**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure three of 10 sampled residents (Residents 1, 2, and 3) were free from involuntary seclusion (separation of a resident from other residents or from her/his room or confinement to her/his room with or without roommates against the resident's will, or the will of the resident representative) by failing to: 1. Ensure Certified Nurse Assistant (CNA) 1 did not use two utility/linen carts (material handling cart used for bedding, linens, and other supplies) to block the entrance/exit (only one entrance and exit) to Resident 1, 2, and 3's Room (RM 1) after CNA 1 witnessed Resident 1 spilling liquid on the floor. As a result, CNA 1 violated Resident 1, 2 and 3's rights and prohibited (not allowed) Residents 1, 2, and 3 from leaving RM [ROOM NUMBER]. These deficient practices had the potential for psychosocial (mental, emotional, social, and spiritual effects) harm, serious injury, serious harm, serious impairment, or death to Residents 1, 2, and 3. On 1/18/2024, at 3:34 pm, while onsite at the facility, an Immediate Jeopardy situation (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. The surveyor notified the Administrator (ADM) and the Director of Nursing (DON) regarding CNA 1 using trash bags to tie two utility/linen carts to the hallway side rail and the strike plate hole (part of a door lock) to RM [ROOM NUMBER]'s entrance/exit and left Residents 1, 2, and 3 involuntarily secluded in RM [ROOM NUMBER] without staff present. The IJ was called in the presence of the facility's ADM and DON. The ADM and DON were informed of the facility's failure to have a system in place to ensure Residents 1, 2, and 3 were free from involuntary seclusion that could result in serious harm that threatened the health and safety for Residents 1, 2, and 3. On 1/19/2024, at 9:30 am, while onsite at the facility, the surveyor reviewed the Plan of Action (POA, a list of steps taken to correct the deficient practices). The surveyor verified and confirmed the facility removed the IJ situation and implemented the POA through observation, interview, and record review. The surveyor removed the IJ on 1/19/2024 at 5:16 pm in the presence of the ADM, DON, and Nurse Consultant (NC). The IJ Removal Plan, dated 1/18/2024 included the following: 1. On 1/18/2024, staff immediately removed the utility carts that blocked Residents 1, 2, and 3 from leaving RM [ROOM NUMBER]. 2. On 1/18/2024, the DON assessed Residents 1, 2, and 3. All three (3) residents were at their baseline condition without any signs or symptoms (S/S - observed or detectable signs, and experienced symptoms of an illness, injury, or condition) of distress. 3. On 1/18/2024, the psychiatrist evaluated Residents 1, 2, and 3 via telehealth and informed the facility that all three (3) residents did not experience any S/S of psychosocial distress. There were no new orders. 4. On 1/18/2024, the DON notified Residents 1, 2, and 3' s Medical Doctor (MD 1) regarding the involuntary seclusion with no new order. 5. On 1/18/2024, the DON notified the family members of Residents 1, 2, and 3 regarding the incident of involuntary seclusion. 6. On 1/18/2024, the ADM provided an in-service to CNA 1 regarding abuse prevention, including involuntary seclusion. 7. On 1/18/2024, CNA 1 was suspended, followed by further disciplinary action, including termination based on the determination/conclusion of the investigation. 8. On 1/18/2024, the ADM and DON notified the staff of the findings stated in the IJ template, dated 1/18/2024, and gave in-services regarding the abuse policy. During the in-services, the ADM and DON emphasized the importance of not confining any resident to a room or area against his/her will. 9. On 1/19/2024, the maintenance supervisor and the housekeeping supervisor stored all clean linens in the linen storage in different hallways and removed all the clean linen carts from the floor. Any linen carts required to be on the floor were placed against the wall, avoiding blocking the entrances, including all residents' rooms. 10. On 1/19/2024, the DON updated the plan of care for Resident 1 who had episodes of grabbing cups from other resident's rooms. The care plan included the interventions of storing extra clean cups inside Resident 1's room and encouraged Resident 1 to participate in group activities to keep Resident 1 occupied. (Cross reference F656) Findings: 1. During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses of paranoid schizophrenia (serious mental illness in which people interpret reality abnormally), unspecified psychosis (severe mental condition in which thought and emotions are so affected that contact is lost with external reality), and obsessive-compulsive personality disorder (a pervasive obsession with order, perfectionism, control, and specific ways of doing things). During a review of Resident 1's History and Physical (H&P), dated 2/19/2023, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS - a standardized resident assessment and care screening tool), dated 11/17/2023, the MDS indicated Resident 1 had severely impaired cognition (ability to think, remember, and function). The MDS indicated Resident 1 required partial/moderate assistance (helper does less than half the effort and lifts or holds trunk or limbs but provides less than half the effort) with toileting hygiene, showering/bathing self, and personal hygiene. 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 the activity and may be provided throughout the activity or intermittently) with oral hygiene, upper body dressing, lower body dressing, and putting on/taking off footwear. The MDS indicated Resident 1 required setup or clean-up assistance (helper sets up or cleans up while the resident completes the activity and helper assists only prior to or following the activity) with eating and required supervision or touching assistance with sitting to lying, lying to sitting on side of bed, sit to stand, chair/bed-to-chair transfer, toilet transfer, tub/shower transfer, walking 10 feet. 2. During a review of Resident 2's AR, the AR indicated Resident 2 was admitted to the facility on [DATE] with diagnoses of schizophrenia, major depressive disorder (serious illness that negatively affects how one feels, thinks and acts), and anxiety disorder (persistent feeling of dread or panic that can interfere with daily life). During a review of Resident 2's untitled care plan, dated 5/2/2022, the care plan indicated Resident 2 had ineffective coping related to a past traumatic incident, manifested by uncontrollable mood swings causing anger and paranoid thoughts, thinking someone was coming after Resident 2, causing stress. Interventions included to build a trusting relationship during day-to-day activities, encourage group activities, and provide a safe environment and atmosphere of acceptance. During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 had severely impaired cognition. The MDS indicated Resident 2 required substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half effort) with showering/bathing self. The MDS indicated Resident 2 required partial/moderate assistance with toileting hygiene, upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygiene. The MDS indicated Resident 2 required supervision or touching assistance with oral hygiene. The MDS indicated Resident 2 required setup or clean up assistance with eating and required supervision or touching assistance with rolling left to right, sitting to lying, lying to sitting on side of bed, sitting to standing, chair/bed-to-chair transfers, toilet transfers, walking 10 feet. 3. During a review of Resident 3's AR, the AR indicated Resident 3 was admitted to the facility on [DATE] with diagnoses of paranoid schizophrenia, anxiety disorder, and major depressive disorder. During a review of Resident 3's H&P, dated 6/10/2023, the H&P indicated Resident 3 had the capacity to make decision for activities of daily living (ADL- the tasks of everyday life fundamental to caring for oneself). During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3 had moderately impaired cognition. The MDS indicated Resident 3 required partial/moderate assistance with showering/bathing self. The MDS indicated Resident 3 required supervision or touching assistance with oral hygiene, toileting hygiene, upper and lower body dressing, putting on/taking off footwear, and personal hygiene. The MDS indicated Resident 3 required setup or clean-up assistance with eating. The MDS indicated Resident 3 required supervision or touching assistance with toilet transfers. The MDS indicated Resident 3 required setup or clean-up assistance with rolling left and right, sitting to lying, lying to sitting on side of bed, sitting to standing, chair/bed-to-chair transfers, and walking 10 feet. During a concurrent observation and interview on 1/18/2024 at 9:50 am, while on a tour with the Social Services Director (SSD), two blue utility/linen carts were tied to the hallway siderail and the strike plate hole in front of RM [ROOM NUMBER]'s doorway. The SSD stated two utility carts were blocking RM [ROOM NUMBER]'s doorway. The SSD stated there was a clear trash bag that tied both utility carts together, a clear trash bag that tied the left utility cart to the inside of RM [ROOM NUMBER]'s strike plate hole, and a clear trash bag that tied the right utility cart to the right siderail in the hallway. The SSD stated the SSD was unclear why there were trash bags tying two utility carts in place to block RM [ROOM NUMBER]'s doorway. During a concurrent observation and interview on 1/18/2024 at 9:52 am, with CNA 1, in front of RM [ROOM NUMBER]'s doorway, there were two utility carts blocking the doorway. CNA 1 stated the utility carts were tied with clear trash bags. CNA 1 stated the Residents in RM [ROOM NUMBER] (Residents 1, 2, and 3) could not get out the room unless CNA 1 or another staff member (in general) untied the three trash bags and moved the two utility carts out of RM [ROOM NUMBER]'s doorway. CNA 1 stated the purpose of blocking RM [ROOM NUMBER]'s doorway was to block Resident 1 from coming out of RM [ROOM NUMBER] due to Resident 1's behavioral issues. CNA 1 stated Resident 1 stole other residents' (unidentified) cups and while walking, Resident 1 spilled water on the floor. During an interview on 1/18/2024 at 10:03 am, with Licensed Vocational Nurse (LVN) 1, in front of Resident 1's doorway, LVN 1 stated CNA 1 informed LVN 1 that CNA 1 barricaded (blocked) Resident 1's doorway with two utility carts and tied the carts with trash bags to keep Resident 1 in the room. LVN 1 stated, CNA 1 needed to keep Resident 1 in the room while housekeeping staff (in general) cleaned the floor because Resident 1 spilled liquid from Resident 1's cups all over the floor. LVN 1 stated blocking RM [ROOM NUMBER]'s doorway could lead to injury to Resident 1 in an emergency. During a concurrent observation and interview on 1/18/2024 at 10:11 am, with LVN 2, in front of RM [ROOM NUMBER]'s doorway, LVN 2 untied three, clear trash bags anchored to two utility carts in RM [ROOM NUMBER]'s doorway. LVN 2 stated Residents 1, 2, and 3 were in RM [ROOM NUMBER] at the time RM [ROOM NUMBER]'s doorway was blocked. LVN 2 stated Residents 2 and 3 were trapped inside RM [ROOM NUMBER] with Resident 1 and could not get out of the room. LVN 2 stated blocking Residents 1, 2, and 3 in their room was a type of abuse used for staff convenience. During an interview on 1/18/2024 at 10:18 am, Resident 2 stated Resident 2 did not know why staff blocked RM [ROOM NUMBER]'s doorway so Resident 2 could not get out of the room. Resident 2 stated Resident 2 did not like it when staff did that. Resident 2 stated staff were not nice, and it made Resident 2 feel terrible when staff blocked the doorway. Resident 2 stated Resident 2 wished staff would stop blocking the doorway because it did not make sense when he was trapped in the room with Resident 1. Resident 2 stated Resident 2 did not know how to ask for help when Resident 2 wanted to get out of the room or needed assistance. During an interview on 1/18/2024 at 11:38 am, with CNA 1, CNA 1 stated Resident 3 would yell and scream to be let out of the room to smoke cigarettes when the doorway was barricaded. During an interview with CNA 3 on 11/18/2024, at 11:56 am, CNA 3 stated CNA 1 barricaded Resident 1's doorway because housekeeping staff (in general) had to spend time cleaning up whatever Resident 1 dropped on the floor. CNA 3 stated this happened every day. CNA 3 stated when CNA 3 saw RM [ROOM NUMBER]'s doorway barricaded, CNA 3 untied the utility carts, but CNA 3 would get yelled at by other nursing staff (unable to identified). CNA 3 stated barricading Resident 1 inside RM [ROOM NUMBER] was abuse in the form of involuntary seclusion. CNA 3 stated Resident 3 liked to smoke cigarettes and when RM [ROOM NUMBER] was blocked by the utility/linen carts, Resident 3 could not go out to smoke. CNA 3 stated Resident 3 had to yell and scream until staff eventually let Resident 3 out of the room to smoke. During an interview on 1/18/2024 at 12:12 pm, with Resident 3, Resident 3 stated Resident 3 liked to smoke. Resident 3 stated it made Resident 3 really mad and upset because Resident 3 had to yell and scream to get someone to let Resident 3 out of RM [ROOM NUMBER] to smoke. Resident 3 stated it generally took over 15 minutes for staff to let Resident 3 out of the room. Resident 3 stated it felt like staff forget about everyone in RM [ROOM NUMBER]. Resident 3 stated it was stupid Resident 3 had to ask for permission to leave the room and Resident 3 hated it. During an interview on 1/18/2024 at 12:31 pm, with the Infection Prevention Nurse (IPN), the IPN stated the IPN had put the utility carts in RM [ROOM NUMBER]'s doorway before, but never tied the carts with trash bags. The IPN stated this practice (blocking RM [ROOM NUMBER]'s doorway) was done by the IPN and other staff (unidentified) to diminish (reduce) Resident 1's traffic around the facility because Resident 1 walked around the facility with cups of water and spilled the water everywhere. The IPN stated the utility carts were generally put in RM [ROOM NUMBER]'s doorway in the morning when staff were busy. During a concurrent observation and interview on 1/18/2024 at 12:47 pm, with the DON and Admissions Director (AD), the facility's security footage of Camera Two was reviewed. The DON stated on 1/18/2024 at 8:29:14 am, Resident 1 went into RM [ROOM NUMBER]. The DON stated on 1/18/2024 at 8:30:11 am, CNA 1 held a trash bag in CNA 1's hands. The DON stated on 1/18/2024 at 8:31:46 am, CNA 1 moved two utility carts into the doorway of RM [ROOM NUMBER]. During a concurrent interview and record review on 1/18/2024 at 2:49 pm, with LVN 2, Residents 1, 2, and 3's AR were reviewed. Residents 1, 2, and 3 had diagnoses of schizophrenia and Residents 2 and 3 had anxiety. LVN 2 stated Residents 1, 2, and 3's schizophrenia could have been exacerbated from being barricaded in RM [ROOM NUMBER]. LVN 2 stated Residents 2 and 3 could have anxiety attacks (intense feeling of dread, fear, or discomfort, with a feeling of losing control or that one's life is in danger when no threat is present) and pass out. LVN 2 stated staff would not know if a medical emergency (illness or injuries that need care right away) was happening in RM [ROOM NUMBER] because the residents (Residents 1, 2, and 3) were barricaded inside. During an interview on 1/16/2024 at 3:18 pm, with the DON, the DON stated the utility carts were supposed to be used for linens, towels, and blankets for the residents. The DON stated utility carts were to be stored in the hallways along the walls. The DON stated the utility carts were not supposed to be used to block RM [ROOM NUMBER]'s doorway and barricade Residents 1, 2, and 3 inside their room. The DON stated doing so was abuse in the form of involuntary seclusion. The DON stated Residents 1, 2, and 3 who were involuntarily secluded to their rooms were at risk for depression, anxiety, and negative behaviors. The DON stated Residents 1, 2, and 3 who had diagnoses such as schizophrenia, depression, and anxiety were at higher risk of having an exacerbation of their illness symptoms by being involuntarily secluded in their room. The DON stated Residents 1, 2, and 3 could become entangled by the barricade and become injured or die when Residents 1, 2, and 3 attempt to get out. During a review of the facility's policy and procedure (PP) titled, Involuntary Seclusion, undated, the PP indicated the goal was to ensure all residents would be free of involuntary seclusion. The PP indicated examples of involuntary seclusion included confining a resident to his or her room as form of punishment or for staff convenience, and any attempt to keep a resident confined to a certain area by blocking the exit with furniture or a closed door. The PP indicated secluding or confining a resident against his or her will was prohibited. During a review of the facility's PP titled, Resident Rights, revised 2/2021, the PP indicated employees shall treat all residents with kindness, respect, and dignity. The PP indicated residents had the right to be free from involuntary seclusion.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Based on observation, interview, and record review, the facility failed to provide care and services for one of two sampled residents (Resident 19), who had history of aspiration pneumonia (swelling and infection of the lungs caused when food or liquid is breathed into the airway or lungs instead of being swallowed), by failing to: Ensure Licensed Vocational Nurse 1 (LVN 1) transcribed (put into written or printed form) and followed Medical Doctor 1's (MD 1's) verbal order (spoken orders given by a physician to a person authorized to receive and record the orders in accordance with applicable policies, laws, and regulations) according to the facility's policy and procedure titled, Physician Orders and Telephone Orders. MD 1 gave LVN 1 a verbal order for Resident 19 to remain sitting upright for one to two hours after eating his meals (breakfast, lunch, and dinner) due to Resident 19 had a history of hospitalizations for sepsis (life-threatening complication of an infection) that resulted from aspiration pneumonia. Resident 19 required intubation (a breathing tube placed through the mouth, down the throat, and into the lungs), the use of a ventilator (a life support machine that moves breathable air in and out of the lungs when a person is unable to breath on his/her own), and admission to the Intensive Care Unit (ICU, a unit of a hospital that provides intensive treatment and close monitoring for seriously ill patients). These deficient practices had the potential to result in recurrent (occurring often or repeatedly) aspiration pneumonia, re-hospitalization (being hospitalized again), intubation, and death for Resident 19. On 3/9/2023, at 12:20 PM, during a recertification survey, the California Department of Public Health (CDPH) called 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) regarding the facility's failure to ensure Resident 19 remained sitting upright for one to two hours after meals, per MD 1's verbal order, in the presence of the Administrator (ADM) and the Director of Nursing (DON). The CDPH informed the ADM and the DON regarding the facility's deficient practice could cause recurrent aspiration pneumonia that could lead to serious harm to Resident 19's health. On 3/10/2023, at 1:05 PM, the facility's ADM submitted an acceptable Plan of Action (POA/IJ removal plan, a detailed plan to address the IJ findings) while onsite, the surveyors verified the implementations of the POA by observation, interview, and record review. The CDPH confirmed the removal of the IJ on 3/10/2023, at 2:37 PM while onsite, in the presence of the ADM and the DON. The acceptable IJ Removal Plan included the followings: A. On 3/9/2023 and 3/10/2023, the DON provided in services to all nurses (licensed nurses and certified nursing assistants) from all shifts regarding aspiration precautions (practices that help prevent food or fluid get into the airway/the passage by which air reaches the lungs). The in-services indicated for all nurses to keep Resident 19 sitting upright in the wheelchair during and after meals. B. On 3/9/2023, the DON called MD 1 and MD 1 ordered for Resident 19 to remain sitting upright in the wheelchair for 30 minutes after each meal. C. On 3/9/2023, the Speech Therapist (ST, also called a speech-language pathologist is a specialist who assesses, diagnoses, and treats people with communication and swallowing problems) completed a speech screening for Resident 19 who was on a puree diet (blended foods that do not need to chew, for people who have trouble chewing or swallowing). Resident 19 tolerated puree diet. D. On 3/9/2023, the DON and the Director of Staff Development (DSD) observed Resident 19 eating dinner while sitting upright in Resident 19's wheelchair and remained sitting upright for 30 minutes after dinner. Cross Reference F711 and F656. 2. Based on observation, interview, and record review, the he facility also failed to provide the necessary care and treatment for one of two sampled residents (Resident 28) in a total resident sample of 42 by failing to apply the Geri-sleeves (a breathable cotton-blend material that protects against skin tears caused by friction and shearing) to Resident 28 as ordered by the physician. This deficient practice had the potential to cause injury to Resident 28's skin. Findings: A review of Resident 19's admission Record indicated Resident 19 was originally admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses that included, pneumonia (infection that swells the air sacs that might be filled with fluid or pus in one or both lungs), sepsis (a life-threatening medical emergency in which the body responds improperly to an infection,) respiratory failure (a serious condition that makes it difficult to breathe), and gastro-esophageal reflux disease (GERD, occurs when stomach acid repeatedly flows back into the tube [esophagus] connecting the mouth and stomach). A review of Resident 19's Change of Condition (COC, a sudden clinically important deviation from a patient's baseline in physical, cognitive [ability to think and process information], behavioral, or functional domains) Assessment Form, dated 12/6/2022, indicated Resident 19 had shortness of breath (difficulty breathing), and trouble breathing when lying flat. The COC indicated at 11 AM, Resident 19 was sitting up in the wheelchair waiting for lunch. At 12:30 PM, Resident 19 was found breathing fast, looked pale with audible congestion (a sign that something blocks the airway), and rhonchi (low-pitched sounds usually indicating secretions [saliva or mucus] in the airway) in both lungs by auscultation (listening by using a stethoscope [an instrument that's used to hear the heart beats or breathings inside the chest]). The COC indicated the facility called 911 (phone number for emergency services) and the paramedics (a healthcare professional who responds to emergency calls for medical help outside of a hospital) transferred Resident 19 to the hospital. A review of Resident 19's General Acute Care Hospital 1 (GACH 1) admission History and Physical Exam, dated 12/6/2022, indicated Resident 19 had shortness of breath, was tachypneic (breathing that is abnormally rapid and shallow) and required intubation. Resident 19 was admitted to GACH 1 for aspiration pneumonia. The GACH record indicated Resident 19 had acute (sudden) respiratory failure and depended on a respirator (depended on a mechanical ventilation/breathing machine to sustain respiration/breathing). A review of Resident 19's GACH 1 Multi-Discipline Progress Notes, dated 12/23/2022, indicated Resident 19 received a Modified Barium Swallow Study (MBSS, speech therapy evaluation with special X-ray [image study that takes pictures of the bones and soft tissues] to find the reason for difficulty swallowing) on 12/17/2022. The MBSS results indicated Resident 19 had moderate dysphagia (difficulty swallowing) characterized by poor base of the tongue retraction (action of drawing something back), and silent laryngeal aspiration (when the residents accidentally inhale food or liquid in the airway, and they do not know it) of thin and mildly thick liquids. The note indicated feeding precautions included for Resident 19 to sit entirely upright, and for staff (in general) to monitor Resident 19 for fever spike (sharp rises in body temperature) after meals, coughing, choking (severe difficulty in breathing because an object or food lodges in the throat or windpipe blocking the flow of air) or throat clearing during meals. A review of Resident 19's GACH 1 Discharge summary, dated [DATE], indicated Resident 1 had sepsis due to aspiration pneumonia, recurrent aspiration pneumonia, acute hypoxemic respiratory failure (low blood oxygen level resulting from sudden impairment of gas exchange between the lungs and the blood which may cause shortness of breath, anxiety [a feeling of worry], confusion, cardiac dysfunction [heart failure], and cardiac arrest [no heartbeat]), and respirator dependence. The discharge summary indicated for Resident 19 to have puree diet with moderately thickened liquid (liquid mixed with thickener to help prevent choking and stop fluid from entering the lungs for safer swallowing), and for staff (in general) to observe strict aspiration precautions during and immediately after meals. A review of Resident 19's Minimum Data Set (MDS, a resident assessment and care screening tool), dated 2/22/2023, indicated Resident 19 had severe impaired cognition (ability to understand and process information). Resident 19 required extensive physical assistance (resident involved in activity, staff provide weight-bearing support) from one-person during bed mobility, transfers (moving a resident from one flat surface to another), eating and personal hygiene. A review of Resident 1's MD 1 Progress Notes, dated 1/4/2023, indicated Resident 19 needed oxygen and completed a seven-day course of Levaquin (medication that treats a wide range of infections) to treat the aspiration pneumonia. The note indicated strict aspiration precautions were to be followed given Resident 19's high-risk for re-aspiration. During an observation on 3/7/2023, at 9:32 AM, Resident 19 was lying flat on Resident 19's bed with his eyes closed. There was a printed signage (any kind of graphic display intended to convey information to an audience) above Resident 19's head of bed indicated, per MD 1, Please have resident up in wheelchair for meals and to remain sitting upright for 1-2 hrs. [hours]. During an observation on 3/7/2023, at 11:40 AM, Resident 19 was sitting up in wheelchair eating his lunch. Resident 19 had puree diet and thicken liquid on Resident 19's meal tray. During an observation and a concurrent interview with Resident 19 on 3/7/2023, at 12:19 PM, Resident 19 was lying in his bed flat. Resident 19 nodded his head when surveyor asked if he wanted to get up. During an interview on 3/7/2023 at 12:22 PM, LVN 2 stated she was aware of MD1's order for Resident 19 to remain sitting upright for one to two hours after meals due to the signage with instruction posted over Resident 19's head of bed. LVN 2 stated Resident 19 had GERD, and history of aspiration pneumonia. LVN 2 stated Resident 19 needed to be sitting upright after meals as aspiration precautions to prevent gastric secretions backflow (a flowing back or returning especially toward a source) to the airway. During a concurrent interview Certified Nursing Assistant 5 (CNA 5), CNA 5 stated she and another staff (unidentified) assisted Resident 19 back to bed after Resident 19 finished his lunch. CNA 5 stated she was aware of MD 1's instruction to have Resident 19 sitting upright in the wheelchair after meals. CNA 5 stated there were two signages with instructions to have Resident 19 up in wheelchair for meals and to remain sitting upright for 1-2 hrs. posted on the wall above Resident 19's head of bed, and at the back of Resident 19's door. During an interview, on 3/8/2023 at 1:33 PM, and a concurrent review of Resident 19's physician orders, care plans, and nurses progress notes, dated from 12/24/2022 to 3/6/2023, the DON stated the posted signages in Resident 19's room were to remind staff (in general) to keep Resident 19 sitting upright in the wheelchair for one to two hours after meals for aspiration precautions. The DON stated not following aspiration precautions could put Resident 19 on a ventilator again and or Resident 19 could die from choking. The DON reviewed Resident 19's physician orders and stated there was no written order for Resident 19 to sit upright in the wheelchair during and after meals. The DON continued to review Resident 19's care plan, nurses notes, and stated there was no documentation in the nurse's progress notes and no care plan interventions corelating with the aspiration precautions. The DON stated LVN 1 who received MD 1's instruction/verbal order needed to document MD 1's instruction/verbal order in Resident 19's progress notes. During a telephone interview on 3/9/2023 at 8:44 AM, MD 1 stated Resident 19 had a history of aspiration pneumonia which required hospitalization. MD 1 stated he gave a verbal order to LVN 1 during an onsite visit shortly after Resident 19 readmitted to the facility from the hospital. MD 1 stated he did not remember the date that he gave the verbal order. MD 1 stated the order was to have Resident 19 sitting upright in the wheelchair during meals and to remain sitting upright for one to two hours after meals. During an interview on 3/9/2023 at 9:12 AM, LVN 1 stated after Resident 19 was readmitted to the facility (on 12/24/2022), MD 1 told her to make sure to keep Resident 19 sitting upright in the wheelchair at least one to two hours after meals. LVN 1 stated she did not remember the date when MD 1 gave her the verbal order. LVN 1 stated she did not enter MD 1's verbal order in Resident 19's physician order summary. LVN 1 stated she did not document MD 1's verbal order in the nurse's notes and did not update Resident 19's care plan interventions for aspiration precautions. LVN 1 stated Resident 19 needed to remain sitting upright after meals due to Resident 19's history of GERD, aspiration pneumonia to prevent recurrent aspiration pneumonia, rehospitalization, sepsis, and death. During an interview on 3/9/2023, at 9:46 AM, the DON stated LVN 1 who received MD 1's verbal order needed to update Resident 19's care plan regarding aspiration precautions. A review of the facility's policy and procedure titled, Aspiration Precaution, undated, indicated Avoid lying down right after feeding. Remain sitting in a upright position for at least 20 to 30 minutes to prevent aspiration. A review of the facility's policy and procedure titled, Physician Orders and Telephone Orders, dated 1/2004, indicated All orders must be specific and complete with necessary details to carry out the prescribed order. The policy indicated All orders shall indicate how the order was received, the name of the prescriber, the name of the attending physician and the name of the nurse taking the order. 2. A review of Resident 28's admission Record indicated the facility admitted Resident 28 on 1/25/2023, with diagnoses that included fracture of the left femur (broken thighbone), dementia (decline in mental ability severe enough to interfere with daily life), and hypertension (high blood pressure). A review of Resident 28's Physician Order dated 1/25/2023, indicated for the staff to apply Geri-sleeves daily for safety and protection of fragile skin due to senile purpura (purplish spots appear on the arms and legs due to the thinness of the skin and frailty of the blood vessels). A review of Resident 28's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 2/2/2023, indicated the resident rarely/never made herself understood, rarely/never understood others, and had severe impairment of cognitive skills (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). The MDS indicated Resident 28 required extensive assistance (resident involved in activity, staff provided weight-bearing support) from the staff for bed mobility transfer, locomotion on and off unit, and toilet use. The MDS indicated Resident 27 was at risk for developing skin injuries. A review of Resident 28's Care Plan dated 2/2/2023, indicated Resident 28 was at risk for skin discoloration, bruising secondary to fragile skin (thin skin that tears easily), aging process, and cognitive impairment (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The care plan indicated for the staff to apply Geri-sleeves to bilateral upper extremities (BUE) due to senile purpura. During a concurrent observation and interview with Certified Nursing Assistant (CNA 3) on 3/7/2023 at 2:23 PM, Resident 28 was lying in bed without the Geri-sleeves on Resident 28's BUE. CNA 3 stated Resident 28 did not have Geri-sleeves when she received the resident in the morning. CNA 3 stated she was not aware that Resident 28 needed to wear Geri-sleeves. During an interview with Licensed Vocational Nurse 1 (LVN 1) on 3/7/2023 at 2:23 PM, LVN 1 stated Geri-sleeves were used to protect the skin of residents with fragile skin. LVN 1 stated the staff needed to apply the Geri-sleeves on Resident 28 to protect the resident's skin. According to https://www.woundsinternational.com), consideration should be made within the healthcare setting for patients who are at risk of skin tears, in terms of minimizing the risk of potential trauma. This should include factors such as: 1. Avoiding friction and shearing - ensuring to use good manual handling techniques and using products such as hoists and glide sheets where required 2. Ensuring a generally safe environment - e.g. ensuring adequate lighting and removing any manual obstacles - particularly in patients who may have impaired vision or cognition issues 3. Encouraging use of protective clothing/devices where required, such as shin guards, long sleeves and/or tubular bandages/stockinette.