Every finding on record at Bay Vista Healthcare & Wellness Centre, LP

Based on observation, interview, and record review, the facility failed to ensure facility staff supervised residents' whereabouts to prevent two of two residents (Resident 1 & Resident 2) from leaving the facility without facility staff's knowledge on 8/21/2026.This deficient practice resulted in Resident 1 & Resident 2 eloping (the act of leaving a facility unsupervised and without prior authorization) from the facility on 8/21/2026 placing Resident 1 & Resident 2 at risk for serious injury, harm, or death from hazards in the community, including traffic accidents, falls, exposure to environmental conditions or inability to obtain needed medical assistance.Findings:During an observation on 8/21/2026 at 7:39 a.m. in the nursing station, Licensed Vocational Nurse (LVN) 1 was observed on the phone stating the facility staff reviewed video surveillance footage at around 5:00 a.m. and the facility staff could not find a resident.a. During a review of Resident 1's Face Sheet (front page of the chart that contains a summary of basic information about the resident) dated 8/24/2026, the Face Sheet indicated the facility admitted Resident 1 on 5/15/2026 and was readmitted on [DATE] with diagnoses including paranoid schizophrenia (a mental illness that affects how a person thinks and understands what is real), abnormalities of gait and mobility, type 2 diabetes mellitus (a condition where your body has trouble controlling blood sugar levels), and anxiety (constantly feeling worried and nervous).During a review of Resident 1's History and Physical (H&P) dated 5/15/2026, the H&P indicated Resident 1 did not have the capacity to understand and make decisions.During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 5/22/2026, the MDS indicated Resident 1 had severe impairment of the ability to think or make decisions. The MDS indicated Resident 1 had a behavior of wandering. The MDS indicated Resident 1 needed supervision with eating, oral hygiene, upper body dressing, and personal hygiene. The MDS indicated Resident 1 needed moderate assistance from staff with toileting, showering, lower body dressing and putting on or taking off footwear.During a review of Resident 1's Change in Condition Evaluation (COC) dated 7/14/2026, the COC indicated Resident 1 attempted to leave facility following someone exiting front door. The COC indicated physician was notified of Resident 1's attempt to exit the facility and ordered to closely monitor resident's whereabouts.During a review of Resident 1's Elopement Evaluation dated 7/14/2026, the Elopement Evaluation indicated Resident 1 had wandering behaviors that was non-goal directed (confused, aimless, enters others' rooms and explores their belongings) and had a history of elopement or an attempted elopement while at home.During a review of Resident 1's COC dated 8/8/2026, the COC indicated Resident 1 had increased episode of anger outburst, screaming, yelling, verbal and physical aggression - throwing things at staff and pacing in the hallway. The COC indicated physician was notified of Resident 1's change in condition and recommended sending Resident 1 to a psychiatric hospital.During a review of Resident 1's Elopement Evaluation dated 8/19/2026, the Elopement Evaluation indicated Resident 1 had wandering behavior that were both goal directed (follows a pattern, with a specific destination in mind, going home) and non-goal directed. The Elopement Evaluation indicated Resident 1 had a history of elopement or attempting to leave the facility without informing staff.b. During a review of Resident 2's Face Sheet dated 8/24/2026, the Face Sheet indicated the facility admitted Resident 2 on 3/2/2026 with diagnoses including schizophrenia (a mental illness that is characterized by disturbances in thought), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety (constantly feeling worried and nervous).During a review of Resident 2's H&P dated 3/3/2026, the H&P indicated Resident 2 had fluctuating capacity to understand and make decisions.During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2 had the ability to think and make decisions. The MDS indicated Resident 2 did not have a behavior of wandering. The MDS indicated Resident 2 was independent with eating, needed setup assistance with oral hygiene, toileting hygiene and upper and lower body dressing, needed supervision with showering, putting on and taking off footwear, and personal hygiene.During a review of Resident 2's Elopement Evaluation dated 6/6/2026, the Elopement Evaluation indicated Resident 2 did not have a history of elopement or an attempted elopement while at home. The Elopement Evaluation indicated Resident 2 did not have a history of elopement or attempted leaving the facility without informing staff. The Elopement Evaluation indicated Resident 2 did not have a wandering behavior.During a concurrent observation and interview on 8/21/2026 at 8:36 a.m. with the Administrator (ADMN), the video surveillance titled Shed dated 8/21/2026 was reviewed. The ADMN stated, at 5:03 a.m. the window in room [ROOM NUMBER] (near the facility shed located at the back of the parking lot) was broken from inside the building. The ADMN stated Resident 1 broke, and climbed through the window and at 5:04 a.m. Resident 1 was seen walking down the side of the building parallel to the facility's parking lot. The ADMN stated, at 5:05 a.m. Resident 2 exited the facility through the window and walked behind the shed through the facility's parking lot.During an interview on 8/21/2026 at 10:23 a.m. with LVN 1, LVN 1 stated Certified Nursing Assistant (CNA) 2 informed her of a resident breaking the window. LVN 1 stated when she went to check room [ROOM NUMBER], Resident 2 was still in bed. LVN 1 stated she instructed CNA 1 to monitor the broken window in room [ROOM NUMBER]. LVN 1 stated after bringing Resident 1 back into the facility, facility staff checked all residents and noticed Resident 2 was missing.During an interview on 8/21/2026 at 11:43 a.m. with CNA 1, CNA 1 stated he was assigned to room [ROOM NUMBER] and room [ROOM NUMBER] which were located at the back of the facility. CNA 1 stated CNA 2 informed him about a broken window in room [ROOM NUMBER]. CNA 1 stated the facility staff were alerted about Resident 1 exiting the building through the window. CNA 1 stated he was not monitoring the broken window once Resident 1 exited, as he responded to help return Resident 1 to the facility. CNA 1 stated when the facility staff returned into the building, LVN 1 instructed facility staff to check on all residents then upon checking all residents, Resident 2 was missing.During an interview on 8/21/2026 at 11:56 a.m. with CNA 2, CNA 2 stated she was tending to another resident when she heard glass breaking. CNA 2 stated when she checked room [ROOM NUMBER], all the residents in room [ROOM NUMBER] were still in the room. CNA 2 stated she was not monitoring the broken window in room [ROOM NUMBER] as she was cleaning the blood off the floor in the hallway when Resident 1 was brought back into the building.During a concurrent observation and interview on 8/21/2026 at 12:23 p.m. with the ADMN, video surveillance titled main entrance and front street dated 8/21/2026 were reviewed. The ADMN stated, at 5:04 a.m. Receptionist (RCPS) and CNA 6 ran through the main entrance to respond. The ADMN stated, at 5:06 a.m. LVN 1, CNA 3, and CNA 1 were walking to the parking lot and retrieved Resident 1.During an interview on 8/21/2026 at 12:48 p.m. with RCPS, the RCPS stated, at approximately 5:03 a.m. he noticed movement on the Shed camera. The RCPS stated he identified the person on the camera as Resident 1 exiting the building through the window. The RCPS stated he did not notice Resident 2 leave the facility as he was still outside the building with other facility staff.During a concurrent interview and record review on 8/24/2026 at 11:46 p.m. with the Director of Nursing (DON), Resident 1's COC dated 7/14/2026 and Resident 2's electronic medical records were reviewed. The DON stated Resident 1 had attempted to exit the facility on 7/14/2026. The DON stated Resident 2 had no attempts to exit the facility, the attempt to exit the facility on 8/21/2026 was Resident 2's first attempt to exit the facility. The DON stated since Resident 1 and Resident 2 exited the facility through the same window, the facility staff should have monitored the broken window upon the discovery of Resident 1 exiting the facility. The DON stated the importance of making sure residents were monitored when there was a known incident of elopement was to ensure all residents were safe and would be protected from any potential accidents or injuries. The DON stated if residents were not being monitored during a known incident of elopement, residents would have an increased risk for physical injury or harm.During a review of the facility's Facility Receptionist job description undated, the job description did not indicate the role of a receptionist when responding to resident elopements, codes (emergencies), or procedures for monitoring the facility's video surveillance to ensure resident safety.During a review of the facility's policy and procedure (P&P) titled P-AP17 Wandering and Elopement dated 2/10/2023, the P&P indicated 6. Response to Resident Elopement . c. Staff will also be assigned to perform a perimeter search around the exterior of the building to ensure the missing resident is not behind any structures (bushes, mechanics, trellis, parts of the architecture, etc.) that could provide cover. The P&P did not indicate procedures for staff monitoring of exit doors or windows.

Based on interview and record review, the facility failed to implement the care-planned interventions for one of two residents (Resident 1), who was identified as being at risk for elopement (the act of leaving a facility unsupervised and without prior authorization) This failure resulted in Resident 1 leaving the facility unsupervised and had the potential for Resident 1 experiencing injury or harm.Findings:During a review of Resident 1's Face Sheet (front page of the chart that contains a summary of basic information about the resident) dated 8/24/2026, the Face Sheet indicated the facility admitted Resident 1 on 5/15/2026 and was readmitted on [DATE] with diagnosis including paranoid schizophrenia (a mental illness that affects how a person thinks and understands what is real), abnormalities of gait and mobility, type 2 diabetes mellitus (a condition where your body has trouble controlling blood sugar levels), and anxiety (constantly feeling worried and nervous).During a review of Resident 1's History and Physical (H&P) dated 5/15/2026, the H&P indicated Resident 1 did not have the capacity to understand and make decisions.During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 5/22/2026, the MDS indicated Resident 1 had severe impairment of the ability to think or make decisions. The MDS indicated Resident 1 had a behavior of wandering. The MDS indicated Resident 1 needed supervision with eating, oral hygiene, upper body dressing, and personal hygiene. The MDS indicated Resident 1 needed moderate staff assistance with toileting, showering, lower body dressing and putting on or taking off footwear.During a review of Resident 1's Change in Condition Evaluation (COC) dated 7/14/2026, the COC indicated resident attempted to leave facility following someone exiting the front door. The COC indicated physician was notified of Resident 1's attempt to exit the facility and ordered to closely monitor resident's whereabouts. During a review of Resident 1's Elopement Evaluation dated 7/14/2026, the Elopement Evaluation indicated Resident 1 had wandering behaviors that were non-goal directed (confused, aimless, enters others' rooms and explores their belongings) and had a history of elopement or an attempted elopement while at home.During a review of Resident 1's Elopement Evaluation dated 8/19/2026, the Elopement Evaluation indicated Resident 1 had wandering behavior that were both goal directed (follows a pattern, with a specific destination in mind, going home) and non-goal directed. The Elopement Evaluation indicated Resident 1 had a history of elopement or attempting to leave the facility without informing staff.During a review of Resident 1's Care Plan Report revised 8/21/2026, the Care Plan Report indicated Observe resident when near exit doors and intervene promptly if exit-seeking behavior is noted.During a concurrent interview and record review on 8/24/2026 at 11:46 p.m. with the Director of Nursing (DON), Resident 1's Care Plan Report dated 7/14/2026 was reviewed. The DON stated the Care Plan Report indicated interventions to observe resident when near exit door and intervene promptly if exit seeking behavior is noted. The DON stated the importance following care plan interventions was to ensure Resident 1 was monitored for her wandering and exit seeking behavior and to prevent attempt of elopement. The DON stated if Resident 1's Care Plan interventions were not implemented; Resident 1 would be at risk for physical injury or harm.During a review of the facility's policy and procedures (P&P) titled P-NP04 Person-Centered Care Planning dated 5/22/2025, the P&P indicated 4. Comprehensive Care Plan a. The facility must develop and implement a comprehensive person-centered care plan for each resident consistent with the resident rights, that includes measurable objectives, and timeframes to meet a resident's medical, nursing, and mental and psychological needs that are identified in the comprehensive assessment.

Based on interview and record review, the facility failed to ensure its Payroll Based Journal (a mandated reporting system used by the Centers for Medicare & Medicaid Services (CMS) to collect auditable employee-level staffing data from long-term care facilities) was submitted for the first fiscal year quarter.This deficient practice resulted in the facility's failure to provide required information regarding staffing levels necessary to ensure the provision of safe and comprehensive care for all residents in accordance with federal regulations. Findings:During a review of the facility's PBJ Staffing Data Report for Fiscal Year Quarter 1 2026 (October 1 through December 31), the PBJ report indicated the facility failed to submit data for the fiscal year one quarter. During a concurrent interview and record review on 7/14/2026 at 10:10 a.m., with the Administrator (ADMIN), CMS Submission Report for the PBJ validation report, dated 2/13/2026, was reviewed. The ADMIN stated the PBJ validation report indicated fiscal year quarter 2 was submitted instead of fiscal year 1 which covers October 2025 through December 2025. The ADMIN stated the PBJ was required to be submitted quarterly, and the facility's consulting group was responsible for submitting the PBJ fiscal year information timely. The Admin stated the risk of not submitting the facility's PBJ in a timely manner could result in submitting not accurate data and not being able to prove care services are being provided to the residents in the facility. During a record review of the State Operations Manual (SOM), dated 7/23/2025, the SOM indicates the facility is responsible for submitting staffing data through the CMS Payroll-Based Journal (PBJ) system. The facility's failure to submit PBJ data, as required, will be reflected on their CASPER report and result in a deficiency citation.

Based on interview and record review, the facility failed to ensure three of 12 sampled residents (Resident 5, 30 and 46) had completed 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) correctly in the medical records when:a. Failing to ensure Resident 5 had an AD acknowledgement form.b. Failing to ensure Resident 30 had an AD acknowledgement form.c. Failing to ensure Resident 46 had an advance directive acknowledgement form.These failures had the potential to result in care being provided that was inconsistent with the residents' wishes and could compromise the residents' rights to make decisions regarding their medical care during emergencies, end of life, and changes in condition.Findings: a. During a review of Resident 5's admission Record, the admission Record indicated the facility admitted the resident on 4/3/2023 and readmitted on [DATE] with diagnoses including rhabdomyolysis (a breakdown of muscle tissue that releases a damaging protein into the blood), and sepsis (a life-threatening blood infection) and Alzheimer's disease(a disease characterized by a progressive decline in mental abilities) During a review of Resident 5's Minimum Data Set (MDS - a resident assessment tool), dated 6/23/2026, the MDS indicated Resident 30's cognition (ability to make decisions of daily living) was severely impaired. The MDS indicated Resident 5 was dependent (helper does all the effort) on staff with eating, oral hygiene, toileting hygiene. During a concurrent interview and record review on 7/14/2026 at 11:19 a.m., with the admission Coordinator (AC), Resident 5's medical record was reviewed. The AC stated Resident 5's acknowledgement for Advance Directives was not completed. b. During a review of Resident 30's admission Record, the admission Record indicated the facility admitted the resident on 6/9/2026 with diagnoses including paranoid schizophrenia (a mental illness that is characterized by disturbances in thought), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior) and centrilobular emphysema (a type of lung disease that mainly affects the center of small lung units in the upper parts of the lungs). During a review of Resident 30's History and Physical (H&P), dated 6/11/2026, the H&P indicated Resident 30 did not have the ability to understand and make decisions. During a review of Resident 30's MDS, dated [DATE], the MDS indicated Resident 30's cognition was moderately impaired. The MDS indicated Resident 30 required supervision assistance (helper provides verbal cues and/ or touching/ steadying and/or contact guard assistance as resident completes activity) with eating, oral hygiene, toileting hygiene, personal hygiene, and moderate assistance (helper does less than half the effort to complete the task) with showering. During a concurrent interview and record review on 7/15/2026 at 12:31 p.m., with the Social Service Director (SSD), Resident 30's Social Services Assessment, dated 6/16/2026 was reviewed. The SSD stated she did not verify Resident 30's decision-making capacity before discussing the AD with Resident 30. The SSC stated Resident 30 lacked decision-making capacity. The SSD stated she should have discussed Resident 30's AD with the resident's Public Guardian (court-appointed individuals responsible for managing the affairs of people who do not have the capacity to make decisions for themselves). During an interview on 7/16/2026, 11:35 a.m., with the DON, the DON stated only a physician, or another qualified licensed practitioner could determine a resident's decision-making capacity. The DON stated if the resident lacked the capacity to make sound decisions, the SSD should have discussed the AD with the resident's legally authorized representative to honor resident's wishes regarding their care when they are no longer able to make decisions for themselves. c. During a review of Resident 46's admission Record, the admission Record indicated Resident 46 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including dementia (group of thinking and social symptoms that interfere with daily functioning), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), and anxiety disorder (constantly feeling worried and nervous). During a review of Resident 46's H&P dated 3/17/2026, the H&P indicated Resident 46 did not have the capacity to make decisions. During a review of Resident 46's MDS, dated [DATE], the MDS indicated Resident 46 had moderate cognitive impairment. The MDS indicated Resident 46 was dependent on facility staff for toileting hygiene, bathing, upper body (above waist) and lower body (below waist) dressing, personal hygiene, sit to lying, lying to sitting on side of bed, chair/bed-to-chair transfer, and required substantial assistance (helper does more than half) for eating, oral hygiene, and rolling left to right. During a review of Resident 46's Social Service Progress Note dated 4/22/2026 at 10:35 a.m., the social service progress note indicated Resident 46 had a public guardian and education was provided to the resident/representative on their right to formulate an Advance Directive (brochure provided). The social service progress note indicated Resident 46 did not have an Advance Directive due to impaired cognition. During an interview on 7/14/2026 at 11:32 a.m., with the SSD, the SSD stated advance directives are offered upon admission and indicated a brochure was provided whether the resident wishes to formulate or decline an advance directive. The SSD stated when the resident was unable to make decisions independently, their representatives are notified regarding the option to formulate an advance directive. During a concurrent interview and record review on 7/14/2026 at 11:36 a.m., with the SSD, the SSD Resident 46's Social Service Progress Note dated 4/22/2026 indicated Resident 46 was under conservatorship as she was unable to formulate an advance directive. The SSD stated advance directives are offered as it was the residents' rights to formulate what their wishes and indicated without an advance directive, the facility would not be able to honor the residents' wishes. The SSD stated they do not have any documentation that indicated Resident 46 or their public guardian had declined to formulate an advance directive. The SSD stated the policy titled Advance Directives does not cover what happens if a resident refuses to formulate an advance directive. During an interview on 7/16/2026 at 1:07 p.m. with the DON, the DON stated advance directives are offered so the facility was aware of the residents' wishes regarding their care when they are no longer able to make decisions for themselves. The DON stated that without an advance directive, the facility may not be able to honor the residents' preferences regarding their care. During a review of the facility's policy and procedures (P&P) titled, Advance Directive, revised date 7/25/2024, the P&P indicated upon admission, the Admissions Staff or Designee will provide written information to the resident concerning his or her right to make decisions concerning medical care; including the right to accept of refuse medical or surgical treatment, and the right to formulate advance directives. The Interdisciplinary Team will periodically review the Advance Directive, if applicable, with the resident or resident representative, to ensure that it still reflects the resident's wishes.

Based on observation, interview, and record review, the facility failed to ensure to store and handle food in a sanitary manner to prevent growth of microorganisms that could cause food borne illness (food poisoning: any illness resulting from the food spoilage of contaminated food, pathogenic bacteria, viruses, or parasites that contaminate food, as well as toxins) for 61 out of the 70 residents in the facility by failing to ensure: 1.There were no pests in the storage room.2.The dry storage room temperature was not above the appropriate range of 50 Fahrenheit ( F, temperature scale) - 70 F 3.Frozen food items were dated and ensure and accurately labeled.4. Food items in the residents' refrigerator were dated, had resident identifiers, and a log of when the refrigerator was cleaned. 5. The kitchen staff performed proper hand hygiene in-between tasks. These deficient practices had the potential to result in pathogen (germ) exposure to residents and placed residents at risk for developing foodborne illness (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea and fever and can lead to other serious medical complications and hospitalization.Findings:During a concurrent observation and interview on 7/13/2026 at 8:29 a.m., with the Dietary Services Supervisor (DSS), in the dry storage room, there was a fly sitting on top of an opened plastic bag with an opened box of sugar. The dry storage room temperature also read 'danger' with a temperature of 78 F. The thermometer in the room indicated to maintain the temperature of a dry storage to between 50 F - 70 F or 60 percent (%) relative humidity (RH, measures the amount of moisture in the air compared to the maximum amount the air can hold at that specific temperature, expressed as a percentage). The RH% on the thermometer in the dry storage room read 82%, and per DSS, they go based off of the RH% for the dry storage room temperature. During an observation on 7/13/2026 at 8:36 a.m., in the kitchen side door freezer, there was a bag of unlabeled frozen items stored.During an observation on 7/13/2026 at 8:38 a.m., in the dining room freezer, there were four bags of undated broccoli florets stored. During a concurrent observation and interview on 7/13/2026 at 8:43 a.m., with the Dietary Services Supervisor (DSS), the DSS stated the freezer named chest wall on left side in the basement storage did not have a thermometer in it. During an observation on 7/13/2026 at 8:46 a.m. in the basement storage, the chest middle freezer had a box of Tony's Cheese Pizza that had a prepared date of 9/11/2026. A box written peaches unopened had a prepared date of 9/11/2026.During an observation on 7/13/2026 at 1:03 p.m., in the resident's refrigerator, there were two bags labeled pasta for chicken noodle soup with no date, room number, and resident identifier. During an interview on 7/14/2026 at 8:16 a.m., with the DSS, the DSS stated food items should be dated to ensure staff knew when the items need to be used by to prevent illnesses and to prevent keeping items that are potentially expired. The DSS stated without a date, they would not know when the food item expired. The DSS stated they would not know if the food items were spoiled without an accurate date label on the food items. The DSS stated the storage room was supposed to be 70-80% and indicated the storage room should be kept at the recommended temperature as the room can get hot and produce needs to be kept at a certain temperature to avoid spoilage. During a concurrent observation and interview on 7/14/2026 at 9:19 a.m., with the DSS, the DSS stated facility staff did not keep a log of when the resident's refrigerator was cleaned. The DSS stated there were two bags of items that were labeled pasta for chicken noodle soup in the resident's refrigerator with no date and resident identifier. The DSS stated there was supposed to be a name and date on the bags of pasta. The DSS stated items should be labeled with owner's name to know who the items belong to so they would not give it to the wrong resident and each item should be dated to prevent giving expired food to the residents. During a concurrent observation and interview on 7/14/2026 at 12:05 p.m. with DA 1, DA 1 was observed getting gloves and started plating the food with no hand hygiene observed. DA 1 stated hand washing was performed in between tasks and when coming in and out of the kitchen for infection control. DA 1 stated she did not perform hand hygiene when performing the tasks of taking the temperatures of the food, emptying out the water of the peas, and putting on gloves to start plating the food. DA 1 stated she was supposed to wash hands before wearing gloves. During an interview on 7/14/2026 at 12:42 p.m., with the DSS, the DSS stated hand hygiene should be performed after every task, when coming in and out of the kitchen. The DSS stated gloves should be worn when touching food, when mixing seasoning, dishwashing, and when serving food. The DSS stated hand hygiene was performed to prevent cross contamination. The DSS stated there was a thermometer in the freezer to ensure the food was stored at the appropriate temperature and indicated if the temperature was not within range, the food items have to be discarded as it can cause food borne illness and residents can get sick. During an interview on 7/14/2026 at 2:43 p.m., with the DSS, the DSS stated ants, roaches, or fruit flies are considered pests. The DSS stated it was not acceptable for a fly to be sitting on top of an open bag that contains an open box of sugar. The DSS stated the sugar box had to be discarded as flies have germs that can cause infectious diseases harmful to the residents. During a review of the facility's policy and procedures (P&P) titled, Food Storage and Handling, effective date 6/4/2024, the P&P indicated Frozen Meat, Poultry, and Food: store items promptly at 0 F or below. Foods should be labeled, dated, and in their original contained if designed for freezing. Dry Storage Area: place opened products in storage contained with tight fitting lids, monitor area routinely for pest activity.During a review of the facility's P&P titled, Food Brought in by Visitors, effective date 5/22/2025, the P&P indicated place the food in a food container that is clearly labeled with the resident's name and date received and stored in a refrigerator designated for this purpose. When refrigerated, it will be labeled, dated, and discarded after 48 hours if not consumed. During a review of the facility's P&P titled, Dietary Department Infection Control for Dietary Employees, effective date 3/25/2026, the P&P indicated proper hand hygiene: immediately before engaging in food preparation, including working with non-prepackaged food, clean equipment and utensils. After handling soiled equipment or utensils, during food preparation, as often as necessary to remove soil and contamination, and to prevent cross-contamination when changing tasks, before initially donning gloves for working with food, before dispensing or serving food and handling clean tableware and serving utensils in the food service area, after engaging in any other activities that contaminate the hands.

Based on observation, interview, and record review, the facility failed to:Ensure the padded bed side rails that were wrapped with porous foam were effectively disinfected for two of six sampled residents (Resident 1 and Resident 50).Complete the Infection Screening Evaluation form for one of five sampled residents (Resident 57), who was on the facility's Infection Prevention Surveillance Program for [DATE].These failures had the potential to increase the risk of cross-contamination (the transfer of bacteria, viruses, microorganisms or other harmful substances from one surface to another through improper or unsanitary equipment, procedures, or products) and spreading infection for Resident 1 and Resident 50, and negatively impact the treatment for Resident 57. Findings: 1.During a review of Resident 1's admission Record, the admission Record indicated the facility readmitted the resident on [DATE] with diagnoses including hemiplegia a (total paralysis of the arm, leg, and trunk on the same side of the body), hemiparesis (inability to move one side of the body) following cerebral infarction (stroke-blockage of the flow of blood brain, causing or resulting in brain tissue death) and seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness). During a review of Resident 1's History and Physical (H&P), dated [DATE], the H&P indicated the resident had the ability to make needs known but could not make medical decisions. During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated [DATE], the MDS indicated the resident's cognitive (ability think and reason) skills for daily decision making were moderately impaired. The MDS indicated Resident 1 required set up assistance (helper sets up or cleans up; resident completes activity) with eating, supervision assistance (helper provides verbal cues and/ or touching/ steadying and/or contact guard assistance as resident completes activity) with oral hygiene, toileting hygiene, moderate assistance (helper does less than half the effort to complete the task) with showering, and personal hygiene. During a review of Resident 50's admission Record, the admission Record indicated the facility readmitted the resident on [DATE] with diagnoses including hemiplegia, hemiparesis following cerebral infarction (stroke-blockage of the flow of blood brain, causing or resulting in brain tissue death) and epilepsy (disorder that causes episodes of seizures or altered consciousness). During a review of Resident 50's H&P, dated [DATE], the H&P indicated the resident had fluctuating ability to understand and make decisions. During a review of Resident 50's MDS, dated [DATE], the MDS indicated the resident's cognitive skills for daily decision making were moderately impaired. The MDS indicated Resident 50 required supervision assistance (helper provides verbal cues and/ or touching/ steadying and/or contact guard assistance as resident completes activity) with eating, oral hygiene, moderate assistance (helper does less than half the effort to complete the task) with toileting hygiene, showering, and personal hygiene. During an interview on [DATE] at 09:50 a.m., with Housekeeping (HK) 1, HK 1 stated she cleaned the residents' room daily, including the foam-padded side rails, with a disinfectant identified as Hydrogen Peroxide (disinfectant). During an observation on [DATE] at 10:00 a.m., in Resident 50's room, Resident 50's upper side rails were observed padded with black foam. During an observation on [DATE] at 10:52 a.m., in Resident 1's room, Resident 1's upper side rails were observed padded with black foam wrapped with black electrical tape. During a concurrent interview and record review on [DATE] with the Infection Preventionist Nurse (IPN), manufacturer's instructions on the label of hydrogen Peroxide, undated was reviewed. The IPN stated the Hydrogen Peroxide should not be used on porous (material with tiny holes so liquid and air passes through it) materials such as the foam wrapped around Resident 1 and Resident 50's bed rails. The IPN stated, the hydrogen peroxide was intended for use on nonporous surfaces. During a concurrent observation and interview on [DATE] at 9:26 am with the Infection Preventionist Nurse (IPN) in Resident 1 & 50's room, the residents' side rails were observed with padded black foam. The IPN stated the disinfectant identified Hydrogen Peroxide was intended for nonporous surfaces and was not appropriate for use on the porous foam. The IPN stated the porous surface might not be adequately disinfected, place vulnerable residents including Resident 1 and Resident 50 at risk of infection. During an interview on [DATE] at 11:35 a.m., with the Director of Nursing (DON), the DON stated the facility should clean and disinfect reusable medical equipment, including padded side rails, in accordance with the manufacturer's instructions to prevent the spread of infection. During a review of the faculty 's policy and procedure (P&P) titled, Cleaning and Disinfection of Resident-Care Equipment, dated [DATE], the P&P indicated, staff should verify the disinfectant is compatible with the equipment and follow manufacturer recommendations for cleaning equipment. During a review of the manufacturer's product label for Hydrogen Peroxide, undated, the label indicated the disinfectant is designed for hard and non-porous surfaces. 2.During a review of Resident 57's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] and was readmitted on [DATE] with the following but not limited to diagnoses of muscle weakness, dementia (decline in memory, thinking, or reasoning skills) and anxiety (a feeling of intense worry, nervousness). During a review of Resident 57's Minimum Data Set (MDS – a resident assessment tool), dated [DATE], the MDS indicated the resident has severe cognitive impairment (inability to think and make decisions for themselves). The MDS also indicated the resident requires full assistance with every aspect of daily living. During a review of Resident 57's Order Summary Report (OSR) dated [DATE], the OSR indicated Resident 57's moisture associated skin damage (MASD-skin breakdown, irritation, or rashes caused by your skin being wet for too long) be treated with Nystatin External Powder, bilaterally to the breast folds, every day and evening shifts, for 30 days with an initiated date of [DATE] and target date of [DATE]. During a review of Resident 57's Care Plan Report (CPR), (undated), the CPR indicated Resident 57's bilateral breast folds were to be monitored for spreading or signs of infection with an initiated date of [DATE] and target date of [DATE]. During a concurrent interview and record review on [DATE] at 11:15 a.m. with Infection Preventionist (IPN), Infection Control Line Listing Log (IPCLLL), (undated) was reviewed. The IPCLLL indicated Resident 57 has a MASD, with an onset date of [DATE] and stop date of [DATE]. IPN stated the log is to keep track of residents with ongoing infections. During a concurrent interview and record review on [DATE] at 12:10 p.m. with IPN, Resident 57's Infection Screening Evaluation (ISE), dated [DATE] was reviewed. The ISE indicated, the Infection Analysis portion was not completed. IPN stated that it was her responsibility to determine which criteria applied, or to indicate if none were met—based on the Infection Analysis options. The IPN also stated it is essential to thoroughly complete the ISE form before informing the physician about any infections. As his process helps ensure residents are not prescribed incorrect medications or antibiotics, which could result in unnecessary or inappropriate treatment. Such errors may contribute to the spread of infection and foster antibiotic resistance, where bacteria adapt to survive drugs intended to eliminate them. During concurrent interview and record review on [DATE] at 2:01 p.m. with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Infection Control Surveillance, dated [DATE] was reviewed. The P&P indicated, a license nurse is to initiate the gathering of surveillance data for each resident being monitored for infection. The DON stated her expectation was for IPN to follow the facility's P&P and to report any issues related to infections within the facility. The DON added, all assessments outlined in the Infection Screening Evaluation must be completed, as they enable the IPN to verify whether the correct treatment has been ordered. Neglecting these preventative assessments could lead to residents spreading infections within the facility and developing antibiotic resistance.

Based on observation, interview and record review, the facility failed to provide evidence that their ice machine was being serviced routinely to be maintained in a safe operating condition.This failure had the potential to result in a widespread foodborne illness with the residents.Findings:During an interview on 7/15/2026 at 2:34 p.m. with the Central Worker (CW), the CW stated there was no log documenting previous ice machine vendor service, however, a magnet attached to the ice machine displayed the most recent service date.During a concurrent observation and interview on review on 7/15/2026 at 2:40 p.m. with the CW in the staff breakroom, a magnet on the ice machine indicated that maintenance was required every three months and showed 5/27/2025 as the next scheduled service date. The CW stated the date on the magnet was incorrect.During an interview on 7/16/2026 at 8:57 a.m. with the Dietary Supervisor (DS), the DS stated the ice machine is serviced by an external vendor once a year.During a concurrent interview and record review on 7/16/2026 at 9:14 a.m. with the CW, Vendor 1's Invoice #122013, dated 5/13/2026 was reviewed. The Invoice #122013 indicated that Vendor 1 carried out routine maintenance on the facility's ice machine on 5/13/2026. The CW stated that 5/13/2026 was the most recent service date for the ice machine. The CW also stated he will establish a log for future ice machine maintenance, as this will help ensure accurate records of when service was last performed and reduce the risk of bacterial buildup in the ice machine, which could potentially cause stomach discomfort among residents.During an interview on 7/16/2026 at 9:40 a.m. with the Maintenance Supervisor (MS), the MS stated they were unsure of the exact dates when Vendor 1 serviced the ice machine.During an interview on 7/16/2026 at 2:33 p.m. with the Administrator (Admin), the Admin stated there was no log to keep track of previous service dates by Vendor 1. The Admin added that the absence of a tracking system for previous service dates makes it challenging to determine when the ice machine was last serviced, which could result in improper use and potentially pose a risk to residents.

Based on observation, interview, and record review, the facility failed to ensure that one of one sampled resident (Resident 5) was provided the opportunity to eat her meals at the same time as other residents during lunch at the dining room.This failure had the potential to diminish the resident's dignity, promote social isolation during mealtime, and result in an unsatisfactory dining experience. Findings: During a record review of Resident 5's admission Record (Face Sheet), the admission record indicated Resident 5 was admitted to the facility on [DATE] with a diagnoses including Alzheimer's disease (a progressive neurodegenerative disorder that impairs memory, thinking, and daily functioning), unspecified dementia (a decline in cognitive function affecting memory, reasoning, and the ability to perform activities of daily living), dysphagia, oropharyngeal phase (difficulty swallowing due to impaired movement of food from the mouth and throat to the esophagus), chronic kidney disease (progressive loss of kidney function over time), and protein-calorie malnutrition (inadequate intake or absorption of protein and calories resulting in poor nutritional status).During a record review of Resident 5's Minimum Data Set (MDS - a resident assessment tool) dated 6/23/2026, the MDS indicated Resident 5 had a Brief Interview for Mental Status (BIMS) score of 0, indicating severe cognitive impairment. The MDS also indicated Resident 5 was dependent on eating, oral hygiene, toileting hygiene, upper body dressing, lower body dressing, and putting on and taking off footwear, and was not attempted for showering/bathing due to a medical condition or safety concerns.During a record review of Resident 5's Care Plan (Focus), revised 5/20/2026, the Care Plan indicated, Resident 5 is (dependent on staff, etc.) for meeting emotional, intellectual, physical, and social needs related to diagnosis of Alzheimer's disease, interventions indicated Resident 5 was dependent for eating , requiring staff assistance during meals. During a concurrent dining observation on 07/13/2026 at 12:50 p.m., and interview with Certified Nurse Assistant 1, Resident 5 observed her lunch tray was not in her table and had not begun eating her lunch while three other Residents got fed by the respected assigned CNAs. Resident 5 remained seated in her wheelchair awaiting meal assistance. CNA 1 stated she was assigned to feed Resident 5.During an interview on 07/13/2026 at 12:50 p.m. with CNA 1, CNA 1 stated Registered Nursing Assistants (RNAs) and CNAs are responsible for feeding residents. CNA 1 stated meal trays are delivered without a specific delivery time. CNA 1 stated LVNs, RNAs, and CNAs are responsible for ensuring residents at the same dining table are served and assisted with meals. CNA 1 stated that if unable to feed an assigned resident promptly, she notifies the LVN or another CNA to provide meal assistance.During an interview on 07/16/2026 at 9:45 a.m. with the Director of Staff Development (DSD), DSD stated the CNAs and RNAs, are responsible in making sure residents receive meal assistance. DSD stated CNAs are educated to verify the correct diet, perform hand hygiene before meal service, set up meal trays, and monitor residents during meals. DSD stated residents assigned to the same dining table should receive meal assistance at the same time to preserve residents dignity.During a record review of the facility's Policies and Procedures (P&P) titled, Resident Rights, revised 1/1/2012, the P&P indicated the facility will promote and protect the rights of all residents. The P&P indicated staffs are to treat all residents with kindness, respect, and dignity, encourage residents to participate in planning their daily care routines, including activities of daily living (ADLs), and gather and document residents' personal preferences to facilitate resident choice and participation in preferred activities.

Based on observation, interview and record review, the facility failed to offer the influenza (a highly contagious viral infection that attacks the nose, throat, and lungs) and pneumococcal (an illness caused by the Streptococcus bacteria [a common bacteria on the nose and throat] immunizations (the process of making your body immune to a specific disease) at the time of admission, for one of five sampled residents (Resident 56).This failure had the potential to result in the resident contracting influenza or pneumococcal and developing a life-threatening infection.Findings: During a review of Resident 56's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE] with the following but not limited to diagnoses of encephalopathy (damage or malfunction of the brain), epilepsy (a brain disorder that causes repeated, unprovoked seizures) and catatonic schizophrenia (a condition that effects one's movements and speech).During a review of Resident 56's Minimum Data Set (MDS - a resident assessment tool), dated 7/3/2026, the MDS indicated Resident 56 was unable to complete the cognitive (mental capacity) assessment due to the inability to complete brief interview for mental status. The MDS also indicated, the resident requires assistance with every aspect of daily living.During a review of Resident 56's Medical Record (MR), the MR did not indicate the resident received the influenza and/or pneumococcal immunizations for 2025-2026.During an interview on 7/15/2026 at 9:52 a.m. with the Infection Preventionist (IPN), the IPN stated Resident 56 was not offered the influenza and pneumococcal immunizations because the resident was unable to make decisions independently, and the responsible party did not respond to a phone call made on 7/10/2026 to either consent to or decline the immunizations. IPN also stated there was no follow up phone call to Residents 56's responsible party.During an interview on 7/16/2026 at 2:05 p.m. with the Director of Nursing (DON), the DON stated that an additional follow-up call should have been made to Resident 56's responsible party to confirm whether the influenza or pneumococcal immunizations were wanted.During a review of the facility's policy and procedure (P&P) titled, IPC601 Pneumococcal Vaccination, dated 10/02/2025, the P&P indicated the facility will provide all residents the opportunity to receive the pneumococcal vaccine.During a review of the facility's P&P titled, Influenza Prevention and Control, dated 9/10/2020, the P&P indicated the facility is to offer all residents an influenza immunization.

Based on interview and record review, the facility failed to ensure Medical Director or designee attended the Quality Assessment and Assurance Committee (QAA committee, a group of people within an organization who are responsible for reviewing identifying and addressing quality issues) meeting held on 6/26/2026 as required QAA committee meetings.This failure had the potential to adversely affect the facility's quality assessment and performance improvement process by limiting clinical oversight and guidance.Findings:During a review of the facility's QAA Steering Committee attendance sign-in sheet, dated 6/26/2026, the attendance sheet indicated the Medical Director's did not attend the meeting.During an interview on 7/16/2026 at 3:50 p.m., with the Administrator (ADMIN). The ADMIN stated, the Medical Director or designee did not attend the QAA Committee meeting held on 6/26/2026 as required, and no additional documentation was available regarding the Medical Director's absence. The ADMIN stated the Medical Director's participation is essential to provide clinical oversight, educate nursing staff, and support quality improvement activities.During a review of the facility's Policy and Procedure (P&P) titled, Quality Assurance and Performance Improvement (QAPI) Program, revised 3/28/2024, the P&P indicated, members of the committee must include Medical Director or designee.

Based on observation, interview and record review, the facility failed to ensure two of five sampled residents selected for unnecessary medications (Resident 3 and Resident 46) were free from the use of unnecessary medications by:Failing to monitor and document Resident 3 who was receiving anticoagulant therapy (blood thinners to prevent harmful blood clots from forming or getting larger).Failing to provide an actual indication for the continued use of Ativan (a psychotropic [chemical substance that alters brain function that affects mood and behavior] medication used to treat anxiety) for Resident 46.This deficient practice had the potential for licensed staff to miss signs of bleeding from anticoagulant therapy, increasing the risk for serious complications and delayed medical intervention for Resident 3 and for Resident 46 to experience a diminished quality of life due to adverse effects such as sedation, coma, and death for the continued use of Ativan when it was not indicated. Findings: 1.During a record review of Resident 3's admission record, the admission record indicated that Resident 3 was admitted to the facility on [DATE] with diagnoses of acute embolism and thrombosis of unspecified deep veins of the right lower extremity (a blood clot in the deep veins of the right leg), long-term (current) use of anticoagulants (ongoing treatment with blood-thinning medication to prevent or treat blood clots), Type 2 diabetes mellitus with hyperosmolar hyperglycemic state without nonketotic hyperglycemic-hyperosmolar coma (a severe complication of diabetes characterized by markedly elevated blood glucose and dehydration).During a record review of Resident 3's Minimum Data Set (MDS- a resident assessment tool) dated 6/10/2026, Resident 3 had a Brief Interview for Mental Status (BIMS - evaluates attention, orientation, and short-term memory) score of 9, indicating moderate cognitive impairment, with moderately impaired daily decision-making and no signs or symptoms of delirium. Resident 3 required setup assistance with eating; supervision or touching assistance with oral hygiene, toileting hygiene, dressing, bed mobility, transfers, and toilet transfers; and partial/moderate assistance with showering and personal hygiene.During a record review of the Medication Administration Record (MAR), the MAR dated 5/01/2026–5/31/2026 documented an order for Eliquis (prescription anticoagulant) 5 milligrams (mg - a unit of measurement) by mouth twice daily for Deep Vein Thrombosis (DVT - any medical or preventive measure taken to guard against a disease, infection, or health condition before it occurs) prophylaxis, initiated on 5/03/2026 and administered as ordered. The MAR's dated 6/01/2026–6/30/2026 and 7/01/2026 indicated continued to document Eliquis 5 mg by mouth twice daily. There was no documentation on the MAR or associated records demonstrating ongoing monitoring for signs and symptoms of bleeding following initiation of anticoagulant therapy. During a record review of the titled All Active Medications at Time of Discharge Reconciliation (formal process in which healthcare providers compare a patient's current medication orders with the medications they are actually taking) dated 5/02/2026 at 4:41 p.m., Eliquis (apixaban – a medication prescription anticoagulant) was not listed among the Resident 3's discharge medications at the time of discharge reconciliation to the skilled nursing facility.During a concurrent interview on 7/15/2026 at 9:50 a.m. with Licensed Vocational Nurse 2 (LVN 2) and record review of medication reconciliation from General Acute Care Hospital (GACH) was reviewed. LVN 2 stated the facility performs medication reconciliation upon admission using hospital transfer records, physician orders, and diagnoses. LVN 2 stated residents receiving anticoagulants require monitoring for signs and symptoms of bleeding and that licensed nurses initiate Change of Condition (COC) documentation for significant changes in treatment or condition or why starting the prescribed medication. LVN 2 stated Eliquis 5 mg was initiated on 5/04/2026 and no COC documentation was initiated following the start of anticoagulant therapy. LVN 2 stated Eliquis is not at the medication reconciliation.During a concurrent interview on 7/15/2026 at 10:00 a.m. with the Registered Nurse 1 (RN 1), RN 1 stated that prophylaxis refers to preventing a medical condition rather than treating an existing diagnosis. RN 1 stated Resident 3's diagnosis of acute embolism and thrombosis supported the use of Eliquis (apixaban) to prevent recurrent thrombosis. RN 1 stated staff are instructed to monitor for signs and symptoms of bleeding every shift, including discolored urine, black tarry stools (a warning sign of bleeding in the upper gastrointestinal (GI) tract), sudden severe headache, nausea, vomiting, diarrhea, muscle or joint pain, lethargy, bruising, changes in mental status or vital signs, shortness of breath, and nosebleeds. RN 1 stated that medications should have a documented diagnosis, pharmacists perform monthly medication reviews to ensure appropriate dosing and reduce the risk of bleeding, and medication reconciliation is completed using hospital transfer documents and physician orders. During a concurrent interview on 7/16/2026 at 1:44 p.m. with the Director of Nursing (DON), the DON stated Resident 3 was prescribed Eliquis 5 mg on 5/03/2026 and stated no Change of Condition (COC) documentation was initiated following the start of anticoagulant therapy. The DON stated licensed nurses should initiate COC documentation for changes in condition, abnormal laboratory results, new diagnoses, and new skin issues. The DON stated Resident 3 was receiving anticoagulants requires monitoring for signs and symptoms of bleeding because anticoagulant therapy places residents at risk for bleeding and other adverse effects. The DON stated the resident's care plan addressed anticoagulant therapy and there was no documentation demonstrating ongoing monitoring for signs and symptoms of bleeding.During a record review of the facility's Policy and Procedure (P&P) titled Change of Condition Notification, effective 8/25/2022 and reviewed 8/25/2022, the P&P indicated the facility to notify the physician/Advanced Practice Provider (APP) and initiate a Change of Condition (COC) when a resident experienced a significant change in treatment or condition requiring medical assessment and a change in the treatment plan. 2.During a review of Resident 46's admission Record, the admission Record indicated Resident 46 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including dementia (group of thinking and social symptoms that interfere with daily functioning), bipolar disorder (irregular mood swings that range from the lows of depression to elevated periods of emotional highs), and anxiety disorder (constantly feeling worried and nervous). During a review of Resident 46's H&P dated 3/17/2026, the H&P indicated Resident 46 did not have the capacity to make decisions. During a review of Resident 46's MDS, dated [DATE], the MDS indicated Resident 46 had moderate cognitive (ability to think and make decisions) impairment The MDS indicated Resident 46 was dependent on toileting hygiene, bathing, upper body (above waist) and lower body (below waist) dressing, personal hygiene, sit to lying, lying to sitting on side of bed, chair/bed-to-chair transfer, and required substantial assistance (helper does more than half) for eating, oral hygiene, and rolling left to right. During a review of Resident 46's order summary report dated 6/10/2026, the order summary report indicated a physician's order for Ativan Oral Tablet 0.5 milligram (mg, unit of mass) (generic name Lorazepam): give 1 tablet by gastrostomy (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) every 12 hours as needed for anxiety manifested by (m/b) attempting to get out of bed. During a review of Resident 46's Medication Administration Record (MAR) dated 6//1/2026 - 6/20/2026 the MAR indicated Resident 46 received Ativan 0.5 mg on 16 days (6/1/2026, 6/3/2026, 6/4/2026, 6/8/2026, 6/9/2026, 6/10/2026, 6/13/2026, 6/14/2026, 6/16/2026, 6/18/2026, 6/21/2026, 6/23/2026, 6/25/2026, 6/27/2026, 6/28/2026, and 6/30/2026) without any documentation indicating Resident 46 had any behaviors. During a review of Resident 46's order summary report dated 7/2026, the order summary report indicated a renewed physician's order for Ativan Oral Tablet 0.5 mg : give 1 tablet by gastrostomy every 12 hours as needed for anxiety or 27 Days m/b attempting to get out of bed placing resident at risk for injury with order date 7/8/2026 end date 7/22/2026. During a concurrent interview and record review on 7/15/2026 at 11:22 a.m., with Registered Nurse (RN) 1, Resident 46's order summary report dated 7/2026 was reviewed. RN 1 stated on Resident 46's had a renewed order for Ativan Oral Tablet 0.5 mg, : give 1 tablet by g-tube, every 12 hours as needed for anxiety or 27 Days m/b attempting to get out of bed placing resident at risk for injury with order date 7/8/2026 end date 7/22/2026. RN 1 stated if a resident does not have episodes of trying to get out of bed, Ativan should not be given. During a concurrent interview and record review on 7/15/2026 at 11:39 a.m., Resident 46's MAR with RN 1, RN 1 stated on the MAR dated 6/1/2026 – 6/30/2026 was reviewed. RN 1 stated, Resident 46 received Ativan 0.5mg on the following days: 6/10/2026, 6/12/2026 to 6/16/2026, 6/18/2026 to 6/21/2026, 6/23/2026, 6/25/2026 to 6/28/2026, and 6/30/2026. RN 1 stated the administration of Ativan was not necessary based on no documented behaviors to justify administering the Ativan. RN 1 stated possible side effects of getting a medication the resident does not need include adverse effects such as shortness of breath and respiratory depression (breathing becomes too slow or shallow). RN 1 stated it was important for the resident to be monitored for their behavior to assess how they are progressing (improving or declining) and to determine whether the resident continues to require this medication or if it can be gradually discontinued. During a concurrent interview and record review on 7/16/2026 at 1:21 p.m. with the DON, the DON stated the Behavior Management/Psychoactive Committee Meeting -Initial/Change of Condition (COC) document dated 7/8/2026 at 11:55 a.m. indicated attempting to get out of bed placing resident at risk for injury, anger outburst, sudden mood changed and renewal of Ativan 0.5mg. The DON stated they do not have specific documentation that the use of Ativan was discussed with the doctor and indicated the Ativan was renewed. The DON stated documentation was important to ensure the doctor knows the status of the resident as the renewal of Ativan 0.5mg had been ongoing. The DON stated the doctor may want to try something else or continue renewing Ativan and indicated this may have been discussed during the meeting but was not documented. The DON stated Ativan had been renewed due to the continue behavior Resident 46 exhibits (attempting to get out of bed). During a review of the facility's policy and procedures (P&P) titled, Behavior/Psychoactive Drug Management, effective date 1/30/2026, the P&P indicated if the resident exhibits mood or behavior problems upon admission, assessments will be conducted to address the resident's mood or behavior status. Assessment will be documented on the Behavior Management/Psychoactive Committee Meeting – Initial/COC Committee Noted. The Licensed Nurse will collaborate with the healthcare practitioner family, resident, resident representative, and/or Interdisciplinary (IDT, resident's healthcare team consisting of various specialties that share and combine their knowledge and information to create the best possible care plan for the resident) members, to identify the contributing factors related to the resident's mood/behavior and the non-medication interventions to be implemented. The IDT will reassess the effectiveness of the psychoactive medication at least quarterly during the IDT Care plan meeting, or psychoactive behavior management committee. Residents have the right to be free from chemical restraints. The Behavior Management/Psychoactive Review Committee will review the following and make recommendations based on resident's need: The effectiveness of non-medication interventions; Continued use of psychoactive medication; Possible nonpharmacological alternatives During a review of the facility's P&P titled, Psychotropic Medication Use, effective date 6/2021, the P&P indicated the facility should not use psychotropic medications to address behaviors without first determining if there is a medical, physical, functional, psychological, social, or environmental cause of the resident's behaviors. Facility staff should take a holistic approach to behavior management that involves a thorough assessment of underlying causes of behaviors. Staff should become familiar with the culture, medical, and psychological information about the resident to identify potential environmental and other triggers to prevent or reduce behavioral symptoms and/or distress, types and the consequences of behaviors exhibited by the resident and interventions that may be indicated for a specific behavior type. Psychotropic medications to treat behaviors will be used appropriately to address specific underling medical or psychiatric causes of behavioral symptoms. For psychotropic prn medications, excluding antipsychotics, if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order.

Based on interview and record review, the facility failed to ensure Resident 4 received appropriate care when staff did not recognize and respond to:a) Resident 4's multiple episodes of loose stools while receiving Lactulose (a prescription laxative used to treat chronic constipation), and a physician's order to hold the medication for loose stools, for one of one sampled residents (Resident 4).b) Resident 3's change in condition following the initiation of anticoagulant therapy, without initiating a Change of Condition (COC), for one of one sampled residents (Resident 3).These failures have the potential to result in inconsistent care delivery, breakdowns in communication of resident specific interventions among interdisciplinary staff, unmet resident needs, and a decline in physical or psychosocial well being, ultimately reducing the quality of care.Findings: a.During a record review of Resident 4's admission record, the admission Record indicated Resident 4 was admitted to the facility on [DATE] with a diagnoses including but not limited to hemiplegia and hemiparesis following cerebral infarction affecting the right non-dominant side (weakness or partial paralysis affecting the right side of the body resulting from a stroke), chronic obstructive pulmonary disease (COPD) (a chronic progressive lung disease characterized by airflow limitation), type 2 diabetes mellitus with hyperglycemia (a chronic metabolic disorder resulting in elevated blood glucose levels due to insulin resistance or inadequate insulin production), hyperlipidemia (elevated cholesterol and lipid levels in the blood), major depressive disorder, recurrent (a mental health disorder characterized by repeated episodes of persistent sadness and loss of interest), peripheral vascular disease (reduced blood flow to the extremities due to narrowed blood vessels).During a record review of the Minimum Data Set (MDS - a resident assessment tool) dated 6/26/2026, Resident 4 had a Brief Interview for Mental Status (BIMS) score of 12, indicating Resident 4 was cognitively intact. Resident 4 required dependent assistance with eating, oral hygiene, toileting hygiene, bathing, dressing, footwear management, bed mobility, and wheelchair mobility. Resident 4 used a manual wheelchair for mobility and demonstrated impairment in the range of motion (the full movement potential of a joint, usually measured in degrees of a circle) of one upper extremity. Resident 4 was assessed as occasionally incontinent of bowel. During a concurrent interview on 7/16/2026 at 9:36 a.m. with Licensed Vocational Nurse 2 (LVN 2), and during a record review of Resident 4's bowel movements since 7/6/2026, it indicated that Resident 4 had multiple episodes of loose stools. The LVN's continued administering Lactulose, and the physician was not notified. LVN 2 stated the medication should have been held because loose stools place the resident at risk for dehydration and there is a physician's order. During a review of Resident 4's Medication Administration Record (MAR) dated 07/05/2026, 07/06/2026, 07/08/2026, and 07/09/2026, Lactulose (a prescription laxative to treat chronic constipation) was administered on the days Resident's 4 had episodes of loose stools.b.During a record review of Resident 3's admission record, the admission record indicated Resident 3 was admitted to the facility on [DATE] with diagnoses of acute embolism and thrombosis of unspecified deep veins of the right lower extremity (a blood clot in the deep veins of the right leg), long-term (current) use of anticoagulants (ongoing treatment with blood-thinning medication to prevent or treat blood clots), Type 2 diabetes mellitus with hyperosmolar hyperglycemic state without nonketotic hyperglycemic-hyperosmolar coma (a severe complication of diabetes characterized by markedly elevated blood glucose and dehydration), During a record review of Resident 3's MDS dated [DATE], Resident 3 had a BIMS score of 9, indicating moderate cognitive impairment, with moderately impaired daily decision-making and no signs or symptoms of delirium. Resident 3 required setup assistance with eating; supervision or touching assistance with oral hygiene, toileting hygiene, dressing, bed mobility, transfers, and toilet transfers; and partial/moderate assistance with showering and personal hygiene.During a record review of the MAR, the MAR dated 5/01/2026-5/31/2026 documented an order for Eliquis (prescription anticoagulant) 5 milligrams( mg-unit of measurement) by mouth twice daily for Deep Vein Thrombosis (DVT - any medical or preventive measure taken to guard against a disease, infection, or health condition before it occurs) prophylaxis, initiated on 5/03/2026 and administered as ordered. The MAR dated 6/01/2026-6/30/2026 and 7/01/2026-7/15/2026 indicated continued to document Eliquis 5 mg by mouth twice daily. There was no documentation on the MAR demonstrating ongoing monitoring for signs and symptoms of bleeding following initiation of anticoagulant therapy. During a record review of the titled All Active Medications at Time of Discharge Reconciliation (formal process in which healthcare providers compare a patient's current medication orders with the medications they are actually taking) dated 5/02/2026 at 4:41 p.m., Eliquis (apixaban - a medication prescription anticoagulant) was not listed among the Resident 3's discharge medications at the time of discharge reconciliation to the skilled nursing facility.During a concurrent interview with a Licensed Vocational Nurse (LVN 2) on 7/16/2026 at 9:36 a.m. and record review of Resident 4 bowel movement, LVN 2 stated that when a resident has multiple loose bowel movements, the nurse would assess Resident 4 for abdominal pain, bowel sounds, mental status, and stool characteristics, notify the physician immediately, initiate a Change of Condition (COC) after the second or third episode, notify the Director of Nursing (DON), continue monitoring the resident, obtain a stool specimen if ordered, and develop a care plan the same day the COC is initiated.During a continued interview Licensed Vocational Nurse (LVN 2) on 7/16/2026 at 9:36 a.m. and record review of Resident 3's MAR and Resident's 3 medication reconciliation records was reviewed , LVN 2 stated Eliquis 5 mg was initiated on 5/04/2026 and no COC documentation was initiated following the start of anticoagulant therapy.During an interview with the Registered Nurse (RN 2) on 7/16/2026 at 12:41 p.m., RN 2 stated that Resident 4 experienced loose bowel movements on 7/5/2026, 7/6/2026, 7/8/2026, and 7/9/2026, and that a Change of Condition (COC) should have been initiated on 7/9/2026 and medication should have been on hold RN 2 stated that medications should be administered according to the Physician's orders, and a care plan should be developed on the same day a COC is initiated. During an interview with the Director of Nursing (DON) on 7/16/2026 at 1:11 p.m., the DON stated that residents with anticoagulant therapy, skin issues, and loose bowel movements should have individualized care plans with appropriate interventions. The DON stated that a Change of Condition (COC) should have been initiated for Resident 4's anticoagulant therapy that started in the facility and a corresponding care plan should have been developed the same day. The DON stated that lactulose be held for loose bowel movements in accordance with the Physician's order, and failure to follow physician orders could place the resident at risk for dehydration and compromise continuity of care. During a record review of the facility's policy and procedure (P&P) titled, Change of Condition Notification, effective 8/25/2022, the facility's P&P indicated it requires staff to promptly notify the physician/advanced practice provider, resident, and resident representative of any significant change in the resident's condition. The policy defined a change of condition as any sudden or marked adverse change requiring medical assessment, physician consultation, coordination of care, and changes to the resident's treatment plan, to ensure timely communication and appropriate interventions.

Based on observation,interview and record review, the facility failed to ensure appropriate skin care plan for Resident 16 with dermatitis (inflammation of the skin, commonly causing red, itchy, and swollen skin) to address the resident's skin care needs for one of 1 sampled resident (Resident 16).This failure had the potential to result in unidentified care and delayed medical intervention.Findings: During a record review of Resident 16's admission record, the admission record indicated Resident 16 was admitted to the facility on [DATE] with diagnoses including dermatitis, unspecified (inflammation of the skin causing redness, itching, and irritation), other specified dermatitis (a specific type of skin inflammation not otherwise classified), impetigo, unspecified (a contagious bacterial skin infection characterized by sores and blisters), and non-bullous impetigo (the most common form of impetigo, causing crusted skin lesions without large fluid-filled blisters).During a record review of the Minimum Data Set (MDS - a resident assessment tool) dated 5/28/2026, Resident 16 had a Brief Interview for Mental Status (BIMS - a short, standardized test used by healthcare providers in nursing homes and rehabilitation centers to evaluate a person's memory, thinking, and orientation) score of 3, indicating severe cognitive impairment. Resident 16 was independent with mobility and most self-care activities but required supervision with showering, dressing, footwear, and personal hygiene. During a review of Resident 16's Medication Administration Record (MAR) dated 7/1/2026 to 7/31/2026, the resident had physician orders for Clobetasol Propionate (topical steroid used to treat severe skin and scalp conditions like eczema, plaque psoriasis, and lichen sclerosus) 0.05% (50 out of 100 parts, equal to one half) cream to treat a generalized body rash, Mupirocin 2% (prescription topical antibiotic containing 20 mg of mupirocin per gram of cream or ointment) ointment for open skin lesions on the bilateral arms and left leg, and Zinc Oxide 20% (topical skin protectant ointment or cream containing 20 percent active zinc oxide) cream to protect the buttocks, coccyx, and bilateral inner thighs. During a record review of Resident 16's care plan dated 7/14/2026, the care plan indicated Resident 16's dermatitis included interventions for skin care, hygiene, hydration, and prescribed treatments. The care plan did not identify the specific affected skin sites and did not include interventions to monitor the progression or resolution of Resident 16's dermatitis. During a concurrent observation and interview on 7/14/2026 at 10:28 a.m. with the TXN1, the TXN1 stated Resident 16 had dermatitis on multiple areas of the body and received prescribed treatments. TXN1 stated that Resident 16's skin is assessed during treatment, changes are reported to the physician, and the care plan is updated when Resident 16's skin condition changes. The TXN1 stated the care plan did not identify the specific affected skin site to monitor progress and care. During a record review of the facility's Policy and Procedure (P&P) titled, Comprehensive Person-Centered Care Planning, revised 8/24/2023, the P&P indicated the facility will provide person-centered, comprehensive, and interdisciplinary care that reflects best practice standards and ensure a comprehensive person-centered care plan is developed for each resident.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), who had recommendations to have referrals and/or consultations with the cardiologist (medical doctor specializing in diseases of the heart) and neurologist (medical doctor specializing in diseases of the brain, spinal cord, nerves and muscles), were implemented. These failures resulted in Resident 1's referrals being delayed for more than nine months. These failures also had the potential to delay necessary specialty assessments, interrupted continuity of care, and increased the risk that changes in Resident 1's medical condition would go unrecognized which could affect Resident 1's health, safety, and overall, well being.Findings:During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnoses included hepatic encephalopathy (a decline in brain function which occurs when the liver cannot remove toxins from the blood), type 2 diabetes mellitus ([DM] a disorder characterized by difficulty in blood sugar control and poor wound healing) and legal blindness (significant loss of vision).During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 1/17/2026, the MDS indicated Resident 1's cognition (ability to register and recall information) was moderately impaired and was able to understand and be understood by others. The MDS indicated Resident 1 required partial to moderate assistance (helper does more than half the effort) from staff for his activities of daily living ([ADLs] activities such as bathing, dressing, and toileting a person performs daily).During a telephone interview on 3/9/2026 at 12 p.m., Resident 1's RP 1 stated the facility was inconsistent with assisting Resident 1, who is legally blind, with showering. RP 1 stated that during her visits in 2/2026, Resident 1 appeared in dirty clothes, sitting in dirty bed linen and did not appear groomed. RP 1 stated that on 2/23/2026, Resident 1's birthday, she arrived to take him to a doctor's appointment and to celebrate his birthday and found him in dirty clothes and not showered. RP 1 stated she attempted to reach the Social Services Director (SSD) multiple times regarding her concerns but found the SSD difficult to reach and unresponsive. RP 1 stated that on 3/1/2026, after 7 p.m., she called and informed Licensed Vocational Nurse (LVN) 3 that Resident 1 had an appointment on 3/2/2026 at 9 a.m. RP 1 stated she told LVN 3 it was important that Resident 1 be showered and ready when she arrived. RP 1 stated LVN 3 assured her Resident 1 would be ready. RP 1 stated that when she arrived on 3/2/2026, she found Resident 1 sitting in his room in dirty clothes and eating breakfast. RP 1 stated she felt emotionally stressed, frustrated, and distrustful of the facility, which led her to call law enforcement to make a police report. RP 1 stated the facility did not inform her of the grievance process and did not respond to her complaints regarding Resident 1's showers or the police report until she filed a complaint with the California Department of Public Health (CDPH). RP 1 stated she is frustrated with the lack of communication the facility provides.During a concurrent observation and interview on 3/10/2026 at 8:30 a.m. with Resident 1 in Resident 1's room, Resident 1 was lying in bed wearing a stained T shirt and lying on bedsheets that appeared stained with gray material. Resident 1 appeared ungroomed. Resident 1 stated he felt frustrated that he cannot shower regularly. He stated staff does not consistently assist him to the shower, stating sometimes he will be given a towel to wash up. Resident 1 stated he is legally blind and needs assistance gathering his clothes and supplies and being led to the shower. Resident 1 stated staff accuses him of refusing showers, but he stated this is untrue and that he would like to shower daily if possible. Resident 1 stated that due to inconsistent showering, he now has a rash that he believes was caused by lack of showering. Resident 1 stated that on 2/23/2026, his birthday, staff did not provide him with an opportunity to shower before going out on pass, which caused him to feel angry and frustrated on his birthday. Resident 1 stated another occurrence happened on 3/2/2026 when staff claimed he did not want to shower the night before and needed to be rushed the morning of 3/2/2026, causing him to feel distrustful of the facility and frustrated throughout the day. Resident 1 stated he has tried to reach out to SSD to regarding his complaints but stated she doesn't follow up with him on a daily basis. Resident 1 stated he asked his RP to be the one to make complaints and grievances. Resident 1 stated he has not heard a response from the facility regarding his or his RP's concerns.During an interview on 3/10/2026 at 9 a.m. the SSD stated she most recently updated the grievance log on 3/3/2026 and there were no grievances filed by Resident 1 or his RP 1 from 12/2025 to 2/2026. The SSD stated to her knowledge, she was not aware of any outstanding grievances. During a review of Resident 1's Bathing Log, dated 2/10/2026 to 3/10/2026, the log indicated Resident 1's shower dates were Tuesdays and Fridays. The log indicated from 2/10/2026 to 2/23/2026 (13 days), Resident 1 received was only showered once, on 2/20/2026. The log did not indicate any instances when Resident 1 refused a shower. During a review of Resident 1's Interdisciplinary Team Note ([IDT] healthcare professionals from different specialties (nursing, therapy, social work, medicine) who work together to create, implement, and review a single, unified care plan for a resident), dated 2/25/2026, the note indicated Resident 1 noted to provide exaggerated and inconsistent accounts of care to RP 1, including statements of not being showered.showers documented twice a week per care plan, if shower declined or not completed, bed bath is provided and documented. The note further indicated generalized body dermatitis noted on 2/24/2026 per physician's assessment. There was no documentation indicating Resident 1's allegations regarding care concerns were investigated by the facility nor the outcome communicated in a timely manner to Resident 1 or RP 1.During an interview on 3/10/2026 at 12:58 p.m., the Minimum Data Set Nurse (MDS) stated residents in the facility are provided with showers at least two times a week on their scheduled shower days. The MDS nurse stated residents will be accommodated if they choose to shower on a different date and more frequently if requested. The MDS nurse stated, residents have the right to shower at whatever time of day they like. The MDS nurse stated based on her review of Resident 1's documentation, the bathing logs indicate Resident 1 was bathed only on 2/20/2026 between 2/10/2026 through 2/23/2026. The MDS nurse stated based on her review, there is no indication that Resident 1 refused showers during the time period. The MDS nurse stated based on further review of Resident 1's records, the IDT note dated 2/25/2026 indicated the team discussed Resident 1's and RP 1's concerns about lack of showering but did not provide an update or resolution to Resident 1 or RP 1. The MDS nurse stated it is important to investigate any concerns of care and follow up in a timely manner with the resident affected and their RP to ensure consistent communication. The MDS nurse stated failure to follow up on care concerns can lead to resident and RP 1 distrust in the facility and a potential delay in care.During an interview on 3/11/2026 at 3 p.m., the Director of Nursing (DON) acknowledged being aware of the concerns raised by Resident 1 and RP 1 during the IDT meeting on 2/25/2026. The DON stated the facility did not enter Resident 1's and RP 1's allegations regarding lack of showers into the grievance log to initiate the grievance process. The DON stated she was also aware that RP 1 complained that Resident 1 did not receive a shower on 3/2/2026. The DON stated RP 1 and Resident 1 became so upset at the staff that on 3/2/2026 at approximately 10 am, RP 1 called the police alleging lack of care. The DON stated the SSD did not provide a copy of the grievance report dated 3/2/2026 to CDPH because the facility was still working on completing the grievance form. The DON stated the facility provided Resident 1's RP a verbal update regarding the shower grievance/police report but did not provide the update in writing. The DON stated she believed the matter was resolved and did not think Resident 1 or RP 1 had additional concerns. The DON stated failing to follow the facility's grievance process can result in unresolved issues and resident /RP concerns. The DON stated facility policy requires staff to investigate and resolve all grievances and clearly communicate outcomes to residents and their representatives. The DON stated failure to address grievances can delay care and cause frustration and distrust among residents and families.During a review of the facility's policy and procedure (P&P) titled, Grievances and Complaints, revised 11/14/2025, the P&P indicated when the facility staff member overhears or receives a grievance/complaint from a resident, a responsible representative, family member, the facility staff member encourages and offers to facilitate the completion of a Grievance/Complaint investigation report. Upon receiving the grievance/complaint report, the grievance officer or designee provides a copy of the report to the appropriate department manager to being the investigation and subsequent resolution. The Grievance Official will be provided with a completed Resident Grievance/Complaint Investigation Report withing five business days of the start of the investigation.the facility will inform the resident and his RP with a summary of findings and corrective action if applicable.the disposition of all written grievances and/or complaints is recorded on the Resident Grievance/complaint log.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) whose Responsible Party (RP) 1 verbalized a complaint to facility staff, was informed of and helped in completing a Grievance/Complaint Investigation Report. This failure resulted in Resident 1 and RP 1 not receiving timely or formal communication regarding the outcome or resolution of the complaint, which led to distrust toward the facility. This failure had the potential to delay necessary care and services to Resident 1 and could negatively impact Resident 1's mental health and emotional well being.Findings:During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnoses included hepatic encephalopathy (a decline in brain function which occurs when the liver cannot remove toxins from the blood), type 2 diabetes mellitus ([DM] a disorder characterized by difficulty in blood sugar control and poor wound healing) and legal blindness (significant loss of vision).During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 1/17/2026, the MDS indicated Resident 1's cognition (ability to register and recall information) was moderately impaired and was able to understand and be understood by others. The MDS indicated Resident 1 required partial to moderate assistance (helper does more than half the effort) from staff for his activities of daily living ([ADLs] activities such as bathing, dressing, and toileting a person performs daily).During a telephone interview on 3/9/2026 at 12 p.m., Resident 1's RP 1 stated the facility was inconsistent with assisting Resident 1, who is legally blind, with showering. RP 1 stated that during her visits in 2/2026, Resident 1 appeared in dirty clothes, sitting in dirty bed linen and did not appear groomed. RP 1 stated that on 2/23/2026, Resident 1's birthday, she arrived to take him to a doctor's appointment and to celebrate his birthday and found him in dirty clothes and not showered. RP 1 stated she attempted to reach the Social Services Director (SSD) multiple times regarding her concerns but found the SSD difficult to reach and unresponsive. RP 1 stated that on 3/1/2026, after 7 p.m., she called and informed Licensed Vocational Nurse (LVN) 3 that Resident 1 had an appointment on 3/2/2026 at 9 a.m. RP 1 stated she told LVN 3 it was important that Resident 1 be showered and ready when she arrived. RP 1 stated LVN 3 assured her Resident 1 would be ready. RP 1 stated that when she arrived on 3/2/2026, she found Resident 1 sitting in his room in dirty clothes and eating breakfast. RP 1 stated she felt emotionally stressed, frustrated, and distrustful of the facility, which led her to call law enforcement to make a police report. RP 1 stated the facility did not inform her of the grievance process and did not respond to her complaints regarding Resident 1's showers or the police report until she filed a complaint with the California Department of Public Health (CDPH). RP 1 stated she is frustrated with the lack of communication the facility provides.During a concurrent observation and interview on 3/10/2026 at 8:30 a.m. with Resident 1 in Resident 1's room, Resident 1 was lying in bed wearing a stained T shirt and lying on bedsheets that appeared stained with gray material. Resident 1 appeared ungroomed. Resident 1 stated he felt frustrated that he cannot shower regularly. He stated staff does not consistently assist him to the shower, stating sometimes he will be given a towel to wash up. Resident 1 stated he is legally blind and needs assistance gathering his clothes and supplies and being led to the shower. Resident 1 stated staff accuses him of refusing showers, but he stated this is untrue and that he would like to shower daily if possible. Resident 1 stated that due to inconsistent showering, he now has a rash that he believes was caused by lack of showering. Resident 1 stated that on 2/23/2026, his birthday, staff did not provide him with an opportunity to shower before going out on pass, which caused him to feel angry and frustrated on his birthday. Resident 1 stated another occurrence happened on 3/2/2026 when staff claimed he did not want to shower the night before and needed to be rushed the morning of 3/2/2026, causing him to feel distrustful of the facility and frustrated throughout the day. Resident 1 stated he has tried to reach out to SSD to regarding his complaints but stated she doesn't follow up with him on a daily basis. Resident 1 stated he asked his RP to be the one to make complaints and grievances. Resident 1 stated he has not heard a response from the facility regarding his or his RP's concerns.During an interview on 3/10/2026 at 9 a.m. the SSD stated she most recently updated the grievance log on 3/3/2026 and there were no grievances filed by Resident 1 or his RP 1 from 12/2025 to 2/2026. The SSD stated to her knowledge, she was not aware of any outstanding grievances. During a review of Resident 1's Bathing Log, dated 2/10/2026 to 3/10/2026, the log indicated Resident 1's shower dates were Tuesdays and Fridays. The log indicated from 2/10/2026 to 2/23/2026 (13 days), Resident 1 received was only showered once, on 2/20/2026. The log did not indicate any instances when Resident 1 refused a shower. During a review of Resident 1's Interdisciplinary Team Note ([IDT] healthcare professionals from different specialties (nursing, therapy, social work, medicine) who work together to create, implement, and review a single, unified care plan for a resident), dated 2/25/2026, the note indicated Resident 1 noted to provide exaggerated and inconsistent accounts of care to RP 1, including statements of not being showered.showers documented twice a week per care plan, if shower declined or not completed, bed bath is provided and documented. The note further indicated generalized body dermatitis noted on 2/24/2026 per physician's assessment. There was no documentation indicating Resident 1's allegations regarding care concerns were investigated by the facility nor the outcome communicated in a timely manner to Resident 1 or RP 1.During an interview on 3/10/2026 at 12:58 p.m., the Minimum Data Set Nurse (MDS) stated residents in the facility are provided with showers at least two times a week on their scheduled shower days. The MDS nurse stated residents will be accommodated if they choose to shower on a different date and more frequently if requested. The MDS nurse stated, residents have the right to shower at whatever time of day they like. The MDS nurse stated based on her review of Resident 1's documentation, the bathing logs indicate Resident 1 was bathed only on 2/20/2026 between 2/10/2026 through 2/23/2026. The MDS nurse stated based on her review, there is no indication that Resident 1 refused showers during the time period. The MDS nurse stated based on further review of Resident 1's records, the IDT note dated 2/25/2026 indicated the team discussed Resident 1's and RP 1's concerns about lack of showering but did not provide an update or resolution to Resident 1 or RP 1. The MDS nurse stated it is important to investigate any concerns of care and follow up in a timely manner with the resident affected and their RP to ensure consistent communication. The MDS nurse stated failure to follow up on care concerns can lead to resident and RP 1 distrust in the facility and a potential delay in care.During an interview on 3/11/2026 at 3 p.m., the Director of Nursing (DON) acknowledged being aware of the concerns raised by Resident 1 and RP 1 during the IDT meeting on 2/25/2026. The DON stated the facility did not enter Resident 1's and RP 1's allegations regarding lack of showers into the grievance log to initiate the grievance process. The DON stated she was also aware that RP 1 complained that Resident 1 did not receive a shower on 3/2/2026. The DON stated RP 1 and Resident 1 became so upset at the staff that on 3/2/2026 at approximately 10 am, RP 1 called the police alleging lack of care. The DON stated the SSD did not provide a copy of the grievance report dated 3/2/2026 to CDPH because the facility was still working on completing the grievance form. The DON stated the facility provided Resident 1's RP a verbal update regarding the shower grievance/police report but did not provide the update in writing. The DON stated she believed the matter was resolved and did not think Resident 1 or RP 1 had additional concerns. The DON stated failing to follow the facility's grievance process can result in unresolved issues and resident /RP concerns. The DON stated facility policy requires staff to investigate and resolve all grievances and clearly communicate outcomes to residents and their representatives. The DON stated failure to address grievances can delay care and cause frustration and distrust among residents and families.During a review of the facility's policy and procedure (P&P) titled, Grievances and Complaints, revised 11/14/2025 the P&P indicated when the facility staff member overhears or receives a grievance/complaint from a resident, a responsible representative, family member, the facility staff member encourages and offers to facilitate the completion of a Grievance/Complaint investigation report. Upon receiving the grievance/complaint report, the grievance officer or designee provides a copy of the report to the appropriate department manager to being the investigation and subsequent resolution. The Grievance Official will be provided with a completed Resident Grievance/Complaint Investigation Report withing five business days of the start of the investigation.the facility will inform the resident and his RP with a summary of findings and corrective action if applicable.the disposition of all written grievances and/or complaints is recorded on the Resident Grievance/complaint log.

Based on interview and record review, the facility failed to ensure Restorative Nurse Assistant (RNA 1) accurately documented for one of three sampled residents (Resident 1), indicating Resident 1 received RNA services when there was no order and when those services were not provided. This deficient practice resulted in RNA 1 documenting Resident 1 was provided passive range of motion ([PROM] the movement of a joint when an outside force, such as a person or machine, moves the body part while the person is relaxed) exercises, to her bilateral lower ([BL] both legs) and bilateral upper extremities ([BLE] both upper arms), a splint (a rigid material or apparatus used to support in impaired joint) was applied to his right knee, and pressure relief ankle foot orthosis boot ([PRAFO] a specialized orthopedic boot designed to position the foot and ankle correctly, relieve pressure on the heel, and prevent complications such as pressure ulcers and contractures [permanent and painful tightening of the muscles that restricts movement]), when those services were not provided.This deficient practice had the potential to result in inaccurate care for the resident. Findings:During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), contracture of the right and left ankle and right and left hand, and abnormal posture.During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 12/5/2025, the MDS indicated Resident 1 was dependent (resident does none of the effort to complete the activity) on facility staff with toileting, upper and lower body dressing, personal hygiene and eating. During a review of Resident 1's Interdisciplinary (IDT) Notes dated 1/7/2026, the IDT notes indicates the team identified pressure and friction from the orthopedic devices (tools used to prevent sores and tightening and shortening of the muscles) may have contributed to the superficial abrasions and skin discoloration of the bilateral lower extremities. These devices were placed on hold and orders were discontinued once the abrasions were identified to prevent Resident 1 from having further skin breakdown. During a record review of Resident 1's Documentation Survey Report ([DSR] document indicating when RNA services are provided by staff) RNA 1 documented the following services were provided to Resident 1:1. On 1/12/2026 at 8 a.m., RNA 1 documented she provided PROM to Resident 1's right and left BUE and BLE, applied Resident 1's right knee extension splint, and applied Resident 1's PRFAO boots.2. On 1/13/2026 at 11:45 a.m., RNA 1 documented she provided PROM to Resident 1's right and left BUE and BLE, applied Resident 1's right knee extension splint, and applied Resident 1's PRAFO boots.During a review of Resident 1's Order Summary Report (Physician's Orders) dated 1/12/2026 and 1/13/2026, the Physician's Order indicated there were no orders indicating Resident 1 was to receive RNA services.During a review of Resident 1's Physician's Orders dated 1/19/2026, an order was placed for RNA to apply right knee extension split and PRAFO four to six hours a day as tolerated, RNA program for Resident 1 to receive PROM to right and left lower extremities five days a week, and PROM to right and left upper extremities five times a week or as tolerated. During a concurrent interview and record review on 1/21/2026 at 12:43 p.m., with Registered Nurse 1 (RN 1), Resident 1's medical records were reviewed. RN 1 stated on 1/6/2026 Resident 1 was discharged to a General Acute Care Hospital (GACH). RN 1 stated upon discharge, the Physician's Orders indicated facility staff to hold the application of Resident 1's right knee extension splint, PROM to BLE and PRAFO boots due to swelling and abrasions on BLE. RN 1 stated when Resident 1 returned to the facility, the previous orders were not resumed. During a concurrent interview and record review on 1/21/2026 at 2 p.m., with RNA 1, Resident 1's DSR dated 1/12/2026 and 1/13/2026 was reviewed. RNA 1 stated on 1/12/26 and 1/13/2026 she documented that she applied Resident 1's right knee extension splint and PRAFO and provided PROM to Resident 1's BLE. RNA 1 stated she did not perform the PROM, apply right knee splint or the bilateral PRAFO's because there were no physician's orders at that time. RNA 1 acknowledged that her documentation was entered by mistake and confirmed that the error should not have occurred. During a concurrent interview and record review on 1/22/2026 at 3:30 p.m., with the Director of Nursing (DON), Resident 1's medical records were reviewed. The DON stated on 1/7/2026 there was an IDT meeting and the IDT decided to hold Resident 1's order for PRAFO boots and right knee extension splint due to Resident 1 having bilateral foot swelling and superficial abrasions. The DON stated Resident 1's orders for PRAFO boots, right knee splint and PROM to bilateral upper and lower extremities were resumed on 1/19/2026 and that RNA 1 should not have documented that she provided RNA services on 1/12/2026 and 1/13/2026 when there was no order and if the services were not provided. The DON stated documentation needs to be accurate so that staff know what is being done for the residents.During a review of the facility's policy and procedure (P&P) titled, Documentation, revised 1/12/2012, the P&P indicated resident progress in the Restorative Nursing Program is documented accurately and timely. The P&P indicated physicians orders are to be obtained prior to the resident's participation to the Restorative Nursing Program for Ambulation Range of Motion Restorative program.

Based on interview and record review the facility failed to ensure a Registered nurse (RN) worked eight consecutive hours a day seven days a week on 2/1/25, 2/2/25, 2/8/25, 2/9/25, 2/15/25, 2/23/25, 3/9/25 and 3/23/25. This failure had the potential to affect the residents' quality of care and not be able to provide advanced care activities such as resident assessments, developing and evaluating care plans, and consulting with physicians. Findings: During a concurrent interview and record review on 6/25/25 at 4:08 p.m. with the Director of Staff Development (DSD). The facility's Census and Direct Care Service Hours Per Patient Day (DHPPD) dated 1/1/2025 through 6/24/25 were reviewed. The DHPPD indicated on 2/1/25, 2/2/25, 2/8/25, 2/9/25, 2/15/25, 2/23/25, 3/9/25 and 3/23/25 there was no RN coverage on those days. The DSD stated there needs to be an RN in case of an emergency because the RN has more knowledge in assessing the residents. During a concurrent interview and record review on 6/25/25 at 4:08 p.m. with the Administrator (ADM). The DHPPD dated 1/1/2025 through 6/24/25 was reviewed. The DHPPD indicated on 2/1/25, 2/2/25, 2/8/25, 2/9/25, 2/15/25, 2/23/25, 3/9/25 and 3/23/25 there was no RN coverage on those days. The ADM stated in those days they did not have an RN working. The ADM stated the RN has a different skill set of knowledge and that not having an RN could potentially affect the resident's quality of care. During a review of the Facility assessment dated [DATE], the Facility Assessment indicated, based on the facility's resident population and their needs for care and support, the following are the facility's general approaches to staffing to ensure that the facility has sufficient staff members with appropriate competencies and skill sets to meet the needs of the residents, as identified through resident assessments and care plans at any given time. The general staffing plan for licensed nurses providing direct care was to have one RN from 7am to 7pm and one RN from 7pm to 7am. The facility determines and reviews individual staff member assignments for coordination and continuity of care for the residents within and across the staff assignment and reviews acuity and care needs of the residents.

Based on observation, interview and record review, the facility failed to ensure safe and sanitary food storage and preparation practices when the facility failed to: 1.Ensure an open bag of frozen salisbury steak was stored in a sealed plastic bag in the freezer. 2.Ensure an open box of hot rice cereal was dated, labeled and stored in a sealed bag or container. These failures had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to food borne illness (illness caused by food contaminated with bacteria, viruses, parasites, or toxins ). Findings: During an initial kitchen observation and interview on 6/23/2025, at 8:11 a.m. with Dietary Manager (DM),observed an open plastic bag of frozen salisbury steaks in an open carton box was stored in the freezer. Observed DM took another plastic bag , placed the frozen salisbury steak in the plastic bag and returned the frozen steaks in the freezer. Observed an open box of rice hot cereal sitting on the kitchen countertop without an open date label. Observed DM she threw the rice cereal box in the garbage as the kitchen staff did not put the rice cereal in a bag to maintain the freshness of the food, and it was not labeled with an open date. During an interview on 6/25/2025, at 8:50 a.m. with [NAME] (CK1), CK 1 stated an open bag of frozen salisbury steak should be stored in a tight sealed bag to ensure freshness of the food being served to the residents. CK 1 stated an open box of rice hot cereal should have been stored in a bag and labeled with an open date so the staff would know when it will be expired. CK 1 stated not labeling and dating open food items could place residents at risk for food poisoning. During an interview on 6/25/2025, at 9;14 a.m. with DM, DM stated an open bag of frozen salisbury steaks not properly stored in a sealed bag could create freezer burns affecting the quality of food. DM stated an open box of hot rice cereal should be labeled with an open date and stored in a sealed plastic bag to ensure freshness so the kitchen staff will know when the food items will expire. DM stated not labeling and dating open food items can affect the quality of food and if served it can put residents at risk for food-borne illnesses. During an interview on 6/26/2025 at 1:10 p.m. with Registered Dietician (RD), RD stated it was important to store open bag of frozen steaks in a bag because it will prevent freezer burns. RD stated food items with freezer burns will diminish the quality of food and open frozen foods in the freezer could get contaminated in the freezer which could place residents at risk for food borne illnesses. RD stated labeling open food items with open date and storing them in a sealed bag will ensure the freshness of food and can minimize the risk of residents getting sick because staff will know when the food will expire. During a review of facility's policy and procedure (P&P) titled, Food Storage and Handling, dated 6/4/2024, the P&P indicated food items will be stored properly and prepared in accordance with sanitary practices and prevention of food-borne illnesses. The P&P indicated all food items will be correctly labeled, dated and foods to be frozen should be stored in an airtight container.

Based on interview and record review, the facility's Quality Assessment and Assurance Committee ([QAA] develop and implement appropriate plans of action to correct identified quality deficiencies) and the Quality Assurance Performance Improvement ([QAPI] a group who takes a systemic, interdisciplinary, comprehensive, and data driven approach to maintaining and improving safety and quality in nursing homes while involving residents and families) failed to ensure effective oversight of the facility and implementation of the facility's plan of correction (POC) of the deficient practices identified during the previous recertification survey. This failure resulted in the facility having repeat deficiencies in the areas of activities of daily living care provided for dependent residents, formulating advance directives (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), infection prevention, Quality Assurance and Performance Improvement, food storage, free of medication error rates of five percent or more, and free from psychotropic (substances that change how the brain works, affecting the person's mood, thoughts, feelings, and behavior) medication use. Findings: During a review of the facility's Statement of Deficiencies for the 2024 Recertification survey indicated the following repeat deficiencies in advance directives, activities of daily living (ADLs), infection prevention, Quality assurance and performance improvements, pharmacy services, psychotropic medication use, and food storage. During an interview on 6/26/2025 at 2:57 p.m., with the Administrator (ADM), the ADM stated the QAPI committee is currently working on falls and behavior management. The ADM stated the QAPI committee could improve address the repeat deficiencies by providing additional training, education, and in-services to the staff, increase rounding on the residents, and ensure the social services director (SSD) has a better understanding of the advance directive process. During a review of the facility's policy and procedure (P&P) titled, Quality Assurance and Performance Improvement (QAPI) Program, dated 2022, the P&P indicated, the facility implements and maintains an ongoing, facility-wide QAPI Program designed to monitor and evaluate the quality of resident care, pursue methods to improve quality of care, and resolve identified issues. The purpose is to implement a process that identifies opportunities for improvement and leads to optimal achievement in clinical and operational outcomes, and overall quality of care. To provide a structure and process to correct identified opportunities for improvement and establish benchmarks to measure outcomes.

2.During a review of Resident 38's admission Record, the admission Record indicated Resident 38 was initially admitted on [DATE] and was readmitted on [DATE] to the facility with diagnoses including paranoid schizophrenia( a pattern of behavior where a person feels distrustful and suspicious of other people and acts accordingly), schizoaffective disorder bipolar type(a mental illness that can affect thoughts, mood, and behavior) depression( a serious mental health condition characterized by persistent sadness and a loss of interest in activities, impacting how a person feels, thinks and handles daily tasks), and anxiety disorder (intense, excessive, and persistent worry and fear about everyday situations). During a review of Resident 38's History and Physical (H&P) dated 2/8/2025, the H&P indicated Resident 38 can make needs known but cannot make medical decisions. During a review of Resident 38's Minimum Data Set (MDS- resident screening tool) dated 4/30/2025, the MDS indicated Resident 38 had severely impaired cognitive skills and required supervision or touching assistance ( helper provides verbal cues and touching steadying and /or contact guard assistance as the resident completes the activity) with eating, oral hygiene, dressing, and personal hygiene. The MDS indicated Resident 38 was taking antipsychotic (medications that help manage symptoms of psychosis[ mental state where a person has difficulty distinguishing between what is real and what is not]), antianxiety ( medications used to treat anxiety) and antidepressant ( medicine used to treat depression) medications. During a review of Resident 38's PASSAR Level 1 dated 10/17/2025, the PASSAR Level 1 indicated negative for serious mental illness. During a review of Resident 38's Care Plan titled The resident banged head on the wall, initiated on 3/12/2025 and behavior was observed by the facility on 3/26/2025. The Care Plan's interventions included applying foam mat wall tiles for safety initiated 3/28/2025,providing companion care ( a person who has their eyes and ears on the resident on regular basis), resident will be wearing helmet as needed when she bangs head on the wall for safety, and informing the physician when behavior occurs. During a review of Resident 38's Order Summary Report, the Order Summary report indicated the following physician orders: 1.Depakote (medicine used to treat bipolar disorder) 250 milligrams (mgs.- unit of measurement) 2 tablets two times a day for bipolar disorder manifested by outburst of anger ordered on 3/7/2025. 2.Ativan( Lorazepam- medicine used for to treat anxiety) 1 mg. give 1 tablet by mouth every 4 hours as needed for anxiety for 14 days manifested by irritability and pacing with verbal outburst ordered on 6/20/2025. 3.Rexulti (Brexpiprazole- an antipsychotic medication used to treat schizophrenia ) 2 mgs. give 1 tablet by mouth one time a day for schizophrenia manifested by talking to self/ hearing voices ordered on 4/3/2025. 4.Seroquel(Quetiapine Fumarate- antipsychotic medication that helps manage schizophrenia and bipolar disorder) ) 25 mgs. give 1 tablet by mouth two times a day for schizoaffective disorder manifested by aggressive behavior of scratching staff ordered on 6/13/2025. 5.Trazodone (a medicine used for depression) 50 mgs. give 0.5 tablet by mouth at bedtime for depression manifested by inability to sleep at night ordered on 5/3/2025. During a concurrent interview and record review on 6/25/2025, at 10:17 a.m. with Minimum Data Set Nurse (MDSN), Resident 38's PASSAR Level 1 and electronic record were reviewed. The MDSN stated the facility should submit another PASSAR Level 1 if the resident was having a significant change in condition like change in psychotropic medicines or behavioral changes. MDSN stated she did not review the PASSAR Level 1 that was submitted by another facility when resident was admitted in the facility. MDSN stated they should have submitted another PASSAR Level 1 and agreed Resident 38 had behavioral problems like banging her head on the wall. MDSN stated Resident 38 could have missed recommendations from the Department of Health Care Services for specialized care related to her mental illness because the information submitted in the PASSAR was not complete and accurate. During a review of the facility's policy and procedure (P&P) titled, Pre-admission Screening Resident Review (PASARR), dated 2022, the P&P indicated, The purpose is to ensure that all residents are screened for mental illness and intellectual disability or a related condition. During a review of the facility's P&P titled, Pre-admission Screening Level II Resident Review, dated 2022, the P&P indicated, The IDT will review the level II evaluation report to develop a care plan and arrange the Specialized Services recommended for the resident as appropriate. The States is responsible for providing and paying for specialized services for residents with mental illness or intellectual disabilities residing in a skilled nursing facility. Based on interview and record review, the facility failed to follow through and accurately assess with the Preadmission Screening and Resident Review (PASARR- a federal assessment requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are placed in facilities that can provide the appropriate care) Level I for three of 28 sampled residents (Resident 1,Resident 38 and Resident 223) to determine the facility's ability to provide the special need of the residents. The facility failed to: 1.Complete a preadmission screening and annual resident review (PASARR) I properly for Resident 1 and 223. 2. Review submitted PASARR 1 for accuracy on Resident 38 who had diagnosis of mental illness, was on psychotropic medicines ( drugs that affect the brain and influence mental processes, emotions and behavior)and had a change in behavior involving self-harm during the course of resident's stay in the facility. These failures had the potential to put Resident 1, 38 and 223 at risk for not receiving necessary care and services they need. Findings: 1. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), schizophrenia (a mental illness that is characterized by disturbances in thought), anxiety (a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 4/28/2025, the MDS indicated Resident 1 had severe cognitive impairment (someone with significant difficulty with thinking, understanding, learning, and remembering things) was severely impaired. B. During a review of Resident 223's admission Record, the admission Record indicated Resident 223 was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder (a mental illness can affect thoughts, mood, and behavior), psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), and anxiety. During review of Resident 223's MDS dated [DATE], the MDS indicated Resident 223 had moderate cognitive impairment. During a record review of Resident 1 PASARR I dated 4/23/2025 and Resident 223's PASARR I dated 6/11/2025, the PASARR I's indicated Resident 1 and 223 had serious mental illness diagnoses and were prescribed psychotropic medications but their PASARR I screening was negative. During a concurrent interview and record review on 6/24/2025 at 1:58 p.m., with the Minimum Data Set Nurse (MDSN), the MDSN indicated the interdisciplinary team (IDT- team members from different departments working together with a common purpose to set goals and make decisions to ensure residents receive the best care) review the PASARR's to ensure accuracy and if not, the PASARR is sent back to the hospital to be redone. The MDSN validated Resident 1 has a diagnosis of bipolar, but his PASARR I was negative and should have been positive. The MDSN validated Resident 223 has diagnoses of schizoaffective disorder, bipolar, and anxiety but his PASARR I was negative and should have been positive. The MDSN stated the PASARR I not being done accurately could result in the residents not receiving the necessary services and care, being hospitalized , and safety concerns if their care is not being managed with the proper resources. During an interview on 6/26/2025 at 6:10 p.m., with the Director of Nursing (DON), the DON stated she expects her staff to review and ensure the PASARR is completed accurately so the facility can provide the right care for the residents. The DON stated her understanding of the PASARR is if a resident has a mental illness, is stable and functioning, their PASARR I would be negative and only positive if the resident is unstable.

Based on observation, interview and record review, the facility failed to ensure the resident, who had a history of banging her head on the wall, did not banged her head on the wall and sustained an injury for one of three sampled resident (Resident 1). The facility failed to: 1. Ensure a Certified Nursing Assistant (CNA) 1, who was assigned to provide Resident 1 with 1:1 (a constant observation provided by a care giver/sitter) supervision for safety, prevented Resident 1 from walking towards the wall and start banging her head on the wall. 2. Ensure CNA 1 was informed and had knowledge of Resident 1's behavior of banging her head on the wall. 3. Ensure the facility's policy and procedure (P&P) titled, Resident Safety, dated 4/15/25, which indicated, the purpose is to provide a safe and hazard free environment was followed. These failures resulted in Resident 1 banging her head on the wall and falling on the floor sustaining laceration (a deep cut or tear in the skin) on the left forehead (the left [NAME] of the front head) requiring six sutures (a stitch or row of stitches holding together the edges of a wound or surgical incision [surgical cut]). On 3/26/25 at 2:47 p.m. Resident 1 was transferred to the General Acute Care Hospital (GACH) for evaluation and treatment. Findings: During a review of Resident 1's Admission Record, the Admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including paranoid schizophrenia (is a type of schizophrenia [mental illness that is characterized by disturbance in thoughts] characterized by prominent delusions {these are fixed, false beliefs that are not based on reality}, hallucinations, (sensory experiences that are not real, such as hearing voices or seeing things that aren't there), anxiety disorders (excessive worry, fear, and other physical and behavioral symptoms that interfere with daily life), chronic obstructive pulmonary disease (COPD a chronic lung disease causing difficulty breathing). During a review of Resident 1's Minimum Data Set (MDS-resident assessment tool) dated 2/15/2025, the MDS indicated Resident had severe impairment in cognitive skills (ability to think, understand, learn, and remember) for daily decision-making. The MDS indicated Resident 1 required moderate assistance (helper does less than half the effort, helper lifts, holds, or supports trunk or limbs) from staff for activities of daily living (ADL- routine tasks/activities such as bathing, dressing and toileting) and with transfers between surfaces. During a review of Resident 1's Physician's Order Summary dated, 3/11/25, the Physician Order Summary indicated a physician's order on dated 3/11/25 for Resident 1 to have a care companion in the room and line of sight in the hallway/outside of room for safety. During a review of Resident 1's care plan titled, Resident 1 bangs head on the wall initiated on 03/12/25 and revised on 03/27/25, the care plan indicated the goal for Resident 1 was to minimize injury related to hitting head on the wall. The care plan interventions included Resident 1 to wear helmet (used to protect resident from head injuries), as necessary when banging head on the wall for safety, install pads on walls, and continue to monitor Resident 1's behavior (banging head on the walls) causing harm to self. During review of Resident 1's care plan titled, Resident 1 is non-complaint with wearing a helmet initiated on 03/13/2025, the care plan indicated the goal for Resident 1 was to minimize injury related to hitting the head. The care plan interventions included to have a care companion in the room and line of sight for safety. During a review of Resident 1's Transfer Form dated 3/26/2025, the Transfer Form indicated Resident 1 was transferred to the GACH for evaluation and treatment related to a fall on 3/26 at 2:47 pm. During a review of Resident 1's GACH's Trauma Flow Sheet dated 3/26/25, the GACH's Trauma Flow Sheet indicated Resident 1 was brought to the ER from the facility with four-centimeter (cm-unit of measurement) long laceration to the left forehead. The GACH's Trauma Flow Sheet indicted Resident 1 received six sutures (a stitch or row of stitches holding together the edges of a wound) to the left forehead. During a review of Resident 1's Nursing Progress Notes dated 03/26/25 and timed at 8:16 pm, Resident 1 return to facility from the GACH's emergency room (ER) with sutures on the left forehead open to air with lump (a swelling or bump on or under the skin) in the middle of forehead. The Nursing Progress Notes indicated to continue with 1:1 supervision at bed side for safety. During a review of Resident 1's Interdisciplinary Team ([IDT] team members from different departments working together with a common purpose to set goals and make decisions that ensure residents receive the best care) Note dated 03/27/25 and timed at 5:25 pm, the IDT Note indicated Resident 1 had a history of hitting her head on the wall. The IDT Note indicated interventions included for Resident 1 to wear a padded helmet to prevent injury, but the resident was non-compliant with wearing a helmet. The IDT Note indicated due to Resident 1's noncompliance in wearing the padded helmet, Resident 1 to have a care companion in the room and within line of sight in the hallway for safety. The IDT Note indicated the new safety measures implemented included to remove Resident 1's side table and television and pad the wall to prevent further injury. During record review of Change of Condition Evaluation (COC) dated 3/31/25, the COC indicated Resident 1 had the left forehead laceration, with lump/hematoma (a solid swelling of clotted blood within the tissues) on the center of Resident 1's forehead. The COC indicated Resident 1 remains on continued frequent monitoring, and 1:1 supervision with a sitter (a caregiver who provides constant observation and is often used for residents at risk of falls or injury). During a concurrent observation and interview on 04/03/25 at 3:06 pm with Resident 1, in Resident's 1 room, Resident 1 was observed sitting in bed with 1:1 sitter (CNA 2) who was sitting in a chair by the resident's bed side. During the observation it was noted that the wall in front and all at the sides of Resident 1's bed was padded. Resident 1 was observed to have six sutures on her left forehead with no dressing over it. Resident 1 was observed to have a purple discoloration around the left eye with swelling. CNA 2 stated her responsibilities as 1:1 sitter included to keep close supervision on Resident 1 for safety and prevent Resident 1 from falling or banging her head on the walls. CNA 2 stated she was not working on the day Resident 1 bang her head on the wall and fell on the floor (3/26/25). CNA 2 stated to prevent Resident 1 from banging her head on the wall, she will sit closer to Resident 1 and will get up anytime Resident 1 gets out of bed or chair to provide safety. During a phone interview on 4/03/25 at 3:47 pm CNA 1 stated she was the 1:1 sitter for Resident 1 on 3/26/25 from 7 am to 3 pm shift. CNA 1 stated she was sitting beside Resident 1 when Resident 1 suddenly got up and walked towards the wall near the room door. CNA 1 stated Resident 1 started to hit and bang her head on the wall. CNA 1 stated she could not catch Resident 1 in time because Resident 1 got up too quickly. CNA 1 stated she was able to grab Resident 1 partway down as she was falling to the floor. CNA 1 stated she yelled for help because Resident 1 was bleeding from the front of her head. CNA 1 stated she felt bad over Resident 1's injury as it could have been prevented. CNA 1 stated that she was not informed about Resident 1 banging her head against the walls until after the incident on 3/26/25. CNA 1 stated she was told that the reason why Resident 1 required 1:1 sitter was because the resident was losing her balance and wandering (moving from place to place without a fixed plan) in the hallway. CNA 1 stated that if she had been aware of Resident 1's behavior of banging her head against the walls, she could have been more vigilant and sat closer to Resident 1 to help prevent injuries and falls. During a phone interview on 03/3/25 at 4:01 pm Licensed Vocational Nurse l (LVN 1) stated she was the charge nurse on 3/26/25. LVN 1 stated she was passing medication when she heard CNA 1 yelling for help. LVN 1 stated when she entered Resident 1's room, Resident 1 was sitting on the floor and blood was coming out of Resident 1's forehead. LVN 1 stated Resident 1 was sent to the GACH via 911 due to laceration on the forehead. During a phone interview on 3/4/25 at 4:13 pm Resident 1's Family member (FM 1) stated Resident 1's injury could have been prevented if the facility staff (CNA 1), who was watching Resident 1, paid a close attention to Resident 1. FM 1 stated she was surprised when she saw Resident 1' s face with bruises and laceration on her left forehead. During an interview on 4/4/25 at 4:03 pm the Director of Nursing, (DON) stated Resident 1 has a history of wandering and throwing herself on the floor. The DON stated the incident happened so fast, in spite CNA 1 sitting close to Resident 1, as Resident 1's behavior was unpredictable. During a concurrent observation and interview on 04/04/25 at 4:26 pm with the Administrator (ADM) and the DON, in Resident 1's room, the ADM demonstrated on how the incident happened on 3/26/25 based on CNA 1's interview. The ADM demonstrated that CNA 1 was seated at the foot of Resident 1's bed facing the resident, who was sitting on the side of the bed. Resident 1 quickly crossed in front of CNA 1 and bang her head against the wall near the cabinet, which was located at the foot of the bed. During the observation, the distance from where Resident 1 was seated on the side of the bed to the wall near the cabinet where Resident 1 bangs her head was approximately eleven steps. The DON stated the incident could have been prevented if CNA 1 was fast enough to stop Resident 1. During a review of the facility's P&P titled, Resident Safety, dated 4/15/25, the P&P indicated the purpose of this policy is to provide a safe and hazard free environment. Residents will be evaluated on admission, quarterly and whenever there is a change in condition to identify circumstances that pose a risk for the safety and wellbeing of the resident. During a review of the facility's P&P titled, Sitters dated 1/25/24, the P&P indicated, to assist residents who need additional observation and/or companionship in obtaining sitters or companion care.

Based on observation, interview, and record review, the facility failed to ensure one of six sampled residents (Resident 1) was not physically assaulted by another resident (Resident 2). This deficient practice resulted in Resident 1 sustaining a laceration (a deep, jagged tear or cut in the skin, often caused by a sharp object or blunt trauma, resulting in an irregular wound that could bleed significantly) to his right hand between his right thumb and right pointer finger, that required eight sutures (a stitch or row of stitches holding together the edges of a wound or surgical incision) and abrasions (a minor injury to the skin that occurs when the skin is rubbed or scraped) to his right forearm, right knee and left knee. Findings: During a review of Resident 1's Admission Record (Face Sheet), the Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including metabolic encephalopathy (a brain disorder that occurs when there is a chemical imbalance in the blood caused by an illness), and gait and mobility abnormalities (changes in a person's walking patterns or balance that occur because of problems in the body). During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 1/18/2025, the MDS indicated Resident 1 was able to make decisions that were consistent and reasonable, and he was independent ambulating (the act of walking and moving about) and transferring from bed/chair to chair in the facility. During a review of Resident 1's Change of Condition Evaluation (COC) dated 2/8/2025 and timed at 10:38 a.m., the COC indicated Resident 1 was hit on his hand by Resident 2 with a Wet Floor sign (a sign placed on a slippery/wet floor to alert people of a fall risk, typically measuring 25 inches tall by 11 inches wide) and sustained a cut to his right hand between his thumb and second finger requiring sutures. The COC indicated Resident 1 complained of pain rated two out of 10 on a pain rating scale (an eleven-point scale where pain is rated from zero to 10; 0=no pain, 1-3=mild pain, 4-6=moderate pain, and 7-10=severe pain, and 10=worst imaginable pain), to his right hand. During a review of Resident 1's Transfer Form dated 2/18/2025 and timed at 10:54 a.m., the Transfer Form indicated Resident 1 was transferred to a General Acute Care Hospital (GACH) because of a cut on his right hand between his thumb and second digit (finger). During a review of Resident 2's Admission Record (Face sheet), the Face Sheet indicated Resident 2 was admitted to the facility on [DATE] with diagnosis including paranoid schizophrenia (a type of mental disorder that involves extreme feelings of paranoia [suspicions], delusions [false beliefs], hallucinations [seeing or hearing things that are not there], disorganized speech and behavior, difficulty concentrating, feelings of being controlled by someone and suicidal thoughts and behaviors). During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2 was able to make decisions that were consistent and reasonable and required partial to moderate assistance with walking in the facility. During a review of Resident 2's COC dated 2/8/2025 and timed at 10:19 a.m., the COC indicated Resident 2 had behavioral symptoms that included agitation (restless moving, shouting, twitching and jerking of the body) and psychosis (a condition when a person's thoughts and perceptions are disrupted, with difficulty recognizing what is real and what is not). The COC indicated Resident 2 was aggressive and went inside Resident 1's room, hit Resident 1 with a Wet Floor sign cutting Resident 1's right hand between his thumb and second finger. During a review of the GACH's Patient Education and Visit Summary dated 2/8/2025 and timed at 11:26 a.m., the Patient Education and Visit Summary indicated Resident 1 was brought to the GACH by paramedics for treatment because of a right-hand laceration after being assaulted by his roommate. The GACH Visit Summary indicated Resident 1's right hand laceration was sutured. During an interview on 2/12/2025 at 2:14 p.m., Resident 1 stated on 2/8/2025 around 10:30 a.m., he was in his room taking a nap, when Resident 2 came into his room screaming and accusing him (Resident 1) of killing her family. Resident 1 stated he was shocked and scared when Resident 2 hit him with a Wet Floor sign on his right hand/arm, right knee and left leg. Resident 1 stated he had injuries to his right hand, right forearm, right knee and left knee. Resident 1 stated multiple staff came to help him and to stop Resident 2 from hitting him, but it was too late because he was already hurt and bleeding badly from the cut on his right hand. Resident 1 stated his right hand was painful to touch and he was worried if his hand would function after this injury. During an interview on 2/13/2025 at 11:02 a.m., Certified Nursing Assistant 2 (CNA 2) stated on 2/8/2025 at around 10:30 a.m., she was in another resident's room washing her hands when she heard Resident 2 screaming angrily in a foreign language. CNA 2 stated she immediately when to check on Resident 2 and saw Resident 2 at the foot of Resident 1's bed and CNA 1 and a housekeeper (HK) trying to remove the Wet Floor sign from Resident 2's hands. CNA 2 stated Resident 1 was bleeding from his right hand. During an interview on 2/13/2025 at 11:32 a.m., the HK stated during the morning shift (unsure of the time) on 2/8/2025 she was cleaning a resident's bathroom when she heard a resident (Resident 2) screaming loudly. The HK stated she walked to the hallway and saw Resident 2 screaming angrily in a foreign language in front of Resident 1's room. The HK stated she saw Resident 2 enter Resident 1's room, pick up a Wet Floor sign and hit Resident 1 with the sign many times. The HK stated she asked for help and she and CNA 1 went inside Resident 1's room to stop Resident 2 from hitting Resident 1. During a telephone interview on 2/13/2025 at 12 p.m., Licensed Vocational Nurse (LVN) 2 stated she was at the nursing station when she heard screaming and yelling coming from a resident's room. LVN 2 stated she went into Resident 1's room and observed CNA 1 telling Resident 2 to stop hitting Resident 1 while directing Resident 2 to leave the room. During an observation on 2/13/2025 at 12:51 p.m. in Resident 1's room, with Treatment Nurse 1 (TXN 1), Resident 1's right hand was observed with eight sutures and there were multiple dark purple discolorations to the palm of Resident 1's right hand surrounding the laceration/sutures and on the back of his right hand. During a telephone interview on 2/13/2025 at 1:13 p.m., CNA 1 stated she was providing care to another resident when she heard someone say shut up in a loud voice and saw Resident 2 run across the hallway into Resident 1's room. CNA 1 stated she saw Resident 2 pick up a Wet floor sign and hit Resident 1 with it. During an interview on 2/13/2025 at 4:35 p.m., the Administrator (ADM) stated it was everyone's responsibility to ensure residents were safe and free from any abuse. During a review of the facility's Policy and Procedure (P/P) titled Abuse-Prevention, Screening, & Training Program revised 7/2018, the P/P indicated the facility does not condone any form of resident abuse.

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) was not subjected to a physical abuse by Resident 2. The facility failed to: 1. Ensure Resident 1, who had a history of aggressive behavior toward residents and staff and was sent out to a general acute care hospital (GACH) on 5150 (temporary, involuntary psychiatric commitment of residents who present a danger to themselves or others due to signs of mental illness) hold on 4/18/2024, was not placed in the same room with Resident 2 upon re-admission to the facility on [DATE]. 2. Ensure staff followed Resident 2's care plan titled, Alleged altercation per another roommate on 4/11/2024, to prevent Resident 2 altercations with Resident 1 on 4/27/2024. 3. Provide Resident 2 with 1:1 sitter (constant observation by a staff member for the residents and companions safety) to prevent Resident 2 from altercation with other residents per care plan titled, Alleged altercation per another roommate (Resident 3) on 4/11/2024. 4. Ensure Resident 1 was assessed upon re-admission to the facility and ongoing for the appropriate placement in the same room with Resident 2 to prevent possible altercation between both residents per facility's policy and procedure (P&P) titled, Abuse-Prevention, Screening, & Training Program. As a result, Resident 2 punched Resident 1 in the face leading Resident 1 to fall on the floor. Resident 1 sustained a left upper eye lid laceration (skin cut) and skin tears (traumatic wounds that may result from a variety of mechanical forces such as falls) on a right forearm (arm area between the elbow and wrist). Resident 1 was transferred the GACH on 4/27/2024 for evaluation of head trauma. Findings: During a review of Resident 1's Admission Record, the Admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including paranoid schizophrenia (involves delusions [false beliefs], hallucinations [hearing or seeing things that do not exist), unusual physical behavior, disorganized (abnormal thought process, thinking or speech) and bipolar disorder (a mental illness that causes extreme shifts in a person's mood, energy, activity levels, and concentration). During a review of Resident 1's History and Physical (H&P) dated 4/26/2024, the H&P indicated Resident 1 could make needs known but could not make medical decisions. During a review of Resident 1's Minimum Data Set ([MDS], a standardized assessment and care screening tool), dated 5/3/2024, the MDS indicated Resident 1 had a moderate impairment in cognitive (relating to the process of acquiring knowledge and understanding) skills for daily decision-making. The MDS indicated, Resident 1 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with oral hygiene, toileting, hygiene, and showering/bathing. During a review of Resident 2's Admission Record, the Admission Record indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses including paranoid schizophrenia suicidal ideations (suicidal thoughts or ideas), restlessness, agitation, and violent behavior. During a review of Resident 2's H&P dated 4/14/2024, the H&P indicated Resident 2 was able to make decisions for activities of daily living. During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2 had a moderate impairment in cognitive skills for daily decision-making. The MDS indicated, Resident 2 required partial to moderate assistance (helper does less than half the effort) with oral hygiene, toileting, hygiene, and showering/bathing. During a review of Resident 1's care plan titled, Resident has a behavior problem: Defecating and urinating on a floor, initiated on 3/14/2024, the care plan indicated the goal for Resident 1 was to have fewer behavioral episodes weekly by the target date 6/15/2024. The care plan indicated the interventions included to intervene as necessary to protect the rights and safety of others, remove Resident 1 from the situation (unspecified), to take the resident to alternative location as needed, monitor behavior episodes, and attempt to determine underlying cause, and consider location, time of day, person involved and situation. During a review of Resident 1's Nursing Progress Notes (NPN) dated 4/18/2024 and timed at 7:32 a.m., the NPN indicated Resident 1 tried to get out of the facility, was physically aggressive toward staff when redirected, pacing (walk at a steady and consistent speed back and forth) the entire night and making sexual comments to staff. During a review of Resident 1's NPN dated 4/18/2024 and timed at 2:02 p.m., the NPN indicated Resident 1 was on monitoring for increased agitation, verbal, and physical aggression. The NPN indicated Resident 1 was not cooperative with care and refused medication. Resident 1 was sent out to a GACH on 5150 hold. During a review of Resident 1's Admission record dated 4/26/2024, the Admission Record indicated Resident 1 was readmitted back to the facility from the GACH and was placed in the same room with Resident 2. During a review of Resident 1's change of condition ([COC]-a sudden change from the resident's baseline) note dated 4/27/2024, the COC indicated around 4:15 a.m., Resident 1 was observed sitting on the floor at the foot of his bed and leaning with his back against the wall. The COC indicated Resident 1 verbalized Resident 2 hit him on the face and he fell on the floor. The COC indicated Resident 1 sustained a left upper eye lid cut and the right lower arm skin tear from the fall. During a review of Resident 1's Physician's Order Summary Report dated 4/27/2024, the Physician's Order Summary Report indicated the following orders: 1. Cleanse left upper eyelid cut with Normal Saline (cleansing solution) gently pat dry, then leave it open to air every day and as need daily for 14 days. 2.Cleanse skin tear to the right lower dorsal (back) arm with Normal Saline gently pat dry then cover with foam dressing daily and as needed for 14 days. 3.Computerized Tomography scan ([CT]- diagnostic imaging procedure) of the head. During a review of Resident 1's GACH Emergency Department (ED) note dated 4/27/2024, the GACH ED' note indicated Resident 1 was brought in by ambulance from the facility for evaluation of head injury status post (after) assault (physical attack). The ED note indicated, Resident 1 was punched in the face five times, mainly around the left eye, which caused Resident 1 to fall on the ground. The ED note indicated, Resident 1 hit his head on the wall, slid down and fell , landing on his right elbow on the floor. The ED note indicated, Resident 1 experienced the left eye pain, left eye swelling, and right elbow pain. During a review of Resident 1's NPN dated 4/30/2024, the NPN indicated Resident 1 had the left periorbital (around the eye) swelling with discoloration, left upper eyelid cut and the right forearm multiple skin tears. During a review of Resident 2's care plan titled, Alleged altercation per another roommate (Resident 3) on 4/11/2024, initiated on 4/11/2024, the care plan indicated the goal for Resident 2 was not to have further altercations with another residents by target date of 7/4/2024. The care plan intervention included to continue to provide 1:1 sitter (constant observation by a staff member for the residents and companions safety) until Resident 2 discharged , administer medication as ordered, send to the hospital for behavior management, and separate Resident 1 and Resident 3 immediately to prevent further altercation. During a review of Resident 2's COC dated 4/11/2024, the COC indicated Resident 2 took Resident 3's walker threw the walker toward Resident 3's direction and punched him on the forehead. The COC indicated, the facility informed the psychiatrist (a physician specialized in mental illness) and had an order to transfer Resident 2 to a GACH. During a review of Resident 2's GACH record, dated 4/12/2024, indicated Resident 2 was presented on a 5150 hold for danger to others. The GACH's clinical record indicated Resident 2 was placed on 5150 hold for aggression towards other residents. The GACH's record indicated, upon one-to-one interaction with nursing staff on admission to the GAHC Resident 2 remained silent, refused to cooperate with admission process, and remained unpredictable for violence. During a review of Resident 2's Psychiatric Progress Note from the GACH, dated 4/20/2024, indicated, Resident 2 was still very disorganized in thought process and was unable to engage in any reality-based conversation. The Psychiatric Progress Note indicated Resident 1 will continue to require ongoing psychiatric management in a structured environment such as GACH. During a review of Resident 2's COC dated 4/27/2024 indicated Resident 2 had alleged physical altercation with Resident 1, his roommate. The COC indicated when Resident 2 was asked what happened he did not respond. The COC indicated Resident 2 was placed on 1:1 sitter observation for safety. During a review of Resident 2's care plan titled, Resident 2 had a behavior problem of refusing all care and medications, spitting on the floor and spreading feces on the facility walls, initiated on 4/25/2024, the care plan indicated the goal for Resident 2 was to have fewer episodes of refusing care, spitting on the floor, refusing medications, and spreading feces on the wall daily/weekly by a target date of 7/04/2024. The care plan intervention included to monitor Resident 2 behavioral episodes and attempt to determine underlying causes, consider location, time of day, persons involved, and situations, and document behavior and potential causes. During an interview on 5/9/2024 at 10:40 a.m., a Certified Nursing Assistant (CNA 1) stated Resident 2 was very short tempered and shout at the facility's staff. CNA 1 stated, Resident 1 was very hard to take care of because he was getting mad when he was asked a question. CNA 1 stated, it was not safe for Resident 2's door to be close for safety. CNA 1 stated, he should have done more frequent visual check every 1-2 hours and get another nurse to check Resident 2 for safety. During a concurrent observation and interview on 5/9/2024 at 11:08 a.m., Resident 1 was observed with dry dark scabs on his right forearm and light discoloration under his left eyelid. Resident 1 stated, he remembered about the alleged incident with Resident 2. Resident 1 stated, on the day of the incident (4/27/2024), Resident 1 used the bathroom and on the way back to his bed he noticed Resident 2 was closing the room door and started punching Resident 1's face. Resident 1 was observed with increased tone of voice. Resident 1 stated he did not feel safe and felt scared when he thought about the incident. During an interview on 5/9/2024 at 10:30 a.m., the Social Service Director (SSD) stated Resident 2 had another altercation with another resident (Resident 3) on 4/11/2024 when Resident 2 took Resident 3's walker in the hallway and threw it towards Resident 3's direction. The SSD stated Resident 2 was sent out to the hospital via Psychiatric Emergency Team ([PET] a mobile [NAME] operated by psychiatric hospitals) on 5150 hold. The SSD stated Resident 2 was physically violent toward Resident 1. The SSD stated Resident 1 had a bruise on his left eye at that time. The SSD stated upon police arrival on 4/27/2024 to the facility, Resident 1 wanted to press charges against Resident 2, and Resident 2 was detained by the police. During an interview on 5/9/2024 at 11:40 a.m. CNA 2 stated on the days she took care of Resident 2 (dates unknown), the resident was getting angry and was aggressive toward other residents and staff. During an interview on 5/9/2024 at 11:56 a.m., the Registered Nurse Supervisor (RNS 1) stated based on Resident 2's diagnoses of mental illnesses and history of aggressive behavior toward other residents, the facility staff should make frequent rounds every hour or two hours and ensure the room door was not close to check on residents' safety and prevent possible altercation between Resident 1 and Resident 2. During a phone interview on 5/09/2024 at 12:27 a.m. CNA 3 stated she heard a loud sound, like something fell on the ground. CNA 3 stated she ran to check where the sound came from when she reached Resident 1 and 2's room, the door was close. CNA 3 stated, when she attempted to open the door, it was hard to open and felt like someone was pushing against the door. CNA 3 stated she had to call for help to open Resident 1 and Resident 2's room door. CNA 3 stated when the door was opened, she saw Resident 1 was sitting on a floor next to his bed, leaning towards the right side of his body. CNA 3 stated Resident 2 was standing next to the door. CNA 3 stated, Resident 1 looked very scared. CNA 3 stated Resident 1 verbalized Resident 2 punched him. CNA 3 stated Resident 2's facial expression looked like the one that conveys anger or frustration. CNA 3 stated, around 11 p.m. Resident 1 was observed sleeping in bed. CNA 3 stated Resident 2 was observed pacing inside the room and outside of the room. CNA 3 stated the last time she checked on Resident 1 and Resident 2 was 11 pm. CNA 3 stated that Resident 2 had no 1:1 sitter on 4/27/2024 to prevent the altercation between Resident 1 and Resident 2. During a phone interview on 5/9/2024 at 12:50 p.m. the Licensed Vocational Nurse (LVN 1) stated when they were trying to open Resident 2's room door it was hard to open as if someone was pushing against it. LVN 1 stated when the door was finally opened Resident 1 was observed sitting on the floor. LVN 1 stated upon assessment Resident 1 had a skin tear on his right lower arm, and laceration of his left eyelid approximately 1.5 centimeters ([cm] a unit of measurement) long on his left eyelid. LVN 1 stated Resident 1 and Resident 2 last checked was around between 12 1 a.m. on 4/27/2024. LVN 1 stated the incident happened around 4 a.m. on 4/27/2024. LVN 1 stated, staff should make rounds often at least every 2 hours especially Resident 1 and 2 who have history of aggressive behavior toward other residents and staff, and to assess and monitor their behavior such as anxiety, restlessness, verbal agitation, or pacing and to ensure safety of both residents. During a concurrent interview and record review on 5/13/2024 at 9:10 a.m., with the Director of Nursing Service (DON), the DON stated Resident 2 had a history of alleged physical aggression towards other residents when Resident 2 threw a walker towards the direction of Resident 3 and punched Resident 3 in the hallway. The DON stated based on Resident 2's history of physical aggression toward other residents the facility should have assess and consider who could be the roommate for Resident 2 to prevent any trigger, outburst, and anger. The DON stated the facility staff should have monitored Resident 2's behavior every shift for the first 72 hours of readmission to the facility for any outburst of anger, and monitor behavior every 2 hours. The DON stated the facility will move Resident 2 to room closer to the nursing station to monitor the resident's facial expression, body language, and pacing or any environment that can bother Resident 2. The DON stated the facility should have assessed if Resident 1 would be compatible to be in one room with Resident 2 who had a history of aggressive behavior. During a review of the facility's policy and procedure (P&P) titled Abuse-Prevention, Screening, & Training Program, revised 07/2018, the P&P indicated the facility does not condone any form of resident abuse, neglect, misappropriation of resident property, exploitation, and/or mistreatment. Physical abuse is defined as, but not limited to, hitting, slapping, punching, and/or kicking. It also includes corporal punishment which is physical punishment used to correct and/or control behavior. The facility conducts resident pre-admission, admission, and ongoing assessments (screening) and care planning for appropriate interventions and monitoring of residents with needs and behaviors which might lead to conflict or neglect.

Based on interview, and record review, the facility failed to follow the plan of care to keep blood sugar levels in control with stable numbers for one of one resident (Resident 45), who was diagnosed with diabetes (abnormal blood sugar levels) by failing to: a. Follow the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure resulted in the physician not notified when Resident 45's blood sugar levels reached 400 mg/dL and above per the sliding scale (the dose of insulin ([MEDICATION(S)], medication given to lower blood sugar level), to be given depending on the blood sugar results) for total of 16 times in May 2021, 15 times in June 2021, and 20 times in July 2021 . b. Follow the plan of care to monitor signs and symptoms of [CONDITION(S)] (elevated blood sugar level can cause symptoms such as increased thirst, frequent urination, fatigue, and nausea) and initiate the change of condition ([COC] guidelines set by the facility for staff to follow if any of the COC criteria was met) protocol after the resident had blood sugars levels greater than 400 mg/dL, c. Reassess and monitor Resident 45 after administering insulin when the blood sugar levels were greater than 400 mg/dL to ensure the amount of insulin given was affective in lowering the high blood sugar levels. d. Notify Resident 45 and the family member when the resident's blood sugar levels were 400 mg/dL or greater. These deficient practices placed Resident 45 at a high risk for diabetic ketoacidosis (condition where the body does not get the sugar it needs for energy, so the body begins to burn fat for energy) leading to long term complications (damage to blood vessels, kidneys, eyes, nerves), coma (prolonged unconsciousness), hospitalization , and death. On 7/16/2021 at 4:25 p.m., an Immediate Jeopardy ([IJ] a situation in which the facility's noncompliance with one or more requirements of participation has cause, or is likely to cause, serious injury, harm impairment or death to a resident) was identified, and declared due to the facility's failure to notify the physician when Resident 45's blood sugar levels were 400 mg/dL and greater, failed to monitor the resident for signs and symptoms of [CONDITION(S)], failed to recheck the blood sugar levels after administering insulin when the levels were 400 mg/dL and higher, and failed to notify the resident/family for blood sugar levels greater than 400 mg/dL. The IJ was called in the presence of the Administrator (ADM), Infection Preventionist Nurse (IPN), Director of Staff Development (DSD), Vice President of Operations (VPO), and the Registered Nurse Consultant 1 (RNC 1). During an interview on 7/17/2021 at 1:30 p.m., the ADM submitted an acceptable Plan of Action ([POA] interventions to correct the immediacy of the deficient practices). The acceptable POA included Resident 45's immediate needs: 14 diabetic residents, identified by the facility that were on sliding scale insulin, were audited and addressed for adequacy of diabetic management; Seven residents were identified having unmanaged blood sugars levels needing adjustments: and in services to Licensed Nursing Competency in diabetic management and COC process were conducted. 1. POA for Resident 45 were as follows: a. On 7/16/21, Resident 45's physician was notified of the resident's blood sugar results and current insulin sliding scale coverage in the last 2 weeks and ordered to change the sliding scale coverage of [MEDICATION(S)] insulin, and increased [MEDICATION(S)] (type of insulin) from 40 to 45 units, and Hemoglobin A1c (blood test that measures the average blood glucose, or blood sugar levels over the last three months) lab ordered for 7/19/21. b. Resident 45 was placed on monitoring by the licensed nurses for 72 hours for signs and symptoms of [CONDITION(S)] (low blood sugars) and [CONDITION(S)]. c. On 7/16/2021 the facility notified the resident and family of Resident 45's blood glucose above 400 mg/dL. 2.POA for 14 residents were as follows: a. On 7/16/2021, the licensed nurses notified the physician, reported blood sugar trends for last 2 weeks, reviewed current diabetic management, received orders, and carried the orders out. b. On 7/16/2021, care plans for diabetic management which included continuous monitoring for signs and symptoms of hypo/ [CONDITION(S)] were created. 3. POA for 7 facility identified residents were identified to have had episodes of blood sugars below 70 mg/dl or above 400 mg/dl and those with unmanaged blood sugars levels including high or low ranges that needed adjustments. a. On 7/16/2021, the Licensed Nurses notified the Physician, reported blood sugar trends for last 2 weeks, reviewed current diabetic management, received orders, and carried orders out. b. Between 7/16/2021 and 7/17/2021, residents and family were notified of blood glucose outside ordered parameters for each resident involved. c. Residents were monitored for 72 hours for signs and symptoms of [CONDITION(S)] and [CONDITION(S)] and significant changes were reported to the attending physician. This was initiated between 7 16 2021 and 7/17/2021. 4. POA for licensed staff, on 7/16/2021, the Regional Quality Management Consultant provided a re education to licensed nurses on diabetic management, change of condition, and pharmacy recommendations with emphases on the following: a. Following physicians' orders for notification when blood sugar is below 70 mg/ dL or above 400 mg/ dL, as per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . b. Initiating change of condition assessment when blood sugars are below 70 mg/ dL or above 400 mg/dL. c. Rechecking of the residents' blood sugar after treating a blood sugar greater than 400 mg/ dL or below 70 mg/dL; and d. Notification of resident/family of changes of condition. 5. Systemic Changes a. During the daily morning clinical meetings, Monday Friday, the director of nursing (DON)/designee will review residents with new changes of condition from the prior day to identify residents with blood sugars that are below 70 mg/ dL or above 400 mg/ dL to ensure that the resident identified was assessed and the attending physician, resident and family were notified. Any issues identified will be immediately addressed. b. The DON/designee will conduct an audit of residents' blood sugar results weekly for 4 weeks, then bi monthly for 2 months to ensure that residents' blood sugar results are reviewed. For identified blood sugars that are below 70 mg/ dL or above 400 mg/ dL, the DON/ designee will ensure that the residents are assessed, and physician and resident/family are notified. Any issues identified will be immediately addressed. The IJ was lifted on 7/18/2021 at 1:30 p.m., after the team verified and confirmed the POA was implemented per observations, interviews, and record review, while onsite. Findings: During a record review of Resident 45's Admission Record, face sheet (document gives resident quick information briefly), indicated the resident was admitted on [DATE]. Resident 45's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 45's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 6/11/2021, the MDS indicated the Resident 45 had the ability to express ideas and wants, and had the ability to understand others and responded adequately. The MDS assessment indicated Resident 45 was cognitively intact with daily decision making. The MDS assessment indicated resident 45 required supervision to total assistance from staff with activities of daily living such as grooming, eating, and toileting. During a review of Resident 45's care plan titled, COC Due to Elevated Blood Sugars, dated 4/12/2021, the interventions indicated to notify the physician and responsible party of changes as appropriate. During a review of resident 45's care plan titled, Diabetes, dated 5/2/2021, the care plan indicated the resident's blood sugar will remain within normal limits. The interventions indicated to observe for signs and symptoms of [CONDITION(S)] and [CONDITION(S)], change in level of consciousness, mood change, sweating, slurred speech, thirst, excessive appetite, nausea and vomiting, headache, and dizziness. During a review of Resident 45's laboratory results dated [DATE] at 6:10 a.m., the laboratory results indicated Hemoglobin A1c was 10.2% (normal reference range are from 4.8% 5.6%, glycemic control for adults with diabetes is 7.0%). The laboratory results had a written note dated 5/13/2021 at 9:35 a.m., which indicated the results were sent to the physician. However, there was no recorded documentation to show there was reevaluation of the amount of insulin given to the resident to control the high A1c, and the high blood sugar level. During a review of Resident 45's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order indicated to administer [MEDICATION(S)] insulin following the specific sliding scale parameters listed: 151 200 mg/dl = 2 units 201 250 mg/dl = 4 units 251 300 mg/dl= 6 units 301 350 mg/dl = 8 units 351 400 mg/dl = 10 units Above 400 mg/dl = 12 units and call MD if greater than 400 mg/dL. A review of Resident 45's May, June and July 2021 Medication Administration Records (MARs) for the blood sugar checks obtained before meals and bedtime, the MARs indicated to call the physician for blood sugar levels greater than 400 mg/dL. The MARs for the months of May, June, and July 2021, indicated the following elevated blood sugar levels: 5/5/2021 at 11:30 AM = 540 mg/dl 5/11/2021 at 6:30 AM = 401 mg/dl 5/11/2021 at 11:30 AM = 531 mg/dl 5/11/2021 at 4:30 PM = 404 mg/dl 5/12/2021 at 11:30 AM = 477 mg/dl 5/12/2021 at 4:30 PM = 404 mg/dl 5/13/2021 at 11:30 AM = 433 mg/dl 5/14/2021 at 6:30 AM = 458 mg/dl 5/14/2021 at 11:30 AM = 415 mg/dl 5/17/2021 at 11:30 AM = 430 mg/dl 5/18/2021 at 6:30 AM = 406 mg/dl 5/20/2021 at 6:30 AM = 401 mg/dl 5/22/2021 at 11:00 AM = 405 mg/dl 5/23/2021 at 11:30 AM = 427 mg/dl 5/24/2021 at 11:30 AM = 427 mg/dl 5/28/2021 at 11:30 AM = 413 mg/dl 5/28/2021 at 4:30 PM = 410 mg/dl 6/13/2021 at 6: 30 AM = 407 mg/dl 6/13/2021 at 11: 30 AM = 411 mg/dl 6/19/2021 at 6: 30 AM = 421 mg/dl 6/20/2021 at 6: 30 AM = 407 mg/dl 6/21/2021 at 6: 30 AM = 409 mg/dl 6/22/2021 at 6: 30 AM = 455 mg/dl 6/26/2021 at 11:30 AM = 440 mg/ dl 6/28/2021 at 6: 30 AM = 418 mg/dl 7/1/2021 at 6:30 AM = 423 mg/dl 7/2/2021 at 11:30 AM = 426 mg/dl 7/3/2021 at 6:30 AM = 418 mg/ dl 7/3/2021 at 11:30 AM =431 mg/ dl 7/3/2021 at 9:00 PM = 493 mg/dl 7/4/2021 at 11:30 AM = 546 mg/dl 7/4/2021 at 4:30 PM = 404 mg/dl 7/5/2021 at 6:30 AM = 448 mg/ dl 7/7/2021 at 6:30 AM = 520 mg/ dl 7/7/2021 at 11:30 AM = 462 mg/dl 7/8/2021 at 6:30 AM = 438 mg/ dl 7/8/2021 at 11:30 AM = 457 mg/dl 7/9/2021 at 6:30 AM = 474 mg/ dl 7/9/2021 at 11:30 AM = 426 mg/dl 7/10/2021 at 6:30 AM = 426 mg/ dl 7/10/2021 at 11:30 AM = 448 mg/dl 7/10/2021 at 4:30 PM = 408 mg/dl 7/10/2021 at 9:00 PM = 408 mg/dl 7/11/2021 at 6:30 AM = 447 mg/ dl 7/11/2021 at 11:30 AM = 479 mg/dl 7/12/2021 at 6:30 AM = 408 mg/ dl 7/14/2021 at 6:30 AM = 410 mg/ dl 7/14/2021 at 11:30 AM = 441 mg/dl During a record review of the Licensed Nurses Progress notes, and the Nurse's Medication notes for May, June, and July 2021, there was no documented evidence to show the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During a concurrent interview and record review on 7/16/2021 at 9:50 a.m., with Registered Nurse (RN 2), RN 2 eviewed Resident 45's COC, Nurses Notes, physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . RN 2 stated COC process was supposed to be initiated for any changes in the insulin coverage as indicated by the physician. RN 2 stated the physician should have been notified when Resident 45's blood sugar levels were 400 mg/dL, or greater. RN 2 stated as part of the facility's protocol Resident 45's blood sugar levels should have been rechecked after insulin was administered but was not done. RN 2 stated the family or responsible party should have been notified Resident 45's COC's but was not able to show documented evidence if the physician and family member were notified when the blood sugar levels were at 400 mg/dL, or greater in May, June, and July 2021. During a phone interview on 7/16/2021 at 11:55 p.m., with physician (MD 2), MD 2 stated he was the physician for Resident 45. MD 2 stated he visited Resident 45 at least monthly. MD 2 stated he had an order to notify him when Resident 45's blood sugar levels were 400 mg/dL, or greater, but the facility failed to notify him. MD 2 stated if he was notified, MD 2 would have adjusted the diabetic regimen for Resident 45. During an interview on 7/16/2021 at 3:30 p.m., with Resident 45, Resident 45 stated after insulin administration for elevated blood sugar levels the nurses did not recheck the her (Resident 45) blood sugars. During a review of the facility's policy titled Change of Condition, dated 4/1/2015, indicated a licensed nurse will notify the resident's attending physician and legal representative or an appropriate family member when there is a need to alter treatment significantly (e.g. based on lab/x ray results, a need to discontinue an existing form of treatment due to change of condition). A review of the facility's policy titled Diabetic Care, dated 1/1/2012, indicated the following: 1. A licensed nurse will monitor the resident's blood glucose per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 2. If the resident's blood sugar is greater than 350 mg/dl, the attending physician must be notified, unless otherwise noted on the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 3. Licensed nurses must notify the resident and/or the resident's family/representative of blood glucose results beyond the defined parameters. 4. Nursing staff will monitor the resident for signs and symptom of [CONDITION(S)] or [CONDITION(S)], initiate interventions if necessary, and notify the attending physician and responsible party if signs and symptoms are present.

Based on interview and record review, the facility failed to address the Pharmacist Consultant (PC) irregularities and recommendations found on 5/2021 and 6/2021 during the Medication Regimen Review ([MRR] a review of all medications the patient is currently using in order to identify potential problems) for one of 15 residents (Resident 45). Resident 45, who was diabetic (abnormal blood sugar levels), experienced 48 instances of high blood sugar levels greater than 400 milligram/deciliter ([mg/dL] Normal Reference Range [NRR] from 70-130 mg/dL), which the PC recommended to report to the physician to adjust drug therapy, were not addressed by the attending physician and the Director of Nursing (DON), to ensure the irregularities were acted upon. These deficient practices placed Resident 45 at higher risk for diabetic ketoacidosis (condition where the body does not get the sugar it needs for energy, so the body begins to burn fat for energy) leading to long term complications such as damage to blood vessels (tubular structure carrying blood through the tissue and organs), kidneys (pair of organs in the abdominal cavity that excretes urine), eyes, nerves (whitish fiber that transmits impulses of sensation to the brain), coma (prolonged unconsciousness), hospitalization , and/or death. On 7/16/2021 at 4:25 p.m., an Immediate Jeopardy ([IJ] a situation in which the facility's noncompliance with one or more requirements of participation has cause, or is likely to cause, serious injury, harm impairment or death to a resident) was identified, and declared due to the facility's failure to notify the physician of the MRR recommendations to decrease Resident 45's blood sugar levels of 400 mg/dL and or greater. The IJ was called in the presence of the Administrator (ADM), Infection Preventionist Nurse (IPN), Director of Staff Development (DSD), Vice President of Operations (VPO), and the Nurse Consultant 1 (RNC 1). During an interview on 7/17/2021 at 1:30 p.m., the ADM submitted an acceptable Plan of Action ([POA] interventions to correct the immediacy of the deficient practices). The acceptable POA included Resident 45's immediate needs; an additional 14 diabetic residents identified by the facility on sliding scale (the increasing administration of the pre-meal insulin dose based on the blood sugar level before the meal), were audited and addressed for adequacy of diabetic management; Seven residents with identified with unmanaged blood sugars levels were reviewed and treatment adjusted; and in-services to Licensed Nursing in competency in diabetic management and Change of Condition (COC) process were conducted. 1. POA for Resident 45 was as followed: a. On 7/16/2021, Resident 45's physician was notified of the resident's blood sugar results and current insulin sliding scale coverage in the last 2 weeks and ordered to change the sliding scale coverage of [MEDICATION(S)] (type of insulin), and increase [MEDICATION(S)] (type of insulin) from 40 to 45 units, and A1C (blood test that measures the average blood glucose, or blood sugar, levels over the last 3 months) lab ordered on 7/19/2021. b. Resident 45 was placed on monitoring by the licensed nurses for 72 hours for signs and symptoms of [CONDITION(S)] (low blood sugar) and [CONDITION(S)] (high blood sugar). c. On 7/16/2021 the facility notified Resident 45's Responsible Party and the resident of the blood glucose above 400 mg/dL. 2. POA for 14 facility identified residents was as followed: a. On 7/16/2021, the licensed nurses notified the physician, reported blood sugar trends for last 2 weeks, reviewed current diabetic management received orders, and carried the orders out. b. On 7/16/2021 care plans for diabetic management, which included continuous monitoring for signs and symptoms of hypo/ [CONDITION(S)] were created. 3. POA for 7 facility identified residents identified to have had episodes of blood sugars below 70 mg/dl or above 400 mg/dl and those with unmanaged blood sugars levels including high or low ranges that needed adjustments. a. On 7/16/2021, the Licensed Nurses notified the Physician, reported blood sugar trends for last 2 weeks, reviewed current diabetic management, received order, and carried orders out. b. Between 7/16/2021 and 7/17/2021 residents and family were notified of blood glucose outside ordered parameters for each resident involved. c. Residents were monitored for 72 hours for signs and symptoms of [CONDITION(S)] (low blood sugar levels) and [CONDITION(S)] and significant changes were reported to the attending physician. This was initiated between 7-16-2021 and 7/17/2021. 4. The POA for Licensed staff, on 7/16/2021, the Regional Quality Management Consultant provided a re-education to Licensed Nurses on diabetic management, change of condition, and pharmacy recommendations with emphases on the following: a. Following physicians' orders for notification when blood sugar is below 70 mg/ dL or above 400 mg/ dL, as per physician's orders and outside of physician's parameters. b. Initiating change of condition assessment when blood sugars are below 70 mg/ dL or above 400 mg/dL. c. Rechecking of the residents' blood sugar after treating a blood sugar greater than 400 mg/ dL or below 70 mg/dL; and d. Notification of resident/family of changes of condition. 5. Systemic Changes a. During the daily morning clinical meetings, Monday-Friday, the Director of Nursing (DON)/designee will review residents with new changes of condition from the prior day to identify residents with blood sugars that are below 70 mg/ dL or above 400 mg/ dL to ensure that the resident identified was assessed and the attending physician, resident and family were notified. Any issues identified will be immediately addressed. b. The DON/designee will conduct an audit of residents' blood sugar results weekly for 4 weeks, then bi-monthly for 2 months to ensure that residents' blood sugar results are reviewed. For identified blood sugars that are below 70 mg/ dL or above 400 mg/ dL, the DON/ designee will ensure that the residents are assessed, and physician and resident/family are notified. Any issues identified will be immediately addressed. The IJ was lifted on 7/18/2021 at 1:30 p.m., after the team verified and confirmed the POA was implemented per observations, interviews, and record review, while onsite. Findings: During a review of Resident 45's Admission Record (Face Sheet), the face sheet indicated Resident 45 was admitted to the facility on [DATE]. Resident 45's diagnoses including type 2 diabetes mellitus (abnormal blood sugar levels), diabetic [CONDITION(S)] (type of nerve damage that can occur with diabetes), [CONDITION(S)] (excess body fat), acquired absence of right leg below the knee (removed the leg below the knee), and [CONDITION(S)] (blood circulation disorder). During a review of Resident 45's Minimum Data Set (MDS), a standardized assessment and care-screening tool, dated 6/11/2021, the MDS indicated Resident 45 had the ability to express ideas and wants, and had the ability to understand others and responded adequately. The MDS assessment indicted Resident 45 was cognitively intact with daily decision making. The MDS indicated Resident 45 required supervision to total assistance from one-person physical assist from staff with activities of daily living such as grooming, eating, and toileting. During a review of Resident 45's physician orders, dated 3/17/2021, the order indicated to check Resident 45's blood sugar levels before meals and at bedtime. The order indicated to administer [MEDICATION(S)] insulin following the specific sliding scale (medication given to lower blood sugar levels and the dose to be given depending on the blood sugar results) parameters listed: 151-200 = 2 units 201-250 = 4 units 251-300= 6 units 301-350 = 8 units 351-400 = 10 units Above 400 = 12 units and call physician if greater than 400 mg/dL. During a review of Resident 45's care plan titled, Diabetes, reviewed on 3/4/2021, the care plan indicated the resident's blood sugar would remain within normal limits. The staffs' interventions indicated to observe for signs and symptoms of [CONDITION(S)] and [CONDITION(S)], change in level of consciousness, mood change, sweating, slurred speech, thirst, excessive appetite, nausea and vomiting, headache, and dizziness. During a review of Resident 45's care plan titled, Blood Sugars will Remain Within Normal Limits, dated 3/4/2021 and reviewed on 4/12/2021, the staffs' interventions indicated to notify the physician and responsible party of changes as appropriate. During a review of Resident 45's May, June, and July 2021 Medication Administration Records (MARs) for the blood sugar checks obtained before meals and bedtime, the MAR indicated to call the physician for blood sugar levels greater than 400 mg/dL. The MARs for the months of May, June, and July 2021, indicated the following hyperglycemic episodes: 5/5/2021 at 11:30 AM = 540 mg/dl 5/11/2021 at 6:30 AM = 401 mg/dl 5/11/2021 at 11:30 AM = 531 mg/dl 5/11/2021 at 4:30 PM = 404 mg/dl 5/12/2021 at 11:30 AM = 477 mg/dl 5/12/2021 at 4:30 PM = 404 mg/dl 5/13/2021 at 11:30 AM = 433 mg/dl 5/14/2021 at 6:30 AM = 458 mg/dl 5/14/2021 at 11:30 AM = 415 mg/dl 5/17/2021 at 11:30 AM = 430 mg/dl 5/18/2021 at 6:30 AM = 406 mg/dl 5/20/2021 at 6:30 AM = 401 mg/dl 5/22/2021 at 11:00 AM = 405 mg/dl 5/23/2021 at 11:30 AM = 427 mg/dl 5/24/2021 at 11:30 AM = 427 mg/dl 5/28/2021 at 11:30 AM = 413 mg/dl 5/28/2021 at 4:30 PM = 410 mg/dl 6/13/2021 at 6: 30 AM = 407 mg/dl 6/13/2021 at 11: 30 AM = 411 mg/dl 6/19/2021 at 6: 30 AM = 421 mg/dl 6/20/2021 at 6: 30 AM = 407 mg/dl 6/21/2021 at 6: 30 AM = 409 mg/dl 6/22/2021 at 6: 30 AM = 455 mg/dl 6/26/2021 at 11:30 AM = 440 mg/ dl 6/28/2021 at 6: 30 AM = 418 mg/dl 7/1/2021 at 6:30 AM = 423 mg/dl 7/2/2021 at 11:30 AM = 426 mg/dl 7/3/2021 at 6:30 AM = 418 mg/ dl 7/3/2021 at 11:30 AM =431 mg/ dl 7/3/2021 at 9:00 PM = 493 mg/dl 7/4/2021 at 11:30 AM = 546 mg/dl 7/4/2021 at 4:30 PM = 404 mg/dl 7/5/2021 at 6:30 AM = 448 mg/ dl 7/7/2021 at 6:30 AM = 520 mg/ dl 7/7/2021 at 11:30 AM = 462 mg/dl 7/8/2021 at 6:30 AM = 438 mg/ dl 7/8/2021 at 11:30 AM = 457 mg/dl 7/9/2021 at 6:30 AM = 474 mg/ dl 7/9/2021 at 11:30 AM = 426 mg/dl 7/10/2021 at 6:30 AM = 426 mg/ dl 7/10/2021 at 11:30 AM = 448 mg/dl 7/10/2021 at 4:30 PM = 408 mg/dl 7/10/2021 at 9:00 PM = 408 mg/dl 7/11/2021 at 6:30 AM = 447 mg/ dl 7/11/2021 at 11:30 AM = 479 mg/dl 7/12/2021 at 6:30 AM = 408 mg/ dl 7/14/2021 at 6:30 AM = 410 mg/ dl 7/14/2021 at 11:30 AM = 441 mg/dl During a review of Resident 45's MRR recommendations completed by the PC, dated 5/4/2021, the MRR indicated Resident 45's fingerstick (measure the amount of blood sugar levels by making a small prick into the fingertip and collecting a blood sample on to a specially designed test strip) readings showed very high blood sugar levels. The MRR recommendations indicated to contact Resident 45's physician to adjust the diabetic therapy. During a review of Resident 45's MRR recommendations, dated 6/1/2021, the recommendation indicated the last Hemoglobin A1C was done on 5/21/2021, which was very high at 10.2 percent ([%] NRR were from 4.8 % to 5.6 %, diabetics usually around 7.0 %). The MRR recommendations indicated to contact Resident 45's physician to adjust the resident's diabetic therapy. During a concurrent interview and review of Resident 45's clinical record, COCs, and Interdisciplinary Team ([IDT] team from different disciplines working together, with a common purpose, to set a goal, make decisions for the residents) notes on 7/15/2021 at 11:28 a.m., Licensed Vocational Nurse (LVN 5) stated and confirmed there were no documented evidence to show Resident 45's physician was made aware of the recommendations made by PC to adjust the diabetic treatment for the months of May and June 2021. LVN 5 stated the nurses should have notified the physician of the PC's recommendations. During a concurrent interview and review of Resident 45's nursing notes on 7/16/2021 at 9:50 a.m., Registered Nurse (RN 2) stated and confirmed there was no documented evidence to show nursing notified the physician of the PC's recommendations to adjust Resident 45's diabetic regimen due to elevated blood sugar results. RN 2 stated nursing should have informed the physician of the recommendations. During a telephone interview on 7/16/2021 at 11:45 a.m., PC stated and confirmed reviewing all resident's medications were reviewed before making necessary recommendations to the facility. The PC stated the MRR recommendations were submitted to the DON. PC stated he did not contact the physician about the recommendations made of the blood sugars as it was not their workflow and it was the nurses' responsibility to communicate the recommendations. The PC stated the MRR recommendations made for Resident 45 during visits on May and June 2021 were to notify Physician 2 to adjust the sliding scale due to elevated blood sugars. During a phone interview on 7/16/2021 at 11:55 p.m., Physician 2 stated as the attending physician for Resident 45, the facility staff should have notified him of the PC's recommendations to change Resident 45's diabetic regimen. Physician 2 stated nursing failed to notify him about high blood sugars obtained for Resident 45. Physician 2 stated if facility staff would have notified him, he (physician 2) physician 2 would have adjusted the diabetic regimen for Resident 45. During a review of the facility's policy and procedures (P/P) titled, Consultant Pharmacist: Pharmacist Medication Regimen Review, dated 2/23/2015, the P/P indicated the consultant pharmacist reviewed the medication regimen of each resident at least monthly. The P/P indicated the consultant pharmacist documented potential or actual medication therapy problems and communicated them to the responsible physician and the DON. The P/P indicated in the event of a problem requiring immediate attention, the consultant pharmacist would notify the director of nursing or the nurse caring for the resident. During a review of an undated facility's DON Services Job Description, the job description indicated the DON assumed ultimate responsibility for coordinating plans for the total care of each resident which comply with physician orders, governmental regulations, and facility resident care policies. The job descriptions indicated part of the DON's responsibilities included communicating with doctors about resident's health.

Based on interview and record review, the facility's staff failed to adhere to the physician's verbal order and the facility's policy and procedure for a resident's change of condition (COC) for transferring via 911 (emergency services), which stipulated intense pain was considered an emergency and the resident should be transferred by 911 to the hospital for one of three sampled residents (Resident 1). Resident 1, who fell and sustained a closed head (skull not open) injury, had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . (Crossed referenced to F678). These deficient practices, of not transferring Resident 1 to the GACH timely and providing effective pain medications resulted in the resident's pain level and blood pressure increasing to abnormal high level and a delay in diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 1 was found without vital signs (blood pressure, respiration and pulse) and was pronounced deceased within nine (9) hours of being readmitted to the facility from the GACH. On [DATE] at 12:33 p.m., the Administrator (ADM) and the Director of Nursing (DON), were notified an Immediate Jeopardy ([IJ], a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was called for the facility's inability to provide the necessary care and services to manage a resident's pain by failing to assess, notify the primary physician of the medications ineffectiveness and follow the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility's ADM and DON were notified of the immediacy and seriousness of the Resident 1's health and safety being threatened. On [DATE] at 5:05 p.m., the ADM, Regional Director of Clinical Operations (RDCO), and DON submitted an acceptable Plan of Action (POA) for the correction of the IJ which included: 1. The Resident (Resident 1) no longer resides at the facility and expired on [DATE]. 2. On [DATE], the Registered Nurse 1 (RN 1) Supervisor was provided one-on-one (1:1) education by the Nursing Consultant on accurate neurological evaluation, obtaining blood pressure, pain assessment, pre and post assessment to check for efficacy after administration of pain medication and following physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 3. On [DATE], the Administrator provided education to the DON on the policy and procedure on Incident Investigation and Interviews to ensure that incidents and accidents are properly investigated, and interviews conducted with staff and other witnesses are appropriately conducted. 4. On [DATE], the DON and ADON conducted an audit of 11 residents who had planned and unplanned discharges to the GACH via 911 or regular ambulance transport and ensure accurate and timely assessment has been completed which included accurate vital signs and neuro checks, pain assessment and pain medication administration and efficacy, and if an ER transfer via 911 was ordered from the attending physician was followed timely. 5. On [DATE], the DON and ADON conducted an audit of 43 residents' Pain Assessments and Care Plans to ensure accurate assessments and interventions such as pain medications and non-pharmacological interventions were implemented, as well as pain assessment and pain management was reflected in the care plan. 6. On [DATE], the DON and ADON conducted an audit of 43 residents' Fall Risk Assessments and Care Plans to ensure accurate assessments and the care plan reflects the current fall risk assessment and plan for the residents. 7. On [DATE], the director of staff development (DSD) conducted an audit of all Cardiopulmonary Resuscitation ([CPR] C=cardio [heart] P=pulmonary [lung] R=resuscitation [chest compression and artificial breathing are used to maintain blood circulation to the brain]) CPR certification of all Licensed Nurses to ensure all employed in the facility have current CPR. 8. On [DATE], the Nursing Consultants provided education to the licensed nurses on the following: a) Fall Management - with emphasis on fall prevention of residents and ensuring fall prevention plan of care is being implemented and reevaluated for effectiveness. b) Emergency Response - with emphasis on rapid response and assessment to residents with significant change of condition such as Altered Level of Consciousness, Intractable (hard to control) Pain, Head Trauma, Fracture (broken bone), Respiratory Distress including [CONDITION(S)] (sudden, unexpected loss of heart function, breathing, and consciousness). c) Pain Management - with emphasis on pre and post assessment of pain and efficacy of intervention provided. d) Documentation Practice - with emphasis on accurate and factual documentation of resident's condition in the clinical record with the actual timeline and details of events e) Blood Pressure and Neuro checks - with emphasis on ensuring accurate assessment of blood pressure and neurological assessments 9. On [DATE], the DSD provided reeducation to the certified nurse assistant (CNA) on Fall Prevention, Obtaining Vital Signs, Emergency Response, and Reporting Changes of Condition which will be completed by [DATE] 10. On [DATE], the Nursing Consultants initiated competency skills for nurses with return demonstration on obtaining Blood Pressure, Pulse Oximetry and completing Neurological Evaluation, which included a video on Neurological Evaluation shown to the licensed nurses. 11. The Clinical Education Specialist and Respiratory Therapist will provide additional education on Physical Assessment, Respiratory Assessment, Emergency Response and a Mock Code Blue (simulation of a real code to ensure staff prepare and competent) Drill on [DATE]. 12. The Clinical Education Specialist/Respiratory Therapists and Nursing Consultants together with the DON and DSD will conduct a Skills Fair for the nursing staff on [DATE] and [DATE] to increase clinical skills and capabilities. 13. Newly hired Licensed Nurses and CNAs will complete skills competencies within the first 30 days of employment and after 30 days skills check will be provided to the nursing staff based on identified need. 14. The DON/DSD will conduct re-education to the Nursing Staff on the following clinical areas listed below every two weeks for the next three months and monthly for another three months and will reevaluate the need for additional training as warranted: 1) Fall Management 2) Emergency Response 3) Pain Management 4) Documentation Practice 5) Blood Pressure and Neuro checks 15. The Interdisciplinary Team ([IDT] a team of multiple health professionals, who have a shared interest and work together towards a care goal for the residents) will conduct a review of the fall incidents from previous day and residents who were transferred to the acute care center either planned or unplanned via 911 transfers or regular ambulance transport to ensure that the resident was accurately and timely assessed for any for any significant changes in condition such as falls, injury, pain, to ensure timely and accurate assessment and thorough and factual documentation is completed and if transfer to the acute care hospital is warranted as ordered by the physician, that the residents are transferred timely as ordered by the attending physician and to ensure appropriate interventions in response to the change of condition were implemented according to the resident's assessment and plan of care. Any findings or concerns will be immediately addressed for resolution. 16. The DON/designee will conduct Pain Management audits by reviewing Pain Assessment Flowsheets and Medication Administration Records specific to Pain Medication Administration to ensure that residents with complaints of pain are accurately assessed for pre and post pain scale, provided with necessary interventions to address pain and that efficacy of interventions are assessed to ensure that residents' pain are managed weekly for the next three months. 17. The Administrator and DON will present the results of the above audits related to Pain Management and Acute Care Transfers - unplanned or planned and via 911 or regular transport related to significant changes of condition to the Quality Assurance and Performance Improvement Committee for review and recommendations monthly for six months and then quarterly thereafter until substantial compliance is achieved. 18. The Administrator and DON will be responsible for monitoring and sustained compliance. 19. The above education will be completed by [DATE]. On [DATE] at 1:30 p.m., during a concurrent observation, interview and record review, while onsite the Regional Director of Clinical Operations (RDCO) was notified the IJ was lifted, after the team verified the Plan of Action (POA) was followed and implemented. Findings: A review of Resident 1's Face Sheet (Admission Record) indicated Resident 1 was first admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Minimum Data Set (MDS), a standardized care screening and assessment tool, dated [DATE] indicated Resident 1 was able to make herself understood and understand others. The MDS indicated Resident 1 required limited assistance of a one-person physical assist for bed mobility, transfers, and toileting. The MDS indicated Resident 1 had an unsteady gait (method of walking). A review of Resident 1's Fall Risk Assessment, dated [DATE] indicated Resident 1 had a score of 8 (10 or greater = high risk for falls). A review of Resident 1's care plan titled, Fall Risk, revised on ,d+[DATE] indicated Resident 1 was at risk for falls due to poor balance, vision/communication deficit, unsteady gait, forgets to use call light, impulsive behavior, engages in independent transfer/ambulation despite explanation of risk, history of falls and dementia. The care plan goal was to minimize Resident 1's risk for falls. The staffs' interventions included to orient Resident 1 to environment, maintain call light within reach, maintain bed in low position, refer to RNA ([Restorative Nurse Aide] health-care professionals responsible for providing rehabilitation care to residents) and rehabilitation program as needed, report side effects of medication and report to physician. A review of Resident 1's IDT, dated [DATE] indicated the facility's staff would continue to encouraged Resident 1 to use the call light for assistance when going to the restroom. The IDT indicated the staff would continue to monitor and educate Resident 1 on the use of the call light for assistance. A review of Resident 1's untimed document titled, Emergency Transfer Communication (ETC), dated [DATE] indicated Resident 1 was transferred to the emergency room (ER) after sustaining an unwitnessed fall and experiencing left side head pain on a pain scale of ,d+[DATE] (0 = 0 pain and 10= worse pain). The ETC report indicated Resident 1 was found on the floor laying on her right side, grimacing and verbalizing severe pain with a B/P of ,d+[DATE], respirations of 22 (NRR is ,d+[DATE]), pulse of 90 beats per minute ([bpm] NRR ,d+[DATE] bpm) and oxygen saturation (oxygen in the blood) at 93 percent (%) room air ([NRR] ,d+[DATE]%). The ETC report indicated Resident 1's physician was notified and ordered a transfer to the ER for evaluation. A review of Resident 1's untimed pain reassessment, dated [DATE] indicated Resident 1 was experiencing a horrible dull pain (persistent deep ache pain felt in an area) new onset of pain to the left side of the head. A review of Resident 1's physician telephone order, dated [DATE] and timed at 9 p.m. indicated to transfer Resident 1 to the GACH's ER for evaluation due to intractable (hard to control) pain to the head after a fall. A review of Resident 1's Medication Administration Record (MAR) for the month of ,d+[DATE], dated [DATE] and timed at 9:15 p.m. indicated Resident 1 received two tablets of Tylenol (medication use for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR did not indicate the intensity of Resident 1's head pain. A review of Resident 1's Neurological (assessment of a resident's mental status, cranial nerves, motor system, reflexes, sensory system, coordination, station and gait to determine if the nervous system was impaired) Flow Sheet, dated [DATE] with various times; at 9 p.m. blood pressure was ,d+[DATE] ([B/P] ,d+[DATE] - ,d+[DATE] normal reference ranges [NRR]) and a pain level of ,d+[DATE] (10 being the worse pain, 0= no pain); at 9:15 p.m., B/P of ,d+[DATE] with pain level of ,d+[DATE]; at 9:30 p.m. B/P was ,d+[DATE] with pain level of ,d+[DATE] and at 9:45 p.m., a B/P of ,d+[DATE] with a pain level of ,d+[DATE]. A review of Resident 1's Basic Life Support ([BLS] for residents who require a stretcher and basic medical care during transport such as oxygen, suctioning or monitoring of vital signs until arrival at a GACH) transportation report, dated [DATE] and timed at 9:44 p.m. indicated Resident 1's B/P was elevated at ,d+[DATE] with a pain level of ,d+[DATE]; at 10:07 p.m. the same day, Resident 1's B/P was ,d+[DATE] with pain of ,d+[DATE]. The BLS report indicated Resident 1 complained of neck stiffness and pain level of ,d+[DATE]. A review of Resident 1's GACH ER note, dated [DATE] and timed at 10:14 p.m., indicated Resident 1 was seen in the ER for a closed head injury with loss of consciousness ([LOC] abnormal state of lack of response to sensory stimuli, resulting from injury, illness, shock, or some other bodily disorder), B/P of ,d+[DATE] and respirations of 24 bpm. The report indicated Resident 1 sustained a Type III dens (break of the second bone of the neck) C-2 fracture and a right sided scalp hematoma (collection of blood outside the blood vessels). A review of Resident 1's GACH Neurosurgeon ([NS] a physician who specializes in the prevention, diagnosis, surgical treatment, and rehabilitation of disorders affecting the brain, spinal cord, central and peripheral nervous system, and [CONDITION(S)] system) Consultation, dated [DATE] and timed at 11:23 p.m. indicated Resident 1 sustained a ground level fall when attempting to get out of bed when she fell striking her head sustaining a C-2 fracture with mild displacement. The NS recommendations indicated for Resident 1 to wear a C-collar (neck brace [a medical device used to support/immobilize]) while in bed and removed only for cleaning and washing purposes. A review of an online Spine-Health article last updated on [DATE] indicated if the spinal cord become compressed at the C2 level, it could cause pain, tingling, numbness, and/or weakness in the arms or legs, loss of bowel and/or bladder control. The Spine-Health article indicated cases of spinal cord injury at C2 could be fatal because breathing and other critical body functions might be impaired or stop and in some cases paralysis (inability to move) of the body below the injured region of the spinal cord could also occur. https://www.spine-health.com/conditions/spine-anatomy/c1-c2-vertebrae-and-spinal-segment On [DATE] at 7:06 a.m., during an interview and review of Resident 1's MAR and post-fall assessment, for the month of ,d+[DATE] Registered Nurse 1 (RN 1) stated on [DATE] at 9 p.m. Resident 1 been assessed after found on the floor by the roommate. RN 1 stated upon entering the room, Resident 1 was found laying on her right side. RN 1 stated Physician 1 was notified at 9 p.m. and ordered to transfer Resident 1 to the GACH's ER due to extreme pain that did not subside after administration of Tylenol 650 mg. RN 1 stated not all ER transfers are 911 transfers and stated he did not consider Resident 1's excruciating headache of ,d+[DATE] after [MEDICATION(S)] head trauma required a 911 transfer because the pain was on the resident's left side of the head only. RN 1 stated although Resident 1's B/P was increasing, he did not consider it to be an emergency, despite Physician 1's order to transfer Resident 1 to the ER. RN 1 stated Resident 1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 10:46 a.m., during an interview and review of Resident 1's neuro checks sheet dated dated [DATE] and timed at 9 p.m., the DON stated resident's transfers to the GACH depended on the resident's status and if a 911 (emergency service) was required. The DON stated a resident with excruciating pain required a 911 transfer and the DON stated she/he was not being aware of Resident 1 having excruciating pain after the fall for more than 45 minutes. The DON stated RN 1 should have transferred Resident 1 immediately (as soon as possible) to the GACH because the resident hit her head. On [DATE] at 4:43 p.m., during a telephone interview, Resident 1's primary physician (Physician 1) stated the facility's staff called her and she called them back and was informed Resident 1 fell and was complaining of excruciating head pain. Physician 1 stated when she called the staff back, Resident 1 was still in the facility and she told the staff to transfer the resident to ER now which meant 911 as an emergency. Physician 1 stated a resident with a head injury complaining of pain should be transferred immediately via 911. A review of the facility's policy and procedures (P/P) titled, Change in Condition Notification, dated [DATE] indicated the facility would promptly inform the resident's attending physician when there was a significant COC such as life-threatening conditions. The P/P indicated intense pain was considered an emergency and required for the licensed nurse to contact the physician as soon as possible (ASAP) and transfer the resident via 911 to the GACH. A review of the facility's P/P titled, Fall Management Program, dated [DATE] indicated the facility staff would notify the physician if there was a deviation from the resident's normal status for further instructions.

Based on interview and record review, the facility's nursing staff failed to initiate cardiopulmonary resuscitation ([CPR] chest compression and artificial breathing used to maintain blood circulation to the brain) immediately upon identifying no pulse for one of three sampled residents (Resident 1), as per the facility's policy to commence one-person CPR for one minute prior to calling for help and according to the nursing standards of practice to provide immediate CPR and delegate assignments to unlicensed staff. Resident 1 was found unresponsive (unable to respond or wake-up) without vital signs (clinical measurements such as pulse rate, temperature, respiration rate, and blood pressure, indicating the state of a resident's essential body functions) and four (4) CPR certified facility's staff members, Certified Nurse Assistant 1 (CNA 1), Licensed Vocational Nurse 1 and 2 (LVNs 1 and 2) and Registered Nurse 2 (RN 2) observed Resident 1 unresponsive without vital signs and left the resident unattended (unspecified amount of time) without initiating CPR immediately. This deficient practice resulted in a delay in life sustaining measures for Resident 1, who was found unresponsive without vital signs on [DATE] at approximately 7:45 a.m. Resident 1 was pronounced deceased in the facility on [DATE] at 8:10 a.m., nine (9) hours after being readmitted to the facility from the GACH. On [DATE] at 12:33 p.m., the Administrator (ADM) and the Director of Nursing (DON), were notified an Immediate Jeopardy ([IJ], a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was called for the facility's inability to provide the necessary care and emergency services immediately in performing CPR to Resident 1. The facility's ADM and DON were notified of the immediacy and seriousness of the residents' health and safety being threatened. On [DATE] at 5:05 p.m., the ADM, Regional Director of Clinical Operations (RDCO), and DON submitted an acceptable Plan of Action (POA) for the correction of the IJ which included: 1. The Resident (Resident 1) expired on [DATE]. 2. On [DATE], the RN Supervisor was provided 1:1 education by the Nursing Consultant on accurate neurological evaluation (assessment of sensory motor responses, reflexes, to determine whether the nervous system is impaired), obtaining blood pressure, pain assessment, pre and post assessment to check for efficacy after administration of pain medication and following physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 3. On [DATE], the Administrator provided education to the DON on the policy and procedure on Incident Investigation and Interviews to ensure that incidents and accidents are properly investigated, and interviews conducted with staff and other witnesses are appropriately conducted. 4. On [DATE], the DON and ADON conducted an audit of 11 residents who had planned and unplanned discharges to the GACH via 911 or regular ambulance transport and ensure accurate and timely assessment has been completed which included accurate vital signs and neuro checks, pain assessment and pain medication administration and efficacy, and if an ER transfer via 911 was ordered from the attending physician was followed timely. 5. On [DATE], the DON and ADON conducted an audit of 43 residents' Pain Assessments and Care Plans to ensure accurate assessments and interventions such as pain medications and non-pharmacological (no medication treatments) interventions were implemented, as well as pain assessment and pain management was reflected in the care plan. 6. On [DATE], the DON and ADON conducted an audit of 43 residents' Fall Risk Assessments and Care Plans to ensure accurate assessments and the care plan reflects the current fall risk assessment and plan for the residents. 7. On [DATE], the director of staff development (DSD) conducted an audit of all CPR certification of all Licensed Nurses to ensure all employed in the facility have current CPR 8. On [DATE], the Nursing Consultants provided education to the licensed nurses on the following: a) Fall Management - with emphasis on fall prevention of residents and ensuring fall prevention plan of care is being implemented and reevaluated for effectiveness. b) Emergency Response - with emphasis on rapid response and assessment to residents with significant change of condition such as Altered Level of Consciousness, Intractable Pain, Head Trauma, Fracture, Respiratory Distress including [CONDITION(S)]. c) Pain Management - with emphasis on pre and post assessment of pain and efficacy of intervention provided. d) Documentation Practice - with emphasis on accurate and factual documentation of resident's condition in the clinical record with the actual timeline and details of events. e) Blood Pressure and Neuro checks - with emphasis on ensuring accurate assessment of blood pressure and neurological assessments. 9. On [DATE], the DSD provided reeducation to the CNAs on Fall Prevention, Obtaining Vital Signs, Emergency Response, and Reporting Changes of Condition which will be completed by [DATE]. 10. On [DATE], the Nursing Consultants initiated competency skills for nurses with return demonstration on obtaining Blood Pressure, Pulse Oximetry (measurement of the oxygen in the blood) and completing Neurological Evaluation, which included a video on Neurological Evaluation shown to the licensed nurses. 11. The Clinical Education Specialist and Respiratory Therapist will provide additional education on Physical Assessment, Respiratory Assessment, Emergency Response and a Mock Code Blue Drill on [DATE]. 12. The Clinical Education Specialist/Respiratory Therapists and Nursing Consultants together with the DON and DSD will conduct a Skills Fair for the nursing staff on [DATE] and [DATE] to increase clinical skills and capabilities. 13. Newly hired Licensed Nurses and CNAs will complete skills competencies within the first 30 days of employment. After 30 days skills check will be provided to the nursing staff based on identified need. 14. The DON/DSD will conduct re-education to the Nursing Staff on the following clinical areas listed below every two weeks for the next three months and monthly for another three months and will reevaluate the need for additional training as warranted: 1) Fall Management 2) Emergency Response 3) Pain Management 4) Documentation Practice 5) Blood Pressure and Neuro checks 15. The IDT will conduct a review of the fall incidents from previous day and residents who were transferred to the acute care center either planned or unplanned via 911 transfers or regular ambulance transport to ensure that the resident was accurately and timely assessed for any for any significant changes in condition such as falls, injury, pain, to ensure timely and accurate assessment and thorough and factual documentation is completed and if transfer to the acute care hospital is warranted as ordered by the physician, that the residents are transferred timely as ordered by the attending physician and to ensure appropriate interventions in response to the change of condition were implemented according to the resident's assessment and plan of care. Any findings or concerns will be immediately addressed for resolution. 16. The DON/designee will conduct Pain Management audits by reviewing Pain Assessment Flowsheets and Medication Administration Records specific to Pain Medication Administration to ensure that residents with complaints of pain are accurately assessed for pre and post pain scale, provided with necessary interventions to address pain and that efficacy of interventions are assessed to ensure that residents' pain are managed weekly for the next three months. 17. The Administrator and DON will present the results of the above audits related to Pain Management and Acute Care Transfers - unplanned or planned and via 911 or regular transport related to significant changes of condition to the Quality Assurance and Performance Improvement Committee for review and recommendations monthly for six months and then quarterly thereafter until substantial compliance is achieved. 18. The Administrator and DON will be responsible for monitoring and sustained compliance. 19. The above education will be completed by [DATE]. On [DATE] at 1:30 p.m., during a concurrent observation, interview and record review, while onsite the Regional Director of Clinical Operations (RDCO) was notified the IJ was lifted, after the team verified the Plan of Action (POA) was followed and implemented. Findings: A review of Resident 1's Face Sheet (Admission Record) indicated Resident 1 was first admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Minimum Data Set (MDS), a standardized care screening and assessment tool, dated [DATE] indicated Resident 1 was able to make herself understood and understand others. The MDS indicated Resident 1 required limited assistance of a one-person physical assist for bed mobility, transfers, and toileting. The MDS indicated Resident 1 had an unsteady gait (method of walking). A review of Resident 1's untimed document titled, Emergency Transfer Communication (ETC), dated [DATE] indicated Resident 1 was transferred to the emergency room (ER) after sustaining an unwitnessed fall and experiencing left side head pain of ,d+[DATE] on a pain scale (0 being no pain and 10 being the worse). The ETC report indicated Resident 1 was found on the floor laying on her right side, grimacing and verbalizing severe pain with a blood pressure ([B/P] ,d+[DATE] - ,d+[DATE] normal reference ranges [NRR]) of ,d+[DATE], respirations of 22 (NRR is ,d+[DATE] breaths per minutes [bpm]), pulse of 90 beats per minute ([bpm] NRR ,d+[DATE] bpm) and oxygen saturation (oxygen in the blood) at 93 percent (%) room air ([NRR] ,d+[DATE]%). The ETC report indicated Resident 1's physician was notified and ordered a transfer to the ER for evaluation. A review of Resident 1's physician telephone order, dated [DATE] and timed at 9 p.m., indicated to transfer Resident 1 to the GACH's ER for evaluation due to intractable (hard to control or deal with) pain to the head after a fall. A review of Resident 1's GACH ER note, dated [DATE] and timed at 10:14 p.m., indicated Resident 1 was seen in the ER for a closed head injury with loss of consciousness ([LOC] an abnormal state of lack of response to sensory stimuli, resulting from injury, illness, shock, or some other bodily disorder), elevated B/P of ,d+[DATE] and respirations of 24 bpm. The report indicated Resident 1 sustained a Type III dens (break of the second bone of the neck) C-2 (break of the second bone of the neck) fracture (broken bone) and a right sided scalp hematoma (collection of blood outside the blood vessels). A review of Resident 1's readmission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Licensed Personal Weekly Progress Note, at 7:42 a.m., on [DATE], CNA 1 found Resident 1 unresponsive and immediately called for help. The progress note indicated Resident 1's vital signs were unattainable, CPR initiated immediately [sic] and paramedics were called. A review of the Center for Medicare & Medicaid Services (CMS) All Facility Letter Reference S & C ,d+[DATE]-NH, revised on [DATE], indicated that prior to the arrival of emergency medical services (EMS), nursing homes must provide basic life support, including CPR, to a resident who experiences [CONDITION(S)] (cessation of respirations and/or pulse) in accordance with that resident's advance directives or in the absence of advance directives or a DNR order. The L&C Letter indicated that CPR-certified staff must always be available. A review of a Prehospital Care Report Summary, documented by the 911 paramedics emergency services, dated [DATE] indicated a call was received from the facility at 7:45 a.m., and the paramedics were assisting Resident 1 at 7:55 a.m. The report indicated Resident 1 was pulseless, unresponsive, with pupils fix and dilated (pupils may become fixed and dilated before the heart and respiration stops, or it may occur after), pale and apneic (temporary stop of breathing). The Report Summary indicated Resident 1 was pronounced deceased at 8:10 a.m. after unsuccessful CPR. A review of Resident 1's death certificate indicated the resident expired on [DATE] at 8:10 a.m., with the immediate cause of death listed as [MEDICATION(S)] Spinal Trauma (injury to the body caused by forceful impact, injury, or physical attack) after a mechanical fall. On [DATE] at 4:20 p.m., during an interview, CNA 1 stated on [DATE] at approximately at 7:45 a.m., she observed Resident 1 was not responding when told her breakfast was at the bedside. CNA 1 stated she called Registered Nurse 2 (RN 2) upon observing Resident 1 without chest movement and cold skin. CNA 1 stated RN 2 left the room to call for help after she assessed Resident 1 and stated, She is dead. CNA 1 stated LVNs 1 and 2 initiated CPR on Resident 1 after being called into the room. On [DATE] at 5:50 p.m., during an interview, LVN 1 stated on [DATE] at approximately 7:40 a.m., CNA 1 notified RN 2 Resident 1 was not breathing. LVN 1 stated upon entering Resident 1's room and after checking resident's vitals, both LVNs 1 and 2 initiated CPR. LVN 1 stated Resident 1 had no pulse, no blood pressure and was not breathing upon assessment. On [DATE] at 6:16 p.m., during an interview, RN 2 stated on [DATE] at approximately 7:45 a.m., CNA 1 stated Resident 1 was not responding. RN 2 stated upon entering the room, Resident 1 was unresponsive and had no vital signs. RN 2 stated LVNs 1 and 2 initiated CPR. RN 2 stated she did not remember the reason why she did not initiate CPR on Resident 1 when she found the resident unresponsive. On [DATE] at 4:45 p.m., during a telephone interview, Resident 1's physician (Physician 1) stated she received a call from the facility's staff on [DATE] and was informed Resident 1 had fallen and was complaining of pain. Physician 1 stated she ordered to transfer Resident 1 to the ER for evaluation due to excruciating pain. On [DATE] at 7:49 a.m., during an interview, LVN 2 stated the morning of [DATE] she was called to Resident 1's room and staff took the resident's vital signs and check for pulse. LVN 2 stated after finding the resident had no pulse, she left the room to check if resident was a full code (agree to heroic measures, such as CPR for resuscitation), then return to the room and provided CPR. LVN 2 stated not being aware why RN 2 did not initiate CPR. On [DATE] at 9:40 a.m., during an interview, LVN 1 stated on [DATE] walked into the Resident 1's room, took vital signs and then left the room to call 911 without initiating CPR. On [DATE] at 10:46 a.m., during an interview, the Director of Nurses (DON) stated the resident returned to the facility on [DATE] at approximately 11 p.m. and he was not sure if the staff was prepared to care for a resident with a C2 fracture. The DON stated he did not investigate why the staff did not initiate CPR timely when Resident 1 was found unresponsive on [DATE]. On [DATE] at 1:59 p.m., during an interview and record review of the facility's policy and procedures with the Administrator, DON, and Regional Director of Clinical Operations 1 and 2 (RDCOs 1 and 2), the DON stated Resident 1's death was unusual because of the severity of the resident's injury after the fall on [DATE] and how sudden she passed away. The DON confirmed there was no investigation or documentation done regarding the staff's delay in rendering CPR to Resident 1 after being found unresponsive on [DATE]. A review of the facility's policy and procedure (P/P) titled, Cardiopulmonary Resuscitation last revised on [DATE], indicated cardiopulmonary resuscitation (CPR) is instituted in cases of recognized cardiac and/or pulmonary arrest until medical emergency personnel are available to take over the resuscitation efforts. Cardiopulmonary resuscitation is instituted on all residents except those designated as No Code or No CPR. The P/P indicated the staff who performed CPR would document in the resident's clinical chart why and who initiated CPR, vital signs including pupil size and response to light, whether the residents suffered from cardiac or respiratory arrest, when the resident was found and CPR initiated, how long the resident received CPR, any other measures implemented and time when paramedics arrived. A review of the facility's policy and procedure titled, Medical Emergencies- Code Blue last revised on [DATE] indicated to ensure the prompt and effective response by the facility personnel during medical emergencies using the code blue procedure. The facility will provide an appropriate level of response to the resident during medical emergencies. A medical emergency is defined as any of the following conditions requiring immediate medical intervention and the initiation of the code blue procedure: respiratory or [CONDITION(S)]. The P/P stipulated the first of the facility's personnel to arrive and find a resident with any of the above conditions will identify whether there is a cardiopulmonary or respiratory arrest by shaking the person and calling out their name a minimum of three times. Respond to the resident immediately and send available staff to call a code blue. Commence one-person CPR, according to current practice. If alone, do resuscitation for one minute before leaving the resident to call for help.

Based on interview and record review, the facility's nursing staff failed to initiate cardio-pulmonary resuscitation ((CPR) an emergency lifesaving procedure done when breathing or the heart stops) for one of three sampled residents (Resident 1). Resident 1 was found unresponsive with low oxygen saturation (percentage of oxygen in the blood) at 30 percent ((%) normal oxygen level is ,[DATE]% (below 90% is a low level of oxygen saturation)) and no blood pressure (force of blood pushing against the walls of your arteries each time your heart beats, it pumps blood into the arteries). This deficient practice resulted in a delay of appropriate medical interventions for Resident 1, who was found unresponsive with unstable vital signs (important medical measurements that indicate the status of the body's vital functions). Resident 1 was pronounced deceased in the facility on [DATE]. Findings: A review of Resident 1's Admission Face Sheet indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A stroke occurs when blood flow to a part of the brain is blocked). A review of Resident 1's quarterly Minimum Data Set (MDS), a resident assessment and care screening tool, dated [DATE], indicated Resident 1 had cognitive (thought process) problems, impaired decision-making, but was able to make needs known and usually able to understand others. According to the MDS, the resident was assessed as requiring a two-person physical assistance with bed mobility, transferring, and was totally dependent with locomotion on and off the unit and personal hygiene. A review of Resident 1's physician orders, dated [DATE] indicated for the resident to receive continuous oxygen at two (2) liters per minute (L/min) via nasal cannula (a flexible plastic tube used to deliver oxygen) to keep oxygen saturation (percentage of oxygen in the blood) at or above 94 % (percent) for [MEDICAL CONDITION]. The physician's orders [REDACTED]. A review of Resident 1's baseline care plan summary, dated [DATE] indicated Resident 1 had an advance directive (a 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) indicated the resident was a Full Code (CPR provided in the event Resident 1 was found unresponsive, the health care professional will start chest compressions and/or administer life saving measures). Resident 1's baseline care plan summary was signed by several staff members including the former Director of Nursing (DON) and the Social Services Director (SSD). A review of Resident 1's untimed Licensed personnel weekly progress note written by Licensed Vocational Nurse 1 (LVN 1), dated [DATE] indicated At approximately 5:30 a.m., resident (Resident 1) was found in bed unresponsive, unable to record blood pressure and oxygen saturation measured at 30 %. Called 911 emergency services at approximately 5:40 a.m. (sic). Paramedics arrived at around 5:50 a.m. (sic) and examined resident (Resident 1) and pronounced resident dead on arrival. A review of Resident's 1 untimed licensed personnel weekly progress note written by LVN 1, dated [DATE] indicated Late entry - At 11 p.m., made rounds seen resident in bed asleep, but arousable (to stir to action or strong response); vital signs ,[DATE] (normal reference range (NRR) ,[DATE] -,[DATE] millimeter of mercury (mm Hg) unit of measurement), Pulse rate 82 (NRR ,[DATE]), body temperature 97.8 degrees Fahrenheit (NRR 97XXX,[DATE].8), Respirations 18 (NRR ,[DATE] breaths per minute (bpm)). Skin warm and dry to touch in no respiratory distress. At approximately 3 a.m., [DATE] the resident (Resident 1) was cleaned and brief changed by CNA (unknown certified nursing assistant). At approximately 5:30 a.m., on [DATE], while passing medication, the resident (Resident 1) was found to be unresponsive. Blood sugar checked and was 200 milligrams per deciliter (mg/dL (unit of measurement)) (NRR= ,[DATE] mg/dL) oxygen saturation at 30 %, respirations 12, pulse 100. Unable to record obtain blood pressure. Called 911 at approximately 5:40 a.m., paramedics arrived at 5:50 a.m. (sic). Resident (Resident 1) started breathing (sic). The documentation indicated the paramedics started CPR (sic) at approximately 6:10 a.m. and the resident was pronounced deceased by paramedics. A review of the Paramedics Incident Report, dated [DATE] and timed at 5:53 a.m., indicated: called received at 5:53 a.m., dispatched for Full Arrest (([MEDICAL CONDITION]) a sudden loss of blood flow resulting from the failure of the heart to pump effectively). Arrival to scene at 6:02 a.m. Patient (Resident 1) found lying in bed in supine position (flat on back) at nursing home with no pulse or respirations. Staff stated the resident last known well at 2:30 a.m. Patient in rigor mortis (stiffening of the joints and muscles of a body usually a few hours after death), pupils fixed (completely unresponsive to light) and unresponsive, negative response to painful stimuli, negative palpable pulse and apical pulse (audible heart beats; by placing a stethoscope (medical instrument) over the heart and counting for one minute). Provisional impression patient (Resident 1) dead. According to the Paramedics Incident report, Resident 1 was dead upon their arrival, apneic (not breathing) and skin was cold. The Paramedics Incident report indicated the reason for withholding CPR resuscitation was due to the resident having rigor mortis. The paramedics documented Resident 1's death was determined, and the paramedics left Resident 1's body at the facility. A review of Resident 1's certificate of death indicated Resident 1's date of death was on [DATE] at 5:30 (before arrival of the paramedics) indicated the immediate cause of death was listed as acute Cardiopulmonary Arrest ([MEDICAL CONDITION]). On [DATE] at 5:52 a.m., during a telephone interview, LVN 1 stated he was Resident 1's assigned nurse on [DATE] (11 p.m. to 7 a.m. shift) to the morning of [DATE]. LVN 1 stated during his shift rounds at an unknown time, he saw Resident 1 asleep in bed before he took his break at unspecified time. According to LVN 1, he did not see the resident at any other time during the shift until he started to pass the morning medication at 5:30 a.m. ([DATE]) and discovered Resident 1 was unresponsive and decided to check Resident 1's blood sugar. LVN 1 stated Resident 1 was breathing with respirations of 12 and a heart rate of 100 beats per minute. LVN 1 stated he attempted to take Resident 1's blood pressure and was unsuccessful. LVN 1 stated he did not remember if he provided Resident 1 with oxygen (physician's orders [REDACTED]. LVN 1 stated he raised Resident 1's head of bed up and left Resident 1 to call 911 and did not initiate CPR on Resident 1. LVN 1 stated, The paramedics initiated CPR on Resident 1 (sic). On [DATE] at 11:27 a.m., during a telephone interview, Resident 1's physician (Physician 1), who was the facility's medical director, in the presence of the Administrator (ADM) and the current DON, Physician 1 stated Resident's 1 documented vital signs were an indication the resident was unstable. Physician 1 stated he was not notified of the resident's change in condition. Physician 1 stated rigor mortis sets in when a person was deceased for more than ten (10) minutes, and the brain was deprived of oxygen more than six (6) minutes. Physician 1 stated, If a person's pupils are fixed and dilated it indicated the vital signs are completely gone. Physician 1 stated the nurse should have started CPR immediately and called 911 (emergency services) and notified him of the resident's change in condition. On [DATE] at 4:06 p.m., during a telephone interview, Resident 1's former roommate, Resident 2, stated the last time he saw Resident 1 alive was on [DATE] in the late afternoon. Resident 2 stated a staff member came in for a physical therapy session with Resident 1, who was slow to respond. Resident 2 stated later a staff member brought Resident 1's dinner on the evening of [DATE] and the meal was left uneaten and was never touched. According to Resident 2, from approximately 9 p.m. on [DATE] until the early morning hours of the next morning [DATE], Resident 1 was lying in bed and did not make any sounds. Resident 2 stated he did not see a staff member come in all night to clean or check on Resident 1, until he was found unresponsive. Resident 2 stated he was lying in the same room next to Resident 1 and the facility's staff did not come in to check on Resident 1 or take Resident 1's vital signs. A review of Resident 2's Admission Face Sheet indicated Resident 2 was admitted to the facility on [DATE]. A review of Resident 2's MDS, dated [DATE] indicated Resident 2 had no cognitive (thought process) problems and/or impaired decision-making, and was able to make needs known and understand others. A review of the facility's policy and procedure (P/P) titled, Cardiopulmonary Resuscitation last revised on [DATE] indicated cardiopulmonary resuscitation (CPR) is instituted in cases of recognized cardiac and/or [MEDICAL CONDITION] arrest until medical emergency personnel are available to take over the resuscitation efforts. Cardiopulmonary resuscitation is instituted on all residents except those designated as No Code or No CPR (to allow natural death). A review of the facility's P/P titled, Medical Emergencies- Code Blue (indicates medical emergency such as cardiac or respiratory arrest) last revised [DATE] indicated to ensure the prompt and effective response by the facility personnel during medical emergencies through the use of the code blue procedure. According to the P/P the facility will provide an appropriate level of response to the resident during medical emergencies. A medical emergency is defined as any of the following conditions requiring immediate medical intervention and the initiation of the code blue procedure: respiratory or [MEDICAL CONDITION]. The first of the facility personnel to arrive and find a resident with any of the above conditions will identify whether there is a cardiopulmonary or respiratory arrest by shaking the person and calling out their name a minimum of three times. The P/P indicated to respond to the resident immediately and send available staff to call a code blue. Commence one person CPR, according to current practice. If alone, do resuscitation for one minute before leaving the resident to call for help.

Based on observation, interview and record review, the facility failed to ensure nine of nine sampled residents (Residents 1, 2, 3, 4, 5, 6, 7, 8, and 9) were not neglected (failure to provide care/services to prevent physical harm, pain, mental anguish and emotional distress), physically, verbally, and emotionally abused by the facility's staff nurses and had a fear free environment when: 1. Resident 1 was transfer to the general acute care hospital (GACH) on 1/15/2020. The GACH identified a right heel Stage 1 pressure ulcer ([open sore] close and reddish upper layer of the skin is), left heel deep tissue injury ([DTI] localized area of intact skin with dark discoloration, such as purple, maroon, or a bruise like appearance, or a blood-filled blister), and an unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough ([shedding of dead tissue] yellow, tan, gray, green or brown) and/or eschar ([death tissue] tan, brown or black), coccyx (small triangular bone at the base of the spinal column) ulcer, and left elbow unstageable ulcer. 2. Resident 2 felt humiliated (feeling ashamed by injuring a person dignity and self-respect) when a Certified Nurse Assistant 2 (CNA 2) made fun of the resident after changing her adult brief and CNA 2 pulled off her adult brief rough causing her to have a burning sensation and sustaining a skin tear on her right upper hip under the abdomen skin fold. 3. Residents 3, 4, 5, 6, 7, 8, and 9 felt harassed (abusing, insulting, or harming someone on a regular basis), humiliated, intimidated (fighting someone to do something), worthless (having no value) and like objects when the staff nurses would leave them wet all night, and at times refuse to answer their call light and/or answering the call lights in a rude manner by smacking their lips when answering the call lights, forcing the residents to have a bowel movement in their adult brief and forcing them into bed by 7:30 p.m. These deficient practices resulted in Resident 1 not receiving the care required to prevent multiple pressure ulcers, Residents 2, 3, 4, 5, 6, 7, 8 and 9 feeling humiliated neglected intimidated and harassed by the staff when the residents would activate the call light. On 2/4/2020 at 6:16 p.m., during an interview and record review with the Administrator (ADM), Director of Nursing (DON), Registered Nurse Consultant (RNC), and Compliance Officer (CO) were notified of the immediacy and seriousness of the residents' health and safety being threatened. They were notified an Immediate Jeopardy ([IJ], a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was called for the facility's inability to provide the necessary care and services and protect residents from being threatened, intimidated, and humiliated by the facility staff, a patterned of not answering call lights and staff responding in a rude disrespectful way to residents and responsible parties creating an environment of fear. On 2/6/2020 at 4:15 p.m., the ADM and RNC submitted an acceptable Plan of Action (POA) for the correction of the IJ which included: 1. Resident 1 was discharge on 1/15/2020 2. Resident 2's wounds were re-evaluated by the DON and Treatment Nurse on 2/4/2020. The results of the wound re-evaluation were reported to the attending physician on 2/4/2020, and new orders were carried out. The skin care plan of the resident was revised on 2/4/2020 to reflect the assessment and interventions. 3. The DON and License Nurse (LN) staff conducted a skin sweep to all the resident in the facility to identify any potential pressure injury, non - pressure, skin tears and other skin integrity issues on 2/4/2020 to ensure appropriate and accurate assessment and treatment plan for prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] 4. Director of Staff Develop (DSD) in-serviced licensed nurses and certified nursing assistants (CNA) beginning 2/4/2020 on the Policy and Procedures (P/P) for Pressure Injury Management, Treatment and Prevention and Accurate Skin Assessment, on turning and re-positioning for pressure prevention and management, and on shower skin sheets. 5. The DON/Treatment Nurse will conduct a monthly skin sweep (checking the all resident's skin) on the first Friday of each month. 6. The RNC provided training to treatment nurse on 2/5/2020 on assessment, treatments, care planning and policy. 7. Beginning on 2/5/2020, treatment nurse and the DON will review daily new admissions and changes in condition (COC). 8. The CNAs will complete skin shower sweeps according to resident's shower schedule and will report findings to the license nurse. Licensed nurse will verify accurate assessment and treatment plan is in place. 9. Nursing staff will not be allowed to report for duty on the floor until they have completed the in-service. 10. Administrator/Designee conducted resident room rounds and interviewed residents to ensure resident were treated with respect and call lights were answered timely. 11. The Administrator will make himself available by making daily rounds while in the facility ensuring resident safety and provide the residents with his contact information for future concerns. Administrator will be attending council meeting with permission of the residents. 12. Administrator/Designee will provide in-service to all staff beginning 2/4/2020 on resident rights and timely call light responses. On 2/6/2020 at 4:16 p.m., ADM and the RNC were notified the IJ was lifted while onsite, after the team verified the POA was followed and implemented. Findings: On 2/3/2020 at 2:38 p.m., during an initial tour of the facility, call lights were observed and heard ringing. The call light panel was signaling three room call lights were blinking, three staff members were observed at the nurses' station documenting in clinical records. A staff member was observed responding to one of the call lights six (6) minutes after. On 2/3/2020 at 3:35 p.m., during an observation of the nurse's station, the call light panel was observed blinking and ringing, four staff members sitting at the nurse's station. The call light across from the nurse's station was answered 11 minutes after it was first observed ringing. A review of the resident council minutes dated 11/25/19 and 1/29/2020 indicated the resident complained of call lights not being answered. The council minutes dated 12/30/19 indicated the residents indicated the facility staff needed improvement in answering the call lights. 1. A review of Resident 1's Face Sheet (Admission Record) indicated the facility first admitted the resident on 12/16/19 and last readmitted on [DATE]. Resident 1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Minimum Data Set (MDS), a resident assessment and care-screening tool, dated 12/24/19 indicated the resident was moderately impaired of cognition (ability to acquire knowledge and understanding) and was able to usually understand and understood others. The MDS indicated the resident required extensive assist (staff provide guided-maneuvering of limbs or other non-weight bearing assistance) with a one-person physical assist for bed mobility (how the resident moves to and from lying position, turning side to side, and positioning of body) and personal hygiene. The MDS indicated Resident 1 was always incontinent of bowel and bladder (lack of voluntary control over urination or defecation). The MDS indicated Resident 1 did not have pressure ulcers but was at risk to develop them. A review of Resident 1's care plan titled, Skin, dated 1/9/2020 indicated Resident 1 was at risk for skin break/ulcer formation related to impaired mobility and incontinence. The care plan goal was to minimize the risk of pressure ulcer development. The staffs' interventions included care and reposition, provide pressure redistribution devices, and provide skin care frequently and monitor for signs of infection. A review of Resident 1's Change of Condition ([COC] decline or improvement in a resident's mental or physical functioning) dated 1/10/2020 indicated the resident was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] A review of Resident 1's physician's telephone order, dated 1/15/2020 and timed at 1:30 p.m., indicated Resident 1 was transfer to the GACH's emergency room (ER) via 911 (emergency number). A review of Resident 1's GACH's Wound Care Note, dated 1/16/2020 and timed at 2:30 p.m., indicated Resident 1 was admitted to the GACH with a sacral pressure injury Stage III (full thickness of the skin and may extend into the subcutaneous tissue layer), midback pressure injury Stage III, left and right heel DTI, left medial (middle) ankle blister (fluid-filled pocket), and bilateral (both sides) posterior ears. On 2/3/2020 at 3:35 p.m., during a concurrent observation of the call lights, interview and review of Resident 1's nurse's notes, Licensed Vocational Nurse 1 (LVN 1) stated on 1/10/2020 a left elbow unstageable wound was identified and treated. LVN 1 stated Resident 1 was admitted on [DATE] with no wound identified during the initial assessment. LVN 1 stated wounds can develop when residents are not repositioned every two hours. 2. A review of Resident 2's Face Sheet indicated the facility admitted the resident on 1/8/2020. Resident 1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 2's MDS, dated [DATE], indicated the resident's cognition was intact and was able to understand and make herself understood. The MDS indicated Resident 2 required extensive assist of a two-person physical assist for toilet use, personal hygiene and bed mobility. A review of Resident 2's care plan titled, Bowel and Bladder, dated 1/20/2020 indicated the goal was to keep the resident dry, clean and comfortable. The staffs' approach included to check the resident every two hours and provide care after each incontinence case. On 2/4/2020 at 4:05 p.m., during an interview, Resident 2 stated while stated while CNA 2 was providing Activities of Daily Living ([ADL] brushing hair, teeth, showering, changing clothing, going to the bathroom) care CNA 2 pulled her diaper off her roughly hurting Resident 2's inner thigh and the upper part of the hip by the abdomen resulting in a burning like sensation. Resident 2 stated she told CNA 2 she was hurting her and not to pull the diaper hard. Resident 2 stated it was not the first time it happened. Resident 2 stated the nurses take a long time to answer the call light and are always in a hurry. Resident 2 stated she felt like the staff didn't care about her or how she felt. On 2/4/2020 at 4:10 p.m., during a concurrent observation and interview, in the presence of the DON, LVN 1 identify new wounds on Resident 2's right buttocks, left buttocks skin peel and a right lateral (side) abdomen skin tear. LVN 1 stated she did not assess or treat Resident 2's wounds because she was not made aware of them until now. On 2/4/2020 at 5:30 p.m., during an interview, CNA 2 stated a few days prior, after cleaning Resident 2, she came out of Resident 2's room and made a comment that it smelled bad. CNA 2 stated Resident 2's wounds being there for a long time but was not aware of the one in the Resident 2's right side of the abdomen. 3. A review of Resident 3's Face Sheet indicated the facility admitted the resident on 10/28/19. Resident 3's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 3's MDS, dated [DATE] indicated Resident 3's cognition was intact and was able to understand and make herself understood. The MDS indicated Resident 3 required extensive assist with a one-person physical assist for toilet use, personal hygiene and bed mobility. A review of Resident 3's care plan titled, Bowel and Bladder, dated 10/29/19 indicated the goal was to keep the resident dry, clean and comfortable. The staffs' approach included to take the resident to the bathroom every two hours and as needed (PRN) and observe for skin abnormalities. On 2/3/2020 at 3:10 p.m., during an interview, Resident 3 stated on 2/2/2020 night shift she asked the staff to please change her diaper but had to wait until 2/3/2020 at 9 a.m. to be changed leaving her wet with urine all night. Resident 3 stated on 2/3/2020 at 7 a.m. she asked to be changed but was told they could not at that moment because they were passing breakfast trays. Resident 3 stated it was not the first time she was left wet all night feeling hopeless, neglected and humiliated. Resident 3 stated during the resident council meeting, the resident brought up the call light issue to be addressed but the issue continued to reoccur. Resident 3 stated, We are scare of the nurses. 4. A review of Resident 4's Face Sheet indicated the facility first admitted the resident on 2/18/17 and was last readmitted on [DATE]. Resident 4's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 4's MDS, dated [DATE] indicated the resident's cognition was intact and was able to understand and make herself understood. The MDS indicated Resident 4 required an extensive assist with a one-person physical assist for toilet use, personal hygiene and bed mobility. A review of Resident 4's care plan titled, Activities of Daily Living (ADL), dated 9/28/19 indicated the resident required assistance with bed mobility, bathing, and toileting. The staffs' approach included to assist with ADLs. On 2/4/2020 at 2:25 p.m., during an interview and in the presence of the ADM, Resident 4 stated the staff would follow to her room and have her get in bed at 7 p.m. Resident 4 stated the nurses would not answer the call lights after 11 p.m. 5. A review of Resident 5's Face Sheet indicated the facility admitted the resident on 10/22/19. Resident 5's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 5's MDS, dated [DATE] indicated Resident 5's cognition was intact and was able to understand and make herself understood. The MDS indicated Resident 5 required an extensive assist with a one-person physical assist for toilet use, personal hygiene and bed mobility. A review of Resident 5's care plan titled, Skin, dated 10/23/19 indicated Resident 5 was at risk for skin break/ulcer formation related to thin skin. The care plan goal was to minimize the risk of pressure ulcer development. The staffs' interventions included care and reposition, provide pressure redistribution devices, and provide skin care frequently and monitor for signs of infection. On 2/3/2020 at 2:55 p.m., during an interview, Resident 5 stated the nurses do not answer the call lights, specifically at night. Resident 5 complained of being left wet on several occasions. Resident 5 stated, It's bad, it makes me feel like nobody cares, like we are a burden to the staff. 6. A review of Resident 6's Face Sheet indicated the facility admitted the resident on 12/7/15. Resident 6's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 6's MDS, dated [DATE] indicated Resident 6's cognition was intact and was usually (missed sometimes) able to understand and be understood by others. The MDS indicated Resident 6 required extensive assist with a one-person physical assist for toilet use, personal hygiene and bed mobility. A review of Resident 6's care plan titled, ADL/Rehab Potential evaluated on 2/2020 indicated the resident required assistance with bed mobility, bathing, and toileting. The staffs' approach included to assist with ADLs and turning and repositioning every two hours, and as needed. On 2/3/2020 at 2:45 p.m., during a concurrent observation and interview, Resident 6 was observed with tearing eyes stating, staff from night shift don't answer the call lights. I felt worthless and nasty. Resident 6 stated the staff takes two hours or sometimes all night to answer the call light. Resident 6 stated 2/2/2020 was the second night she was left wet without being changed. Resident 6 stated it was depressing and humiliating to be left wet as an adult. Resident 6 stated the staff comes in to the room and tells the resident they must wait to be changed in the morning. On 2/4/2020 at 4:40 p.m., during an interview, Resident 6 stated a couple nights prior, while sleeping, she was awakened by a staff member hitting her in the stomach twice. Resident 6 stated she did not want to state the nurse's name due to fear of retaliation by the staff. 7. A review of Resident 7's Face Sheet indicated the facility first admitted the resident on 4/13/15 and was last readmitted the resident on 12/27/19. Resident 7's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 7's MDS, dated [DATE] indicated the resident's cognition was intact and was able to understand and make herself understood. The MDS indicated Resident 7 required an extensive assist with a one-person physical assist for toilet use, personal hygiene and bed mobility. A review of Resident 7's care plan titled, ADL, dated 12/27/19 indicated Resident 7 required assistance with bed mobility, bathing, and toileting. The staffs' approach included to assist with ADLs. On 2/4/20 at 2:25 p.m., during an interview, Resident 7 stated the staff do not treat the residents with respect, they bully and belittle the residents, and made her feel like an object and not a person. Resident 7 stated the staff on the 11-7 shift (night) would not answer the call lights and would make comments, I will come back to you because I am helping another resident because the family is here. Resident 7 stated the staff does not identify themselves when they come into the room. 8. A review of Resident 8's Face Sheet indicated the facility first admitted the resident on 10/25/11 and was last readmitted on [DATE]. Resident 8's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 8's MDS, dated [DATE] indicated the resident's cognition was intact and was able to understand and make herself understood. The MDS indicated Resident 8 required limited assist with a one-person physical assist for toilet use, personal hygiene and bed mobility. A review of Resident 8's care plan titled, ADL, dated 7/16/19 indicated Resident 8 required assistance with bed mobility, bathing, and toileting. The staffs' approach included to assist with ADLs. On 2/5/2020 at 9:40 p.m., during an interview, Resident 8 stated on 2/2/2020 the resident stated he asked the staff to please get him up to go use the restroom. Resident 8 stated he was told by the staff they could not get him up because they were short-staff. Resident 8 stated he was wet all day and felt dirty. Resident 8 stated it was not the first time it happened, but he did not like complaining because of fear of the nurses getting mad. 9. A review of Resident 9's Face Sheet indicated the facility first admitted Resident 9 on 11/16/12 and was last readmitted on [DATE]. Resident 9's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 9's MDS, dated [DATE] indicated Resident 9 was usually able to understand and make herself understood. The MDS indicated Resident 9 was totally dependent with a two-person physical assist for toilet use, personal hygiene and bed mobility. A review of Resident 9's care plan titled, ADL, dated 10/22/19 indicated Resident 9 required assistance with bed mobility, bathing, and toileting. The staffs' approach included to assist with ADLs. On 2/5/2020 at 10:25 a.m., during an interview, Resident 9 stated she did not want to report the nurses because she was afraid of them. Resident 9 stated she was being left wet for extended periods of times making her feel uncomfortable, as if I do not matter. Resident 9 stated mentioning to the staff to not leave her wet because it will worsen the wound in her back. Resident 9 stated three nights prior on 2/2/2020 she was crying for over an hour due to pain and being left wet. On 2/4/20 at 10 a.m., during an interview, Certified Nurse Assistant 1 (CNA 1) stated the licensed nurses will not assist in answering call lights when the CNAs are busy, and the licensed nurses tell the CNAs it was not their job to answer call lights. CNA 1 stated being short-handed at times and not having enough time to reposition residents every two hours. CNA 1 stated management has been informed on multiple occasions regarding the shortage of staff affecting the care of the residents. On 2/4/2020 at 10:15 a.m., during an interview, Social Services Director (SSD) stated she was not aware of the concerns the resident were having with the nurses not answering their call lights. On 2/4/2020 at 11:58 a.m., during an interview, CNA 3 stated the facility being short staffed has affected the care delivery to the residents, such as repositioning the residents every two hours and answering the call lights in a timely manner. CNA 3 stated licensed nurses do not help to answer call lights when the CNAs are caring for other residents. CNA 3 stated they are told by the licensed nurses, Your resident is calling and needs you. On 2/4/2020 at 12:32 p.m., during an interview, CNA 2 stated the facility was short staffed which affected the care of the residents. CNA 2 stated residents sometimes do not get reposition during the shift and call lights are not answered. CNA 2 stated she did not receive help from the licensed nurses when she was busy with other residents. CNA 2 stated at times it takes her up to four hours to respond to the residents' needs. On 2/4/2020 at 12:54 p.m., during an interview, the ADM stated Resident 3 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The ADM was unable to provide documented evidence of Resident 3's fabricating, such as care plans or nurses notes that identified Resident 3's behavior of fabricating stories. On 2/4/2020 at 1:40 p.m., during an interview and review, the Director of Staff Development (DSD) stated the facility used the same system to ensure call lights are being answered since 10/2019. The DSD stated she was not aware there was a problem with licensed nurses not wanting to answer call lights. The DSD stated it was everyone in the facility responsibility to answer the call lights. The DSD stated the DON had been made aware of the call lights concern and she was working on trying to change the mentality of the licensed nurses instead of focusing on paper compliance to focus on the resident's care. On 2/4/2020 at 2:25 p.m., during a council meeting held by the ADM with four sampled residents (Residents 3, 4, 6, 7), two resident's Responsible Party (RPs 1 and 2), and in the presence of the CO, Residents 3, 4, 6, 7, Resident 2's Responsible Party 1 (RP 1) and Resident 4's RP 2 stated the following: Resident 2's RP 1 stated in 1/2020 a grievance was placed to the staff regarding Resident 2 being left soiled on multiple occasions. RP1 stated a few days prior she overheard CNA 2 say, while in the hallway and laughing, she had to open the windows because it smelled bad. RP 1 stated CNA 2 had left Resident 2's room after changing the soil adult brief and made the comment in the hallway right outside the room. RP 1 stated the nurses usually take between 30 minutes or more to answer the call lights and when they answer the call light they would comments, I'm not your nurse, and they would not return. Resident 4's RP 2 stated the staff takes between 30 minutes to an hour to respond to the call lights, and when they do, in her presence, the staff tells the resident to go (urinate/defecate) in her adult brief. RP 2 stated she would like for Resident 4 to live a meaningful life with dignity and respect. RP 2 stated the staff was intimidating Resident 4 by following her around and telling her to go to bed at 7:30 p.m. RP 2 stated on 2/3/2020 a staff member followed Resident 4 around and made her go to bed at 7:30 p.m. Resident 7 stated the staff do not treat the residents with respect, they bully and belittle the residents, and made her feel like an object and not a person. Resident 7 stated on 2/1/2020 at night time, Resident 9 was calling for more than 4 minutes to have a nurse change her because she was wet. Resident 7 stated Resident 9 was crying because she was uncomfortable and felt unimportant. Resident 7 stated the staff on the 11-7 shift (night) would not answer the call lights and would make comments, I will come back to you because I am helping another resident because the family is here. Resident 7 stated the staff does not identify themselves when they come in to the room. Resident 3 stated on 2/3/2020 a staff member from the 3-11 shift (pm) told her it was her fault the Department of Health was investigating the facility and that thee nurses would be in trouble because of her complaint. On 2/4/2020 at 3:55 p.m., during a concurrent observation and interview, the call light board at the nurse's station was blinking and there was no nurse answering the call light. Registered Nurse 1 (RN 1) stated it was everyone's responsibility to answer the call lights. RN 1 stated he did not get up to answer the call light earlier because he was charting. A review of the facility's interviews conducted on 2/5/2020 indicated 22 of 58 in house residents interviewed indicated the facility's staff did not answer call lights and 9 of the 58 residents stated the staff speaks to them in a disrespectful manner. On 2/6/2020 at 4:15 p.m., during an interview, the RNC stated the facility's corporate did not tolerate abusive behaviors in the facility. The RNC stated the facility's management appreciated that the residents were forthcoming in reporting the abuse now because they were not aware of all the abuse issues. The RNC stated all staff were responsible to answer the call lights and ensure residents needs were met. On 2/13/2020 at 1:15 p.m., during a telephone interview, the Medical Director (Physician 1) stated the call lights not being answered has been a problem over the past few months. Physician 1 stated he was not made aware during their quarterly meetings that the problem continued. Physician 1 stated he was not aware the residents at the facility felt intimidated by the staff and stated abuse was not tolerated and should be addressed immediately. A review of the facility's policy and procedures titled, Abuse-Prevention, Screening, & Training Program, dated 7/2018 indicated the facility did not condone any form of residents' abuse, neglect and mistreatment and develops facility's policies, procedures, training programs, and screening and prevention system to promote an environment free from abuse, neglect and mistreatment. The policy indicated verbal abuse was defined as any use of oral, written, gestured communication, or sounds that willfully includes disparaging and derogatory terms; Neglect, was define as failure to provide good and services necessary to attain or maintain physical, mental and phycological well-being; emotional abuse, was verbal or nonverbal conduct that causes humiliation, fear, shame, agitation or deration.

Based on interview and record review, the facility failed to follow the physician's orders to transcribe and carry-out orders to draw STAT (immediately) [MEDICATION(S)] level and transfer the resident to the general acute care hospital (GACH) as prescribed by the physician for one of nine sampled residents (Resident 1). Resident 1's [MEDICATION(S)] level was not drawn until 24 hours after the physician ordered it STAT, which was identified as elevated abnormal that was not reported to the physician timely. This deficient practice resulted in a delay in care and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 1 was diagnosed with an acute [CONDITION(S)] (fluid buildup in the air sacs of the lungs) and required intubation (tube placed in the trachea [windpipe] for oxygen exchange and placed on a mechanical ventilator (machine used to assist with breathing), [CONDITION(S)] of the liver (long-term damage to the liver), and septic shock (multiple organ damage due to an infection resulting in dangerously low blood pressure). Resident 1 died on [DATE] at 6:20 p.m. Findings: A review of Resident 1's Face Sheet (Admission Record) indicated the facility first admitted the resident on [DATE] and was last readmitted on [DATE]. Resident 1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Minimum Data Set (MDS), a resident assessment and care-screening tool, dated [DATE] indicated the resident was moderately impaired in cognition (thought process), but was usually able to understand and be understood. The MDS indicated the resident required extensive assist (staff provide guided-maneuvering of limbs or other non-weight bearing assistance) with a one-person physical assist for bed mobility (how the resident moves to and from lying position, turning side to side, and positioning of body) and personal hygiene. The MDS indicated Resident 1 was always incontinent of bowel and bladder (lack of voluntary control over urination or defecation). A review of Resident 1's care plan titled, Cognitive Loss, dated [DATE] indicated Resident 1 had periods of confusion and disorientation. The staffs' interventions included to monitor for changes in mental status and report to the physician and assess for contributing factors such as infection, medications and diagnosis. A review of Resident 1 untimed Licensed Personnel Weekly Progress note dated [DATE] indicated Resident 1 was responsive but very lethargic (sluggish) and confused with stable vital signs. The note indicated the primary physician was notified, and orders received for [MEDICATION(S)] levels (can help identify the cause of changes in behavior and consciousness) drawn STAT and transfer Resident 1 to the GACH if the resident's [MEDICATION(S)] level was high. A review of Resident 1 physician's telephone order, dated [DATE] and timed at 10:30 a.m., indicated an [MEDICATION(S)] laboratory order. A review of the diagnostic laboratory results dated [DATE] indicated Resident 1's [MEDICATION(S)] levels was drawn on [DATE] at 11:03 a.m., (24 hrs. after the physician's STAT order) and results received on [DATE] at 4:48 p.m., indicating Resident 1's [MEDICATION(S)] level was elevated at 104 ([NRR] ,d+[DATE]). A review of Resident 1's change of condition ([COC] sudden, clinical deviation from a resident's baseline), dated [DATE] indicated Resident 1 was transferred to the GACH after being found difficult to arouse by the staff. A review of Resident 1's physician's telephone order, dated [DATE] and timed at 1:30 p.m., indicated Resident 1 was transfer to the GACH's emergency room . A review of the paramedics run sheet, dated [DATE] indicated the paramedics saw Resident 1 at 1:05 p.m. and transferred the resident to the GACH for altered level of consciousness (ALOC). The paramedic documented the staff informed them that they believed the resident had ALOC due to the [MEDICATION(S)] level. Resident 1 was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's GACH admission note included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 4 p.m., during an interview and review, Licensed Vocational Nurse 2 (LVN 2) stated on [DATE] at 12:50 p.m., Resident 1 did not appear to look normal and called 911 (emergency number). LVN 2 stated on [DATE] at 11:47 a.m., the laboratory called and notified her of Resident 1's critical lab results from the lab drawn early that morning. LVN 2 stated she did not notify the physician because she was waiting for a hard copy of the laboratory results. On [DATE] at 1:40 p.m., during an interview, the Administrator (ADM) stated LVN 2 not reporting Resident 1's critical lab results to the physician when she received the call from the laboratory would had not made a difference in the residents care. On [DATE] at 6:30 p.m., during an interview and a review of the facility's policy and procedures, the Director of Nurses (DON) stated according to the facility's policy, LVN 2's responsibility was to call the critical lab results to the physician and not to wait for a hard copy. The DON stated LVN 2 should had reported Resident 1's [MEDICATION(S)] results and follow the physicians' orders when LVN 2 talked to the physician. On [DATE] at 3:15 p.m., during an interview, the DON stated the staff should had followed the physician's orders given on [DATE] to transfer the resident to the GACH for elevated [MEDICATION(S)] levels. The DON stated not being aware why the staff did not transfer Resident 1 to the GACH as indicated by the physician. The DON stated STAT orders are to be done within four hours of the order received. A review of the facility's policy and procedures titled, Laboratory-Critical Values, dated ,d+[DATE] indicated the facility would report immediately to the physician critical laboratory values (if left untreated could be life threatening). A review of the facility's policy titled, Change in Condition Notification, dated [DATE] indicated the facility would promptly inform the resident attending physician when there is a significant COC such as life-threatening conditions and critical lab results would be communicated immediately to the physician via phone.

Based on observation, interview and record review, the facility failed to provide the necessary care and services as indicated in a resident's plan of care, which included keeping the resident clean and dry and repositioning to prevent the development of pressure ulcers (injury to skin and underlying tissues from prolonged pressure on the skin) for two of two sampled residents (Residents 1 and 2). Residents 1 and 2 were admitted to the facility without a pressure ulcer (Cross referenced F600). This deficient practice resulted in a delay in care and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 1 also developed a deep tissue injury ([DTI] intact skin with dark discoloration, such as purple, maroon, or a bruise like appearance, or a blood-filled blister) to the left heel. Resident 2 sustained a skin tear (wound caused by shear, friction, and/or [MEDICATION(S)] force) to the right upper hip and right/left buttocks. Findings: 1. A review of Resident 1's Face Sheet (Admission Record) indicated the facility first admitted the resident on 12/16/19 and last readmitted on [DATE]. Resident 1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Minimum Data Set (MDS), a resident assessment and care-screening tool, dated 12/24/19 indicated the resident was moderately impaired of cognition (ability to acquire knowledge and understanding) and was able to usually (misses sometimes) understand and understood others. The MDS indicated the resident required extensive assist (staff provide guided-maneuvering of limbs or other non-weight bearing assistance) with a one-person physical assist for bed mobility (how the resident moves to and from lying position, turning side to side, and positioning of body) and personal hygiene. The MDS indicated Resident 1 was always incontinent of bowel and bladder (lack of voluntary control over urination or defecation). The MDS indicated Resident 1 did not have pressure ulcers but was at risk to develop them. A review of Resident 1's Braden Scale (scale for predicting pressure sores), dated 1/1/2020 indicated Resident 1's score for pressure sores development was mild risk with a total score of 15. A review of Resident 1's care plan titled, Skin, dated 1/9/2020 indicated Resident 1 was at risk for skin break/ulcer formation related to impaired mobility and incontinence. The care plan goal was to minimize the risk of pressure ulcer development. The staffs' interventions included care and reposition, provide pressure redistribution devices, and provide skin care frequently and monitor for signs of infection. A review of Resident 1's Change of Condition ([COC] decline or improvement in a resident's mental or physical functioning) dated 1/10/2020 indicated the resident was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] A review of Resident 1's Wound Assessment and Plan, dated 1/10/2020 indicated Resident 1 was evaluated with a left elbow unstageable pressure measuring 5 centimeters ([cm] unit of measurement) in length by 5 cm in width (without depth) and with no signs and symptoms of infection. The wound assessment indicated to cleanse wound with normal saline (salt water) and cover with dry clean dressing after applying Santyl (ointment use to remove dead tissue). The review did not indicate other wounds were identified during the wound assessment. A review of Resident 1's COC, dated 1/15/2020 indicated Resident 1 was transfer to the general acute care hospital (GACH) after being found difficult to arouse by the staff. A review of Resident 1's physician's telephone order, dated 1/15/2020 and timed at 1:30 p.m. indicated Resident 1 was transfer to the GACH's emergency room (ER) via 911 (emergency service). A review of Resident 1's GACH's Wound Care Note, dated 1/16/2020 and timed at 2:30 p.m., indicated Resident 1 was admitted to the GACH on 1/15/2020 with altered mental status, sacral pressure injury Stage III, midback pressure injury Stage III, left and right heel DTI, left medial ankle blister, and bilateral (both sides) posterior ears. On 2/3/2020 at 3:35 p.m., during a concurrent interview and review of Resident 1's nurse's notes, Licensed Vocational Nurse 1 (LVN 1) stated on 1/10/2020 a left elbow unstageable wound was identified and treated. LVN 1 stated Resident 1 was admitted on [DATE] without a wound identified during the initial assessment. LVN 1 stated wounds can develop when residents are not being repositioned every two hours. LVN 1 stated Resident 1 had no Registered Dietitian ([RD] expert in human nutrition and diets) recommendations while at the facility. On 2/4/2020 at 12 p.m., during an interview and review Resident 1 nurses' notes, LVN 1 stated Resident 1 was admitted to the facility on [DATE] without wounds. LVN 1 stated on 1/10/2020 a wound to the left elbow was identified. LVN 1 stated no other wounds identified. On 2/6/2020 at 4:30 p.m., during an interview and review in the presence of the Registered Nurse Consultant (RNC), the Director of Nursing (DON) stated Resident 1 was admitted on [DATE] without wounds. The DON stated Resident 1 required assistance with mobility and ambulation and a wound goes untreated it can become a problem for the residents' health. 2. A review of Resident 2's Face Sheet indicated the facility admitted the resident on 1/8/2020. Resident 1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 2's MDS dated [DATE], indicated Resident 2's cognition was intact and was able to understand and make herself understood. The MDS indicated the resident required an extensive assist with a two-person physical assist for toilet use, personal hygiene and bed mobility. A review of Resident 2's care plan titled, Bowel and Bladder, dated 1/20/2020 indicated the goal was to keep the resident dry, clean and comfortable. The staffs' approach included to check the resident every two hours and provide care after each incontinence case. On 2/4/2020 at 10 a.m., during an interview, Certified Nurse Assistant 1 (CNA 1) stated the licensed nurses will not assist in answering call lights when the CNAs are busy, and the licensed nurses tell the CNAs it was not their job to answer call lights. CNA 1 stated being short-handed at times and not having enough time to reposition residents every two hours. CNA 1 stated management has been informed on multiple occasions regarding the shortage of staff affecting the care of the residents. On 2/4/2020 at 2:25 p.m., during an impromptu council meeting, held by the Administrator (ADM) with four sampled residents (Residents 3, 4, 6, 7), two resident's responsible party (RPs 1 and 2), and in the presence of the Compliance Officer (CO), Resident 2's RP 1 stated in 1/2020 a grievance was placed to the staff regarding Resident 2 being left soiled on multiple occasions. RP 1 stated the nurses usually take between 30 minutes or more to answer the call lights and when they answer the call light they would comments, I'm not your nurse, and they would not return. On 2/4/2020 at 4:05 p.m., during an interview, Resident 2 stated while CNA 2 was providing Activities of Daily Living (ADL) care CNA 2 pulled her diaper off her roughly hurting Resident 2's inner thigh and the upper part of the hip by the abdomen resulting in a burning like sensation. Resident 2 stated she told CNA 2 she was hurting her and not to pull the diaper hard. Resident 2 stated not being the first time it happened. Resident 2 stated the nurses take a long time to answer the call light and are always in a hurry. On 2/4/2020 at 4:10 p.m., during a concurrent observation and interview, in the presence of the DON, LVN 1 identified new wounds on Resident 2's right buttocks, left buttocks skin peel and a right lateral abdomen skin tear. LVN 1 stated she did not assess or treat Resident 2's wounds because she was not made aware of them until now. The review of the facility's policy and procedures titled, Pressure Injury Prevention, dated 8/12/16 indicated the Licensed Nurse will develop a care plan that contains interventions for residents who have risk factors for developing pressure injuries. The policy indicated the licensed staff would implement interventions identified in the care plan based on the individual risk factors such as reposition and turning, heel and elbow protectors and nursing staff would observe for any active pressure injury daily while providing nursing care.

Based on record review and interview, the facility failed to ensure one of three sampled residents (Resident 1) were free of verbal abuse and follow its policy and report an abuse allegation to the Professional Certification Branch for a certified nursing assistant's (CNA) misconduct. These failures resulted in Resident 1 being verbally abused by a Certified Nursing Assistant 1 (CNA 1), and placed Resident 1 at risk of feeling vulnerable, unsafe, and had the potential for emotional distress. Findings: On 7/12/17 at 1:21 p.m., an unannounced entity reported incident (ERI) investigation was conducted regarding Resident 1 being verbally abused and confronted by CNA 1. A review of Resident 1's Admission Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE], and readmitted on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 5/12/17, indicated Resident 1's cognition (thought process) was intact and had a Brief Interview for Mental Status (BIMS) score of 14 (a score of 9-15 = interviewable). The MDS indicated Resident 1 required extensive assistance with bed mobility, dressing, and personal hygiene and was totally dependent with transfers in and out of bed. According to the MDS, Resident 1 was incontinent (inability to control voluntary urination or bowel) of bowel and bladder, and unable to walk. On 7/12/17 at 1:40 p.m., during an interview, Resident 1 stated (CNA 1) came into her room, the morning of 7/7/17, while she was eating breakfast and pulled open the curtain. Resident 1 stated CNA 1 had a do-rag (hat used to cover one's head) on her hair, tied to the front like Tupac (rapper/musician who often wore the style). Resident 1 stated CNA 1 told her CNA 2 told her Resident 1 said something nasty about her. Resident 1 stated CNA 1 was confronting her and she felt scared, threatened, and uncomfortable. Resident 1 stated she did not want CNA 1 or 2 to take care of her anymore. Resident 1 stated she was afraid CNA 1 would do something to her while she was asleep. On 7/12/17 at 2:09 p.m., during an interview, CNA 3 stated she was in Resident 1's room feeding another resident, on 7/7/17, when the incident occurred. CNA 3 stated she overheard CNA 1 asked Resident 1 if she was speaking bad about her. CNA 3 stated, I did not know if CNA 1 wanted to fight Resident 1 , but she was confronting her about something that was said by another girl (CNA 2) who works here. On 7/12/17 at 2:48 p.m., during an interview, the Director of Staff Development (DSD) stated, I interviewed the resident (Resident 1), CNA 1 and CNA 3, when I compared the stories CNA 1's version was different. I wrote an incident report about the incident. A review of a hand written note, written by Registered Nurse 1 (RN 1) on 7/7/17, indicated at 7:45 a.m., Resident 1 called the nurses station and stated that CNA 1 confronted her during breakfast. According to the note, Resident 1 stated, I thought she (CNA 1) was ready to get down with an old lady. The note indicated Resident 1 stated, CNA 1 told the resident she was talking about her. On 7/17/17 at 3:24 p.m., during an interview, the DSD stated, The CNA (CNA 1) did not pass the ninety-day probation period, and was suspended the day of the incident (7/7/17), and then terminated. On 7/17/17 at 3:36 p.m., during an interview, the Assistant Administrator (AA) stated he did not report CNA 1 to the professional certification branch for misconduct in regards to the abuse allegation. The AA stated, No, I did not report this because, I did not think it was necessary because it was verbal abuse. I am strict with customer service and this CNA (CNA 1) did not meet the expectations of our customer service. On 7/26/17 at 12:03 p.m., during a telephone interview, RN 1 stated Resident 1 told her she felt scared and threatened because CNA 1 was confronting her about something said between her and another CNA. RN 1 stated CNA 1 was sent home immediately, so that Resident 1 would feel safe. On 7/28/17 at 9:23 a.m., during an interview, the Social Services Director (SSD) stated, she interviewed various residents about the care they received from CNA 1, and overall, the residents stated, CNA 1 was pleasant and helpful. The SSD stated this situation should not have occurred, because the CNA works in a clinical capacity and their job is to take care of the residents, not confront them (residents). A review of the facility's internal investigation conclusion, dated 7/11/17, indicated CNA 1 was suspended immediately after the incident (7/7/17), and upon conclusion of the investigation CNA 1 was terminated on 7/11/17. A review of the facility's employee handbook, dated January 2017, under Section 3 titled, Employee Relations, indicated that while it was not possible to provide an exhaustive list of all types of conduct that are unacceptable in the workplace, the following was an example of conduct that was prohibited and will not be tolerated, .any employee/ resident abuse. A review of CNA 1's personnel file indicated CNA 1 was hired on 5/5/17, and received abuse training on 5/5/17. The file indicated CNA 1 acknowledged receipt of the training and education by signing a copy of the facility's abuse policy, along with an illustration of various types of abuse on 5/5/17. A review of the facility's policy titled, Abuse, Reporting, and Investigations, dated November 2016, indicated if the suspected perpetrator was an employee, remove the employee immediately from the care of the resident and immediately suspend the employee pending the outcome of the investigation in accordance with facility's policies. The policy also indicated if the investigation confirmed that the alleged incident, corrective action will be taken immediately under the supervision of the Administrator. According to the policy, notification would be made to the appropriate licensing agency, which included the professional branch for CNAs, if the incident involved a nursing assistant. Inquiries concerning abuse reporting and investigations should be referred to the Administrator or the director of nursing.