (RN) 1 offered that the staff could grab Resident 1 and bring the resident inside, but the FM did not want to forcefully bring Resident 1 back to the facility. The DON stated since the FM refused the staff ' s help at that time [on 11/27/24] and allowed Resident 1 kept walking away, the facility had to respect the FM ' s choice and followed up with the FM by phone to check the whereabouts of Resident 1. The DON stated the facility did not send a staff to follow Resident 1 because the staff could not follow Resident 1 wherever she was going to walk to. The DON stated when RN 1 knew about Resident 1 was missing, the facility did not report to the police, instead, RN 1 advised the FM to report to the police to find Resident 1.
During a telephone interview on 12/3/2024 at 12:52 PM, with RN 1, RN 1 stated on 11/27/2024 at 6:30 PM, the FM came inside the facility and said she brought Resident 1 back to the facility. The FM stated Resident 1 was still outside the facility, because the resident refused to come back inside the facility and walking away. RN 1 stated the FM said Resident 1 was acting out at home and yelling at the FM, and she could not control Resident 1 at home. RN 1 stated she did not see Resident 1 outside the facility lobby at that time. RN 1 stated she asked the FM if it was ok for the staff to grab Resident 1 and bring her in, but the FM did not want to force Resident 1 to go inside and wanted Resident 1 to be willing to go back to the facility. RN 1 stated she offered help, but the FM refused at that time. RN 1 stated she did not send any facility staff outside to check on Resident 1 because if Resident 1 would not listen to the FM, then, she would not listen to a facility staff who the resident was not familiar with. RN 1 stated she told the FM to follow Resident 1 and kept a visual on her, then, she called twice to follow up with the FM regarding the whereabouts of Resident 1. RN 1 stated 20 minutes later, she saw the FM was sitting in the car outside of the facility, and the FM said she did not know where Resident 1 was. RN 1 stated she advised the FM to report to the police. RN 1 stated Resident 1 was found around 9:30 PM. RN 1 stated Resident 1 was out on pass, the FM was responsible for the resident. RN 1 stated the facility would be responsible for Resident 1 until she was checked in back to the facility. RN 1 stated she was not sure or aware if Resident 1 was at risk for elopement.
During a telephone interview on 12/3/2024 at 2:36 PM, with the FM, the FM stated on 11/27/2024 morning, Resident 1 was getting more difficult and agitated as the day progressed and she could not control Resident 1 at home anymore, so she decided to bring Resident 1 back to the facility. The FM stated Resident 1 had dementia and was showing the symptoms of early stage of dementia, but the aggressive behavior at home was new to her and she did not know how to handle Resident 1 safety at home. The FM stated she drove Resident 1 to the facility, but when Resident 1 was 10 feet away from the facility ' s lobby door, Resident refused to go inside and started to walk away. The FM stated she tried to convinced Resident 1 but Resident 1 just kept walking further away. The FM stated she did not know what to do and went inside the facility to ask for help. The FM stated she could not get help from the facility staff at the front lobby until RN 1 came out and talked to her. The FM stated RN 1 asked if she agreed to have the staff to grab Resident 1, and she replied she did not want to force Resident 1 back to the facility and she did not know what to do. The FM stated RN 1 told her to follow Resident 1 and keep an eye on the resident. The FM stated she tried to follow Resident 1, but when Resident 1 saw her, Resident 1 turned around and walked away from her, so she decided to wait in the car, in hoping that Resident 1 would return on her own if Resident 1 did not see her following, but she did not see Resident 1 walked back to the facility. The FM stated when she told RN 1 that she did not know where Resident 1 was, RN 1 told her that she had to call the police herself. The FM stated she went inside the facility to ask for help because she did not know what to do when Resident 1 refused to go inside the facility and walked away. The FM stated she thought the facility staff would send someone outside to talk to Resident 1 and bring her in the facility calmly, but the facility did not send anyone outside to check on Resident 1. The FM stated she felt helpless at that time because she did not have the professional knowledge of dealing with a situation like this and she expected the facility staff to provide professional assistance to address Resident 1 ' s behavior and ensure the resident safety.
During an interview on 12/3/2024 at 3:55 PM, with the DON, the DON stated the facility had the responsibility for Resident 1 ' s safety when the resident was outside the facility. The DON stated Resident 1 had a diagnosis of dementia and was showing signs and symptoms of distress when the FM tried to bring Resident 1 back to the facility. The DON stated the staff should addressed Resident 1 ' s distress and provide professional assistance to check on Resident 1 right away, bring her back to the facility, and call the police as needed to ensure the resident ' s safety.
During an interview on 12/10/2024, at 3 PM, the DON stated as this time, the staff would receive dementia care training upon hire and regular dementia care in-service during facility huddle and daily rounding. The DON stated the facility did not have a competency checklist for each staff about dementia care. The DON stated dementia care was not included in the staff annual competency evaluation. The DON stated there were 14 residents residing at the facility assessed at risk for elopement.
During a review of the facility ' s Policy and Procedures (P&P), Behavioral Health Services, dated 2/2019, indicated Residents who exhibit signs of emotional/psychosocial distress receive services and support that address their individual needs and goals for care. The P&P indicated Staff must promote dignity, autonomy .and safety as appropriate for each resident and are trained in ways to support residents in distress.
During a review of the facility ' s Hand in Hand Dementia Training Acknowledgement, dated 4/23/2024, indicated Registered Nurse (RN) 1 certified that she was able to effectively listen and speak with a person with dementia and understand the actions and reactions of persons with dementia as forms of communication.
During a review of the facility ' s Facility Assessment (FA), dated 7/1/2024 to 9/1/2024, The FA indicated the facility would address the diagnosis and condition of dementia and would provide training in non-pharmacological interventions, dementia care, change of condition, baseline and care plan content and resident rights. The FA also indicated the facility would provide dementia training twice per year.

Based on observation, interview and record review, the facility failed to provide adequate monitoring and supervision to ensure one of two sampled resident (Resident 1), who had severely impaired cognition and memory and was assessed at risk for elopement with diagnoses of dementia (a term used to describe a group of symptoms affecting memory, thinking and social abilities) did not elope from the facility on 11/14/2024.
The deficient practice had resulted in Resident 1 eloping from the facility on 11/14/2024. As of 11/15/2024, Resident 1 had not been found by the facility staff. Resident 1 had the potential for fall and injury from being struck by motor vehicles. Resident 1 also had the potential to be exposed to extreme weather and malnutrition (lack of proper nutrition.
Findings:
During a review of Resident 1 ' s admission Record indicated the facility admitted Resident 1 on 10/23/2024 with diagnoses that included dementia and heart failure (a condition that the heart isn ' t pumping as well as it should).
During a review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 11/4/2024, indicated Resident 1 had severely impaired cognition (ability to think and reason) and memory. The MDS indicated Resident 1 required supervision or touching assistance for eating, chair/bed-to-chair transfer, walk 50 feet with two turns and walking 10 feet on uneven surfaces, and partial/moderate assistance with oral hygiene, toileting hygiene, shower/bathe self, and personal hygiene. The MDS also indicated Resident 1 had wander/elopement alarm.
During a review of Resident 1 ' s Elopement Evaluation, dated 10/30/2024, indicated Resident 1 was at high risk for elopement. The Elopement Evaluation indicated Resident 1 had a history of elopement or attempted leaving the facility without informing staff; Resident 1 verbally expressed the desire to go home, packed belongings o go home or stayed near an exit door; Resident 1 wanders; Resident 1 ' s wandering behavior is a pattern, goal-directed with specific destination in mind; Resident 1 ' s wandering behavior likely to affect the safety or well-being of self/others; and Resident 1 has been recently admitted and is not accepting the situation.
During a review of Resident 1 ' s Order Summary Report, dated 10/31/2024, indicated the physician order Resident 1 may have wander guard due to elopement risk score at six (high risk), starting on 10/30/2024.
During a review of Resident 1 ' s Care Plan, dated 10/30/2024, the Care Plan indicated the goal was the resident will not leave facility unattended and the resident ' s safety will be maintained. The Care Plan indicated to identify if there is a certain time of day wandering/elopement attempts occur.
During a review of Resident ' s with Wanderguard, dated 11/11/2024, indicated Resident 1 was on the list of Resident ' s with Wanderguard.
During a review of the Facility ' s Elopement Binder, Resident 1 ' s picture and information were in the Elopement Binder.
During an interview on 11/15/2024 at 11:52 AM, with the Licensed Vocational Nurse (LVN), the LVN stated Resident 1 always asked if he lived in the facility and he remembered the place where he used to live. The LVN stated Resident 1 was high risk for elopement and they put a wander guard on his wrist, and she checked his wander guard around 6:50 AM on 11/14/2024 which was working. The LVN stated the last time she saw Resident 1 was between 12 PM and 12:15 PM when she was passing medications to other residents. The LVN stated Resident 1 walked passing the medication cart and got some juice from her. The LVN stated it was between 12:50 PM and 1 PM, the Treatment Nurse (TXN) came to the nursing station and asking if someone saw Resident 1, then, everyone started to look for him and Code 10 (a code activated when a patient is missing) was called.
During an interview on 11/15/2024 at 12:24 PM, with the Receptionist, the Receptionist stated his responsibility was stay at the front desk in the lobby to monitor the residents in the lobby. The Receptionist stated Resident 1 hangs out in the lobby and the activity room which the door was facing the lobby, and Resident 1 has said he wanted to leave the facility. The receptionist stated Resident 1 always held a plastic bag packed with his belongs and trying to go out. The Receptionist stated he reported Resident1 ' s behavior to the nurses, and they put a wander guard on his wrist. The Receptionist stated it was around 12:30 PM on 11/14/2024, he needed to use the restroom, then, he checked with an activity staff who was supervising the dining room during lunch time and the nursing supervisor at the nursing station who was assisting a resident, but they were busy at that time, so he decided to leave his post and go to the restroom without making sure someone was monitoring the lobby. The receptionist stated he saw Resident 1 sitting inside the activity room, holding his plastic bag, and looking outside before he left his post. The Receptionist stated he returned to his post 40 seconds later and the wander guard alarm by the lobby entrance was not beeping and he did not notice Resident 1 had eloped. The Receptionist stated he was unsure if Resident 1 was wearing the wander guard. The Receptionist stated the facility did not pre-assign other staff to cover his post when he was on break, and he could not find coverage for his break sometimes because everyone was busy with their own work. The Receptionist stated he should find someone to monitor the lobby before he left his post yesterday to prevent Resident 1 from leaving the facility without supervision.
During a concurrent observation and interview on 11/15/2024 at 1:45 PM, with the Administration (ADM), the facility ' s video footage of the surveillance camera at the lobby was reviewed. The ADM stated the Receptionist left his post and disappeared from the footage at 12:31:07 PM on 11/14/2024, shortly after, Resident 1, who was holding a plastic bag came out from the activity room, walked towards the entrance door, and left the facility at 12:31:23 PM on 11/14/2024 without staff ' s supervision. The ADM stated the Receptionist returned his post at 12:32:15 PM on 11/14/2024. The ADM stated there was no staff monitoring the lobby area during the time Resident 1 eloped and there should be a staff at the front desk to always monitor the lobby.
During an interview on 11/15/2024 at 1:55 PM, with Resident 2, Resident 2 stated Resident 1 always said that he did not like here and he wanted to leave. Resident 2 stated he was looking for Resident 1 before lunch and he could not find him yesterday.
During an interview on 11/15/2024 at 2 PM, with the Acting Director of Nursing (ADON), the ADON stated the Receptionist was supposed to find coverage before he left the post to ensure resident ' s safety and she did not why the Receptionist did not ask someone to cover him.
During an interview on 11/15/2024 at 2:46 PM, with the Director of Nursing (DON), the DON stated Resident 1 ' s elopement on 11/14/2024 was because the Receptionist left his post without making sure someone was monitoring the lobby area. The DON stated the receptionist must find someone to cover the post and have staff available to help with coverage to ensure residents ' safety. The DON stated the facility did not provide adequate supervision to ensure Resident 1 ' s safety and Resident 1 was still not found at this time.
During a follow up telephone interview on 11/26/2024 at 2:08 PM, with the ADM, the ADM stated the police informed him that Resident 1 was located and placed under police custody. The ADM stated the police informed him it was not clear if Resident 1 would return to the facility at this time.
During a review of the facility ' s policy and procedure (P&P) titled, Receptionist, dated 10/2003, indicated the receptionist promotes a safe environment for residents, visitors, and staff at all times.
During a review of the facility ' s P&P titled, Safety and Supervision of Residents, dated 7/2017, indicated Resident supervision is a core component of the systems approach to safety.
During a review of the facility ' s P&P titled, Nursing-Wandering and Elopement, dated 6/2018, indicated the facility to enhance the safety of the residents, reinforce proper procedures for leaving the facility for residents assessed to be at risk for elopement, and provide extra monitoring on the residents ' whereabouts.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide the resident with access to personal and medical records pertaining to him or herself, upon an oral or written request, in the form and format requested by one of two sampled residents (Resident 1), or in a readable hard copy form or such other form and format as agreed to by the facility and the resident, within 24 hours (excluding weekends and holidays), in accordance with the facility ' s Policy and procedure [P&P] titled Resident Rights and Release of Information.
This deficient practice violated the rights of Resident 1 to access personal and medical records pertaining to him or herself.
Findings:
A review of Resident 1 ' s the admission Record indicated Resident 1 was admitted to the facility on [DATE], with a primary diagnosis of polyneuropathies (disease affecting nerves).
A review of Resident 1 ' s History and Physical dated 7/27/2024, indicated Resident 1 had capacity to understand and make decisions.
A review of Resident 1 ' s Minimum Data set (MDS- a federally mandated resident assessment tool) dated 8/9/2024, indicated resident 1 has moderate cognitive impairment (may need extra assistance with daily activities).
During an interview on 10/10/2024 at 10:02AM with Resident 1, Resident 1 stated that she initially requested a copy of her medical records in August 2024 and had a discussion with the Administrator (ADM) regarding the process of requesting medical records. Resident 1 stated she had made multiple attempts to obtain her medical records from the facility but had not yet received the medical release form to obtain copies of her medical records.
During an interview on 10/10/2024 at 10:34 AM with the Administrator (ADM), the ADM stated he recalled Resident 1 requesting her medical records and had instructed Medical Records [MR] Staff to provide Resident 1 with the medical records release form. The ADM explained that after the request to medical records department was made, he did not follow up with Medical Records staff anymore to ensure Resident 1 received a copy of her records. The ADM stated it is important to allow residents to access to their personal medical records because it is their right as a resident.
During an interview on 10/10/2024 at 10:35 AM with Medical Records [MR] Staff, MR Staff stated she had received a text message from the ADM indicating that Resident 1 was requesting her medical records and required a release form to proceed. MR Staff stated that when she approached Resident 1 [unable to provide a date] to provide the medical release form, Resident 1 no longer wished to receive her medical records. MR Staff stated she did not document Resident 1 ' s wishes not to pursue receiving a copy of her medical records.
During an interview on 10/10/2024 at 10:51 AM with Resident 1, Resident 1 stated that MR Staff never offered her the opportunity to fill out a medical release form and denied ever having refused or changed her mind in regard to wishing to receive a copy of her medical records.
A review of the facility ' s policy and procedure (P&P) titled, Resident Rights, revision date of December 2016, the P&P indicated, Federal and state laws guarantee certain basic rights to all residents of the facility. These rights include the resident ' s right to access personal and medical records pertaining to him or herself.
A review of the Facility ' s policy and procedure (P&P) titled, Release of Information ' , revision date of November 2009, the P&P indicated, the resident may have access to his or her records within 5 days (excluding weekends or holidays) of the resident ' s written or oral request.

Based on interview, observation and record review, the facility failed to ensure the facility ' s recent (last survey was on 10/5/2023) survey binder with past survey result (outcome of the survey that were conducted to protect residents and to ensure that all residents receive the quality of care) were accessible and available for all the residents, including Resident 27, 102 and 106 who attended the facility ' s resident council meeting on 10/2/2024.
This deficient practice had the potential for the residents and their legal representatives to not fully informed of the facility's deficient practices and how they were corrected.
Findings:
During a review of Resident 27's admission Record indicated the facility admitted Resident 27 on 5/7/2024 with diagnoses that included diabetes mellitus (a group of diseases that result in too much sugar in the blood), malnutrition (inadequate intake of food as a source of protein, calories, and other essential nutrients), and lack of coordination.
During a review of Resident 27 ' s Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 8/9/2024, indicated Resident 27 was cognitively intact, had capacity to understand and make decisions.
During a review of Resident 102's admission Record indicated the facility admitted Resident 27 on 8/28/2024 with diagnoses that included malnutrition, hypertension (high blood pressure), and lack of coordination.
During a review of Resident 102 ' s MDS, dated 9/3/24, indicated Resident 102 was cognitively intact, had capacity to understand and make decisions.
During a review of Resident 106's admission Record indicated the facility admitted Resident 106 on 9/13/2024 with diagnoses that included lack of coordination, pain in right foot, and depression (mood disorder that causes a persistent feeling of sadness and loss of interest in life).
During a review of Resident 106 ' s MDS, dated 9/17/24, indicated Resident 106 was cognitively intact, had capacity to understand and make decisions.
During the facility ' s resident council meeting interview on 10/2/2024 at 10:55 AM with ten residents included Resident 27, Resident 102, and Resident 106, stated they were not aware of the availability and location of the survey report and how the facility corrected the deficiencies that were identified in the past survey. The residents stated they would like to know the facility's latest survey inspection results and the corrections that the facility put into place.
During a concurrent interview and observation on 10/2/2024 at 11:02 AM with the Director of Nurses (DON), the DON stated, the facility had a binder which content all past survey results. The DON stated, they have a designated table in the entrance area where they usually left the binder in the drawers. The DON was observed opening the designated table ' s drawers and could not find the survey binder. The DON stated, she could not locate the survey binder and would ask Medical Record (MR) where survey binder went.
During an interview on 10/2/2024 at 11:34 AM with the facility ' s MR, the MR stated, she took the survey binder to her office the day before and did not bring it back.
During an interview on 10/4/2024 at 1:22 PM with the DON, the DON stated, the survey binder should be accessible to the residents and visitors, because they had the right to know what was going on with the facility. The DON stated, if the binder was not available, the residents and their representatives could be frustrated not able to know the past deficiencies and how the facility corrected them. The DON stated, the residents and their representatives had the right to know facility ' s past deficient practices and how they were corrected.
During a review of the facility ' s policy and procedure (P&P) titled, Resident Rights, revised February 2021, the P&P indicated, Federal and state laws guarantee certain basic rights to all residents of this facility, these rights include the resident ' s right to examine survey results.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents provide necessary care and services for skin breakdown and pressure injuries (localized damage to the skin and underlying soft tissue, usually occurring over a bony prominence or related to medical devices) to prevent skin breakdown for one of three sampled residents (Resident 4) by failing to ensure Resident 4 who uses a low air loss mattress (LAL Mattress -air filled mattress used to relieve pressure) was set according to resident's weight.
As a result of this deficient practice placed Resident 4 at additional risk for developing pressure injuries.
Findings:
During a review of Resident 4's admission Record (Face Sheet), dated 9/12/2023, the face sheet indicated the facility admitted Resident 4 on 9/12/2023, and readmitted on [DATE] with diagnoses including Chronic Obstructive Pulmonary disease (COPD - lung disease which makes breathing difficult), muscle weakness and generalized osteoarthritis ( degenerative joint disease, in which the tissues in the joint break down over time).
During a review of Resident 4's Minimum Data Set (MDS-a federally mandated resident assessment tool.), dated 6/4/2024, indicated has severe cognitive impairment (the ability to think and process information). The MDS indicated the resident is totally dependent on staff for dressing, toilet use, personal hygiene, and bathing.
During a review of Resident 4's History and Physical (H&P), dated 6/24/2024, indicated, Resident 4 had the mental capacity to make medical decisions.
During a review of Resident 4's Order Summary Report, dated 8/2/2024 indicated to provide a low air loss mattress (LAL Mattress) to Resident 4 for wound management set mode for alternating and settings base on comfort and/or comfort and/or weight of the resident check setting and functionality every shift.
During a review of Resident 4's Weight Summary, dated 9/6/2024, indicated Resident 4' s weight 204 pounds (lbs.-unit of measurement).
During an observation on 10/2/2024 at 12:24 PM, Resident 4 was observed with a LAL Mattress was set for a person weighing 550 lbs.
During a concurrent interview and record review on 10/2/2024 AM 2:20 PM with Treatment Nurse (TN) 1, Resident 4's Weight Summary, dated 9/6/2024 was reviewed. The Weight Summary indicated Resident 4 weight was 204 lbs. TN1 stated the LAL Mattress getting goes by weight and Resident 4's LAL Mattress was not set correctly. TN 1 stated the LAL Mattress setting for Resident 4 should be at 250 since Resident 4's weigh is 204 lbs. TN 1 stated incorrect settings of LAL mattress places the resident at higher risk for further skin breakdown. TN 1 stated that setting the LAL Mattress was set at a weight higher than Resident 4's actual weight makes the mattress too hard which prevents the wounds from healing, therefore there was a potential to cause harm, when setting of LAL Mattress were incorrectly set.
A review of manufacturer's recommendation of Low Air Loss Mattress Owner's Manual, (undated), indicated, The Med Aire Edge Mattress Replacement System is a high-quality powered air support surface that is specifically designed for the prevention and treatment of pressure injuries while optimizing patient comfort. The owner ' s manual also indicated This digital control unit includes intuitive controls for adjusting the air pressure based on the patient ' s weight and comfort levels. Weight settings range from =250-1,000 lbs and can be used to adjust the pressure of the inflated cells based on the patient ' s weight and comfort level.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide appropriate device and appropriate rehabilitation services (assessment and evaluation of the residents to determine exercises or devices needed to improve or maintain mobility) to maintain or improve mobility for one of two sampled residents (Resident 58). with limited mobility and contractures (a permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff) on both arms was observed with towel between the arms.
This failure practice had a potential to result in Resident 58's worsened elbow contractures that could lead to pain, discomfort and high risk for fractures (broken bones).
Findings:
During a review of Resident 58's admission Record indicated the facility initially admitted Resident 58 on 4/27/2021 and readmitted on [DATE] with diagnoses that included dementia (a progressive state of decline in mental abilities), schizophrenia (a mental illness that is characterized by disturbances in thought), and anxiety disorder (a group of mental disorders characterized by significant feelings of fear that affect with daily activities).
During a review of Resident 58 ' s Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 8/9/2024, indicated Resident 58 ' s cognition (a term for the mental processes that take place in the brain, including thinking, attention, language, learning, memory, and perception) was severely impaired, and was dependent (helper does all of the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity) in roll left and right, sit to lying, lying to sitting on side of bed, sit to stand.
During a review of Resident 58 ' s History and Physical, dated 1/13/2024, indicated Resident 58 was bed bound (confined to bed due to illness/weakness), his arms were contracted, and he did not have the capacity to understand and make decisions.
During a review of Resident 58 ' s care plan (a document that outlines the facility ' s plan to provide personalized care to a resident based on the resident ' s needs), dated 4/11/2024, indicated Resident 58 had limitation noted to shoulders, elbows and fingers, with the goal of minimizing the risk of further loss of ROM daily, and the interventions included to position resident to prevent further contractures with pillow or splints as needed.
During an observation on 10/1/2024 at 12:05 PM in Resident 58 ' s room, Resident 58 was lying in bed, left and right arms were bent at the elbow with stiffness and contracted. Four rolled towels were observed in the elbow between the bent contracted arms.
During a concurrent observation and interview on 10/3/2024 at 2:23 PM with Certified Nurse Assistant (CNA) 8 in Resident 58 ' s room, CNA 8 was placing one rolled towel in each of Resident 58 ' s contracted arm. CNA 8 stated, Resident 58 ' s arms had been severely contracted since admission to the facility and she usually place rolled towels between his upper and lower arms to help his arms to relax, prevent further contractures and pain if any.
During an interview on 10/3/2024 at 2:28 PM with Physical Therapist (PT) 1, PT 1 stated. The facility usually utilizes a splint to prevent the resident ' s further contractures. PT 1 stated, she would not recommend using a rolled towel to help prevent further contractures because it could fall off and will not be effective.
During a concurrent interview and observation on 10/3/2024 at 2:48 PM with Rehabilitation Director (RHD), RHD was able to flex Resident 58's arms to 45 degrees (unit of angle). RHD stated, the facility always utilizes a splint for residents with contracted arms who could flex more than 30 degree and based on her assessment, Resident 58 should already have a splint to prevent further contractures. RHD stated, rolled towels are not a standard of practice to use in preventing resident ' s worsen contractures because it ' s not therapeutic. RHD stated, he was not referred to Rehabilitation since 8/13/2021 for both arms with contractures to determine the device to use to prevent further decline. RHD stated, she would readmit Resident 58 to Rehabilitation for reassessment and evaluation.
During an interview on 10/4/2024 at 1:07 PM with the Director of Nurses (DON), the DON stated, the towels should not be used to prevent worsen arms and elbow contractures because they are too soft and not able to prevent any contracture. The DON stated, the resident should have been reevaluated. The DON stated, not using a proper device such as a splint, the resident is at risk for further arms and elbow contracture.
During a review of the facility ' s policy and procedure (P&P) titled, Resident Mobility and Range of Motion, dated July 2017, indicated: Residents with limited ROM will receive treatment and services to increase and/or prevent a further decrease in ROM. Residents with limited mobility will receive appropriate services, equipment and assistance to maintain or improve mobility unless reduction in mobility is unavoidable.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During a review of Resident 63's admission Record (Face Sheet), dated 2/18/2022, the face sheet indicated the facility admitted Resident 63 on 2/18/2022, and readmitted on [DATE] with diagnoses including Chronic Obstructive Pulmonary disease (COPD - lung disease which makes breathing difficult), and bronchiectasis (a condition where your airways widen or develop pouches).
During a review of Resident 63's History and Physical (H&P), dated 3/3/2024, indicated, Resident 63 had the mental capacity to make medical decisions.
During a review of Resident 63's Smoker's Risk Assessment, dated 7/21/2024, indicated Resident 63 was an independent smoker (no supervision needed).
During a review of Resident 63's Order Summary Report, dated 10/2/2024, the Order Summary Report indicated a physician order on 3/3/2024, ordered Resident 63 to receive oxygen at two (2) liters per minute (L/min) via nasal cannula (device use for delivery of oxygen) to maintain oxygen saturation (amount of oxygen carried in blood) at 92% (normal range 90-100%).
During a review of Resident 63's Minimum Data Set (MDS-a federally mandated resident assessment tool.), dated 8/15/2024, indicated the cognitive (the ability to think and process information) skills for daily decisions making was intact, and independent for activities of daily living.
During a concurrent observation and interview on 10/2/2024 at 11:30 a.m., Resident 63 was observed sitting at the edge of his bed in his room. Oxygen machine was observed in resident ' s room. A white grocery bag with a bag of tobacco a pipe at the resident ' s bedside. Resident 63 stated he makes his own cigarettes. Resident 63 stated the bag with tobacco pipe was bought by his family.
During an interview on 10/2/2024 at 9:05 a.m. with the Social Worker Designee (SSD) stated the resident was not allowed to have tobacco in his room. The SSD stated Resident 63 was non-compliant and had one bag of tobacco confiscated (taken away) previously. SSD stated she does not know how the Resident 63 was obtained to obtain the bag of tobacco.
During a concurrent observation and interview on 10/3/2024 at 9:30 a.m., with the Registered Nurse Supervisor 4 (RN 4), the RN4 confirmed that the resident had the bag of tobacco in his room, and he should not have tobacco inn his room because he has oxygen in his room. The RN 4 stated the bag will be confiscated.
During an interview on 10/4/2024 at 3:15 p.m. with the Director of Nursing (DON), DON stated it was not safe for Resident 63 to have tobacco in his room, We do not allow anyone to have cigarettes in the room. We inform the family as well that residents are not allowed to have cigarettes in their possession because the cigarettes need to be given to the activities staff. DON stated it is against the facility's policy for the resident to keep smoking materials in the room. The DON stated residents should not keep lighters or smoking materials with them or at the bedside due to safety reasons.
During a review of the facility ' s policy and procedure (P&P) titled, Smoking by Resident, released 9/2018, P&P indicated, Use of Oxygen of Oxygen in prohibited in Smoking areas. Residents who smoke and are on oxygen may not be allowed to retain smoking materials in the room and/or in their possession and smoking shall be prohibited in any room or other locations in the facility where combustible gases or oxygen is used or stored in other hazardous locations.
Based on observation, interview and record review, the facility failed to provide a safe and hazard free environment to two of three sampled residents (Resident 87 and 63) by failing to ensure:
1. Resident 87's bed alarm (a device used to monitor a patient's movements in bed) was monitored and in functioning condition.
This deficient practice placed Resident 87 at risk for falls or accidents when Resident 87 was getting out of bed without supervision.
2. Resident 63 who was a smoker and receives oxygen therapy via nasal cannula tubing (a device used to deliver supplemental oxygen placed directly on a resident's nostrils) retained bag of tobacco at the bedside.
As a result of this deficient practice, the potential for an accidental fire in the facility and can lead to injury to the residents and other people in the facility.
Findings:
During a review of Resident 87's admission Record indicated the facility originally admitted Resident 87 on 9/15/23 and readmitted on [DATE] with diagnoses that include dementia (a group of thinking and social symptoms that interferes with daily functioning) and muscle weakness.
During a review of a Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 9/16/24, indicated Resident 87 had severely impaired cognitive (ability to understand and make decisions) skills for daily decision making. The MDS indicated Resident 87 required partial/moderate assistance with eating, oral hygiene, toilet hygiene, shower/bathe self, personal hygiene, chair/bed-to-chair transfer and sit to stand.
During a review of Resident 87's Order Summary Report (OSR), dated 9/30/24, the OSR indicated a physician order to apply bed alarm: monitor placement every shift for fall prevention to alert staff to respond quickly and assist residents.
During an observation on 10/1/24 at 9:29 AM, Resident 87 was lying on her bed awake, but she did not have eye contact and did not respond to the surveyor. A bed alarm monitor was observed hanging on the right bed siderail (barriers attached to the side of a bed to prevent falls and provide support) of Resident 87 ' s bed. Resident 87 ' s bed pad sensor (connects wirelessly with a handheld monitor and the alarm will sound when weight is removed from the pad) was observed not connected to the bed alarm monitor, and the light on the bed alarm monitor was off.
During a concurrent observation and interview on 10/1/24 at 9:38 AM, with Certified Nursing Assistant (CNA) 6, Resident 87 ' s bed alarm monitor was observed. CNA 6 stated the bed alarm was not in a working condition because the bed pad sensor connector was unplugged from the bed alarm monitor and there was no green light flash on the bed alarm monitor to indicate the bed alarm was functioning. CNA 6 stated Resident 87 was confused and attempted to get out of bed without assistance. CNA 6 stated if the bed alarm was not working properly, Resident 87 was at risk for falls.
During an interview on 10/1/24 at 9:47 AM, with CNA 7, CNA 7 stated checking on Resident 87 around 7:10 AM and 7:20 AM this morning. CNA 7 stated she did not pay attention to Resident 87 ' s bed alarm because she was too busy to care for other residents. CNA 7 stated she did not know for how long Resident 87 ' s bed alarm was not on and functioning. CNA 7 stated she should check the bed alarm to ensure it was working properly to prevent fall and injury to the resident.
During an interview on 10/2/24 at 3:10 PM, with the Director of Nursing (DON), the DON stated facility staff should check residents ' bed alarms to make sure they were in working condition so that when the residents were attempting to get out of the bed, the staff could respond quickly to prevent fall and accident to the residents.
During a review of the facility ' s policy and procedure (P&P) titled, Protekt Ultimate Alarm, dated 2024, the P&P indicated Top mounted flashing lights helps to verify that the monitor is armed (slow green flash) .
During a review of the facility ' s policy and procedure (P&P) titled, Fall Risk Assessment, dated 3/2018, the P&P indicated to identify and address fall risk factors and interventions to minimize the consequences of fall risk factors.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents who needs respiratory care were provided such care, consistent with professional standards of practice, care plan goals, and facility's policy and procedure for four of four sampled residents (Resident 258, 63, 26 and 55) by failing to ensure:
1. Resident 258, 63 who uses and was receiving oxygen in the room had an oxygen in use warning sign was posted on the resident's doorway.
2. Resident 258 does not receive oxygen therapy since 9/16/2024 without a physician ' s order.
3. Resident 26 and Resident 55 nebulizers (a small machine that turns liquid medicine into a mist that can be easily inhaled) were stored in a sanitary manner and changed according to facility's policy and procedure.
These deficient practices had the potential to cause a fire at the resident(s) in the facility that resulting in injuries and death. In addition, for Resident 258 could receive excessive oxygen that could result in oxygen toxicity (develop toxins in the body and result in lung damage due breathing in too much oxygen), and for Residents 26 and 55 had the potential for the transmission of bacteria and the risk for respiratory infection (any infectious disease of the parts of the body involved in breathing).
Findings:
1. During a review of Resident 26's admission Record indicated the facility initially admitted Resident 26 on 1/31/23 and readmitted on [DATE] with diagnoses that include respiratory failure (a serious condition that makes it difficult to breathe on your own) and dementia (a group of thinking and social symptoms that interferes with daily functioning).
During a review of a Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 9/10/24, indicated Resident 26 had severely impaired cognitive (ability to understand and make decisions) skills for daily decision making. The MDS indicated Resident 26 required supervision or touching assistance with eating, and required partial/moderate assistance with oral hygiene, toilet hygiene, shower/bathe self, chair/bed-to-chair transfer.
During a review of Resident 26 ' s Order Summary Report (OSR), dated 9/30/24, the OSR indicated the physician ordered to administer albuterol sulfate (a medication is used to prevent and treat wheezing, difficulty breathing, chest tightness, and coughing) inhalation nebulizer solution (2.5 milligram [MG, unit of measurement]/3 milliliter (ML, unit of measurement]) 0.083 % [percent]) six ML inhale orally via nebulizer every four hours for shortness of breath and wheezing while awake, started on 9/6/24.
During a review of Resident 26 ' s Medication Administration Record (MAR), dated 9/1/24 to 9/30/24 and 10/1/24 to 10/31/24, the MAR indicated Resident 26 received Albuterol sulfate inhalation nebulizer solution inhale orally via nebulizer every four hours from 9/7/24 to 10/2/24.
During an observation on 10/1/24 at 10:52 AM, Resident 26 was sitting at the edge of her bed. Resident 26 had a nebulizer mask covering her nose and mouth with a blue head strap over her head, securing the nebulizer mask in place. Resident 26 was observed receiving breathing treatment via nebulizer mask.
During a concurrent observation and interview on 10/1/24 at 11:41 AM, in Resident 26 ' s room, Resident 26 ' s nebulizer mask was observed inside the top drawer of the nightstand on the right side of the Resident 26 ' s bed, not stored in a bag. A stained paper drawer liner was covering the bottom of the top drawer. Inside Resident 26 ' s drawer there were five disposable plastic cups lying on top of the stain of the paper drawer liner. One white dirty bottle cap, a hairbrush, one unopen paper straw, an undated mask, and a roll of plastic bags were observed inside the top drawer. The nebulizer mask had direct contact with the hairbrush, the straw and the paper liner.
During a concurrent observation and interview on 10/1/24 at 11:50 AM, with Licensed Vocational Nurse (LVN) 5, Resident 26 ' s nebulizer, kept in Resident 26 ' s nightstand was observed. LVN 5 stated Resident 26 ' s nebulizer mask should be kept inside a plastic bag with the date and the resident ' s name on the bag. LVN 5 stated not knowing how long Resident 26 ' s mask was stored, uncovered. LVN5 stated since Resident 26 ' s nebulizer mask was not stored in a bag while not in use, there was a risk for respiratory infection, due to inappropriate storage of the nebulizer mask.
During an interview on 10/2/24 at 3:09 PM, with the Director of Nursing (DON), the DON stated the nebulizer mask should be stored in a plastic bag, labeled with the resident ' s name and dated to ensure the nebulizer mask was clean, and to prevent infection.
During a review of the facility's policy and procedure (P&P) titled, Administering Medications through a Small Volume (Handheld) Nebulizer, dated 10/2010, the P&P indicated to store equipment, including mask, in a plastic bag with the resident ' s name and the date on it.
2. During a review of Resident 55's admission Record indicated the facility initially admitted Resident 55 on 1/28/21 and readmitted on [DATE] with diagnoses that include acute respiratory failure (a condition where there's not enough oxygen in your body) and diabetes mellitus (a group of diseases that result in too much sugar in the blood).
During a review of Resident 55's MDS, dated [DATE], indicated Resident 1 had severely impaired cognitive (ability to understand and make decisions) skills for daily decision making. The MDS indicated Resident 55 was dependent with eating, oral hygiene, toilet hygiene, shower/bath self, personal hygiene, and chair/bed-to-chair transfer.
During a review of Resident 55's OSR, dated 9/30/24, the OSR indicated the physician ordered to administer ipratropium (a medication that relaxes and opens the airways to help with breathing) albuterol inhalation nebulizer solution 0.5-2.5 MG/3 ML three ML inhale orally every four hours for shortness of breath and wheezing, and acetylcysteine (a medication is used to help with breathing) inhalation solution 10% two ML inhale orally every four hours for shortness of breath and wheezing, started on 7/24/24.
During a review of Resident 55's MAR, dated 10/1/24 to 10/31/24, the MAR indicated Resident 55 received ipratropium-albuterol inhalation nebulizer solution and acetylcysteine inhalation solution 10% inhale orally via nebulizer every four hours from 10/2/24 to 10/4/24.
During an observation on 10/4/24 at 9:14 AM, Licensed Vocational Nurse (LVN) 4 was holding Resident 55's nebulizer mask at bedside and squeezed a vial of ipratropium-albuterol inhalation nebulizer solution 0.5-2.5 MG/3 ML into the medication chamber of the nebulizer mask. Resident 55's nebulizer mask was labeled 9/25/24.
During a concurrent observation and interview on 10/4/24 at 9:15 AM, in Resident 55 ' s room, with the Infection Preventionist (IP) and LVN4, Resident 55's nebulizer treatment was observed. The IP stopped LVN 4 from placing the nebulizer mask on Resident 55 and instructed LVN 4 to obtain a new nebulizer mask. The IP stated the nebulizer mask should be changed every seven days. The IP stated Resident 55's nebulizer mask was dated 9/25/24. The IP stated the staff did not change the mask after 7 days and continued to use on Resident 55 for another three days, which put the resident at risk for infection.
During an interview on 10/4/24 at 11:12 AM, with the Director of Nursing (DON,) the DON stated nebulizer mask should be changed every seven days to prevent infection.
During a review of the facility's policy and procedure (P&P) titled, Administering Medications through a Small Volume (Handheld) Nebulizer, dated 10/2010, the P&P indicated to change equipment, including mask, every seven days.
2. A review of Resident 258's admission Record, indicated the resident was admitted to the facility on [DATE] with diagnoses that included chronic respiratory failure (a progressive condition in which the lungs cannot meet the body ' s oxygen demands)chronic obstructive pulmonary disease (COPD) (lung disease causing restricted airflow and breathing problems) and malignant neoplasm of upper lobe, right bronchus or lung (lung cancer).
A review of Resident 258's Minimum Data Set (MDS- a federally mandated resident assessment tool) dated 9/20/2024, the MDS indicated, Resident 258's cognitive status (ability to think and remember or thought process) was moderately impaired. The MDS indicated Resident 258 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and or contact guar assistance as resident completes activity) with eating, partial/moderate assistance (helper does less than half the effort) with personal hygiene, roll left and right , sit to stand, and required substantial/maximal assist (helper does more than half the effort) with toileting and bathing.
During an observation on 10/1/2024 at 9:30 AM in Resident 258's room, Resident 258 was asleep while continuously receiving oxygen at 2 liters per minute. The doorway of Resident 258 ' s room or in the room did not have an oxygen in use warning sign posted.
During an interview on 10/1/2024 at 9:45 AM with Licensed Vocational Nurse (LVN) 3 by Resident 258's room. LVN 3 stated, Resident 258's doorway should have a posted warning sign oxygen in use as per facility's policy, because the facility allows smokers in designated area, and smoking and oxygen had the potential to cause fire.
During an interview on 10/1/2024 at 10AM with Registered Nurse (RN) 3. RN 3 stated, Resident 258 had been receiving oxygen since admitted to the facility, and his doorway should have a warning sign of oxygen in use as per policy, because we have smokers in the building, to prevent potential accident or fire.
During a concurrent interview and record review, on 10/2/2024, at 4 PM, with Licensed Vocational Nurse (LVN) 2, Resident 258 ' s facility document titled Order Summary Report dated 10/2/2024 was reviewed. The document indicated, Resident 258 was admitted on [DATE] and the order to administer oxygen at 2 liters per minute via nasal cannula was just ordered 10/2/2024. LVN 2 stated, Resident 258 had been receiving oxygen since admission to the facility on 9/16/2024 without a physician ' s order.
During a concurrent interview and record review, on 10/2/2024 at 4:15 PM, with LVN 3, Resident 258 ' s documents titled ' Progress Notes (PN) dated 9/16/2024 and Medication Administration Record (MAR) for the month of September 2024 was reviewed. The PN indicated Resident 258 had been receiving oxygen at 2 liters per minute upon admission to the facility on 9/16/2024 and Resident 258 was receiving oxygen continuously without a physician ' s order since. LVN 3 stated, he missed getting an order for oxygen. LVN 3 stated, oxygen should have an order before administering because it could cause oxygen toxicity.
During a concurrent interview and record review, on 10/2/2024 at 4:25 PM, with Director of Nurses (DON), Resident 258 ' s facility document titled Order Summary Report dated 10/2/2024 was reviewed. DON stated, Resident 258 was receiving oxygen since admission to the facility on 9/16/2024, but did not have an order until today 10/2/2024. DON stated, the admitting nurse and the staff missed getting an order for oxygen until today. DON stated oxygen is a drug so it should have a physician order prior to administration because it has a potential to cause oxygen toxicity. DON also stated, Resident 258 who was receiving oxygen should have had a warning sign oxygen in use posted on the doorway because the facility allows smoking, and smoking and oxygen has a potential to cause fire.
A review of the facility's policy and procedure (P&P) titled, Oxygen Administration, dated 10/2010, indicated: a) the purpose is to provide guidelines for safe oxygen administration, b) preparation includes to verify that there is a physician order for the procedure, c)equipment necessary when performing the procedure includes No Smoking/Oxygen in Use sign, and d) remove all potentially flammable items (smoking articles) from the immediate area where oxygen is to be administered.
A review of the facility's policy and procedure (P&P) titled, Physician Orders, (undated), indicated: a) ensure all physician orders are followed and documented as given without errors, and b) do not start any due medications if not yet verified from the physician or nurse practitioner.
3. During a review of Resident 63 ' s admission Record dated 2/18/2022, the record indicated the facility admitted Resident 63 on 2/18/2022 and readmitted on [DATE] with diagnoses including Chronic Obstructive Pulmonary disease (COPD - lung disease which makes breathing difficult), and Bronchiectasis (a condition where your airways widen or develop pouches).
During a review of Resident 63 ' s History and Physical (H&P), dated 3/3/2024, indicated, Resident 63 had the capacity to make medical decisions.
During a review of Resident 63 ' s Order Summary Report, dated 10/2/2024, the Order Summary Report indicated an order on 3/3/2024, indicating may use oxygen at two (2) liters (a unit of measurement) per minute (L/min) via nasal cannula (device use for delivery of oxygen) to maintain oxygen saturation (amount of oxygen carried in blood) at 92%.
During a review of Resident 63's Minimum Data Set (MDS-a federally mandated resident assessment tool.), dated 8/15/2024, indicated the cognitive (the ability to think and process information) skills for daily decisions making was intact, and independent for activities of daily living.
During an observation on 10/2/2024 at 11:30 a.m., Resident 63 was observed sitting at the edge of his bed in his room. Resident 63 ' s oxygen machine was observed in resident ' s room. There was no precautionary signage posted on Resident 63 ' s door indicating oxygen was in used in the room or smoking was prohibited.
During a concurrent observation and interview on 10/1/2024 11:33 a.m. CNA 4 stated that there was no precautionary signage posted on Resident 63 ' s door indicating oxygen was in use, or smoking was prohibited.
During an interview on 10/3/2024 at 9:30 a.m., with the Registered Nurse Supervisor 4 (RN 4), RN4 stated smoking signage should be posted at the entrance door of residents receiving oxygen therapy to alert staff and visitors that oxygen was in use, and to avoid smoking for resident safety.
During a review of the facility ' s policy and procedure (P&P) titled, Oxygen Administration, revised 10/2010, P&P indicated, equipment and supplies are necessary when performing the procedure to place No smoking/Oxygen in Use signs.

Based on observation, interview and record review, the facility failed to verify one of seven sampled residents (Resident 89)'s identity before medication was administered to the resident in accordance with the facility's policy and procedure.
The deficient practice had put Resident 89 at risk of receiving the wrong and unnecessary medications that could cause the adverse effects (an undesired effect of a drug or other type of treatment).
Findings:
During a review of Resident 89's admission Record indicated the facility admitted Resident 89 on 9/29/23 with diagnoses that included diabetes mellitus (a group of diseases that affect how the body uses blood sugar) and hypertension (high blood pressure).
During a review of a Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 7/10/24, indicated Resident 89 had moderately impaired cognitive (ability to understand and make decisions) skills for daily decision making. The MDS indicated Resident 89 required setup or clean-up assistance with eating, partial/moderate assistance with oral hygiene, substantial/maximal assistance with chair/bed-to-chair transfer, and was dependent with toilet hygiene, shower/bathe self and personal hygiene.
During a review of Resident 89 ' s Order Summary Report (OSR), dated 9/30/24, the OSR indicated physician ordered to administer multivitamin-minerals (a supplemental medication is used to support health needs) one tablet by mouth one time a day for supplement.
During a review of Resident 89's Medication Administration Record (MAR), dated 10/1/24 to 10/31/24, the MAR indicated Resident 89 received multivitamin-minerals one tablet by mouth at 9 AM on 10/2/24.
During an observation on 10/2/24 at 9:32 AM, Resident 89 was lying on his bed. Licensed Vocational Nurse (LVN) 1 went into Resident 89 ' s room and stood at the foot of Resident 89 ' s bed. Observed Resident 89 did not have identification (ID) band on his wrists. LVN 1 called Resident 89 ' s last name and told Resident 89 that she would administer his medication. Resident 89 stated OK. LVN 1 returned to the medication cart and checked Resident 89 ' s physician order on the electronic health record (HER). The EHR had no profile picture of Resident 89 on his EHR. LVN 1 prepared one tablet multivitamin-minerals and walked to Resident 89 ' s room. LVN 1 administered the medication to Resident 89 without confirming his name and date of birth to ensure Resident 89 ' s identity.
During a concurrent interview and record review on 10/2/24 at 9:35 AM, with LVN 1, Resident 89 ' s profile picture on EHR was reviewed. LVN 1 stated there was no picture of Resident 89 on the EHR and she could not identify if Resident 89 was right resident just by calling his last name.
During a concurrent observation and record review on 10/2/24 at 9:36 AM, with LVN 1, Resident 89 did not have a wrist ID band. LVN 1 stated the wrist ID band was important because it helped the staff to identify the residents correctly.
During an interview on 10/2/24 at 9:40 AM, with LVN 1, LVN 1 stated she only called Resident 89 ' s last name to verify his identity before she administered the medication to Resident 89. LVN 1 should use three identifiers, including the name, wrist band, e-MAR, birthday, picture, and room number, to verify the resident ' s identity to prevent administer the wrong medications to the wrong resident.
During a concurrent interview and record review on 10/2/24 at 3:07 PM, with the Director of Nursing (DON), the facility ' s policy and procedure (P&P) titled, Administering Medications, dated 4/2019, was reviewed. The DON stated according to the P&P, the nurse should verify the resident ' s identity before giving medications by checking identification band, checking photograph attached to medical record, and verifying resident identification with other facility personnel. The DON stated by calling only the resident ' s last name was not enough to identify the resident and could put the resident at risk of medication error and adverse consequences.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure two of five sampled residents (Resident 58 and 4) were free of unnecessary psychotropic medications (any medication capable of affecting the mind, emotions, and behavior) in accordance with the facility's policy and procedureby [NAME] to ensure:
(any medication capable of affecting the mind, emotions, and behavior) in accordance with the facility policy and procedure. Resident 58
1. Resident 58 with diagnoses of schizophrenia (a mental illness that is characterized by disturbances in thought) and depression (mood disorder that causes a persistent feeling of sadness and loss of interest in life) recieved specific indication for Risperidone (medication used to treat symptoms of schizophrenia) and Trazodone (medication used to treat depression), and behavior for the indication of use were monitored and documented from the period of 7/1/2024 to 10/4/2024.
These efficient practices had potential to result in placing Resident 58 at risk for significant adverse consequence (unwanted, uncomfortable, or dangerous effects that a drug may have) from the use of unnecessary psychotropic drug, which could result to impairment or decline in the residents' mental, physical condition, functional, and psychosocial status.
2. Resident 4 was administered Lorazepam (brand name Ativan, a medication to treat anxiety [fear of the unknown or extreme worry] disorders) without a physician order and clinical reason for use.
As a result of this deficient practice the resident was at risk for the use of unnecessary medication, or non-therapeutic use of psychotropic medication.
Findings:
During a review of Resident 58's admission Record indicated the facility initially admitted Resident 58 on 4/27/2021 and readmitted on [DATE] with diagnoses that included schizophrenia, depression, dementia (a progressive state of decline in mental abilities), and anxiety disorder (a group of mental disorders characterized by significant feelings of fear that affect with daily activities).
During a review of Resident 58 ' s Order Summary Report, indicated Resident had a physician order on 1/8/2024 for Trazodone HCl tab 50 mg (milligram, unit of weight) to give 0.5 tablet by mouth at bedtime for depression and a physician order on 1/10/2024 for Risperidone tab 3 mg to give 1 tablet by mouth two times a day for Schizophrenia manifested by mumbling to himself.
During a review of Resident 58 ' s History and Physical, dated 1/13/2024, indicated Resident 58 was aphasia (a disorder that makes it difficult to speak), bed bound (confined to bed due to illness/weakness), and did not have the capacity to understand and make decisions.
During a review of Resident 58 ' s care plan (a document that outlines the facility ' s plan to provide personalized care to a resident based on the resident ' s needs), titled Behavioral Symptoms, dated 4/11/2024, indicated Resident 58 had potential altered behavioral patterns manifested by mumbling to himself with the goals that minimize frequency of behavior exhibited, reduce risk for potential harm and ensure resident ' s safety and the interventions included to monitor behavior indicators as needed.
During a review of Resident 58 ' s care plan, titled Psychotherapeutic Medication Use, dated 4/11/2024, indicated resident has periods of psychosis manifested by mumbling to himself with medication used as Risperdal (brand name for Risperidone), and resident has periods of depression manifested by sad facial expression with medication used as Trazodone. The record indicated, the goals were to maximize resident ' s functional potential, reduce risk of potential adverse effects of medication usage and minimize noted behaviors. The interventions included to monitor and record episodes of behavior per facility policy/protocol.
During a review of Resident 58 ' s Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 8/9/2024, indicated Resident 58 ' s cognition (a term for the mental processes that take place in the brain, including thinking, attention, language, learning, memory, and perception) was severely impaired, and was dependent (helper does all of the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity) in oral/personal hygiene, bathe self, upper and lower body dressing.
During a review of Resident 58 ' s Psychotropic Assessment, dated 1/8/2024, indicated Resident 58 was on Risperidone 3 mg BID (two times a day) for diagnosis of Schizophrenia with auditory hallucination, and no specific description of auditory hallucination was documented.
During a review of Resident 58 ' s Note to Attending Physician/Prescriber, dated 7/10/2024, documented by the facility ' s Consultant Pharmacist (CP) indicated Resident 58 has been receiving Risperidone 3 mg BID and Trazodone 25 mg QHS (at bedtime) to manage behavior, stabilize mood or treat a psychoactive condition. The record indicated the CP recommended for a review of the resident associated behaviors and monitoring parameters for worsening of behaviors to determine if the behaviors noted have been non to minimal. The record indicated, Federal nursing facility regulations require that gradual dosage reduction (GDR) be attempted in two separate quarters (with at least one month between attempts) within the first year in which a resident is admitted on a psychopharmacologic medication, or after the facility has initiated such medication, and then every 6 months thereafter unless clinically contraindicated. The record indicated, Resident 58 ' s physician disagreed with the CP ' s recommendations due to the benefits out-weight the risks with no explanation of benefits and risks were documented.
During an observation on 10/2/2024 at 10:15 AM in Resident 58 ' s room, Resident 58 was in bed and awake. Resident 58 did not answer, not nodding or shaking head with any questions asked by the surveyor.
During a concurrent observation and interview on 10/3/2024 at 2:23 PM with Certified Nurse Assistant (CNA) 8, Resident 58 was observed in bed, staring at the ceiling. CNA 8 stated, Resident 58 had been nonverbal and required total care since his admission on [DATE]. CNA 8 stated, she had not seen Resident 58 talking to himself and stated, Resident 58 ' s facial expression had been flat.
During a concurrent record review and interview on 10/4/2024 at 9:41 AM with Licensed Vocational Nurse (LVN) 1, Resident 58 ' s Psychotropic Assessment, and care plan were reviewed. LVN 1 stated, based on the records, Resident 58 was on Risperidone for hallucination manifested by mumbling to himself and Trazodone for depression manifested by sad face expression. LVN 1 stated, Resident 58 had been nonverbal and bedbound with total care upon admission on [DATE]. LVN 1 stated, when Resident 58 made a long argggg sound sometimes, she believed that was how he was mumbling to himself. LVN 1 stated, Resident 58 had been having a flat face with no expression.
During an interview on 10/4/2024 at 11:22 AM with Registered Nurse (RN) 4, RN 4 stated, Resident 58 had been nonverbal since admission on [DATE]. RN 4 stated, per policy, when a resident was on psychotropic medications with specific target behaviors, the LVNs are responsible to check the episodes of manifesting behavior and document them, then the RN would count the total number of episodes at the end of the month. RN 4 stated, they needed to count and monitor so that they could decrease or discontinue the medications if the resident did not have any episode of noted behaviors anymore.
During a concurrent record review and interview on 10/4/2024 at 12:05 PM with RN 4, Resident 58 ' s Psychotropic Summary Sheet was reviewed. RN 4 stated, the form was used to monitor monthly total number of episodes that Resident 58 exhibited behaviors of mumbling to himself and sad face expression and the RNs are responsible to count and document them. RN 4 stated, based on the record, there was no total count from the month of July 2024.
During a concurrent record review and interview on 10/4/2024 at 12:10 PM with RN 4, Resident 58 ' s electronic Medication Administration Record (eMAR) for August, September and October 2024 were reviewed. RN 4 stated, the eMAR indicated no numbers of episode of mumbling to self was documented since 8/1/2024. RN 4 stated, the LVNs had been documenting incorrectly or there must be a mistake from IT department that they could not document a number in the record. RN 4 stated, there was no episodes tracking since 8/1/2024. RN 4 stated, with no tracking, they could not assess the resident to initiate GDR, and they would not know if the resident still needed the medications or not, so the resident would be at risk for unnecessary psychotropic medications.
During a concurrent record review and interview on 10/4/2024 at 12:20 PM with RN 4, Resident 58 ' s Psychiatric notes, since admission on [DATE] were reviewed. RN 4 stated, there had been no GDR attempted in the past 9 months.
During an interview on 10/4/2024 at 12:33 PM with the Director of Nurses (DON), the DON stated, mumbling to himself should not be the indication of Risperidone use for schizophrenia and auditory hallucination is too general because it should specify what hallucinations, what he saw, what he heard. The DON stated, sad face alone should not be an indicator for Trazodone use to treat depression. The DON stated, a long sound arggg could not indicate that he was mumbling to himself. The DON stated, the facility ' s CP usually reviewed the medications record alone and send the recommendation to her, she would then review it and suggest it to the doctor. The DON stated, she did not review the suggestion from the pharmacist, which was documented in Resident 58 ' s Note to Attending Physician/Prescriber, dated 7/10/2024. The DON stated, she just brought the recommendation to the doctor and asked him to sign it. The DON stated, she should have reviewed the recommendation and assessed the resident for need to continue the medications or not and discuss with the doctor for possible GDR. The DON stated, the doctor should have explained in detail why he disagrees with GDR and wanted to continue Risperidone and Trazodone. The DON stated RNs are assigned to count the episodes every month and bring it to IDT meeting. The DON stated, the staffs did not properly monitor the resident ' s behaviors. The DON stated, they need to know how many episodes of hallucinations so that they know if the medication is effective, if it needed to be discontinued or decrease. The DON stated the indications for Risperidone and Trazodone were not accurate and should be more specific to use. The DON stated, Resident 58 is at risk for unnecessary psychotropic medications.
During a review of the facility ' s policy and procedure (P&P) titled, Psychoactive Drug Monitoring, dated March 2023, indicated the following:
-The continued need for the psychoactive medication shall be reassessed regularly by the prescriber and the care planning team. If continuation is deemed necessary, this is indicated in the medical record. Effects of the medications are documented as a part of the care planning process. Unless medically contraindicated, periodic dosage reductions shall be attempted, and the results documented.
-Conditions shall be satisfied prior to initiation and/or continuation of therapy included: long-term daily use has been accompanied by unsuccessful gradual dosage reductions.
-Residents receive antipsychotic medication only for behaviors that are quantitatively and objectively documented through the use of behavioral monitoring charts or a similar mechanism.
-Residents receive antipsychotic medication only for behaviors that are persistent, that are not caused by preventable reasons and are causing the resident to: present a danger to self or others, continuously screaming/yell/space, and experience psychotic symptoms.
During a review of the facility's P&P titled, Antipsychotic Medication Use, dated December 2016, indicated the following:
-Residents who are admitted from the community or transferred from a hospital and who are already receiving antipsychotic medications will be evaluated for the appropriateness and indications for us. Re-evaluate the use of the antipsychotic medication at the time of admission to consider whether or not the medication can be reduced, tapered, or discontinued.
-Diagnoses alone do not warrant the use of antipsychotic medication. Antipsychotic medications will generally only be considered if the behavioral symptoms present a danger to the resident or others, and (1) the symptoms are identified as being due to mania or psychosis (such as auditory, visual, or other hallucinations); or (2) behavioral interventions have been attempted and included in the plan of care.
-The Physician shall respond appropriately by changing or stopping problematic doses or medications, or clearly documenting (based on assessing the situation) why the benefits of the medication out-weight the risks or suspected or confirmed adverse consequences.
2. During a review of Resident 4's admission Record (Face Sheet), dated 9/12/2023, the face sheet indicated the facility admitted Resident 4 on 9/12/2023, and readmitted on [DATE] with diagnoses including Chronic Obstructive Pulmonary disease (COPD - lung disease which makes breathing difficult), and muscle weakness.
During a review of Resident 4's Minimum Data Set (MDS-a federally mandated resident assessment tool.), dated 6/4/2024, indicated has severe cognitive impairment (the ability to think and process information). The MDS indicated the resident is totally dependent on staff for dressing, toilet use, personal hygiene, and bathing.
During a review of Resident 4's History and Physical (H&P), dated 6/24/2024, indicated, Resident 4 had the mental capacity to make medical decisions.
During a review of Resident 4's Order Summary Report, dated 10/3/2024, the Order Summary Report indicated an order dated 8/1/2024, to administer Lorazepam (Ativan) Tab (tablet) 0.5mg (milligram)- Give one tablet by mouth every six hours as needed for anxiety for 14 days m/b (manifested by) sudden outburst of anger with an order end date of 8/14/2024.
During a review of nursing notes dated 9/5/2024 at 9:15 PM, Lorazepam 0.5 mg tablet given p.o. (by mouth) PRN (as needed) to administer for anxiety.
During a review of nursing notes dated 9/5/2024 at 11:36 PM, Ativan 0.5 mg given at 9:15 PM and was effective at 11:30 PM, no anxiety noted.
During a review of nursing notes dated 9/14/2024 at 5:30 AM, Ativan 0.5 mg tablet 1 tablet given p.o. PRN anxiety m/b (manifested by): sudden outburst of anger.
During a review of nursing notes dated 9/14/2024 at 5:30 AM, Ativan given at 5:30 PM effective at 6:30 PM.
During a review of nursing notes dated 9/26/2024 at 5AM, Lorazepam 0.5 mg tablet 1 tablet given p.o. PRN anxiety, effective at 6PM
During a review of nursing notes dated 9/26/2024 at 5:50 AM, Late entry: Lorazepam 0.5 mg tablet 1 tablet given p.o. PRN anxiety, m/b agitation, effective at 7PM
During a review of Record of Controlled Substance indicated, Lorazepam was administered to Resident 4 as follow:
8/31/2024 at 9:30PM
9/5/2024 at 9:15PM
9/14/2024 at 5:30PM
9/26/2024 at 5PM
9/27/2024 at 5:50PM
During a concurrent interview and record review on 10/3/2024 at 4:38 PM, with the Registered Nurse Supervisor 4 (RN 4), Resident's 4 record of Controlled substances, was reviewed. The record of Controlled Substances indicated Resident 4 was administered Lorazepam on 8/31/24, 9/15/24, 9/14/24, 9/26/24, and 9/27/24 (a total of five times) without a physician's order. RN 4 stated that medication such as Ativan should not had been administered without the ordered and every medication needs some orders.
During an interview on 10/3/2024 at 4:55 PM with the DON stated the medication should had been given the Ativan to me after the medication was discontinue. DON stated that if the medication was discontinued and if the resident needs it, they need to call the doctor to obtain an order for the medication before administering the medication. The DON stated the nurse should not have administered the Ativan without a physician order. I understand that lorazepam is just ordered for 14 days and then the resident need to be reassessed for the need to Ativan.
During a concurrent interview and record review on 10/3/2024 at 5:18 PM, Licensed Vocational Nurse 2 (LVN 2) stated, she was aware that the Ativan was due for renewal. LVN 2 stated she thought the Ativan order was renewed. LVN 2 stated there is monitoring for the medication but no order to administer Lorazepam in the medication administration record (MAR). LVN 2 stated she could not remember where she documented that she administered the medication. LVN 2 confirmed there is no record of her administering the medication in the MAR.
During a review of the facility's policy and procedure (P&P) titled, Administering Medication, revised on 4/2019, P&P indicated, Medications are administered in a safe and timely manner, and as prescribed. Medications are administered in accordance with prescriber orders, including any required timeframe. The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure drugs and biologicals used in the facility were, stored under proper temperature, are labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable in accordance with the facility's policy and procedures.
The facility failed to:
1. Ensure the medication room [ROOM NUMBER] ' s thermometer readings were monitored and recorded in the Daily Room Temperature Log to assure a safe temperature range for medication storage.
2. Label Resident 257's opened multi-dose medication bottles (a bottle of medication in the forms of liquid, tablet, or capsule, that contains more than one dose of medication) with the name in the Medication Cart #1 for:
a. Ascorbic acid (vitamin C, a dietary supplement) 500 milligram (mg, a unit of measurement)
b. Vitamin E (a dietary supplement) 400 unit (a unit of measurement)
c. Vitamin D3 (a dietary supplement) 25 micrograms (mcg, a unit of measurement)
3. Label the opened multi-dose medication bottle with the open date in the medication cart #2 for:
a. Pro-Stat (a medical food that is a concentrated liquid protein supplement) 15 grams (g, a unit of measurement) of protein in one fluid ounce (fl oz, a unit of measurement)
b. Bismuth subsalicylate (a medication to relieve upset stomach, gas, heartburn, and diarrhea) 525 mg/30 milliliter (ml, a unit of measurement)
c. Geri-Lanta (a medication is used to treat upset stomach, heartburn, and bloating) 355 ml
d. One battle of Sterile normal saline (a mixture of salt and water) 100 ml
This deficient practice had the potential for harm to residents due to the potential loss of strength of the drugs, the potential for the residents to receive ineffective drug dosages, and the potential to result in medication error.
Findings:
1. During a concurrent observation and interview on 10/3/24 at 10:52 AM, with Licensed Vocational Nurse (LVN) 6, the digital thermometer was attached to the wall, next to the Daily Room Temperature Log, in the medication room [ROOM NUMBER], but the thermometer display was blank. LVN 6 stated the night shift nurse was responsible to check the temperature and document it on the Daily Room Temperature Log every day, but the temperature for 10/3/24 was not documented. LVN 6 stated she did not know for how long the thermometer was not working.
During a concurrent interview and record review on 10/3/24 at 11AM, with the Director of Staff Development (DSD), the updated Daily Room Temperature Log was reviewed. The Daily Room Temperature Log indicated there was no documentation on the specific month and the location of the temperature log was monitoring. The DSD stated the updated Daily Room Temperature Log was the current log for October for the medication room [ROOM NUMBER]. The DSD stated the 3 on the log indicated the date for 10/3/24. The DSD stated the nurse, who worked the night shift last night, should check the temperature and documented it on the log before the end of her shift. The DSD stated the nurse only documented her signature and the shift 11-7 AM, but she did not document the temperature on the log. The DSD stated the night shift nurse might not be able to read the temperature because the thermometer was not working during her shift. The DSD stated it was important to monitor the temperature in the medication room to ensure the temperature was within the range and assure the potency of the medication stored in the medication room.
2. During a review of Resident 257's admission Record indicated the facility admitted Resident 257 on 9/20/24 with diagnoses that include hypertension (high blood pressure) and muscle weakness.
During a review of Resident 257 ' s MDS, dated [DATE], indicated Resident 257 had moderately impaired cognitive (ability to understand and make decisions) skills for daily decision making.
During a review of Resident 257 ' s Order Summary Report (OSR), dated 10/4/24, the OSR indicated the physician ordered to administer Ascorbic acid 500 mg give 500 mg by mouth in the morning for supplement and Vitamin E 400-unit one tablet by mouth in the morning for supplement.
During a concurrent observation and interview on 10/3/24 at 11:22 AM, with LVN 6, observed an opened multi-dose bottle of Ascorbic acid 500 mg, an opened multi-dose bottle of Vitamin E 400 unit, and an opened multi-dose bottle of Vitamin D3 25 microgram were stored in a drawer in the medication cart #1. Observed these opened bottles were only labeled with Resident 257 ' s room number without the resident ' s name on it. LVN 6 stated Resident 257 brought these medications to the facility, and they kept them in the medication cart. LVN 6 stated she should write Resident 257 ' s name on the bottles instead of the room number to prevent loss and/or administered it to the wrong resident if Resident 257 was transferred to a different room.
3. During a concurrent observation and interview on 10/3/24 at 4:13 PM, with LVN 7, observed an opened multi-dose bottle of liquid form of Pro-Stat 15 g of protein in one fluid ounce , an opened multi-dose bottle of liquid form of bismuth subsalicylate 525 mg/30 ml, an opened multi-dose bottle of liquid form of Geri-Lanta 355 ml, and an opened bottle of sterile normal saline were stored in a drawer in the Medication Cart #2. LVN 7 stated these four bottles of medication were not labeled with an opened date. LVN 7 stated these liquid medications were only good for 30 days after they were opened, and it was important to label the bottle on when it was opened so that the nurse will know when to discard the expired medications. LVN 7 stated the nurse, who opened the multi-dose bottle of medication, should label the date it was opened to ensure the potency of the medication and prevent infection from the overgrowth of the germs in these liquid medications.
During an interview on 10/4/24 at 10AM, with the Infection Preventionist (IP), the IP stated an opened bottle of an over the counter (OTC) liquid medication was good for three months after the date it was opened. The IP stated the nurse should label the open date of the medication when he or she opened it to ensure the medication potency and prevent infection which bacteria might overgrow in it.
During an interview on 10/4/24 at 11:17 AM, with the Director of Nursing (DON), the DON stated it was important to ensure the thermometers in the medication rooms were working, the staff monitor the temperature and document it in the log every day, and the staff label the opened bottles with the open date to prevent the loss of medication potency and infection. The DON stated the staff should label the resident ' s medication with his or her name on the bottle to prevent the loss of the medication and medication error.
During a review of the facility ' s policy and procedure (P&P) titled, Medication Labeling and Storage, dated 2/2023, the P&P indicated The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. The P&P indicated the medication label included resident ' s name. The P&P indicated multi-dose vials that have been opened are dated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide food prepared in a form designed to meet individual needs for one of twenty-three sampled residents (Resident 23) with dysphagia (difficulty swallowing) and was ordered by the physician to be served Regular diet (diet that does not include any restrictions) with mechanical soft texture (any foods that can be blended, mashed, pureed, or chopped using a kitchen tool such as a knife, a grinder, a blender, or a food processor) since 7/16/2024.
This failure resulted in Resident 23 received regular texture instead of mechanical soft texture as ordered from 7/16/2024 to 10/3/2024, which could place her at risk for aspiration (happens when food, liquid, or other material enters a person ' s airway by accident. It can happen as a person swallows) and choking.
Findings:
During a review of Resident 23's admission Record indicated the facility initially admitted Resident 23 on 4/1/2015 and readmitted on [DATE] with diagnoses that included hemiplegia (a condition that causes partial or complete paralysis or weakness on one side of the body and hemiparesis (weakness or an inability to move on one side of the body) following cerebral infraction (stroke, a serious condition that occurs when blood flow to the brain is disrupted, causing brain tissue to die) affecting right dominant side, muscle weakness, cognitive communication deficit, aphasia (loss of the ability to understand or express spoken or written language), and dysphagia .
During a review of Resident 23 ' s Speech Therapy SLP (Speech-Language Pathologist) Discharge Summary, dated 9/29/2023, indicated the treatment included utilization of safe swallow strategies such as small bites/sips.
During a review of Resident 23 ' s History and Physical, dated 8/12/2024, indicated Resident 23 had fluctuating capacity to understand and make decisions.
During a review of Resident 23 ' s care plan (a document that outlines the facility ' s plan to provide personalized care to a resident based on the resident ' s needs), dated 9/6/2024, indicated Resident 23 was at risk for weight loss, decline in functional status, and aspiration/choking during meals. The goals were to reduce/minimize risk of aspiration/choking during meals, and to receive adequate nutrition/hydration daily. The interventions included mechanical soft diet with thin liquid, assistance during meals as needed, and staffs to monitor resident ' s tolerance with food ' s texture.
During a review of Resident 23 ' s Nutritional Screening, dated 9/5/2024, indicated Resident 23 ' s diet order was Regular, mechanical soft texture, and supervision was needed during eating.
During a review of Resident 23 ' s Order Summary Report, indicated Resident 23 had a physician order on 7/16/2023 for Regular diet with mechanical soft texture.
During a concurrent dining observation and interview on 10/1/2024 at 12:15 PM with Resident 23 in her room, Resident 23 was observed in bed eating alone with no assistance. Resident 23 was observed using a spoon to cut up a piece of chicken that was close to 2x3 inches (unit of length) in size.
During a concurrent observation and interview on 10/1/2024 at 12:45 PM with Certified Assistant Nurse (CNA) 4 in Resident 23 ' s room, Resident 23 ' s lunch tray and tray card was observed. CNA 4 stated, Resident 23 ' s tray card indicated Regular diet with no indication for mechanical soft texture as ordered.
During a concurrent interview and record review on 10/3/2024 at 2:25 PM with the Dietary Service Supervisor (DSS), the facility ' s policy and procedure (P&P) titled, Regular Mechanical Soft Diet, dated 2023, was reviewed. The DSS stated, the facility only provided grounded meat for dysphagia residents who had diet order for mechanical soft texture to prevent aspiration and choking. The DSS stated, when a resident was admitted to the facility, the nurse would bring a slip with the resident ' s name and diet order to him. The DSS stated, he usually based on the information in the slip to transfer it to his computer and create a tray card for that resident. The DSS stated, he was not aware that Resident 23 had order for mechanical soft texture because Resident 23 ' s tray card only showed Regular diet. The DSS stated, they had been providing Resident 23 with regular texture diet since her admission on [DATE]. The DSS stated, Resident 23 ' s diet order could have been revised and he was not aware to update with the new texture. The DSS stated, there could be a risk that Resident 23 could aspirate or choke when the facility provided her with the wrong diet texture.
During a concurrent record review and interview on 10/3/2024 at 6:15 PM with the Director of Nurses (DON), Resident 23 ' s Order Summary Report was reviewed. The DON stated, Resident 23 ' s physician diet order had been mechanical soft texture since 7/16/2023. The DON stated, Resident 23 ' s tray card should have indicated mechanical soft texture. The DON stated, the DSS must have transferred Resident 23 ' s diet order incorrectly into his system. The DON stated, they have been providing Resident 23 with regular texture instead of grounded meat since 7/16/2023. The DON stated, Resident 23 could have aspirated or choked when provided with the wrong diet texture.
During a review of the facility ' s P&P titled, Diet Order, dated 2023, indicated diet orders prescribed by the Physician will be provided by the Food & Nutrition Services Department. Nursing will send a Diet Order Communication slip to the Food & Nutrition Services Department. The FNS Director or [NAME] in charge will make or adjust the diet profile and tray card as prescribed.
During a review of the facility ' s P&P titled, Regular Mechanical Soft Diet, dated 2023, indicated the mechanical soft diet is designed for residents who experience chewing or swallowing limitations. The regular diet is modified by mechanically altering, chopped or ground. Food including meats, poultry and fish are allowed in ground form, avoid whole. Chopped meat only allowed when ordered by Speech Therapist, and is recommended to chop in bite size, 0.5 inches moist.

Based on observation, interview, and record review, the facility failed to ensure the food were stored prepared and distributed of food under sanitary conditions to all the residents in the facility by failing to:
1.Ensuring to store food with label and open date.
2.Ensure expired food was not stored in the kitchen.
3.Monitoring and documenting Sanitization Bucket Log.
4.Monitoring and documenting Ice Machine cleaning log.
5.Monitoring and documenting cleaning and maintenance schedule log.
These deficient practices placed the residents at risk for foodborne illnesses (refers to illness caused by the ingestion of contaminated food or beverages).
Findings:
a. During a concurrent observation and interview on 10/1/2024 at 8:55 a.m., during an initial Kitchen tour in the presence of [NAME] (Cook) 1. There were several open items without label and open date. Those items were a liquid whole egg carton, three squeeze bottles containing apple sauce, cottage cheese container, a sliced watermelon covered with plastic wrap with no use by date, Buttermilk Ranch dressing container with no open date, Sliced potatoes in a container covered with plastic wrap with no used by date. [NAME] 1 stated that the items should have been labeled with open date and use by date.
During a review of the facility's policy and procedure (P&P) titled, Labeling and Dating of Foods , indicated newly opened food items will need to be closed and labeled with an open date and used by the date.
b. During a concurrent observation and interview on 10/1/2024 at 9:30 a.m. during the kitchen tour with the Dietary Service Supervisor (DSS) observed several items that were expired and stored in the kitchen. in the walk-in fridge Parmesan cheese with a use by date of 9/24/24, Turkey salad observed with a use by date of 9/30/24 were observed. The Dietary Service Supervisor (DSS) stated the food was no good and had to be discarded. The following condiments were observed Nutmeg ground expired 9/24/24 and Turmeric ground expiration date 6/2/24. DSS they should have been discarded.
During a review of the facility's policy and procedure (P&P) titled, Labeling and Dating of Foods , indicated No food will be kept longer than the expiration date on the product.
c. During a concurrent observation and interview on 10/1/2024 at 9:45 a.m. during an initial kitchen tour with the DSS, a review of the log for the month of September 2024 titled Sanitizer Bucket Log had missing dates with the test results from 9/19/2024 and 9/20/2024 from 1 p.m. to 7 pm. On 9/28/2024 and 9/30/2024 had missing test results for the entire day. DSS stated staff is supposed to fill out the log after each meal, after each use. The DSS verified that log entries were missing for the dates mentioned above. The DSS stated the sanitizing bucket is used to sanitize the food preparation area to reduce the number of bacteria on non-food contact surfaces. The incomplete log indicated the facility's kitchen was not sanitized according to the facility's policy. On 10/1/2024 at 9:45 a.m., during an initial tour of the kitchen with Dietary Services Supervisor (DSS), the Record of Sanitizer Bucket Log was reviewed. The form indicated to use Quaternary sanitizing solution: Concentration range 200ppm (parts per million or ppm means out of a million), immerse test strip for 10 seconds. The form had columns to enter the data eight times a day at 5 a.m., 7 a.m., 9 a.m., 11 a.m., 1 p.m., 3 p.m., 5 p.m., and 7 p.m. however, there were many blank columns. The last entry on the record was at 7 p.m., on 9/29/2024.
During an interview with the DSS on 10/1/2024 at 9:50 a.m., when asked about the procedure of completing the Record of Sanitizer Agent, DSS stated staff is supposed to fill out the log after each meal, after each use. Or if the PPM is not within acceptable range, make new sanitizer and retest. Change more often as needed. The DSS verified that log entries were missing from 9/19/2024 and 9/20/2024 from 1 p.m. to 7 pm, 9/28/2024 and 9/30/2024 had missing test results for the entire day.
During an interview with the DSS on 10/1/2024 at 9:50 a.m., DSS stated he is responsible making sure the log is filled out after each use of the test strip. When asked about the missing entries on the Record of Sanitizer bucket log. The DSS stated that every staff member of the kitchen is responsible for completing the log. The DSS stated he may have missed it. The DSS stated he would follow up and make sure everyone follows through. The DSS stated he would make sure the log is filled out accurately and consistently.
During a review of the facility's policy and procedure (P&P) titled, Quaternary Ammonium Log Policy, indicated the concentration of the ammonium in the quaternary sanitizer will be tested to ensure the effectiveness of the solution. Food and Nutrition Services staff will record the readings twice a day, once in the morning and once in the PM, to document the process was completed.
d. During a concurrent observation and interview on 10/1/2024 at 10:00 a.m., a review of the log for the month of September 2024 titled Ice Machine Cleaning Log had missing dates with staff initials for 9/20/2024, 9/21/2024, 9/27/2024 and 9/28/2024. DSS stated staff is supposed to fill out the log daily. It is the kitchen staff responsibility to clean the outside of the ice machine and scoop daily. DSS stated it is his responsibility to follow up with the staff, so they understand their duties, but I did not follow up.
e. During a concurrent observation, review and interview on 10/1/2024 at 10:10 a.m., a log titled Cleaning and maintenance Schedule for the month of July was observed posted in the Refrigerator 2, which was observed to have multiple missing entries. The DSS stated that the log is for the month of September 2024, but he forgot to change the month to September when he printed the log. The DSS provided the log for August and July logs that were incomplete. The DSS stated that this log was recently implemented in the month of July and the kitchen staff did complete the logs. The DSS stated it his responsibility to make sure the log is filled out accurately and consistently.
During a review of the facility's policy and procedure (P&P) titled, Sanitation, indicated The FNS (food & nutrition services) Director will write the cleaning schedule in which he designates by job title and/or employee who is to the task.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.During a review of Resident 86's admission Record indicated the facility initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that include dementia (a group of thinking and social symptoms that interferes with daily functioning) and dysphagia (difficulty swallowing foods or liquids).
During a review of a Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 9/2/24, indicated Resident 86 had severely impaired cognition (ability to understand and make decisions) skills for daily decision making. The MDS indicated Resident 86 required substantial/maximal assistance with eating, and was dependent with oral hygiene, toilet hygiene and personal hygiene.
During a review of Resident 86 ' s Order Summary Report (OSR), dated 8/29/24, indicated the physician ordered the resident to receive Jevity 1.5 (a liquid nutritional supplement that can be used for patients who are at risk of malnutrition or have altered taste perception) at 100 milliliter (ML, unit of measurement) per hour for 12 hours via pump per G-tube from 7 PM to 7 AM and to flush G-tube with 20-30 ML of water before and after administration of medication pass.
During a concurrent observation and interview on 10/1/24 at 9:56 AM, with the Director of Staff Development (DSD), in Resident 86 ' s room, Resident 86 was sitting on his bed and a G-tube feeding pump was secured on an intravenous (IV, a way of giving a drug or other substance through a needle or tube inserted into a vein) pole (a medical device to provide a secure place to hang bags of medicine or fluid for administration to a patient) next to his bed. The G-tube feeding pump was currently off. A feeding syringe was inside a pole bag, which was hung on a hook of the IV pole. The pole bag was labeled as 9/29/24 at 9 AM. The DSD stated the feeding syringe was used for flushing the G-tube, check placement of the G-tube and administering medications to the resident. The DSD stated the feeding syringe should be changed every 24 hours by the night shift nurse, but the nurse did not change the feeding syringe for 2 days which put the resident at risk of contracting an infection.
During an interview on 10/2/24 at 3:08 PM, the Director of Nursing (DON), the DON stated the night shift nurse should change the feeding syringe every 24 hours and label the bag with the date and time to prevent infection.
During a review of the facility ' s Policy and procedure (P&P) titled, Enteral Feedings-Safety Precautions, dated 11/18, the P&P indicated Change syringe every 24 hours during 11-7 shift and as needed.
During a review of Resident 1's admission Record indicated the facility initially admitted Resident 1 on 10/1/96 and readmitted on [DATE] with diagnoses that include sepsis (a life-threatening medical emergency that occurs when the body has an extreme response to an infection or injury) and diabetes mellitus (a group of diseases that result in too much sugar in the blood).
During a review of Resident 1 ' s MDS, dated [DATE], indicated Resident 1 had moderately impaired cognition (ability to understand and make decisions) skills for daily decision making. The MDS indicated Resident 1 was dependent with eating, oral hygiene, toilet hygiene, shower/bath self, personal hygiene, and chair/bed-to-chair transfer.
3. During a review of Resident 55's admission Record indicated the facility initially admitted Resident 55 on 1/28/21 and readmitted on [DATE] with diagnoses that include acute respiratory failure (a condition where there's not enough oxygen in your body) and diabetes mellitus (a group of diseases that result in too much sugar in the blood).
During a review of Resident 55 ' s MDS, dated [DATE], indicated Resident 55 had severely impaired cognition (ability to understand and make decisions) skills for daily decision making. The MDS indicated Resident 55 was dependent with eating, oral hygiene, toilet hygiene, shower/bath self, personal hygiene, and chair/bed-to-chair transfer.
During an observation on 10/3/24 at 9:10 AM, Registered Nurse (RN) 5 used a wrist (BP) monitor to check Resident 55 ' s BP, then, she placed the used wrist BP monitor on top of the medication cart without cleaning and disinfecting.
During an observation on 10/3/24 at 9:14 AM, RN 5 took the BP monitor that was not disinfected from the top of the medication cart and used it to check Resident 55 ' s BP.
During an interview on 10/3/24 at 9:16 AM, with RN 5, RN 5 stated she did not disinfect the BP monitor after using it on Resident 55 and did not disinfect it before using it on Resident 55. LVN 4 stated she should disinfect the BP monitor after and before each use to prevent the spread of infection to the residents.
During an interview on 10/4/24 at 11:15 AM, with the DON, the DON stated staff should disinfect the wrist BP monitor and other re-usable equipment before and after each to prevent infection spreading to other residents.
During a review of the facility ' s P&P titled, Cleaning and disinfection of Resident-Care Items and Equipment, dated 9/2022, the P&P indicated Reusable items are cleaned and disinfected .between residents (e.g., stethoscopes, durable medical equipment).
4. During a review of Resident 95's admission Record indicated the facility initially admitted Resident 95 on 2/8/2024 and readmitted on [DATE] with diagnoses that included spondylosis (a condition in which there is abnormal wear on the cartilage [strong, flexible connective tissue supports and protects bones] and bones of the neck), disorder of the lung, and metabolic encephalopathy (a brain dysfunction caused by a chemical imbalance in the blood that affects the brain's normal functioning).
During a review of Resident 95 ' s Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 8/9/2024, indicated Resident 95 ' s cognition (a term for the mental processes that take place in the brain, including thinking, attention, language, learning, memory and perception) was moderately impaired,
During a review of Resident 95 ' s Order Summary Report, indicated the physician ordered on 9/18/2024 for Resident 95 to receive oxygen at 2 liters per minute (LPM) via NC or face mask as needed for shortness of breath or oxygen saturation (measures how much oxygen blood carries in comparison to its full capacity) below 90% (normal range 90-100%)
During an observation on 10/1/2024 at 10:25 AM in Resident 95 ' s room, Resident 95 was observed lying in bed with oxygen in use at 2 LPM via NC without a date of when it was to be changed.
During a concurrent observation and interview on 10/1/2024 at 11:41 AM with Licensed Vocational Nurse (LVN) 1 in Resident 95 ' s room. LVN 1 stated, she could not find the label with date on when the NC was to be changed on the resident ' s NC. LVN 1 stated, the NC was required to be labeled with the date that the NC was last changed to track and make sure the NC was changed weekly to prevent infection per facility ' s policy.
During an interview on 10/4/2024 at 1:05 PM with the Director of Nurses (DON), the DON stated, it was in the facility ' s policy that all NCs to be dated so they could track and make sure to have them changed every 7 days to prevent infection, such as lung infection.
During a review of the facility ' s policy and procedure (P&P) titled, Departmental (Respiratory Therapy) - Prevention of Infection, revised November 2011, the P&P indicated, change the oxygen cannula and tubing every 7 days, as needed.
Based on observation, interview, and record review, the facility failed to implement the facility's infection control program (a system in preventing, controlling infections and communicable diseases) for six of six sampled residents (Residents 258, 86, 55, 95, 43 and 257).
The facility failed to:
1. Ensure for Resident 258 the nasal cannula (a device that delivers extra oxygen through a tube and into your nose), the hand held nebulizer (HHN- machine that turns liquid medication into a mist so that it can be breathed directly into the lungs mouthpiece) circuit were not labeled of the date of the initial use, the HHN circuit was not placed in a plastic bag and the humidifier bottle was not labeled with date and initials upon opening.
2. Ensure for Resident 86 the feeding syringe (a tool used to deliver small amounts of liquid into a person ' s [ gastric tube [G-tube, a tube that is inserted into the stomach to provide food, liquids, or drugs, or to remove substances from the stomach] was not changed every 24 hours.
3. Ensure for Resident 55 the blood pressure (BP, the force of the blood pushing against the walls of the arteries [tubelike structures transporting blood from the heart to the rest of the body) monitor was not Cleaned and disinfected (remove dirt or stains, and apply a chemical to a surface in order to destroy germs) a before and after each use.
4. Ensure the nasal cannula (NC, a flexible tube that provides oxygen through the nose) for Resident 95 was labeled when the NC will be changed.
5. Ensure facility staff performed hand hygiene while distributing resident meal trays for two sampled residents (Resident 43 and Resident 257) according to policy and procedure.
These deficient practices had the potential for the device to contact contaminated (containing disease causing organism) areas and cause the spread of infection (a process when a microorganism, such as bacteria, fungi, or a virus, enters a person's body and causes harm) to the residents and others in the facility.
Findings:
1. A review of Resident 258's admission Record, indicated Resident 258 was admitted to the facility on [DATE] with diagnoses that included acute and chronic respiratory failure (a condition in which the lungs have a hard time loading the blood with oxygen or removing carbon dioxide), chronic obstructive pulmonary disease (COPD) (lung disease causing restricted airflow and breathing problems) and malignant neoplasm of upper lobe, right bronchus or lung (lung cancer).
A review of Resident 258's Minimum Data Set (MDS- a federally mandated resident assessment tool) dated 9/20/2024, the MDS indicated, Resident 258 cognitive status was moderately impaired. The MDS indicated Resident 258 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and or contact guar assistance as resident completes activity) with eating, partial/moderate assistance (helper does less than half the effort) with personal hygiene, roll left and right , sit to stand, and required substantial/maximal assist (helper does more than half the effort) with toileting and bathing.
During an observation on 10/1/2024 at 9:30 AM in Resident 258's room, Resident 258 lying in bed with eyes close receiving oxygen at 2 liters per minute (a unit of measurement) the nasal cannula, oxygen humidifier, HHN circuit was not labeled of dated on when the tube was first used, also the HHN circuit was not stored inside the plastic bag to prevent the tube from contacting contaminated surface.
During an interview on 10/1/2024 at 9:45 AM with Licensed Vocational Nurse (LVN) 1 inside Resident 258's room, LVN 1 stated, Resident 258's had been receiving oxygen since admission to the facility on 9/16/2024 and his nasal cannula, oxygen humidifier and HHN circuit should have been labeled and dated of initial use, also the HHN circuit should be in a plastic bag. LVN 1 stated, not having a label of the date the device was initially used, would not let the nurses know the last time it was change. LVN 3 stated, if the oxygen equipment's are old it will harbor bacteria and virus and could cause and/or spread of infection and diseases.
During an interview on 10/1/2024 at 10 AM with Registered Nurse (RN) 1, RN 1 stated, Resident 258's nasal cannula and oxygen humidifier should be labeled of the dated it was initially used, and the HHN circuit should be placed in a plastic bag and should be labeled and dated it was initially used. RN 1 stated, nursing would not know the last time it was used and if it was old, and it could harbor bacteria and virus and can cause or even spread infection.
During an interview on 10/1/2024 at 10:15 AM with Infection Preventionist Nurse (IPN), IPN stated, Resident 258's nasal cannula, humidifier should be labeled and dated it was initially used and the HHN circuit should be in a plastic bag and dated of when it was initially used and labeled. IPN stated, otherwise it could be old equipment and could harbor bacteria or virus that can cause and spread infection.
A review of Resident 258's facility document titled 'Progress Notes (PN) dated 9/16/2024 was reviewed, the PN indicated Resident 258 was receiving oxygen at 2 liters per minute upon admission on [DATE].
A review of Resident 258's facility document titled Order Summary Report dated 10/2/2024 was reviewed. The document indicated a physician order for Albuterol Sulfate (medication used for to prevent and treat wheezing, difficulty breathing), inhalation nebulization solution 2.5mg/0.5 ML to be administered every four hours as needed via HHN.
5. During a review of Resident 43 ' s admission Record dated 1/27/2022, the record indicated the facility admitted Resident 43 on 1/27/2022, and readmitted on [DATE] with diagnoses including Spinal Stenosis (abnormal narrowing of the spinal canal that may occur in any of the regions of the spine), Chronic Obstructive Pulmonary disease (COPD - lung disease which makes breathing difficult), and Dysphagia (difficulty swallowing).
During a review of Resident 43's Minimum Data Set (MDS-a federally mandated resident assessment tool.), dated 7/24/2024, indicated the cognitive (the ability to think and process information) skills for daily decisions making was moderately impaired, and required moderate assistance for activities of daily living.
During a review of Resident 43 ' s Order Summary Report, dated 10/03/2024, the Order Summary Report indicated an order on 6/02/2024 to provide the resident a consistent carbohydrate, No Added Salt Diet mechanical soft texture (a texture-modified diet that restricts foods that are difficult to chew or swallow), Regular/Thin consistency finely chopped.
During a review of Resident 257 ' s admission Record dated 9/20/2024, the record indicated the facility admitted Resident 43 on 9/20/2024, with diagnoses including Muscle weakness, and Hypertension (HTN - elevated blood pressure.
During a review of Resident 257's Minimum Data Set (MDS-a federally mandated resident assessment tool.), dated 9/24/2024, indicated the cognitive (the ability to think and process information) skills for daily decisions making was moderately impaired, and required moderate assistance for activities of daily living.
During a review of Resident 257 ' s Order Summary Report, dated 10/03/2024, the Order Summary Report indicated an order on 10/02/2024 to provide the resident a consistent carbohydrate diet, Regular/Thin consistency.
During an observation on 10/2/2024, at 12:30 p.m., Certified Nurse Assistant (CNA 4) was observed obtaining a meal tray from the meal tray cart and entered Resident 43 ' s room. CNA 4 was observed setting up the meal tray for Resident 43.CNA 4 was then observed exiting Resident 43 ' s room and then obtaining another meal tray from the meal tray cart for Resident 257. CNA 4 entered Resident 257 ' s room, CNA 4 was observed not performing hand hygiene in between meal tray distribution and set up for Resident 43 and Resident 257.
During an interview on 10/2/2024 at 12:35 p.m., CNA 1 stated not performing hand hygiene in between assisting Resident 43 and 257. CNA 1 stated she should have performed hand hygiene before and after entering or exiting any resident ' s room. CNA 1 stated it was important to performed hand hygiene to prevent cross contamination between residents.
During an interview on 10/4/2024 at 3:20 p.m. with the Director of Nursing (DON), the DON stated according to the facility's policy, all nursing staff were supposed to wash their hands prior to any physical contact or providing care and to wash their hands before and after the procedure.
During a review of the facility's policy and procedure (P&P) titled, Hand Hygiene indicated use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: Before and after assisting a resident with meals.
A review of the facility's policy and procedure (P&P) titled, [Departmental (Respiratory Therapy) - Prevention of Infection], dated 11/2011, indicated: a) the purpose is to guide prevention of infection associated with respiratory therapy task and equipment, among residents and staff, b) use distilled water for humidification per facility protocol, mark bottle with date and initials upon opening and discard after twenty-four (24) hours, b) change the oxygen cannula and tubing every seven (7) days, or as needed, c) infection control consideration related to medication nebulizers includes store the circuit in a plastic bag, marked with date and resident's name between uses, and discard the administration set-up every seven days.
A review of the facility's policy and procedure (P&P) titled, [Administering Medications through a small volume (Handheld) Nebulizer], dated 10/2010, indicated: a) when equipment is completely dry, store in a plastic bag with the resident's name and the date on it, b) change equipment and tubing every seven days, or according to facility protocol.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to screen for the need of pneumococcal (PNA) vaccine (an administration of vaccine that stimulate the body's own immune system to protect the person against infection or disease) and offer the vaccine to one of five sampled residents (Resident 160) when the resident was initially admitted to the facility as indicated in the facility's policy and procedure titled, Pneumococcal Vaccine
The deficient practice had the potential to result in Resident 160 did not receive the PNA vaccine as recommended by the Department of Public Health and Centers of Disease Control and Prevention (CDC), which out the resident at risk for contracting pneumonia (a severe lung infection).
Findings:
During a review of Resident 160's admission Record indicated the facility admitted Resident 160 on 9/5/24 with diagnoses that include depression (a common mental disorder, involving a depressed mood or loss of pleasure or interest in activities for long periods of time) and low back pain.
During a review of a Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 9/9/24, indicated Resident 160 had moderately impaired cognition (ability to understand and make decisions) skills for daily decision making. The MDS indicated Resident 160 required supervision or touching assistance with eating, partial/moderate assistance with oral hygiene, personal hygiene and chair/bed-to-chair transfer, and substantial/maximal assistance with toileting hygiene and shower/bathe self.
During a concurrent interview and record review on 10/3/24 at 8:45 AM, with the Infection Preventionist (IP), Resident 160 ' s Informed Consent (a process that ensures a person has enough information to make an informed decision about a medical procedure, treatment, or clinical trial) for Pneumococcal Vaccine, dated 9/27/24, was reviewed. The IP stated she was responsible to screen the pneumococcal vaccine to all the residents upon their admission or couple days after the admission. The IP stated Resident 160 was admitted on [DATE] and she did not screen and offer Resident 160 the pneumococcal vaccine until 9/27/24 because she was busy with other tasks in the facility. The IP stated she should have screened the resident for the pneumococcal vaccine timely so that the resident was informed about the vaccine and how to protect herself from contracting pneumonia.
During an interview on 10/4/24 at 11:13 AM, with the Director of Nursing (DON), the DON stated the staff should screen the residents for the need to have pneumococcal vaccine when the resident was admitted into the facility to ensure the resident was informed about the vaccine and offered the vaccine to protect the residents from contracting pneumococcal infection.
During a review of the facility ' s policy and procedure (P&P) titled, Pneumococcal Vaccine, dated 3/2022, indicated Assessments of pneumococcal vaccination status are conducted within five working days of the resident ' s admission .

Based on observation, interview, and record review, the facility failed to maintain a safe and sanitary environment for one of three sampled residents (Resident 160) who was observed with stained and soiled both upper bed siderails (one of the long narrow members connecting the headboard and footboard of a bed).
This deficient practice had the potential to result in Resident 160's discomfort and the spread of infection.
Findings:
During a review of Resident 160's admission Record indicated the facility admitted Resident 160 on 9/5/24 with diagnoses that include depression (a common mental disorder, involving a depressed mood or loss of pleasure or interest in activities for long periods of time) and low back pain.
During a review of a Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 9/9/24, indicated Resident 160 had moderately impaired cognitive (ability to understand and make decisions) skills for daily decision making. The MDS indicated Resident 160 required supervision or touching assistance with eating, partial/moderate assistance with oral hygiene, personal hygiene and chair/bed-to-chair transfer, and substantial/maximal assistance with toileting hygiene and shower/bathe self.
During a concurrent observation and interview on 10/1/24 at 10:41 AM, with Resident 160, Resident 160 was observed lying in bed. Resident 160's siderails were observed with multiple brown stains and clumped accumulations of dust. Resident 160 stated since admission to the facility two weeks ago, Resident 160's siderails already had the brown stains and dust. Resident 160 stated informing the maintenance supervisor (MS) when Resident 160 was admitted to the facility regarding the dirty side rails, however no one came to clean Resident 160's siderails. Resident 160 stated utilizing siderails to move herself in bed and to get out of bed, but she did not want to touch the siderails because they were dirty. Resident 160 stated she did not feel comfortable staying in a bed with dirty bed siderails.
During a concurrent observation and interview on 10/1/24 at 10:45 AM, with Certified Nursing Assistant (CNA) 5, Resident 160 ' s side rails were observed. CNA 5 stated Resident 160 ' s siderails were dirty and that Resident 160 ' s side rails should be cleaned to provide a clean and sanitary environment. CNA 5 stated housekeeping was responsible for cleaning resident side rails.
During an interview on 10/1/24 at 10:58 AM, with Housekeeping (HK) 1, HK 1 stated the bed siderails were considered as the high touch area (those that people frequently touch with their hands) which required daily cleaning to prevent the spread of infection and provide a sanitary environment to the resident. HK 1 stated not cleaning Resident 160 ' s siderails. During an interview on 10/4/24 at 11:14 AM, with the Director of Nursing, the DON stated staff should clean the bed siderails daily to maintain a safe and sanitary environment for all residents in the facility.
During a review of the facility ' s policy and procedure (P&P) titled, Homelike Environment, dated 2/2021, the P&P indicated Resident are provided with a safe, clean, comfortable and homelike environment .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to obtain an informed consent for psychotropic (any drug that affects behavior, mood, thoughts, or perception) drug for one of one sampled resident (Resident 99) who was prescribed Quetiapine (medication used to treat a mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions), and Zolpidem (medication used for used to treat insomnia (trouble sleeping) .
This deficient practice had violated Resident 99's rights to be informed when choosing the type of care or treatment to be received, make decisions on alternative measures the resident or responsible party preferred, which could negatively affect Resident 99 ' s quality of life.
Findings:
A review of the admission record indicated Resident 99 was admitted on [DATE] with diagnoses that included dementia (a group of related symptoms associated with an ongoing decline of the brain and its abilities), psychotic disorder (affect the mind, where there has been some loss of contact with reality), and cognitive communication deficit.
A review of Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 6/4/2024, indicated Resident 99 ' s cognitive status was severely impaired. The MDS indicated Resident 99 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and or contact guar assistance as resident completes activity) with eating, partial/moderate assistance (helper does less than half the effort) with toileting and substantial/maximal assist (helper does more than half the effort) with bathing and personal hygiene.
During an observation on 10/1/2024 at 10:03 AM in the facility dining room, Resident 99 on a wheelchair with activity staff verbalizing nonsensical (having no meaning; making no sense) words.
During a concurrent observation and interview on 10/3/2024 at 11:00 AM with certified nurse assistant (CNA) 3 Resident 99 was in bed asleep. CNA 3 stated, Resident 99 gets confused with episodes of agitation, and the staff would just redirect resident 99 ' s attention.
During an interview on 10/3/2024 at 11:15 AM with Director of Staff Development (DSD) stated, Resident 99 was receiving psychotropic medications, and it should have a consent obtained and signed by the physician as per policy. DSD stated, the physician needs to explain the cause and effect of the medication and other alternatives. DSD stated, not having consent for psychotropic medication, violates resident rights.
During a concurrent interview and record review, on 10/3/2024, at 11:30 AM, with Director of Nurses (DON), Resident 99 ' s Informed Consent for psychotropic drugs Quetiapine and Zolpidem, (undated) was reviewed. The documents did not have a date and a physician name or signature who obtained consent. DON stated, the psychotropic informed consent should have a signature of the doctor per policy. DON stated, she did not have any documented proof, consent for psychotropic drugs was obtained by the doctor from Resident 99 or responsible party. DON stated, it was important for the doctor to obtain the consent for psychotropic medication, so he can explain pros and cons of the medications and alternative options. DON stated, not having not having psychotropic medication consents violates Resident 99 ' s rights.
A review of Resident 99 ' s facility document Order Summary Report (OSR), dated 10/1/2024, , the document indicated order for: a) Quetiapine Fumarate 25 mg (unit of weight) to give 1 tablet at bedtime for schizophrenia (serious mental illness that affects how a person thinks, feels, and behaves) ordered 5/31/2024, and b) Zolpidem Tartrate 10 mg to give 1 tablet at bedtime for insomnia manifested by inability to sleep, ordered 9/23/2024.
A review of the facility ' s policy and procedure (P&P) titled Informed Consent, dated 6/2019, indicated: a) to involve residents in their care decisions by facilitating information and obtaining consent for the use of psychotropic drugs, b) if resident is determined not to have the capacity to make informed decisions a surrogate decision maker is identified, c) when initiating a new order in psychotropic drugs the attending physician will obtain inform consent from resident or responsible party.
A review of the facility ' s policy and procedure (P&P) titled Resident Rights, dated 2/2021, indicated, federal and state law guarantee certain basic rights to all residents of the facility, these rights included rights to: a) be notified of his or her medical condition and of anu changes in his or her condition, and b) be informed of , and participate in, his or her care planning and treatment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide communication board (a sheet of symbols, pictures, or photos that one can use by point to, to help people who have limited spoken language ability to communicate with others.) to facilitate and help residents express and have their needs met for one of twenty-three sampled residents (Resident 23).
This failure had a potential to result in Resident 23's needs not met, feeling upset, potential decline in quality of care provided to her and her overall quality of life.
Findings:
During a review of Resident 23's admission Record indicated the facility initially admitted Resident 23 on 4/1/2015 and readmitted on [DATE] with diagnoses that included hemiplegia (a condition that causes partial or complete paralysis or weakness on one side of the body and hemiparesis (weakness or an inability to move on one side of the body) following cerebral infraction (stroke, a serious condition that occurs when blood flow to the brain is disrupted, causing brain tissue to die) affecting right dominant side, muscle weakness, cognitive communication deficit, aphasia (loss of the ability to understand or express spoken or written language), and dysphagia (difficulty swallowing).
During a review of Resident 23 ' s Speech Therapy SLP (Speech-Language Pathologist, a communication expert that assess and treat people who have speech, language, voice, and fluency disorders) Evaluation and Plan of Treatment, dated 7/15/2023, indicated Resident 23 had profound expressive language skills characterized by mostly nonverbal speech. The record indicated Resident 23 was able to express occasional yes/no answers to questions, follow directions, read written text but unable to write, and recommended interventions included implementation of simple communication boards to facilitate with wants/needs.
During a review of Resident 23's History and Physical, dated 8/12/2024, indicated Resident 23 had fluctuating capacity to understand and make decisions.
During a review of Resident 23's care plan (a document that outlines the facility ' s plan to provide personalized care to a resident based on the resident ' s needs), dated 3/6/2024, indicated Resident 23 was at risk of communicate her needs due to problems with inability to express self making self-understood by others. The goal was to use a form of communication to help Resident 23 effectively communicate with others and ensure all her needs anticipated and met by the facility. The interventions included to provide alternative means of communication, including use of communication board.
During a concurrent dining observation and interview on 10/1/2024 at 12:15 PM with Resident 23 in her room, Resident 23 was observed eating alone with no assistant and unable to cut up a piece of adult palm size chicken. Resident 23 pointed to her right arm to express that her right arm could not move and that she could not use her right hand to cut up the chicken to eat.
During a concurrent observation and interview on 10/1/2024 at 12:45 PM with Certified Assistant Nurse (CNA) 4 in Resident 23's room, Resident 23 was pointing at the lunch tray and making gesture with four fingers while CNA 4 was observed guessing what Resident 23 wanted for approximately 10 minutes. CNA 4 stated, she could not understand what Resident 23 wanted. When surveyor asked Resident 23 if she wanted to cut the chicken up in four pieces, Resident 23 nodded her head. CNA 4 stated, she usually guessed what Resident 23 wanted and she had never seen any communication board in the facility. CNA 4 stated, there should be a communication board with pictures to help understand the resident better because Resident 23 could read and understand when staff communicated with her.
During a concurrent observation and interview on 10/3/2024 at 4:04 PM with CNA 9 in Resident 23 ' s room, Resident 23 was observed upset, lying on the right-hand side and making left hand gesture toward CNA 9, CNA 9 was observed guessing what Resident 23 wanted. CNA 9 stated, she was not Resident 23 ' s regular CNA so she did not understand what Resident 23 was trying to say. CNA 9 stated, she would come out and request help from her coworker. CNA 9 stated, she had never seen any communication board in the facility.
During a concurrent observation and interview on 10/3/2024 at 4:10 PM with CNA 10 in Resident 23 ' s room, CNA 10 stated, she came to help CNA 9 to understand what Resident 23 wanted. CNA 10 stated, she could not understand what Resident 23 wanted. CNA 10 stated, she had not seen any communication board with pictures and simple languages in the facility.
During an interview on 10/3/2024 at 6:08 PM with the Director of Nurses (DON), the DON stated, the facility had communication board with pictures to assist in helping staff communicate with the residents who had difficulty in expressing their needs. The DON stated, without communication board, the staff could neglect what Resident 23 ' s needs and not able to provide the services that she needed. The DON stated, the resident could feel upset for not able to communicate what she wanted, and her health could decline.
During a review of the facility ' s policy and procedure (P&P) titled, Accommodation of Needs, dated March 2021, the P&P indicated in order to accommodate individual needs and preferences, staffs are to interact with the residents in ways that accommodate the physical or sensory limitations of the residents, promote communication, and maintain dignity.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During a review of Resident 3's admission Record indicated the facility admitted Resident 3 on 6/3/24 with diagnoses that include schizoaffective disorder (a mental health condition that is marked by a mix of symptoms, such as hallucinations [a perception of something that seems real but is not, and can involve any of the senses] and delusions [a false belief or judgement about external reality], mood disorder [a mental health condition that primarily affects the emotional state] and mania [a condition in which you have a period of abnormally elevated, extreme changes in your mood or emotions, energy level or activity level]) and dementia (a group of thinking and social symptoms that interferes with daily functioning).
During a review of a Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 9/3/24, indicated Resident 3 had moderately impaired cognition (ability to understand and make decisions) skills for daily decision making. The MDS indicated Resident 3 required partial/moderate assistance with eating and chair/bed-to-chair transfer, and required substantial/maximal assistance with oral hygiene, toilet hygiene, shower/bathe self and personal hygiene.
During a review of Resident 3's Order Summary Report (OSR), dated 9/30/24, the OSR indicated physician ordered the resident to receive Olanzapine (a medication that can treat several mental health conditions) 10 milligram (MG, a unit of measurement) one tablet by mouth at bedtime for psychosis (a condition that causes a person to lose touch with reality, making it difficult to distinguish what is real and what is not) manifested by delusional (holding a false belief or judgement about external reality).
During a review of Resident 3's Medication Administration Record (MAR), dated from 6/2024 to 10/2024, the MAR indicated Resident 3 received Olanzapine 10 MG one tablet by mouth at bedtime from 6/3/24 to 10/3/24.
During a concurrent interview and record review on 10/3/24 at 2:10 PM, with Licensed Vocational Nurse (LVN) 5, Resident 3's Care Plan (CP) was reviewed. LVN 4 stated Resident 3 was receiving psychotropic medication-Olanzapine. LVN 5 stated Resident 3 did not have a care plan to address interventions in the use of a psychotropic medication, there should have been a care plan developed to provide guidance to the staff how to care for the resident safely.
During a concurrent interview and record review on 10/3/24 at 2:15 PM, with Registered Nurse (RN) 3, Resident 3's CP was reviewed. RN 3 stated there was no CP to address the use of a psychotropic medication for Resident 3. RN 3 stated it was important to develop and implement the CP for Resident 3 regarding the use of olanzapine because the CP could guide staff what to monitor the side effects of olanzapine and how to intervene effectively to ensure Resident 3 ' s safety.
3. During a review of Resident 70's admission Record indicated the facility originally admitted Resident 70 on 6/1/23 and readmitted on [DATE] with diagnoses that include dementia and psychotic disorder (severe mental illnesses that cause abnormal thinking and perceptions, and a loss of touch with reality).
During a review of Resident 70 ' s MDS, dated [DATE], indicated Resident 70 had intact cognitive (ability to understand and make decisions) skills for daily decision making. The MDS indicated Resident 70 required setup or clean-up assistance with eating and oral hygiene, partial/moderate assistance with personal hygiene, substantial/maximal assistance with chair/bed-to-chair transfer, and was dependent with toileting hygiene.
During a review of Resident 70's OSR, dated 10/3/24, the OSR indicated the physician ordered for Resident 70 to receive medications list below, started on 6/27/24:
a. Divalproex sodium (a medication is used to stabilize mood) 500 MG one tablet by mouth every 12 hours for mood stabilizer
b. Olanzapine 10 MG one tablet by mouth two times a day for striking out at staff and/or roommate
c. Paliperidone Palmitate (a medication is used to treat the symptoms of mental disorders) 235 MG/1.5 milliliter (ML, a unit of measurement) inject 0.5 ML intramuscularly one time a day starting on the 23rd and ending on the 23rd every month for rapid mood cycling sudden shifts in mood from pleasant to extreme anger as evidence by screaming and yelling
d. Risperidone (a medication is used to treat the symptoms of mental disorders) one MG one tablet by mouth one time a day for striking out at staff and/or roommate
e. Sertraline (a medication is used to treat the symptoms of a mental disorder) 100 MG one capsule by mouth one time a day for irritability manifested as verbal aggression
During a review of Resident 70 ' s MAR, dated from 6/2024 to 10/2024, the MAR indicated Resident 70 received Divalproex sodium 500 MG one tablet by mouth every 12 hours, Olanzapine 10 MG one tablet by mouth two times a day, Risperidone one MG one tablet by mouth one time a day, and Sertraline 100 MG one capsule by mouth one time a day from 6/28/24 to 10/2/24. The MAR indicated Resident 70 received Paliperidone Palmitate 235 MG/1.5 ML inject 0.5 ML intramuscularly one time a day on 7/23/24 and 8/23/24.
During a concurrent interview and record review on 10/3/24 at 2:12 PM, with Licensed Vocational Nurse (LVN) 5, Resident 70 ' s Care Plan (CP) was reviewed. LVN 4 stated Resident 70 s was receiving multiple psychotropic medications and the CP to address the intervention while receiving these psychotropic medications should be developed to provide guidance to the staff how to care for the resident safely. The LVN 5 stated the CP of the use of multiple psychotropic medications was not completely developed for Resident 70.
During a concurrent interview and record review on 10/3/24 at 2:17 PM, with Registered Nurse (RN) 3, Resident 70 ' s CP was reviewed. RN 3 stated the CP to address interventions to monitor the resident while receiving Divalproex, Risperdal and Olanzapine including their adverse effects and side effects, were not initiated on 6/27/24, but there was no intervention documented on the CP. RN 3 also stated there was no CP to address interventions to monitor the resident while receiving the use of Divalproex, Sertraline, and Paliperidone Palmitate for Resident 70. RN 3 stated it was important to develop and implement the complete CP for Resident 70 regarding the use of multiple psychotropic medications because the CP could guide staff what to monitor the side effects of her psychotropic medications and how to intervene effectively if the side effects occurred to ensure Resident 70 ' s safety.
During an interview on 10/4/24 at 11:16 AM, with the Director of Nursing (DON), the DON stated if a resident was on a psychotropic medication, the nurse should develop and implement the complete care plan regarding the use of the psychotropic medication to ensure safe care to the resident.
During a review of the facility ' s policy and procedure (P&P) titled, Behavior/Psychotropic Drug Management, dated 6/2019, the P&P indicated The Care Plan shall reflect .use of psychoactive medication(s), adverse reactions to psychoactive medication(s) .experienced by the resident and interventions taken.
Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan (a document that outlines the facility's plan to provide personalized care to a resident based on the resident's needs) for four of five sampled residents (Resident 58, 3, 70 and 63) by failing to:
1. Develop a care plan for dementia Resident 58 with dementia (a progressive state of decline in mental abilities)
2. Develop a plan of care for Resident 3 and Resident 70 while receiving psychoactive medications ( medications that affects mood and behavior).
3. Develop a plan of care for Resident 63 who refused to have the nasal canula (a device used to deliver supplemental oxygen placed directly on a resident's nostrils) placed in a bag when not in use.
These deficient practices had the potential for the residents not to recieve the necesary care and services to achieve their highest potential and/or in adverse side effects (undesired effect) from the use of psychoactive medications.
Findings:
1. During a review of Resident 58's admission Record indicated the facility initially admitted Resident 58 on 4/27/2021 and readmitted on [DATE] with diagnoses that included dementia, schizophrenia (a mental illness that is characterized by disturbances in thought), and anxiety disorder(a group of mental disorders characterized by significant feelings of fear that affect with daily activities).
During a review of Resident 58 ' s Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 8/9/2024, indicated Resident 58 ' s cognition (a term for the mental processes that take place in the brain, including thinking, attention, language, learning, memory and perception) was severely impaired.
During a review of Resident 58 ' s History and Physical, dated 1/13/2024, indicated Resident 58 did not have the capacity to understand and make decisions.
During a concurrent interview and record review on 10/4/2024 at 9:41 AM with Licensed Vocational Nurse (LVN) 1, Resident 58 ' s care plan was reviewed. LVN 1 stated, there was no care plan initiated for Resident 58 ' s dementia. LVN 1 stated, Resident 58 ' s diagnosis included dementia upon admission and there should have been a care plan for Resident 58 ' s dementia diagnosis. LVN 1 stated care plans were necessary for resident care, and not having a care plan for a resident ' s specific needs was a risk to resident ' s health and care, since staff would not know what interventions to implement or what to monitor. LVN1 stated the care plan was needed to ensure interventions were effective or not, and by implementing a care plan licensed nurses could monitor residents more effectively.
During an interview on 10/4/2024 at 12:57 PM with the Director of Nurses (DON), the DON stated, it was important to have a care plan addressing each of the diagnosis for Resident 58 including dementia so staffs would know how to take care of the resident and to discuss in the Interdisciplinary Team meeting (IDT, a coordinated group of experts from several different fields). The DON stated, Resident 58 would not have the right interventions for the specific behavior, and facility staff could not provide the care and services needed for Resident 58 ' s specific needs.
During a review of the facility ' s policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, dated March 2022, the P&P indicated, a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident ' s physical, psychosocial and functional needs is developed and implemented for each resident.
4. During a review of Resident 63 ' s admission Record (Face Sheet), dated 2/18/2022, the face sheet indicated the facility admitted Resident 63 on 2/18/2022, and readmitted on [DATE] with diagnoses including Chronic Obstructive Pulmonary disease (COPD - lung disease which makes breathing difficult), and bronchiectasis (a condition where your airways widen or develop pouches).
During a review of Resident 63 ' s History and Physical dated 3/3/2024, indicated, Resident 63 had the mental capacity to make medical decisions.
During a review of Resident 63 ' s Order Summary Report, dated 10/2/2024, the Order Summary Report indicated an order on 3/3/2024, the order indicated may use oxygen at two (2) liters per minute (L/min) via nasal cannula (device use for delivery of oxygen) to maintain oxygen saturation (amount of oxygen carried in blood) at 92% (normal range 90-100%).
During a review of Resident 63's MDS, dated [DATE], indicated the cognitive (the ability to think and process information) skills for daily decisions making was intact, and independent for activities of daily living.
During a concurrent observation and interview on 10/1/2024 11:33 a.m., CNA 4 stated Resident 63 refuses to put the nasal cannula in a bag.
During a review of Resident 63's Care Plans did not indicate the resident refused to have nasal canula placed in a bag when not in use.
During a concurrent observation and interview on 10/4/2024 at 11:34PM with Resident 63 in resident's room. Resident 63 stated, he likes the tubbing just like it is. He does not like it in a bag.
During an interview on 10/4/2024 at 3:20 PM with the Director of Nursing (DON), stated the resident's behavior of not wanting the nasal canula in a bag should have been addressed and care planned accordingly.
During a review of the facility's P&P titled, Care Plans, Comprehensive Person-Centered, dated 3/2022, the P&P indicated the comprehensive, person-centered care plan is developed for each resident within seven days of completion of required MDS assessment, and no more than 21 days after admission.
During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person- Centered, revised 4/2022, P&P indicated, a comprehensive person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychological and functional needs is developed for each resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the quarterly Minimum Data Sets (MDS - a federally mandated resident assessment tool) were completed within the required time frame for four out of four sampled residents (Residents 2, 30, 60, and 77).
This deficient practice had the potential to negatively affect the provision of necessary care and services for Residents 2, 30, 60, and 77.
Findings:
During a review of Resident 2's admission Record, indicated the facility initially admitted Resident 2 on 8/4/2020 and readmitted on [DATE].
During a review of Resident 30's admission Record, indicated the facility admitted Resident 30 on 2/21/2024.
During a review of Resident 60's admission Record, indicated the facility admitted Resident 60 on 11/10/2022.
During a review of Resident 77's admission Record, indicated the facility initially admitted Resident 77 on 2/13/2023 and readmitted on [DATE].
During an interview on 10/2/2024 at 3:52 PM with the MDS Nurse, the MDS Nurse stated, all residents were required to have MDS assessment quarterly after their admission date. The MDS Nurse stated, the system had a list of residents with their Assessment Reference Date (ARD-referring to resident assessments), and she had 14 days to complete the assessment after the ARD.
During a concurrent record review and interview on 10/2/2024 at 3:57 PM with the MDS Nurse, Resident 2's quarterly MDS was reviewed. The MDS Nurse stated, based on the record, Resident 2's most recent quarterly MDS assessment ' s ARD was 8/16/2024 and her deadline to complete the assessment was 8/30/2024. The MDS Nurse stated, she completed Resident 2's assessment on 10/1/2024, which was 33 calendar days late.
During a concurrent record review and interview on 10/2/2024 at 4:05 PM with the MDS Nurse, Resident 30's quarterly MDS was reviewed. The MDS Nurse stated, based on the record, Resident 30's most recent quarterly MDS assessment ' s ARD was 8/20/2024 and her deadline to complete the assessment was 9/3/2024. The MDS Nurse stated, she completed Resident 30's assessment on 10/2/2024, which was 29 calendar days late.
During a concurrent record review and interview on 10/2/2024 at 4:10 PM with the MDS Nurse, Resident 60's quarterly MDS was reviewed. The MDS Nurse stated, based on the record, Resident 60's most recent quarterly MDS assessment ' s ARD was 8/22/2024 and her deadline to complete the assessment was 9/5/2024. The MDS Nurse stated, she completed Resident 60 ' s assessment on 10/2/2024, which was 27 calendar days late.
During a concurrent record review and interview on 10/2/2024 at 4:20 PM with the MDS Nurse, Resident 77's quarterly MDS was reviewed. The MDS Nurse stated, based on the record, Resident 77's most recent quarterly MDS assessment's ARD was 8/15/2024 and her deadline to complete the assessment was 8/29/2024. The MDS Nurse stated, she completed Resident 77's assessment on 9/27/2024, which was 29 calendar days late.
During an interview on 10/2/2024 at 4:30 PM with the MDS Nurse, the MDS Nurse stated, she had been late for the residents assessment because there was a pilling of a number of residents assessment, and she did not have enough time to complete them all.
During an interview on 10/4/2024 at 1:12 PM with the Director of Nurses (DON), the DON stated, she was aware that residents assessment had been completed late. The DON stated, there was an MDS consultant that oversaw the MDS Nurses. The DON stated, if the residents assessment were late, there might be something wrong with the resident that we would not be able to assess and update the care plan timely. The DON stated, she would coordinate with the MDS consultant to make sure the residents are assessed and submitted timely.
During a review of the facility's policy and procedure (P&P) titled, MDS Completion and Submission Timeframes, revised July 2017, the P&P indicated, the facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes, timeframes for completion and submission of assessments is based on the current requirements published in the Resident Assessment Instrument (RAI) Manual.
During a review of the facility's P&P titled, RAI OBRA-required (Omnibus Budget Reconciliation Act, federal law passed in 1987 that established standards for nursing home care and the rights of nursing home residents) Assessment Summary, dated October 2024, indicated for the non-comprehensive quarterly MDS assessment, the MDS completion date must be no later than 14 calendar days following the ARD.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure assistance was provided ADLS (Activities of Daily Living- (routine tasks, activities such as eating, that a person performs daily to care for themselves) during mealtimes for one of twenty-three sampled residents (Resident 23).
This failure resulted in Resident 23's feeling upset, not able to eat her chicken during lunch on 10/1/2024, and a potential risk for malnutrition and weight loss. In addition, could result in a decline in the resident ' s ability to perform ADLS.
Findings:
During a review of Resident 23's admission Record indicated the facility initially admitted Resident 23 on 4/1/2015 and readmitted on [DATE] with diagnoses that included hemiplegia (a condition that causes partial or complete paralysis or weakness on one side of the body and hemiparesis (weakness or an inability to move on one side of the body) following cerebral infraction (stroke, a serious condition that occurs when blood flow to the brain is disrupted, causing brain tissue to die) affecting right dominant side, muscle weakness, cognitive communication deficit, aphasia (loss of the ability to understand or express spoken or written language), and dysphagia (difficulty swallowing).
During a review of Resident 23 ' s Speech Therapy SLP (Speech-Language Pathologist, a communication expert that assess and treat people who have speech, language, voice, and fluency disorders) Discharge Summary, dated 9/29/2023, indicated the treatment included utilization of safe swallow strategies such as small bites/sips.
During a review of Resident 23 ' s History and Physical, dated 8/12/2024, indicated Resident 23 had fluctuating capacity to understand and make decisions.
During a review of Resident 58 ' s Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 9/3/2024, indicated Resident 23 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) with eating (ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident) and oral hygiene.
During a review of Resident 23 ' s care plan (a document that outlines the facility ' s plan to provide personalized care to a resident based on the resident ' s needs), dated 9/6/2024, indicated Resident 23 was at risk for weight loss, decline in functional status, and aspiration/choking during meals. The goals were to reduce/minimize risk of aspiration/choking during meals, and to receive adequate nutrition/hydration daily. The interventions included diet for mechanical soft diet with thin liquid, provide assist during meals as needed, and monitor tolerance with texture of food.
During a review of Resident 23's Nutritional Screening, dated 9/5/2024, indicated Resident 23 ' s diet order was Regular, mechanical soft texture, and supervision was needed during eating.
During a review of Resident 23's Order Summary Report, indicated Resident 23 had a physician order on 7/16/2023 for Regular diet with mechanical soft texture, regular/thin consistency.
During a concurrent dining observation and interview on 10/1/2024 at 12:15 PM with Resident 23 in her room, Resident 23 was observed in bed eating alone with no assistance. Resident 23 was observed using a spoon to cut up a piece of chicken that was close to 2x3 inches (unit of length) in size. A knife and a fork were observed on the right side of the lunch tray, and Resident 23 was observed unable to reach her left hand to the fork. When surveyor asked if she could reach to her fork, Resident 23 shook her head and pointed to her right arm expressing that her right arm could not move.
During an observation on 10/1/2024 at 12:35 PM in Resident 23's room, no staff was observed coming to check on Resident 23. Resident 23 was observed getting upset not able to use the spoon to cut and eat the chicken. Resident 23 nodded her head when the surveyor asked if Resident 23 needed assistance from the nurses during meals. Surveyor walked to the nurses ' station to request for assistance for Resident 23.
During a concurrent observation and interview on 10/1/2024 at 12:45 PM with Certified Assistant Nurse (CNA) 4 in Resident 23 ' s room, Resident 23's lunch tray was observed. CNA 4 stated, the chicken looked too big for the resident to eat. CNA 4 stated, the resident should be assisted to cut the chicken into bite size or grounded (meat that has been finely chopped using a meat grinder or chopping knife) to make it easy for Resident 23 to scoop the food and put in her mouth. CNA 4 stated, Resident 23 had right side weakness and used only her left hand to eat during meals time. CNA 4 stated, Resident 23 should have been assisted during meals time.
During an interview on 10/3/2024 at 6:15 PM with the Director of Nurses (DON), the DON stated, Resident 23 should have been assisted during mealtimes due to her right-side weakness. The DON stated, Resident 23 could be upset not able to eat her food and would be potential at risk for malnutrition and weight loss.
During a review of the facility's policy and procedure (P&P) titled, Activities of Daily Living (ADL), Supporting, dated March 2018, indicated appropriate care and services will be provided for residents who are unable to carry out ADLs independently, including appropriate support and assistance with dining (meals and snacks).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report immediately and within two hours an allegation or suspicion of physical abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish) to the Administrator (the facility ' s Abuse Coordinator), state agency, responsible party, police department and ombudsman (state personnel that advocates for the residents in the facility) for one of three sampled residents (Resident 106) in accordance with the facility ' s policy Abuse Reporting and Investigation.
LVN 4 witnessed the confrontation between Resident 106 and Resident 29 in front of the nursing station #1 after Resident 106 allegedly poured water on Resident 29 while the resident was asleep, and did not report the incident to the Abuse Coordinator or designee within two hours.
CNA 3 changed Resident 106's wet bed linens and wet floor in the resident's floor and heard about the altercation, but did not report the incident immediately to the Abuse Coordinator.
The Social Services Director (SSD) reported the abuse incident to the enforcement agencies on 10/4/24 at 2:02 PM (eight days after the incident happened).
This deficient practice had the potential to result in repeat altercation and abuse between the residents and also result in unidentified abuse in the facility that could result in injury and psychosocial decline (emotional being).
Findings:
During a review of Resident 106's admission Record indicated the facility admitted Resident 106 on 9/13/2024 with diagnoses that include schizophrenia (a mental health condition that is marked by a mix of symptoms, such as hallucinations and delusions, mood disorder depression, and mania) and anxiety disorder (a mental illness that causes a person to experience excessive and uncontrollable feelings of fear or anxiety).
During a review of a Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 9/17/2024, indicated Resident 106 had moderately impaired cognitive (ability to understand and make decisions) skills for daily decision making. The MDS indicated Resident 106 required supervision or touching assistance with eating, and partial/moderate assistance with oral hygiene, toilet hygiene, shower/bathe self and personal hygiene, and chair/bed-to-chair transfer.
During a review of Resident 106 ' s Progress Notes, dated 10/4/24, the Progress Notes indicated there was no documentation on the altercation-to-altercation between Resident 106 and Resident 29.
During a review of Resident 29's admission Record indicated the facility originally admitted Resident on 2/13/24 and readmitted on [DATE] with diagnoses that include schizophrenia (a mental health condition that is marked by a mix of symptoms, such as hallucinations and delusions, mood disorder depression, and mania) and dementia (a chronic condition that causes a decline in cognitive abilities, such as thinking, remembering, and reasoning, that interferes with daily life).
During a review of a Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 9/4/24, indicated Resident 29 had moderately impaired cognitive (ability to understand and make decisions) skills for daily decision making. The MDS indicated Resident 29 required supervision or touching assistance with eating, and partial/moderate assistance with oral hygiene, toilet hygiene, shower/bathe self and personal hygiene, and chair/bed-to-chair transfer.
During a review of Resident 29 ' s Progress Notes, dated from 9/1/24 to 10/2/24, the Progress Notes indicated there was no documentation on the altercation-to-altercation between Resident 106 and Resident 29.
During a review of Report of Suspected Dependent Adult/Elder Abuse (SOC 341, a form, as adopted by the California Department of Social Services CDSS, is required under Welfare and Institutions Code WIC. Use SOC 341 to report suspected dependent adult/elder abuse), dated 10/4/24, indicated that the incident related to Residents 109 and 29 ' s altercation was reported to the Department on 10/4/24 at 2:02 PM via facsimile transmission.
During an interview on 10/1/24 at 3:20 PM, with Resident 106, Resident 106 stated he remembered the altercation occurred the day Resident 29 was transferred to his room, and they became roommates. Resident 106 stated at around 7:30 PM while he was asleep on his bed, Resident 29 suddenly walked toward his bed and poured a cup of water on him. Resident 106 stated Resident 29 walked out the room right away, and he followed Resident 29 to the nursing station #1. Resident 106 stated he asked Resident 29 why he poured water on him, but Resident 29 did not answer and pretended he did not pour water on him. Resident 106 stated Resident 29 had issues and he always tried to look for trouble. Resident 106 stated Resident 29 poured the water on him on purpose. Resident 106 stated the staff separated them immediately after the incident occurred. Resident 106 stated he was upset at that time, and he had to keep an eye on Resident 29 all the time to make sure he did not try to do something to him again.
During an interview on 10/2/24 at 4:25 PM, with Licensed Vocational Nurse (LVN) 4, LVN 4 stated he could not remember when, but he saw Resident 29 walked out the room with Resident 106 following behind him. LVN 4 stated Resident 29 and Resident 106 stopped and stood face to face about one foot away from each other in front of the Nursing Station #1. LVN 4 stated Resident 106 asked Resident 29 loudly why did you pour water me? LVN 4 stated Resident 29 stayed quiet and did not say anything. LVN 4 stated Resident 106 and Resident 29 got really close to each other, then, the staff separated the residents. LVN 4 stated he did not witness how Resident 29 pour water on Resident 106, but he saw Resident 106 ' s bed was wet, so the Certified Nursing Assistant (CNA) 3 changed the wet bed linens for Resident 106 and housekeeping came to clean the floor. LVN 4 stated he thought the altercation was reported and the DON was aware because the DON was in the facility at that time.
During an interview on 10/2/24 at 4:30 PM, with CNA 3, CNA 3 stated she did not witness Resident 29 poured water on Resident 106, but after the incident, she was sent to change Resident 106 ' s bed. CNA 3 stated she saw Resident 106 ' s bed was wet, and she changed the bed linens for Resident 106. CNA 3 stated she only remembered the altercation occurred sometime last week but could not remember the exact date.
During an interview on 10/4/24 at 11:20 AM, with the Director of Nursing (DON), the DON stated she did not know about the altercation between Resident 106 and Resident 29 occurred last week and no staff had reported it to her until the surveyor informed her. The DON stated the facility did not report since she did not know about it. The DON stated a resident-to-resident altercation between Resident 106 and Resident 29 should be reported immediately within two hours after the incident occurred.
During an interview on 10/4/24 at 1:08 PM, with Registered Nurse (RN) 4, RN 4 stated Resident 29 was transferred to Resident 106 ' s room on 9/26/24.
During an interview on 10/4/24 at 5PM, with the Administrator (ADM), the ADM stated he and the DON did not know about the altercation between Resident 106 and Resident 29 until today. The ADM stated he did not know that the staff who were aware of the altercation on 9/26/24 did not report or document it. The AMD stated the staff should reported to the DON or himself immediately, so they did not delay the reporting process.
During a review of the facility ' s policy and procedure (P&P) titled, Abuse Reporting and Investigation, dated 11/2018, indicated The facility will report ALL allegations of abuse as required by law and regulations to the appropriate agencies within 2 hours .Allegations of abuse, neglect, mistreatment, or exploitation are to be reported to the Abuse Prevention Coordinator immediately.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement facility's written abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish) policy and procedure for two of three sampled residents (Resident 106 and Resident 29) by not conducting a thorough investigation when the two residents were involved in a resident-to-resident altercation.
Resident 106 allegedly physically abused by Resident 29 during a resident -to-resident altercation on 9/26/24. Resident 29 poured a cup of water on Resident 106, who was sleeping on his bed around 7:30 PM on 9/26/24. Resident 29 walked out the room with Resident 106 following behind him. Resident 29 and Resident 106 stopped and stood face to face about one foot away from each other in front of the nursing station #1. Resident 106 asked Resident 29 loudly why did you pour water me? Resident 29 stayed quiet and did not say anything.
These deficient practices resulted in the residents not protected from repeat abuse and residents at risks from injury from abuse, feeling of intimidation and neglect.
Findings:
During a review of Resident 106's admission Record indicated the facility admitted Resident 106 on 9/13/24 with diagnoses that include schizophrenia (a mental health condition that is marked by a mix of symptoms, such as hallucinations and delusions, mood disorder depression, and mania) and anxiety disorder (a mental illness that causes a person to experience excessive and uncontrollable feelings of fear or anxiety).
During a review of a Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 9/17/24, indicated Resident 106 had moderately impaired cognitive (ability to understand and make decisions) skills for daily decision making. The MDS indicated Resident 106 required supervision or touching assistance with eating, and partial/moderate assistance with oral hygiene, toilet hygiene, shower/bathe self and personal hygiene, and chair/bed-to-chair transfer.
During a review of Resident 29's admission Record indicated the facility originally admitted Resident 29 on 2/13/24 and readmitted on [DATE] with diagnoses that include schizophrenia (a mental health condition that is marked by a mix of symptoms, such as hallucinations and delusions, mood disorder depression, and mania) and dementia (a chronic condition that causes a decline in cognitive abilities, such as thinking, remembering, and reasoning, that interferes with daily life).
During a review of a Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 9/4/24, indicated Resident 29 had moderately impaired cognitive (ability to understand and make decisions) skills for daily decision making. The MDS indicated Resident 29 required supervision or touching assistance with eating, and partial/moderate assistance with oral hygiene, toilet hygiene, shower/bathe self and personal hygiene, and chair/bed-to-chair transfer.
During a review of Resident 106 ' s Progress Notes, dated from 9/26/24 to 10/4/24, the Progress Notes indicated there was no documentation and investigation related to the altercation between Resident 106 and Resident 29.
During a review of Resident 29 ' s Progress Notes, dated from 9/1/24 to 10/2/24, the Progress Notes indicated there was no documentation related to the altercation between Resident 106 and Resident 29.
During an interview on 10/1/24 at 3:20 PM, with Resident 106, Resident 106 stated, he remembered the day Resident 29 was transferred to his room, and they became roommates. Resident 106 stated it was at around 7:30 PM while he was sleeping on his bed, Resident 29 walked toward his bed suddenly poured a cup of water on him. Resident 106 stated Resident 29 immediately walked out their room right away, he then followed Resident 29 to the nursing station #1. Resident 106 stated he asked Resident 29 why he poured water on him, but Resident 29 did not answer and pretended he did not do it. Resident 106 stated Resident 29 had issues and he always tried to look for trouble. Resident 106 stated Resident 29 poured the water on him on purpose. Resident 106 stated the staff separated them immediately after the incident occurred. Resident 106 stated he was upset at that time, and he had to keep an eye on Resident 29 all the time to make sure he did not try to do something to him again.
During an interview on 10/2/24 at 4:25 PM, with Licensed Vocational Nurse (LVN) 4, LVN 4 stated he could not remember if it happened on 9/25/24 or 9/26/24 around 7:30 PM, he saw Resident 29 walked out the room with Resident 106 following behind him. LVN 4 stated Resident 29 and Resident 106 stopped and stood face to face about one foot away from each other in front of the nursing station #1. LVN 4 stated Resident 106 asked Resident 29 loudly why did you pour water me? LVN 4 stated Resident 29 stayed quiet and did not say anything. LVN 4 stated Resident 106 and Resident 29 got really close to each other, then, the staff separated the residents. LVN 4 stated he did not witness how Resident 29 pour water on Resident 106, but he saw Resident 106 ' s bed was wet, so the Certified Nursing Assistant (CNA) 3 changed the wet bed linens for Resident 106 and housekeeping came to clean the floor. LVN 4 stated he thought the altercation was reported and the DON was aware because the DON was in the facility at that time.
During an interview on 10/2/24 at 4:30 PM, with CNA 3, CNA 3 stated she did not witness Resident 29 poured water on Resident 106, but after the incident, she was sent to change Resident 106 ' s bed. CNA 3 stated she saw Resident 106 ' s bed was wet, and she changed the bed linens for Resident 106. CNA 3 stated she only remembered the altercation occurred sometime last week but could not remember the exact date.
During an interview on 10/4/24 at 11:20 AM, with the Director of Nursing (DON), the DON stated she did not know about the altercation between Resident 106 and Resident 29 occurred last week and no staff had reported it to her until the surveyor informed her. The DON stated she did not investigate since she did not know about it. The DON stated a resident-to-resident altercation between Resident 106 and Resident 29 should be investigated and intervene effectively to protect the residents in the facility.
During an interview on 10/4/24 at 1:08 PM, with Registered Nurse (RN) 4, RN 4 stated Resident 29 was transferred to Resident 106 ' s room on 9/26/24.
During an interview on 10/4/24 at 5:00 PM, with the Administrator (ADM), the ADM stated he and the DON did not know about the altercation between Resident 106 and Resident 29 until today. The ADM stated he did not know that the staff who were aware of the altercation on 9/26/24 did not report or document it. The AMD stated a thorough investigation should be conducted to prevent reoccurrence of the altercation and protect the residents.
During a review of Report of Suspected Dependent Adult/Elder Abuse (SOC 341, a form, as adopted by the California Department of Social Services CDSS, is required under Welfare and Institutions Code WIC. Use SOC 341 to report suspected dependent adult/elder abuse), dated 10/4/24, indicated the incident was reported to the Department on 10/4/24 at 2:02 PM via facsimile transmission.
During a review of the facility ' s policy and procedure (P&P) titled, Abuse Reporting and Investigation, dated 11/2018, indicated When the Abuse Prevention Coordinator receives a report of an incident or suspected incident of resident abuse, mistreatment, neglect, exploitation or injuries of an unknown source, the APC will initiate an investigation immediately. The P&P indicated to inform resident of results of investigation or Corrective Action and provide a written report of the results of all abuse investigations and appropriate action taken to the California Department of Public Health Licensing and Certification and others that may be required by state or local laws, within five working days for the reported allegation

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure adequate supervision for one of three sampled residents (Resident 1) by not escalating the process of finding Resident 1 ' s whereabout by not informing the Medical Doctor (MD), Director of Nurses (DON)] or the Social Worker (SW) for guidance when Resident 1 went out on pass (OOP) (temporary permission of a patient to leave the hospital in a specified time) on 5/23/2024 at 8:30 AM, and did not return to the facility the same day at 12:00 PM (which was Resident 1 ' s estimated time of return).
This incident delayed the notification of law enforcement and other appropriate agencies, who were notified more than 24 hours from the time of the incident.
Resident 1 returned to the facility on 5/25/2024 at 1:30 AM (more than 24 hours from the time resident went OOP), feeling tired, with untidy clothes and dirty hands and feet. Resident 1 also missed 2 days of due medications.
This deficient practice had the potential for Resident 1 to sustain accidents and physical injury while out of the facility.
Findings:
A review of Resident 1 ' s admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily), schizoaffective disorder, bipolar type (Episodes of mania {extreme highs} and sometimes major depression {severe lows}, and hypertension (high blood pressure).
A review of Resident 1 ' s History and Physical Examination, dated 2/27/2024, indicated Resident 1 had the capacity to understand and make decisions.
A review of Minimum Data Set (MDS, a standardized assessment and care screening tool), date 3/4/2024, indicated Resident 1 ' s cognitive skills (ability to make daily decisions) was moderately impaired. The MDS indicated Resident 1 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and or contact guard assistance as resident completes activity) with eating and partial/moderate assistance (helper does less than half the effort) with personal hygiene.
A review of Resident 1 ' s physician order dated 3/9/24, indicated Resident 1 may go out on pass.
A review of Resident 1 ' s care plan (CP) titled Out on Pass, dated 3/9/2024, the CP indicated concern Resident may sustain injury going out on pass. The CP intervention included; if Resident is due for medication during the time that he or she will be out on pass, the Resident will be given medications that are due for that time and written and or oral instructions on when and how to administer the medications that are to be issued.
A review of Resident 1 ' s facility document titled Temporary Leave of Absence (TLA), dated 5/23/2024, indicated Resident 1 went OOP on 5/23/2024 at 8:30 AM with estimated time of return of 12:00 noon.
A review of Resident 1 ' s facility document titled Departmental Notes (DN), dated 5/24/2024 timed at 2:27 PM, indicated Primary Medical Doctor (PMD), and the Police was notified regarding Resident 1 have not returned from going OOP from 5/23/2024 at 8:30 AM (more than 24 hours from Resident 1 estimated time of return).
A review of Resident 1 ' s facility document titled Departmental Notes (DN), dated 5/25/2024 timed at 5:30 AM, indicated, Resident 1 returned to the facility around 1:30 AM clothes were untidy, hands and feet were dirty, overall appearance were disheveled (messy).
During an interview on 5/28/2024 at 12:20 PM with the Director of Nurses (DON), the DON stated, Resident 1 went OOP on 5/23/2024 at 8:30 AM and did not return until 5/25/24 at 1:30 AM. The DON stated Resident 1 missed two days of scheduled medications. The scheduled medications included Fluoxetine 10 mg daily for depression, Senna 8.6 mg daily for constipation, metoprolol 50 mg tablet twice daily for hypertension, quietapine 100 mg twice daily for schizophrenia, gabapentin 300 mg three times daily for neuralgia/seizure, another quietapine 200 mg at bedtime.
During a concurrent observation and interview on 5/28/2024 at 12:28 PM with Resident 1 in Resident 1 ' s room, Resident 1 stated, she usually goes OOP frequently. On 5/23/2024 Resident 1 stated, she went OOP to go to a pawnshop and get money to fix herself, manicure, and shopping. Resident 1 stated, she had trouble getting transportation to go back to the facility and her phone stopped working. Resident 1 stated, she stayed at a (Store 1) the whole time and random people and Store 1 owner did not let her use their phone to call the facility. Resident 1 stated she felt cold while outside the facility and her feet hurts. Resident 1 stated, on 5/25/2024 at around 1 AM, a good citizen (Citizen 1), called transportation for her to get back to the facility.
During an interview on 5/28/2024 at 1 PM with the Social Worker (SW), the SW stated, Resident 1 was gone for more than 24 hours (Resident 1 went OOP 5/23/2024), and Resident 1 whereabouts should have been addressed immediately when Resident 1 did not return from her expected time of return on 5/23/2024 at 12 noon. The SW stated, she was not informed of Resident 1 not returning from OOP until the next day, 5/24/2024. The SW stated, she informed the police, the ombudsman, and the Department of Health 5/24/2024, and it should be documented.
During an interview on 5/28/2024 at 1:15 PM with the DON, the DON stated, the OOP order was not complete, it should include the duration the resident is allowed to be OOP. The DON stated, she should have been notified when Resident 1 did return from OOP immediately, so she could have notified the Police earlier. The DON stated it is important to always know Resident 1 ' s whereabouts for her safety.
During an interview on 5/28/2024 at 1:45 PM with Licensed Vocational Nurse (LVN) 1, stated, if a resident did not return from going OOP at the expected time of return, and unable to contact the resident, it should be escalated to upper management for guidance. LVN 1 stated, regarding Resident 1 ' s incident, the PMD, the DON, and SW should have been notified immediately to alert authorities. LVN 1 stated, the facility is responsible for Resident 1 ' s safety.
During an interview on 5/28/2024 at 1:45 PM with Registered Nurse (RN) 1 (RN supervisor 7 to 3 shift 5/23/2024), stated, on 5/23/2024 when Resident 1 did not return from going OOP at 12 PM (estimated time of return), she should have escalated the concern and notify the MD, DON, and SW to alert the authorities.
During a concurrent interview and record review, on 5/28/2024, at 2:15 PM, with the DON, Resident 1 ' s Medication Administration Record (MAR) for the month of May 2024 indicated, for 5/22/2024 and 5/23/2024 medications were initialed N. The DON stated, N indicated the medications were not given for 2 days which included medication for high blood pressure. The DON stated, Resident 1 not getting her blood pressure medication and other scheduled medications had the potential for harm.
During an interview on 5/28/2024 at 3:25 PM with LVN 2 (worked on 5/23/2024 7 to 3 shift), stated, when Resident 1 did not return from going OOP she should have escalated the issue and notified the MD, DON, and SW for guidance. LVN 2 stated, it is important to know Resident 1 ' s whereabout because it is a safety issue and something bad might happen to her.
During an interview on 5/28/2024 at 3:25 PM with LVN 3 (worked on 5/23/2024 3 to 11 shift), stated, it was endorsed to her by the previous shift, that Resident 1 went OOP and had not returned yet. LVN 3 stated, she should have escalated the concern and inform the resident ' s physician, the DON, and the SW for guidance and alert authorities. LVN 3 stated, knowing Resident 1 whereabouts is a patient safety issue.
During an interview on 5/28/2024 at 4 PM with the DON, the DON stated, she expected the staff to inform her if a resident did not return at least within 4 hours from the time the resident is supposed to comeback from OOP so she can report it to the appropriate agencies as an unusual occurrence.
A review of the facility ' s policy and procedure (P&P) titled Signing Resident Out, revised 8/2006. The P&P indicated; a) unless otherwise prohibited by law, medications that must be administered while the resident is out will be given to the resident /person signing the resident out, b) written and/or oral instruction on when and how to administer the medication will be provided to the resident or to the person signing the resident out, and only medications that must be administered while the resident is out will be issued.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and record review, the facility failed to provide adequate supervision for one of five residents (Resident 1) based on the resident ' s individual and assessed needs.
This lack of supervision has increased risk for falls and injuries due to resident ' s wandering (Going one location to another aimlessly, usually without a plan or definitive purpose).
This deficient practice had the potential for Resident 1 to sustain injuries and increases the risk of altercations with other residents.
Findings:
A review of Resident 1 ' s admission Record indicated the resident was admitted on [DATE], with diagnosis of, but not limited to, dementia (decline in mental ability server enough to interfere with daily function) and Alzheimer ' s disease (A progressive disease that destroys memory and other important mental functions).
A review of Resident 1 ' s History and physical dated 11/2/2023, indicates Resident 1 does not have the capacity to understand and make decisions with chief complaint of wondering behavior and Dementia.
A review of Resident 1 ' s Minimum Set Data (MDS - a standardized assessment and screening tool) dated 4/16/2024, indicated Resident 1 has severe cognitive impairment. The MDS also indicated the resident is dependent for all aspects of personal hygiene, dressing, bathing and indicated resident has presence of wandering behavior, occurring daily.
A review of Residents 1 ' s Physicians orders dated 12/10/2023, indicated to Monitor whereabouts of Resident every hour.
A review of Resident 1 ' s Medication Administration Record with a start date of 12/10/2023, indicated to monitor whereabouts of resident every hour. However, the MAR indicated documentation were completed every shift (8 hours - Day, Evening, Night).
A review of Resident 1 ' s Care plan dated 10/30/2023, indicated a problem/need, that showed Resident 1 was at risk for injuries secondary to wandering behavior with a goal of Resident 1 will have no injuries and interventions. The interventions indicated to monitor the resident ' s location with visual check at least every 2 hours.
A review of Resident 1 ' s records indicated Resident 1 was monitored hourly from 4/20/24 to 4/23/24 but no documentation found that Resident 1 was monitored every 2 hours after 4/24/24.
A review of Resident 1 ' s Care plan dated 4/20/2024, indicated the resident will have 1:1 supervision as needed. A review of Resident 1 ' s records indicated that Resident 1 had no 1:1 supervision from 4/20/2024 up to present. Resident 1 ' s records indicated Resident 1 was monitored hourly from 4/20/24 to 4/23/24 only.
A review of Resident 1 ' s record titled Renew SBAR dated 4/20/24 timed at 2:47 PM, indicated that an altercation happened between Resident 1 and Resident 2. Resident 2 physically assaulted Resident 1. Resident 2 punched Resident 1 on the left cheek because Resident 1 walked inside Resident 2 ' s room. The SBAR indicated, Resident 1 did not sustain injuries.
During an interview on 5/6/2024 at 9:45 am with the DON, when asked how the facility staff monitor Resident 1 as indicated in the care plan and physician orders. The DON stated the CNA assigned to the area where Resident 1 was, would be responsible for monitoring the location of the resident and document in the MAR every shift. The DON noted during a concurrent review of the Physician Order indicated to monitor the resident every hour.
During a concurrent record review and interview on 5/6/2024 at 10:40 am, with LVN 1, stated it was normal for Resident 1 to wander. LVN 1 stated Resident 1 does go into other resident ' s rooms occasionally. LVN 1 stated the facility staff make sure to make a visual check every 30 minutes and stated the physician order indicated Resident 1 should be monitored every hour, but the Medication Administration Record indicated to document every shift. This is the only documentation we do.
During an observation on 5/6/24 at 11 am, inside Resident 1 ' s room, Resident 1 was lying in bed and unable to verbalize needs and unable to respond to basic questions.
During an interview on 5/6/24 at 12:50 pm, the DON was asked how supervision was being provided to Resident 1. The DON stated that Resident 1 only had 72 hours monitoring after the altercation occurred on 4/20/24. The DON stated after that, Resident 1 had every shift monitoring. The DON stated Resident 1 had wandering behavior in the past but did not recall going inside other resident's rooms or displaying hostile behaviors.
On 5/6/2024 at 1:30 pm, during an observation, inside Resident 1 ' s room, Resident 1 was found on the floor, next to the resident ' s bed. Resident 1 ' s body was lying with head facing the foot of the bed with abdomen almost prone position on the floor. No visible signs of bleeding or lacerations noted. Observed resident not moving, no vocalization of being in pain or calling for help. No audible sound alarming from the bed. During the observation, and [NAME] Resident 1 was on the floor, CNA2 was inside the room in the next bed, assisting Resident 1 ' s roommate. CNA 2 was asked if he knew Resident 1 was on the floor. CNA 1 stated oh he is just crawling.
During the same concurrent observation and interview, on 5/6/24 at 1:35 pm, CNA 2 assisted Resident 1 back in bed. CNA 2 stated he did not see Resident 1 get out of bed, even if he is just in the next bed assisting the roommate. When asked if Resident 1 was able to walk independently, CNA 2 stated Resident 1 was able to walk when he wants to. When asked why Resident 1 was still in bed at 1:35 pm, CNA 2 had no answer. During the observation, Resident 1 was attempting to get out of bed with unsteady gait and requiring maximum assistance of CNA2 to walk.
On 5/6/24 at 1:36 pm, the DON stated that Resident 1 ' s behavior is at his baseline and that the facility would have to place a bed alarm to alert staff.
On 5/6/24 at 3:15 pm, the SSD stated that she interviewed Resident 2, after the altercation and Resident 2 informed him that Resident 1 came inside his room behaving agitated, that is why he hit Resident 1. The SSD stated that Resident 1 is a fall risk.
A review of Facility ' s policies and procedures titled Wandering and Elopement dated 7/2018, Indicated purpose: to enhance the safety of Residents, to help identify Resident who are at risk and to minimize possible injury.
A resident who are deemed to be high risk for elopement or wandering will have a photograph maintained in their medical record and IDT will develop a plan of care considering the individual risk factors of the Resident. Person- centered approach/ interventions to prevent elopement and /or divert wandering behavior will be included in the plan- of - Care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to comprehensively assess the root cause of behavioral symptoms and develop measurable goals and interventions to address care and treatment of a resident with dementia (a disorder of mental processes caused by brain disease or injury and marked by memory disorder, personality changes, and impaired reasoning) for one of five sampled residents (Resident 1) with diagnosis of dementia with behaviors.
This deficient practice had the potential to negatively affect the safety, wellbeing, and the delivery of services.
Findings:
A Review of admission record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1 ' s diagnoses included but was not limited to Dementia (loss of memory, language, problem – solving and other thinking abilities) with behavioral disturbances, schizoaffective disorder (hallucinations or delusions, and symptoms of a mood disorder, such as depression), anxiety disorder( responds to situations with fear and dread), and Alzheimer ' s disease( loss of memory and thinking skills and, loss of ability to carry out simple tasks).
A review of Resident 1 ' s History and physical report completed on 11/2/2023, indicated resident 1 does not have the capacity to understand and make decisions with diagnosis of advanced Dementia (loss of memory, language, problem – solving and other thinking abilities).
A review of Resident 1 ' s Minimum Set Data (MDS – a standardized comprehensive assessment and care planning tool) dated 4/16/2024, indicated the resident displays wandering behavior daily with potential for hallucinations (Perceptual experiences in the absence of real external sensory stimuli).
A review of Resident 1 ' s Physician order dated 12/10/2023, indicated to monitor resident 1 ' s whereabouts every hour with diagnosis of Alzheimer ' s disease.
A review of Resident 1 ' s Medical Administration Records indicated resident 1 receives Donepezil 10mg tablet: every day at 9 pm for Dementia.
A review of Resident 1 ' s Care plan dated 10/30/2023, indicated a problem/need, that showed Resident 1 was at risk for injuries secondary to wandering behavior with a goal of Resident 1 will have no injuries and interventions. The interventions indicated to monitor the resident ' s location with visual check at least every 2 hours.
A review of Resident 1 ' s records indicated Resident 1 was monitored hourly from 4/20/24 to 4/23/24 but no documentation found that Resident 1 was monitored every 2 hours after 4/24/24.
A review of Resident 1 ' s Care plan dated 4/20/2024, indicated the resident will have 1:1 supervision as needed. A review of Resident 1 ' s records indicated that Resident 1 had no 1:1 supervision from 4/20/2024 up to present. Resident 1 ' s records indicated Resident 1 was monitored hourly from 4/20/24 to 4/23/24 only.
A review of Resident 1 ' s record titled Renew SBAR dated 4/20/24 timed at 2:47 PM, indicated that an altercation happened between Resident 1 and Resident 2. Resident 2 physically assaulted Resident 1. Resident 2 punched Resident 1 on the left cheek because Resident 1 walked inside Resident 2 ' s room.
During a concurrent record review and interview on 5/6/2024 at 10:40 am, with LVN 1, stated it was normal for Resident 1 to wander. LVN 1 stated Resident 1 does go into other resident ' s rooms occasionally.
During an observation on 5/6/24 at 11 am, inside Resident 1 ' s room, Resident 1 was lying in bed and unable to verbalize needs and unable to respond to basic questions.
During an interview on 5/6/24 at 12:50 pm, the DON was asked how supervision was being provided to Resident 1. The DON stated that Resident 1 only had 72 hours monitoring after the altercation occurred on 4/20/24. The DON stated after that, Resident 1 had every shift monitoring. The DON stated Resident 1 had wandering behavior in the past but did not recall going inside other resident ' s rooms or displaying hostile behaviors.
On 5/6/2024 at 1:30 pm, during an observation, inside Resident 1 ' s room, Resident 1 was found on the floor, next to the resident ' s bed. Resident 1 ' s body was lying with head facing the foot of the bed with abdomen almost prone position on the floor. No visible signs of bleeding or lacerations noted. Observed resident not moving, no vocalization of being in pain or calling for help. No audible sound alarming from the bed. During the observation, and [NAME] Resident 1 was on the floor, CNA2 was inside the room in the next bed, assisting Resident 1 ' s roommate. CNA 2 was asked if he knew Resident 1 was on the floor. CNA 1 stated oh he is just crawling.
During the same concurrent observation and interview, on 5/6/24 at 1:35 pm, CNA 2 assisted Resident 1 back in bed. CNA 2 stated he did not see Resident 1 get out of bed, even if he is just in the next bed assisting the roommate. When asked if Resident 1 was able to walk independently, CNA 2 stated Resident 1 was able to walk when he wants to. When asked why Resident 1 was still in bed at 1:35 pm, CNA 2 had no answer. During the observation, Resident 1 was attempting to get out of bed with unsteady gait and requiring maximum assistance of CNA2 to walk.
On 5/6/24 at 1:36 pm, the DON stated that Resident 1 ' s behavior is at his baseline and that the facility would have to place a bed alarm to alert staff.
On 5/6/24 at 3:15 pm, the SSD stated that she interviewed Resident 2, after the altercation and Resident 2 informed him that Resident 1 came inside his room behaving agitated, that is why he hit Resident 1. The SSD stated that Resident 1 is a fall risk.
During a concurrent record review and interview on 5/6/2024 at 4:00 pm with the DON, the DON stated Dementia care plan was not created or implemented for Resident 1.
During a concurrent record review and interview on 5/6/2024 at 4:00 the pm with DON, the DON stated there is no record of IDT meeting conducted for Resident 1 ' s dementia diagnosis and manifesting behaviors associated with dementia.
A review of the Facility ' s Policy Revised December 2016 Titled Care Plans indicated a plan of care shall be developed to assure that that the resident ' s needs are met and maintained including but not limited to goals, and Therapy services and to updated as necessary.

Based on observation, interview, and record review the facility failed to provide the resident's call light (device used to alert facility staff assistance as needed by residents) within reaxh as indicated in the care plan, for one out of three sampled residents (Resident 2).
This deficient practice had the potential in a delay in meeting the resident ' s needs for assistance and can lead to frustration, unavoidable falls and accidents.
Findings:
A review of Resident 2 ' s admission Record indicated the facility admitted the resident on 8/5/2023, with diagnoses including but not limited to cognitive communication deficit (difficulty with understanding information and knowledge), difficulty in walking, muscle weakness.
A review of Resident 2 ' s History and Physical dated 12/8/2023, indicated Resident 2 does not have the capacity to understand and make decisions.
A review of Resident 2 ' s Minimum Data Set (MDS – a comprehensive standardized assessment and screening tool) dated 2/7/2024, indicated moderate assistance is required for all transfers from chair/bed to chair and toilet transfers and walk 10 feet.
A review of resident 2 ' s Care plan titled At risk for injuries dated 12/8/2023, revised on 3/2024, indicated Resident 2 would have no injuries and anticipate the residents need based upon behaviors.
During an observation on 3/21/2024 at 11:15 am, Resident 2 was observed sitting in a wheelchair on the right side of the bed. During the observation, the resident's call light was observed on the floor and not within reach of Resident 2, as indicated in the care plan.
During an interview on 3/21/2024 at 11:15 am, with Certified Nursing Assistant (CNA) 3, CNA 3 stated if a resident does not have a call light within reach, they can not notify the staff if they need to be assisted.
During a review of the facility Policy titled Answering the Call light Nursing Services Policy and Procedure Manual for Long-Term Care Dated 2001, revised on 10/2010, indicated the purpose of this procedure is to respond to the resident ' s requests and needs. General Guidelines to include but not limited to when the resident is in bed or confined to a chair be sure that call light is within easy reach of the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide care in a manner that maintained or enhanced a resident's dignity and respect in full recognition of his individuality for one (1) of seven sampled residents (Resident 5).
The facility staff was observed removing Resident 5's shirt and exposing Resident 5's upper body in the facility's Activity Room, in the presence of Resident 6, Resident 7, and Resident 6's Family Member (FAM 1).
This deficient practice had the potential to affect Resident 5 's self-esteem and self-worth.
Findings:
A review of Resident 5 ' s admission Record, indicated Resident 5 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included vascular dementia (changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain), psychotic disorder (a collection of symptoms that affect the mind, where there has been some loss of contact with reality. During an episode of psychosis, a person's thoughts and perceptions are disrupted and they may have difficulty recognizing what is real and what is not), and seizures (a burst of uncontrolled electrical activity between brain cells (also called neurons or nerve cells) that causes temporary abnormalities in muscle tone or movements (stiffness, twitching or limpness), behaviors, sensations or states of awareness).
A review of Resident 5's History and Physical (H&P), dated 1/3/24, indicated Resident 5 does not have the capacity to understand and make decisions.
A review of Resident 5's Minimum Data Set (MDS- a comprehensive assessment and screening tool) dated 11/24/2023, indicated the resident ' s cognition was severely impaired. The MDS indicated Resident 5 was dependent (helper does all the effort) for eating, oral hygiene, personal hygiene , upper body dressing, lower body dressing, rolling to the left and right, sit to stand, lying to sitting on the side of the bed, chair/bed-to chair transfer, toilet transfer, tub, shower transfer, toileting hygiene.
A review of Resident 6 ' s admission Record, indicated Resident 6 was admitted to the facility on [DATE], with diagnoses that included vascular atrial fibrillation (extremely fast and irregular beats from the upper chambers of the heart (usually more than 400 beats per minute), hypertension (high blood pressure), and dysphagia (difficulty swallowing).
A review of Resident 7 ' s admission Record, indicated Resident 7 was admitted to the facility on [DATE], with diagnoses that included failure to thrive (syndrome of weight loss, decreased appetite and poor nutrition, and inactivity, often accompanied by dehydration, depressive symptoms, impaired immune function, and low cholesterol), and cognitive communication deficit (difficulty with thinking and how someone uses language).
During an observation on 2/02/2024 at 12:58 PM, at the facility's Activity Room, Resident 5 was observed sitting in the wheelchair, Resident 5's shirt was wet and dirty. During the observation, Certified Nurse Assistant (CNA) 3 removed Resident 5's shirt and exposed Resident 5's upper body inside the Activity Room, in the presence of two other residents (Resident 6) and (Resident 7), who were also in the Activity Room. During the observation, there was one family member (FAM 1) sitting with the resident inside the Activity Room.
During an observation and interview on 2/02/2024 at 1:02 PM, at the facility's Activity Room, Resident 5 was observed sitting in the wheelchair, with the upper body exposed and CNA 3 was observed assisting Resident 5 to put on his shirt. During the observation, the Director of Nursing (DON) approached CNA 3 and informed CNA 3 to cover up Resident 5 and take the resident back to his room. The DON stated CNA 3 should have not change Resident 5's clothes while in the Activity Room and exposed Resident 5 in public, to preserve the resident ' s dignity.
During an interview on 2/02/2024 at 2:01 PM, CNA 3 stated she should not have changed Resident 5's shirt in the Activity Room which is a public place. CNA 3 stated Resident 5 may have felt uncomfortable and humiliated. CNA 3 stated Resident 5 may not have want to show his body to anyone.
A review of the facility's policies and procedures titled Quality of Life - Dignity, revised in February 2020, indicated each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, feeling of self-worth and self-esteem. Residents are treated with dignity and respect at all times. Staff inform and orient residents to their environment. Procedures are explained before they are performed and residents will be told in advance if they are going to be taken out of their usual or familiar surroundings. Staff personal promote, care and maintain during and treatment protect procedures. resident privacy, including bodily privacy during assistance with personal care and during treatment procedure.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure Resident 1 was free from physical restraints by allowing emergency medical technicians (EMT) to apply physical restraints attached in a gurney to Resident 1 ' s wrists and ankle on 11/15/2023 from 9:30 AM to 10:45 AM (one hour and 15 minutes) while waiting for Resident 1 to be evaluated by the Psychiatric Evaluation Team (PET), without a physician ' s order, on-going assessments and monitoring of the resident while on physical restraints, in accordance with the facility policy and procedure on Physical Restraint Application.
This failure resulted in Resident 1 ' s restriction of freedom of movement and had the potential to result in the resident ' s increased anxiety, agitation, and loss of dignity.
Findings:
A review of Resident 1 ' s Face Sheet (document that gives a patient ' s information such as contact details and brief medical history) indicated the facility admitted Resident 1 on 9/12/2023, with diagnoses that included major depressive disorder, severe with psych symptoms (a distinct type of depressive illness in which mood disturbance is accompanied by either delusions, hallucinations or both), generalized anxiety disorder (condition of excessive worry about everyday issues and situations) and schizoaffective disorder (mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucination or delusions, and mood disorder symptoms, such as depression or mania.)
A review of Resident 1 ' s Patient Care Plan: Behavior, dated 9/12/2023, indicated Resident 1 needed behavior management for the diagnosis of anxiety as manifested by restlessness. The care plan approach included giving Clonazepam (medication used to treat agitation) 0.5 mg as ordered to manage Resident 1 ' s behavior.
A review of Resident 1 ' s Order Summary Report for November 2023, indicated a physician order dated 11/11/2023, to administer Clonazepam 0.5 mg every 8 hours PRN (as needed) for agitation, for 14 days.
A review of Resident 1 ' s Minimum Data Set (MDS – a standardized assessment and care planning tool) dated 9/18/2023, indicated Resident 1 had moderately impaired cognition (ability to think, remember, and reason). The MDS indicated Resident 1 had behavioral symptoms not directed towards others (e.g., hitting or scratching self, screaming, disruptive sounds) and had a history of rejecting evaluation or care (e.g., bloodwork, taking medications, ADL assistance).
During a review of Resident 1 ' s Physician Telephone Orders, dated 11/15/2023 (no time), the Physician Telephone Orders indicated Resident 1 was to be transferred to GACH via 5150 (California Welfare and Institutions Code that allows for a 72 hours involuntary hold for treatment; criteria for hold includes a person exhibiting mental health issues that pose a threat to themselves or others, or are gravely disabled) for psychiatric evaluation, with bed hold for 7 days.
During a review of Resident 1 ' s Progress Notes, dated 11/15/2023 at 10:45AM and signed by the Registered Nurse Supervisor (RNS), the Progress Notes indicated Resident 1 left in the facility via ambulance (5150) in her usual self.
During an interview on 11/17/2023 at 10:49 AM with the RNS, the RNS stated Resident 1 ' s discharge plan to transfer to an acute hospital was initiated on 11/14/2023, but Resident 1 was not transferred until 11/15/2023, because the facility was waiting for the PET ' s evaluation and for transportation. The RNS stated the PET needed to determine if Resident 1 was a danger to self or others. The RNS stated that the EMTs (Emergency Medical Technicians – emergency response ambulance staff) arrived to the facility on [DATE] at 9:30 AM to pick up Resident 1, however, Resident 1 was not evaluated by the PET until around 10:08 AM, on 11/15/2023. The RNS stated that she did not transfer Resident 1 to the EMTs until she received the 5150 paperwork from the PET evaluation at around 10:30 AM. The RNS stated that Resident 1 was not transferred to the GACH until about 10:45 AM, on 11/152023, via ambulance.
During a concurrent interview and record review, on 11/17/2023, at 11:02 AM, with the RNS, Resident 1 ' s physician progress notes from Psychiatrist 1, [undated] was reviewed. The RNS stated Psychiatrist 1 ordered Resident 1 to be discharged on 11/14/2023, but the RNS wrote the order to transfer the resident on 11/15/2023. The RNS stated Psychiatrist 1 came to the facility on [DATE], but Resident 1 had already been transferred. The RNS stated she did not find notes from Psychiatrist 1 about Resident 1 ' s behavior and PET evaluation for 5150 transfer.
On 11/17/2023 at 12:05 PM, during a concurrent review and interview of the security camera surveillance footage of the facility lobby with the Administrator (ADM) and Maintenance Supervisor (MS), inside the ADM ' s office, the surveillance footage timestamped dated 11/15/2023, at 9:34 AM, showed two EMTs entering the facility ' s front lobby entrance with an empty gurney. The MS stated that the facility ' s security camera surveillance footage had about a 12-minute delay between the actual time and the time shown on the surveillance footage. During the continued review of the facility ' s security camera surveillance footage, timestamped at 10:54 AM, the surveillance footage showed Resident 1 leaving the facility with the two EMTs via gurney. The facility ' s security camera surveillance footage showed Resident 1 lying on the gurney with bilateral wrists and bilateral ankles soft restraints secured to the gurney. The ADM stated Resident 1 exhibited delusions that day, including believing there were cameras in her room and her roommate was somebody else (another name referred to a God). The ADM stated he believed Resident 1 ' s transfer took time because the EMTs were waiting for Resident 1 to agree with the transfer as ordered by the physician. The ADM stated the details of what transpired should be documented in Resident 1 ' s records.
During an interview on 11/17/2023 at 12:47 PM with the ADM, the ADM stated the facility does not use physical restraints with its residents. The ADM stated Psychiatrist 1 comes to the facility to evaluate residents once every two weeks, and leaves progress notes in the residents ' charts.
During an interview on 11/17/2023 at 1:24 PM with the facility ' s Receptionist (RCP), the RCP stated that in the morning of 11/15/2023, the RCP saw Resident 1 angrily banging on tables. The RCP stated when the EMTs arrived at the facility on 11/15/2023, Resident 1 was walking the hallways of the facility. The RCP stated she was not monitoring Resident 1 but believed Resident 1 was placed in the gurney when the EMTs arrived. The RCP stated Resident 1 was discharged out of the facility at around 10:45AM.
During an interview on 11/17/2023 at 1:53 PM with the RNS, the RNS stated the order for Resident 1 ' s transfer on 5150 was endorsed to her by the previous shift. The RNS stated there was a discussion on 11/14/2023, but she was not working that day; during that discussion, Psychiatrist 1 instructed the facility to call the PET for a 5150 hold for Resident 1. The RNS stated PET evaluation for Resident 1 was conducted via a phone call on 11/15/2023 at around 10:08AM. The RNS stated the facility received the 5150 transfer order form via fax at around 10:30 AM. The RNS stated the EMT ' s ambulance arrived at around 9:30 AM, and during that time, Resident 1 was walking around the facility. The RNS further stated the EMTs immediately placed Resident 1 on restraints because Resident 1 was fighting.
During an interview on 11/17/1023 at 2:09 PM with the Director of Nursing (DON), the DON stated that on 11/14/2023, Psychiatrist 1 instructed the facility to transfer Resident 1 to the GACH. The DON stated the licensed nurses should prepare the paperwork needed for the transfer and continue to observe the resident. The DON stated the facility practice was the facility ' s case manager arranges for the PET to come evaluate the resident, and arrange for the transportation. The DON stated the case manager called for an ambulance on 11/14/2023, but they did not come to the facility on [DATE], so the facility followed up again on 11/15/2023. The DON stated the ambulance arrived at the facility around on 11/15/2023 at around 9:30AM, and left at 10:45AM. The DON stated when the ambulance came, Resident 1 was paranoid and did not believe the ambulance was for her. The DON stated the facility did not have the 5150 evaluation and order form, so the EMTs could not take Resident 1. The DON stated the facility ' s case manager called the PET team to request for the required paperwork again. The DON stated that before the facility case manager called for the transportation or ambulance, the 5150 hold paperwork should had been ready.
During the same interview on 11/17/2023 at 2:18 PM with the DON, the DON stated when the two EMTs approached Resident 1, Resident 1 began cursing and yelling saying that was not her ambulance. The DON stated the facility staff assisted the EMTs in putting Resident 1 on the gurney because Resident 1 was kicking and screaming at the EMTs. The DON stated Resident 1 was strapped to the gurney for around one hour while the licensed nurses were obtaining the 5150-hold paperwork from the PET, because the EMTs could not leave without it. The DON stated the facility is restraint-free and it was not the facility ' s policy to put the residents in the gurney. The DON stated it was considered a physical restraint if the resident ' s wrists/ankles were strapped to the gurney. The DON stated that on 11/15/2023 Resident 1 was strapped in the EMT ' s gurney in front of the nurses ' station for about an hour. The DON stated that while Resident 1 was strapped in the gurney, Resident 1 was resisting and kicking the two EMTs. The DON stated that Resident 1 ' s attending physician was not notified while Resident 1 was combative and yelling during that time and there was no order to apply physical restraints while waiting to be transferred out of the facility. The DON stated Resident 1 was angry, trying to move her hands, and yelling You will be punished for this . [God] does not like what you ' re doing to me. The DON stated this was not a reason for Resident 1 to be physically restrained to the gurney. The DON stated Resident 1 was placed in front of the Nursing Station while lying on the gurney, for everyone in the facility to supervise. The DON stated there was no documented evidence that facility staff assessed and monitored Resident 1 for complications from physical restraints.
During a concurrent interview on 11/17/2023 at 2:56 PM with the Case Manager (CM), in the presence of the DON, the CM stated that she called for an ambulance to transport Resident 1 to the GACH. The CM stated the ambulance was from a private company. The CM stated she could not recall the time of her call to the ambulance company, but the ambulance company informed her that the ambulance was scheduled to arrive within two to three hours from the time of the call.
During a concurrent interview and record review on 11/17/2023 at 3:46 PM, with the DON, Resident 1 ' s Medication Administration Record (MAR) for November 2023 was reviewed. The DON stated that Resident 1 had an order for Clonazepam (medication used to treat agitation) as needed for agitation. The DON stated the MAR did not indicate that Clonazepam was administered to Resident 1 on 11/15/2023 for agitation. The DON stated the Clonazepam was not administered because Resident 1 was refusing medications. The DON stated the MAR did not indicate documented evidence that Resident 1 ' s physician was notified and refusing medication on 11/15/23 prior to the GACH transfer.
A review of the facility ' s policy and procedure titled, Physical Restraint Application, dated October 2010, indicated Physical Restraints are defined as any manual method, or physical, mechanical device, material or equipment attached or adjacent to the resident ' s body that the individual cannot remove easily which restricts freedom of movement. The policy and procedure further indicated to verify physician ' s order for the use of restraints and review the resident ' s care plan to assess for any special needs of the resident, including checking the resident every 30 minutes.
The policy and procedure indicated the following should be recorded in the resident ' s medical record:
1. Date and time restraints was applied
2. The name and title of the individual(s) who applied the restraint
3. The type of physical restraint applied
4. The specific reason the restraint was applied
5. The length of time the restraint will be used
6. Each time the device is released for resident exercise, toileting, and position change
7. Each time the resident is monitored.
8. All assessment data (e.g bruises, rashes, sores, etc.) observed during the procedure
9. If and how the resident participated in the procedure or any changes in the resident ' s ability to participate in the procedure
10. Any problems or complaints made by the resident related to the restraint application
11. If the resident refused treatment and the reason(s) why
12. The signature and title of the person recording the data

Based on interview, observation, and record review, the facility failed to follow its policy and procedure on Oxygen Administration for one of 3 sampled residents (Resident 67) who had a was receiving oxygen therapy (a supplemental delivery of oxygen) without a physician's order.
This deficient practice had the potential for Resident 67 and other residents receiving oxygen therapy to develop complications associated with oxygen therapy such as oxygen toxicity (also called oxygen poisoning is a lung damage due to receiving too much (supplemental) oxygen that can cause coughing, trouble breathing and in severe cases leads to death).
Findings:
A review of Resident 67's Face sheet (admission Record) indicated the facility initially admitted Resident 67 to the facility on 2/18/22 and readmitted date of 3/30/23 with the diagnoses that included, emphysema (gradual damage of lung tissue or alveoli [tiny air sacs] this damage causes the air sacs to rupture and traps air in the damaged tissue and prevents oxygen from moving through the bloodstream that causes the lungs to overfill with air and makes breathing more difficult), hepatic failure (failure of the liver to function that can cause serious complications such as bleeding and increased pressure in the brain) and schizophrenia (disorder that affects a person's ability to think, feel, and behave clearly which involve false beliefs and seeing or hearing things that don't exist).
A review of Resident 67's History and Physical (H&P) dated 3/30/23, indicated Resident 67 does not have capacity to understand and make decision.
A review of Resident 67's Minimum Data Set (MDS, a standardized resident assessment and care screening tool) dated 8/22/23, indicated Resident 67 had no impairment in memory and cognitive (ability to reason) level for daily decision making.
During an observation on 10/4/23 at 12:10 P.M., Resident 67 was observed lying in bed while receiving oxygen therapy at 2 liters per minute (L/min) via nasal cannula (a device used to deliver supplemental oxygen that should be placed directly on the resident's nostrils) from the oxygen concentrator (a medical device that concentrates oxygen from environmental air used for supplemental oxygen) located at the bedside.
During an observation and concurrent interview with Certified Nursing Assistant (CNA) 2 on 10/4/23 at 12:12 PM, CNA 2 stated Resident 67 was receiving oxygen 2 L/min oxygen.
During an interview on 10/4/23 at 12:20 P.M., the License Vocational Nurse (LVN ) 1 stated, Resident 67 uses oxygen therapy as needed for comfort.
During an interview and concurrent record review of the Physician's order for October 2023, conducted with LVN 3 on 10/5/23 at 8AM, LVN 3 stated, Resident 67 had no physician's order to receive oxygen therapy at 2 L/min for comfort as needed. LVN 3 stated there should be a physician's order if the resident receives oxygen therapy. LVN 3 stated the resident could develop oxygen toxicity if the resident received oxygen if they do not need oxygen.
During an interview and record review of Resident 67 Physician's order for the month of October 2023 with the Director of Nursing (DON) on 10/05/23 at 8:14 AM, the DON stated there should be a physician's order for Resident 67 to receive oxygen therapy. The DON stated, to ensure the residents receive the right amount of oxygen therapy, because without the physician's order, the residents could receive more or less oxygen than needed.
A review of the facility's undated policy and procedure titled Oxygen Administration, revised on 10/2010, indicated the facility will provide guidelines for safe oxygen administration by verifying if there was a physician's order for the procedure and the facility staff will review the physician's orders or facility protocol for oxygen administration.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to receive care consistent with professional standards of practice (specialty practice guidelines or protocols of care for specific populations) to prevent worsening of pressure injury/ulcers (a skin injury resulting from prolonged unrelieved pressure or being in one position in the bony areas of the body) and/or does not develop new pressure ulcers that were unavoidable by ensuring one of three sampled residents (Resident 21) received and documented the skin treatment as ordered by the physician for skin redness on both heels on 10/1/23.
This deficient practice had the potential for the Resident 21 and other potential residents with pressure ulcer to develop worsened pressure injury/ulcer.
Findings:
During a review of Resident 21's Face Sheet, an admission record, Resident 21 admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included hypertension (high blood pressure) and muscle weakness.
During a review of Resident 21's History and Physical Examination (H&P), dated 5/25/2023, indicated Resident 21 does not have the capacity to understand and make decisions.
During a review of Resident 21's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 8/24/2023, indicated the resident had severely impaired cognition (ability to think and reason) for daily decision making. The MDS indicated Resident 21 required supervision (oversight, encouragement or cueing) with eating, and extensive assistance (resident involved in activity, staff provide weight-bearing support) with bed mobility, transfer, dressing, toilet use and personal hygiene.
During a review of Resident 21's Wound Assessment Report, dated 9/23/2023, indicated Resident 21 had non-blanchable (skin remained with skin discoloration or redness when pressed) that measured 2.5-centimeter (cm) x 1.5 cm x UTD (unable to determined) on the right heel and non-blanchable redness measured 3.0cm x 1.5 cm x UTD on the left heel.
During a review of a Physician Orders indicated on 9/24/2023 the physician ordered to treat Resident 21's right heel and left heel redness with NS, pat dry, apply A&D (Vitamin A and D) ointment (an ointment to treat diaper rash or redness and protects and soothes dry, irritated skin) and leave open to air daily for 30 days.
During a concurrent interview and record review of the Treatment Record and Progress notes for October 2023 on 10/4/2023 at 10:41 AM, with the Treatment Nurse (TXN), indicated Resident 21's right and left heel on 10/1/2023 treatments were not documented in the Treatment Record and Department Notes to indicate the treatment was provided. The TXN stated she was off on 10/1/2023 and the licensed nursed who performed the treatment for Resident 21 should have document on the treatment for Resident 21. The TXN stated it was important to document treatment on the Treatment Record, so the other staff would know what and when a treatment Resident 21 received.
During an interview on 10/4/2023 at 11:48 AM, the Licensed Vocational Nurse (LVN) 1 stated, she provided treatment for Resident 21 on 10/1/2023 because there was no Treatment Nurse assigned to work on 10/1/23, but she did not document the treatment provided in the Resident 21's clinical records. LVN 1 stated she did not know how to document it on the TR. LVN 1 stated she asked other licensed staff working that day, and no one knew how to document it on the TR. LVN 1 stated it was important to document the wound treatment when administred so that the next shift nurse and other staff could know what treatment and when the resident received to avoid confusion on the residents' care.
During an interview on 10/4/2023 at 11:55 AM, LVN 2 stated she worked on 10/1/2023 and there was no treatment nurse working on that day. LVN 2 stated important to document the administration of wound treatment correctly in residents' medical record.
During an interview and concurrent record review on 10/4/2023 at 2:30 PM, with the Director of Nursing (DON), the DON stated there was no documentation in Resident 21's medical record indicating Resident 21 received wound treatment to her left and right heel on 10/1/2023. The DON stated it was important to document the administration of wound care treatment correctly to avoid confusion in the resident's care and to ensure consistency and continuation of care.
During a review of the facility's policy and procedure titled, Wound Care, dated 10/2010, indicated information including the type of wound care given and the date and time the wound care was given should be recorded in the resident's medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. A review of Resident 46's admission Record indicated the resident was initially admitted to the facility on [DATE] with the diagnosis of paranoid schizophrenia (a severe mental health condition that can involve delusions and paranoia) and encephalopathy (damage or disease that affects the brain).
A review of Resident 46's Minimum Data Set (MDS a standardized assessment and care screening tool), dated 8/30/2023, indicated that Resident 46 had moderate impaired cognition (the ability or mental action or process of acquiring knowledge and understanding).
During a concurrent interview and record review of Resident 46's Care Plan, with the Director of Nursing (DON), on 10/4/2023, at 11:35 AM, the DON stated there was no care plan in Resident 46's medical records for elopement. The DON stated Resident 46 had a history of elopement on 3/17/2022 from the facility. The DON stated the care plan for elopement should have been in Resident 46's medical records. The DON stated the elopement care plan was important for Resident 46 to monitor his behavior and to protect him from wandering outside the facility and getting injured.
5. A review of Resident 342's admission Record indicated the resident was initially admitted to the facility on [DATE] with the diagnosis of paranoid schizophrenia (a severe mental health condition that can involve delusions and paranoia) and human immunodeficiency virus (HIV-virus that attacks the body's immune system).
A review of Resident 342's MDS, dated [DATE], indicated that Resident 342 had moderate impaired cognition (the ability or mental action or process of acquiring knowledge and understanding).
During a interview and record review of Resident 342's Care plans, with Registered Nurse 1 (RN1), on 10/3/2023 at 2:28 PM, Registered Nurse (RN1) stated that Resident 342 did not have a care plan in his chart indicating he was on hospice care, therefore, RN1 stated she would initiate a hospice care plan for Resident 342.
During an interview on 10/4/2023 at 1:55 PM, the DON stated there should have been a care plan initiated for Resident 342 hospice care The DON stated initiating a care plan for Hospice for Resident 342 was not only the responsibility of the hospice nurse, but facility staff since the facility also provided end of life care.
A review of the facility's policy titled, Care Plans, Comprehensive Person-Centered revised 12/2016, indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the residents physical, psychosocial and functional needs is developed and implemented for each resident.
Based on interview, and record review, the facility failed to develop and/or implement an individualized person-centered plan of care with measurable objectives, timeframe, and interventions to meet the resident's needs for 5 of 10 sampled residents (Resident 46, Resident 47, Resident 60, Resident 70 and Resident 342).
1. Resident 47 did not have a comprehensive, resident specific care plan for Gastrostomy Tube (GT- gastrostomy an opening into the stomach from the abdominal wall, made surgically for the introduction of food) care that included cleansing the GT site daily, in accordance with the physician's order.
2. Resident 60 did not have a comprehensive, resident specific care plan for RNA decreased range of motion (how far and in what direction a person can move a joint or muscle) that included objectives in measurable outcomes, in accordance with the facility's policy on Care Plans, Comprehensive Person-Centered.
3. Resident 70 did not have a comprehensive care plan for RNA care plan: Decrease in ROM initiated on 11/16/2022, the intervention for gentle passive range of motion (PROM) exercised to be performed on both lower extremities (BLE). The care plan did not indicate the frequency to perform PROM exercises to BLE that included daily five times a week, as indicated in the physician's order.
4. Resident 46 did not have a care plan for history of elopement (leaving the facility without permission).
5. Resident 342 did not have a care plan for hospice care (focuses on the care, comfort, and quality of life of a person with a serious illness who is approaching the end of life).
These deficient practices had the potential to delay care and services specific to Resident 46, 47, 60, 70 and Resident 342's needs.
Findings:
1. A review of Resident 47's Face Sheet indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of, but not limited to, gastrostomy (an opening into the stomach from the abdominal wall, made surgically for the introduction of food), paraplegia (Paralysis that affects all or part of the trunk, legs, and pelvic organs), contracture of the right ankle (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) and schizoaffective disorder (a mental health disorder that is marked by a combination of symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania).
A review of Resident 47's comprehensive admission Minimum Data Set (MDS - a standardized assessment and screening tool) dated 9/25/2023, indicated the resident had severely impaired cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making. The MDS indicated the resident was extensively dependent to totally dependent on staff for activities of daily living (ADLs - term used in healthcare to refer to daily self-care activities).
A review of Resident 47's History and Physical dated 9/10/2022 indicated that the resident does not have the capacity to make decisions.
A review of Resident 1's Physician's Order dated 9/9/2022, indicated enteral feed order: cleanse GT site with normal saline, pat dry, cover with dry dressing every shift, notify MD (physician) for signs and symptoms of infection.
A review of Resident 47's care plan for GT Site initiated on 12/2022 indicated approaches/plan included to check GT site as needed to prevent odors, and monitor site for discharge, swelling, pain or redness. The care plan did not include to cleanse GT site with normal saline, pat dry, cover with dry dressing every shift as ordered by the physician.
During an interview and concurrent record review of Resident 47's care plans and physician orders on 10/05/2023 at 7:54 am, the DON stated the care plan for Res 47 should be specific and resident centered. The DON stated that the care plan approaches to check and cleanse GT site should indicate that it is checked every shift, as per physician's orders and reflected what the resident needs.
2. A review of Resident 60's Face Sheet indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses of, but not limited to, gastrostomy (an opening into the stomach from the abdominal wall, made surgically for the introduction of food), quadriplegia (paralysis that the body from the neck down, including arms, legs), and dementia (is a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment).
A review of Resident 60's MDS dated [DATE], indicated the resident had severely impaired cognitive skills for daily decision-making. The MDS indicated the resident was extensively dependent to totally dependent on staff for activities of daily living.
A review of Resident 60's History and Physical dated 11/2/2022 indicated that the resident does not have the capacity to understand and make decisions.
A review of Resident 60's Physician Orders dated 1/26/23 indicated RNA to provide PROM exercises on right upper extremities (RUE) and left upper extremities (LUE) every day, five times a week as tolerated.
A review of Resident 60's care plan titled RNA care plan: Decreased Range of Motion (ROM) initiated on 11/20/2022, showed a goal that indicated Review every month. The care plan did not indicate a goal that was specific to Resident 60's desired outcome for having a decreased in ROM.
During an interview and concurrent record review of Resident 60's RNA care plan: Decreased Range of Motion (ROM) on 10/05/2023 at 8:08 am, the DON stated that the goal of Resident 60's care plan is for the facility to review the care plan every three months. The DON stated the care plan did not indicate a goal that was specific to Resident 60's desired outcome for having a decreased in ROM.
3. A review of Resident 70's Face Sheet indicated the resident was admitted to the facility on [DATE], with diagnoses of, but not limited to, dementia, heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), and adult failure to thrive (a syndrome of weight loss, decreased appetite and poor nutrition, and inactivity).
A review of Resident 70's MDS dated [DATE], indicated the resident had severely impaired cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making. The MDS indicated the resident was extensively dependent to totally dependent on staff for activities of daily living (ADLs - term used in healthcare to refer to daily self-care activities).
A review of Resident 70's History and Physical dated 11/3/2022, indicated the resident did not have the capacity to make decisions.
A review of Resident 70's Physician Orders dated 11/16/2022, indicated RNA for BLE PROM exercises everyday, five times a week as tolerated.
A review of Resident 70's care plan titled RNA care plan: Decrease in ROM initiated on 11/16/2022, the intervention for gentle passive range of motion (PROM) exercised to be performed on both lower extremities (BLE). The care plan did not indicate the frequency to perform PROM exercises to BLE that included daily five times a week, as indicated in the physician's order.
During an interview and concurrent record review of Resident 70's RNA care plan: Decrease in ROM on 10/05/2023 8:10 am, the DON stated the care plan did not indicate the frequency to perform PROM exercises to Resident 70's BLE that included daily five times a week, as indicated in the physician's order.
During an interview on 10/05/2023 at 8:15 am, the DON stated the purpose of the care plan is to guide the resident's care so the facility staff can provide the proper care to meet the resident's needs. The DON stated that resident care plans should not be general and must be specific to the resident's needs.
A review of the facility's policy and procedure titled, Care Plans, Comprehensive Person-Centered, dated 12/2016, indicated that, The comprehensive person-centered care plan will include measurable objectives and timeframes; describe the services that are to be furnished, and reflect treatment goals, timetables and objectives in measurable outcomes.

Based on observation, interview and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment by not repairing a leaking flushometer of a toilet (a metal water-diverter that uses an inline handle to flush tankless toilets or urinals) for one of four residents (Resident 17).
The failure had the potential to result in Resident 17 falling and sustaining an injury from the slipping on the wet restroom floor.
Findings:
During a review of Resident 17's Face Sheet indicated the facility admitted Resident 17 on 9/23/2022 with diagnoses that included dementia (a term for a range of conditions that affect the brain's ability to think, remember, and function normally) and difficulty in walking.
During a review of Resident 17's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 6/29/2023, indicated the resident had moderately impaired cognition (ability to think and reason) for daily decision making. The MDS indicated Resident 17 required supervision (oversight, encouragement or cueing) with bed mobility, transfer, walking in room, dressing, eating, toilet use and personal hygiene.
During a review of Resident 17's History and Physical Examination (H&P), dated 9/21/2023, indicated Resident 17 has fluctuating capacity to understand and make decisions.
During a review of Resident 17's Care Plan, dated on 9/26/2022, indicated Resident 17 was at risk for fall and the intervention was to maintain safe environment.
During an observation and concurrent interview on 10/2/2023 at 9:58 AM, with Resident 78's family member (FM 1) who was in the room of Resident 78 stated the floor in the shared restroom in the room was dirty and wet. FM 1 stated she did not see any staff check or clean the floor.
During an observation on 10/2/2023 at 9:58 AM, Resident 17 was walking out from the restroom in his room. Resident 17 nodded his head when asking him if he used the restroom.
During an observation on 10/2/2023 at 10:00 AM, in the shared restroom of Resident 78 and 17's room had two areas with puddle of water on the restroom floor around the base of toilet. The flushometer of the toilet was observed leaking water dripping on the floor.
During an interview on 10/2/2023 at 10: 05 AM, FM 1 stated, she visited Resident 78 every day and observed the water in the restroom floor. FAM 1 stated Resident 78 stays in bed at all times and does not use the restroom.
During a concurrent observation and interview on 10/2/2023 at 10:23 AM, with the Housekeeping (HK), HK stated the flushometer was leaking water to the floor in Resident 17 and Resident 78's restroom. The HK stated he did not check the restroom today and did not know for how long the flushometer had been leaking. HK stated the flushometer should not be leaking because the wet floor could put Resident 17 at risk for slipping and falling.
During a concurrent observation and interview on 10/2/2023 at 10:43 AM, with the Maintenance Direction (MD), MD stated the flushometer was leaking and causing the puddles of water in the restroom floor. MD stated he did not know for how long the flushometer had been leaking. MD stated he will make sure the flushometer was working properly because the wet floor could cause residents to slip and fall.
During a current interview and record review on 10/2/2023 at 2:30 PM with MD, the Maintenance Log (ML), dated 5/4/2023 to 10/1/2023, indicated there was no documentation that the flushometer was reported leaking. The MD stated he did not know the flushometer was leaking until the notification from the surveyor today.
During an interview on 10/3/2023 at 2:38 PM with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 17 used the restroom to urinate and defecate which put him at risk of slipping and falling.
During a review of the facility's policy and procedure titled, Quality of Life-Homelike Environment, dated 5/2017, indicated Residents are provided with a safe, clean, comfortable and homelike environment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A review of Resident 38's Face Sheet (admission record) indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including dysphagia following cerebral infarct (difficulty swallowing), polyneuropathy (when multiple peripheral nerves symptoms include problems with sensation, coordination, or other body functions), and depression (constant feeling of sadness).
A review of Resident 38's History and Physical (H&P) dated 8/24/23, indicated Resident 38 had fluctuating capacity to understand and make decision.
A review of Resident 38's Minimum Data Set (MDS, a standardized resident assessment and care screening tool) dated 7/12/23, indicated Resident 38 had severe cognitive impairment.
On 10/03/23 at 09:10 AM during a review of Resident 38's Physician Orders for Life-Sustaining Treatment Resident (POLST- a portable medical order form that records patients' treatment wishes so that emergency personnel know what treatments the patient wants in the event of a medical emergency taking the patient's current medical condition into consideration). A POLST form form prepared on 1/05/21, indicated not to attempt resuscitation (DNR - medical order that directs healthcare providers not to administer cardiopulmonary resuscitation [CPR] in the event of cardiac or respiratory arrest. The POLST indicated the resident Refused to sign.
During an interview with the Social Services Director (SSD), on 10/03/23 at 9:15 AM, and review of Resident 38's POLST, the SSD stated the Resident 38's POLST indicated DNR facility consider Resident code DNR even though resident refused to sign.
During an interview with the Licensed Vocational Nurse (LVN )1, on 10/03/23 1:45 PM , and review of Resident 38's POLST, the LVN1 stated she is assigned to Resident 38 and POLST indicated Resident 38 refused to sign. LVN 1 stated she is not sure if Resident 38 is DNR or Full code. Stated the POLST is confusing since resident refused to sign. LVN stated if a document is not sign it is not valid. Stated the order should have been clarified with provided, stated it can lead to delay in care and Resident wish may not be respected.
During an interview with the Registered Nurse (RN)1 , on 10/03/23 2:03 PM , and review of Resident 38's POLST, the RN 1 stated even though the POLST indicated Resident 38 refused to sign since it has doctors signature she consider Resident 38 DNR and she will not provide CPR.
During an interview with the Director of Nursing (DON), on 10/03/23 2:34 PM , and review of Resident 38's POLST, the DON stated upon admission Resident 38 was able to make the decision and he decided to be DNR but refused to sign. DON stated Resident 38 is under interdisciplinary team (IDT- a group of experts from several different fields) meeting. The DON stated she was under impression the POLST was signed by Resident 38. DON stated Resident 38 Code status should have should been discussed during IDT meeting with physician.
A review of the facility's policies and procedures titled Advance Directives, revised in December 2016, indicated Advance directives will be respected in accordance with state law and facility policy. If the resident is incapacitated and unable to receive information about his or her right to formulate an advance directive, the information may be provided to the resident's legal representative. Prior to or upon admission of a resident, the Social Services Director or designee will inquire of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record. The Attending Physician will provide information to the resident and legal representative regarding the resident's health status, treatment options and expected outcomes during the development of the initial comprehensive assessment and care plan.
A review of the facility's policy and procedure, titled Physician Orders for Life Sustaining Treatments (POLST) indicated the facility will advise residents about their rights to make healthcare decisions and the facility will honor those wishes. The California POLST form will be utilized for end of life planning based on the resident's values, beliefs and goals for care and tbe health care professional presents then resident/patient's diagnosis, prognosis, and treatment alternatives. The POLST will be honored if received on adtnission and signed by both the resident and a physician in accordance with the guidelines. Advanced Directives complement the POLST.
Based on interview and record review, the facility failed to determine on admission and/or offer the resident or the responsible party to formulate an Advance Directives (a written instruction, such as a living will or durable power of attorney for health care, recognized under State law, relating to the provision of health care when the individual is incapacitated), and ensure the DNR (Do Not Resuscitate- any medical intervention used to restore circulatory and/or respiratory function that has ceased) code status (level of medical interventions a person wishes to have started if their heart or breathing stops) was clearly indicated for two of 24 sampled residents (Residents 38 and Resident 60) clinical records in accordance with the facility's policy and procedures.
The facility failed to ensure:
1. Resident 60's representative was offered and given an Advance Directives information.
2. The licensed staff clarified with Resident 38's physician the code status or DNR status of the resident's code status of the resident which indicated the refused to sign the provision of CPR-cardiopulmonary resuscitation (CPR -method of reviving the heart and lungs when it ceased.
This deficient practice had the potential for Resident 38 not to receive care and services including a delay in provision of emergency services. In addition Resident 38 had the potential to result in the resident not to receive care according to his wishes. This deficient practice also resulted in the potential for Resident 60 representative not to exercise the right to formulate an advanced directive.
Findings:
1. A review of Resident 60's Face Sheet indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of, but not limited to, gastrostomy (an opening into the stomach from the abdominal wall, made surgically for the introduction of food), quadriplegia (paralysis that the body from the neck down, including arms, legs), and dementia (is a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment). The Face Sheet indicated Resident 60 had one responsible party (Family 2).
A review of Resident 60's Minimum Data Set (MDS - a standardized assessment and screening tool) dated 7/19/2023, indicated the resident had severely impaired cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making.
A review of Resident 60's History and Physical dated 2/23/2023 indicated the resident did not have the capacity to make decisions.
A review of a facility document titled Advance Directive Acknowledgement Form dated 11/2/2022, indicated Resident 60 does not have an Advanced Directive and declined to execute an advanced directive. The Advance Directive Acknowledgement Form indicated it was signed by the facility's Social Services Designee (DSD). The Advance Directive Acknowledgement Form did not indicate the name or signature of Resident 60's surrogate decision maker which was a court ordered conservator.
During an interview and concurrent record review of Resident 60's Advance Directive Acknowledgement form on 10/5/2023 at 8:05 am, the Director of Nursing (DON) stated that the Advance Directive Acknowledgement form was a required document to be completed by facility staff upon all resident's admission. The DON stated that Resident 60's Advance Directive Acknowledgement form was incomplete because Resident 60's responsible party did not fill out and sign the form.
During an interview and concurrent record review of Resident 60's Advance Directive Acknowledgement form on 10/5/2023 at 10:22 am, the Social Services Designee (SSD) stated that the Advance Directive Acknowledgement form was part of the admission process to show that the resident or the resident's responsible party received information about the right to have an advanced directive.
A review of the facility's policy and procedure, titled Advance Directives, dated 12/2016 indicated that, Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical surgical treatment and to formulate an advance directive if he or she chooses to do so.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement the facility's policy and procedure for infection control practices by failing to:
1. Implement the facility's policy and procedure titled Departmental (Respiratory Therapy) Prevention of Infection by ensuring the oxygen nasal cannula (NC) tubing (a device used to deliver supplemental oxygen placed directly on a resident's nostrils) was labeled when first used for one of 3 sampled residents (Resident 67).
2.Implement the facility's policy and procedure titled Legionella Water Management Program related to prevention, detection and control of water-borne (recreational or drinking water contaminated by disease-causing organisms) contaminants, including Legionella (a bacteria that can cause Legionellosis, a serious type of pneumonia (lung infection) that can lead to severe respiratory failure (failure of the lungs to oxygenate the body), septic shock (a life threatening condition due to severe infection) and multi-organ failure (failure of the major organs in the body to meet the body's demand) for 86 of 86 residents in the facility and the staffs and visitors.
These deficient practices had the potential to result in a widespread infection of Legionellosis and other water-borne diseases throughout the facility. In addition Resident 67 and other potential residents had the potential to develop an infection associated with the use of NC that was not labeled to when it was last changed.
Findings:
1. A review of Resident 67's Face sheet (admission Record) indicated the facility initially admitted Resident 67 to the facility on 2/18/22 and readmitted date of 3/30/23 with the diagnoses that included, emphysema (gradual damage of lung tissue or alveoli [tiny air sacs] this damage causes the air sacs to rupture and traps air in the damaged tissue and prevents oxygen from moving through the bloodstream that causes the lungs to overfill with air and makes breathing more difficult), hepatic failure (failure of the liver to function that can cause serious complications such as bleeding and increased pressure in the brain) and schizophrenia (disorder that affects a person's ability to think, feel, and behave clearly which involve false beliefs and seeing or hearing things that don't exist).
A review of Resident 67's History and Physical (H&P) dated 3/30/23, indicated Resident 67 does not have capacity to understand and make decision.
A review of Resident 67's Minimum Data Set (MDS, a standardized resident assessment and care screening tool) dated 8/22/23, indicated Resident 67 had no impairment in memory and cognitive (ability to reason) level for daily decision making.
During an observation on 10/4/23 at 12:10 P.M., Resident 67 was observed lying in bed while receiving oxygen therapy at 2 liters per minute (L/min) via nasal cannula (a device used to deliver supplemental oxygen that should be placed directly on the resident's nostrils) connected to the oxygen concentrator (a medical device that concentrates oxygen from environmental air used for supplemental oxygen) located at the bedside. The nasal cannula tubing did not have a date or label, and the nasal cannula had yellow discoloration around the nostrils.
During an observation and concurrent interview with Certified Nursing Assistant (CNA) 2 on 10/4/23 at 12:12 PM, CNA 2 stated Resident 67 was receiving oxygen 2 L/min oxygen.
During an interview on 10/04/23 at 12:20 P.M., License Vocational Nurse (LVN )1, stated the nasal cannula tubing must be labeled with the date when it was first removed from the package so that the staff know when it should be changed which is every 7 days per facility's policy and procedure to prevent infection. LVN 1 stated if the nasal cannula was not labeled with the date the staff will not know when it will need to be changed or the last time it was changed.
During an interview with Director of Nursing (DON), on 10/5/23 at 8:14 AM, the DON stated Resident 67 uses oxygen 2 L for comfort as needed, DON stated nasal cannula tubing must have a date and needs to be changed every 7 days to prevent infection per facility policy.
A review of the facility's policy revised November 2011, titled Departmental (Respiratory Therapy) -Prevention of Infection, indicated the purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment, including ventilators, among residents and staff, change the oxygen cannula and tubing every seven (7) days, or as needed.
2. During an interview with the Infection Preventionist (IP) Nurse, 10/4/2023 at 2:16 PM, the IP Nurse stated the Maintenance Supervisor was responsible to check the water system in the facility for the presence of Legionella.
During an interview with the Maintenance Supervisor, 10/4/23 at 2:30 PM, he stated Legionella is an infection which can cause harm. The Maintenance Supervisor stated he does not know how to check the water system at the facility for the presence of. The MS stated facility he did not have any system or method to check the water for presence of Legionella prior to 10/2/23.
During an interview with the Director of Nursing (DON) on 10/4/23 at 3:04 PM, she stated,
prior to 10/2/2023, the facility did not have Legionella Water Management Program. The DON stated she already discussed with the IP nurse, maintenance supervisor, and Administrator to check the water system for Legionella.
During an interview with the IP Nurse on 10/5/23 at 9:48 AM, the IP Nurse stated Legionella is a bacterium that can be found in the pipe, especially older pipe, and most people catch the infection by inhaling the Legionella bacteria from the water and cause lung infection that could lead to pneumonia which is manifested by flu like symptoms, fever, chills, that could lead to harm. The IP Nurse stated checking the water system for Legionella must be done annually (yearly). The IP Nurse stated prior to 10/2/2023, the facility did not have a system to check the water system for Legionella and she does not have any documentation that shows the water system was checked for Legionella prior to 10/02/2023.
A review of the facility's policy and procedure titled Legionella Water Management Program, revised on September 2022, indicated the facility was committed to the prevention, detection and control of water-borne contaminants, including Legionella. As part of the infection prevention and control program, the facility has a water management program, which is overseen by the water management team. The water management team consists of at least the following personnel: The infection preventionist; The administrator. The medical director (or designee);d. The director of maintenance; and e. The director of environmental services.
The purposes of the water management program are to identify areas in the water system where Legionella bacteria can grow and spread, and to reduce the risk of Legionnaire's disease. The water management program used by the facility is based on the Centers for Disease Control and Prevention and ASH [NAME] recommendations for developing a Legionella water management program. The water management program includes the following elements: a. An interdisciplinary water management team (see above); b. A detailed description and diagram of the water system in the facility, including the following:(1) Receiving;(2)Cold water distribution; (3)Heating; (4)Hot water distribution; and (5)Waste.
The water management program is reviewed at least once a year, or sooner if any of the following occur:
a. The control limits are consistently not met;
b. There is a major maintenance or water service change;
c. There are any disease cases associated with the water system; or
d. There are changes in laws, regulations, standards or guidelines.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to monitor and review their hospice communication binder for 2 of 2 sampled residents (Resident 63 and Resident 342) which contains hospice nurse sign-in sheet, weekly calendar visits and hospice nurses notes that include treatment recommendations.
This deficient practice had the potential to negatively affect the delivery of care and services related to the resident's change of health (including but not limited to pain, shortness of breath, spiritual and psychosocial needs related to dying) and may put at risk the personal needs that are particular to end of life issues not being met.
Finding:
A review of Resident 63's admission Record indicated the resident was readmitted to the facility on [DATE] with the diagnosis of schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves) and human immunodeficiency virus (HIV -virus that attacks the body's immune system).
A review of Resident 63's Minimum Data Set (MDS, a standardize assessment and care screening tool), dated 7/13/2023, indicated Resident 63 had severe impaired cognition (the ability or mental action or process of acquiring knowledge and understanding).
A review of Resident 63's History and Physical, dated 9/14/2023, indicated Resident 63 did not have the capacity to understand and make decisions.
A review of Resident 63's undated Hospice Weekly Staff Visit Sheet, indicated two (2) dates, 4/4/2021 and 4/18/2021, indicating dates the
hospice nurse visited Resident 63.
A review of Resident 63's Hospice Residents Calendar, dated 9/2023 indicated hospice visits were every Monday, Wednesday, Thursday and every other Fridays.
A review of Resident 342's admission Record, indicated Resident 342 admission to the facility was on 8/26/2022, with the diagnosis of paranoid schizophrenia (a severe mental health condition that can involve delusions and paranoia) and human immunodeficiency virus (HIV -virus that attacks the body's immune system).
A review of Resident 342's MDS, dated [DATE], indicated Resident 342 had moderately impaired cognition (the ability or mental action or process of acquiring knowledge and understanding).
A review of Resident 342's Hospice Weekly Staff Visit Sheet, indicated no date and staff name with no signature for all designated lines.
A review of Resident 342's Hospice Residents Calendar, indicated no scheduled hospice nurse visits, and no indication specifying which days the hospice nurses would visit.
During a concurrent interview and record review of Resident 63's Hospice Binder, with Registered Nurse (RN1), on 10/3/2023 at 2:38 PM, RN1 stated there were no hospice nurses notes indicated in Resident 63's hospice binder. RN1 stated the binder did not indicate days the hospice nurse was to visit Resident 63. RN1 stated the hospice nurse communicated with RN1 through text message and did not enter the information in the binder for Resident 63. RN1 stated since notes were not indicated on Resident 63's hospice binder, any change in care could be missed, and could have a negative affect when providing end-of life care for Resident 63.
During a concurrent interview and record review of Resident 342's Hospice Binder on 10/3/2023 at 2:58 PM with RN1, RN1 stated the hospice nurse for Resident 342 communicated with RN1 through text message. RN 1 stated the hospice binder did not indicate notes regarding Resident 342's hospice visits, no sign-in sheets, and no indication on the days a hospice nurse would visit Resident 342. RN1 stated since the hospice binder did not have nurses notes to indicate care was given or treatment recommendations, it could have a negative impact on Resident 342's care while on hospice.
During a concurrent interview and record review of Resident 63 and 342's Hospice binder on 10/4/2023 at 1:55 PM, with the Director of Nursing (DON), the DON stated that Resident 63 and Resident 342 hospice binders were not completed by the hospice nurses and the binder was not being monitored by RN1. The DON stated the hospice binder was important since it was used to communicate care between hospice staff and the facility. The [NAME] stated using the hospice binder ensures that residents who are on hospice get the specialized care for end-of-life issues so they are not in pain.
A review of the facility's policy titled, Hospice Program revised 7/2017, indicated in general, it is the responsibility of the hospice to manage the resident's care as it relates to the terminal illness and related conditions, including: determining the appropriate hospice plan of care, changing the level of services provided when it is deemed appropriate, providing medical direction, nursing and clinical management of the terminal illness and providing spiritual, bereavement and/or psychosocial counseling and social services as needed. The policy further indicated, in general, it is the responsibility of the facility to meet the residents personal care and nursing needs in coordination with the hospice representative and ensure that the level of care provided is appropriately based on the individual resident's needs which includes communicating with the hospice provider (and documenting such communication) to ensure that the needs of the resident are addressed and met 24 hours per day.

Based on observation and interview and record review the facility failed to follow its policy and procedure on food storage, preparation, distribution and serving food in accordance with professional standards for food service safety by failing to:
1. Label the cut-up cantaloupe, ham slices and cheese sandwiches with the date of when the food were prepared and when to be consumed by.
2. Remove an egg carton with white liquid from the storage refrigerator.
3. Store two uncracked eggs with other uncracked eggs in the same egg carton.
These deficient practices had the potential to result in food contamination, growth of microorganisms (disease causing organism) that could cause foodborne illness (food poisoning or food illness due to pathogens (harmful organism that cause illness such as bacteria, viruses, or parasites) and toxins that contaminate food.
Findings:
1. During an initial kitchen observation conducted with the Dietary Manager (DM) on 10/2/2023 at 8:38 AM, the walk-in refrigerator had a cut-up cantaloupe was wrapped in a clear plastic wrapper and stored in a clear plastic food storage box with three uncut honeydews. The cut-up cantaloupe had no label of the date the cantaloupe was cut-up. In a concurrent interview, the DM stated the staff did not label the date that the cantaloupe was cut-up or when to be used by or for how long the cantaloupe was left cut-up in the refrigerator. The DM stated he does not know if the cantaloupe was still safe for the residents to consume, and consuming the cantaloupe might put residents at risk for foodborne illnesses.
During concurrent observation and interview on 10/2/2023 at 8:40 AM with the DM, the walk-in refrigerator shelf had 10 pieces of half-cut ham and cheese sandwiches that were on a food tray. The sandwiches were not labeled with the date of when the sandwiches were prepared or when to be used (consumed) by. The DM stated the 10 sandwiches were not properly labeled, and the staff should have labeled the date the sandwiches were prepared of used by. The DM stated without the proper labeling of the food, the staff would not know when the sandwiches were prepared and for how long these sandwiches would be safe to consume. The ADM stated consuming the sandwiches could put residents at risk for foodborne illnesses.
2. During a concurrent observation and interview on 10/2/2023 at 8:42 AM with the DM, the walk-in refrigerator had murky white liquid at the bottom of empty egg carton slots (divider in the carton) and the egg carton had two cracked raw eggs and five other uncracked raw eggs in it. The DM stated the murky white liquid was the residual of egg white from the cracked raw eggs which were disposed. The DM stated the dirty egg carton should be removed from the storage refrigerator because bacteria could grow in it and cause contamination to other food stored in the refrigerator.
3. During a concurrent observation and interview on 10/2/2023 at 8: 43 AM with DM, in the walk-in refrigerator, two cracked raw eggs were in the same egg carton with five other uncracked raw eggs. The DM stated the cracked raw eggs should be disposed immediately and should not be stored in the refrigerator with other produce because bacteria could grow in them quickly and put residents at risk for foodborne illness if consumed.
During an interview on 10/2/2023 at 8: 44 AM, the [NAME] stated she did not know when the two eggs were cracked and for how long the eggs had been in the refrigerator. The [NAME] stated she was too busy and did not dispose the two cracked eggs this morning. The [NAME] stated she should dispose the cracked raw eggs and not to use them for meal preparation to prevent foodborne illness.
During a review of the facility's policy and procedure titled, Food Receiving and Storage, dated 7/2014, indicated all foods stored in the refrigerator will be covered, labeled, and dated ('use by' date). The policy indicated Food services, or other designated staff, will maintain clean food storage areas at all times. The policy indicated Foods shall be received and stored in a manner that complies with safe hood handing practices.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to administer two doses of Norco (a medication used to treat pain) 5/325 milligrams (mg - a unit of measure for mass) on 8/2/23 for one of three sampled residents (Resident 1).
Failure to administer pain medication according to the physician ' s order increased the risk that Resident 1 could have experienced increased pain resulting in a decline in ability to perform activities of daily living (ADLs - everyday activities like brushing teeth or bathing) and quality of life.
Findings:
A review of Resident 1 ' s Face Sheet, dated 8/3/23, indicated she was admitted to the facility on [DATE] with diagnoses including essential hypertension (high blood pressure) and muscle weakness.
A review of Resident 1 ' s Minimum Data Set (MDS - a comprehensive resident assessment tool) section C (Cognitive Patterns) indicated Resident 1 had a Brief Interview for Mental Status (BIMS - a interview tool used to determine cognitive impairment) score of 12 (moderately impaired.)
A review of Resident 1 ' s History and Physical note (H&P - the formal document that physicians produce through the interview with the patient, the physical exam, and the summary of the testing either obtained or pending) dated 6/3/23, indicated Resident 1 had the capacity to understand and make decisions.
A review of Resident 1 ' s physician order dated 6/9/23 indicated the physician prescribed Norco 5/325 mg to take one tablet by mouth every six hours as needed for moderate pain (pain score 4 to 6).
A review of Resident 1 ' s eMAR, dated August 2023 and printed 8/3/23, indicated one dose of Norco 5/325 mg was given to Resident 1 at 10:58 PM on 8/1/23 and no additional doses were given on 8/2/23.
A review of Medicare Skilled Daily Note (a daily nursing progress note), dated 8/2/23, authored by LVN 1, included no entry concerning missing Norco 5/325 mg, pain score ratings, attempts to follow up with the pharmacy regarding the missing Norco 5/325 mg, e-kit usage, etc.
A review of Resident 1 ' s Care Plan, dated 6/1/23, indicated she was at risk for chronic pain due to neuropathy (nerve pain), arthritis (inflammation of the joint) in her left knee and bursitis (inflammation of tissue that cushions bones, tendons, and muscles near joints) in her left knee with targeted interventions to monitor for pain every shift and administer Norco 5/325 mg every 6 hours as needed.
On 8/3/23 at 3:29 PM, during an interview, the DON stated LVN 1 was the nurse assigned on the morning shift (7 AM to 3 PM) on 8/2/23 and LVN 2 was the nurse assigned on the preceding night shift of 8/1/23 (11 PM to 7 AM) to Station 2, Medication Cart 2. The DON stated that at the start of LVN 1 ' s morning shift on 8/2/23 (7 AM to 3 PM shift) around 9 AM, LVN 1 notified her that there were 14 tablets of Norco 5/325 mg missing from Resident 1 ' s controlled medications supply. The DON stated that she looked for Resident 1 ' s Norco 5/325 mg medications in Medication Cart 2, all other medication carts, and medication storage rooms in the facility but could not locate the medications. The DON stated she contacted the pharmacy to provide a replacement supply of Norco 5/325 mg, on 8/2/23. The DON stated the facility ' s pharmacy authorized one dose of Norco 5/325 mg from the controlled medication emergency kit (e-kit) and advised that the facility pharmacy would provide a replacement supply of Resident 1 ' s Norco 5/325 mg. The DON stated the newly ordered replacement supply of Norco 5/325 mg was delivered to the facility on 8/2/23 at around 11 PM.
During the same interview, on 8/3/23 at 3:29 PM, the DON stated LVN 1 (7 AM to 3 PM shift) and LVN 2 stated they signed the Controlled Drugs - Count Record but did not perform the controlled medication reconciliation for Medication Cart 2 together, as indicated in the facility ' s policy, during LVN 1 and 2 ' s shift change (8/2/23 at 7 AM). The DON stated LVN 1 administered one dose of Norco 5/325 mg to Resident 1 from the facility ' s e-kit on 8/2/23 around 11:00 AM after the medication was discovered missing.
During the same interview, on 8/3/23 at 3:29 PM, the DON stated LVN 3 administered the last known dose of Norco 5/325 mg from the missing supply (pharmacy delivery dated 7/16/23) on 8/1/23 at around 9 PM. The DON stated LVN 3 worked on 8/1/23 during the 3 PM to 11 PM shift and was also assigned to Medication Cart 2. The DON stated on 8/1/23 at around 11 PM, when LVN 3 was ready to leave the facility, LVN 2 who was scheduled to work the 11 PM to 7 AM shift, had not yet arrived at the facility. The DON stated LVN 3 performed a controlled medication reconciliation with another licensed nurse scheduled during the same 3 PM to 11 PM shift, Registered Nurse (RN) 1, on 8/1/23 at around 11 PM. The DON stated RN 1 later (unknown time) performed a controlled medication reconciliation for Medication Cart 2 with LVN 4 who was assigned as a charge nurse team leader during the 11 PM to 7 AM shift on 8/1/23. The DON stated LVN 4 (11 PM to 7 AM shift) and LVN 2 (11 PM to 7 AM shift) performed a controlled medication reconciliation for Medication Cart 2 at some point prior to leaving the facility at approximately 7 AM on 8/2/23.
On 8/3/23 at 4:20 PM, during an interview, LVN 3 stated she was assigned to Medication Cart 2 on 8/1/23 for the 3 PM to 11 PM shift. LVN 3 stated that on 8/1/23, LVN 3 performed a controlled medication reconciliation with RN 1 around 10:50 PM because her shift was nearing its end, and LVN 2 (11 PM to 7 AM shift LVN) had not yet arrived at the facility. LVN 3 stated she provided one dose of Norco 5/325 mg to Resident 1 around 10:45 PM on 8/1/23. LVN 3 stated, after arriving on her shift (3 PM to 11 PM) the next day, on 8/2/23 around 3:20 PM, LVN 3 performed a controlled medication reconciliation with the DON because Resident 1 ' s Norco 5/325 mg had been reported missing earlier that day. LVN 3 stated there was no Norco 5/325 mg available for Resident 1 during her shift that day, on 8/2/23 andthat Resident 1 did not ask her for it at any time during her shift. LVN 3 stated she assessed Resident 1 for pain during her shift around 4 PM or 5 PM and Resident 1 indicated her pain level was 4 to 5/10 (pain score on a scale from 0 to 10 where 0 is no pain and 10 is the worst possible pain). LVN 3 stated she administered Tylenol (a medication used to treat mild pain) for that pain score but does not remember whether she documented any of Resident 1 ' s pain ratings in the medical record.
On 8/3/23 at 5:35 PM, during an observation of Medication room [ROOM NUMBER] on Nursing Station 1, the controlled medication e-kit was observed sealed with intact green plastic seals and combination pad lock. No apparent doses of any medication were observed missing. No accompanying written record of any recent usage was available. The e-kit was observed with a pharmacy fill date of 6/26/23 on the prescription label. The e-kit was observed to contain extra red plastic seals.
On 8/3/23 at 5:40 PM, during a concurrent observation of Medication room [ROOM NUMBER] on Nursing Station 2 with LVN 3, no controlled medication e-kit was observed in Medication room [ROOM NUMBER]. During a concurrent interview, LVN 3 stated the facility has two total medication rooms and three total medication carts. LVN 3 stated the facility only has one controlled medication e-kit and it is kept in Medication room [ROOM NUMBER].
On 8/3/23 at 5:45 PM, during an interview with the DON, the DON acknowledged it appears as if the controlled medication e-kit had not been used or replaced. The DON stated it is possible that LVN 1 was not truthful that she administered one dose of Norco 5/325 mg to Resident 1 from the facility ' s e-kit as she previously stated. The DON stated there is no record of any controlled medication being utilized from the controlled medication e-kit. The DON stated there is no record of any licensed staff administering Norco 5/325 mg to Resident 1 on 8/2/23 in the eMAR. The DON stated it appears LVN 1 failed to note anywhere in Resident 1 ' s clinical record that controlled medications were missing or e-kit doses were given noted in the skilled daily nursing note.
On 8/4/23 at 10:08 AM, during an interview with the DON, the DON stated she contacted LVN 1 regarding what happened the day Resident 1 ' s Norco 5/325 mg was discovered missing. The DON stated LVN 1 informed her that she assessed Resident 1 ' s pain the morning of 8/2/23 and LVN 1 indicated it was 2/10. The DON stated LVN 1 determined Tylenol was sufficient at that time but tried to locate the Norco 5/325 mg in case it was not effective later. The DON stated LVN 1 was unable to find the Norco 5/325 mg available at that time. The DON stated LVN 1 informed her she failed to sign the eMAR for medication administrated or make a progress note log entry regarding the missing medications.
A review of a pharmacy delivery receipt, dated 7/16/23, indicated a previous delivery was made to the facility for 60 tablets of Norco 5/325 mg on 7/16/23 timed at 1:23 AM for Resident 1.
A review of the pharmacy delivery receipt dated 8/2/23, indicated 30 tablets of Norco 5/325 mg (replacement supply) was delivered to the facility on 8/2/23 timed at 10:30 PM for Resident 1.
A review of Resident 1 ' s eMARs (printed 8/3/23) dated July and August 2023, indicated the following information:
1. A review of Resident 1 ' s July 2023 MAR indicated Resident 1 received a total of 31 doses of Norco 5/325 mg between 7/16/23 (the date the most recent supply of Norco 5/325 mg was received from the pharmacy) to 7/31/23.
2. A review of Resident 1 ' s August 2023 MAR indicated Resident 1 received a total of 1 dose of Norco 5/325 mg on 8/1/23 to 8/2/23 (the date the Norco 5/325 mg goes missing). The MAR indicated one dose of Norco 5/325 mg was given to Resident 1 on 8/1/23 at 10:58 PM and no additional doses were given on 8/2/23.
3. A review of Resident 1 ' s July and August 2023 MARs indicated that between 7/16/23 (the date the most recent supply of Norco 5/325 mg was received from the pharmacy) to 8/2/23 (the date the Norco 5/325 mg goes missing) indicated a total of 28 doses out of the 60 doses of Norco 5/325 mg supply of Resident 1 ' s Norco 5/325 mg were unaccounted for.
On 8/4/23 at 10:39 AM, during a telephone interview with the Pharmacy Manager (PM), PM stated LVN 1 called the pharmacy around 9 AM on 8/2/23 stating Resident 1 ' s Norco 5/325 mg was missing. PM stated the pharmacy processed a refill of the Norco 5/325 mg which was delivered later that evening and provided the access code to the controlled medication e-kit for immediate use. PM stated he was unaware whether the facility utilized any Norco 5/325 mg from the e-kit. PM stated the pharmacy dispenses the e-kit with green seals and if the facility uses any doses from the e-kit it is resealed with the red seals. PM stated the facility then needs to call the pharmacy to request the e-kit be replaced. PM stated there had been no request from the facility to replace the facility ' s current controlled medication e-kit.
On 8/4/23 at 10:52 AM, during a telephone interview, LVN 1 stated she worked on 8/2/23 during the 7 AM to 3 PM shift, but did not arrive until right before 8 AM. LVN 1 stated LVN 2 (previous shift [11 PM to 7 AM]) had already left by the time she arrived at the facility, so LVN 1 did not count the controlled medications with any other nurse as indicated in the facility policy. LVN 1 stated she counted the controlled medications of other residents using the Record of Controlled Substances when she arrived at the facility by herself and did not find discrepancies (inconsistencies). LVN 1 stated she would not have known at that time if Resident 1 ' s controlled medication supply of Norco 5/325 mg for Resident 1 was missing because the corresponding Record of Controlled Substances document was also missing. LVN 1 stated she assessed Resident 1 ' s pain around 9 AM and determined Resident 1 had 2/10 pain. LVN 1 stated she administered Tylenol, as the pain rating was not sufficient to administer Norco at that time. LVN 1 stated she then searched Medication Cart 2 to determine whether the Norco 5/325 mg was available in case the Tylenol was ineffective. LVN 1 stated she did not administer anything from the e-kit because the resident did not complain of pain at a high enough severity at that time or during the remainder of her shift to warrant it. LVN 1 stated she failed to document Resident 1 ' s pain rating in the clinical record, failed to document the administration of Tylenol in the eMAR, and failed to document that the resident ' s Norco 5/325 mg was missing in the clinical progress note. LVN 1 stated she could not find Resident 1 ' s Norco medications. LVN 1 stated she immediately informed the DON that Resident 1 ' s Norco 5/325 mg controlled medications were missing. LVN 1 stated the DON proceeded to search her Medication Cart and all other facility carts and medication storage rooms but was unable to locate the medication. LVN 1 stated she contacted the pharmacy for a replacement supply . LVN 1 stated she failed to document that Resident 1 ' s Norco 5/325 mg was missing in Resident 1 ' s progress note. LVN 1 stated she performed a controlled medication reconciliation with LVN 3 before leaving from her shift around 3 PM on 8/2/23. LVN 1 stated she failed to follow facility policy of performing controlled medication reconciliation with LVN 2 when she started her shift in the morning, on 8/2/23. LVN 1 stated it was important to ensure controlled medication counts are correct to ensure the availability of the medications for the residents. LVN 1 stated if controlled medications are missing, there is a chance residents could experience medical complications like increased pain or accidental exposure which could cause decreased quality of life.
On 8/4/23 at 12 PM, during a concurrent observation and interview in Resident 1 ' s room, Resident 1 was observed sitting up on her bed. Resident 1 stated that on 8/2/23 she requested Norco 5/325 mg for severe pain at 4:45 PM and 11 PM. Resident 1 stated she was told by the licensed nurses (could not recall which licensed nurse) at both times the facility was out of the Norco. Resident 1 stated she did not remember which specific licensed nurse attended to her at those times. Resident 1 stated her pain was worsened because she did not receive her pain medication at those times, and she was supposed to be able to get the Norco every six hours. Resident 1 stated she would describe her pain at that time as severe. Resident 1 stated she never asks the licensed nurses for only Tylenol. Resident 1 stated nursing staff never ask her to rate her pain on a scale from 0 to 10. Resident 1 stated she usually must ask for her pain medication rather than it being offered Resident 1 stated sometimes licensed nurses tell her they will have to come back with her Norco because we keep them in a different place.
On 8/4/23 at 12:45 PM, during an observation of Medication Cart 2 on Nursing Station 2, Resident 1 ' s supply of Norco 5/325 mg showed five doses missing. Observation of the Record of Controlled Substances corroborated a total of five doses administered and indicated staff administered the first dose from this supply on 8/3/23 at 11 AM and the second at 3:45 PM.
A review of Resident 1 ' s August 2023 eMAR, printed 8/3/23 at approximately 5 PM, did not indicate any doses of Norco 5/325 mg were administered to Resident 1 on 8/2/23 or 8/3/23.
A review of the facility ' s policy Administering Medication, revised April 2019, indicated Medications are administered in a safe and timely manner, and as prescribed . Medications are administered in accordance with prescriber orders, including any required time frame . The individual administering the medication initials the resident ' s MAR on the appropriate line after giving each medication and before administering the next ones .
A review of the facility ' s policy Pain - Clinical Protocol, revised March 2018, indicated The staff will reassess the individual ' s pain and related consequences at regular intervals; at least each shift for acute pain or significant changes in levels of chronic pain and at least weekly in stable chronic pain. Review should include frequency, duration and intensity of pain, ability to perform activities of daily living (ADLs), sleep pattern, mood, behavior, and participation in activities.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain a system-wide method of accountability for controlled medications (medication with a high risk of abuse or theft) and maintain a system to ensure accountability of controlled medications to track compliance with its policy on Controlled Substances. The Controlled Drug-Count Records (the title of the document the facility uses for the controlled medication reconciliation [a process of counting all the controlled medication in the medication cart between the nurse leaving and the nurse coming on duty to determine if there are any discrepancies]) were not signed by two nurses during shift change between 6/3/23 and 8/2/23 totaling 102 times, in accordance with the facility's policy and practice to have licensed nurses sign the Controlled-Drug-Count Records as a documentation that controlled medication reconciliation had been performed between two nurses during shift change, for three of three sampled medication carts (Medication Carts 1, 2, and 3).
In addition, the facility licensed nurses failed to follow proper procedures in accordance with the facility's practice and policy to ensure that controlled medications are counted at the end of each shift, between the licensed nurses coming on duty and the licensed nurses going off duty, on 8/1/23 and 8/2/23 while working on their respective nursing shifts. The Director of Nurses (DON) failed to maintain adequate oversight of Resident 1's Norco 5/325 mg Record of Controlled Substances (a log containing the date, time, and nurse's signature for all administered doses of a specific supply of a controlled medication) corresponding to the facility's pharmacy delivered supplies of Resident 1's Norco 5/325 mg dated 7/16/23 during the licensed nurses daily controlled medication reconciliation between 7/16/23 to 8/2/23. As a result, the facility was unable to account for 28 doses of Norco (a controlled medication used to treat pain) 5/325 milligrams (mg - a unit of measure for mass) for one of three sampled residents (Resident 1).
These deficient practices increases the risk of diversion (the illegal distribution or abuse of prescription drugs or their use for purposes not intended by the prescriber) of controlled medications, staff working in an impaired state, increases the risk that medications are not available to residents when needed, and potential for accidental exposure to controlled substances for 94 of 94 total residents (facility census on 8/4/23) possibly resulting in respiratory depression (the inability to breathe) leading to hospitalization or death.
On 8/4/23 at 3:34 PM, the Department of Public Health (Department) called an Immediate Jeopardy (IJ) situation (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) in the presence of the Administrator (ADM), Director of Nursing (DON), and Assistant Administrator (AADM).
On 8/5/23 at 1:13 PM, the facility provided the Department with an IJ Removal Plan that included the following summarized actions:
1. On 8/4/23, the AADM visited and assessed Resident 1 in her room. Resident had no complaints of pain. Per Resident 1, pain medication is effective. No signs and symptoms of adverse effects noted.
2. On 8/4/23, the DON conducted an immediate in-service (used to describe training done during time at work) to Licensed Nurses regarding the facility's policies and procedures titled Controlled Medication Storage and Medication Administration - General Guidelines. All narcotic (a controlled medication or other substance that affects mood or behavior) medication will be kept in the medication cart narcotic drawers for each respective nursing station and are double-locked. The DON emphasized the failure of maintaining accountability of controlled substances and potential impact to residents. The DON further stressed that when as needed medications are administered, the licensed nurse shall sign the electronic Medication Administration Record (eMAR - an electronic record of all medications a resident receives). The DON will continue until all licensed nurses have received in-services with an expected completion date of 8/14/23.
3. On 8/4/23, the DON initiated an in-service to licensed nurses regarding timeliness in arriving to the facility for duty and proper endorsement between licensed nurses coming off duty and licensed nurses coming on duty. Licensed nursing coming off duty are not to leave the facility until the relieving licensed nurse coming on duty is present to receive endorsement. In the event of an emergency, and the licensed nurse coming off duty or the licensed nurse coming on duty are unable to endorse to each other, the Licensed Nurse supervisor coming on duty will receive endorsement from the licensed nurse coming off duty. When the Licensed Nurse coming on duty arrived, he/she will receive endorsement from the licensed nurse supervisor, the DON, or another designated licensed nurse shall be present during the accountability of narcotic medications. These nurses shall sign off on the Controlled Drugs - Count Record. The DON will continue until all licensed nurses have received in-services with an expected completion date of 8/14/23.
4. On 8/5/23, the Pharmacy Consultant (PC) will also provide additional mandatory in-service to licensed nurses regarding the facility's policies and procedures titled Controlled Medication Storage and Medication Administration - General Guidelines and conduct medication pass observation. The PC will also check narcotic medication for all nursing station for accurate reconciliation and account for all controlled medications.
5. On 8/4/23, the DON initialed skills competency evaluation for all licensed nurses, focusing on medication administration which includes accountability of controlled substances and documentation of PRN medication administration.
6. On 8/4/23, Situation Background Assessment Recommendation (SBAR - a nursing communication tool used to monitor for a resident's possible change in health status) and care plan were initiated for Resident 1 to monitor for signs and symptoms of pain and decline in the ability to perform Activities of Daily Living (ADL).
7. On 8/4/23, SBAR and care plans were initiated by licensed nurses for all current residents to monitor for respiratory depression (a breathing disorder characterized by slow and ineffective breathing) related to possible exposure of narcotic consumption, which will be continued every shift for 72 hours through 8/7/2023.
8. During change of shift, two licensed nurses, which include the nurse coming on duty and the nurse going off duty for each station, will count the narcotic medications in the medication cart narcotic drawer in the presence of the Licensed Nurse Supervisor coming on duty. The two licensed nurses and the licensed nurse supervisor coming on duty will sign the Controlled Drug-Count Record revised on 8/5/2023 to acknowledge that the licensed nurse coming on duty and the licensed nurse coming off duty have counted the controlled drug on hand and have found that the quantity of each medication counted is in agreement (matched) with the quantity stated on the Controlled Drug-Count Record. The revised Controlled Drug - Count Record shall include the written names and signatures of the licensed nurse coming on duty, the licensed nurse coming off duty, and the Licensed Nurse Supervisor coming on duty. The licensed nurse coming off duty will endorse the medication cart keys which included the narcotic drawer key to the licensed nurse coming on duty under the supervision of the Licensed Nurse Supervisor.
9. Licensed nurses will provide a copy of any new physician's orders for controlled substances, a copy of the pharmacy receipt for those controlled substances, and a copy of the controlled substance count sheets (a log containing the date, time, and nurse's signature for all administered doses of a specific supply of a controlled medication) to the DON which will be kept in a designated binder in the DON's office for accurate reconciliation and accounting for all controlled medications.
10. A triple check (means to check again with extra caution/attention) will be conducted monthly by two (2) facility-designated licensed nurses and licensed pharmacy nurse for each medication cart, including narcotic/controlled substances to ensure accurate reconciliation and accounting for all controlled medications by validating medications through each residents' physician orders, medication administration record, and the actual medication on hand. An audit of the Controlled Drug-Count Record will be conducted Monday through Friday for 7 am to 3 pm shift and 3 pm to 11 pm shift by the Medical Records Director/Designee utilizing the Audit Tool Controlled/Medication to the Medication Administration Record (MAR) Form. The Licensed Nurse Supervisor will audit the Controlled Drug-Count Record Monday through Friday 11 pm - 7 am shift and Saturday and Sunday 7 am to 3 pm shift, 3 pm to 11 pm shift, and 11 pm to 7 am shift utilizing the Audit Tool Controlled/Medication, Pro Re Nata (PRN - refers as needed medications) medication to MAR form to acknowledge that the incoming licensed nurse and outgoing licensed nurse have counted the controlled drug on hand and have found that the quantity of each medication counted is in agreement with the quantity stated on the Controlled Drug-Count Record. Additionally, the Medical Record Director/Designee will conduct an audit of the Controlled Drug-Count Record form Monday through Friday to ensure that the correct licensed nurses are signing the form by checking the signatures against the licensed nurses' floor schedule as written on Nursing Staffing Assignment and Sign-In Sheet. Findings will be reported and discussed by the Medical Records Director/Designee.
11. Any deficient practices will be immediately reported to the DON/Designee who will investigate and make every reasonable effort to reconcile (resolve) all reported discrepancies. Discrepancies which cannot be immediately resolved shall be documented by the DON/Designee in a report to the Administrator. If a major discrepancy or pattern of discrepancies occurs or if there is apparent criminal activity, the DON/Designee shall notify the ADM and PC immediately. A determination shall be made by the ADM, the PC, and the DON/Designee concerning possible notification of police or other enforcement agencies and any other actions to be taken.
12. The DON/Designee will discuss and review findings of accountability of controlled substances to the monthly Quality Assurance Performance Improvement (a structured approach in to evaluating the performance of systems in an organization) meetings to ensure corrective actions are sustained.
On 8/5/23 at 3:24 PM, while onsite and after confirming the facility's implementation of the IJ Removal Plan by observation, interview, and record review, the Department accepted the IJ removal plan and removed the Immediate Jeopardy, in the presence of the ADM, AADM, DON, and Senior [NAME] President (SVP).
Cross-referenced with F760
Findings:
A review of Resident 1's Face Sheet, dated 8/3/23, indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including essential hypertension (high blood pressure) and muscle weakness.
A review of Resident 1's Minimum Data Set (MDS - a comprehensive resident assessment tool) section C (Cognitive Patterns) indicated Resident 1 had a Brief Interview for Mental Status (BIMS - a interview tool used to determine cognitive impairment) score of 12 (moderately impaired.)
A review of Resident 1's History and Physical note (H&P - the formal document that physicians produce through the interview with the patient, the physical exam, and the summary of the testing either obtained or pending) dated 6/3/23, indicated Resident 1 had the capacity to understand and make decisions.
A review of Resident 1's physician order dated 6/9/23 indicated the physician prescribed Norco 5/325 mg to take one tablet by mouth every six hours as needed for moderate pain (pain score 4 to 6).
A review of Resident 1's eMAR, for the month of August 2023 and printed 8/3/23, indicated one dose of Norco 5/325 mg was given to Resident 1 on 8/1/23 at 10:58 PM and no additional doses were given on 8/2/23.
A review of Resident 1's Care Plan, dated 6/1/23, indicated Resident 1 was at risk for chronic pain due to neuropathy (nerve pain), arthritis (inflammation of the joint) in her left knee and bursitis (inflammation of tissue that cushions bones, tendons, and muscles near joints) in her left knee with targeted interventions to monitor for pain every shift and administer Norco 5/325 mg every 6 hours as needed.
A review of a pharmacy delivery receipt, dated 7/16/23, indicated a recent previous delivery was made to the facility for 60 tablets of Norco 5/325 mg on 7/16/23 timed at 1:23 AM for Resident 1.
A review of the pharmacy delivery receipt dated 8/2/23, indicated 30 tablets of Norco 5/325 mg (replacement supply) was delivered to the facility on 8/2/23 timed at 10:30 PM for Resident 1.
On 8/3/23 at 3:29 PM, during an interview, the DON stated LVN 1 was the nurse assigned on the morning shift (7 AM to 3 PM) on 8/2/23 and LVN 2 was the nurse assigned on the preceding night shift of 8/1/23 (11 PM to 7 AM) to Station 2, Medication Cart 2. The DON stated that at the start of LVN 1's morning shift on 8/2/23 (7 AM to 3 PM shift) around 9 AM, LVN 1 notified her that there were 14 tablets of Norco 5/325 mg missing from Resident 1's controlled medications supply. The DON stated that she looked for Resident 1's Norco 5/325 mg medications in Medication Cart 2, all other medication carts, and medication storage rooms in the facility but could not locate the medications. The DON stated she contacted the pharmacy to provide a replacement supply of Norco 5/325 mg, on 8/2/23. The DON stated the facility's pharmacy authorized one dose of Norco 5/325 mg from the controlled medication emergency kit (e-kit) and advised that the facility pharmacy would provide a replacement supply of Resident 1's Norco 5/325 mg. The DON stated the newly ordered replacement supply of Norco 5/325 mg was delivered to the facility on 8/2/23 at around 11 PM.
During the same interview, on 8/3/23 at 3:29 PM, the DON stated that the facility's pharmacy had delivered Norco 5/325 mg supplies with pharmacy delivery receipt dated 7/16/23. The DON stated Resident 1's Record of Controlled Substances (a log containing the date, time, and nurse's signature for all administered doses of a specific supply of a controlled medication) that corresponds to the missing supply of Resident 1's Norco 5/325 mg delivered on 7/16/23 was also missing.
During the same interview, on 8/3/23 at 3:29 PM, the DON stated LVN 1 (7 AM to 3 PM shift) and LVN 2 stated they signed the Controlled Drugs - Count Record but did not perform the controlled medication reconciliation for Medication Cart 2 together, as indicated in the facility's policy, during LVN 1 and 2's shift change (8/2/23 at 7 AM).
During the same interview, on 8/3/23 at 3:29 PM, the DON stated LVN 3 administered the last known dose of Norco 5/325 mg from the missing supply (pharmacy delivery dated 7/16/23) on 8/1/23 at around 9 PM. The DON stated LVN 3 worked on 8/1/23 during the 3 PM to 11 PM shift and was also assigned to Medication Cart 2. The DON stated on 8/1/23 at around 11 PM, when LVN 3 was ready to leave the facility, LVN 2 who was scheduled to work the 11 PM to 7 AM shift, had not yet arrived at the facility. The DON stated LVN 3 performed a controlled medication reconciliation with another licensed nurse scheduled during the same 3 PM to 11 PM shift, Registered Nurse (RN) 1, on 8/1/23 at around 11 PM. The DON stated RN 1 later (unknown time) performed a controlled medication reconciliation for Medication Cart 2 with LVN 4 who was assigned as a charge nurse team leader during the 11 PM to 7 AM shift on 8/1/23. The DON stated LVN 4 (11 PM to 7 AM shift) and LVN 2 (11 PM to 7 AM shift) performed a controlled medication reconciliation for Medication Cart 2 at some point prior to leaving the facility at approximately 7 AM on 8/2/23.
On 8/3/23 at 4:20 PM, during an interview, LVN 3 stated she was assigned to Medication Cart 2 on 8/1/23 for the 3 PM to 11 PM shift. LVN 3 stated that on 8/1/23, LVN 3 performed a controlled medication reconciliation with RN 1 around 10:50 PM because her shift was nearing its end, and LVN 2 (11 PM to 7 AM shift LVN) had not yet arrived at the facility. LVN 3 stated she provided one dose of Norco 5/325 mg to Resident 1 around 10:45 PM on 8/1/23. LVN 3 stated, after arriving on her shift (3 PM to 11 PM) the next day, on 8/2/23 around 3:20 PM, LVN 3 performed a controlled medication reconciliation with the DON because Resident 1's Norco 5/325 mg had been reported missing earlier that day. LVN 3 stated there was no Norco 5/325 mg available for Resident 1 during her shift that day, on 8/2/23. LVN 3 stated she assessed Resident 1 for pain during her shift around 4 PM or 5 PM and Resident 1 indicated her pain level was 4 to 5/10 (pain score on a scale from 0 to 10 where 0 is no pain and 10 is the worst possible pain).
On 8/4/23 at 10:08 AM, during another interview with the DON, the DON stated interviewing LVN 1 again regarding what happened with Resident 1's Norco 5/325 mg when it was discovered missing on 8/2/23. The DON stated LVN 1 informed her that she assessed Resident 1's pain the morning of 8/2/23 and LVN 1 indicated it was 2/10 pain. The DON stated LVN 1 determined Tylenol (over the counter medication for mild pain) was sufficient at that time but tried to locate the Norco 5/325 mg in case the Tylenol was not effective later. The DON stated LVN 1 was unable to find Resident 1's Norco 5/325 mg available on 8/2/23. The DON stated LVN 1 informed her LVN 1 failed to make a progress note log entry regarding Resident 1's missing Norco 5/325 mg-controlled medications supply.
On 8/4/23 at 10:39 AM, during a telephone interview with the Pharmacy Manager (RXM), RXM stated LVN 1 called the facility pharmacy at around 9 AM on 8/2/23 and stated Resident 1's Norco 5/325 mg was missing. RXM stated the pharmacy processed a refill of the Norco 5/325 mg which was delivered later that evening and provided the access code to the controlled medication e-kit for immediate use. RXM stated he was unaware whether the facility utilized any Norco 5/325 mg from the e-kit.
On 8/4/23 at 10:52 AM, during a telephone interview, LVN 1 stated she worked on 8/2/23 during the 7 AM to 3 PM shift, but did not arrive until right before 8 AM. LVN 1 stated LVN 2 (previous shift [11 PM to 7 AM]) had already left by the time she arrived at the facility, so LVN 1 did not count the controlled medications with any other nurse as indicated in the facility policy. LVN 1 stated she counted the controlled medications of other residents using the Record of Controlled Substances when she arrived at the facility by herself and did not find discrepancies (inconsistencies). LVN 1 stated she would not have known at that time if Resident 1's controlled medication supply of Norco 5/325 mg for Resident 1 was missing because the corresponding Record of Controlled Substances document was also missing. LVN 1 stated she assessed Resident 1's pain around 9 AM and determined Resident 1 had 2/10 pain. LVN 1 stated she administered Tylenol, as the pain rating was not sufficient to administer Norco at that time. LVN 1 stated she then searched Medication Cart 2 to determine whether the Norco 5/325 mg was available in case the Tylenol was ineffective. LVN 1 stated she could not find Resident 1's Norco medications. LVN 1 stated she immediately informed the DON that Resident 1's Norco 5/325 mg controlled medications were missing. LVN 1 stated the DON proceeded to search her Medication Cart and all other facility carts and medication storage rooms but was unable to locate the medication. LVN 1 stated she contacted the pharmacy for a replacement supply . LVN 1 stated she failed to document that Resident 1's Norco 5/325 mg was missing in Resident 1's progress note. LVN 1 stated she performed a controlled medication reconciliation with LVN 3 before leaving from her shift around 3 PM on 8/2/23. LVN 1 stated she failed to follow facility policy of performing controlled medication reconciliation with LVN 2 when she started her shift in the morning, on 8/2/23. LVN 1 stated it was important to ensure controlled medication counts are correct to ensure the availability of the medications for the residents. LVN 1 stated if controlled medications are missing, there is a chance residents could experience medical complications like increased pain or accidental exposure which could cause decreased quality of life.
On 8/4/23 at 12 PM, during a concurrent observation and interview in Resident 1's room, Resident 1 was observed sitting up on her bed. Resident 1 stated that on 8/2/23 she requested Norco 5/325 mg for severe pain at 4:45 PM and 11 PM. Resident 1 stated she was told by the licensed nurses (could not recall which licensed nurse) at both times the facility was out of the Norco. Resident 1 stated she did not remember which specific licensed nurse attended to her at those times. Resident 1 stated her pain was worsened because she did not receive her pain medication at those times, and she was supposed to be able to get the Norco every six hours. Resident 1 stated she would describe her pain at that time as severe. Resident 1 stated she never asks the licensed nurses for only Tylenol. Resident 1 stated sometimes licensed nurses tell her they will have to come back with her Norco because we keep them in a different place.
A review of Medicare Skilled Daily Note (a daily nursing progress note), dated 8/2/23, authored by LVN 1, included no entry concerning missing Norco 5/325 mg, pain score ratings, attempts to follow up with the pharmacy regarding the missing Norco 5/325 mg, e-kit usage.
A review of the facility's Controlled Drug - Count Record for Medication Cart 1 indicated the document was not signed according to facility policy a total of 28 times between 6/1/23 to 8/2/23.
A review of Resident 1's eMARs (printed 8/3/23) dated July and August 2023, indicated the following information:
1. A review of Resident 1's July 2023 MAR indicated Resident 1 received a total of 31 doses of Norco 5/325 mg between 7/16/23 (the date the most recent previous supply of Norco 5/325 mg was received from the pharmacy) to 7/31/23.
2. A review of Resident 1's August 2023 MAR indicated Resident 1 received a total of 1 dose of Norco 5/325 mg on 8/1/23 to 8/2/23 (the date the Norco 5/325 mg goes missing).
3. A review of Resident 1's July and August 2023 MARs indicated that between 7/16/23 (the date the most recent previous supply of Norco 5/325 mg was received from the pharmacy) to 8/2/23 (the date the Norco 5/325 mg goes missing) indicated a total of 28 doses out of the 60 doses of Norco 5/325 mg supply of Resident 1's Norco 5/325 mg were unaccounted for.
A review of the facility's Controlled Drug - Count Record for Medication Cart 2 indicated the document was not signed according to facility policy a total of 13 times between 6/1/23 to 8/2/23.
A review of the Controlled Drug - Count Record for Medication Cart 3 indicated the document was not signed according to facility policy a total of 61 times between 6/1/23 to 8/2/23.
A review of the Controlled Drug - Count Record for Medication Carts 1, 2, and 3 indicated the documents were not signed according to facility policy a total of 102 times, facility-wide between 6/1/23 to 8/2/23.
On 8/4/23 at 12:48 PM, during a telephone interview, LVN 2 stated her assignment was a charge nurse on Station 2, Medication Cart 2 on the night shift, of 8/1/23 during the 11 PM to 7 AM shift. LVN 2 stated that she arrived at the facility for her shift around 12:10 AM and did not count the controlled medications with anyone at that time. LVN 2 stated LVN 3 who was assigned to Medication Cart 2 for the previous shift (3 PM to 11 PM) had already left the facility. LVN 2 stated she counted everything that was in her lockbox inside Medication Cart 2 by herself but did not count any of Resident 1's Norco. LVN 2 stated all of Resident 1's supplies of Norco in Medication Cart 2 had been removed from Medication Cart 2 and relocated inside Medication room [ROOM NUMBER] and put into a lock box there. LVN 2 stated this change occurred about a month ago at the direction of the DON. LVN 2 stated she was unclear on why the Norco supplies for residents in Medication Cart 2 was moved in a lockbox inside Medication room [ROOM NUMBER]. LVN 2 stated she was unclear if there was a different controlled medication reconciliation process for the Norco controlled medications that had been relocated to Medication room [ROOM NUMBER]. LVN 2 stated she had not been reconciling the medication counts for any of the Norco since the Norco supplies were relocated from Medication Cart 2 to a lockbox in Medication room [ROOM NUMBER].
During the same interview, on 8/4/23 at 12:48 PM, LVN 2 stated that in the morning of 8/2/23, at around 7 AM before leaving the facility, she counted all the controlled medications in Medication Cart 2 with LVN 4. LVN 2 stated LVN 4 (11 PM to 7 AM) was also leaving from night shift at that time and was not the nurse taking over accountability of the controlled medications in Medication Cart 2 for oncoming shift (7 AM to 3 PM) on 8/2/23. LVN 2 stated LVN 1 was scheduled to relieve her for the next shift, on 8/2/23 at 7 AM but had not yet arrived at the facility, by the end of her shift.
On 8/4/23 at 1:20 PM, during a telephone interview, RN 1 stated she was scheduled to work on 8/1/23 for 3 PM to 11 PM shift. RN 1 stated that on 8/1/23, LVN 3 left around 11 PM and was unable to perform a controlled medication reconciliation with LVN 2 because LVN 2 had not yet arrived at the facility. RN 1 stated she counted the controlled medications with LVN 3 so LVN 3 could go home. RN 1 stated LVN 2 arrived around 12:10 AM, but RN 1 did not count the controlled medications with LVN 2 when she took over Medication Cart 2. RN 1 stated she also did not count the controlled medications with LVN 4 at any time prior to leaving the facility, on 8/1/23. RN 1 stated all the Norco supplies from Medication Cart 2 had been removed from Medication Cart 2 and placed in a lockbox inside Medication room [ROOM NUMBER]. RN 1 stated the keys to the lockbox were kept hanging on the side of the lockbox inside Medication room [ROOM NUMBER]. RN 1 stated anyone with keys to Medication room [ROOM NUMBER] could have accessed the Norco in the lockbox that was supposed to be in Medication Cart 2. RN 1 stated she was unsure why the DON made the decision to move the Norco to Medication room [ROOM NUMBER]. RN 1 stated if controlled medications are in two different places and people other than the responsible licensed staff have access to the controlled medications, the risk for diversion or accidental exposure to residents are increased.
On 8/4/23 at 1:34 PM, during a concurrent interview and record review of Resident 1's MAR and pharmacy delivery receipts, the DON stated and acknowledged that it was a total of 28 doses of Norco 5/325 mg missing instead of 14 tablets mentioned previously.
During the same interview, on 8/4/23 at 1:34 PM, the DON stated about a month ago she decided to move all the Norco from Medication Cart 2 into a lockbox in Medication room [ROOM NUMBER]. The DON stated she made this decision because in the past, Resident 1 and licensed staff disagreed on whether Resident 1 received her Norco. The DON stated her intent for doing this was to ensure at least two licensed nurses would need to be involved in administering Resident 1's Norco for verification that the medication administration occurred. The DON stated she failed to consider that by removing the Norco from Medication Cart 2, there would be no way to ensure the accountability of the controlled substances from shift to shift between licensed nurses when performing controlled medication reconciliation. The DON stated she failed to address the potential with which the Controlled Drugs - Count Record would not be signed for the Norco supplies according to facility policy by the oncoming and outgoing nurse between 6/1/23 to 8/2/23 if the controlled medications were on a separate location. The DON stated if one nurse is late, the nurse who was scheduled to leave should not leave before the next nurse arrives.
During the same interview, on 8/4/23 at 1:34 PM, the DON stated the facility did not have a policy to address what licensed nurses needed to do to endorse over the accountability of controlled medications in the case that two licensed nurses' shifts on duty do not overlap. The DON stated if both the incoming and outgoing nurses do not sign off on the Controlled Drugs - Count Record then there would be a break in the chain of accountability for the controlled medications. The DON stated if a licensed nurse counts the medications themselves or if two nurses who are both leaving from the same shift, count the controlled medications together it does not serve the purpose of continuous accountability. The DON stated because the facility failed to maintain adequate oversight on the controlled medication reconciliation process and because controlled medications are now missing, the facility's residents are at risk of accidental exposure possibly leading to hospitalization or death, increased pain, ADL decline, and quality of life decline. The DON stated that failure to maintain oversight of the controlled medications such as leaving the key hanging by the lockbox inside Medication room [ROOM NUMBER] and the licensed nurses controlled medication reconciliation process further increased the risk of medication diversion, misappropriation of resident property, or staff providing resident care in an impaired state.
A review of the facility's policy Controlled Substances, revised April 2019, indicated The facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled substances . Access to controlled medications remains locked at all times and access is recorded . Controlled substances are reconciled upon receipt, administration, disposition, and at the end of each shift ., Controlled medications are counted at the end of each shift. The nurse coming on duty and the nurse going off duty determine the count together .
A review of the facility's policy Administering Medication, revised April 2019, indicated Medications are administered in a safe and timely manner, and as prescribed . Medications are administered in accordance with prescriber orders, including any required time frame . The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones .

Based on interview and record review, the facility failed to ensure the resident and/or Responsible Party (RP, a person responsible for a resident who are unable to make decisions for themself) was informed prior to the administration of psychotropic (a drug that changes brain function and results in alterations in perception, mood, consciousness, or behavior) medication for one of three sampled residents (Resident 1).
This deficient practice violated the resident's right to make an informed decision regarding the use of psychotropic medications, including the risk and benefits.
Findings:
A review of Resident 1's Face Sheet indicated the facility admitted Resident 1 on 4/21/23, with diagnoses that included psychosis (severe mental disorder that cause abnormal thinking and perceptions) and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest).
A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 4/26/23, indicated Resident 1 had moderately impaired memory and cognition (ability to think and reason). Resident 1 exhibited symptoms including feeling down, depressed, or hopeless, trouble falling or staying asleep, or sleeping too much, poor appetites or overeating, and trouble concentrating on things, such as reading the newspaper or watching television. Resident 1 had received medications including antipsychotic, antianxiety, antidepressant and hypnotic since admission.
During a review of Resident 1 ' s History and Physical (H&P), dated on 4/21/23, indicated Resident 1 had diagnoses of psychosis and cognitive impairment. The H&P indicated Resident 1 had the capacity to understand and make decisions.
During a review of Resident 1 ' s Physician Orders, for the month of April 2023, indicated to give Resident 1 the following medications starting on 4/21/23:
1. Risperdal (antipsychotic, treat certain mental/mood disorders) 1 milligram (mg) tablet (tab) twice a day (BID) for psychosis disorder manifested by paranoia (An unrealistic distrust of others or a feeling of being persecuted, harassed, or betrayed by others).
2. Risperdal 2 mg tab every day at 9 PM for psychosis disorder manifested by paranoia.
3. Remeron (antidepressant, treat depression) 15 mg tab every day at 9 PM for depression manifested by feeling sad.
4. Zolpidem (sedative, treat sleeping problems) 10 mg tab at bedtime for insomnia oral every day as needed.
5. Ativan (antianxiety, treat anxiety) 1 mg tablet every 6 hours as needed for anxiety manifested by agitation.
During a review of Resident 1 ' s Medication Administration Record (MAR, legal record of medication administration to a resident at a facility by a health care professional), for the month of April 2023, indicated Resident 1 received Risperdal 1 mg BID oral from 4/21/23 to 4/26/23, Risperdal 2 mg and Remeron 15 mg oral at bedtime from 4/21/23 to 4/25/23, Zolpidem 10 mg oral at bedtime from 4/23/23 to 4/24/23 and Ativan 1 mg oral one time on 4/24/23.
During a concurrent interview and record review on 5/11/23 at 4:49 PM, Registered Nurse (RN 1) stated there was no documented evidence that informed consent was obtained from Resident 1 prior to the administration of the psychotropic medications (Risperdal 1 mg, Risperdal 2 mg, Remeron, Zolpidem, and Ativan) on 4/21/23. RN 1 stated Resident 1 ' s MAR indicated Resident 1 received psychotropic medications from 4/21/23 to 4/26/23 (6 days). RN 1 stated it was important to inform the residents and/or RP about the purpose, risks, and benefits of using psychotropic medication.
During an interview on 5/11/23, at 5:10 PM, the Director of Nursing (DON) stated an informed consent for psychotropic medication should be signed and dated before administering the medications. DON stated it was important to inform the residents about the use, risks, and benefits of psychotropic medications so that they could participate in and make decisions on their care.
During a review of the facility ' s policy and procedure titled, Informed Consent-Psychotherapeutic Medications and Restraint Devices, dated 12/14/17, indicated informed consent should be obtained from the resident/surrogate decision maker prior to receipt of the medication when a psychotherapeutic medication is ordered throughout the resident ' s stay in the facility.