**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to notify the physician for one of three sampled residents (Resident 371), who had developed edema (swelling caused by a collection of fluid in the spaces that surround the body's tissues) on the left elbow, in accordance with the facility ' s Policy and Procedure (P&P) for Change in Condition. This deficient practice had the potential to result in delayed care and treatment and could lead to tissue damage for Resident 371. Findings: During a review of Resident 371 ' s admission Record (AR), the AR indicated that Resident 371 was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including chronic respiratory failure (a long-term condition in which the breathing system is unable to adequately exchange oxygen and carbon dioxide in the body) with hypoxia (low levels of oxygen in your body tissues), contracture (a stiffening/shortening at any joint, that reduces the joint's range of motion) of right elbow and right hand, and heart failure (a long-term condition when the heart muscle doesn't pump blood as well as it should). During a review of Resident 371 ' s Minimal Data Sheet (MDS- a resident assessment tool), dated 5/15/2025, the MDS indicated Resident 371 had severely impaired cognition (never/rarely made decisions). The MDS indicated that Resident 371 ' s range of motion on the upper and lower extremities (shoulder, elbow, wrist, hand, hip, knee, ankle, and foot) were impaired. The MDS also indicated that Resident 76 was dependent (Helper does all of the effort. Resident does none of the effort to complete the activity. Or, the assistance of two or more helpers is required for the resident to complete the activity) on rolling left and right. During a review of Resident 371 ' s admission Assessment, dated 5/8/2025, the AR indicated Resident 371 ' s upper extremities were paralyzed, and the resident ' s general skin condition was dry and warm with no edema documented. During a review of Resident 371 ' s Skin & Wound Evaluation, dated 5/9/2025, the Evaluation indicated there was no documentation that Resident 371 ' s left elbow was red and swollen when the resident was readmitted to the facility on [DATE]. During a review of Resident 371 ' s Care Plan, dated 5/18/2025, the Care Plan indicated Resident 371 was at risk for fluid retention secondary to congestive heart failure (CHF- a chronic condition where the heart can't pump enough blood to meet the body's needs). The Care Plan goal indicated to reduce the risk of fluid alteration daily, with interventions to observe for signs of excess fluid such as edema and to notify the physician. During a concurrent observation and interview on 5/20/2025 at 10:10 AM with the treatment nurse (TXN) in the resident ' s room, Resident 371 ' s left elbow was red, swollen, and warm to touch. The TXN stated Resident 371 could not state what happened to Resident 371 ' s left elbow and TXN he was not sure if the condition was already reported to the physician. The TXN stated, there was no active treatment orders for Resident 371 ' s swollen left elbow. During a concurrent observation and interview on 5/20/2025 at 10:25 AM with Licensed Vocational Nurse (LVN) 2, LVN 2 assessed Resident 371 and stated the resident ' s left elbow appeared swollen, red, and warm to touch. LVN 2 stated she did not notice Resident 371 ' s left elbow was swollen when she performed an assessment on Resident 371 at the beginning of her shift (7 AM). LVN 2 stated she should have assessed Resident 371 more thoroughly. LVN 2 stated that she thought the redness and swelling of Resident 371 was reported to the physician since Resident 371 was on furosemide (a medication to help treat fluid retention and swelling that is caused by congestive heart failure, liver disease, kidney disease, or other medical conditions.) During a concurrent record review and interview on 5/20/2025 at 10:25 AM with LVN 2, Resident 371 ' s physician orders dated 5/8/2025 was reviewed. Resident 371 ' s physician order indicated on 5/8/2025, Resident 371 had a physician order for Lasix (furosemide) via gastrostomy tube (G-tube, a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) one time a day for CHF. During a concurrent record review and interview on 5/20/2025 at 10:35 AM with LVN 2, Resident 371 ' s Change of Condition (COC) since admission dated 5/8/2025, Resident 371 ' s Nursing Progress Notes since admission dated 5/8/2025, and Resident 371 ' s admission assessment dated [DATE] were reviewed. LVN 2 stated, she could not find any documented evidence that Resident 371 ' s physician was notified about Resident 371 ' s left elbow edema and any interventions or treatment orders were received. During an interview on 5/21/2025 at 11:20 AM with Registered Nurse (RN) 1, RN 1 stated Resident 371 had CHF and was currently on Lasix. RN 1 stated, he was not sure when Resident 371 ' s left elbow swelling developed but LVN 2 and Resident 371 ' s assigned CNA should have assessed the resident thoroughly and immediately reported to the physician. During an interview on 5/22/2025 at 3:50 PM with the Director of Nursing (DON), DON stated the expectation for licensed nurse was to assess the resident thoroughly to recognize a change in Resident 371 ' s condition. The DON stated Resident 371 ' s of swollen left elbow should have been reported promptly to the physician to ensure there was no delay in interventions and treatments. During a review of the facility ' s Policy and Procedures (P&P) titled Change of Condition undated, the P&P indicated that a change of condition is a sudden or marked difference in resident including Vital signs, open or red areas, skin condition (e.g. swelling or discoloration). All changes of condition in a resident shall be handled promptly. Upon a change of condition for any reason, nursing staff members are to take the following actions: a. Nursing 24-hour report form shall be completed. b. Physician shall be called promptly. c. Daily assessment of condition change shall be handled by Nurse Supervisor under the direction of the DON. d. Documentation of change in condition shall be performed by the Licensed Nurse accordingly. e. Identification by Certified Nursing Assistant. CNAs will report change in condition of residents to the charge nurse as soon as possible.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to: 1. Identify and define specific problematic behaviors related to the use of quetiapine (a medication used to treat mental illness) in one of five residents sampled for unnecessary medications (Resident 16.) 2. Perform a gradual dosage reduction (GDR - a periodic attempt to lower the dosage of a medication or discontinue a medication to control a resident ' s symptoms with lower doses or fewer medications) related to the use of quetiapine in one of five residents sampled for unnecessary medications (Resident 16.) The deficient practices of failing to identify and define specific problematic behaviors and perform a GDR related to the use of psychotropic medications (medications that affect brain activities associated with mental processes and behavior) increased the risk that Resident 16 could have experienced adverse effects (unwanted or dangerous medication-related side effects) related to psychotropic medication therapy, such as drowsiness, dizziness, constipation, or increased risk of fall, possibly leading to impairment or decline in her mental or physical condition or functional or psychosocial status. Cross referenced to F756. Findings: During a review of Resident 16 ' s admission Record (a document containing a resident ' s diagnostic and demographic information), dated 5/21/25, indicated she was admitted to the facility on [DATE] and most recently readmitted on [DATE] with diagnoses including: dementia (the loss of cognitive function, including memory, thinking, and reasoning, that interferes with daily life) and psychosis (a mental disorder characterized by a disconnection from reality which may occur as a result of psychiatric illness, a health condition, medication, or other drug use.) During a review of Resident 16 ' s History and Physical (H&P - a record of a comprehensive physician ' s assessment), dated 8/18/24, indicated she did not have the capacity to understand and make decisions. During a review of Resident 16 ' s Physician Order Summary (a monthly summary of all active physician orders), dated 3/24/25, indicated she was prescribed quetiapine (an antipsychotic medication) 25 milligrams (mg - a unit of measure for mass) by mouth on 2/21/25 for psychosis manifested by constant physical movement to exhaustion. During a review of Resident 16 ' s Order Audit Reports (a report with information about a previous medication order), dated 5/21/25, indicated, between 8/12/24 and 2/21/25, the orders for the use of quetiapine changed as follows: 8/12/24 to 8/13/24 - Quetiapine 25 mg once daily for schizophrenia (a mental illness characterized by hearing or seeing things that are not there or believing things that are untrue.) 8/13/24 to 11/5/24 - Quetiapine 25 mg once daily for psychosis. 11/5/24 to 2/21/25 - Quetiapine 25 mg once daily for psychosis manifested by inability to eat and participate in daily living activities causing sadness. 2/21/25 to 5/21/25 - Quetiapine 25 mg once daily for psychosis manifested by constant physical movement to exhaustion. During a review of the Resident 16 ' s care plan for quetiapine, dated 8/22/24, indicated quetiapine was being used for psychosis manifested by inability to cope with daily living activities causing anger. During a review of Resident 16 ' s Informed Consent (a documentation verifying a resident or their representative have opted into treatment after education about a psychotropic medication ' s potential risks and benefits), dated 2/21/25, indicated Resident 16 was receiving quetiapine 25 mg once daily for psychosis manifested by constant physical movement to exhaustion. During a review of Resident 16 ' s Medication Administration Record (MAR - a document containing a record of all medications administered and monitoring performed for a resident), between August 2024 and May 2025, indicated Resident 16 was being monitored for behaviors of psychosis manifested by inability to cope with daily living activities causing anger related to the use of quetiapine. During a review of the consultant pharmacist ' s (a medical professional responsible for a monthly review of all residents ' medication regimens) recommendations, dated 2/5/25, indicated the pharmacist recommend a GDR for Resident 16 ' s quetiapine. Further review of the pharmacist ' s recommendation indicated the facility left a message with the psychiatrist on 2/9/25 concerning the request but contained no response from the physician or documentation of any additional attempts to follow up. During a review of Resident 16 ' s clinical record indicated there was no record of Resident 16 receiving psychiatric care and no documentation that a physician considered a GDR request for quetiapine and either approved a lower dose or documented that an attempt would be contraindicated (should not be performed due to potential harm) with an accompanying resident-specific clinical rationale. During an interview on 5/21/25 at 9:32 AM with the Director of Nursing (DON), the DON stated the facility failed to identify a specific behavioral issue related to Resident 16's use of quetiapine. The DON stated the problematic behaviors identified in the physician ' s order and the informed consent documentation are different than the problematic behaviors identified in the resident's care plan and MAR. The DON stated this makes the reason for the use of quetiapine and the need for its continued use unclear for Resident 16. The DON stated the facility is required to perform GDRs on psychotropic medications, including quetiapine, twice a year in the first year and then once a year thereafter. The DON stated the pharmacist requested a GDR on 2/5/25 for Resident 16's quetiapine, but a GDR was not done. The DON stated the dose of quetiapine for Resident 16 has not changed since it was initially prescribed in August 2024. The DON stated there was no documentation available concerning a response to the pharmacist's request indicating that a GDR attempt would be clinically contraindicated. The DON stated failing to define specific problematic behaviors, perform a GDR on psychotropic medications, or respond to the pharmacist's recommendations related to psychotropic medications could have increased this resident's drowsiness and fall risk, negatively affecting her quality of life and increasing her risk of medical complications from falls. During a review of the facility ' s undated policy Psychotherapeutic Medications, indicated The use pf psychotherapeutic medication shall be kept to a minimum in this facility. These medications are to be used only for specific behaviors by a resident, quantitatively and qualitatively documented by the facility that cause: A. Danger to self. B. Danger to other residents or staff. C. Psychotic symptoms (hallucinations, paranoia, delusion) that create frightful distress in the resident . A specific diagnosis, and a specific behavior or thought process justifying the need for psychotherapeutic medications are to be identified in the resident ' s health record . Drug holidays and gradual dose reductions will be attempted as follows: A. GDR will be attempted during at least two quarters during the first year unless clinically contraindicated and B. GDR will be attempted at least once a year during following years unless clinically contraindicated .

Based on interview and record review, the facility failed to ensure Resident 86 was assessed using the standardized Quarterly Review assessment tool (Minimum Data Set [MDS], a resident assessment tool) no less than once every 3 months between comprehensive assessments and transmitted to Center of Medicare and Medicaid Services (CMS) in accordance with current federal and state submission timeframes for one of two sampled residents (Resident 86). This deficient practice failed to provide CMS specific resident information for quality care measure and tracking purposes. Findings: During a review of Resident 86 ' s admission Record (AR), the AR indicated a readmission to the facility on 4/29/2024 with diagnoses that included anxiety (a group of mental health conditions that cause fear, dread and other symptoms) , hypothyroidism (a condition in which the thyroid gland doesn't produce enough thyroid hormone). During a review of Resident 86 ' s History and Physical [H&P] dated 5/10/2025, the H&P indicated the resident did not have the capacity to understand and make decisions. During a concurrent interview and record review on 5/21/2025 at 9:05 AM of Resident 86 ' s electronic health records with MDS coordinator, the MDS coordinator stated the most recent quarterly MDS for resident 86 was due on 3/20/2025. MDS assistant stated the MDS was completed on 5/18/2025 but was not transmitted. MDS coordinator stated Resident 86 ' s MDS was late. MDS Coordinator stated MDS should be completed upon a resident's admission, quarterly, upon change of condition During a review of the Centers for Medicare & Medicaid Services (CMS) submission report provided by facility dated 5/21/2025, timed at 11:32 AM, the Report indicated Resident 86 ' s quarterly MDS target date was 3/20/2025, and the MDS was submitted and accepted on 5/21/2025 at 11:32 AM. During an interview on 5/22/2025 at 1:38 PM with Director of Nursing (DON), the DON stated all resident MDS ' s must be completed and submitted on time to CMS to ensure the facility was providing accurate and correct information. During a review of the facility ' s policy and procedure titled Advanced Directives revised on March 2022, indicated A comprehensive assessment of every resident ' s needs is made at intervals designated by OBRA and PPS requirements.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for two of four sampled residents (Resident 67 and 9) by failing to: 1. Ensure Resident 67's primary language was indicated in the care plan. 2. Ensure Resident 9' s hard of hearing (HOH) and hearing aids (HA, a device worn in or behind the ear designed to amplify sound for individuals who have difficulty hearing) use were indicated in the care plan. These deficient practices had the potential to result in a delay of nursing care and medical interventions for Resident 67 due to language barrier and the potential for Resident 9's specific needs to not be met, and for facility staff to not monitor and evaluate the effectiveness for resident-centered care. Findings: 1. During a review of Resident 67's admission Record (AR), the AR indicated the facility originally admitted Resident 67 on 11/10/2021 and readmitted him on 11/27/2024 with diagnoses that included dementia (a group of thinking and social symptoms that interferes with daily functioning) and diabetes mellitus (a disease that result in too much sugar in the blood). The AR indicated Resident 67 ' s primary language was Korean. During a review of Resident 67's Minimum Data Set (MDS, a resident assessment tool), dated 5/1/2025, the MDS indicated Resident 67 ' s preferred language was Korean and needed or wanted an interpreter to communicate with a doctor or health care staff. The MDS indicated Resident 67 had severely impaired memory and cognition (ability to think and reason). The MDS indicated Resident 67 required supervision or touching assistance with eating, oral hygiene and chair/bed-to-chair transfer, partial/moderate assistance with shower/bathe self and personal hygiene, and substantial/maximal assistance with toileting hygiene. During an observation on 5/19/2025 at 11:52 PM, Resident 67 was observed in the facility lobby, sitting in his wheelchair. Resident 67 did not response when spoken to in English. During a concurrent interview and record review on 5/20/2025 at 11:35 PM with Registered Nurse (RN) 3, Resident 67 ' s Comprehensive Care Plan (CCP) was reviewed. RN 3 stated Resident 67 mainly spoke Korean and there was no CCP developed to address the language barrier of Resident 67. During an observation on 5/20/2025 at 2:00 PM, Resident 67 was sitting in the activity room. Resident 67 did not response when spoken to in English, however when the same question was asked to Resident 67 in Korean by the Social Services Director, Resident 67 responded. During an interview on 5/20/2025 at 2:21 PM with Family Member (FM) 1, FM 1 stated Resident 67 ' s primary language was Korean, and to avoid any confusion or misunderstanding, Resident 67 ' s preferred language was Korean. During a concurrent interview and record review on 5/21/2025 at 8:58 AM with RN 2, Resident 67 ' s CCP was reviewed. RN 2 stated Resident 67 ' s preferred language was Korean and there was no CCP developed to indicate Resident 67 ' s language barrier. RN 2 stated a CCP should have been developed to address Resident 67 ' s language barrier to ensure better communication and to meet Resident 67 ' s specific needs. During an interview on 5/22/2025 at 1:41 PM with the Director of Nursing (DON), the DON stated a person-centered CCP should be developed and updated after a comprehensive assessment to address each resident's specific needs. The DON stated Resident 67 ' s language barrier should be included in the CCP to ensure good communication and smooth delivery of care to the resident. During a review of the facility ' s policies and procedures (P&P) titled, Care Plans, Comprehensive Person-Centered, dated 3/2023, the P&P indicated The comprehensive, person-centered care plan is developed within seven days of the completion of the required MDS assessment .and no more than 21 days after admission. The P&P also indicated The comprehensive, person-centered care plan .describes the services that are to be furnished to attain or maintain the resident ' s highest practicable physical, mental, and psychosocial well-being and Services provided for or arranged by the facility and outlined in the comprehensive care plan are culturally competent. 2. During a review of Resident 9 ' s admission Record (AR), the AR indicated that Resident 9 was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including end stage renal disease (ESRD-irreversible kidney failure), legal blindness (a status of severe vision loss granted by United States government), acquired absence of right leg below knee, and acquired absence of left leg above knee. During a review of Resident 9 ' s Order Summary Report, the Report indicated Resident 9 had a physician order on 10/5/2023 for audiology consult as needed for hearing problems. During a review of Resident 9 ' s Minimum Data Set (MDS - a resident assessment tool) dated 3/7/2025, the MDS indicated the following: 1. Resident 9 had difficulty in hearing and used a pair of HA, and Resident 9 ' s vision was severely impaired (no vision or sees only light, colors or shapes; eyes do not appear to follow objects). 2. Resident 9 was cognitively intact (a person has sufficient judgment, planning, organization, self-control, and the persistence needed to manage the normal demands of the environment). 3. Resident 9 required partial/moderate assistance (helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) on eating and oral hygiene. 4. Resident 9 was dependent (helper does all of the effort. Resident does none of the effort to complete the activity. Or, the assistance of two or more helpers is required for the resident to complete the activity) on toileting hygiene, shower/ bathe self, and lower body dressing. During a review of Resident 9 ' s active Care Plan dated from 10/5/2023 to 5/19/2025, there was no comprehensive care plan developed for Resident 9 ' s impaired hearing and the utilization of HA. During a review of Resident 9 ' s Licensed Nurses Weekly Notes (LNN), dated from 3/8/2025 to 5/10/2025, the LNN indicated that Resident 9 ' s hearing was severely impaired and required the use of HA. During a concurrent observation and interview on 5/20/2025 at 12:45 PM with Resident 9 and CNA 2 in the resident ' s room, Resident 9 was alert, lying in bed, and had to raise his voice when speaking to CNA 2, who also had to raise her voice to communicate with Resident 9. Resident 9 stated he was not using his HA. Resident 9 stated, when he received his HA by Provider 2 on 3/6/2025, the background noise was disturbing him, so did not like to use his HA. Resident 9 stated, he was told to give the new HA a try for a few more days. Resident 9 stated, he tried his HA but two days later, he requested to return his HA because it did not work properly for him, and he also requested for an appointment with Provider 1. Resident 9 stated, he requested updates for his HA and appointments with Provider 1, however had not had any updates regarding his HA or appointment scheduled with Provider 1 to obtain a new HA. During the same concurrent observation and interview, on 5/20/2025 at 12:45 PM, CNA 2 stated Resident 9 was hard of hearing with impaired vision. CNA 2 stated, when speaking with Resident 9, facility staff needed to speak close and raiser their voice, so that Resident 9 could hear. During a concurrent interview and record review on 5/20/2025 at 3:20 PM with licensed vocational nurse (LVN) 4, Resident 9 ' s active care plan was reviewed. LVN 4 stated, Resident 9 was HOH and required the use of HA to communicate with the facility ' s staffs. LVN 4 stated, she could not find any care plan for Resident 9 ' s impaired hearing or for the use of his HA. LVN 4 stated, Resident 9 should have a care plan indicating Resident 9 ' s HOH and for the use a HA. During an interview on 5/21/2025 at 3:15 PM with the SSD, the SSD stated Resident 9 was HOH and legally blind. SSD stated, Resident 9 could not hear adequately without his HA. SSD stated, she did not know there was no comprehensive care plan developed for Resident 9 ' s impaired hearing. SSD stated, it was part of her responsibilities to participate in the interdisciplinary team (IDT) to ensure the facility develops and implements residents ' care plan. SSD stated Resident 9 should have had a Care Plan initiated indicating Resident 9 ' s use of a HA and for his impaired hearing. During an interview on 5/22/2025 at 3:50 PM with the Director of Nursing (DON), the DON stated that the licensed nurse or anyone in IDT should have developed a person-centered care plan for Resident 9 ' s impaired hearing, to ensure the problem was identified. The DON stated interventions should be specific to Resident 9 ' s hearing impairment and use of the HA to ensure Resident 9 ' s specific needs were met. During a review of the facility ' s Policy and Procedures (P&P) titled Care Plans, Comprehensive Person-Centered revised in 03/2023, 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 within seven days of the required MDS assessment, and implemented for each resident. The IDT, in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. The care plan is derived from a thorough analysis of the information gathered as part of the comprehensive assessment. The comprehensive, a person-centered care plan describes the services that are to be furnished to attain or maintain the highest practicable physical, mental, and psychosocial well-being, including which professional services are responsible for each element of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of seven sampled residents (Resident 3), received restorative nursing treatment (nursing interventions that help people maintain or regain their ability to perform daily activities after an illness, injury, or surgery) that included application of left ankle-foot orthosis [AFO - a device worn on the foot and ankle to support and control movement, often used to help with walking, improve stability, or correct foot drop (a condition where it's difficult to lift the front part of the foot and toes, often causing them to drag during walking)] from 5/16/2025 to 5/22/2025 (total of 7 days) and application of left resting hand splint from 5/20/2025 to 5/22/2025 (total of 3 days) as ordered by Resident 3 ' s physician on 3/5/2025. This failure had the potential to result in Resident 3 further decline in range of motion (ROM, movement of the joints) and foot drop. Findings: During a review of Resident 3's admission Record (AR), the AR indicated the facility admitted Resident 3 on 1/18/2016 and readmitted on [DATE] with diagnoses that included hemiplegia (paralysis of one side of the body), affecting left nondominant side, left hand contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints), and left ankle contracture. During a review of Resident 3 ' s Minimal Data Set (MDS-resident assessment tool), dated 4/29/2025, the MDS indicated Resident 3 ' s cognition (ability to think, remember, and reason) was moderately impaired and needed maximal assistance (helper does more than half the effort, helper lifts or holds trunk or limbs and provides more than half the effort) in personal hygiene. During a review of Resident 3 ' s Order Summary Report (OSR), the OSR indicated on 3/5/2025, Resident 3 had a physician order for restorative nursing assistant (RNA) assisted exercises that included PROM exercises (passive range of motion - moving a joint through its full range of motion by someone or something else, without the individual actively using their muscles) on LLE (left lower extremity) followed by application of left AFO for 4 hours a day, 7 times per week as tolerated. The OSR also indicated Resident 3 had a physician order for PROM exercises on LUE (left upper extremity) followed by application of the left resting hand splint for 4 hours daily 7 times per week as tolerated. During a review of Resident 3 ' s Care plan, dated 3/5/2025, the Care Plan indicated Resident 3 was at risk for further development of contractures due to sequela (a condition which is the consequence of a previous disease or injury) of CVA (cerebrovascular accident, or stroke - damage to the brain from interruption of its blood supply) with left hemiparesis (weakness or the inability to move on one side of the body) and decrease mobility with the interventions that included to provide restorative nursing treatment as ordered by the physician: RNA for PROM exercises on LLE followed by application of left AFO for 4 hours a day, 7 days per week as tolerated, and RNA for PROM exercises on LUE followed by application of left resting hand splint for 4 hours a day, 7 days per week as tolerated. During a review of Resident 3 ' s Documentation Survey Report V2 for the month of May 2025, the Report indicated for no RNA to the right lower extremity (RLE) and application for left AFO provided from 5/16/2025 to 5/22/2025. During a concurrent observation and interview on 5/20/2025 at 9:32 AM with Resident 3 in her room, Resident 3 stated her left side was weak and was not able to move her LUE and LLE. Resident 3 did not have a splint placed on her LUE and no AFO on her LLE. Resident 3 stated, she usually had a splint on her left hand and an AFO on her left foot but had not have them on in the last few days. During a concurrent observation and interview on 5/22/2025 at 11:15 AM with Resident 3 in her room, Resident 3 did not have a splint placed on her LUE and no AFO to her LLE. Resident 3 stated, she still did not have any splint on her left hand and any AFO on her left foot. Resident 3 stated, the last time she had a splint on her LUE and an AFO on her LLE was a few days ago. During a concurrent observation and interview on 5/22/2025 at 12:45 PM with RNA 1 in Resident 3 ' s room, Resident 3 had no splint on her LUE and no application of AFO on her LLE. RNA 1 stated, she usually placed the splint and the AFO on Resident 3 around 10-10:30 AM daily. RNA 1 could not state why Resident 3 ' s splint and AFO was not placed on Resident 3. During an interview on 5/22/2025 at 1 PM with CNA 5, CNA 5 stated, Resident 3 did not have any splint on her LUE or any AFO on her LLE since she started her shift at 7 AM. CNA 5 stated, she could not recall the last time Resident 3 had the splint on her LUE and the AFO on LLE. During an interview on 5/23/2025 at 2:20 PM with the Director of Physical Therapy (DPT), the DPT stated, it was important that RNA followed the physician ' s order to apply the splint onto Resident 3 ' s LUE and AFO on the LLE because to prevent further decline in ROM and foot drop. During a review of the facility ' s policy and procedure (P&P) titled, Restorative Nursing Services, revised July 2017, the P&P indicated, residents will receive restorative nursing care as needed to help promote optimal safety and independence. Restorative goals and objectives are individualized and resident-centered and are outlined in the resident ' s plan of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide an environment free of hazard for one of four sampled residents (Resident 107), who was at risk for fall due to dementia [the loss of cognitive functioning (thinking, remembering, and reasoning) to such an extent that it interferes with a person's daily life and activities] and had a history of recent fall on 3/14/2025, by failing to: 1. Ensure that CNA 1 placed a call light within Resident 107 ' s reach as indicated in the resident ' s care plan, when CNA 1 took Resident 107 back to the resident ' s room and left the resident alone in the wheelchair. 2. Ensure LVN 3 and LVN 4 placed a floor mat in accordance with Resident 107's physician's orders dated 3/11/2025 after the room was deep cleaned prior to the resident returned to bed. This failure had the potential to result in serious physical injury and compromise both the resident ' s safety and quality of care. Findings: During a reviewed of Resident 107's admission Record (AR), the AR indicated that Resident 107 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Parkinson's Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and dementia (a progressive state of decline in mental abilities). During a review of Resident 107's Physician Order, dated 3/11/2025, the order indicated to keep low bed with floor mat to decrease potential injury every shift. During a review of Resident 107's History and Physical (H&P), dated 3/13/2025, indicated Resident 107 did not have the capacity to understand and make decisions. During a review of Resident 107's Care Plan dated 3/13/2025, the care plan indicated Falling Star Program due to at risk for fall, and the interventions included to attach call light to within access of resident. During a review of Resident 107's SBAR (Situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents), dated 3/14/2025, the SBAR the SBAR indicated that Resident 107 slid off the bed, found on the floor on the right side and was unwitnessed with no injury noted. During a review of Resident 107's Fall Risk Assessment (FRA), dated 3/14/2025, the FRA indicated that Resident 107 was at high risk for fall due to intermittent (occasional) confusion, poor safety awareness, current fall, elimination (bowel and bladder) status incontinent (no control), and unable to stand without assistance/ unsteady gait. During a review of Resident 107's Minimum Data Set (MDS- a resident assessment tool), dated 4/11/2025, the MDS indicated that Resident 107 was cognitively severely impaired (never/rarely made decisions). The MDS indicated that Resident 107 required substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) on rolling left and right. The MDS indicated Resident 107 was dependent (Helper does all of the effort. Resident does none of the effort to complete the activity. Or the assistance of two or more helpers is required for the resident to complete the activity) on sit to lying and lying to sitting on the side of bed. During an observation on 5/19/2025 at 12:15 PM, CNA 1 took Resident 107 back into the resident's room, and stepped out to assist other residents, leaving Resident 107 alone in the room. A star sign was noted on the wall of Resident 107's head of bed. During an observation and concurrent interview on 5/19/2025 at 12:55 PM with LVN 4 in the room with Resident 107, Resident 107 was observed sitting in wheelchair finishing lunch. LVN 4 stated the call light was not within access to the resident. LVN 4 stated Resident 107 should be provided with a call light within reach at all times for the resident to call for help if needed. LVN 4 also stated the staff that took Resident 107 back to room should have made sure call light was provided to the resident before leaving. During an observation and concurrent interview on 5/19/2025 at 3:15 PM with LVN 3 in the room with Resident 107, LVN 3 stated that Resident 107 was at fall risk due to dementia and history of fall, currently was in the Falling star program. LVN 3 stated there was no floor mat placed next to Resident 107, but it should have been there to prevent serious injury for the resident as ordered by the physician. During an interview on 5/22/2025 at 3:40 PM with the Director of Nursing (DON), DON stated that Resident 107 was on Falling Star Program or Super Star Program due to Parkinson's Disease and history of fall. DON stated nursing staffs are responsible to ensure fall precaution interventions were implemented such as to keep call light within resident's reach when the resident was in the bed or sitting down in the chair at bedside, to keep low bed position, and make sure floor mat(s) is in place as ordered. During a review During a review of the facility's Policy and Procedure (P&P) titled Super Star Program undated, indicated the following: 1. Policy: The Super Star Program is for residents who are severely high risk for falls and injuries. 2. Background: This special program is for residents who have a score of 8 (eight) or above on the Fall Risk Assessment and any of the following: a. History of falls b. History of neurological conditions; e.g. Parkinsonism c. New admission 3. Procedure: a. Low bed with mat and padding. b. Thin floor mats at key locations, e.g. around bed, as appropriate. c. In-service to staff on both Falling Star and Super Star Program.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide necessary care and services to one of three residents (Resident 76) with an indwelling catheter (a device that drains urine [pee] from urinary bladder into a collection bag outside of body) by failing to: 1. Follow the facility ' s Policy and Procedure (P&P) titled Fluid Intake& Output (I&O) to evaluate Resident 76 for the need of continue monitoring and documenting the resident ' s I&O at the completion of the 30-day period. 2. Monitor and document findings of Resident 76 ' s bladder distention (swelling or enlargement of the bladder due to an inability to empty it completely or a buildup of urine) as indicated in Resident 76 ' s physician ' s orders and care plan. The deficient practices had the potential to increase risk for recurring Urinary Tract Infection (UTI- an infection in the bladder/urinary tract) that could lead to a decline in the resident ' s well-being. Findings: During a review of Resident 76 ' s admission Record (AR), the AR indicated that Resident 76 was originally admitted on [DATE] and readmitted on [DATE] with diagnoses including UTI, obstructive and reflux uropathy (a condition in which the flow of urine is blocked and backward from the bladder into a ureter and toward a kidney), benign prostatic hyperplasia [BPH, a benign (not cancer) condition in which the prostate gland (a gland in the male reproductive system) is larger than normal] with lower urinary tract symptoms, retention of urine, and chronic respiratory failure (a long-term condition in which the breathing system is unable to adequately exchange oxygen and carbon dioxide in the body) with hypoxia (low levels of oxygen in your body tissues). During a review of Resident 76 ' s Care Plan (CP), revised 11/14/2024, the CP indicated Resident 76 was at risk for alteration in urinary elimination and at risk for UTI secondary to use of indwelling catheter due to obstructive uropathy. The CP indicated the goal was Resident 76 ' s bladder will be adequately emptied without complication as evidenced by no bladder distention. The CP indicated interventions that included to monitor Resident 76 ' s urine for sediment (solid substance in the urine), cloudiness, odor, blood, and amount of output, to notify MD if decreased or no urine output, and to observe abdomen for distention to rule out urinary retention. During a review of Resident 76 ' s General Acute Care Hospital (GACH)1 ' s Discharge Summary Notes, dated 3/28/2025, indicated Resident 76 was admitted on [DATE] with severe sepsis (a life-threatening blood infection) including UTI and bacteremia (bacteria in the bloodstream) with multiple organisms growing in the cultures. The DS also indicated Resident 76 was discharged with sulfamethoxazole-trimethoprim (medication used to treat infection) 800mg-160mg (milligram, unit of weight) tablet two times daily until 3/31/2025, and levofloxacin (medication used to treat infection) 500 mg tablet once daily until 3/31/2025. During a review of Resident 76 ' s Order Summary Report (OSR), indicated on 3/28/2025 Resident 76 had physician orders as listed: 1. An indwelling catheter attached to bedside drainage bag due to urinary retention related to BPH 2. Monitor the indwelling catheter ' s urinary drainage bag and document the following: Color, consistency, odor, hematuria (presence of blood in the urine), bladder distention, burning sensation for the presence of S/S (signs and symptoms) of UTI [(+) meaning presence of S/S of UTI, (0) meaning absence of S/S of UTI]. And, to notify the physician and document in nurse ' s progress notes if monitored and any of the S/S above observed. During a review of Resident 76 ' s Minimal Data Sheet (MDS- a resident assessment tool) dated 4/1/2025, the MDS indicated that Resident 76 was cognitively severely impaired (never/rarely made decisions). The MDS also indicated that Resident 76 was dependent (Helper does all of the effort. Resident does none of the effort to complete the activity. Or, the assistance of two or more helpers is required for the resident to complete the activity) in toileting hygiene, shower/bathe self, and personal hygiene. During a review of Resident 76 ' s Evaluations of Intake/Output (EIO), dated from 4/6/2025 to 4/20/2025, the EIO indicated weekly evaluations of lows and highs volume of Resident 76 ' s I&O. The EIO indicated there was no records of Resident 76 ' s I&O after 4/27/2025. The EIO indicated the evaluation was not reported and discussed with Resident 76 ' s physician to obtain order for continuing or discontinuing recording of Resident 76 ' s I&O. During a review of Resident 76 ' s Treatment Administration Record (TAR) dated 5/15/2025 and 5/16/2025, Resident 76 ' s Licensed Nurses Notes (LNN), dated 5/15/2025 and 5/16/2025, and Resident 76 ' s progress notes were reviewed. The TAR indicated Resident 76 had presence S/S of UTI with no documented for specific S/S on 5/15/2025 and 5/16/2025 during the evening shift (3-11PM). The LNN indicated no documented evidence that Resident 76 ' s bladder distention was assessed and what S/S of UTI were present. During a review of Resident 76 ' s COC/Interact Assessment Form (SBAR), dated 5/17/2025, indicated on 5/17/2025 around 12:30 AM, blood was noted on Resident 76 ' s urethral meatus (the opening of the urethra, the tube that carries urine from the bladder out of the body), nurse (unidentified) attempted to flush the indwelling catheter with no return. Registered Nurse (RN, unidentified) was notified and Resident 76 ' s indwelling catheter was replaced and excreted 1700 bloody urine with blood clots. Resident 76 was sent to GACH 1 around 7:15 AM on 5/17/2025. During a review of Resident 76 ' s GACH 1 Discharge Summary (DS) dated 5/17/2025, the DS indicated that Resident 76 was diagnosed with Gross Hematuria (visible blood in the urine). During a review of Resident 76 ' s OSR, dated 5/19/2025, indicated to flush indwelling catheter with 60cc (cubic centimeters) to 200cc of NS (normal saline- a saltwater solution). During an observation on 5/20/2025 at 10:45 AM with Resident 76 in the room, observed Resident 76 ' s foley catheter urinary bag with pinkish and clear urine output. During an interview on 5/22/2025 at 9:19 AM with Licensed Vocational Nurse (LVN) 1, LVN 1 stated that Resident 76 used to have Intake and Output Record for 30 days when readmitted back to the facility. LVN 1 stated, after 30 days, she monitored Resident 76 ' s output by visualizing urine output in the drainage bag and would not be able to verify the actual output amount if the Certified Nurse Assistant (CNA) did not measure and verbally report it to her. LVN 1 stated she would not know Resident 76 ' s urine output volume if the CNAs did not measure and report it to her. During a concurrent interview and record review on 5/22/2025 at 9:30 AM with RN 1, Resident 76 ' s TAR and GACH 1 ' s laboratory report dated 3/22/2025 were reviewed. The laboratory report indicated Resident 76 ' s urine character was cloudy while the resident ' s TAR indicated no S/S of UTI. RN 1 stated he could not explain the discrepancy. RN 1 stated, Resident 76 ' s urine output was only recorded for the first 30 days of readmission. RN 1 stated not sure whether evaluation was done at completion of 30-Day EIO. RN 1 also stated that Resident 76 ' s urine output would not be monitored if CNAs did not report the measurement to charge nurses and/or if charge nurses were not competent in nursing judgment to identify urinary retention and decreased urine output. During a concurrent interview and record review on 5/22/2025 at 11:30 AM with the Treatment Nurse (TXN), Resident 76 ' s TAR for May 2025 was reviewed. The TXN stated, he observed Resident 76 ' s pinkish urine and documented (+) as indication for S/S of UTI in Resident 76 ' s TAR on 5/15/2025, and 5/16/2025 but did not document Resident 76 ' s pinkish urine in any progress note. The TXN stated the physician was notified on 5/16/2025 during the night shift and was sent to GACH 1. During an interview on 5/23/2025 at 2:00 PM with the Director of Nursing (DON), the DON stated that it was nursing staff ' s responsibility to identify S/S of UTI, urinary retention, and document any findings as ordered by the physician. The DON stated, to assess for bladder distention as ordered by the physician, the nurses were supposed to palpate the resident's bladder to ensure no distention, determine sufficient urine output by visualizing the indwelling catheter's drainage bag, assessed for intact and patent indwelling catheter with urine presented, and document their findings in their nursing notes. During a review of the facility ' s Policy and Procedure (P&P) titled, Fluid Intake& Output, undated, the P&P indicated that at the completion of the 30-day period, a licensed nurse shall evaluate the resident to determine further need for documentation of intake and output. The evaluation shall be recorded on the Intake and Output Assessment Form. During a review of the facility ' s P&P titled, Foley Catheter (indwelling catheter) Maintenance, undated, the P&P indicated to measure urine drainage at the end of each eight-hour shift, unless it is needed or ordered more often, and maintain (record of) intake and output on those residents requiring it. The P&P also indicated to irrigate catheter (only when ordered by a physician) through appropriate portal and record the amount of irrigating solution used.

**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 for one of three sampled residents (Resident 9), who was hard of hearing (HOH) and not satisfied with the hearing aids (HA, a device worn in or behind the ear designed to amplify sound for individuals who have difficulty hearing), by failing to follow up and make an appointment with the audiologist (a physician specialized in hearing loss). This deficient practice resulted in Resident 9 not utilizing the facility provided HA and leaving Resident 9 to remain hearing impaired and negatively impacting Resident 9 ' s quality of life and well-being. Findings: During a review of Resident 9 ' s admission Record (AR), the AR indicated that Resident 9 was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including end stage renal disease (ESRD-irreversible kidney failure), legal blindness (a status of severe vision loss, acquired absence of right leg below knee, and acquired absence of left leg above knee. During a review of Resident 9 ' s Order Summary Report, the Report indicated Resident 9 had a physician order on 10/5/2023 for audiology consult as needed for hearing problems. During a review of Resident 9 ' s Minimum Data Set (MDS - a resident assessment tool) dated 3/7/2025, the MDS indicated the following: Resident 9 had difficulty in hearing and used a pair of HA, and Resident 9 ' s vision was severely impaired (no vision or sees only light, colors or shapes; eyes do not appear to follow objects) Resident 9 was cognitively intact (a person has sufficient judgment, planning, organization, self-control, and the persistence needed to manage the normal demands of the environment). Resident 9 required partial/moderate assistance (helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) on eating and oral hygiene. Resident 9 was dependent (helper does all of the effort. Resident does none of the effort to complete the activity. Or, the assistance of two or more helpers is required for the resident to complete the activity) on toileting hygiene, shower/ bathe self, and lower body dressing. During a review of Resident 9 ' s Social Service Progress Note (SSPN), dated 3/6/2025, the SSPN indicated that new hearing aids were delivered to Resident 9, and were tested with a Registered Nurse (unspecified), Audiologist (unspecified), and SSD (Social Service Director). The note indicated the HA were working and Resident 9 was happy that he was able to hear well. During a review of Resident 9 ' s SSPN, dated 5/1/2025, the SSPN indicated Resident 9 ' s HA were checked on 4/29/2025 with Resident 9 ' s audiologist. The SSPN indicated during the visit, Resident 9 stated, he did not like the background noise when using the HA, so Resident 9 requested to return the HA. The SSPN indicated, Nurse (unspecified) told the audiologist that Resident 9 wanted to return his HA from the beginning and was suggested to have the audiologist check it one more time. The SSPM stated, the audiologist still did not take Resident 9 ' s HA back. During a review of Resident 9 ' s Licensed Nurses Weekly Notes (LNN), dated from 3/8/2025 to 5/10/2025, the LNN indicated that Resident 9 ' s hearing condition was highly impaired and required the use of a pair of HA. During a review of Resident 9 ' s SSPN dated from 3/6/2025 to 5/20/2025, there was no documented evidence that SSD clarified with Resident 9 or RP 1 for Provider 1 ' s contact information and no documented evidence that the SSD contacted Provider 1 for an audiologist appointment as Resident 9 requested. During a concurrent observation and interview on 5/20/2025 at 12:45 PM with Resident 9 and CNA 2 in the resident ' s room, Resident 9 was alert, lying in bed, and had to raise his voice when speaking to CNA 2, who also had to raise her voice to communicate with Resident 9. Resident 9 stated he was not using his HA. Resident 9 stated, when he received his HA by Provider 2 on 3/6/2025, the background noise was disturbing him, so did not like to use his HA. Resident 9 stated, he was told to give the new HA a try for a few more days. Resident 9 stated, he tried his HA but two days later, he requested to return his HA because it did not work properly for him, and he also requested for an appointment with Provider 1. Resident 9 stated, he requested updates for his HA and appointments with Provider 1, however had not had any updates regarding his HA or appointment scheduled with Provider 1 to obtain a new HA. During the same concurrent observation and interview, on 5/20/2025 at 12:45 PM, CNA 2 stated Resident 9 was hard of hearing with impaired vision. CNA 2 stated, when speaking with Resident 9, facility staff needed to speak close and raiser their voice, so that Resident 9 could hear. During a telephone interview on 5/22/2025 at 4:01 PM with Resident 9 ' s responsible party (RP 1), RP 1 stated about a week ago, the SSD told him that there was no solution, no new plan or schedule for Provider 1 ' s appointment related to Resident 9 ' s HA issue. RP 1 stated, he spoke with the SSD sometime in March 2025 regarding Resident 9 ' s HA which was received on 3/6/25. RP 1 stated Resident 9 requested the SSD to set an appointment with Provider 1; however, RP 1 never heard back from the SSD regarding an appointment with Provider 1 for Resident 9. During an interview on 5/23/2025 at 9:50 AM with Registered Nurse (RN) 2, RN 2 stated being present when Resident 9 received a new pair of HA on 3/6/2025. RN 2 stated, on 3/6/2025, Resident 9 tested his HA in front of the Audiologist and the SSD and told them that he still heard an echo and background noise. RN 2 stated after trying the new pair of HA for one to two days, Resident 9 was not happy with the HA, so RN 2 assisted Resident 9 to inform the SSD that the new HA did not work properly for him, and that Resident 9 requested an appointment with Provider 1, who provided his previous HA. RN 2 stated, the SSD responded that she would follow up. RN 2 stated, she helped Resident 9 a week ago and requested updates for the HA issue with the SSD, the SSD responded with not sure if Resident 9 ' s insurance will approve but will follow up. During an interview on 5/21/2025 at 3:15 PM with the SSD, the SSD stated Resident 9 was hard of hearing and legally blind. SSD stated, Resident 9 could not hear adequately without his HA. During a concurrent record review and interview on 5/23/2025 at 9:50 AM with the SSD, Resident 9 ' s SSPN dated from 3/6/2025 to 5/22/2025 was reviewed. The SSD stated, on 3/6/2025, when Resident 9 received his new HA from Provider 2, Resident 9 tried the HA on in front of the SSD and stated, it was working, so she documented it as he was happy with his new HA. The SSD stated that two months ago, RN 2 reported to her that Resident 9 was not satisfied with his new HA and wanted to make an appointment with Provider 1. The SSD stated not being able to contact Provider 1. SSD stated she did not make appointment with Provider 1 for Resident 9. The SSD stated she received several requests for update from Resident 9, RP 1, and RN 2 regarding the HA. The SSD stated, she did not follow up because it was meaningless for her to call a number never picking up. During an interview on 5/23/2025 at 10:50 AM with the Administrator (ADM), the ADM stated the SSD was expected to assist with Resident 9 ' s referrals and appointments for his needs related to impaired hearing and for the use of HA. ADM stated, it was the SSD ' s responsibility to assess Resident 9 ' s needs, provide appropriate services related to his impaired hearing, and ensure Resident 9 was supported for their needs to be met. During a review of the facility ' s Policy and Procedures (P&P) titled Social Service revised 09/2021, the P&P indicated the following 1. The director of social service 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, etc). 3. The social worker/ social service staff are responsible for: a. Assisting or arranging for a resident ' s communication needs through the resident ' s preferred method of communication and/ or in a language that the resident understands. b. Making arrangements for obtaining needed items such as clothing and personal items. c. Making referrals and obtaining needed services from outside entities. During a review of the facility ' s Job Description (JD)- Social Worker dated 1/27/2022, the JD indicated that essential duties and responsibilities include the following: 1. Assist in the provision of medically-related social services to attain or maintain the highest practicable well-being of each resident, including those services identified in the State Operation Manual (SOM). 2. Facilitate any identified problems. Assist with supplying whatever tools necessary to ensure communication to make resident needs known. 3. Creates, reviews, and update care plan and progress notes. 4. Implement social service interventions that achieve treatment goals, address resident needs, link social support, physical care and physical environment to enhance quality of life. To perform the job successfully, an individual should demonstrate the following competencies: 1. Customer services- Manage difficult or emotional customer situations. Respond promptly to customer needs. Respond to request for service and assistance; Meets commitments. 2. Judgment- Exhibits sound and accurate judgment; makes timely decisions. 3. Professionalism- Follows through commitments. 4. Oral communication- Listens and gets clarification. 5. Quality- Demonstrates accuracy and thoroughness. 6. Dependability- Takes responsibility for own actions; Keep commitments.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to respond to the consultant pharmacist ' s (a medical professional responsible for a monthly review of all residents ' medication regimens) request for a gradual dosage reduction (GDR - a periodic attempt to lower the dosage of a medication or discontinue a medication to control a resident ' s symptoms with lower doses or fewer medications) related to the use of quetiapine (a medication used to treat mental illness) in one of five residents sampled for unnecessary medications (Resident 16.) The deficient practices of failing to respond to the consultant pharmacist ' s recommendation to perform a GDR related to the use of psychotropic medications (medications that affect brain activities associated with mental processes and behavior) increased the risk that Resident 16 could have experienced adverse effects (unwanted or dangerous medication-related side effects) related to psychotropic medication therapy, such as drowsiness, dizziness, constipation, or increased risk of fall, possibly leading to impairment or decline in her mental or physical condition or functional or psychosocial status. Cross referenced to F605. Findings: During a review of Resident 16 ' s admission Record (a document containing a resident ' s diagnostic and demographic information), dated 5/21/25, indicated she was admitted to the facility on [DATE] and most recently readmitted on [DATE] with diagnoses including: dementia (the loss of cognitive function, including memory, thinking, and reasoning, that interferes with daily life) and psychosis (a mental disorder characterized by a disconnection from reality which may occur as a result of psychiatric illness, a health condition, medication, or other drug use.) During a review of Resident 16 ' s History and Physical (H&P - a record of a comprehensive physician ' s assessment), dated 8/18/24, indicated she did not have the capacity to understand and make decisions. During a review of Resident 16 ' s Physician Order Summary (a monthly summary of all active physician orders), dated 3/24/25, indicated she was prescribed quetiapine (an antipsychotic medication) 25 milligrams (mg - a unit of measure for mass) by mouth on 2/21/25 for psychosis manifested by constant physical movement to exhaustion. During a review of Resident 16 ' s Order Audit Reports (a report with information about a previous medication order), dated 5/21/25, indicated, between 8/12/24 and 2/21/25, the orders for the use of quetiapine changed as follows: 8/12/24 to 8/13/24 - Quetiapine 25 mg once daily for schizophrenia (a mental illness characterized by hearing or seeing things that are not there or believing things that are untrue.) 8/13/24 to 11/5/24 - Quetiapine 25 mg once daily for psychosis. 11/5/24 to 2/21/25 - Quetiapine 25 mg once daily for psychosis manifested by inability to eat and participate in daily living activities causing sadness. 2/21/25 to 5/21/25 - Quetiapine 25 mg once daily for psychosis manifested by constant physical movement to exhaustion. During a review of the consultant pharmacist ' s recommendations, dated 2/5/25, indicated the pharmacist recommend a GDR for Resident 16 ' s quetiapine. Further review of the pharmacist ' s recommendation indicated the facility left a message with the psychiatrist on 2/9/25 concerning the request but contained no response from the physician or documentation of any additional attempts to follow up. During a review of Resident 16 ' s clinical record indicated there was no record of Resident 16 receiving psychiatric care and no documentation that a physician considered a GDR request for quetiapine and either approved a lower dose or documented that an attempt would be contraindicated (should not be performed due to potential harm) with an accompanying resident-specific clinical rationale. During an interview on 5/21/25 at 9:32 AM with the Director of Nursing (DON), the DON stated the facility failed to identify a specific behavioral issue related to Resident 16's use of quetiapine. The DON stated the problematic behaviors identified in the physician ' s order and the informed consent documentation were different than the problematic behaviors identified in the resident's care plan and MAR. The DON stated this makes the reason for the use of quetiapine and the need for continued use unclear for Resident 16. The DON stated the facility was required to perform GDRs on psychotropic medications, including quetiapine, twice a year in the first year and then once a year thereafter. The DON stated the pharmacist requested a GDR on 2/5/25 for Resident 16's quetiapine, but a GDR was not done. The DON stated the dose of quetiapine for Resident 16 has not changed since it was initially prescribed in August 2024. The DON stated there was no documentation available concerning a response to the pharmacist's request indicating that a GDR attempt would be clinically contraindicated. The DON stated failing to define specific problematic behaviors, perform a GDR on psychotropic medications, or respond to the pharmacist's recommendations related to psychotropic medications could have increased this resident's drowsiness and fall risk, negatively affecting her quality of life and increasing her risk of medical complications from falls. During a review of the facility ' s policy Consultant Pharmacist Reports, dated June 2021, indicated Recommendations are acted upon and documented by the facility staff and or the prescriber. Physician accepts and acts upon suggestion or rejects and provides an explanation for disagreeing .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of nine sampled residents' (Resident 52) food preference was honored. This deficient practice had the potential for Resident 52 ' s to refuse meals and negatively affect Resident 52 ' s nutritional status. Findings: During a review of Resident 52's admission Record (AR), the AR indicated the facility admitted Resident 52 on 3/26/2025 and readmitted on [DATE] with diagnoses that included hypertension (high blood pressure), anemia (a condition that develops when the blood produces a lower-than-normal amount of healthy red blood cells), osteoarthritis (a common joint disease that causes pain, stiffness, and loss of mobility), dementia [the loss of cognitive functioning (thinking, remembering, and reasoning) to such an extent that it interferes with a person's daily life and activities], and muscle weakness. During a review of Resident 52 ' s Minimal Data Set (MDS-resident assessment tool), dated 4/29/2025, the MDS indicated Resident 52 ' s cognition (ability to think, remember, and reason) was moderately impaired and needed set up or clean up assistance in eating. During a review of Resident 52 ' s Order Summary Report, the Report indicated Resident 52 had a physician order on 5/13/2025 for no added salt (NAS) diet, mechanical soft texture (foods that are soft and easy to chew and swallow), and thin consistency. During a review of Resident 52 ' s Nutrition/Dietary Notes, dated 5/13/2025, indicated Resident 52 ' s food preferences indicated a dislike for beef. During a review of Resident 52 ' s Care plan, revised on 5/13/2025, indicated Resident 52 had alteration in nutritional status related to hypertension, anemia, and dementia. The Care Plan interventions indicated to honor Resident 52 ' s food preference. During a review of the facility ' s May menu for the week of 5/19/2025 to 5/25/2025, the menu indicated, on 5/20/2025 for lunch, the facility would serve beef chop suey (a dish that typically consists of sliced beef stir-fried with a variety of vegetables) and rice. During a concurrent observation and interview on 5/20/2025 at 12:10 PM with Restorative Nursing Assistant (RNA) 1 in the dining room, RNA 1 assisted Resident 52 with lunch. Resident 52 ' s lunch tray included beef while Resident 52 ' s meal ticket (card on the meal tray that indicated food allergies and food preferences) indicated the resident disliked beef. Resident 52 stated she did not like beef. RNA 1 stated, Resident 52 ' s lunch tray should not include beef since Resident 52 ' s preference indicated a dislike for beef. RNA 1 stated, alternative meat such as chicken, tofu or pork should have been served to Resident 52. During a concurrent observation and interview on 5/20/2025 at 12:20 PM with Dietary Supervisor (DS) in the dining room, Resident 52 ' s lunch tray was served with beef. The DS stated, Resident 52 was served with beef chop suey and rice for lunch today. The DS stated, the [NAME] was responsible to prepare all residents ' food tray based on each resident ' s meal ticket. The DS stated, based on Resident 52 ' s meal ticket which indicated Resident 52 disliked beef, beef should not have been served to Resident 52. During an interview on 5/20/2025 at 12:25 PM with the facility ' s Cook, the [NAME] stated, he was the one who prepared Resident 52 ' s lunch tray. The [NAME] stated, he overlooked Resident 52 ' s meal ticket and still served Resident 52 beef for lunch. During an interview on 5/20/2025 at 12:30 PM with the DS, the DS stated, the [NAME] should review Resident 52 ' s meal ticket carefully when preparing the resident ' s lunch tray to ensure specific food preferences were honored. The DS stated, when Resident 52 was served food that she disliked, Resident 52 might not want to eat, which could potentially cause weight loss due to Resident 52 refusing to eat. During a review of the facility ' s Policy and Procedure (P&P) titled, Resident Food Preferences, indicated residents have the right to have their food preferences honored. During a review of the facility ' s P&P titled, Menu, indicated individual resident trays will have a meal ticket which identifies the residents name, room number, diet order. Also stated on the card: food preferences.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure to maintain a complete and accurate documentation of all services provided to the resident, progress toward the care plan goals, or any changes in the resident ' s medical, physical, functional or psychological condition, in accordance with the facility ' s policy and procedures (P&P) titled Change of Condition and Charting and Documentation. This deficient practice resulted in an inaccurate depiction of Resident 119 ' s care and health status and had placed Resident 119 at risk for having serious health complications. Cross referenced to F678, F695. Findings: During a review of Resident 119 ' s admission Record (AR), the AR indicated Resident 119 was readmitted to the facility on [DATE] with diagnoses that included pneumonia (infection that inflames air sacs in one or both lungs, which may fill with fluid), acute respiratory failure with hypoxia, and chronic obstructive pulmonary disease (COPD, lung disease causing restricted airflow and breathing problems) with (acute) exacerbation (worsening of a disease or an increase in its symptoms). During a review of Resident 119 ' s History and Physical (H&P), dated [DATE], the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 119 ' s Order Summary Report, dated [DATE], the Report indicated a physician order to administer Oxygen at 2L per minute via nasal cannula, may titrate up to 4L per minute for oxygen saturation less than 90% every shift. During a review of Resident 119 ' s care plan titled Oxygen, Resident is receiving Oxygen Therapy due to Acute Respiratory failure and COPD Exacerbation, dated [DATE], indicated to monitor oxygen saturation as ordered, notify physician for any significant change, and to provide oxygen as ordered. During a review of Resident 119 ' s care plan titled Resident is at risk for respiratory distress (shortness of breath (SOB), irregular respiration, wheezing/crackles, rhonchi, activity intolerance, edema) related to COPD, dated [DATE], the care plan indicated resident would have no unrecognized signs and/or symptoms of respiratory distress daily through the next assessment and would reduce episodes and symptoms of respiratory distress thru appropriate interventions daily through the next assessment. The care plan indicated to assess resident for SOB, irregular respiration, wheezing, crackles, rhonchi, coughing, weakness, activity intolerance, excessive secretions, and to inform physician promptly. During a review of Resident 119 ' s previous admission to a General Acute Care Hospital (GACH) 1 from the facility, the GACH 1 History and Physical (H&P) dated [DATE] indicated the resident presented to the emergency room from the facility for symptoms of respiratory distress. The GACH 1 H&P indicated in the emergency room Resident 119 was hypoxic at 88% with blood pressure of 54/32 and was also febrile with a temperature of 101 degrees. The GACH 1 H&P indicated Resident 119 was subsequently intubated for hypoxic respiratory failure and had lactic acidosis as well as leukocytosis and initial chest x-ray was unremarkable. The GACH 1 H&P indicated Resident 119 was started on broad-spectrum intravenous (IV) antibiotics for presumed healthcare associated pneumonia. The GACH 1 H&P indicated Resident 119 was septic on admission. During a review of Resident 119 ' s Change of Condition (COC)/Interact Assessment Form dated [DATE] timed at 8:23 PM, authored by RN 4, the COC Background indicated Onset of symptoms identified at 8:20 PM and Situation Identified indicated Hypoxia. The COC indicated Resident 119 ' s blood pressure was 98/58 mm/hg taken at [DATE] at 8:20 PM. The COC indicated Resident 119 ' s pulse was 90 bpm and taken at [DATE] at 8:20 PM. The COC indicated Resident 119 ' s respiration was 17 breaths/min and taken at [DATE] at 8:20 PM. The COC indicated Resident 119 ' s blood glucose was 120 and pain level was 0 (zero) and taken at [DATE] at 8:20 PM. The COC further indicated Resident 119 ' s oxygen saturation was 97 % and taken at [DATE] at 8:20 PM. The COC indicated the facility staff would Monitor vital signs and observe. During the same record review of Resident 119 ' s COC dated [DATE] timed at 8:23 PM authored by RN 4, under Licensed Nurse Note 1, the Note indicated [Resident 119] with history of pneumonia, acute respiratory failure with hypoxia, COPD, anemia, type 2 diabetes, bilateral contracture of the hand and elbow and upper arm, bilateral contracture of lower extremities, chronic kidney disease, dementia, Alzheimer's disease and major depression disorder. At 3 PM, [Resident 119] was received in bed during the beginning of the shift, vital signs were assessed, and with normal limit. [Resident 119] was on oxygen via nasal canula. Oxygen saturation was 99 % at 2 L. There was no apparent distress. Lungs were auscultated and there was clear lung sounds heard on both lungs. Breathing was even and unlabored, no respiratory distress. Bowel sounds were normal active in the four quadrants, when auscultated. [Resident 119] was on G-tube feeding. Diet was Glucerna 1.2 at 55 cc per hour for 20 hours via pump to provide 1100 CC/ 1320 kcal per day. Frequent monitoring and care were ongoing. At 4 PM, during rounds, [Resident 119] was assessed, and there was no apparent distress, he was made comfortable in bed. All orders were carried out per [Resident 119 ' s] physician. At 6 PM, [Resident 119] was seen in bed with no distress, Resident 119 was visited by his representatives at bedside. During care and making rounds at 8 PM, [Resident 119 ' s] oxygen was found to be 90 (%) at 2 L but there was no respiratory distress. Oxygen was titrated up to 5 L per physician order and the oxygen came up to 97 % [sic]. During the same record review of Resident 119 ' s COC dated [DATE] timed at 8:23 PM authored by RN 4, under Licensed Nurse Note 2, the Note indicated [Resident 119 ' s] physician was notified. 911 was called at 8:11 PM. CPR was done. 911 arrived at 8:16 PM, they performed their own care but at 8:23 PM, the resident passed away. [Resident 119 ' s] physician confirmed [Resident 119 ' s] death and and was discharged to his funeral homes. The body was released to a mortuary representative on [DATE] at 11:17 PM. [Resident 119 ' s] belongings were released to the resident ' s representative. The DON and ADM were informed about the deceased [sic]. During a review of Resident 119 ' s Blood Pressure (BP) Summary from [DATE] to [DATE], the BP Summary indicated the following information: [DATE] 6:55 PM 98/58 mmHg (Lying I/arm) [DATE] 12:47 PM 112/61 mmHg (Sitting r/arm) [DATE] 6:44 PM 118/68 mmHg (Lying I/arm) [DATE] 12:50 PM 110171 mmHg (Sitting I/arm) [DATE] 9:48 PM 118/64 mmHg (Lying I/arm) [DATE] 1:45 PM 120174 mmHg (Sitting r/arm) [DATE] 01:37 AM 110/68 mmHg (Lying I/arm) [DATE] 5:10 PM 126/66 mmHg (Lying I/arm) [DATE] 2:40 PM 124/67 mmHg (Lying I/arm) [DATE] 03:49 AM 128/70 mmHg (Lying I/arm) [DATE] 10:43 PM 135/65 mmHg (Lying I/arm) [DATE] 11:24 AM 124/68 mmHg (Lying I/arm) [DATE] 3:35 PM 110/70 mmHg (Lying r/arm) [DATE] 3:30 PM 110170 mmHg (Lying r/arm) During a review of Resident 119 ' s Oxygen Saturation (O2 Sat) Summary from [DATE] to [DATE], the O2 Sat Summary indicated the following information: [DATE] 6:19 PM 97 % (Oxygen via Nasal Cannula) [DATE] 6:18 PM 97 % (Room Air) [DATE] 10:31 AM 97 % (Oxygen via Nasal Cannula) [DATE] 04:33 AM 98 % (Room Air) [DATE] 03:34 AM 98 % (Oxygen via Nasal Cannula) [DATE] 6:10 PM 96 % (Oxygen via Nasal Cannula) [DATE] 10:20 AM 97 % (Oxygen via Nasal Cannula) [DATE] 02:34 AM 98 % (Oxygen via Nasal Cannula) [DATE] 12:39 AM 97 % (Room Air) [DATE] 3:49 PM 98 % (Oxygen via Nasal Cannula) [DATE] 3:44 PM 98 % (Oxygen via Nasal Cannula) [DATE] 10:38 AM 97 % (Oxygen via Nasal Cannula) [DATE] 10:37 AM 97 % (Oxygen via Nasal Cannula) [DATE] 8:07 PM 98 % (Oxygen via Nasal Cannula) [DATE] 8:07 PM 99 % (Oxygen via Nasal Cannula) [DATE] 11:01 AM 98 % (Room Air) 03/14 /2025 03:49 AM 98 % (Room Air) [DATE] 03:45AM 98 % (Room Air) [DATE] 5:43 PM 98 % (Room Air) [DATE] 5:42 PM 98 % (Room Air) [DATE] 1:59 PM 97 % (Oxygen via Nasal cannula) [DATE] 3:30 PM 98 % (Room Air) During a review of Resident 119 ' s Pulse Summary from [DATE] to [DATE], the O2 Sat Summary indicated the following information: [DATE] 6:55 PM 90 beats per minute (bpm) (Regular) [DATE] 12:46 PM 83 bpm (Regular) [DATE] 6:44 PM 80 bpm (Regular) [DATE] 12:50 PM 85 bpm (Regular) [DATE] 21:48 70 bpm (Regular) [DATE] 1:44 PM 76 bpm (Regular) [DATE] 01 :36 AM 84 bpm (Regular) [DATE] 6:10 PM 78 bpm (Regular) [DATE] 2:40 PM 72 bpm (Regular) [DATE] 03:24 AM 78 bpm (Regular) [DATE] 10:43 AM 68 bpm (Regular) [DATE] 11:24 AM 65 bpm (Regular) [DATE] 3:35 PM 99 bpm (Regular) [DATE] 3:34 PM 99 bpm (Regular) [DATE] 3:30 PM 99 bpm (Regular) During a review of Resident 119 ' s Respiration Summary from [DATE] to [DATE], the Summary indicated the following information: [DATE] 6:55 PM 20 Breaths/min [DATE] 6:19 PM 18 Breaths/min [DATE] 10:31 AM 18 Breaths/min [DATE] 04:33 AM 18 Breaths/min [DATE] 6:44 PM 20 Breaths/min [DATE] 6:10 PM 20 Breaths/min [DATE] 10:20 AM 18 Breaths/min [DATE] 12:39 AM 19 Breaths/min [DATE] 9:48 PM 18 Breaths/min [DATE] 3:49 PM 17 Breaths/min [DATE] 10:38 AM 18 Breaths/min [DATE] 01:37 AM 18 Breaths/min [DATE] 8:07 PM 16 Breaths/min [DATE] 11:01 AM 18 Breaths/min [DATE] 03:49 AM 18 Breaths/min [DATE] 5:43 PM 18 Breaths/min [DATE] 11:24 AM 20 Breaths/min 03/12 /2025 3:34 PM 24 Breaths/min 03/12 /2025 3:30 PM 24 Breaths/min During further review of Resident 119 ' s medical records (vital signs, COC, licensed nurses 'progress notes) from [DATE] to [DATE], there was no documented evidence of abnormal vital signs or low and fluctuating blood pressure readings and oxygen saturation levels below 90%. During a review of the Fire Department (FD) Paramedics (911 EMS) Report, dated [DATE], the report indicated the facility called 911 EMS on [DATE] timed at 8:11 PM and dispatch complaint of cardiac arrest. The FD Report further indicated FD paramedics arrived at the facility at 8:18 PM (9 minutes) and at Resident 119 ' s room at 8:20 PM (2 minutes). The FD Report under Disposition indicated Resident 119 was dead prior to arrival (DOA). The FD Report indicated Resident 119 was evaluated by the FD paramedics and further indicated No care or support services required. the FD Report indicated no transport was made to the acute hospital due to the resident being DOA. The FD Report under Patient Assessment further indicated Resident 119 ' s Distress Level as Severe. The FD Report under Primary Impression indicated as DOA/Obvious death. The FD Report indicated on [DATE] timed at 8:22 PM, further physical assessment was performed by the paramedics and showed Resident 119 as unresponsive, both eyes dilated, absent breath sounds to both lungs, skin was clammy and showed signs of lividity (a process where blood pools in the lowest parts of the body after the heart stops pumping that typically begins to appear within 30 minutes to an hour after death. Lividity is noticeable by the human eye within 1 to 2 hours after death). The FD Report Narrative indicated Patient determined to be dead (pronounced dead) at 8:23 PM. Patient found by staff in bed unresponsive. Compressions only CPR provided by staff, no BVM. Patient found pulseless, non-breathing, unresponsive at FD arrival, no lung sounds or heart tones, no response to painful stimuli, pupils fixed and dilated, lividity to lower back and legs, no obvious trauma. Per staff patient last seen alive 2-3 hours ago. No complaints prior, per staff patient bedridden. During a review of Resident 119 ' s Certificate of Death (COD) signed by the physician on [DATE], the COD indicated Resident 119 ' s date of death was [DATE]. The COD indicated Resident 119 ' s immediate cause of death (final disease or condition resulting in death) was cardiopulmonary arrest. The COD indicated Resident 119 ' s underlying cause of death (disease or injury that initiated the event resulting in death) was COPD. During an interview on [DATE] at 9:58 AM, Licensed Vocational Nurse (LVN) 10 (7 AM to 3 PM shift LVN assigned to Resident 119 on [DATE]), LVN 10 stated in the morning of [DATE], Resident 119 had low blood pressure readings that would fluctuate. LVN 10 stated she monitored the blood pressure consistently. LVN 10 stated Resident 119 ' s blood pressure she documented was about 98/58 mm/hg. LVN 10 stated she took Resident 119 ' s blood pressure 2 to 3 times and when he was repositioned the BP became stable. LVN 10 stated she only documented one blood pressure reading she took and could not recall the rest of the BP readings. LVN 10 stated she did not document anything unless something happens with Resident 119 ' s physical condition. During an interview on [DATE] at 10:36 AM, Registered Nurse (RN) 2 (7 AM to 3 PM shift RN assigned to Resident 119 on [DATE]) stated on the day of [DATE], Resident 119 was assessed throughout the dayshift ([DATE]) for fluctuating and low blood pressure readings. RN 2 stated Resident 119 ' s condition was stable on [DATE]. RN 2 stated that if Resident 119 ' s condition was stable, she does not document the low and fluctuating BP readings in the resident ' s records. During an interview on [DATE] at 11:48 AM, Licensed Vocational Nurse (LVN) 8 stated she was the charge nurse assigned to Resident 119 on [DATE]. LVN 8 stated she made her resident rounds (regular visits made by nurses to check on their patients and assess their progress, well-being and safety) before she took her break at 7:30 to 8:00 PM and observed Resident 119 was stable. LVN 8 stated before she left for her lunch break at 7:30 PM, Resident 119 ' s oxygen saturation was fluctuating between 90 to 93% with continuous oxygen at 2 liters via nasal cannula. LVN 8 stated before she left for her break, Resident 119 was able to open eyes when called by name and mouth breathing was shallow. LVN 8 stated she could not recall the color of Resident 119 ' s skin, but appeared weak and tired. LVN 8 stated when she came back from her break at around 8:06 PM, she observed LVN 9 rushing to Resident 119 ' s room and Registered Nurse (RN) 4 was at the Nursing Station calling 911 EMS preparing paperwork for Resident 119 ' s possible transfer to GACH. LVN 8 stated she was informed by LVN 9 that there was an emergency going on with Resident 119. LVN 8 stated Resident 119's blood pressure was fluctuating two days ago and was on the low side with a systolic blood pressure reading about 80 mm/hg. LVN 8 stated Resident 119 appeared weaker during this current readmission to the facility ([DATE]). During the same interview on [DATE] at 12:04 PM, LVN 8 stated Resident 119's usual blood pressure from readmission was as low as 80/40 mm/hg and as high as 90 mm/hg. LVN 8 stated she would only document the good number in Resident 119 ' s electronic records, because if she wrote the bad number she would be questioned (by facility leadership). LVN 8 stated she thought the physician was aware of Resident 119 ' s fluctuating blood pressure. LVN 8 stated when she arrived on her shift on [DATE] at around 3 PM to 3:30 PM, Resident 119 ' s blood pressure was around 80/40 mm/hg and on the low side. LVN 8 stated she could not recall the other blood pressure readings Resident 119 had, but she reported to RN 4 the fluctuating blood pressures results of Resident 119. LVN 8 stated RN 4 informed her to monitor Resident 119 ' s blood pressure because the resident was just readmitted back from GACH 1 recently. LVN 8 stated she did not document Resident 119's fluctuating blood pressure. LVN 8 stated before she left for break, she endorsed to LVN 9 that at the time she did not see any sudden change of condition resident was at baseline. During a telephone interview with Physician 1 on [DATE] at 12:55 PM, Physician 1 stated he could not recall specifically if he was notified of Resident 119 ' s change of condition on [DATE]. Physician 1 stated usually nurses would notify the physician if a resident ' s blood pressure went below expected or if there was a change in a resident's status. Physician 1 stated if resident's blood pressure was unstable I would send him [Resident 119] to emergency room and according to family wishes. During an interview on [DATE] at 3:51 PM, the Director of Nursing (DON) stated nurses/staff should be documenting everything that occurred in a resident. The DON stated nurses should document correct result, to know what they did for the resident, if the physician was notified, and if interventions were provided for the resident. The DON stated if the nurses does not document the correct result and something happens to resident there could be a delay in interventions. The DON stated she expects the nurses to document abnormalities and to notify the physician so that the resident is safe. During an interview on [DATE] at 10:45 AM, RN 4 stated she could not recall if LVN 8 notified her of Resident 119 ' s fluctuating blood pressure. RN 4 stated around 3 to 3:30 PM on [DATE], Resident 119 ' s blood pressure was not fluctuating. RN 4 stated LVN 8 only notified her about Resident 119 ' s oxygen saturation at 90% around 8 PM. RN 4 stated there was nothing alarming between 3 PM to 8 PM. RN 4 stated if Resident 119 had a change of condition like blood pressure going high or going low, she would assess the resident first, if assessment was abnormal she would call 911 immediately and notify physician before calling the family. At 8 PM, RN 4 stated LVN 8 grabbed her and said, come and see the oxygen. RN 4 stated when she came to Resident 119 ' s room, that was when she saw Resident 119 ' s oxygen was 90%, so she went to grab her own pulse oximeter, and Resident 119 ' s oxygen saturation was even lower than 90 % and was 85 to 86 %. RN 4 stated that was when she rushed to the Nurses Station then went back to the resident ' s room and started performing the chest maneuver to Resident 119. During a concurrent interview and record review of Resident 119 ' s Change of Condition on [DATE] at 10:52 AM, RN 4 stated CPR was initiated because she saw Resident 119 ' s oxygen and blood pressure was getting low. RN 4 stated she had already called 911. RN 4 stated CPR was cardiopulmonary resuscitation. RN 4 stated the nurse have to check if resident was full code, then check the pulse, you can start CPR if there is still a pulse. RN 4 demonstrated CPR and stated you interlock hands make sure you press 1 to 2 inches deep about 100 to 120 times per minute, on the chest around the apex of the heart and if you are comfortable you can give mouth to mouth and I did not give breaths. RN 4 stated Resident 119 was breathing, He [Resident 119] was breathing all through until the last minute. RN 4 stated she started chest compressions when the resident ' s oxygen was low at 85 to 86%. RN 4 stated She was doing both chest rub and chest compressions at the same time. RN 4 stated she and LVN 8 were doing both at the same time, alternating chest rub and chest compressions. RN 4 stated the chest rub worked better. RN 4 stated she checked Resident 119 ' s wrist for pulse and it was present. RN 4 stated Resident 119 was desatting [short term for desaturate [oxygen levels are dropping]) which was why she started chest compressions. RN 4 stated Resident 119 ' s pulse was very low, and she still performed chest compressions. RN 4 stated she did not give Resident 119 rescue breaths and that no one did rescue breaths because i was focusing on chest more. RN 4 stated after calling 911 everything was going down. RN 4 stated the paramedics arrived already. RN 4 stated the vital signs were not going low at that time like 90 something, that was the last thing i wrote down. RN 4 confirmed she did not document the abnormal findings and details about what happened when Resident 119 was found unresponsive. RN 4 stated there was no reason why she did not include Resident 119 ' s abnormal vital signs. RN 4stated she did not document of PCC the abnormal vitals, it was important to include the abnormal findings on the note, for reference to compare. RN 4 stated the abnormal findings should be documented. During a review of the facility ' s undated policy and procedure (P&P) titled Change of Condition indicated the purpose was to ensure proper assessment and follow-through for any resident with a change of condition. The P&P indicated documentation of change in condition shall be performed by the Licensed Nurse accordingly: documenting for at least 72 hours, or longer if condition change warrants, using appropriate form for daily charting, documenting vital signs for each shift, and reassess resident condition as needed. During a review of the facility ' s P&P titled Charting and Documentation dated 7/2017 indicated all services provided to the resident, progress toward the care plan goals, or any changes in the resident ' s medical, physical, functional or psychological condition, shall be documented in the resident's medical record. The P&P indicated documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. The P&P indicated documentation of procedures and treatments will include care-specific details, including: the date and time the procedure/treatment was provided; the name and title of the individual(s) who provided care; the assessment data and/or any unusual findings obtained during the procedure/treatment; and notification of family, physician or other staff if indicated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the enteral tube feeding (a feeding tube is a medical device used to provide nutrition to people who cannot obtain nutrition by mouth) formula bag was labeled with the date and time for one of five sampled residents (Resident 80) in accordance to the facility's Policy and Procedure for Enteral Feeding Monitoring. This deficient practice had the potential to place Resident 80 at risk for infection. Findings: During a review of Resident 80's admission Record (AR), the AR indicated the facility originally admitted Resident 80 on [DATE] and readmitted her on [DATE] with diagnoses that included dementia (a group of thinking and social symptoms that interferes with daily functioning) and gastrostomy (creation of an artificial external opening into the stomach for nutritional support). During a review of Resident 80's Minimum Data Set (MDS, a resident assessment tool), dated [DATE], indicated Resident 80 had severely impaired memory and cognition (ability to think and reason). The MDS indicated Resident 80 was dependent with oral hygiene, toileting hygiene, shower/bathe self, personal hygiene, and chair/bed-to-chair transfer. During a review of Resident 80 ' s Order Summary Report, dated [DATE], the report indicated the physician ordered to administer Fibersource HN 1.2 (a nutritionally complete tube feeding formula with fiber) at rate of 50 milliliter (ml, a unit of measurement) per hour for 20 hours via feeding pump (a medical device used to deliver liquid nutrition, medications, or special formulas to patients who cannot eat by mouth) to provide 1000 ml/1200 kcal (kilocalorie, a unit of measurement) per day, starting on [DATE]. The report also indicated a physician ' s ordered to turn the feeding pump on at 12 PM and to turn off the feeding pump at 8 AM, starting on [DATE]. During an observation on [DATE] at 9:48 AM, Resident 80 ' s gastrostomy tube (G-tube, a feeding tube inserted through the belly that brings nutrition directly to the stomach) 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 Resident 80 ' s bed. G-tube feeding pump was turned off. An opened bag of Fibersource formula was observed hanging from the IV pole with the feeding tubing placed inside the feeding pump, ready for infusion. There was no open date indicated on the Fibersource formula bag indicating when the formula bag was opened and started. During a concurrent observation and interview on [DATE] at 9:50 AM, with licensed vocational nurse (LVN) 7, LVN 7 stated Resident 80 ' G-tube feeding was stopped at 8 AM on [DATE]. LVN 7 stated the nurse who opened and hung the current formula bag did not write down the open date on the formula bag. LVN 7 stated he did not know when the current bag was opened and hung, and could not state if the formula bag was expired. LVN 7 stated the nurse should write down the open date, and when the formula bag was hung, so licensed nurses (LN) would know when to change or dispose of Resident 80 ' s formula bag to prevent any potential for infection to the resident. During an interview on [DATE] at 1:42 PM with the Director of Nursing (DON), the DON stated the G-tube feeding formula bag should be labeled with the open date when it was opened and hung, so the nurses would know when to change the formula bag, to prevent potential infection from the overgrowth of bacteria in the old formula bag. During a review of the updated facility ' s policy and procedure (P&P) titled, Enteral Feeding Monitoring, the P&P indicated Licensed nurse will write the time, date, and rate on the formula Bottle including initials and Closed system formula must be discarded after 48 hours.

Based on interview and record review, the facility failed to ensure two of five sampled residents' (Resident 81 and 99) Physician Orders for Life Sustaining Treatment (POLST forms that tell medical staff what to do if you have a medical emergency and are unable to speak for yourself) and Advance Directive (living will, legal document in which a person specifies what actions should be taken for their health if they are no longer able to make decisions for themselves because of illness or incapacity) Acknowledgment Form correctly indicated Resident 81 ' s and 99 ' s Advance Directive. This deficient practice had the potential to result in misinformation of medical care and treatment and not honoring resident ' s wishes in cases where the resident and/or responsible party was unable to participate in making healthcare decisions. Findings: 1. During a review of Resident 81 ' s admission Record (AR), the AR indicated a readmission to the facility on 3/31/2025 with diagnoses that included chronic systolic heart failure (when the heart muscle doesn't pump blood as well as it should), type 2 diabetes mellitus with hyperglycemia (condition in which the level of glucose in the blood is higher than normal). During a review of Resident 81 ' s History and Physical (H&P), dated 4/06/2025, the H&P indicated the resident did not have the capacity was not able to make his own decisions. During a review of Resident 81 ' s POLST, dated 1/23/2024, the POLST indicated the resident had an Advance Directive, dated 1/23/2024. During a review of Resident 81 ' s Advance Directive Acknowledgement form, dated 3/03/2025, the form indicated Resident 81 did not have an Advance Directive. During a review of Resident 81 ' s medical chart on 5/22/2025 at 1:46 PM, no Advance Directive was found. During a concurrent interview and record review of Resident 81 ' s medical chart with the Social Services Director (SSA) on 5/22/2025 at 1:47 PM, the SSD stated she assists with resident admissions with the admission Coordinator and licensed nurses. The SSD stated she would explain the forms to residents and the families on admission and would follow up on the forms during the interdisciplinary team (IDT) admission meetings. The SSD confirmed Resident 81 ' s POLST and Advance Directive Acknowledgment form did not match. The SSD stated it was important to make sure all the dates and documents indicate Resident 81 ' s wishes, in the cases of a medical emergency, facility staff would know what medical interventions to perform. The SSD stated since the advance directive acknowledgment form and the POLST did not match and indicated different information, the SSD stated she should have clarified the information with the family and updated Resident 81 ' s chart. 2. During a review of Resident 99 ' s AR, the AR indicated a readmission to the facility on 7/15/2024 with diagnoses that included Chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood),hypersensitive heart disease with out heart failure(damage to the heart caused by chronic high blood pressure, but without the specific condition of heart failure) During a review of Resident 99 ' s H&P, dated 7/17/2024, the H&P indicated the resident has the capacity to understand and make decisions. During a review of Resident 99 ' s POLST, dated 7/17/2024, the POLST indicated the resident did not have an advance directive. During a review of Resident 99 ' s Advance Directive Acknowledgement form, dated 7/16/2024, the form indicated Resident 99 had an Advance Directive. During a concurrent interview and record review of Resident 99 ' s medical chart with the Social Services Director (SSD) on 5/22/2025 at 1:59 PM, the SSD stated she did not know which facility staff completed Resident 99 ' s from upon admission to the facility. The SSD confirmed Resident 99 ' s POLST and Advance Directive Acknowledgment form did not match. During a concurrent interview and record review of Resident 81 ' s and Resident 99 ' s POLST and Advanced Directive Acknowledgement form with SSD 5/22/2025 at 2:10 PM, SSD stated both forms for Resident 81 ' s and 99 ' s should have been clarified since the information on the forms did not match. SSD stated it was important to obtain correct information, so facility staff know what the resident ' s or families wishes were, in cases of a medical emergency. A review of the facility ' s policy and procedure titled Advanced Directives, revised in September 2022, indicated The resident has the right to formulate and advance directive, including the right to accept or refuse medical or surgical treatment. Advance directives are honored in accordance with state law and facility policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to protect three of three sampled residents' (Residents 29, 5, and 112) privacy to ensure the unauthorized personnels did not have the access to view and obtain the baby monitors for Residents 29, 5, and 112. The deficient practices had potential to violate the residents' right for privacy. Findings: 1. During a review of Resident 29's admission Record (AR), the AR indicated the facility originally admitted Resident 29 on 11/22/2018 and readmitted her on 9/10/2022 with diagnoses that included dementia (a group of thinking and social symptoms that interferes with daily functioning) and hyperlipidemia (a condition in which there are high levels of fat particles in the blood). During a review of Resident 29's Minimum Data Set (MDS, a resident assessment tool), dated 3/4/2025, the MDS indicated Resident 29 had intact memory and cognition (ability to think and reason). The MDS indicated Resident 29 required setup or clean-up assistance with eating, supervision or touching assistance with oral hygiene, personal hygiene and chair/bed-to-chair transfer, and partial/moderate assistance with toileting hygiene and shower/bathe self. During a review of Resident 29 ' s At Risk for Falls Care Plan, dated 3/15/2025, the Care Plan indicated interventions that included to place a baby monitor (an electronic device that enables a person to see or hear a child who is in another room) at the nurses ' station with staff to monitor resident ' s activity in her room and digital screen monitor while in bed to monitor her whereabouts. During an observation on 5/19/2025 at 9:38 AM, in Resident 29 ' s room, a camera was observed in Resident 29 ' s bed, placed in a built-in wall cabinet, facing Resident 29 ' s bed. During a concurrent observation and interview on 5/19/2025 at 11:48 AM with Certified Nursing Assistant (CNA) 5, in Resident 29 ' s room, CNA 5 stated she saw the camera in Resident 29 ' s room, but did not know what the purpose of the camera was for and who had placed the camera in Resident 29 ' s room. During an observation on 5/19/2025 at 4:09 PM, in the lobby outside Nursing Station 1, Resident 29 ' s baby monitor was observed placed on top of Medication Cart 1, visible to people who passed Medication Cart 1. The baby monitor display screen was turned on, and the people who passed by Medication Cart 1 had a direct view of the monitor display screen. Resident 29 ' s bed was visible on the baby monitor display screen, but Resident 29 was not in the room at the moment. During an interview on 5/19/2025 at 4:10 PM with Licensed Vocational Nurse (LVN) 5, LVN 5 stated she placed Resident 29 ' s baby monitor on top of Medication Cart 1 and kept it on, so she could check on Resident 29 any time while she was away from the nursing station to pass medications to other residents. LVN 5 stated the monitor should be turned off when Resident 29 was not in the room and when other staff were in the room with Resident 29. During an interview on 5/19/2025 at 4:30 PM with the Administrator (ADM), the ADM stated the nurses should only use the baby monitor system when the residents were by themselves, without the presence of staff in the room. During an interview on 5/20/2025 at 10:40 AM with Registered Nurse (RN) 3, RN 3 stated Resident 29 ' s baby monitor should be turned on only when the resident was alone, and without the presence of staff in the room, so the nurses could keep an eye on Resident 29 at all times to prevent falls and injuries. RN 3 stated she usually worked night shift and Resident 29 was asleep by herself in the room at night, so she would keep the baby monitor on during the whole night shift. RN 3 stated she would keep the baby monitor on the nurses ' desk behind the nursing station counter. RN 3 stated the baby monitor should be kept in the nursing station at all times, but RN 3 stated she was not aware of other nurses placing the baby camera onto the medication cart while away from the nursing station. 2. During a review of Resident 112's AR, the AR indicated the facility originally admitted Resident 112 on 10/14/2024 and readmitted her on 3/11/2025 with diagnoses that included diabetes mellitus (a disease that result in too much sugar in the blood) and heart failure (a chronic condition in which the heart doesn't pump blood as well as it should). During a review of Resident 112's MDS, dated [DATE], indicated Resident 112 had severely impaired memory and cognition The MDS indicated Resident 112 was dependent with eating, oral hygiene, personal hygiene, chair/bed-to-chair transfer, toileting hygiene and shower/bathe self. 3. During a review of Resident 5's AR, the AR indicated the facility admitted Resident 5/17/2025 with diagnoses that included dementia and hyperlipidemia. During a review of Resident 5's MDS, dated [DATE], indicated Resident 5 had severely impaired cognitive skills for daily decision making. The MDS indicated Resident 5 required supervision or touching assistance with eating, partial/moderate assistance with oral hygiene, personal hygiene, chair/bed-to-chair transfer, and toileting hygiene. During an observation on 5/20/2025 at 4:05 PM, in Resident 112 ' s and Resident 5 ' s room, a camera was observed in the resident's room and placed in a built-in wall cabinet facing Resident 112 and Resident 5 ' s bed. During an observation on 5/20/2025 at 4:08 PM, Resident 112 ' s baby monitor was in Nursing Station 2 on the nurses ' desk, behind the nursing station counter. There was no staff in Nursing Sation 2. Resident 112 ' s baby monitor display screen was on and Resident 112 ' s bed and Resident 5 ' s face and head were visible through the display screen. Resident 112 was not in room. During an interview on 5/20/2025 at 4:09 PM with LVN 6, LVN 6 stated the nurses kept Resident 112 ' s baby monitor on at all times so the nurses could see where and what Resident 112 was doing to prevent falls and injuries. LVN 6 stated the nurses kept the baby monitor on the desk in the nursing station. During an interview on 5/20/2025 at 4:15 PM with LVN 5, LVN 5 stated when the baby monitor was on and the nurses would place it on the desk in the nursing station, which was visible to any passerby's passing by or going into the nursing station, could see the baby monitor display screen which displayed Resident 112 and Resident 5 ' s room. During an observation on 5/22/2025 at 11:23 AM, Resident 112 ' s baby monitor was turned on and was on the desk in Nursing Station 2. Resident 112 was lying on the bed with Resident 5 ' s head visible on the monitor display screen. People passing by the nursing station could have direct view of Resident 112 and Resident 5. There was no staff in the nursing station. During an interview on 5/22/2025 at 11:46 AM with Family Member (FM) 1, FM 1 stated she was not aware that Resident 5 could be seen on the baby monitor display. During an interview on 5/22/2025 at 1:43 PM with the Director of Nursing (DON), the DON stated the nurses kept the baby monitor system on at all times, left the display screen open for authorized people to see, and removed the monitor from the nursing station could potentially violate the residents ' privacy. The DON stated the camera should only capture the resident who the monitoring device was intended to be used on and should not capture other residents ' activities. The DON stated the responsible party should be informed and must agree with the use of monitoring devices to ensure residents ' right to privacy was respected. During a review of the undated facility ' s policies and procedures (P&P) titled, Monitoring Devices, the P&P indicated The monitoring device will be solely used as an intervention to maximize resident ' s safety based on the interdisciplinary team and responsible party ' s decision and included in the resident ' s care plan, Devices must be used in a way that respects the resident's dignity and privacy, and Access to monitor feeds is restricted to authorized staff only.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility to failed to promote resident safety in administering oxygen for three (3) of 3 sampled residents (Resident 71, 119 who were receiving oxygen therapy, in accordance with the facility ' s policy and procedure by failing to: 1. Ensure the oxygen tubing (flexible plastic tubing used to deliver oxygen through nostrils and the tubing is fitted over the patient ' s ears) was labeled with date opened and not touching the floor for Resident 71 2a. Ensure physician order for oxygen administration was followed for Resident 119 to titrate up to 4L per minute for oxygen saturation less than 90% every shift 2b. Ensure that PM shift licensed nurses (LVN 8 and 9), and Registered Nurse (RN) 4 assessed and monitored Resident 119 for signs and symptoms of acute respiratory failure, abnormal vital signs and document in the resident ' s records, when Resident 119 was observed with low and fluctuating BP and oxygen saturations on 3/17/25, to provide immediate respiratory interventions as indicated in the resident ' s care plan. 2c. Ensure LVN 8 and RN 1 assessed, monitored, and documented Resident 119 ' s abnormal vital signs (HR, Oxygen saturation, respiratory rate [RR], body temperature) taken on 3/17/2025 that included abnormal blood pressure (BP) of 80 ' s (systolic BP) and 40 ' s (diastolic BP) on 3/17/25 at the start of the evening shift, around 3:30 PM. 2c. Ensure LVN 8 and RN 1 notified Physician 1 immediately when Resident 119 was observed with abnormal BP of 80 ' s (systolic BP) and 40 ' s (diastolic BP) on 3/17/25 at the start of the evening shift (3 PM to 11 PM) and before LVN 8 go on meal break on 3/17/25 prior to 8 PM, to provide necessary interventions for the abnormal BP and monitored/reported measurement of other vital signs that included abnormal oxygen saturations. 2d. Ensure LVN 8, LVN 9 and RN 4 activated the facility ' s emergency response system (code blue) and implemented BLS sequence of events (airway, breathing, chest compressions) and 911 emergency services (EMS) when Resident 119 was found unresponsive, not breathing, and oxygen saturation (a measure of how much oxygen the blood is carrying) fluctuating between 50% to 80 % on 3/17/25 between the hours of 7:45 PM to 8:11 PM. RN 4 called 911 EMS at 8:11 PM, 26 to 31 minutes after Resident 119 was reported unresponsive by FM 1 to LVN 9 on 3/17/25, in accordance with the facility ' s policy and procedure (P&P) on CPR. 3. Ensure Resident 107 ' s nasal cannula (a flexible tube that provides oxygen through the nose) was dated with an open date and stored in a clean bag when not in use. These deficient practices placed Residents 71, and Resident 107 at risk to harbor bacteria and other contaminants, potentially leading to respiratory infections. These deficient practices resulted in Resident 119 was found dead upon EMS arrival at the facility on 3/17/2025 at 8:18 PM. The EMS Report indicated Resident 119 was found by 911 EMS personnel on 3/17/2025 as unresponsive, both eyes dilated, absent breath sounds to both lungs, skin was clammy and showed signs of lividity (a process where blood pools in the lowest parts of the body after the heart stops pumping that typically begins to appear within 30 minutes to an hour after death. Lividity is noticeable by the human eye within 1 to 2 hours after death). Cross referenced to F678 and F842. Findings: 1. During a review of Resident 71 ' s admission Record (AR), the AR indicated the resident was admitted on [DATE] with diagnoses that included acute respiratory failure with hypoxia (a state in which oxygen is not available in sufficient amounts at the tissue level to maintain adequate homeostasis), pneumonitis (inflammation [swelling and irritation] of lung tissue) due to inhalation of food and vomit, and encounter for attention to gastrostomy (creation of an artificial external opening into the stomach for nutritional support or gastric decompression). During a review of Resident 71 ' s History and Physical (H&P), dated 4/15/2025, indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 71 ' s Order Summary Report dated 4/16/2025, indicated a physician order to administer Oxygen at 2 liters (L, unit of measure) per minute via nasal cannula (medical device to provide supplemental oxygen therapy), may titrate up to 5L per minute for oxygen saturation less than 90% every shift. During an observation in Resident 71 ' s room on 5/19/2025 at 8:47 AM, Resident 71 ' s nasal oxygen tubing was observed on the floor and not labeled with date opened. During a concurrent observation and interview in Resident 71 ' s room on 5/19/2025 at 11:28 AM, verified with certified nursing assistant (CNA) 7 of Resident 71 ' s oxygen tubing on the floor. CNA 7 stated the oxygen tubing should not be touching the floor because it was an infection control issue. During an interview with the Director of Nursing (DON) on 5/23/2025 at 4:05 PM, the DON stated oxygen tubing should be labeled with the date opened to make sure the tubing was good for 7 days. The DON stated oxygen tubing should not touch the floor to avoid accumulation of bacteria. The DON stated once the oxygen tubing touches the floor, the nurse should change the oxygen tubing. 2. During a review of Resident 119 ' s admission Record (AR), the AR indicated Resident 119 was readmitted to the facility on [DATE] with diagnoses that included pneumonia (infection that inflames air sacs in one or both lungs, which may fill with fluid), acute respiratory failure with hypoxia, and chronic obstructive pulmonary disease (COPD, lung disease causing restricted airflow and breathing problems) with (acute) exacerbation (worsening of a disease or an increase in its symptoms). During a review of Resident 119 ' s History and Physical (H&P), dated 3/16/2025, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 119 ' s Order Summary Report dated 3/13/2025, indicated a physician order to administer Oxygen at 2L per minute via nasal cannula, may titrate up to 4L per minute for oxygen saturation less than 90% every shift. During a review of Resident 119 ' s care plan titled Oxygen, Resident is receiving Oxygen Therapy due to Acute Respiratory failure and COPD Exacerbation dated 2/5/2025 indicated to monitor oxygen saturation as ordered, notify physician for any significant change, and to provide oxygen as ordered. During a review of Resident 119 ' s care plan titled Resident is at risk for respiratory distress (shortness of breath (SOB), irregular respiration, wheezing/crackles, rhonchi, activity intolerance, edema) related to COPD dated 2/14/2025 indicated resident would have no unrecognized signs and/or symptoms of respiratory distress daily through the next assessment and would reduce episodes and symptoms of respiratory distress thru appropriate interventions daily through the next assessment. The care plan indicated to assess resident for SOB, irregular respiration, wheezing, crackles, rhonchi, coughing, weakness, activity intolerance, excessive secretions, and to inform physician promptly. During a review of Resident 119 ' s previous admission to a General Acute Care Hospital (GACH) 1 from the facility, the GACH 1 History and Physical (H&P) dated 3/5/2025 indicated the resident presented to the emergency room from the facility for symptoms of respiratory distress. The GACH 1 H&P indicated in the emergency room Resident 119 was hypoxic at 88% with blood pressure of 54/32 and was also febrile with a temperature of 101 degrees. The GACH 1 H&P indicated Resident 119 was subsequently intubated for hypoxic respiratory failure and had lactic acidosis as well as leukocytosis and initial chest x-ray was unremarkable. The GACH 1 H&P indicated Resident 119 was started on broad-spectrum intravenous (IV) antibiotics for presumed healthcare associated pneumonia. The GACH 1 H&P indicated Resident 119 was septic on admission. During a review of GACH 1 Discharge Summary (undated), the GACH 1 Discharge Summary indicated Resident 119 was admitted to GACH 1 on 3/5/2025 and discharged from GACH 1 on 3/12/2025 with discharge primary diagnoses that included but not limited to acute hypoxic respiratory failure status post [s/p] intubation, suspected healthcare associated pneumonia, severe sepsis with shock, acute COPD exacerbation, NSTEMI and left pleural effusion s/p thoracentesis. The Discharge Summary indicated that pulmonary and cardiology GACH 1 physician had cleared Resident 119 for discharge from GACH 1 back to the facility. During a review of Resident 119 ' s Change of Condition (COC)/Interact Assessment Form dated 3/17/2025 timed at 8:23 PM, the COC indicated during rounds at 8 PM, Resident 119 ' s oxygen saturation level was found to be 90% while on 2L of oxygen with no respiratory distress. The COC indicated Resident 119 ' s oxygen was titrated up to 5L per physician order and the oxygen level came up to 97%. During a review of the Fire Department (FD) Paramedics (911 EMS) Report dated 3/17/2025, the report indicated the facility called 911 EMS on 3/17/2025 timed at 8:11 PM and dispatch complaint of cardiac arrest. The FD Report further indicated FD paramedics arrived at the facility at 8:18 PM (9 minutes) and at Resident 119 ' s room at 8:20 PM (2 minutes). The FD Report under Disposition indicated Resident 119 was dead prior to arrival (DOA). The FD Report indicated Resident 119 was evaluated by the FD paramedics and further indicated No care or support services required. the FD Report indicated no transport was made to the acute hospital due to the resident being DOA. The FD Report under Patient Assessment further indicated Resident 119 ' s Distress Level as Severe. The FD Report under Primary Impression indicated as DOA/Obvious death. The FD Report indicated on 3/17/2025 timed at 8:22 PM, further physical assessment was performed by the paramedics and showed Resident 119 as unresponsive, both eyes dilated, absent breath sounds to both lungs, skin was clammy and showed signs of lividity (a process where blood pools in the lowest parts of the body after the heart stops pumping that typically begins to appear within 30 minutes to an hour after death. Lividity is noticeable by the human eye within 1 to 2 hours after death). The FD Report Narrative indicated Patient determined to be dead (pronounced dead) at 8:23 PM. Patient found by staff in bed unresponsive. Compressions only CPR provided by staff, no BVM. Patient found pulseless, non-breathing, unresponsive at FD arrival, no lung sounds or heart tones, no response to painful stimuli, pupils fixed and dilated, lividity to lower back and legs, no obvious trauma. Per staff patient last seen alive 2-3 hours ago. No complaints prior, per staff patient bedridden. During a review of Resident 119 ' s Certificate of Death (COD) signed by the physician on 3/20/2025, the COD indicated Resident 119 ' s date of death was 3/17/2025. The COD indicated Resident 119 ' s immediate cause of death (final disease or condition resulting in death) was cardiopulmonary arrest. The COD indicated Resident 119 ' s underlying cause of death (disease or injury that initiated the event resulting in death) was COPD. During an interview on 5/21/2025 at 11:48 AM, Licensed Vocational Nurse (LVN) 8 stated she was the charge nurse assigned to Resident 119 on 3/17/2025. LVN 8 stated she made her resident rounds (regular visits made by nurses to check on their patients and assess their progress, well-being and safety) before she took her break at 7:30 to 8:00 PM and observed Resident 119 was stable. LVN 8 stated before she left for her lunch break at 7:30 PM, Resident 119 ' s oxygen saturation was fluctuating between 90 to 93% with continuous oxygen at 2 liters via nasal cannula. LVN 8 stated before she left for her break, Resident 119 was able to open eyes when called by name and mouth breathing was shallow. LVN 8 stated she could not recall the color of Resident 119 ' s skin, but appeared weak and tired. LVN 8 stated when she came back from her break at around 8:06 PM, she observed LVN 9 rushing to Resident 119 ' s room and Registered Nurse (RN) 4 was at the Nursing Station calling 911 EMS preparing paperwork for Resident 119 ' s possible transfer to GACH. LVN 8 stated she was informed by LVN 9 that there was an emergency going on with Resident 119. LVN 8 stated Resident 119's blood pressure was fluctuating two days ago and was on the low side with a systolic blood pressure reading about 80 mm/hg. LVN 8 stated Resident 119 appeared weaker during this current readmission to the facility (3/12/25). During the same interview on 5/21/2025 at 12:04 PM, LVN 8 stated Resident 119's usual blood pressure from readmission was as low as 80/40 mm/hg and as high as 90 mm/hg. LVN 8 stated she would only document the good number in Resident 119 ' s electronic records, because if she wrote the bad number she would be questioned (by facility leadership). LVN 8 stated she thought the physician was aware of Resident 119 ' s fluctuating blood pressure. LVN 8 stated when she arrived on her shift on 3/17/2025 at around 3 PM to 3:30 PM, Resident 119 ' s blood pressure was around 80/40 mm/hg and on the low side. LVN 8 stated she could not recall the other blood pressure readings Resident 119 had, but she reported to RN 4 the fluctuating blood pressures results of Resident 119. LVN 8 stated RN 4 informed her to monitor Resident 119 ' s blood pressure because the resident was just readmitted back from GACH 1 recently. LVN 8 stated she did not document Resident 119's fluctuating blood pressure. LVN 8 stated before she left for break, she endorsed to LVN 9 that at the time she did not see any sudden change of condition resident was at baseline. During the same interview on 5/21/2025 at 12:44 PM, LVN 8 stated when she returned from her break at 8:06 PM, she did not hear any overhead page of Code Blue (the facility ' s emergency response system that signifies a medical emergency, specifically a cardiac or respiratory arrest, requiring immediate resuscitation efforts) being called. LVN 8 stated she followed LVN 9 to Resident 119 ' s room and checked Resident 119 ' s vital signs (essential physiological measurements that indicate a person's basic bodily functions and overall health). LVN 8 stated LVN 9 left Resident 119 ' s room. LVN 8 stated Resident 119 ' s oxygen saturation was fluctuating between 70 % to 80%, blood pressure was lower around 70/40 mm/hg more or less. LVN 8 stated she could not recall Resident 119 ' s heart rate. LVN 8 stated she did not know what Resident 119 ' s code status and she (LVN 8) stood by Resident 119 ' s door to ask RN 4 (who was at the Nursing Station) if Resident 119 was a full code or DNR. LVN 8 stated she could not recall exactly what time or what RN 4 brought into Resident 119 ' s room when RN 4 came back to the room. LVN 8 stated Resident 119 was on nasal cannula, and she increased Resident 119 ' s oxygen to 6 to 8 liters via nonrebreather mask (a device that gives you oxygen, usually in an emergency). LVN 8 could not recall who put the mask on Resident 119. LVN 8 stated she could not recall any staff performing CPR on Resident 119. LVN 8 stated RN 4 wanted to do CPR but could not recall if RN 4 started CPR. LVN 8 stated 911 EMS took care over shortly after RN 4 came into the room. During a telephone interview with Resident 119 ' s family member (FM) 1 on 5/22/2025 at 8:43 AM, FM 1 stated he and a friend arrived at the facility on 3/17/2025 at around 7:40 PM and noticed there was something strange with Resident 119. FM 1 stated he comes to the facility every day, at least twice a day and Resident 119 was usually awake with eyes opened and would look at him but was nonverbal. FM 1 stated on 3/17/2025, Resident 119 was not awake despite being called and not responding. FM 1 stated Resident 119 was not breathing through his mouth, and his eyes were closed. FM 1 stated after waiting for about 5 minutes (7:45 PM) trying to wake up Resident 119, FM 1 stated they call the nurse into the room. FM 1 stated he came out to the Nursing Station to call the nurse; the licensed nurse came in and checked the vital signs and told him Everything was low including the blood pressure. FM 1 stated he believed the nurse told him Resident 119 ' s oxygen level was below 50%. FM 1 stated he could not recall if the vital signs machine showed any numbers because he was so worried and focused on Resident 119. FM 1 stated he only recalled that the nurse told him everything was low, and oxygen level (oxygen saturation) was below 50%. FM 1 stated he could not recall who the nurse was, but he witnessed the nurse help Resident 119 with breathing using a mask, but it was not effective. FM 1 stated he could not recall if the nurses ' provided CPR because he was only focused on Resident 119. FM 1 stated he saw about 2 nurses in and out of the room, before 911 arrived. During a telephone interview with LVN 9 on 5/22/2025 at 9:37 AM, LVN 9 stated Resident 119 ' s family member (FM) 1 came to him and said [Resident 119] did not seem right. LVN 9 stated he went over to Resident 119 ' s room to check and the resident ' s blood pressure was 100/50 mm/hg. LVN 9 stated he could not recall Resident 119 ' s oxygen saturation level, but it was within normal range between 90 to 93%. LVN 9 stated he could not recall if he told FM 1 about Resident 119 ' s blood pressure and oxygen levels. LVN 9 stated at the time, Resident 119 did not respond to verbal stimuli but was breathing. LVN 9 stated Resident 119 ' s mouth was closed and appeared to be sleeping but was difficult to arouse. LVN 9 stated he called RN 4. LVN 9 stated RN 4 went into the room and about the same time, LVN 8 returned from her break. LVN 9 stated LVN 8 took over and brought a new blood pressure cuff and pulse oximeter machine (an electronic device that measures the saturation of oxygen carried in your red blood cells). LVN 9 stated Resident 119 was still unresponsive. LVN 9 stated he could not recall the resident ' s vital signs. LVN 9 stated RN 4 left the room to call 911 and to check Resident 119's documented code status. LVN 9 stated he could not recall if the crash cart was brought inside the room or if a code blue was called. LVN 9 stated he told RN 4 about Resident 119 ' s oxygen saturation was low because anything below 95% should be reported especially because Resident 119 had COPD. LVN 9 stated Resident 119 was wearing a nasal cannula at the time and could not recall how many liters of oxygen was given. LVN 9 stated he could not find Resident 119's POLST at that time so they treated it as a full code. LVN 9 stated he saw RN 4 doing compressions, but did not stay in Resident 119 ' s room the whole time. LVN 9 stated he could not recall if RN 4 used the backboard while doing compressions. LVN 9 stated he left Resident 119 ' s room to clear the hallway because the EMS arrived a few minutes after RN 4 called 911. LVN 9 stated Resident 119 ' s family members were at the bedside. During a telephone interview with LVN 9 on 5/22/2025 at 10:09 AM, LVN 9 stated when he returned to Resident 119's room after checking resident's code status he saw RN 4 performing CPR on Resident 119. LVN 9 stated he stood by Resident 119 ' s door and RN 4 was on one side of the bed because the other side of resident's bed was next to a wall. LVN 9 stated he saw both of RN 4's hands on Resident 119 ' s chest. LVN 9 stated he could not recall when CPR was initiated to Resident 119 by RN 4. LVN 9 stated LVN 8 was standing next to Resident 119 ' s bed with RN 4. LVN 9 could not recall if LVN 8 was assisting RN 4 with CPR. During a telephone interview with Physician 1 on 5/22/2025 at 12:55 PM, Physician 1 stated he could not recall specifically if he was notified of Resident 119 ' s change of condition on 3/17/2025. Physician 1 stated usually nurses would notify the physician if a resident ' s blood pressure went below expected or if there was a change in a resident's status. Physician 1 stated if resident's blood pressure was unstable I would send him [Resident 119] to emergency room and according to family wishes. During another interview on 5/23/2025 at 9:42 AM, RN 4 stated on 3/17/2025 at 8 PM, she had already left Resident 119 ' s room and was going to other rooms when LVN 8 grabbed her to go back to Resident 119 ' s room. RN 4 stated when she conducted her 8 PM rounds, Resident 119 looked okay and blood pressure and heart rate were within normal limits at 100/53. RN 4 stated she did not document the vital signs on the facility ' s online charting system. RN 4 stated in the presence of LVN 8, Resident 119 ' s oxygen saturation was 90%. RN 4 stated she titrated the oxygen to 5 liters to keep the oxygen level above 97%. RN 4 stated everything happened within a twinkle of an eye. RN 4 stated when LVN 8 showed her Resident 119 ' s oxygen saturation at 90%, RN 4 rushed out of the room to get her own pulse oximeter. RN 4 stated Resident 119 ' s oxygen saturation level was not steady at 90% and desatting. RN 4 was asked what desatting means and RN 4 stated desatting meant Resident 119 ' s oxygen saturation level was fluctuating and was going below 90%. RN 4 stated everything happened fast and before increasing Resident 119 ' s oxygen rate, Resident 119 ' s oxygen saturation level was around 86 % to 88% which raised a concern. RN 4 stated she rushed out of the room and called 911 and Physician 1. RN 4 stated when she returned to Resident 119 ' s room she started to perform a chest maneuver with Resident 119. RN 4 stated a chest maneuver was like a scrub. RN 4 stated when the 911 EMS arrived Resident 119 ' s oxygen saturation level was at 97%. RN 4 stated when she called 911 EMS, she also called an overhead page Code CPR or Code Blue. RN 4 stated she called the Code Blue at the time Resident 119 ' s oxygen saturation level was 86 to 88%. RN 4 stated Resident 119 ' s oxygen saturation was fluctuating and at that time the heart rate was also fluctuating it was not one value, 110 to 115 and 97 to 99 [beats/minute] and was just fluctuating in the high-low. RN 4 stated she could not recall if Resident 119 ' s heart rate went lower than 97 beats/minute. During the same interview on 5/23/2025 at 9:42 AM, RN 4 stated Resident 119 ' s appearance was Still the same, open eyes and open mouth, he [Resident 119] does not talk. RN 4 stated she performed the chest rub to Resident 119 because the heart rate and oxygen was going up and down. RN 4 stated she changed Resident 119 ' s nasal cannula to a mask. RN 4 stated the crash cart was always there, in front of Resident 119 ' s room and she just grabbed the mask and went inside resident ' s room. RN 4 stated she grabbed the mask with the bag (non-rebreather mask). RN 4 stated when she returned to Resident 119 ' s room she and LVN 8 tried moving and repositioning Resident 119. RN 4 stated that after placing the resident at 5liters of oxygen, she performed the Valsalva maneuver (a breathing technique that involves pinching your nose and breathing out forcefully with the mouth closed) because Resident 119 ' s Heart rate, blood pressure was getting low, and heart rate was going up, both fluctuating. The resident ' s oxygen was up and down. RN 4 stated that together with LVN 8, they were doing the Chest maneuver/compression. RN 4 demonstrated with her one hand how she performed the chest maneuver/compression in circulation motion to Resident 119 ' s chest area and further stated she was rubbing in a circular, gentle pressing around the [resident ' s] chest area. RN 4 stated she did not know what the exact medical term was with the procedure she performed. RN 4 stated when the 911 EMS arrived, the EMS performed their own care. RN 4 stated the 911 EMS pronounced Resident 119 dead at 8:23 PM. RN 4 stated RN 4, LVN 8, and Resident 119 ' s family were at bedside during that time. RN 4 stated she thought the other licensed nurses working that day were in Resident 119 ' s room when she was performing CPR but could not recall exactly who was in the room, but they were helping. RN 4 stated none of the other licensed nurses were involved during the code blue the whole time because they had their own residents. RN 4 stated she could not recall what everyone was doing during the CPR because it was crazy. During the same interview on 5/23/2025 at 10:37 AM, RN 4 stated she was sure LVN 8 was in Resident 119 ' s room and a certified nursing assistant (CNA) was outside the door. RN 4 stated the CNA provided resident ' s belongings during that time. RN 4 stated it did not take long for the 911 EMS to arrive from the time she called 911. RN 4 stated Resident 119 was still breathing before and when the 911 EMS arrived. RN 4 stated she took Resident 119 ' s vital signs and it was the last one she entered in Resident 1 ' s electronic records. RN 4 stated before the paramedics arrived, Resident 119 had a blood pressure and a pulse. RN 4 stated when the 911 EMS arrived Resident 119 was still alive. RN 4 stated the 911 EMS brought their equipment. RN 4 stated she stepped aside when the EMS came. RN 4 stated she did not see what the EMS did. During the same interview on 5/23/2025 at 10:45 AM, RN 4 stated she could not recall if LVN 8 notified her of Resident 119 ' s fluctuating blood pressure. RN 4 stated around 3 to 3:30 PM on 3/17/2025, Resident 119 ' s blood pressure was not fluctuating. RN 4 stated LVN 8 only notified her about Resident 119 ' s oxygen saturation at 90% around 8 PM. RN 4 stated there was nothing alarming between 3 PM to 8 PM. RN 4 stated if Resident 119 had a change of condition like blood pressure going high or going low, she would assess the resident first, if assessment was abnormal she would call 911 immediately and notify physician before calling the family. At 8 PM, RN 4 stated LVN 8 grabbed her and said, come and see the oxygen. RN 4 stated when she came to Resident 119 ' s room, that was when she saw Resident 119 ' s oxygen was 90%, so she went to grab her own pulse oximeter, and Resident 119 ' s oxygen saturation was even lower than 90 % and was 85 to 86 %. RN 4 stated that was when she rushed to the Nurses Station then went back to the resident ' s room and started performing the chest maneuver to Resident 119. During a concurrent interview and record review of Resident 119 ' s Change of Condition on 5/23/2025 at 10:52 AM, RN 4 stated CPR was initiated because she saw Resident 119 ' s oxygen and blood pressure was getting low. RN 4 stated she had already called 911. RN 4 stated CPR was cardiopulmonary resuscitation. RN 4 stated the nurse have to check if resident was full code, then check the pulse, you can start CPR if there is still a pulse. RN 4 demonstrated CPR and stated you interlock hands make sure you press 1 to 2 inches deep about 100 to 120 times per minute, on the chest around the apex of the heart and if you are comfortable you can give mouth to mouth and I did not give breaths. RN 4 stated Resident 119 was breathing, He [Resident 119] was breathing all through until the last minute. RN 4 stated she started chest compressions when the resident ' s oxygen was low at 85 to 86%. RN 4 stated She was doing both chest rub and chest compressions at the same time. RN 4 stated she and LVN 8 were doing both at the same time, alternating chest rub and chest compressions. RN 4 stated the chest rub worked better. RN 4 stated she checked Resident 119 ' s wrist for pulse and it was present. RN 4 stated Resident 119 was desatting [short term for desaturate [oxygen levels are dropping]) which was why she started chest compressions. RN 4 stated Resident 119 ' s pulse was very low, and she still performed chest compressions. RN 4 stated she did not give Resident 119 rescue breaths and that no one did rescue breaths because I was focusing on chest more. RN 4 stated after calling 911 everything was going down. RN 4 stated the paramedics arrived already. RN 4 stated the vital signs were not going low at that time like 90 something, that was the last thing i wrote down. RN 4 confirmed she did not document the abnormal findings and details about what happened when Resident 119 was found unresponsive. RN 4 stated there was no reason why she did not include Resident 119 ' s abnormal vital signs. RN 4 stated she did not document of PCC the abnormal vitals, it was important to include the abnormal findings on the note, for reference to compare. RN 4 stated the abnormal findings should be documented. During an interview on 5/23/2025 at 3:32 PM, the Director of Nursing (DON) stated if staff find a resident unresponsive, they must take vital signs right away, call for help (emergency) call code, and 911. The DON stated there should be a team around and the nurse should start delegating tasks to each staff member like checking resident ' s chart for POLST, notifying family, calling 911, and overhead page the code. The DON stated if staff should check if resident has a pulse and should palpate for a pulse. The DON stated there should be a Crash Cart as soon as the code is called, anyone like the CNAs could bring the crash cart to the resident's room. The DON stated the backboard should be ready to place underneath the resident and if resident has a low air loss mattress staff should deflate it. The DON stated someone should bring oxygen tank and Ambu bag. The DON stated staff should continue CPR if no pulse is found and should administer breaths as well. The DON stated giving breaths is not an option, the Ambu bag should be used. The DON stated staff should not stop CPR until paramedics are in the building. The DON stated chest sternal rub was not compressions. The DON stated the purpose of compressions was to have the heart pump the blood to get to the brain and organs, to stimulate the heart by manually pumping the heart. The DON stated an interruption or stop in compressions would interrupt blood flow to the heart and staff should continue CPR as long as resident has no pulse. During a concurrent interview and record review of Resident 119 ' s order summary on 5/23/2025 at 4:21 PM, the DON stated nurses should be following physician orders at all times because it was a part of resident ' s care. During a review of the facility ' s undated policy and procedure (P&P) titled Oxygen Administration indicated to administer oxygen as per physician orders. The P&P indicated the oxygen tubing should be changed weekly and as needed, including changing the mask, cannula, nebulizer (small machine that turns liquid medicine into a mist that can be easily inhaled) equipment. The P&P indicated when not in use, the oxygen tubing should be stored in a clean bag. The P&P indicated the date, time, and initials should be noted on oxygen equipment when it is initially used and when changed. The P&P indicated oxygen tubing should be used in a manner that prevents it from touching the floor. During a review of the facility ' s undated P&P titled Oximetry, Spot Checks indicated if oxygen saturation (SpO2) is at a critical level, the physician must be notified and nursing informed. During a review of the facility ' s undated P&P titled Emergency Procedure-Cardiopulmonary Resuscitation indicated if an individual is found unresponsive, briefly assess for abnormal or absence of breathing, if sudden cardiac arrest is likely begin CPR: (1) instruct a staff member to activate the emergency response syst[TRUNCATED]

Based on observation, interview, and record review, the facility failed to ensure five of five outdoor refuse containers (a waste container that a person controls that includes dumpsters, trash cans, garbage pails, and plastic trash bags) were closed with a tight-fitting lid and kept covered. This deficient practice had the potential to attract insects and harborage of pests in the refuse area that can cause a wide spread of diseases and affect the residents, staff, and visitors. Findings: During a concurrent observation and interview on 5/19/2025 at 9 AM, in the back driveway of the facility ' s parking lot, with Housekeeping (HK) 1, a total of seven (7) outdoor refuse containers were observed. HK 1 stated, the facility was sharing refuse containers with the facility next door, in which there were five (5) containers that belonged to the facility. HK 1 stated, HK 1 did not know which refuse containers belonged to the facility. During the same concurrent observation and interview, six outdoor refuse containers were observed overfilled with bags of trash. One of the six refuse containers was completely opened, and the other five containers could not close since the containers were overfilled. HK 1 stated, all of refuse containers were always overfilled so the lids of the refuse containers could not be fully closed. During a concurrent observation and interview on 5/9/2025 at 9:08 AM with HK 2, six outdoor refuse containers were observed overflowed with bags of trash. The refuse container was not closed. HK 2 stated she worked at the next-door nursing facility and threw the trash into any of the refuse containers. During a concurrent observation and interview on 5/19/2025 at 9:10 AM, with the Director of Maintenance (DM), the DM stated five of the refuse containers belonged to the facility, but there was no label or signs indicating which refuse container belonged to the facility. The DM stated the refuse containers were overfilled and the refuse container lids could not be closed. The DM stated the refuse containers could not be closed fully and tightly and stayed that way until the waste management company came to the facility around 2-3 PM that afternoon. The DM stated he was aware that the refuse containers were shared with the near by facility, and was the reason the refuse containers overflowed. The DM stated the issue of shared refuse containers was not addressed. The DM stated the lids of the refuse containers should be closed at all times to prevent infestation of insects and rodents, and to prevent illness to the residents, staff and visitors. During a review of the facility ' s policy and procedure (P&P) titled, Food-Related Garbage and Refuse Disposal, dated 10/2017, the P&P indicated all garbage and refuse containers are provided with tight-fitting lids or covers and must be kept covered when stored or not in continuous use and outside dumpsters provided by garbage pickup services will be kept closed and free of surrounding litter.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure two of three sampled residents (Resident 1 and 3) were free from accident hazards as possible by failing to provide monitoring, supervision, identifying hazards and assistance for two of three sampled residents (Resident 1 and 3) who were at risk for fall in accordance with the facility's policy and procedure. In addition for Resident 3 the facility failed to ensure the bed alarm (an alarm that turns on to alert the staff when the resident attempts to get off the bed) was in functioning condition. This deficient practice resulted in Resident 3's fall that caused facial contusion (bruise on your face that caused by fall or being hit on the face resulting in small blood vessels leak blood under the skin) and skin tear on the upper lip and for Resident 1 to have repeat falls that could result in injury and pain. Findings: 1. During a reviewed of Resident 1 ' s admission Record, indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), difficulty in walking, and osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage). During a review of Resident 1 ' s Minimum Data Set (MDS- a resident assessment tool) dated 12/5/24 indicated that Resident 1 was severely cognitively impaired (significant problems with a person's ability to think, learn, remember, use judgement, and make decisions). The MDS also 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) on sit to stand, chair to chair/bed-to-chair transfer, and toilet transfer. During a review of Resident 1 ' s Care Plan revised on 6/22/24 indicated that Resident 1 was at risk for falls because of severe cognitive impairment, arthritis, difficulty walking, poor safety awareness, and unsteady gait (abnormal walking pattern by a lack of stability and balance) The interventions included the resident will be frequently visualized monitored, place frequently used items within reach, place call light within reach. During a review of Resident 1's SBAR (Situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents) dated 1/5/25, indicated that Resident 1 was found on the floor by CNA 1 and sustained no acute injury. A review of the Fall Risk assessment dated [DATE] indicated Resident 1 was on high risk for fall due to intermittent (occasional) confusion, poor safety awareness, history of falls and elimination (bowel and bladder) status incontinent (no control) and unsteady gait ( unable to balance self when walking). During an interview on 3/12/25 at 12:10 pm with Licensed Vocational Nurse (LVN) 1, LVN 1 stated on 1/5/25 around 3:30 am, Certified Nurse Assistant (CNA)1 walked to the nursing station and informed her that Resident 1 fell on the floor. LVN 1 stated as she went to Resident 1 ' s room and Resident 1 was already in bed. LVN 1 stated, CNA 1 told her that she put Resident 1 back in bed first because she (CNA1) needed to take her break. LVN 1 stated CNA1 should have called me first and did not assist Resident 1 up from the floor prior to calling the nurse. During an interview on 3/12/25 at 2:15pm CNA 2 stated Resident 1 was impulsive (acting or done suddenly without any planning or consideration of the results), getting up multiple times during the day and would not call for help, CNA 2 stated she was not made aware by the charge nurses that Resident 1 was at risk for fall, and she was not aware of any intervention to implement to prevent the resident from falling. During an interview on 3/14/25 at 12:30pm with CNA1, CNA1 stated on 1/5/25 when Resident 1 fell, Resident 1 was sitting on the side edge of the bed and she observed Resident 1 fall with head leading to the floor. CNA1 stated she was sitting in the chair at the end of bed and but was not able to stop Resident 1 from falling and did not move her from the edge of the bed to prevent the fall. CNA1 stated after Resident 1 fell she assisted Resident 1 back to bed prior to calling the charge nurse to assess Resident 1's condition and for possible injuries. 2. During a reviewed of Resident 3 ' s admission Record, indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control), difficulty in walking, and muscle weakness. During a review of Resident 3 ' s Minimum Data Set (MDS- a resident assessment tool) dated 1/16/25 indicated that Resident 3 had severe cognitive impairment (significant problems with a person's ability to think, learn, remember, use judgement, and make decisions), The MDS also indicated that Resident 3 was dependent (Helper does all of the effort. Resident does none of the effort to complete the activity, or the assistance of two or more helpers is required for the resident to complete the activity) on rolling left and right, sitting to lying, lying to sitting on side of bed, chair/bed-to-chair transfer, and tub/shower transfer. During a review of Resident 3 ' s SBAR (Situation, Background, Assessment, and Recommendation, a structured communication tool used to facilitate clear and efficient communication, especially in healthcare) dated 3/10/25 timed at 6:30 pm, Resident 3 was found lying on the floor in the room with an injury noted at the inner part of the upper lip. Fall Risk assessment dated [DATE] indicated Resident 3 was on high risk for fall due to intermittent (occasional) confusion/poor safety awareness, history of fall, and unable to stand without assistance/unsteady gait/ poor sitting or standing balance. During an interview on 3/12/25 at 3:39 pm, with LVN 3, LVN 3 stated on 3/10/25 approximately 6:30 pm she was looking for CNA1 to assist Resident 3 back in bed, LVN 3 stated didn ' t see CNA 1 anywhere but when she saw CNA1 and to tell her Resident 3. LVN 3 stated when she entered Resident 3's room the resident was on the floor. LVN 3 stated sometimes she had hard time looking for CNA1 and she reported to the RN Supervisor that day. During an interview on 3/14/25 at 12:30 pm, with CNA1, CNA1 stated she remembered Resident 3 fell on 3/10/25, CNA1 stated she saw Resident 3 was on the floor near the commode, CNA1 stated she pulled commode to around 3 feet away from the bed because the resident kept getting up to try to use the commode which was 3 feet from bed. CNA 1 stated, Apparently she tried to use bathroom but the bed alarm was not working. I left the room and when I walked back by the room and I saw her on the floor, During an interview on 3/14/25 at 10:40 am with the Director of Staff Development (DSD), DSD stated she was responsible for new staffs training, ensuring CNAs job performance competency, and in-service to the staffs. CNA1 need more training on resident care and better understanding of her job. DSD stated she believed CNA1 needed more follow ups and deserved to be given an opportunity to improve that was why she continued to hire her to work overtime when there is a need for staffing. During an interview on 3/12/25 at 4:05 pm with the Administrator (ADM), the ADM stated many CNAs were fresh off school, the facility were giving more trainings to the new staffs. The ADM stated CNA1 was given last and final warning and anymore violation would result in termination at the moment. ADM stated was not aware of the fall incident of Resident 3 but will ask the DON for report and investigation right away. The ADM stated Resident 3's fall incident was not thoroughly invetigated to determine the cause and the interventions to implement to prevent a repeat fall. During a review of the facility ' s Policy and Procedure (P&P) titled Fall Risk Assessment dated 2/25/25, indicated the following: All residents will be assessed using the Fall risk assessment tool within 72 hours from admission and re-admission, then re-assessed quarterly or as needed. The assessment tool is found in the Point Click Care (PCC). If the total score is 10 or greater, the resident should be considered as High Risk for potential fall. A review of the facility's undated policy and procedure, titled Accident/Incident Prevention indicated the facility strives to prevent accidents by providing an environment that is free from accident hazards over which the facility has control, as well as identificaion of each resident at risk for accidents and incidents and the provision of adequate care plans which procedures to prevent accidents.

Based on observation, interview, and record review, the facility failed to ensure one of three Certified Nurse Assistant (CNA 1) demonstrate necessary competency skills necessary to care for residents assigned to CNA 1 as indicated in the residents plan of care. CNA 1 was assigned to work double shifts when the facility was aware that CNA1 ' s job performance demonstrated incompetency and received written warnings due to sleeping during work hours, taking long breaks than scheduled, leaves work without telling anyone in the facility and did not changed residents who found soiled or reposition in bed. This deficient practice had resulted in the residents not to received quality of care necessary to achieve their highest potential and result in a decline in the residents well-being. Cross reference F689 Findings: During a review of CNA1 ' s Employee File on 3/12/25 at 11:15 am with the Director of Staff Development (DSD), indicated CNA 1 ' s date of hire was 12/23/25. A Performance Correction Notice dated 3/3/25 indicated CNA1 was reported by a Registered Nurse (RN) Supervisor on 2/27/25 about not providing necessary care to her residents assigned to CNA1, who were found completely soiled. In addition, CNA1 was reported by charge nurse that CNA1 slept throughout the shift and had to awaken CNA1 to provide care. Additionally, CNA1 was found taking longer breaks than set schedule. During a review of CNA1 ' s Time Card for month of March 2025 and Staff Assignment Sheets, revealed on 3/8/25 CNA1 punched in to work the evening shift at 2:47 pm and punched out at 0:00 (midnight) and continued to work the night shift, then punched out on 3/9/25 at 7:01am. On the same day 3/9/25 at 2:46 pm, CNA1 punched in to work evening shift, then punched out at 0:00 (midnight) and continue to work the night shift, then punched out on 3/10/25 at 7:03am. On the same day 3/10/25 at 2:40 pm CNA1 punched in to work pm shift, then punched out at midnight, and continue to work the night shift, then punched out on 3/11/25 at 7:02 am. On the same day 3/11/25 at 3:01pm CNA1 punched in to work evening shift, then punched out at 11:02 pm ( a total of seven shifts in 4 days). During a review of the Nursing Staffing Assignment and Sign-in Sheet on 3/14/25 at 10:40 am with the DSD, indicated 3/8/25, 3/9/25, and 3/10/25 night shift one CNA called off. The DSD confirmed there was one CNA staffing shortage for the night shift. and CNA1 worked to cover the shortage. During an interview on 3/12/25 at 12:10 pm with LVN 1, LVN1 stated she filed a grievance on 1/5/25 she saw CNA1 was sleeping during work hours on many occasions and did not provide necessary care to her assigned residents that were found with soiled briefs and were not repositioned in bed, improperly responding to a resident ' s fall, and taking extended breaks than set schedule, and she was away from assigned unit during work. LVN 1 stated she did not remember how many times she told the supervisors about issues with CNA1. LVN 1 stated CNA1 hasn ' t improved in any way, which is really dangerous to the residents. During an interview on 3/14/25 at 12:30pm with CNA1, CNA1 stated she informed the charge nurse or relief CNA by saying I ' m going to break. CNA1 stated They (CN) didn ' t listen to me sometimes. They can ignore but I still had to go. I don ' t know about what residents ' safety can be affected but they should listen and understand that I need to take my break. Regarding working double shifts CNA1 stated she was not certain if the facility was short staffing but when there ' s someone called off, they asked everyone if someone would stay over. CNA1 stated she spontaneously offered herself, she felt she could do the job, and the facility did not say no. During an interview on 3/14/25 at 10:40am, the DSD stated they are in the process of hiring and they hire new staff every month. DSD stated the facility was not using staffs from the nursing agency (a service provider agency which provides nurses and healthcare assistants)anymore, and because the facility needed nursing staff on the floor to cover staffing shortage. DSD stated, the facility did not reject when CNA1 offered to help work extra shift. The DSD stated she monitors CNA1 ' s performance by inquiring feedback from charge nurses. The DSD thought CNA1 deserves an opportunity to improve. The DSD did not respond to the surveyor ' s questions when asked if the facility allows staff who already received warning about their poor performance to continued work residents. During a review of the facility ' s Policy and Procedure (P&P) titled Staffing: Sufficient, Competent Nursing dated Year 2001, the P&P indicated the facility will provide sufficient number of nursing staff with the appropriate skills and competency necessary to provide nursing and related care services for all residents in accordance with resident care plans and the facility assessment. The facility defines a Competent Staff: 1. Competency is a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully. 2. All nursing staff must meet the specific competency requirements of their respective licensure and certification requirements defined by state law.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility failed to meet professional standards of quality (care and services are provided according to accepted standards of clinical practice) for one of one sample residents (Resident 27) by failure to apply gentle pressure to the lacrimal duct (a small tube that drains tear from the eyes) to prevent systemic absorption of the medication (medications are absorbed into the whole of an organism, rather than applied to one area.) of Carboxymethylcellulose sodium (medication is used to relieve dry, irritated eyes) ophthalmic (eye). This deficient practice had the potential for the resident to have an adverse reaction (an undesired harmful effect resulting from a medication). Findings, A review of Resident 27's admission Record indicated Resident 27 was admitted to the facility on [DATE], with diagnoses that included Alzheimer's disease (a progressive brain disorder that disables a person from performing everyday activities) and hyperlipidemia (a condition in which there are high levels of fat particles (lipids) in the blood). A review of the Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 2/27/24, indicated Resident 27 had severely impaired cognitive skills (mental action or process of acquiring knowledge and understanding) in decision making. The MDS indicated Resident 27 required partial/moderate assistance (helper does less than half the effort) with toileting hygiene and shower/bathe self. A review of the History and Physical Examination (H&P) dated 9/27/23, indicated Resident 27 does not have the capacity to understand and make decisions. A review of Resident 27's Order Summary Report (a summary of all currently active physician orders), dated 5/23/24, indicated a physician's order to administer Carboxymethylcellulose sodium ophthalmic solution to instill one drop in both eyes four times a day for dry eyes. During a record review of Resident 27's MAR for May 2024, indicated Resident 27 was scheduled to receive Carboxymethylcellulose sodium) ophthalmic everyday at 9AM. During a medication pass (Med Pass) observation on 5/23/24 at 9:49 AM, Licensed Vocational Nurse (LVN 2) prepared the Carboxymethylcellulose sodium ophthalmic solution to administer to Resident 27. During the same Med Pass observation, on 5/23/24 at 9:49 AM, LVN 2 was observed washing hands and donning (putting on) gloves and administering Carboxymethylcellulose sodium ophthalmic solution to both eyes by having Resident 27 tilt her head back, pull down the lower lid, and administered one drop to each eye. LVN 2 wiped excess meds from eyes with two separated tissues. LVN 2 did not place one finger at the corner of the eye near the nose and apply gentle pressure to the lacrimal duct area to prevent the medication from draining away from the eye. LVN 2 removed gloves and washed hands. After administration of the eye drop medication, LVN 2 documented on the Medication Administration Record (MAR). During an interview with LVN 2 on 5/23/24 at 10:13 AM, LVN 2 stated she was not aware of the need to apply pressure to lacrimal duct to prevent systemic absorption of medication. LVN 2 was observed searching web site, Webmed.com for reference on the laptop which was placed on top of the med cart. LVN 2 then stated she should place one finger at the corner of the eye and apply gentle pressure to prevent the medication from draining away from the eye. During an interview with the Director of Nursing (DON) on 5/25/25 at 3:12 PM, the DON stated LVN 2 should gently press the finger to the inside corner of the eye for about one minute to keep the liquid from draining into the tear duct. The DON stated LVN 2 should read the instruction on the product package carefully before administering the eye drop. Reference: https://www.webmd.com/drugs/2/drug-18521/carboxymethylcellulose-sodium-ophthalmic-eye/details To apply eye ointment/drops/gels: Tilt your head back, look up, and pull down the lower eyelid to make a pouch. For drops/gels, place the dropper directly over the eye and squeeze out 1 or 2 drops as needed. Look down and gently close your eye for 1 or 2 minutes. Place one finger at the corner of the eye near the nose and apply gentle pressure. This will prevent the medication from draining away from the eye.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the facility ' s nurses were competent in ensuring their residents' low air loss mattress (LALM, a mattress that designed to distribute the body weight over a broad surface area and help prevent skin breakdown) were maintained with the correct setting based on residents weight. This failure had a potential to result in the resident's to develop pressure ulcer or worsened pressure ulcer (a skin injury due to prolonged unrelieved pressure or being in one position for a long time). Findings: A review of Resident 35's admission Record indicated Resident 35 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis that included type 2 diabetes mellitus (a disease that occurs when the body ' s blood sugar is too high) with hyperglycemia (high blood sugar), dementia (a loss of brain function that occurs with certain diseases that affects one or more brain functions such as memory, thinking, language, judgment, or behavior), and left-hand contracture (disorder in which a skeletal muscle is permanently tightened). A review of Resident 35's Care plan, revised on 5/14/24, indicated Resident 35 was at risk for developing pressure sore and other type of skin breakdown related to sacrum (a thick, triangular bone situated near the lower end of the spinal column) scar issue, reduced mobility, impaired cognition, fragile skin, poor/variable food intake, diabetes, aging, and incontinence with the goal was to minimize the risk of skin breakdown/bruising/pressure sore daily and the interventions included to use pressure relieving devices as needed. A review of Resident 35's Order Summary Report, dated 7/29/23, indicated Resident 35 had a physician order for LALM for skin maintenance. During an observation on 5/21/24 at 8:50 AM in Resident 35's room, Resident 35's LALM's setting was observed at 80 pounds (lbs- unit of weight) During an observation on 5/21/24 at 12:40 PM in Resident 35's room, Resident 35 was observed lying on LALM with the setting at 120 lbs. During an interview on 5/21/24 at 12:45 PM with the Minimum Data Set Nurse (MDSN), the MDSN stated, the LALM's setting was supposed to be set based on the weight of the resident. The MDSN stated, the LALM's setting options on the machine was 40 lbs apart. The MDSN stated, the resident's LALM should be set to lower limit based on the resident weight. The MDSN stated, he did his facility rounds (touring the facility unit) in the morning and found at least four residents with the wrong LALM settings, so he adjusted them according to the residents' weight. The MDSN stated, Resident 35's most recent weight was 134 lbs, so he adjusted the LALM's setting from 80 lbs to 120 lbs. The MDSN stated, LALM was utilized for residents with identified high risk for skin breakdown, and pressure injury. The MDSN stated, if the bed setting was incorrect, it would not maximize the effectiveness of the LALM to prevent skin breakdown. During an interview on 5/21/24 at 3:50 PM with Licensed Vocational Nurse (LVN) 3, LVN 3 stated, the LALM's setting was based on the weight of the residents. LVN 3 stated, she would set the LALM to the closet to the resident's weight closest one. LVN 3 stated, she could not recall if there was any in-service for LALM. LVN 3 stated she had not seen the policy for the LALM. LVN 3 stated, all licensed nurses can change the LALM's setting. During an interview on 5/21/24 at 3:55 PM with LVN 4, LVN 4 stated, she did not know how to set the LALM and could not recall if there was any training given. LVN 4 stated, she did not check the resident's LALM setting because it was the responsibility of the treatment nurse. During an interview on 5/21/24 at 4 PM with LVN 5, LVN 5 stated, she would set the LALM to the upper limit based on the resident's weight. LVN 5 stated, she could not remember when the in-service for LALM was and believed that the facility had never addressed how to correctly set the mattress. During an interview on 5/21/24 at 4:06 PM with the Director of Staff Development (DSD), the DSD stated, the LALM's setting should not be set close to resident's weight, the higher limit setting can could cause the resident to sink while lying in bed. The DSD stated, for example, if the resident weighted 130 lbs, the setting should be set up to 160 lbs instead of lower down to 120 lbs. The DSD stated all LVNs were responsible to check the LALM's setting and not just the treatment nurse to make sure they were set correctly which is part of their round with the residents. During an interview on 5/21/24 at 4:16 PM with the Treatment Nurse (TN), the TN stated, she always checked the resident's LALM setting and would adjust it as needed if the setting was incorrect because incorrect setting could lower the effectiveness of preventing skin breakdown and further worsen of the resident ' s pressure wounds. The TN stated, the setting should be adjusted to the lower limit according to the resident's weight. The TN stated, if the resident weighted 130 lbs, the setting should be set to 120 lbs, not 160 lbs. During an observation on 5/22/24 at 11:49 AM in Resident 35's room, Resident 35 who weight 134 lbs. was observed lying on the LALM with the setting of 160 lbs. During an interview on 5/23/24 at 10:57 AM with the Quality Assurance Consultant (QAC), the QAC stated, the facility just recently changed the LALM company, and the device had a different setting than the old device that the facility staffs were more familiar using. The QAC stated, the product's manual did not specify how to adjust the LALM ' s setting. The QAC stated, she just spoke to the company's specialist and was provided with guidance that the setting should be close to the resident's actual weight. The QAC stated, for example, if the resident's actual weight was 130 lbs, the LALM was supposed to be set at 120 lbs. During an interview on 5/24/24 at 12:14 PM with the Director of Nurses (DON), the DON stated, the LALM setting guidance should be verified and provided with LALM in-service prior to the new products rolled out so that all staff were aware and received the same guidelines. The DON stated, LALM was for skin integrity maintenance, helped to heal the wound, and prevent skin breakdown. The DON stated, the LALM should be set as guidelines to support skin healing to serve the purpose of it. The DON stated, if not set correctly as directed, the resident's wound could decline, prolong healing and get worse. A review of the facility's Policy and Procedure titled Pressure-Reducing mattresses, undated, indicated pressure-reducing mattress was used to prevent and/or minimize pressure on the skin and to provide comfort if resident prefers.

Based on observation, interview and record review, the facility failed to ensure safe provision of pharmaceutical services when one (1) of seven (7) medication cart was left unlocked before entering a resident's room to administer medications. This deficient practice had the potential for non-authorized staff or residents to access the medication cart, which can result to diversion or if the medications were ingested, may cause serious injury/harm. Findings: During a medication pass observation on 5/23/24 at 10:01 AM, the Licensed Vocational Nurse 2 (LVN) did not lock the medication cart before going to Room A to administer medications. Two (2) staff were observed standing across the room in the hallway, where the opened medication cart was located. One resident was observed walking and passing by in front of the unlocked medication cart. During an interview on 5/23/24 at 10:03 AM, LVN 2 stated she forgot to lock the medication cart before entering Room ' s room and stated the cart always had to be locked because the residents might access and take medications in the cart. LVN 2 also stated the cart had to be locked for the safety of the residents. During an interview on 5/23/24 at 2:32 PM, the Director of Nursing (DON) stated the medication nurse had to lock the medication cart for safety reasons because anybody can access the medications in the cart if left unlocked. The DON also stated, Medication cart is to be always locked unless it is in use. A review of the facility's policy and procedure titled, Preparation and General Guidelines, dated October 2017, indicated that during administration of medications, the medications carts is kept closed, locked and secure. The medication cart needs to be secured and locked when unattended.

**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 and facility's protocol titled Enteral Feedings ( also known as Gastrostomy tube [GI] feeding, a tubing inserted into the stomach used to deliver fluids, liquid nutrition and medications into the stomach or small intestine) to one of three sampled residents (Resident 6), who was found with GT feeding on the floor on 5/22/24. This failure had a potential to result in a risk of contracting infections, which could lead to a decline in the resident's health. Findings: A review of Resident 6's admission Record indicated Resident 6 was admitted to the facility on [DATE] with diagnosis that included hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time) with heart failure (a condition that develops when the heart doesn't pump enough blood for the body's needs), gastrostomy (a surgical procedure used to insert a tube, often referred to as a G-tube, through the abdomen and into the stomach) muscle weakness, and dementia (a loss of brain function that affects memory, thinking, language, judgment, or behavior). A review of Resident 6's Minimum Data Set (MDS- a comprehensive assessment and care screening tool) dated 10/19/23 indicated, Resident 6's cognitive skills for daily decision making was severely impairment (difficulty with or unable to make decisions, learn, remember things), and was dependent (Helper does all of the effort. Resident does none of the effort to complete the activity) in eating, oral and personal hygiene. A review of Resident 6's Order Summary Report, dated 8/15/23 and continued on 5/24/24 indicated Resident 6 had enteral feed physician order for Glucerna 1.2 (a type of tube feeding formula) via feeding pump to turn on at 12 PM and turn off at 8 AM or until dose completed. During a review of Resident 6's Care Plan (a document that outlines the facility ' s plan to provide personalized care to a resident based on the resident ' s needs), revised 5/17/21 indicated Resident 6 was receiving GT feeding and was at risk for infection. The record indicated the interventions included to change tubing per policy or as ordered. During a review of Resident 6's Care Plan, revised 11/30/23 indicated Resident 6 was at risk for infection. To prevent infection the facility's interventions included cleaning and disinfection of equipment as indicated, and provide standard precaution at all times. During an observation on 5/22/24 at 10 AM and again at 12 PM in Resident 6's room, Resident 6's tube feeding was on the floor with an uncovered port/tip on the floor while attached to a feeding pump machine that was off. During an observation on 5/22/24 at 12:15 PM in Resident 6's room, Certified Nurse Assistant (CNA) 3 and CNA 5 were observed assisting Resident 6 to reposition in bed, then CNA 5 was observed picking up Resident 6's GT with uncovered port from the floor and reconnected the GT port to Resident 6's GT port that was connected to Resident 6's GT site. Then CNA 5 covered the GT feeding tube connected to the resident with a towel. During an observation on 5/22/24 at 12:23 PM outside Resident 6's room, Registered Nurse (RN) 2 was observed being called by CNA 3 to Resident 6's room and informed RN 2 that Resident 6's GT feeding pump machine was turned on. During an interview on 5/22/24 at 12:25 PM with CNA 5, CNA 5 stated, she found the GT feeding port on the floor and thought it was disconnected from the feeding port, so she picked it up, left the GT tube close to Resident 6's GT port, then covered them with a towel. CNA 5 stated, she called RN 2 to restart the tube feeding because the machine was off. During an interview on 5/22/24 at 12:35 PM with RN 2, RN 2 stated, RN 2 was told by CNA 3 that the feeding port was leaking so she came in assess the GT feeding site. RN 2 stated the GT feeding connector was a little loose so she tightened it up and restarted the GT feeding. RN 2 stated, Resident 6 had a physician order to have feeding turn off at 8 AM and turn on at 12 PM. RN 2 stated, when the GT feeding was not in use, the GT supposed to either still connect to the feeding port from the resident's GT site in the stomach or covered by a clean bag and hang on the GT feeding pump pole to prevent infection. RN 2 stated, if the GT feeding accidentally dropped on the floor, the tube feeding must be changed due to infection issues. RN 2 stated, she did not know that the tube feeding was on the floor, so she just continued with the same tube that was hanging when she came in Resident 6 ' s room. During an interview on 5/24/24 at 9:20 AM with Infection Prevention Nurse (IPN), the IPN stated, when the GT feeding was found on the floor, CNA 5 supposed to let RN 2 know because they needed to change the whole GT feeding system from the formula bottle to the water bag and the feeding tube. The IPN stated, when the GT feeding touched the floor and we did not know how long it had been on the ground, it was already contaminated. The IPN stated, the resident could contract infection, and her health could decline because of the infection. The IPN stated, the old tube feeding that was touching the floor supposed to be disposed. During an interview on 5/24/24 at 12:27 PM with the Director of Nurses (DON), the DON stated, the CNA that found the tube feeding on the floor supposed to notify the Charge Nurse right away to have the tube feeding system changed. The DON stated, the resident could be at risk for infection and ended up in the acute hospital. A review of the facility ' s policy and procedure (P&P) titled, Enteral Feedings, revised March 2023, indicated the following: -Preventing contamination: Maintain aseptic technique at all times when working with enteral nutrition systems and formulas - use closed enteral nutrition systems when possible. -Change administration sets if there is a damage or is contaminated. A review of the facility ' s P&P titled, Infection Control, undated, indicated the facility had established and would maintain an infection control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission od disease and infection

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide and maintain a functioning call light for one of 21 sampled residents (Resident 103) This deficient practice had the potential to result in a delay in meeting the resident ' s needs for assistance and had the potential to lead to accidental falls/accidents. Findings: During an initiated tour on 5/21/24 at 10:35 AM, call lights were randomly checked in Unit Station 1. Resident 103 was residing in Station 1 and her call light in the bathroom was not functioning properly, the metal switch was rusted and loose and could not be activated with the pulling cord. A review of Resident 103 ' s admission Record indicated the resident was originally admitted to the facility on [DATE] and re-admitted to the facility on [DATE], with diagnoses that included type 2 diabetes mellitus (a medication condition characterized by the body ' s inability to regulate blood sugar level) and history of fall. A review of Resident 103 ' s Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 2/27/24, indicated Resident 103 was cognitive skill (mental action or process of acquiring knowledge and understanding for daily decision-making) was moderately impaired. Resident 103 required partial/moderate assistance (helper does less than half the effort) with toileting hygiene, shower/bathe self, and lower body dressing. During a concurrent observation and interview with Resident 103 on 5/21/24 at 10:35 AM, Resident 103 stated she did not know the call light in the bathroom was not working. The Resident 103 stated she did not feel safe to go in the bathroom knowing the call light was not working. During a concurrent interview with Certified Nursing Assistant 1 (CNA) and observation in Resident 103 ' s room on 5/21/24 at 10:37 AM, the CNA 1 activated Resident 103 ' s call light in the bathroom and confirmed the call light was not working due to rust and loosened call light switch. CNA 1 stated Resident 103 could not use the call light to call for help when in the bathroom. CNA 1 stated she will report the problem to Maintenance Supervisor (MS). During a concurrent interview with MS and observation on 5/21/24 at 11:10 AM, the MS stated he performed monthly call light checks for the whole facility. The MS stated he relied on communication between nursing staff and the maintenance department to let him know what was broken and this was not being reported. During an interview with Administrator (Adm) on 5/23/24 at 4:34 PM, the Adm stated the MS was supposed to make sure that the call light was functional, performed monthly checks, and performed maintenance when problems are reported. The Adm stated the call light is vital communication tool for residents to ask for assistance from the bathroom to avoid fall and injury. A review of facility ' s undated policy and procedure titled, Physical Environment Policy, indicated the facility will ensure that physical environment is free from hazard for maximum safety of residents, visitors, and staff. The policy also indicated that maintain all essential mechanical, electronical and patient care equipment in safe operation condition such as scales, mechanical lifts, beds, bedrails, wheel locks, bed cranks, nightstand, dressers, closets, overbed table, shower curtains, wheelchairs, Geri chairs (a large, padded chair that is designed to help seniors with limited mobility.), and call light.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A review of Resident 98's admission Record indicated Resident 98 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis that included muscle weakness, abnormalities of gait and mobility, blindness of left eye, dementia (a loss of brain function that affects memory, thinking, language, judgment, or behavior), anemia, and Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks.) A review of Resident 98's MDS, dated [DATE] indicated, Resident 98's cognitive skills for daily decision making was moderately impaired and needed partial/moderate assistance (helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) for oral hygiene (the ability to use suitable items to lean teeth) and personal hygiene (the ability to maintain personal hygiene, including combing hair, washing/drying face and hands). A review of Resident 98's Care Plan, revised 2/14/244 indicated Resident 98 was at risk for having needs unmet related to difficulty in communication secondary to language barrier due to resident communicates in a foreign language. To ensure Resident 98 communicates his needs appropriately daily, the facility care plan interventions included the use of communication board as needed. During a concurrent observation and interview on 5/21/24 at 8:53 AM with Resident 98, Resident 98's teeth was observed with red gums and food sticking close to the gum line. Resident 98's bedside table and drawer was observed with no oral care kit. Resident 98 stated, since admission, he had never had any teeth cleaning after meals. Resident 98 stated, he had been always very uncomfortable with the uncleanliness of his teeth. Resident 98 stated, the staff had never offered or assisted him to brush his teeth and never brought any toothbrush or toothpaste to him. During an interview on 5/24/24 at 10:05 AM with CNA 4, CNA 4 stated, Resident 98 had been refusing oral care when she was assigned to him. During an observation on 5/24/24 at 10:10 AM in Resident 98's room, CNA 4 was observed asking Resident 98 in a language that the resident did not understand, if he wanted oral care. Resident 98 was observed shaking his head and said No. CNA 4 stated, Resident 98 had been refusing his oral care by saying No. During an interview on 5/24/24 at 10:11 AM with Resident 98, when asked why he said No, Resident 98 stated, he said No because he did not understand what CNA 4 was saying because it was not in a language that he could understand. During an interview on 5/24/24 at 10:13 AM with CNA 4, CNA 4 stated, Resident 98 had communication barrier and would only understand in his preferred language. CNA 4 stated, she should have asked a staff member to translate instead of speaking to Resident 98 in the language that he did not understand. CNA 4 stated, she usually used a communication board with pictures written in Resident 98's preferred language since admission so that he would understand. During a concurrent observation and interview on 5/24/24 at 10:15 AM in Resident 98's room, CNA 4 was observed demonstrating how she had been communicating with Resident 98 by using a communication board. CNA 4 was observed pointing at a picture, which CNA 4 stated was meant for oral care. Resident 98 stated he did not understand anything because the language written in the communication board was not his preferred language. Resident 98 stated, CNA 4 did not use the correct communication board, so he had been confused, and did not realize that he had been missing his oral care because of saying No, which he meant I don't understand. During an interview on 5/24/24 at 10:26 AM with the DON, the DON stated, CNA 4 supposed to use the right communication board with the correct language. The DON stated failure to make sure the resident understand could lead to not meeting the resident's needs, the resident could be frustrated, angry and could cause a noncompliant with care and a decline in resident's health. 3. During a review of Resident 7's admission Record indicated the facility originally admitted Resident 7 on 9/12/13 and readmitted on [DATE] with diagnoses that included dementia (a general term to describe a group of symptoms related to loss of memory and judgment) and anemia (a condition in which the body does not have enough healthy red blood cells. Red blood cells provide oxygen to body parts). During a review of Resident 7's Care Plan (CP), indicated the resident was at risk for falls/injury, revised on 7/29/23, the CP indicated the goal was to reduce risk of falls & injury daily, and the interventions included the facility will keep call light within easy reach to get assistance. During a review of Resident 7's MDS, dated [DATE], indicated Resident 7 had severely impaired memory and cognition. Resident 7 was dependent with eating, oral hygiene, toileting hygiene, shower/bathe self, and personal hygiene. During a concurrent observation in Resident 7's room and interview on 5/23/24, at 11:45 AM, with CNA 4, Resident 7 was lying on the bed with head of bed elevated at 30 degrees angle. Resident 7's call light was on the floor on the left side of the bed. CNA 4 stated Resident 7 could not move by herself, and the call light was on the floor out of Resident 7's reach. CNA 4 stated the call light should be within the residents reach at all times so that they could call for assistance when needed and to ensure resident's safety. During an interview on 5/24/24 at 12:35 PM, with the Administrator (ADM), the ADM stated it was important to keep call light within residents' reach, so they could call for assistance for their needs and in case of emergency. The AMD stated call light should be within reach for resident's safety. During a review of the updated facility's policy and procedure titled, Call Lights, indicated Ensure that the call light is within the resident's reach when in his/her room or when on the toilet. A review of the facility's Policy and Procedure titled Accommodation of Needs Related to Communication Deficits, undated, indicated Communication needs will be identified and appropriate interventions including care planning, will be developed in order to accommodate the needs of the resident. The policy also indicated that the communication needs will be assessed as follows: a. Resident identifying - Language spoken. b. Rehabilitation screening - modes of expression, c. Communication section on Social Service Progress Notes. d. Care plan will be developed, updated quarterly and as indicated to reflect accurate, current assessment related to communication needs. Based on observation, interview, and record review the facility failed to promote the resident's right to receive services in the facility with reasonable accommodation of resident needs and preferences for three of three residents (Resident 88, 7 and 98) by failing to: 1. Accommodate Resident 88's needs by not providing a communication board (a sheet of symbols, pictures or photos that residents will learn to point to, to communicate with those around them) for the resident to effectively communcate her needs. 2. For Resident 98, who spoke and preferred to communicate in his native foreign language was not provided a communication board to be used to communicate with the facility staffs. This failure resulted in violation of the residents rights to communciate their needs, and cause confusion and miscommunication such as Resident 88 not receiving oral care. The deficient practice can also result in a decline in psychosocial being. 3 Ensure Resident 7's call light (a device used by residents to signal his or her needs for assistance) was within reach for one or three sampled residents (Resident 7). This deficient practice had the potential for Resident 7 not able to call the facility staff to ask for help or receive assistance specially during emergency. Findings: 1. A review of Resident 88's admission record indicated resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with history of falling and hypertension (having high blood pressure). A review of Resident 88's Minimum Data Set (MDS - a comprehensive standardized assessment and screening tool), dated 5/14/24, indicated Resident 88 has severe cognitive (mental action or process of acquiring knowledge and understanding for daily decision-making) impairment. The MDS indicated Resident 88 required partial/moderate assistance (helper does less than half the effort) on staff for shower/bath self and required supervision or touching assistance (helper provides verbal cues, touching and/or contact guard assistance) on toilet hygiene, and personal hygiene. A review of the Resident 88's History and Physical Examination (H&P) dated 8/16/23, indicated Resident 88 does not have the capacity to understand and make decisions. During the initial tour on 5/21/24 10:17 AM, Resident 88 was observed in bed. Resident 88 was speaking in a language, not the dominant language in the facility, Resident 88 stated, I am hungry, I want a bowl of rice. Resident 88 repeated the same statement four times. A Certified Nursing Assistant 1 (CNA) was observed responded to Resident 88 in English and stated, You're ok now. During a concurrent interview with Resident 88 and CNA 2 (translated for Resident 88) on 5/21/24 at 10:22 AM, Resident 88 stated she did not have a communication board. Resident 88 stated that she communicated with staff by pointing at the pictures printed on the communication board. During a concurrent interview with CNA 1 on 5/21/24 at 10:23 PM, CNA 1 stated Resident 88 does not speak English and should have a communication board in the drawer that was accessible for resident. CNA 1 stated she could not find the communication board in the drawer. CNA 1 stated she did not know what the Resident 88 said earlier as a result she was not able to provide Resident 88 needs. During an interview with Director of Nursing (DON), on 5/24/24 at 2:12 PM, the DON stated that the facility should provide a communication board for residents whose primary language is not the dominant language in the facility-English or resident will not be able to communicate needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents' medical records were updated to indicate documentation that advance directives (AD-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) were discussed and the written information were provided to the residents and/or responsible parties for four of the five sampled residents (Resident 7, 113, 107, and 39). These deficient practices violated the residents' and/or the representatives' right to be fully informed of the option to formulate their advance directives (AD) and had the potential to cause conflict with the residents' wishes regarding health care. 2. the facility failed to ensure that AD and Physician Orders for Life-Sustaining Treatment (POLST-a form that gives seriously-ill patients more control over their end-of-life care) were current and part of Resident 39's clinical records. This deficient practice had the potential for the resident to receive inaccurate care and/or treatment in regard to life-sustaining treatment especially in an event of emergency. Findings, 1. During a review of Resident 7's admission Record indicated the facility originally admitted Resident 7 on [DATE] and readmitted on [DATE] with diagnoses that included dementia (a general term to describe a group of symptoms related to loss of memory and judgment) and anemia (a condition in which the body does not have enough healthy red blood cells. Red blood cells provide oxygen to body pars). During a review of Resident 7's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated [DATE], indicated Resident 7 had severely impaired memory and cognition (ability to think and reason). Resident 7 was dependent with eating, oral hygiene, toileting hygiene, shower/bathe self, and personal hygiene. During a concurrent interview and record review on [DATE] at 9:40 AM, with Registered Nurse (RN) 2, Resident 7's clinical chart was reviewed, RN 2 stated the Advance Directive Acknowledgement (ADA) form in Resident 7's clinical chart was blank. RN 2 stated Resident 7 ' s ADA form should be signed and kept in the resident's clinical chart to ensure the resident and the responsible party (RP) being informed about their right and making the informed decision regarding her care. During a concurrent interview and record review on [DATE] at 9:52 AM, with RN 2, Resident 7's signed ADA form, dated [DATE], was reviewed. RN 2 stated the facility staff removed the signed ADA form from Resident 7's clinical chart and stored it in the overflow chart which was not immediate accessible to the facility staff to review during the emergency. 3. During a review of Resident 113's admission Record indicated the facility admitted Resident 113 on [DATE] with diagnoses that included paraplegia (a condition in which a person can not deliberately control or move the legs) and hyperlipidemia (an elevated level of lipids [fat particles] in the blood). During a review of Resident 113's History and Physical (H&P), dated [DATE], indicated Resident 113 has the capacity to understand and make decisions. During a review of Resident 113's MDS, dated [DATE], indicated Resident 113 had intact memory and cognition (ability to think and reason). Resident 113 required setup or clean-up assistance with eating and oral hygiene, partial/moderate assistance with toileting hygiene, shower/bathe self, and personal hygiene, and was dependent with sit to lying, sit to stand, chair/bed-to-chair transfer and toilet transfer. During a concurrent interview and record review on [DATE] at 9:42 AM, with RN 2, Resident 113's clinical chart was reviewed, RN 2 stated there was no ADA form in Resident 113's clinical chart. RN 2 stated she would not know if Resident 113 and his RP were provided with the information regarding their right to formulate the Advance Directive when the facility admitted the resident. RN 2 stated ADA form should be signed and kept in the resident ' s clinical chart. 4. During a review of Resident 107's admission Record indicated the facility admitted Resident 107 on [DATE] with diagnoses that included encephalopathy (a disorder of brain function that often impairs consciousness) and hyperlipidemia (an elevated level of lipids [fat particles] in the blood). During a review of Resident 107's H&P, dated [DATE], indicated Resident 107 does not have the capacity to understand and make decisions. During a review of Resident 107's MDS, dated [DATE], indicated Resident 107 had severely impaired memory and cognition (ability to think and reason). Resident 107 was dependent with oral hygiene, toileting hygiene, shower/bathe self, personal hygiene, sit to lying, sit to stand, and tub/shoer transfer. During a concurrent interview and record review on [DATE] at 9:30 AM, with RN 1, Resident 107's clinical chart was reviewed, RN 1 stated there was no ADA form in Resident 107 ' s clinical chart and she did not know if the resident and RP was informed about her right to formulate the AD and the staff would know what the resident and the RP's decision regarding her care during emergency. RN 1 stated when the facility admitted a resident, the licensed nurses and the social workers would provide three forms including the Physician Order for Life-Sustaining Treatment (POLST), the ADA, and the surrogate decision-making form to the resident and RPs. RN 1 stated the contents and the purposes of these three forms were the same. During an interview on [DATE] at 12:34 PM with the Administrator (ADM), the ADM stated residents and their RPs should be informed about their rights to formulate the ADs. The ADM stated the signed ADA form should be kept in the resident's clinical chart and be assessable for review. During a review of the facility's policy and procedure titled, Advance Directives for Care, dated on [DATE], indicated residents and their families are informed regarding advance directive. 2. A review of Resident 39's admission Record indicated the resident was initially admitted on [DATE] and readmitted to the facility on [DATE], with diagnosis that included chronic obstructive pulmonary disease (COPD-a group of lung diseases that block airflow and make it difficult to breathe) and type 2 diabetes mellitus (a medication condition characterized by the body ' s inability to regulate blood sugar level). A review of Resident 39's MDS, dated [DATE], indicated Resident cognitive skill (mental action or process of acquiring knowledge and understanding for daily decision-making) was moderately impaired. The MDS indicated Resident 39 was bed bound and required total dependent (helper does all of the effort) on staff for eating, oral hygiene, and toilet hygiene. During an interview and record review with the Registered Nurse (RN) 1, on [DATE] at 1:59 PM, the RN 1 stated that Resident 39 had the AD and POLST, but they were not in the resident's chart at this time. The RN 1 stated the AD and POLST must be put in the resident's clinical chart in order for a nurse to be able to act in accordance with resident ' s will of treatment decision and end of life issues. A review of the Resident 39's H&P, dated [DATE] and interview with Social Service Director (SSD), on [DATE] at 2:03 PM, the H&P's Advance Directive Executed section, a check mark was placed on No, The SSD stated Resident 39's H&P needed to be updated because Resident 39 had AD and POLST. The SSD stated that AD and POLST were not in the resident's chart and should be. The SSD also stated that she was responsible for ensuring resident's POLST and AD's and/or services to obtain POLST and ADs were provided upon admission to the facility. A review of Resident 39's Order Summary Report (a summary of all currently active physician orders), dated [DATE], indicated Resident 39 had an AD with full code (full support which includes cardiopulmonary resuscitation {CPR}, if the patient has no heartbeat and is not breathing) treatment. A review of the facility policy and procedure titled, Advance Directive Care, revised dated [DATE], indicted if the resident elects to sign an advance directive, a copy is placed in the resident ' s medical record. All staff are advised of the document and shown the document at the time of the first visit with the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the comprehensive Minimum Data Sets (MDS - a comprehensive standardized assessment and screening tool) were completed within the required time frame for four of four sampled residents (Resident 70, 54, 4, and 100). This deficient practice had the potential to negatively affect the provision of necessary care and services for Resident 70, 54, 4, and 100. Findings: 1. During a review of Resident 70's admission Record indicated the facility admitted Resident 70 with diagnoses that included dementia (a general term to describe a group of symptoms related to loss of memory and judgment) and hyperlipidemia (an elevated level of lipids [fat particles] in the blood). During a concurrent interview and record review on 5/23/24 at 10:20 AM, with the MDS Nurse (MDSN), Resident 70's MDS-Nursing Home Comprehensive Item set, dated 4/2/24, and the Final Validation Report (a log that the facility submitted to the MDS data base each day), dated 5/16/24, were reviewed. The MDSN stated the target date for Resident 70's annual comprehensive MDS was 4/2/24, but the MDS was completed on 5/8/24, and it was submitted and accepted in the MDS data base on 5/16/24. The MDSN stated the MDS assessment was completed late which was more than 14 days after the assessment reference date (ARD) because he and the MDS Coordinator were too busy with other tasks in the facility. The MDSN stated he should assess the resident and complete the MDS by the target date which was 4/2/24 and submit it within 30 days of completion date. The MDSN stated the facility did not assess Resident 70, completed and submited the resident's annual MDS timely. 2. During a review of Resident 54's admission Record indicated the facility originally admitted Resident 54 on 2/17/22 and readmitted on [DATE] with diagnoses that hyperlipidemia and anemia (a condition in which the body does not have enough healthy red blood cells. Red blood cells provide oxygen to body parts). During a concurrent interview and record review on 5/23/24 at 10:30 AM, with the MDSN, Resident 54's MDS-Nursing Home Comprehensive Item set, dated 4/2/24, and the Final Validation Report, dated 5/16/24, were reviewed. The MDSN stated the target date for Resident 54's annual comprehensive MDS was 4/2/24, the completion date of the MDS was 5/10/24 and the submission and the accepting date on the MDS data base was 5/16/24. The MDSN stated the assessment was completed late which was more than 14 days after the ARD. The MDSN stated he and the MDS Coordinator should have assessed the resident and completed the MDS by the target date which was 4/2/24, and submitted the MDS assessment within 30 days of completion date. The MDSN stated the facility did not assess Resident 54, completed and submitted the resident's annual MDS timely. 3. During a review of Resident 4's admission Record indicated the facility originally admitted Resident 4 on 9/22/14 and readmitted on [DATE] with diagnoses that dementia and anemia During a concurrent interview and record review on 5/23/24 at 10:40 AM, with the MDSN, Resident 4's MDS-Nursing Home Comprehensive Item set, dated 4/2/24, and the Final Validation Report, dated 5/16/24, were reviewed. The MDSN stated the target date for Resident 4's annual MDS was 4/2/24, the completion date of the MDS was 5/14/24, and the submission and the accepting date in the MDS data base was 5/16/24. The MDSN stated the assessment was completed late which was more than 14 days after the ARD. The MDSN stated he and the MDS Coordinator should have assessed the resident and completed the MDS by the target date which was 4/2/24 and submitted the MDS within 30 days of completion date. The MDSN stated the facility did not assess Resident 4, completed and submitted the resident's annual MDS timely. 4. During a review of Resident 100's admission Record indicated the facility originally admitted Resident 100 on 3/30/23 and readmitted on [DATE] with diagnoses that included seizure (a burst of uncontrolled electrical activity between brain cells, causing changes in behavior, movements, feelings and levels of consciousness) and anemia. During a concurrent interview and record review on 5/23/24 at 10:50 AM, with the MDSN, Resident 100's MDS-Nursing Home Comprehensive Item set, dated 4/1/24, and the Final Validation Report, dated 5/16/24, were reviewed. The MDSN stated the target date for Resident 100's annual MDS was 4/1/24, the completion date of the MDS was 5/14/24 (43 days late), and the submission and the acceptance date in the MDS data base was 5/16/24. The MDSN stated the assessment was completed late which was more than 14 days after the ARD. The MDSN stated the facility staff should assess the resident and complete the MDS by the target date which was 4/1/24 and submit it within 30 days of completion date. The MDSN stated the facility did not assess Resident 100, and complete and submit his annual MDS timely. During an interview on 5/23/24 at 11:08 AM, with the MDSN, the MDSN stated MDS was an assessment tool that guided the facility staff to assess residents timely. The MDSN stated the facility staff had to make sure the assessment reflected the most current condition and any change needed to revise for care plan. The MDSN stated the MDSs were late because they were too busy to do other tasks in the facility and did not have time to complete and submit them on time. The MDSN stated the late assessment could result in delayed treatment, which could comprise residents' quality of care and safety, especially those with major condition change. During an interview on 5/23/24 at 12:10 PM, with the Director of Nursing (DON), the DON stated the facility staff would not be able to develop care pan and provide necessary interventions promptly to the residents whose conditions were changing because the assessment was late. The DON stated it was important to assess the residents timely, and complete and submit the MDS timely to ensure consistent and quality of care to the residents. During a review of the Center for Medicare and Medicaid (CMS)'s Resident Assessment Instrument (RAI) Version 3.0 Manual dated October 2023, indicated the annual (comprehensive) MDS must be completed no later than 14 calendar days from the ARD, the care plan must be completed no later than 7 days from the annual MDS completion date, and the annual MDS must be transmitted no later than 14 days from the care plan completion date. The target date was the ARD.

**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 comprehensive standardized assessment and screening tool) were completed and submitted to the CMS (Center for Medicare and Medicaid) data base within the required time frame for four out of four sampled residents (Resident 70, 54, 4, and 100). This deficient practice had the potential for the residents not to receive or receive delayed necessary care and treatment, which could comprise residents' quality of care and safety, especially for the residents with major condition change that could result in a decline in Residents 70, 54, 4, and 100 wellbeing. Findings: 1.During a review of Resident 70's admission Record indicated the facility admitted Resident 70 with diagnoses that included dementia (a general term to describe a group of symptoms related to progressive loss of memory and judgment) and hyperlipidemia (an elevated level of lipids [fat particles] in the blood). During a concurrent interview and record review on 5/23/24 at 10:25 AM, with the MDS Nurse (MDSN), Resident 70's MDS-Nursing Home Quarterly Item set, dated 1/4/24, and the Final Validation Report (a log that the facility submitted to the MDS data base each day), dated 4/3/24, were reviewed. The MDSN stated the target date for Resident 70's quarterly MDS was 1/4/24, but the MDS was completed on 3/28/24, and it was submitted and the accepted in the CMS data base on 4/3/24. The MDSN stated the assessment was completed and submitted late which was more than 14 days after the assessment reference date (ARD). The MDSN stated he and the MDS Coordinator should assess the resident and complete the MDS by the target date which was 1/4/24 and submit it within 30 days of completion date. The MDSN stated the facility did not assess Resident 70, and complete or submitted the ressident's quarterly MDS timely. 2. During a review of Resident 54's admission Record indicated the facility originally admitted Resident 54 on 2/17/22 and readmitted on [DATE] with diagnoses that hyperlipidemia and anemia (a condition in which the body does not have enough healthy red blood cells. Red blood cells provide oxygen to body parts). During a concurrent interview and record review on 5/23/24 at 10:35 AM, with the MDSN, Resident 54's MDS-Nursing Home Quarterly Item set, dated 1/4/24, and the Final Validation Report, dated 4/3/24, were reviewed. The MDSN stated the target date for Resident 54 ' s quarterly MDS was 1/4/24, the MDS was completed on 3/29/24, and it was submitted and accepted on 4/3/24. The MDSN stated the MDS assessment was completed late which was more than 14 days after the ARD. The MDSN stated he and the MDS Coordinator should assess the resident and complete the MDS by the target date which was 4/2/24 and submit it within 30 days of completion date. The MDSN stated the facility did not assess Resident 54, and completed or submitted Resident 54's quarterly MDS timely. 3. During a review of Resident 4's admission Record indicated the facility originally admitted Resident 4 on 9/22/14 and readmitted on [DATE] with diagnoses that dementia and anemia. During a concurrent interview and record review on 5/23/24 at 10:45 AM, with the MDSN, Resident 4's MDS-Nursing Home Quarterly Item set, dated 1/11/24, and the Final Validation Report, dated 4/3/24, were reviewed. The MDSN stated the target date for Resident 4's Quarterly MDS was 1/11/24, the MDS was completed on 3/29/24, and it was submitted and the accepted on 4/3/24. The MDSN stated the assessment was completed late which was more than 14 days after the ARD. The MDSN stated he and the MDS Coordinator should assess the resident and complete the MDS by the target date which was 1/11/24 and submit it within 30 days of completion date. The MDSN stated the facility did not assess Resident 4, and complete or submit his ' s quarterly MDS timely. 4. During a review of Resident 100's admission Record indicated the facility originally admitted Resident 100 on 3/30/23 and readmitted on [DATE] with diagnoses that seizure (a burst of uncontrolled electrical activity between brain cells, causing changes in behavior, movements, feelings and levels of consciousness) and anemia. During a concurrent interview and record review on 5/23/24 at 10:55 AM, with the MDSN, Resident 100's MDS-Nursing Home Quarterly Item set, dated 1/2/24, and the Final Validation Report, dated 5/16/24, were reviewed. The MDSN stated the target date for Resident 100 ' s quarterly MDS was 1/2/24, the MDS was completed on 2/19/24, and it was submitted and accepted on 5/16/24. The MDSN stated the assessment was completed late which was more than 14 days after the ARD. The MDSN stated the facility staff should assess the resident and complete the MDS by the target date which was 1/2/24 and submit it within 30 days of completion date. The MDSN stated the facility did not assess Resident 100, and completed or submitted the resident's quarterly MDS timely. During an interview on 5/23/24 at 11:08 AM, with the MDSN, the MDSN stated MDS was an assessment tool that guided the facility staff to assess residents timely. The MDSN stated he and the MDS Coordinator had to make sure the assessment reflected the most current condition and any change needed to revise for care plan. The MDSN stated they were having staffing issue so he and the MDS Coordinator were pulled to preform other tasks in the facility, so they did not have time to complete some residents' assessment and MDS. The MDSN stated the late assessment could result in delayed treatment, which could comprise residents' quality of care and safety, especially those with major condition change. During an interview on 5/23/24 at 12:10 PM, with the Director of Nursing (DON), the DON stated the facility staff would not be able to develop care plan and provide necessary interventions promptly to the residents whose conditions were changing because the assessment was late. The DON stated the facility had a staffing issue over the completion the MDS on time, and the faculty utilized an extra staff to help catching up with MDS completion. The DON stated it was important to assess the residents timely, and complete and submit the MDS timely to ensure consistent and quality of care to the residents. During a review of the Center for Medicare and Medicaid (CMS)'s Resident Assessment Instrument (RAI) Version 3.0 Manual dated October 2023, indicated the quarterly MDS must be completed no later than 14 calendar days from the ARD and transmitted no later than 14 days from the MDS completion date. The target date was the ARD.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A review of Resident 98's admission Record indicated Resident 98 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis that included muscle weakness, abnormalities of gait and mobility, blindness of left eye, dementia (a loss of brain function that affects memory, thinking, language, judgment, or behavior), anemia, and Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks.) A review of Resident 98's MDS, dated [DATE] indicated, Resident 98's cognitive skills for daily decision making was moderately impaired and needed partial/moderate assistance (helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) for oral hygiene (the ability to use suitable items to lean teeth) and personal hygiene (the ability to maintain personal hygiene, including combing hair, washing/drying face and hands). A review of Resident 98's Care Plan revised 2/13/24 indicated Resident 98 had self-care deficits with activities of daily living and impaired mobility due to anemia and respiratory failure (failure of the lungs to meet the body's oxygen demand). The care plan goal was to ensure Resident 98 was kept clean, dry and well groomed daily, The care plan interventions included to assist with ADLs as needed, dental/oral care two times a day and as needed, and to provide assistive device for ADLs as needed. A review of Resident 98's Care Plan, dated 2/14/24 indicated, Resident 98 had alteration in oral/dental status secondary to resident had some of natural teeth missing and the interventions included to ensure good oral hygiene; to observe for signs and symptoms of dental disorders such as swollen gums, pin, presence of oral lesions (a break in the skin that occurs on the moist, inner lining of the mouth); and to set up oral hygiene material and assist resident as needed. During a concurrent observation and interview on 5/21/24 at 8:53 AM with Resident 98, Resident 98's teeth was observed with red gums and food sticking close to the gum line. Resident 98 ' s bedside table and drawer was observed with no oral care kit. Resident 98 stated, since admission, he had never had any teeth cleaning after meals. Resident 98 stated, he had been always very uncomfortable with the uncleanliness of his teeth. Resident 98 stated, the staff had never offered or assisted him to brush his teeth and never brought any toothbrush or toothpaste to him. During a concurrent observation and interview on 5/23/24 at 1:18 PM in Resident 98 ' s room, Resident 98 ' s teeth was observed with discoloration, food sticking around the teeth. Resident 98 stated, the staff had not offered or assisted him to have his teeth brush this morning yet and his teeth and mouth had been very uncomfortable. During a concurrent observation and interview on 5/23/24 at 2:44 PM with Licensed Vocational Nurse (LVN) 2 and CNA 3 in Resident 98's room, Resident 98's teeth was observed. LVN 2 stated, Resident 98's teeth looked discolored with plaque and food was stuck in his teeth. CNA 3 stated, she did not brush Resident 98's teeth this morning. During a concurrent record review and interview on 5/23/24 at 3 PM with LVN 2, Resident 98 ' s Dental Notes, dated 4/19/24 was reviewed. LVN 2 stated, according to the record, Resident 98 had poor oral hygiene. During an interview on 5/24/24 at 10:45 AM with CNA 3, CNA 3 stated, since admission, Resident 98 was not comfortable when CNA 3 provided oral care, so she did not brush Resident 98's teeth. CNA 3 stated, Resident 98's teeth condition looked like they were very sensitive. CNA 3 stated, she started providing oral care to Resident 98 a few days ago when Resident 98's family member requested. When surveyor asked why it had been charted that oral care had been done in Resident 98's medical record, CNA 3 stated, the ADL charting was to assess the level of assistance that Resident 98 needed for oral care. CNA 3 stated, the charting did not mean that oral care was done. During an interview on 5/24/24 at 12:32 PM with the DON, the DON stated, the CNAs were expected to brush the resident's teeth and provide oral care as part of their daily task. CNA 3 should have reported to the Charge Nurse once the resident appeared uncomfortable with the oral care so they could assign another CNA that the resident was more comfortable with to receive the care. The DON stated, with inconsistent oral care, the resident was at high risk for teeth infection, dental carries, rotten teeth, heart or lung infection, and could hospitalization. A review of the facility's Policy and Procedure titled A.M. Care, undated, indicated A.M. Care included oral hygiene prior to breakfast by assisting each resident in brushing their teeth or dentures. Based on observation, interview, and record review, the facility failed to assist four of five sampled residents (Residents 19, 87, 98 and 17) who were unable to carry out activities of daily living (ADL) to maintain good grooming, and personal and oral hygiene by failing to 1. Assist Resident 19 and Resident 87 to trim the residents' fingernails during shower. These deficient practices had the potential to result in a negative impact on Resident 17 and Resident 87's quality of life and self-esteem. 2. Assist Resident 98 with oral care. This failure resulted in Resident 98's inconsistent oral care since 3/7/24 and which had a potential to result in dental carries, teeth and gum infections, lung infection, that could lead to hospitalization for higher level of care. Findings, 1. A review of the admission record indicated Resident 19 was originally admitted to the facility on [DATE] and readmitted on [DATE] with contracture (a condition of shortening and hardening of muscles, tendons, and other tissue) of right and left wrist. A review of Resident 19's Minimum Data Set (MDS - a comprehensive standardized assessment and screening tool), dated 4/9/24, indicated Resident 19's cognitive skill (mental action or process of acquiring knowledge and understanding for daily decision-making) was impaired. The MDS indicated Resident 19 required total dependence (full staff performance) on staff for oral hygiene, toilet hygiene, and personal hygiene. During an observation in Resident 19's room on 5/23/24 at 8:32 AM, Resident 19 was observed lying in bed. Resident 19's fingernails were observed untrimmed and with blackish substance underneath the fingernails. A review of Resident 19's Care Plan (a document that outlines the facility's plan to provide personalized care to a resident based on the resident's needs) indicated resident has a self-care deficit related to contractures of the right and left wrist, initiated on 1/18/23. Staff interventions included assisted with grooming and trimming of fingernails. 2. A review of Resident 87's admission record indicated resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with contracture of right and left elbow. A review of Resident 87's MDS, dated [DATE], indicated Resident 87's cognitive skill was severly impaired. The MDS indicated Resident 87 required total dependence (full staff performance) on staff for oral hygiene, toilet hygiene, and personal hygiene. During an observation in Resident 87's room on 5/23/24 at 8:33 AM, Resident 87 was observed lying in bed. The resident's fingernails were observed untrimmed and with yellow substance underneath the fingernails. A review of Resident 87's Care Plan, initiated on 3/11/23, indicated the resident has an ADL self-care deficit related to late Cerebral Vascular Accident (CVA- is an interruption in the flow of blood to cells in the brain) with right hemiparesis (weakness on one side) and contractures (tightening of the muscle). Staff interventions included to assist Resident 87 with grooming and trimming of fingernails. During a concurrent interview and observation in Residents 87's shared room on 5/23/24 at 8:40 AM, Certified Nursing Assistant 2 (CNA 2) stated Resident 19 and Resident 87's fingernails on both hands were long and dirty. CNA 2 stated the assigned CNA was responsible for cutting the residents' fingernails after residents' shower or bath. During an interview with the Director of Nursing (DON), on 5/23/24 at 11:49 AM, the DON stated nails care is part of grooming for the residents. The DON stated nail care is a duty of a CNA, and as a part of the routine care that was done on bath day and as necessary. A review of the facility`s undated policy titled, Nail Care, the purpose to the policy was to ensure that resident's nails are clean and trimmed to reduce risks of infection and to promote dignity.

Based on observation, interview, and record review, the facility failed to follow proper sanitation, preparation, and food handling practices, to prevent the outbreak of foodborne illness (an illness caused by contaminated food) in accordance with the facility's policy and procedure and professional standards for food service and safety by failing to: Replace a can opener that had rust (a reddish or yellowish-brown coating of iron oxide that is formed on iron or steel by oxidation (a process that occurs when atoms or groups of atoms lose electrons) especially in the presence of moisture), and chrome plating (a technique of electroplating a thin layer of chromium onto a metal object) that was peeling off from the kitchen device. Ensure the chlorine level in the water used in the dishwasher had a chlorine level between 50 - 100 PPM (unit of measurement-parts per million) in accordance with the facilities policy and procedure titled Dish Washing Procedures - Dish Machine. The dietary staff did not compare the color of the test strip to the color chart (a chart used as a reference to determine the amount of chlorine that was added to a solution in the dishwasher for disinfection) in the test strip container to determine if the chlorine level in the dishwasher was within the acceptable range to disinfect the dinnerware used by the residents. These deficient practices had the potential to contaminate the food (the unintended presence of potentially harmful substances, including, but not limited to microorganisms, chemicals, or physical objects in food and a transfer of bacteria from one object to another) and dinnerware the residents use which could cause foodborne illnesses, hospitalization, or death. Findings: During a kitchen observation on 5/22/24 at 8:56 AM, a can opener that was heavily rusted with dark brown flaky debris was on top of a three-compartment sink. The can opener also had its chrome plating peeling off on an area that touches the lid of the can that needs to be opened. During a concurrent interview with the Kitchen [NAME] (Cook 1), he stated he used the can opener this morning to open a canned food. During an interview on 5/22/24 at 11:36 AM, the Certified Dietary Manager (CDM) stated that the facility has only one can opener, and they need to replace it due to rust formation on the device and chrome peeling from it. The CDM stated, It ' s time to replace it. The chrome falling off from the can opener could potentially contaminate the food in the container. A review of the facility's undated policy titled, Safety Guidelines, revised in 2019, indicated, Equipment should be kept in proper working condition. Any unsafe items should be reported to the Dietary Service Supervisor immediately. During an observation of the dishwashing process on 5/22/24 at 9:18 AM, the Dietary Assistant (DA 1) took a chlorine test strip from a container and dipped it on top of a plastic drinking cup that went through the dish washing cycle. The DA 1 did not compare the color of the test strip to the color chart in the test strip container to determine if the amount of chlorine that was added to the dishwasher was between 50 - 100 PPM. During a concurrent interview with the DA 1, he stated he used the test strip this morning but did not compare the color of the test strip to the color chart because he knew the right color from memory and experience. A review of the dishwashing procedure written by the manufacturer who services the facility, indicated to use the correct chlorine test strip to test for proper chlorine sanitizer levels at no less than 50 PPM and no higher than 100 PPM. A review of the facility's undated policy titled, Dish Washing Procedures - Dish Machine, indicated that dishes will be properly sanitized through the dish machine with a chlorine level between 50 - 100 PPM. A chlorine log will be kept and maintained by the dish washer to ensure that the chlorine level is within manufacturer ' s guidelines.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow its policy and procedure on Resident lifting/Assisting Transfer Policy, regarding resident lifting for dependent residents (Resident 1). Certified Nurse Assistant (CNA) 1 and CNA 2 did not use the mechanical lift transfer to Resident 1, who was totally dependent with transfers, held Resident 1 ' s arm pits to stand up from the wheelchair. This deficient practice had result in Resident 1 ' s left shoulder fracture and hospitalization. Findings: A review of the admission Record indicated Resident 1 was originally admitted on [DATE], with diagnoses that included but not limited to sclerosis (an abnormal hardening of a tissue or body part (as arteries or muscles) that occurred in several serious diseases), hemiplegia (paralysis that affected only one side of body) on left and right side, osteoporosis, left hand contracture (a permanent tightening of the muscles, tendons, skin, and nearby tissues that caused the joints to shorten and become very stiff). A review of the Resident 1 ' s History and Physical (H&P), dated 3/24/24, indicated the resident had the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and screening tool) dated 3/21/24, indicated the resident had impairment on both sides of upper and lower extremities. The MDS indicated Resident 1 was dependent (helper did all of the effort. Resident did none of the effort to complete the activity) on staff with transfers, sit to stand, dressing, eating, toilet use, personal hygiene, and bathing. A review of Resident 1 ' s care plan, revised on 4/2/24, indicated the resident was at risk for spontaneous/pathological/stress fracture related to: osteoporosis, with intervention to handle gently and carefully during care. A review of Resident 1 ' s Radiology Results Report, dated 4/10/24, indicated probable acute left humeral (upper arm bone) neck fracture (a break or a crack in a bone). A review of the Resident 1 ' s Physician orders dated 4/10/24, indicated Transfer pt [patient] to [acute hospital] for further eval [evaluation] of left shoulder, discomfort pain and swelling. During an interview on 4/25/24 at 10:23 am, CNA 1 stated she was working morning shift on 4/10/24. when Resident 1 needed to be changed. CNA 1 stated Resident 1 required two CNAs ' assistance for transfers. CNA 1 stated Resident 1 was sitting on the wheelchair in her room on 4/10/24 around 2pm, and privacy was provided by closing door. CNA 1 stated, that both she and CNA 2 grabbed Resident 1 ' s arms and assisted Resident 1 to stand up on her feet. CNA 1 stated she was grabbing Resident 1 ' s left armpit and left arm while she cleaned Resident 1 ' s buttocks with her (CNA 1) right hand. CNA 1 stated that CNA 2 was on Resident 1 ' s right side and holding Resident 1 ' s right armpit. According to CNA 1, the whole cleaning and changing process was less than one minute, and Resident 1 was held up standing less than one minute. Per CNA 1, Resident 1 did not complain of pain during that time. CNA 1 stated CNA 1 and 2 returned Resident 1 back on the wheelchair after a new diaper was changed. Per CNA 1, Resident 1 complained of pain on the left shoulder as soon as Resident 1 sat back down on the wheelchair. CNA 1 stated that CNA 1 and 2 did not use the mechanical lift or gait belt was when Resident 1 was assisted with standing up during cleaning and changing. During an interview with the Occupational Therapist (OT 1) on 4/25/24 at 1:54pm, OT 1 stated the facility staff should use a mechanical lift to transfer to dependent residents. OT 1 stated that the appropriate way to assist dependent residents was to use the mechanical lift. OT 1 stated it was not appropriate to hold or grab Resident 1 ' s arm pits to stand up from the wheelchair. OT 1 stated that another appropriate way was to use the gait belt. OT 1 stated, residents with diagnosis of lateral sclerosis, osteoporosis, and cancer, their bone were more fragile and need to be handled more carefully. OT 1 stated the risk of holding on to the arm pits to stand up a resident from wheelchair can cause fracture. During an interview with the Director of Staff Development (DSD) on 4/25/24 at 3:17 pm, the DSD stated that dependent residents needed to be assisted using two people with a mechanical lift, and/or a use a gait belt to transfer. The DSD stated that the facility staff need to change Resident 1 in bed, and they will need to transfer Resident 1 from wheelchair to bed. During a telephone interview with Resident 1 ' s family (Family 1) on 4/25/24 at 3:31 pm, Family 1 indicated that Resident 1 was still hospitalized and complaint about the same level of pain on her left shoulder fracture. A review of the facility ' s policy and procedure titled Use of Transfer Belts Policy, (undated), indicated in the interest of safety and welfare to residents and staff, it is our policy that all facility employees use transfer belts when transferring residents or use the appropriate lifting device. A review of the facility ' s policy and procedure titled Resident lifting/ Assisting Transfer Policy, updated 2/26/14, indicated that No resident lift or assisted transfers will be attempted without using either a Vander-Lift, an Invacare lift, or a Hoyer lift except as detailed below: Note: use of mechanical lift requires at least two persons.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed toensure one of three sampled residents (Resident 1) was free from injury after sustaining a fall in the facility. 1. Certified nurse assistant (CNA)1 failed toreport to licensed nurses that Resident 1 was found on the floor in Resident 1 ' s room, by the foot of the bed on 3/24/24. 2. Registered Nurse 1 failed to immediately conduct an assessment onResident 1 after Resident 1 was found on the floor on 3/24/24. 3. CNA 1 failed to ensure Resident 1 was safely transferredto the bed after sustaining a fall. CNA1 transferred Resident 1 back to bed, alone, without licensed nurses assessing Resident 1 for any other injuries. 4. RN1 failed tonotify the physician and implement the facility ' s fall protocols immediately after Resident 1 ' s unwitnessed fall on 3/24/24. These deficient practices had resulted in the delay of care and services to Resident 1 who experienced pain in the left leg and sustained aleft hip fracture that required a surgical intervention. Findings: Areview of Resident 1 ' s admission Record indicated the facility originally admitted Resident 1 on 11/22/2019 and readmitted on [DATE] with diagnoses that included dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) and displaced fracture of base of neck of left femur (a type of hip fracture [a partial or complete break in the bone]). Areview of Resident 1 ' s Fall Risk Assessment, dated 3/14/2024, indicatedResident 1 was at high riskfor fall. A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 3/18/2024, indicated Resident 1 had moderately impaired cognitive (ability to think and reasonably) impairment and memory. The MDS indicated Resident 1 was independent with oral hygiene, required supervision or touching assistance with eating, toileting hygiene, upper body dressing, lower body dressing, putting on/taking off footwear, chair/bed-to-chair transfer, toilet transfer, walk 10 feet, walk 50 feet with two turns, and walk 150 feet, and required partial/moderate assistance with shower/bathe self. Areview of Resident 1 ' s MDS, dated [DATE], indicatedResident 1 had severely impaired cognitive (ability to think and reasonably) impairment and memory. The MDS indicated Resident 1 required supervision or touching assistancewith eating, oral hygiene, chair/bed-to-chair transferand toilet transfer, requiredpartial/moderate assistancewith upper body dressing, and requiredsubstantial/maximal assistancewith toileting hygiene, shower/bathe self, lower body dressing, putting on/taking off footwear. The MDS indicated walk 10 feet, walk 50 feet with two turns, and walk 150 feet were not attempted due to medical condition or safety concerns. Areview of Resident 1 ' s) Changeof Condition (COC)/Interact Assessment Form Situation, Background, Action, and Response(SBAR), dated 3/24/2024 at 1:11 AM, indicatedthere was no documentation of CNA 1 reporting Resident 1 ' s fall to registered nurse (RN)1. A review of Resident 1 ' s COC/SBAR dated 3/24/2024 at 9:00 AM, indicatedat 10 AM, Resident 1 complained of pain in theleft leg with purplish discoloration on right forearm. The COC/SBARindicated Resident 1 ' s roommate informed licensed vocational nurse (LVN)2 that Resident 1 felllast night on 3/24/24 during the night shift (11 PM-7AM). During a review of Resident 1 ' s 72 Hours neurological assessment check (Neuro check, a routine practice by the registered nurse to assess the mental status and level of consciousness) List, dated3/24/2024, indicated the facility initiated the 72 hours neuro-check on Resident 1 at 10 AM on 3/24/2024 (10 hours after Resident 1 ' s unwitnessed fall). Areview of Resident 1 ' s Progress Notes, dated 3/26/2024, indicatedResident 1 complained of pain in theleft leg during physical therapy and that the staff obtained an order for an x-ray (an imaging test that takes pictures of bones and soft tissues to help providers diagnose and treat medical conditions) to rule out a fracture. Areview of Resident 1 ' s Physical Therapy Treatment Encounter Note(s), dated 3/27/2024, indicatedx-ray to left leg on 3/26/2024 revealed acute left femoral neck fracture and no weight bearing to the left leg at this time. Areview of Resident 1 ' s Radiology (a branch of medicine that uses imaging technology to diagnose and treat disease) Results Report, dated 3/26/2024, indicatedResident 1 sustained an acute fracture of the neck of the femur, with mild displacement. Areview of Resident 1 ' History and Physical (H&P) from the general acute care hospital (GACH), dated 3/27/2024, indicated Resident1 sustained a left hip fracture and was admitted to the GACH for pain management and possible surgical repair of the fractured left hip. Areview of Resident ' s Progress Note of Surgery Orthopedics from the GACH, dated 3/28/2024, indicatedResident 1 and family did not want to proceedwith surgery at this time. During a telephone interview on 4/10/2024 at 1:14 PM with CNA 1, CNA 1 statedhe was conducting his rounds when he found Resident 1 sitting on the floor mat on the floor. CNA1 stated Resident 1 was at the foot of the right side of her bed between the times of 12:00 and 1:00 AM on 3/24/2024. CNA 1 stated assisting Resident1 back to bed, by carrying Resident 1 by himself. CNA1 stated Resident 1 was smacking thebedside rail with her [NAME] moaning. CNA1 stated informingRN (Registered Nurse) 1 that he found Resident 1 at the foot of her bed and that Resident 1 was agitated. CNA 1 stated Resident 1 continued to act restlessly for the rest of the night, and that Resident 1 was very agitated. During an observation on 4/10/2024 at 1:35 PM in Resident 1 ' s room, Resident 1 was lying on the bed with a blue abduction wedge pillow (designed to separate the legs of a patient. It is often used after hip surgery to prevent the new hip from popping out) Resident 1 had a bruise at left upper inner thigh. During an interview on 4/10/2024 at 2:04 PM with Resident 2, Resident 2 statedshe was the roommate of Resident 1. Resident 2 statedshe was awaken up by a loud thud sound around 1AM on 3/24/24. Resident 2 statedshe saw Resident 1 seated on the floor by the foot of Resident 1 ' s bed. Resident 2 statedshe did not see how Resident 1 fell out of the bed and no staff was present when the fall happened. Resident 2 statedthe staff came in after the fall and found Resident 1 was on the floor. A review of Resident 2 ' s admission Record indicated Resident 2 was admitted to the facility on [DATE] with a diagnoses of malignant neoplasm of the pancreas (cancer of the pancreas), unnary tract infection(UTI, bladder infection) , and diabetes (high blood sugar). A review of Resident 2 ' s History and Physical dated 3/17/2024 indicated Resident 2 had the capacity to understand and make decisions. A review of Resident 2 ' s MDS, dated [DATE], indicatedResident 2 had no cognitive impairment. During a telephone interview on 4/10/2024 at 2:29 PM with Registered Nurse 1, RN 1 stated CNA 1 approached her and told her that Resident 1 was restless and if Resident 1 had any medication for restlessness at 12:00 AM on 3/24/2024. RN 1 stated CNA 1 did not tell her that he found Resident 1 sitting on the floor by the foot of the bed and or that Resident 1 fell out of bed. RN 1 stated when she went to assess Resident 1, Resident 1 was restless on the bed, but did not see any visible injuries on Resident 1. RN1 stated Resident 1 did not complain of any pain at that time, but RN 1 stated unawareness of Resident 1 falling out of bed. RN 1 stated she did not ask questions to clarify if Resident 1 had a fall when CNA 1 told her Resident 1 was at the foot of her bed. RN 1 stated she did not conduct a post fall assessment and did not report to other staff and the physician that Resident 1 sustained a fall during her shift from 11:00 PM on 3/23/2024 to 7:00 AM on 3/24/2024 because she was not aware of the fall. RN 1 stated she was informed about Resident 1's fall when she returned to work at 11:00 PM on 3/24/2024. RN 1 stated it was around 9:00 AM on 3/24/2024, the morning shift CNA found Resident 1 with a bruise on the right arm and reported to the mornign shift LVN. RN1 stated the morning shift LVN went to check on Resident 1 and Resident 2 reported to the mornign shift LVN that Resident 1 fell out of the bed the night before. RN 1 stated morning shift LVN initiated the fall protocol on Resident 1 at 10AM on 3/24/2024. RN 1 stated CNA 1 should have reported Resident 1's fall to RN1 and CNA1 to prevent a delay in treatment, and that CNA1 should not move Resident 1 back to the bed by himself before any licensed nurses assessed Resident 1, to prevent further injury to Resident 1. During a telephone interview on 4/10/2024 at 2:49 PM with CNA 1, CNA 1 statedhe informed RN 1 that She (Resident 1) was at the foot of her bed. CNA 1 statedhe did not report to RN1 that Resident 1 was found seated on the floor or that Resident 1 had a fall. During a telephone interview on 4/10/2024 at 3:51 PM with the Physical Therapist (PT), the PT stated Resident 1 was at high riskfor fall prior to her recent fall on 3/24/24. The PT stated conducting a fall assessment on Resident 1 after being notified that Resident 1 fell. The PT statedwhile conducting the fall assessment, Resident 1 was in a lot of pain so the PT notified the physician to obtain x-ray order. The PT stated the results of the Xray indicated Resident 1 had a left hip fracture. During an interview on 4/10/2024 at 4:20 PM with Licensed vocational nurse (LVN) 1, LVN 1 statedif a resident was found on the floor for an unwitnessed fall, CNAs should report to licensed nurses immediatelyand not to move the resident. LVN 1 statedlicensed nurses should assess the resident for injury, change of level of consciousness (LOC), vital signs, skin integrity, and neuro-check, then, notify the physician and responsible party. LVN 1 stated CNAs should not move the resident until the licensed nurse assess the resident for possible fracture and head injury. LVN1 stated it was not until after an assessmentwas conducted and the resident was cleared to be moved, should the CNA safely move a resident after being found on the floor. During an interview on 4/11/2024 at 10:59 AM with CNA 2, CNA 2 stated when as resident was found on the floor, CNAs must report to the charge nurse and the RN supervisor immediately by stating what where and what positionthe resident was found. CNA 2 stated CNAs should not move or touch the resident until the licensed nurses assessed the resident and gave instruction to move the resident because moving the resident without proper assessment could cause more injury to the resident. During an interview on 4/11/2024 at 11:09 AM with RN 2, RN 2 stated Resident 1 was at high riskfor fall. RN 2 stated when a resident had a fall either a witnessed or unwitnessed fall, the licensed nurse should follow the fall protocol immediately, which included assessing the resident for pain and injury RN 1 stated CNAs should report to the licensed nurse immediately when a resident was found on the floor. RN 1 stated the resident should not be moved or touched the resident until the licensed nurse completed theassess ment and determined it was safe to move the resident to prevent further injury. During an interview on 4/11/2024 at 1:18 PM with the Director of Nursing (DON), the DON statedaccording to the facility ' s fall protocol and the standardsof practice, CNA 1 should report to RN 1 that Resident 1 was found sitting on the floor at the foot of the bed. The DON stated CNA 1 should not move Resident 1 back to the bed by himself without an assessment conducted from the licensed nurses. The DON stated by moving Resident 1 without the proper assessment from the licensed nurse could cause more injury to the resident. The DON statedResident 1 was restless on 3/24/2024 after the fall. The DON statedRN 1 did not know that Resident 1 had fall during her shift and did not start the fall protocol on Resident 1 until 10:00 AM on 3/24/2024 when Resident 2 informed the staff. The DON stated Resident 1 ' s 72 hours neurological assessment, which could determine any change of LOC, was not started immediatelyafter Resident 1 ' s fall. The DON statedit was not until 10 AM (10 hours after Resident 1 ' s fall) on 3/24/24 was the neurocheck initiated. The DON statedthe nurse documented Resident 1 had pain at her left leg on 3/24/2024, but the facility did not obtain an x-ray for Resident 1 ' s left leg until the PT noticed Resident 1 had a lot of pain to her left leg and called the doctor for an order for anx-ray of left leg on 3/26/2024. The DON statedthe x-ray results on 3/26/24 of Resident 1 ' s left leg indicatedResident 1 sustained a hip fracture and Resident 1 was transferred to an acute hospital on 3/27/2024. The DON stated Resident 1 ' sfamily member refused any surgical intervention and Resident 1 returned to the facility on 3/30/2024. The DON statedafter a fall, the licensed nurse should immediately follow the fall protocol by conducting post fall assessment, neuro-check assessment and fall risk assessment, and notifying the doctor immediatelyto provide appropriate interventionsand prevent any delay of treatment. During a telephone interview on 4/11/2024 at 3:13 PM with CNA 1, CNA 1 stated he saw Resident 1 was sitting on the floor at the foot of her bed and he tried to help her by assisting her back to her bed, but he did not know that he should not move or touch Resident 1 until the licensed nurses assessed the resident. CNA 1 statedhe worked for a registry company, and he did not receive regular in-service training at the facility as other facility ' s permanent staff. During a review of the updated facility ' s P&P titled, Incidents/Accidents, the P&P indicatedincidents/accidents will be reported to the charge nurse. During a review of the updated facility ' s P&P titled, Fall, the P&P indicatedMD and responsible party will be notified as soon as possible after the incident occurred, and of any significant change noted. The P&P indicatedas soon as an incident of fall occurs, the charge nurse will carefully assess the resident for possible injuriesand a neurological assessment will be conducted for 72 hours to determine any significant changein resident ' s LOC.

Based on observation, interview, and record review the facility failed to follow proper sanitation and safe food handling, in accordance with the facility's policy and procedures on Sanitation and Infection Control, by failing to ensure: 1. Main [NAME] 1 changed gloves while plating lunch, picked up paper from the floor, and proceeded to touch the parsley garnish with same plastic gloves. 2. Kitchen Assistant 1 and Kitchen Assistant 2 were observed not wearing hair net properly, exposing hair during breakfast preparation. These deficient practices had the potential to put residents at risk for foodborne illnesses (illness caused by food contaminated with bacteria, viruses, parasites, or toxins). Findings: On 2/06/2024 at 12:15 PM, during an observation of lunch preparation, [NAME] 1 was observed wearing plastic gloves, grabbing paper lunch slip, dropping paper lunch slip on the floor and picking it up, then grabbed parsley garnish wearing the same gloves and place garnish over a resident plated rice. On 2/06/2024 at 12:18 PM, during a subsequent interview with the DS, the DS stated all staff should always change gloves when preparing and handling food especially if they pick up something from the floor to prevent cross contamination. On 2/07/2024 at 6:50 AM, Kitchen Assistant 1 was observed entering the kitchen putting on a hair net covering only the top of the hair leaving exposed the lower half of Kitchen Assistant 1 ' s backside of head hair. Kitchen Assistant 1 was further observed walking over to the breakfast preparation area and assisted [NAME] 1 with the oatmeal. On 2/07/2024 at 7:18 AM Kitchen Assistant 2 was observed not wearing a hair net and was only wearing a paper hat covering the top of the head, leaving the lower half of the backside of the head hair, while assisting with breakfast plating. On 2/07/2024 at 7:20 AM, during a concurrent interview with the DS, the DS stated it was important for all kitchen staff to always wear a hair net that covered all parts of the hair while in the kitchen to avoid hair contaminating any food item in the kitchen. A review of the facility ' s policy and procedure titled Sanitation and Infection Control dated with revision date of Year 2019 indicated, Personal Hygiene 5. A hair net or head covering which completely covers all hair should be worn at all times. The policy further indicated, Use of Disposable gloves 4. Wash hands when changing gloves. Change disposable gloves when: During food preparation, as often as necessary when it gets soiled and when changing tsk to prevent cross contamination.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the facility ' s policy and procedure titled General Policies for IV (IV- is used to give medications and fluids directly to the vein) therapy, was implemented to infection control practices (a set of practices that prevent or stop the spread of infections and or diseases in the healthcare setting) to prevent infection for one of two sampled residents (Resident 2). This deficient practice placed the residents at risk for potential infection or cross contamination of infections (the physical movement or transfer of harmful bacteria from one person, object, or place to another. Findings: A review of an admission Records indicated resident 2 was admitted to the facility on [DATE] with diagnoses including cellulitis (bacterial skin infection) of left lower limb (leg) and Gastro-esophageal reflux disease (GERD-stomach acid flows into the food pipe and irritates the lining). A review of the Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 11/7/23, indicated Resident 2 was cognitively (a mental process of acquiring knowledge and understanding) intact. The MDS indicated Resident 2 was totally dependent on staff for toilet use, eating, bed mobility and dressing. A review of Resident 2 ' s Order Summary Report for January 2024, indicated Resident 2 has the following orders: 1. Ertapenem (medication to treat infection) 1 GM (gram- a unit of measurement of weight and mass) intravenously (medication delivered into a vein through a catheter) every 24 hours for UTI (Urinary Tract Infection – an infection in any part of the urinary system [kidney, bladder, or urethra]), 2. Change IV tubing every 24 hours for five days 3. Peripheral site (IV insertion site -a small, short plastic catheter that is placed through the skin into a vein, usually in the hand, elbow, or foot) care every 96 hours for site care. During an observation in Resident 2 ' s room on 1/17/24 at 10:20 a.m., Resident 2 was observed lying in bed with an IV line on resident ' s left hand. The tubing was observed without label of the name of the resident and the date the tubing was first used and when the tubing will be changed. During a concurrent observation an interview on 1/17/23 at 10:24 a.m. in Resident 2 ' s room, the Treatment Nurse (TXN) verified that Resident 2 ' s IV tubing did not have label with the Resident 2 ' s name, date, time, and when the IV tubing will be changed, and the initial or name of the licensed nurse who first used the tubing. The TXN stated he could not tell when the tubing was last changed. TXN stated the tubing should be changed every 24 hours, or sooner to promote consistency of practice and minimize the risk of infection and consequently reduce the potential harm for the resident. A review of the facility ' s policy and procedure titled, General Policies for IV therapy, dated June 2018, indicated IV tubing will be changed every 72 hours for continue therapy, and every 24 hours for intermittent use. The policy also indicated that IV tubing will be labeled with the date, time, and the name of the nurse hanged the IV tubing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1) with a gastrostomy tube (G-Tube - a flexible tube surgically inserted through the abdomen into the stomach for feeding, fluid, and medication administration) was assessed and monitored for drainage and infection, in accordance with the facility's policy and procedure on Gastrostomy/Jejunostomy Site Care. In addition, the facility failed to implement Resident 1's care plan interventions for facility staff to provide care to the G-tube daily and assess for redness, pain, swelling, increase temperature and discharges and report to the physician promptly This failure had the potential to result in G-tube complications such as infection and result in Resident 1's change in condition and hospitalization. Findings: A review of Resident 1's admission Record indicated the resident was initially admitted on [DATE] and readmitted to the facility on [DATE] with diagnoses that included dementia (progressive brain disorder that slowly destroys memory and thinking skills), anxiety disorder (a feeling of nervousness, panic, and fear), and Parkinson's Disease (progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement). A review of Resident 1's History and Physical (H&P, the initial clinical evaluation and examination of the patient) indicated Resident 1 does not have the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS- a standardized assessment and care planning tool) dated 4/20/2023, indicated the resident had intact cognition for daily decision making. A review of the Resident 1's care plan initiated on 1/23/2023, indicated G-Tube care daily and assess for redness, pain, swelling, increased temperature and discharges and report to the physician promptly. A review of the SBAR (an acronym for Situation-Background-Assessment-Recommendation is a technique used to provide a framework for communication between members of the health care team) by Licensed Vocational Nurse (LVN) 1 dated 5/15/2023, indicated Resident 1 was found with G-tube formula leaking from the stoma (an artificial opening made int a hollow organ, especially one on the surface of the body leading to the gut or trachea) site. The SBAR indicated the surrounding area of the G-tube had some hard to touch areas. The SBAR indicated Resident 1 had a habit of grabbing and trying to pull out the G-tube. The SBAR indicated that at 4:30 PM, LVN 1 saw Resident 1 try to pull the G-tube out. Resident 1 complained of pain when LVN 1 tried to flush or touch the G-tube. On 5/16/2023 at 2:00 PM, Physician 2 assessed G-tube for milk leaking from the stoma. Physician 2 removed the old percutaneous endoscopic gastrostomy (PEG - a procedure in which a flexible feeding tube is placed through the abdominal wall and into the stomach) and was unable to place a foley catheter (a thin, flexible catheter used specially to drain urine from the bladder) into the stoma. Physician 2 ordered to transfer Resident 1 to the general acute care hospital (GACH) for G-tube placement. A review of the Licensed Nurse Record by LVN 1 dated 5/16/2023, indicated Resident 1 had a G-tube malfunction. The Licensed Nurse Record indicated Physician 2 ordered to transfer to the GACH for further evaluation and G-tube placement due to stoma being closed. A review of the GACH Progress Note by Physician 1 dated 5/17/2023, indicated Resident 1 was found with a leaking G-tube which had been draining into Resident 1's abdomen for a while. The GACH Progress Note indicated there was some inflammation around Resident 1's abdominal area. The GACH Progress Note indicated Resident 1 was treated with antibiotic. A review of the GACH Progress Note by Physician 1 dated 5/19/2023, indicated Resident 1 had an infection of the G-tube site. The GACH Progress Note indicated Resident 1 received IV antibiotics for the infection. [NAME] blood cell (WBC - cells of the immune system that are involved in protecting the body against both infectious disease and foreign invaders) count 21.90 (reference range 4.80 - 10.80 cells per cubic millimeter. A review of the GACH Operative Report by Physician 2 dated 5/24/2023, indicated Resident 1 received an open permanent gastrostomy tube construction. A review of the GACH Microbiology Lab Report dated 6/2/2023 indicated culture wound from the abdomen had Klebsiella pneumoniae (a type of gram-negative bacteria that can cause different types of healthcare-associated infections, including pneumonia [infection in the lungs], bloodstream infections, wound or surgical site infections, and meningitis [an inflammation of the protective membranes covering the brain and spinal cord]) and Escherichia coli (E. coli - bacteria normally live in the intestines of people and animals). A review of the GACH Progress Note by PHY 1 dated 6/7/2023, indicated wound culture showed E. coli and Klebsiella pneumoniae. Plan to continue with IV antibiotic treatment meropenem (used to treat skin and abdominal infections caused by bacteria and meningitis in adults and children three months of age and older) plus vancomycin (used to treat and prevent various bacterial infections). During a telephone interview with family member 1 (FM 1) on 6/13/2023 at 8:28 AM, FM 1 stated a week prior to 5/15/2023, Resident 1 had been complaining of pain where his G-tube was located. FM 1 stated she checked the G-tube and saw milky liquid leaking around the G-tube. FM 1 stated during the week of 5/7/2023 she informed the Treatment Nurse (TX) of the leaking G-tube. FM 1 stated TX checked the GT site, changed the G-tube dressing, and informed FM 1 the G-tube was fine. During an interview with Certified Nursing Assistant (CNA) 1 on 6/13/2023 at 12:36 PM, CNA stated Resident 1 had pulled out his G-tube in the past. CNA 1 stated she had seen Resident 1 fumbling with his G-tube on occasions. CNA 1 stated Resident 1 had a habit of scratching himself around the G-tube and the dressing needed to be replaced. During an interview with TX on 6/13/2023 at 12:58 PM, the TX stated Resident 1 had kept pulling on his G-tube. The TX stated Resident 1 had slight granulation around the GT site since he kept pulling his G-tube. TX stated there was a little bit of milk around the G-tube. TX stated she observed the G-tube site with FM 1 and did not see anything abnormal. TX stated Resident 1's G-tube was normal, therefore she did not notify Physician 1. During an interview with Licensed Vocational Nurse (LVN) 1 on 6/13/2023 at 1:32 PM, LVN 1 stated on 5/15/2023 she saw Resident 1's G-tube site leaking milky color a little bit more than usual and contacted Physician 1. During an interview with the Director of Nursing (DON) on 6/13/2023 at 2:17 PM, the DON stated the nurses should contact the physicians if there was anything wrong with a resident's G-tube. During an interview with TX on 6/13/2023 at 3:19 PM, TX stated she noticed granulation around the G-tube site for over a week along with five percent drainage on the dressing prior to Resident 1's transfer to GACH. TX stated she also had to place an abdominal pad over the G-tube site since Resident 1 was holding his G-tube close to his body. TX stated she did not contact Physician 1, since these findings were normal. During an interview with LVN 2 on 6/13/2023 at 3:52 PM, LVN 2 stated on 5/15/2023 the G-tube site was hard and was noted with a little drainage. During a telephone interview with Physician 1 on 6/13/2023 at 3:53 PM, Physician 1 stated upon Resident 1's arrival to the GACH emergency department on 5/16/2023, the surgeon was summoned and confirmed that the G-Tube was dislodged possibly for a few days already. Physician 1 stated the surgeon had to wait while Resident 1's G-tube matures before placing a new G-tube. During an interview with the DON on 6/13/2023 at 4:42 PM, the DON stated there is a concern for infection when drainage/leaking is present. The DON stated it was not known what was going on inside Resident 1's abdomen, even though the abdomen could be clean on the outside. The DON stated leaking could create further complications. The DON stated there was a possibility Resident 1 would get sepsis (a serious condition resulting from the presence of harmful microorganisms in the blood or other tissues and the body's response to their presence, potentially leading to the malfunctioning of various organs, shock, and death) and peritonitis (a redness and swelling [inflammation] of the lining of the belly or abdomen) when there was a G-tube malfunction. A concurrent review of Resident 1's care plan initiated on 1/23/2023 with the DON, indicated interventions for G-tube are to provide care daily and assess for redness, pain, swelling, increase temperature and discharges and report to the doctor promptly. A review of the facility's policy and procedure titled, Gastrostomy/Jejunostomy Site Care, revised March 2023, indicated assess the stoma site for signs of redness, pain or soreness, swelling, or drainage. Report any of these signs of infection immediately to your supervisor and the resident's physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a resident was provided a communication device (a tool used to communicate with someone) readily available in a language that the resident could understand for one of three sample residents (Resident 1). This deficient practice resulted in the resident not to effectively communicate her care needs with the staffs, which could lead to a delay in receiving appropriate care/treatment when needed. Findings: A review of the admission Record (AR) indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included hyperlipidemia (a condition in which there are high levels of fat particles (lipids) in the blood) and anemia (condition of having low blood count and with low oxygen capacity). The AR indicated Resident 1 ' s primary language was foreign language. A review of the Minimum Data Set (MDS - a comprehensive assessment and screening tool), dated 1/5/23, indicated the resident usually made self-understood and understood others with moderate impairment in cognitive skills (the ability to understand. remember and reason). The MDS indicated Resident 1 required limited assistance (resident highly involved in activity, staff provide non-weight-bearing assistance.) with bed mobility, toilet, and personal hygiene and required supervision with eating. A review of the Care Plan, revised on 10/4/22, indicated Resident 1 had language barrier. The goal of the plan of care was for Resident to be able to communicate her needs in her preferred language on target date 4/12/23. The interventions included to provide resident with an interpreter and provide/utilize communication boards in resident ' s preferred language. During the concurrent interviews and observations, on 1/28/23 at 9:35 AM, Resident 1 was observed speaking in a language that was not the dominant language of the facility. License Vocational Nurse 1 (LVN 1) stated Resident 1 did not speak the facility ' s dominant language. LVN 1 did understand the resident and did not know what the resident needed. LVN 1 stated Resident 1 did not have an accessible communication board in the room. During an interview with Resident 1 and a translator (who spoke the language that Resident 1 speak) on 1/28/23 at 9:48 AM. Resident 1 stated she was able to communicate her basic needs such as water and food. Resident 1 stated she needed help to translate certain words or sentences, but no one was available to translate. Resident 1 stated it would be nice to have a nurse who spoke her language or at minimum, have accessible to a communication board. During an interview, on 1/28/23 at 11:09 AM, Director of Nursing (DON) stated that residents should have a communication board by their bedside if their primary language is not the dominant language in the facility. A review of the facilities undated policy titled Accommodation of Needs Related to Communication deficits, indicated that communication needs will be identified and appropriate interventions, including care planning, will be developed to accommodate the needs of the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the nursing staff failed to assess the characteristics of pain which included the level, intensity, location and what relieves the pain prior to administration of pain medication for one of three sampled residents (R2) as indicated in the residents ' care plan. This deficient practice had the potential to negatively affect the residents' physical comfort, psychosocial (state of mental, emotional, social, and spiritual well-being) well-being, and not receive the needed and necessary services timely. Findings: A review of the admission Record indicated Resident 2 was admitted to the facility on [DATE], with diagnoses that included osteoarthritis (damage of the joint and the underlying bone that causes pain and stiffness, especially in the hip, knee, and thumb joints) and osteoporosis (a condition in which bones become weak and brittle [easily damaged]). A review of Resident 2 ' s Minimum Data Set (MDS, a resident assessment and care screening tool), dated 12/21/22, indicated Resident 2 had severe cognitive (ability to reason, understand and remember) impairment that required total dependence (full staff performance every time) from staff for transfer, eating, and toileting. A review of the care plan revised on 10/17/22, indicated Resident 2 had potential for alteration in comfort and pain related to osteoarthritis and osteoporosis. The care plan indicated a goal to reduce Resident 2 ' s episodes of pain or discomfort through appropriate interventions daily. The care plan interventions included monitoring Resident 2 for signs and symptoms of pain, assessing characteristics of pain (level, intensity, location and what relieves the pain), teaching the resident about pain medication, administering pain medication and would monitor the resident for the effects of pain medication. A review of Resident 2 ' s Order Summary Report, (a physician's order), dated 9/20/23, indicated the resident's pain medication orders as of 1/28/23 included the following: 1. Pain assessment (0=No pain) (1-3 = Mild pain), (4-6=moderate pain), (7-9=severe pain), (10=very severe pain) every shift 2. Monitor for pain during treatment every day shift 3. Tylenol liquid given 20 ml via G-tube (Gastrointestinal Tube-a tube surgically inserted into the stomach to deliver fluids and medications) every four hours for pain management with the start date 9/24/22. 4. Tylenol liquid given 20 millimeters (mL) via G-tube every four hours as needed for mild pain with the start date 9/20/22 5. Tramadol Hcl (medication to treat moderate to severe pain) 50 milligram (Mg) 1 tablet via G-tube every eight hours as needed for severe pain with the start date 11/18/22. During a medication pass (Med-Pass) observation, on 1/28/23 at 9:54 AM, the Licensed Vocational Nurse 1 (LVN 1) administered the pain medications to Resident 2 without assessing for characteristic of pain such as the level, intensity, location and what relieves the pain. In a concurrent interview, LVN 1 stated she did not assess Resident 2 ' s for characteristic of pain prior to administering pain medications. LVN 1 stated Resident 2 did not appear to have pain or discomfort. LVN 1 further stated she should have assessed the characteristic of pain for all residents prior to administration. During an interview and concurrent observation on 1/28/23 at 10:14 AM, Resident 2 was observed lying in bed. In a concurrent interview, Resident 2 stated her back was hurting for prolonged lying-in bed. R2 stated nothing was being done to help manage his pain. During an interview, on 1/28/23 at 11:09 AM, the Director of Nursing (DON) stated licensed nurses should conduct pain assessment consistently every shift as indicated in the facility ' s policy and procedure for pain management. The DON also stated if the resident ' s pain was not properly assessed, the residents ' pain could result in inadequate pain management and could negatively affect the physical, emotional, and psychosocial well-being of residents. A review of the facility's undated policy and procedure, titled Pain Management, indicated the purpose of pain management is to provide guidelines for the consistent assessment, management , and documentation of pain, in order to provide maximum comfort and quality of life. The policy indicated to utilize the most appropriate pain-rating scale; documentation of pain management occurs every shift; and all vital signs taken for resident are to include a pain rate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to obtain an informed consent (process in which residents were given important information, including possible risks and benefits, about a medical procedure or treatment, to help residents with their decision on how to be treated or tested) for one of two sampled residents (Resident 8) prior to use of psychotropic medications (any medication capable of affecting the mind, emotions, and behavior), in accordance with the facility's policy and procedure. This deficient practice had the potential to violate the resident's rights to be informed and to choose the type of care or treatment to be received, or alternatives the resident or responsible party preferred. Findings: A review of the admission Record indicated Resident 8 was admitted on [DATE] with diagnoses that included sepsis (a life-threatening complication of an infection) and unspecified psychosis (loss of contact with reality). A review of Resident 8's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 11/6/2021, indicated Resident 8 was severely impaired with cognitive (a mental action of acquiring knowledge and understanding) skills for daily decision making. Resident 8 had episodes of delusions (misconceptions or beliefs that are firmly held, contrary to reality). Resident 8 was also given antipsychotic medication. Resident 8 required extensive assistance with bed mobility, transfer, locomotion , dressing, eating, toilet use and personal hygiene. A review of Resident 8's Physician Order, dated 11/30/2021, indicated Seroquel 25 milligrams (mg), one tablet by mouth, every 12 hours for unspecified psychosis. During a concurrent record review and interview with the director of nursing (DON) on 2/10/22, at 2:06 pm, DON stated she does not see the Informed Consent for the use of Seroquel in Resident 8's clinical record. DON stated the facility would obtain an Informed Consent for administration of Seroquel and administration of all antipsychotic medications. During an interview with the assistant director of nursing (ADON) on 2/10/22 at 2:29 pm, ADON stated it was important to obtain an Informed Consent from the responsible party or the resident so the doctor could explain to the family the possible side effects of the antipsychotic medication. ADON stated the possible side effects of Seroquel were tardive dyskinesia (a condition affecting the nervous system often caused by long term use of some psychiatric drugs), cognitive impairment, tremors, or akathisia (muscle quivering, restlessness). A record review of the facility's undated policy and procedure titled, Informed Consent, indicated before initiating the administration of psychotherapeutic drugs or physical restraints, facility staff shall verify that the patient's health record contains documentation that the patient has given informed consent to the proposed treatment or procedure. The Informed Consent shall be kept in the clinical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure call light was within reach for two of 24 sampled residents (Resident 29 and Resident 263) as indicated on the facility policy and care plan. This deficient practice had the potential for the residents not to be able to call the staff for assistance, which could result to not receiving or in delayed needed care or services necessary for the residents' well-being. Findings: a. A review of the admission Record indicated Resident 29 was initially admitted to the facility on [DATE] with diagnoses of malaise (feeling of weakness, overall discomfort, illness, or simply not feeling well) and abnormalities of gait ( a person's manner of walking ) and mobility. A review of Resident 29's Fall Care Plan, dated 11/30/2021, indicated Resident 29 was at risk for fall. Care plan interventions included were to place call light within easy reach. A review of Resident 29's History and Physical (H&P), dated 12/10/2021, indicated Resident 29 had the capacity to understand and make decisions. A review of Resident 29's Minimum Data Set (MDS - a comprehensive standardized assessment and care-screening tool), dated 1/10/2022, indicated Resident 29's brief interview of mental status (BIMS, screening that aids in detecting cognitive impairment) score was 13 (a score of 13 - 15 represents intact cognition [mental action or process of acquiring knowledge and understanding]). The MDS also indicated Resident 29 required limited assistance for bed mobility, transfer, dressing, toilet use and personal hygiene. During an observation on 2/7/2022 at 10:49 am, conducted with Licensed Vocational Nurse 1 (LVN 1), Resident 29's call light was observed hanging on the wall above Resident 29's headboard. LVN 1 stated Resident 29's call light should have been placed within reach. LVN 1 also stated Resident 29 would not be able to get help immediately if the call light was not within reach. During an interview on 2/9/2022 at 9:20 am, Assistant Director of Nursing (ADON) stated call light should be within resident's reach for staff to be able to attend to the resident to prevent fall and accidents. A review of the Policy and Procedure (P&P) titled, Call Lights, dated 1/19/2022, indicated to ensure call light was within the resident's reach when in his/her room or when on the toilet. b. A review of the admission Record indicated Resident 263 was initially admitted to the facility on [DATE] with diagnoses of malaise and abnormalities of gait and mobility. A review of Resident 263's History and Physical (H&P), dated 1/14/2022, indicated Resident 263 had the capacity to understand and make decisions. A review of Resident 263's Fall Care Plan, dated 1/17/2022 indicated Resident 263 was at risk for fall related to complex medical condition. Care plan interventions included were to place call light within easy reach. A review of Resident 263's Minimum Data Set (MDS - a comprehensive standardized assessment and care-screening tool), dated 1/19/2022, indicated Resident 263's brief interview of mental status (BIMS, screening that aids in detecting cognitive impairment) score was 12 (a score of 8- 12 represents moderately impaired cognition [mental action or process of acquiring knowledge and understanding]). The MDS also indicated Resident 263 required extensive assistance for bed mobility, transfer, dressing, toilet use and personal hygiene. During an observation on 2/7/2022 at 11:22 am, conducted with Licensed Vocational Nurse 1 (LVN 1), Resident 263's call light was observed on the floor and was not within reach. LVN 1 stated Resident 263's call light should have been placed within reach for staff to be able to assist resident immediately if help was needed. During an interview on 2/9/2022 at 9:20 am, Director of Nursing (DON) stated call light should be within resident's reach for staff to be able to attend to the resident to prevent fall and accidents. A review of the Policy and Procedure (P&P) titled, Call Lights, dated 1/19/2022, indicated to ensure call light was within the resident's reach when in his/her room or when on the toilet.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete and transmit the quarterly minimum data set (MDS, a standardized assessment and care screening tool) assessment timely for one of 24 sampled residents (Resident 1). This deficient practice resulted to a late completion and transmission of Minimum Data Set (MDS, a standardized assessment and care screening tool) to Centers of Medicare and Medicaid (CMS) Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) system. This had the potential to affect the facility's quality monitoring data. Findings: A review of the admission Face Sheet indicated Resident 1 was readmitted to the facility on [DATE] with diagnoses that included hemiplegia (loss of muscle movement on one side of the body), anxiety ( a disorder with episodes of sudden feelings of intense anxiety and/or fear) and dementia (a decline in mental ability severe enough to interfere with daily life). A review of Resident 1's quarterly MDS, dated [DATE], indicated Resident 1 was severely impaired with cognitive skills () for daily decision making. Resident 1 was totally dependent on the staff for bed mobility, transfer, and locomotion, toilet use and personal hygiene. A review of a MDS 3.0 File Submission Report, dated 2/7/2021, indicated Resident 1's quarterly MDS assessment was dated 1/1/2022. The report indicated Resident 1's MDS was completed late, more than 14 days after the Assessment Reference Date (ARD). During a concurrent record review and interview with the MDS Coordinator on 2/11/2022 at 10 am , MDS Coordinator stated Resident 1's quarterly MDS assessment was completed and transmitted late. MDS Coordinator stated the assessment should have been completed no later than 14 days after the ARD per the Resident Assessment Instrument (RAI) manual. MDS coordinator also stated the quarterly MDS assessment must be transmitted 14 days after MDS completion date. MDS Coordinator added the facility did not have a policy on MDS, but follows the RAI manual. MDS Coordinator stated it was important to submit the MDS timely per RAI guidelines. A review of the MDS RAI Version 3.0 Manual, Chapter 5: Submission and Correction of the MDS Assessments, dated 10/ 2019, indicated the quarterly MDS completion date must be completed 14 days after the Assessment Reference Date (ARD) and transmitted 14 days after MDS completion date.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Preadmission Screening and Resident Review (PASRR) Level 1 Screening was completed for one of 24 residents (Resident 71). This deficient practice had the potential for the residents not to be screened for mental disorder (MD) or intellectual disability (ID), which could result to inappropriate placement depriving them of the care and services specific to their needs. Findings: A review of the admission Record indicated Resident 71 was admitted on [DATE] with diagnoses that included schizophrenia (mental health condition that affects how you think, feel, and behave) and hypertension (chronic elevated blood pressure). A review of Resident 71's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 1/3/2022, indicated Resident 71 was severely impaired with cognitive (a mental action of acquiring knowledge and understanding) skills for daily decision making. Resident 71 required extensive assistance with bed mobility, transfer, walking, dressing, eating, and personal hygiene. During an interview on 2/9/2022, at 12:10 pm, MDS Nurse stated Registered Nurse Supervisor (RN 1) completed Resident 71's PASRR I on 2/9/2022 because they could not find one in Resident 71's clinical record. During a concurrent record review and interview with assistant director of nursing (ADON), on 2/10/22, at 2:37 pm, ADON stated the PASRR I screen should be completed upon admission of the resident. ADON stated the PASRR I screen will assist the facility if the resident has mental illness. ADON stated it was important to complete a PASRR I screen upon the resident's admission to be able to provide appropriate care and services to the resident. ADON verified Resident 71 did not have a PASRR I screen on admission. ADON stated Resident 71's PASRR 1 screen was completed on 2/9/2022. During an interview, on 2/11/22 at 10:27 am, DON stated it was the responsibility of the admission Nurse to complete the PASRR I upon the resident's admission. A record review of the California Department of Health Care Services PASRR Facility Training, indicated PASRR is a Preadmission Screening and Resident Review submitted online by the facility, required by per Federal regulations 42 CFR 483. 100-483. 138, and required for all Medicaid certified nursing facility applicants.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to revise the care plan to reflect Resident's preference while smoking for one of 24 sampled residents (Resident 213), as indicated on the facility policy. This deficient practice had the potential for Resident 213 not to receive specific interventions to address preference, resolve underlying cause of preference to ensure safety while smoking. Findings: A review of the admission Record indicated Resident 213 was admitted on [DATE] with diagnoses that included osteoarthritis (a type of arthritis that occurs when flexible tissue at the ends of bones wears down), unspecified cirrhosis of the liver (chronic liver damage), and major depressive disorder (a mental health disorder characterized by persistently depressed mood). A review of Resident 213's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 1/18/2022, indicated Resident 213 had an intact cognitive skills (a mental action of acquiring knowledge and understanding) for daily decision making. During an observation on 2/11/2022, at 9:45 am, Resident 213 refused to smoke at 10 am, but said she would go later in the day possibly after dinner. During an interview and concurrent observation, on 2/11/22, at 9:51 am, Treatment nurse 2 (TN 2) was observed applying cream to Resident 213's upper body area due to complaints of feeling itchy. Resident 213 stated she will not wear the apron because there was only one apron for all of the residents and it made her itchy. Resident 213 stated she had spoken to staff regarding the issue. During an interview, on 2/11/22, at 10:25 am, Administrator (ADM) stated Resident 213 was the only one who used the smoking apron, and it was required for safety. During an interview, 2/11/22, at 10:30 am, Licensed Vocational Nurse 5 (LVN 5) stated residents had choices and they cannot force them to wear an apron, but they will try to explain why it was necessary to wear it. During an interview, on 2/11/22, at 11:34 am, Certified Nursing Assistant 3 (CNA 3) stated she takes Resident 213 out to smoke when she wants to go. CNA 3 stated Resident 213 does not like wearing the smoking apron but ends up putting it on to smoke. CNA 3 stated Resident 213 does complain she is itchy, but the treatment nurse puts cream on the resident. During an interview, on 2/11/22, at 11:40 a.m., TN 2 stated Resident 213 had chronic itchy skin- with no visible rashes, and most likely due to dry skin. TN2 stated Resident 213 receives treatment for it. During a concurrent record review of the Smoking Assessment and interview with the Assistant Director of Nursing (ADON), on 2/11/22 at 12:23 pm, ADON stated Resident 213 Smoking Assessment, dated 1/12/2022, indicated for Resident 213 to wear a smoking apron. ADON stated if Resident 213 refused to wear the smoking apron, its purpose for safety will be explained to the Resident. ADON stated the care plan should be updated to reflect Resident 213's refusal to wear the smoking apron. ADON stated this was important so that everybody will know the kind care needed for the resident. A review of Resident 213's Smoking Care Plan, dated 1/11/2022, indicated Resident 213's capabilities and deficits determined she needed to use smoking apron when smoking. The Smoking Care Plan was not revised and did not indicate Resident 213's refusal to wear the smoking apron as stated by staff. A record review of the undated facility policy and procedure titled, Resident Care Plan, indicated it is the responsibility of the Director of Nursing to ensure that each professional involved in the care of the resident is aware of the written plan of care, its location, the current problems of the resident, and the goals or objectives of the plan. It is the responsibility of the Licensed Nurse to ensure that the plan of care is initiated and evaluated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure medication regimen review (MRR) irregularity identified by the Pharmacy Consultant was acted upon for one of 24 sampled residents (Resident 52) who was on a blood thinner (Lovenox) medication, in accordance with the facility policy. This deficient practice had the potential for unnecessary medication administration to the resident. Findings: A review of the admission Record indicated Resident 52 was admitted to the facility on [DATE] with diagnosis that included malignant neoplasm of the brain (brain cancer), dependence on a ventilator (a machine to provide breathing for a patient who is physically unable to breathe) and epilepsy (brain activity becomes abnormal, causing seizures [sudden, uncontrolled electrical disturbance in the brain which can cause changes in behavior, movements, feelings, and consciousness]). A review of a Minimum Data Set (MDS, a resident interview and care-screening tool), dated 12/19/2021, indicated Resident 52 was totally dependent on the staff for bed mobility (moves to and from lying position), transfers (moves to and from bed, chair, wheelchair), dressing and personal hygiene. A review of Resident 52's Physician order, dated 12/16/2021, indicated Enoxaparin (Lovenox) 40 milligrams (mg) subcutaneously once daily. A record review of a Medication Administration Record (MAR) for February 2022, indicate Enoxaparin 40 mg was administered to Resident 52 daily from 2/1/2022 to 2/9/2022. A record review of a facility document titled, Consultant Pharmacist's Medication Regimen Review (MRR), dated 1/3/2022 - 1/5/2022, received on 1/5/2022, completed by the facility's pharmacist consultant, indicated to consider asking the physician for a term of therapy for Lovenox. During a concurrent record review and interview with the Assistant Director of Nursing (ADON) on 2/10/2022 at 12:58 pm, ADON stated the recommendations from the Pharmacist to obtain a stop date for Lovenox were not followed for Resident 52. ADON stated there were no documentation of Resident 52's physician being informed of the recommendation. ADON further stated Lovenox can cause bleeding and a stop date should be indicated to prevent any unwanted reactions form the medications. During a concurrent record review and interview with the Director of Nursing (DON) on 2/10/2022 at 2:25 pm, DON stated the pharmacy recommendations should be carried out within seven days after receipt of the MRR. DON also stated pharmacy recommendations should be followed up within three to five days for the safety of the residents to ensure that the right medications were given to them. A review of the facility's policy and procedure titled, Consultant Pharmacist Report, dated 6/2021, indicated recommendations are acted upon and documented by the facility staff and or the prescriber. The physician accepts and acts upon suggestions or rejects and provides an explanation for disagreeing by the next physician visit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. A review of the admission Record indicated Resident 68 was readmitted to the facility on [DATE] with diagnoses that included respiratory failure (a condition that develops when the lungs cannot get enough oxygen into the blood), encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition [such as viral infection or toxins in the blood]), and intracerebral hemorrhage (a ruptured blood vessel causes bleeding inside the brain). A review of Resident 68's History and Physical (H&P), dated 9/21/2021, indicated Resident 68 did not have the capacity to understand and make his own decisions. A review of the Minimum Data Set (MDS, standardized assessment and care screening tool), dated 12/24/2021, indicated Resident 68 was severely impaired with cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision-making. Resident 68 was totally dependent on staff for personal hygiene (practices conducive to maintaining health and preventing disease, especially through cleanliness), toilet use, transfers (moving a patient from one flat surface to another) and eating. MDS also indicated Resident 68's use of limb restraint. During an observation, on 2/7/2021, at 10:40 am, in Resident 68's room, Resident 68 had a soft hand mitten on his left hand. During an interview, on 2/9/2022, at 4:29 pm, Registered Nurse (RN) 1 stated a soft mitten was put on Resident 68 because he was trying to pull his tracheostomy tube (a curved tube that was inserted into a tracheostomy stoma [the hole made in the neck and windpipe]) and gastrostomy tube (a tube inserted through the abdomen that delivers nutrition directly to the stomach). A review of Resident 68's Physician Order, dated 2/7/2022, indicated the use of left hand mitten for prevention of pulling out life sustaining tubes. The Physician Order did not indicate an end date to the restraint order. During an interview with Director of Nursing (DON), on 2/9/2022 at 4:36 pm, DON stated restraint orders should have an end date to ensure residents use of restraints were reassessed for its necessity and benefit. A review of the facility's undated policy and procedure titled, Physical Restraints, indicated the licensed nurse shall be responsible for obtaining an order from the attending physician, for restraint use, which is to include the specific type of restraint, the purpose of the restraint, and the time and place of applications. It also indicated the facility is to engage in a systematic and gradual process toward reducing restraints. c. A review of the admission Record indicated Resident 81 was admitted to the facility on [DATE] with diagnoses that included paroxysmal atrial fibrillation (irregular, often rapid heart rate that commonly causes poor blood flow), chronic heart failure (chronic condition in which the heart doesn't pump blood as well as it should), and type 2 diabetes mellitus (an impairment in the way the body regulates and uses sugar as a fuel). A review of Resident 81's History and Physical (H&P), dated 3/10/2021, indicated Resident 81 has the capacity to understand and make her own decisions. A review of the Minimum Data Set (MDS, standardized assessment and care screening tool), dated 12/9/2021, indicated Resident 81 was independent with cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision-making. Resident 81 required limited assistance for personal hygiene (practices conducive to maintaining health and preventing disease, especially through cleanliness), toilet use, and transfers (moving a patient from one flat surface to another). During an observation, on 2/7/2021, at 11:28 am, in Resident 81's room, Resident 81's bed was observed to be pushed against the wall on the right side. There was no space between the bed and the wall for resident 81 to get out of the bed on her right side. During a concurrent record review and interview with the Director of Nursing (DON), on 2/9/2022, at 4:50 pm, DON stated there was no assessment completed to determine that Resident 81 was able to get out of the bed while the bed was pushed against the wall. DON stated Resident 81's medical record did not have any orders or care plan for the bed to be pushed against the wall. DON stated there should have been an assessment to determine if Resident 81 was able to get out of the bed while the bed was pushed against the wall. DON stated the purpose of the assessment was to prevent entrapment and injury to the resident. DON stated a bed pushed against the wall was considered a restraint. A review of the facility's undated policy and procedure (P&P) titled, Physical Restraint, indicated the licensed nurse was responsible for obtaining an order from the attending physician for restraint use, to include the specific type of restrain, and the purpose of the restraint. The facility was responsible in obtaining an informed consent for the use of restraints, from the resident or from the surrogate decision maker. d. A review of the admission Record indicated Resident 85 was admitted to the facility on [DATE] with diagnoses that included respiratory failure (a condition that develops when the lungs cannot get enough oxygen into the blood), pneumonia (infection that inflames air sacs in one or both lungs, which may fill with fluid), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe). A review of Resident 85's History and Physical (H&P), dated 1/11/2022, indicated Resident 85 did not have the capacity to understand and make her own decisions. A review of the Minimum Data Set (MDS, standardized assessment and care screening tool), dated 1/14/2022, indicated Resident 85 was severely impaired with cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision-making. Resident 85 was totally dependent on staff for personal hygiene (practices conducive to maintaining health and preventing disease, especially through cleanliness), toilet use, transfers (moving a patient from one flat surface to another) and eating. MDS also indicated Resident 85's use of limb restraint. During an observation, on 2/8/2022, at 10:40 am, in Resident 85's room, Resident 85 had soft hand mittens restraint on both of her hands. During an interview, on 2/9/2022, at 4:16 pm, Registered Nurse (RN) 1 stated soft mittens were put on Resident 85 because she was trying to pull out her tracheostomy tube (trach, a curved tube that is inserted into a tracheostomy stoma [the hole made in the neck and windpipe]) and gastrostomy tube (g-tube, a tube inserted through the abdomen that delivers nutrition directly to the stomach). A review of Resident 85's Physician Order, dated 2/7/2022, indicated to use restraints, hand mittens for prevention of pulling out life sustaining tubes. The Physician Order did not indicate an end date to the restraint order. During an interview with Director of Nursing (DON), on 2/9/2022 at 4:36 pm, DON stated restraint orders should have an end date to ensure residents use of restraints were reassessed for its necessity and benefit. A review of the facility's undated policy and procedure titled, Physical Restraints, indicated the licensed nurse shall be responsible for obtaining an order from the attending physician, for restraint use, which is to include the specific type of restraint, the purpose of the restraint, and the time and place of applications. It also indicated the facility is to engage in a systematic and gradual process toward reducing restraints. Based on observation, interview and record review, the facility failed to ensure four of four sampled residents (Residents 163, 68, 81 and 85) were free from the use of physical restraints (any manual method, physical or mechanical device/equipment or material that limits a resident's freedom of movement and cannot be removed by the resident in the same manner as it was applied by staff) in accordance with the facility policy. a. Resident 163's Physician order for the use of soft mitten restraints did not have an end date to ensure re-evaluation of its use. b. Resident 68's Physician order for the use of soft mitten restraints did not have an end date to ensure re-evaluation of its use. c. A restraint assessment was not conducted prior to placing Resident 81's bed against the wall. d. Resident 85's Physician order for the use of soft mitten restraints did not have an end date to ensure re-evaluation of its use. These deficient practices had the potential to affect the residents' physical and psychological functioning and quality of life. Findings: a. A review of the admission Record indicated Resident 163 was admitted to the facility on [DATE] with diagnosis that included chronic respiratory failure (too little oxygen passes from your lungs to your blood), tracheostomy (an incision in the windpipe made to relieve an obstruction to breathing) and dementia (a decline in mental ability severe enough to interfere with daily life). A review of the History and Physical, dated 2/4/2022, indicted Resident 163 did not have the capacity to understand and make decisions. During an observation, on 2/7/22 at 10:48 am, in Resident 163's room, Resident 163 was observed laying on her back, wearing bilateral hand mitten restraints. During an observation, on 2/9/2022 at 10:08 am, in Resident 163's room, Resident 163 was observed laying on her back, wearing bilateral hand mitten restraints. A review of Resident 163's Order Summary Report, dated 2/3/2022, indicated the application of bilateral (affecting both sides) hand mittens for prevention of pulling out of life sustaining tubes. During a concurrent observation and interview with Licensed Vocational Nurse 6 (LVN 6), on 2/10/2022 at 10:05 am, Resident 163 was observed wearing bilateral mitten restraints on her left and right hand. LVN 6 stated she was uncertain on when or if there was a stop date for Resident 163's use of physical restraint. LVN 6 stated there was no discontinued orders in Resident 163's Medication Administration Records (MAR). LVN 6 further stated she has not followed up or looked at Resident 163's care plan for restraints. During a concurrent record review and interview with Director of Nursing (DON), on 2/9/2022 at 4:36 pm, DON stated Resident163's restraint order did not and should have an end date to ensure Resident 163's restraint use was reassessed for its necessity and benefit. A review of the facility's undated policy and procedure titled, Physical Restraints, indicated the licensed nurse shall be responsible for obtaining an order from the attending physician, for restraint use, which is to include the specific type of restraint, the purpose of the restraint, and the time and place of applications. It also indicated the facility is to engage in a systematic and gradual process toward reducing restraints.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure proper care and treatment for gastrostomy tube (G-tube, a tube inserted through the abdomen that delivers nutrition directly to the stomach) was provided for two of three sampled residents (Residents 5 and 93) by not keeping Resident 5's and Resident 93's head of bed elevated to an angle of 30-45 degrees while on G-tube feeding in accordance with the Physician order. This deficient practice had the potential to put the residents at risk for aspiration pneumonia (a form of pneumonia that occurs when food particles/foreign materials enter the lungs) and/or choking. Findings: a. A review of the admission Record indicated Resident 5 was admitted to the facility on [DATE] with diagnoses that included chronic respiratory failure (a condition that develops when the lungs cannot get enough oxygen into the blood), epilepsy (disorder in which nerve cell activity in the brain is disturbed, causing seizures), and nontraumatic subdural hemorrhage (a type of bleeding between the brain and its outermost covering). A review of Resident 5's History and Physical (H&P), dated 2/10/2022, indicated Resident 5 did not have the capacity to understand and make her own decisions. A review of the Minimum Data Set (MDS, standardized assessment and care screening tool), dated 10/15/2022, indicated Resident 5 was severely impaired with cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision-making. Resident 5 was totally dependent on staff for personal hygiene (practices conducive to maintaining health and preventing disease, especially through cleanliness), toilet use, transfers (moving a patient from one flat surface to another) and eating. Resident 5 was on feeding tube. During a concurrent observation and interview with Licensed Vocational Nurse 2 (LVN 2), on 2/7/2022, at 10:32 am, in Resident 5's room, Resident 5's G-tube was infusing. Resident 5's head of bed angle indicator (metal ball) was observed to be stuck and did not move up or down when the head of bed was raised or lowered. LVN 2 stated she did not know what angle the head of the bed was set at. LVN 2 stated head of bed looked set at less than 30 degree angle. During an interview, on 2/8/2022, at 2:05 pm, Registered Nurse (RN) 1 stated that she replaced the bed for Resident 5 since the head of bed angle indicator was broken. During a review of Resident 5's Physician Order, dated 2/11/2022, indicated Resident 5's head of bed must always be elevated to 30-45 degrees during G-tube feeding. b. A review of Resident 93's admission Record indicated Resident 93 was admitted to the facility on [DATE] with diagnoses that included acute and chronic respiratory failure (a condition that develops when the lungs cannot get enough oxygen into the blood), encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition [such as viral infection or toxins in the blood]), and type 2 diabetes mellitus (an impairment in the way the body regulates and uses sugar as a fuel). A review of Resident 93's History and Physical (H&P), dated 10/10/2021, indicated Resident 93 did not have the capacity to understand and make her own decisions. A review of the Minimum Data Set (MDS, standardized assessment and care screening tool), dated 1/11/2022, indicated Resident 93 was severely impaired with cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision-making. Resident 93 was totally dependent on staff for personal hygiene (practices conducive to maintaining health and preventing disease, especially through cleanliness), toilet use, transfers (moving a patient from one flat surface to another) and eating. Resident 93 was on feeding tube. During an observation, on 2/7/2022, at 10:20 am, in Resident 93's room, Resident 93's G-tube was infusing with Glucerna 1.5 (a feeding tube formula) at 65 milliliters per hour. Resident 93's head of bed angle indicator was observed to be at a 20-degree angle. During a concurrent observation and interview with Licensed Vocational Nurse 2 (LVN 2), on 2/7/2022, at 10:26 am, in Resident 93's room, Resident 93's head of bed was observed to be at a 20-degree angle. LVN 2 stated the head of bed angle should be at 30-45 degrees when the G-tube feeding is infusing. LVN 2 stated the head of bed angle was at 20 degrees. LVN 2 stated the LVNs and Certified Nurse Assistants (CNAs) should ensure the head of bed is at 30-45 degrees when the G-tube feeding is running to prevent Resident 93 from aspirating (the accidental breathing in of food or fluid into the lungs) the G-tube formula. During a review of Resident 93's Physician Order, dated 2/7/2022, indicated Resident 93's head of bed must always be elevated to 30-45 degrees during G-tube feeding.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. A review of Resident 85's admission Record indicated Resident 85 was admitted to the facility on [DATE] with diagnoses that included Respiratory Failure (a condition that develops when the lungs cannot get enough oxygen into the blood), Pneumonia (infection that inflames air sacs in one or both lungs, which may fill with fluid), Chronic Obstructive Pulmonary Disease (a group of lung diseases that block airflow and make it difficult to breathe). A review of Resident 85's History and Physical, dated 1/11/2022, indicated the resident did not have the capacity to understand and make her own decisions. A review of Resident 85's Minimum Data Sheet (MDS, a standardized assessment and care screening tool), dated 1/14/2022, indicated Resident 85 was severely impaired with cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision-making. Resident 85 was totally dependent on staff for personal hygiene (practices conducive to maintaining health and preventing disease, especially through cleanliness), toilet use, transfers (moving a patient from one flat surface to another) and eating. During an observation, on 2/07/2022, at 9:55 am, a clear plastic cup with pink cream was sitting on Resident 85's bedside table. During an interview, on 2/7/2022, at 9:57 am, Certified Nurse Assistant 1 (CNA 1) stated the pink cream at Resident 85's bedside is from the Treatment Nurse. CNA 1 stated that the cream was for red areas of Resident 85's buttock. CNA 1 stated the cream should not be left at the resident's bedside unattended by staff because residents can use the cream inappropriately. During an interview, on 2/7/2022, at 10:05 am, Treatment Nurse (TN) 1 stated that the pink cream was Calazime. TN 1 stated the cream should be locked in the treatment cart. TN 1 stated the cream should not be left with the residents. A review of the facility's policy and procedure (P&P) titled Medication Storage in the Facility, dated April 2008, the P&P indicated, that medications are stored safely securely and properly. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized. c. During a medication cart observation in red zone (an area dedicated for residents who are Corona Virus 19 [COVID-19, a respiratory illness that can spread from person to person] on 2/08/2022, at 10:38 am, observed a white pill placed in a medication cup left unattended on top of the medication cart. During an interview on 2/08/2022 at 10:40 am, LVN 1, stated medication should not supposed to be left unattended. LVN 1 also stated he totally forgot and medication should not be left unattended because anyone could come by and take the medication. During an interview on 2/09/2022 at 9:24 am, the Assistant Director of Nursing (ADON) stated medication should not be left unattended. ADON also stated confused residents or staff or visitors might took it and for safety purposes. A review of the facility's Policy and Procedure (P&P) titled, Administering Medications, dated 4/2019, indicated when opening a multi dose container, the date opened is recorded on the container. Based on observation, interview, and record review, the facility failed to provide safe and secure storage of medication by failing to: a. Ensure appropriate environmental/temperature controls of resident medications stored in one of two medication rooms (Station 1). b. Ensure to provide safe and secure storage of medication (Calazime cream is used to protect skin from wetness, urine, or stools) that was observed at Resident 85's bedside. c. Ensure to provide safe and secure storage of a white pill unattended on top of the medication cart. These deficient practices had the potential for medications to be exposed to improper temperatures that could alter the medications' integrity and the potential for residents to receive medications not intended for them. Findings: a. During an observation and concurrent interview with Licensed Vocational Nurse 5 (LVN 5) on 2/9/2022 at 11:32 am, four 250 milliliters (ml) bag of Vancomycin (an antibiotic) and six boxes of five ml multi-dose vials of influenza vaccine were observed in Stations one's medication refrigerator. LVN 5 stated the medication refrigerator temperature was not checked on 2/8/2022. LVN 5 stated medication needed to be regulated; if the temperature was too high or too low, the medications would lose their desire effect and residents may not be able to receive their prescribed dose. During an observation of Station 1 medication room and concurrent interview with LVN 5, on 2/9/2022 at 11:36 am. Among other medication bottles, one un-opened bottle of multi-vitamin capsules, and one unopened bottle of ferrous sulfate 325 milligram (mg) tablets were observed in a cabinet. LVN 5 stated the room temp was 70 degrees. LVN 5 stated she was unaware of the acceptable range for medication room temperature or where the temperature log was located. During a concurrent observation, interview and record review, on 2/9/2022 at 11:43 am, the Director of Nursing (DON) confirmed medication room temperatures on 2/4/2022, 2/5/2022, 2/5/2022, 2/6/2022, 2/7/2022, and 2/8/2022 were not monitored or recorded. DON stated it was important to monitor and record room temperature to ensure medications were correctly stored to keep the integrity of the medications. A review of the facility's undated policy titled Medication Refrigerator Temperature Log, indicated check medication refrigerator temperature daily and record - to be within 36-46 degrees Fahrenheit. A review of the facility's undated policy titled Medication Room Temperature Log, indicted it is the policy to maintain the room temperature within the 71 - 81 degrees Fahrenheit. A review of the facility's policy titled Medication Storage in the Facility, effective on 4/2008, indicated medications requiring storage at room temperature are kept at temperatures ranging from 59 - 86 degrees Fahrenheit. Medications requiring refrigeration or temperatures between 36 - 46 degrees Fahrenheit are kept in a refrigerator with a thermometer to allow temperature monitoring.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** f. A review of Resident 85's admission Record indicated Resident 85 was admitted to the facility on [DATE] with diagnoses that included Respiratory Failure (a condition that develops when the lungs cannot get enough oxygen into the blood), Pneumonia (infection that inflames air sacs in one or both lungs, which may fill with fluid), Chronic Obstructive Pulmonary Disease (a group of lung diseases that block airflow and make it difficult to breathe). A review of Resident 85's History and Physical (H&P, admission record), dated 1/11/2022, the H&P indicated that the resident did not have the capacity to understand and make her own decisions. A review of the MDS, dated [DATE], the MDS indicated Resident 85 was severly impaired with cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision-making. Resident 85 was totally dependent on staff for personal hygiene (practices conducive to maintaining health and preventing disease, especially through cleanliness), toilet use, transfers (moving a patient from one flat surface to another) and eating. During a concurrent observation and interview on 2/8/2022, at 12:12 pm, with Treatment Nurse (TN) 1, Resident 85's wound care treatment was observed. TN entered Resident 85's room and approached the resident without putting on an isolation gown. TN 1 stated Resident 85 was on contact precaution isolation because Resident 85 had Candida auris. TN 1 stated she should wear an isolation gown to prevent infecting other residents with Candida auris. TN 1 stated she forgot to put on the gown before entering the room and approaching Resident 85. During a review of Resident 85's Order Summary Report (Physician Order), Dated 2/7/2022, the Physician Order indicated that Resident 85 was on contact isolation for Candida Auris. A review of the facility's policy and procedure (P&P) titled Infection Control, undated, the P&P indicated, that Contact Precautions require gowns to be worn by staff when providing care to residents. Based on observation, interview, and record review, the facility failed to follow infection control practices in accordance with the facility's policy by failing to: a. Ensure to have a monitoring log for cleaning and disinfecting high touch areas in the facility's red zone (an area dedicated for residents who are Corona Virus 19 [COVID-19, a respiratory illness that can spread from person to person] positive). b. Ensure Resident 74's nasal cannula tubing (a device used to deliver oxygen to a resident) was labeled and provided a clean storage bag. c. Ensure Resident 13's enteral tube feeding (delivery of liquid nutrients through a tube directly into the gastrointestinal tract) was labeled as indicated in the facility policy. d. Ensure housekeeper 2 (HK 2) wore Personal Protective Equipment (PPE- to protective clothing, helmets, gloves, face shields, goggles, face masks and/or respirators or other equipment designed to protect the wearer from injury or the spread of infection or illness) when she entered a room of a resident on contact isolation (using PPE when in contact or around a contagious[spread from one person or organism to another by direct or indirect contact] infection). e. Ensure Resident 7's nasal cannula did not touch the floor. f. Ensure appropriate PPE was used by staff while providing treatment to Resident 85 who was on contact isolation for Candida Auris (is a yeast [type of fungus] that causes severe infections and can spread in healthcare settings) as indicated on the facility policy. g. Ensure appropriate PPE was used by staff before entering Residents 8, 26, and 104's rooms in the Yellow Zone (unit for residents who have been in close contact with known cases of COVID-19, newly admitted or re-admitted residents, have symptoms of possible COVID-19 pending test results, and for residents with indeterminate tests). These deficient practices had the potential to transmit infectious microorganisms and increase the risk of infection for the residents and staff members. Findings: a. During an interview and record review on 2/7/2022 at 11:38 am, Housekeeping 1 (HK 1) stated he was not familiar with the monitoring log for cleaning of high touch areas such as hand rails, door knobs, light switches, common areas or nurses station in the red zone. HKP 1 stated he disinfected the high touch areas every two hours but did not have any clinical documentation or any form that he documented the disinfecting of the high touch areas. During an interview on 2/9/2022 at 9:21 am, the facility's Acting Director of Nursing (ADON) stated there was a monitoring log that the housekeeping were supposed to sign every time high touch areas were disinfected. ADON stated it was important to have a monitoring log for disinfecting high touch areas for the staff to know and to prevent spread of infection and have continuity of the care. A review of the facility's COVID-19 Preparedness revised on 2/1/2022, indicated environmental cleaning will be done of highly, frequently touched areas (such as doorknobs, grab rails, telephones, elevator etc). b. A review of Resident 74's admission Record indicated the resident was readmitted to the facility on [DATE] with diagnoses including dysphagia (difficulty swallowing), and chronic respiratory failure), respiratory failure (is a condition in which not enough oxygen passes from the lungs into the blood) with hypoxia (low oxygen level in the blood stream) and encounter for attention to gastrostomy (GT- a tube inserted through the abdomen that delivers nutrition directly to the stomach). A review of Resident 74's Physician Order dated 8/27/2020, indicated to administer oxygen (O2) at three (3) liters per minute (l/min) via nasal cannula (device placed in the nostrils to deliver oxygen) may titrate up to 5 l/min for O2 saturation less than 91%. A review of Resident 74's MDS, dated [DATE], indicated Resident 74's brief interview of mental status (BIMS, screening that aids in detecting cognitive impairment) score was zero(a score of 0 - 7 represents Severely impaired cognition. The MDS also indicated Resident 74 required extensive assistance for bed mobility, dressing, and personal hygiene. The MDS also indicated Resident 74 required total dependence from the staff for toilet use A review of Resident 74's History and Physical (H&P) dated 11/27/2021, indicated Resident 74 did not have the capacity to understand and make decisions. During a concurrent observation and interview on 2/09/2022, at 10:25 am, together with Licensed Vocational Nurse 1 (LVN 1), observed Resident 74's oxygen (O2) tube was undated and with no storage bag. LVN 1 stated O2 tubing should have a date and there should be a storage bag. LVN 1 stated there should be a label of the date and initial in the tubing and storage bag to prevent infection. During an interview on 2/10/2022 at 12:40 pm, the ADON, stated based on the facility's policy, O2 tubing and plastic bag should be labeled with the date and initial of the employee when it was initially used. DON stated if O2 tubing was unlabeled and there was no O2 storage bag it might dangled in the floor and could cause potential infection to the resident. A review of the facility's P&P titled, Oxygen Administration, dated 1/19/2022 the P&P, indicated that oxygen tubing should be changed weekly and as needed, including the mask, cannula, nebulizer equipment, etc. When not in use, the oxygen tubing should be stored in a clean bag; for example, a Ziplock bag, etc. The date, time, initials should be noted on oxygen equipment when it is initially used and when changed. c. A review of Resident 13's admission Record indicated the facility admitted Resident 13 on 12/22/2020 with diagnoses including encounter for attention to gastrostomy and diabetes (a condition that affects the way the body processes blood sugar). A review of Resident 13's MDS, dated [DATE] indicated cognitive skills for daily decision making was severely impaired. The MDS indicated Resident 13 required total dependence from staff for transfer, dressing, eating, toilet use and personal hygiene. A review of Resident 13's Physician's order, dated 11/08/2021, it indicated, Glucerna 1.5 at 40 cubic centimeter (cc) per hour (hr) for 20 hrs via pump (electronic medical device that controls the timing and amount of nutrition delivered to a patient during enteral feeding)to provide 800 milliliter (ml) per 1,200 kilocalories (kcal) per day. During a concurrent observation and interview on 2/7/2022, at 10:14 am, together with LVN 1 observed Resident 13's enteral tube feeding label attached to it was undated. LVN 1 stated tubing should be changed everyday labeled with date and with licensed initial. LVN 1 also stated it was important to know when was the tubing was changed to avoid infection to the residents. During an interview on 02/09/2022 at 9:10 am, the ADON, stated that enteral tubing needs to be labeled with date the moment it was changed. ADON stated, if the enteral tubing was not dated then it was not changed and might cause abdominal problems or can cause infection to the residents. A review of the facility's P&P titled, Enteral Feeding Monitoring, dated 01/19/2022 the P&P indicated the tubing will also be labeled with time and date with initials. d. A review of an admission Record indicated Resident 31 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD, chronic obstruction of lung airflow. health condition that affects an individual's ability to breathe well), atrial fibrillation (irregular heartbeats) and diabetes (elevated blood sugar). A review of an Order Summary Report indicated transmission-based precautions (transmission via droplet, contact, or airborne routes in healthcare) for Candida Auris (an infection found in wounds respiratory and urine specimens) was ordered for Resident 31 on 11/30/2021. A review of a Minimum Data Set (MDS, a resident assessment and care-screening tool), dated 12/3/2021, indicated Resident 31 was cognitively impaired and was totally dependent on transfers, locomotion on and off unit, dressing, eating and personal hygiene. During a concurrent observation and interview with HK 2, on 2/7/2022 at 10:36 am, HK 2 passed the isolation signages and PPE cart and walked into Resident 31's room without any PPE (gown or gloves) on, swept the floor and continued to exit the resident's room. HK 2 stated she was supposed to wear a gown before entering an isolation room to prevent the spread of any infection. During an interview, on 2/8/2022 at 2:13 pm, Housekeeping Supervisor (HS) stated housekeepers should be wearing proper PPE's prior to enter and exit an isolation room and sweeper mop heads changed to prevent the infection to be taken to another room. A review of an undated facility policy, titled Cleaning Isolation Rooms, indicted to obtain and put on gown, mask, and disposable gloves from supplies located outside of the room. e. A review of an admission Record indicated Resident 7 was admitted to the facility on [DATE] with diagnosis that included atrial fibrillation (irregular heartbeat), heart failure (chronic condition in which the heart doesn't pump blood as well as it should) and major depressive disorder (causes feelings of sadness and/or a loss of interest in activities once enjoyed). A review of a Minimum Data Set (MDS, a resident assessment and care-screening tool) dated 11/6/2021, indicated Resident 7 needed extensive assistance (staff provide weight-bearing support) with bed mobility, transfer, dressing, toilet use and personal hygiene. A review of an Order Summary Report, indicated to administer 02 at two liters per minute via NC. During a concurrent observation and interview, on 2/9/2022 at 11:09 am, with Licensed Vocational Nurse 2 (LVN 2), Resident 7's nasal cannula was observed touching the floor. LVN 2 stated the resident's NC should not be touching the floor to avoid contamination and the spread of infection. g. A review of Resident 8's admission Record (Face Sheet) indicated she was admitted on [DATE] with diagnoses that included sepsis (a life-threatening complication of an infection), urinary tract infection (an infection in any part of the urinary system, the kidneys, bladder, or urethra), and unspecified dementia with behavioral disturbance (a group of symptoms that can affect thinking, memory, reasoning, personality, mood and behavior). A review of Resident 8's MDS, dated [DATE], indicated she was severely cognitively impaired (a mental action of acquiring knowledge and understanding). A review of Resident 26's admission Record (Face Sheet) indicated she was readmitted on [DATE] with diagnoses that included pressure ulcer of the right hip Stage 4 (most severe form of bedsores reaching muscles, ligaments, and bones), Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors), and Alzheimer's disease (a progressive disease that destroys memory and other important functions). A review of Resident 26's MDS, dated [DATE], indicated she was severely cognitively impaired (a mental action of acquiring knowledge and understanding). A review of Resident 104's admission Record (Face Sheet) indicated she was readmitted on [DATE] with diagnoses that included anemia (blood doesn't have enough healthy red blood cells), chronic kidney disease (longstanding disease of the kidneys leading to renal failure), and Alzheimer's disease (a progressive disease that destroys memory and other important functions). A review of Resident 104's MDS, dated [DATE], indicated she was severely cognitively impaired (a mental action of acquiring knowledge and understanding). During an observation and concurrent interview on 2/7/22, at 3:22 pm, LVN 3 was observed entering room [ROOM NUMBER] without donning a gown in the Yellow Zone (suspected Covid 19 resident room). When exiting room, LVN 3 stated they did not have to wear a gown when going into a room in Yellow, they had to wear a gown when in Red (Covid 19 positive resident room). During an interview on 2/7/2022, at 3:34 pm, with LVN 4 stated staff was supposed to wear a gown, gloves, respirator, and goggles at all times when entering a Yellow Zone room. LVN 4 stated LVN 3 is known for doing that, not wearing a gown entering the Yellow Zone room. During an interview on 2/8/2022, at 3:28 pm, with infection preventionist nurse (IPN, nurse who helps prevent and identify the spread of infectious agents like bacteria and viruses in a healthcare environment), she stated staff was provided in-services on appropriate PPE to be worn in each cohort, three times a week on Wednesday, Thursday, and Friday for all staff. She stated verbal validation and return demonstration were done during in-services and random checks are done on the floor. The IPN stated the appropriate PPE for each cohort was in [NAME] Zone a N95, face shield was required, in Yellow Zone and Red Zone, a gown, N95, a face shield and gloves were required whether staff was providing resident care or not and staff was taught this during in-services. During an interview, on 2/10/22, at 10:42 am, with certified nursing assistant (CNA 2) she stated she was working in Yellow Zone on 2/10/2022 and she works in Yellow Zone a lot. She stated she received regular training on appropriate PPE donning and doffing when in Yellow Zone and the appropriate PPE worn for each cohort. CNA 2 stated the required PPE worn in Yellow Zone when entering a room is face shield, N95, gown, and gloves. CNA 2 stated required Yellow Zone PPE is worn whether patient care is provided or not. A record review of the facility's floor plan, dated, indicated Resident 8, 26, and 104 were in Yellow Zone. A record review of the facility's undated policy and procedure, dated, titled, Infection Control, indicated this facility has established and will maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection. Color-coded STOP signs are used to identify that Contact Precautions (Isolation) are in effect. This notifies staff and visitors of the need for special precautions and/or to contact nursing staff for further instructions.