Every finding on record at Berkley East Healthcare Center

Based on interview and record review the facility failed to:1. Protect the residents right to be free from physical abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment) for one of the five sampled residents (Resident 1) by Resident 2.2. Consistently monitor the whereabouts of Resident 2 who had behavior of wandering around the facility, wandering into residents rooms and going through residents belongings without permission/authorization. and was physically aggressive with facility staff. On 7/13/2026 at 10pm, while Resident 1 was asleep, Resident 2 entered Resident 1 and Resident 3's room [roommates) without permission or invitation and went straight to Resident 1's bed, took the towel and placed the towel around Resident 1's neck and tried to choke Resident 1. Resident 2 then grabbed Resident 1's legs and dragged Resident 1 to the floor. Resident 2 started hitting Resident 1 on the head with Resident 2's shoe. These deficient practices resulted in Resident 1 suffering distress, anxiety, felt upset and shaken up, and pain level of 2 out of 10 (2/10-numerical pain assessment tool where 0 is no pain and 10 is severe pain) to the right-sided neck, right shoulder pain, and right rib and flank (in the side and lower back, between the bottom of the ribs and the hip) pain, wrist pain, and abrasion (scrap-superficial wound), skin tear and bruising to the right arm. On 7/13/2026 at 10:18 PM the paramedics transferred Resident 1 to a General Acute Care Hospital (GACH) emergency room (ER) for further evaluation and management. Findings: Cross Reference F641 & F656 During a review of Resident 1's admission Record (face sheet - a document containing demographic and diagnostic information) indicated Resident 1 was admitted to the facility on [DATE] with the following diagnoses and not limited to dementia (a condition in which a person loses the ability to think, remember, learn, make decisions, and solve problems); weakness (an overall lack of physical strength or a heavy, tired feeling in most areas of the body); disorder of the muscle(causes patterns of weakness, loss of muscle tissue); abnormalities of gait and mobility (gait - a person's manner of walking); age-related osteoporosis (a condition where bones become thin, weak, and easy to break); wedge-compression fracture of unspecified thoracic vertebra(back bone), and unspecified fracture (break in a bone) of the left acetabulum (is the large, cup-shaped socket on the outer side of the hip bone). During a review of Resident 1's History and Physical (H&P - a physician's complete patient examination) dated 1/21/2026 indicated Resident 1 was alert and oriented to self, location, and time. H&P also indicated Resident 1 had impairments with gait (pattern of walking) and balance. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 5/14/2026 indicated, Resident 1 had a moderately impaired cognition (make poor decisions, cues and supervisions required). The MDS indicated Resident 1 did not have any signs and symptoms of delirium (a serious, sudden state of mental confusion and changed awareness), mood swings (extreme or rapid shifts in a person's emotional state), The MDS also indicated that Resident 1 required a setup or clean-up assistance with laying or sitting on the side of the bed, when transferring from chair to the bed and vice versa, and can independently walk for 10 feet to 150 feet using a walker. The MDS also indicated Resident 1 did not have any skin injuries. During a review of Resident 1's Psychological (relates to the mind, specifically how it affects behavior, emotional responses, and cognitive functions) Service Note dated 6/11/2026 indicated, Resident 1 reported feeling okay; no aggressive behavior anytime recently. A review of Resident 2's Nursing Progress Notes dated 6/12/2026 at 6:13 PM, indicated, Resident 2 definitely needs a 1 to 1 sitter 24 hours a day due to her roaming around the facility. During a review of Resident 1's Nursing Progress Note date 7/13/2026 at 10 PM, the Note indicated Resident 1 sustained a lower back abrasion/skin tear approximately quarter-sized and redness noted to the left harm. During a review of the facility's Summary of Investigation Resident to Resident 5 Day Report dated 7/17/2026, indicated that, on 7/13/2026 at 10pm it was reported to the Administrator and DON that there was a resident-to-resident altercation (is a loud, heated, and angry dispute or argument between people) involving physical injury to Resident 1, inflicted by Resident 2, to which staff promptly responded and intervened to provide safety to Resident 1, roommate, and other residents on the unit. Resident 1 was observed sitting on the floor next to her bed and Resident 1 was attempting to hit her with her shoe when a Certified Nursing Assistant (CNA-unidentified) stopped Resident 2 and two additional staff (unidentified) responded and assisted to remove Resident 2 from the room. Resident 1 was assessed for injury and Medical Doctor (MD) ordered to transfer Resident 1 to emergency room (ER) for further assessment. 911 was called and Resident 1 was brought by paramedics to acute (General Acute Care Hospital-GACH) for evaluation (eval) and treatment. The same facility's Summary of Investigation Resident to Resident 5 Day Report indicated that [Resident 1] stated she was already sleeping when resident (aggressor-Resident 2) wheeling in her wheelchair approached [Resident 1], took the towel from [Resident 1] walker and placed the towel on Resident 1's neck trying to choke Resident 1, but as Resident 1 (victim) tried to push Resident 2, Resident 2 (aggressor) became more upset and then grabbed both of Resident 1's legs and dragged Resident 1 to the floor. Resident 1 (victim) yelled, roommate [Resident 3] also yelled for the charge nurse (LVN 4) at the same time and came immediately taking the Resident 2 (aggressor) away from Resident 1. Resident 3 stated that she noticed Resident 2 (aggressor) was wheeling inside their [Resident 1 and Resident 3] room and then she [Resident 3] heard her roommate [Resident 1] screaming go away. After that Resident 3 saw Resident 2 in the wheelchair dragging her roommate [Resident 1] on the floor and then she [Resident 3] screamed for help, calling for LVN 4 the charge nurse. LVN 4 came immediately for help. LVN 4 I was at the medication (med) cart by room . and heard the residents yelling and immediately went to the room and found Resident 2 attempting to hit Resident 1 with her shoe while Resident 1 was on the ground, Resident 2 was in her wheelchair. We took Resident 2 out of the room back to her room and I (LVN 4) notified the other charge nurse (unidentified), the supervisor and the DON (Director of Nursing) about the incident. The same facility's Summary of Investigation Resident to Resident 5-Day Report indicated that Registered Nurse Supervisor (RNS) 2 stated that LVN 4 called RNS 2 STAT (now) to respond and when I arrived in the room I observed that Resident 1 was sitting on the floor next to her [Resident 1] bed. Resident 1 had some redness to her arm, back and neck. The (unidentified) CNA was interpreting the report that she [Resident 1] was pulled out of bed by her legs, and the other resident [Resident 2] pulled the towel around her neck and tried to hit her [Resident 1] with her shoes. Resident 1 was upset and experiencing pain (location not un specified) so I [RNS 2] decided to call 911 based on her [Resident 1] history and medications. I assigned tasks to the team members to notify . and to ensure that Resident 2 is monitored at all times. During a review of Resident 1's Nursing Progress Note date 7/13/2026 at 10 PM, the Note indicated Resident 1 sustained a lower back abrasion/skin tear approximately quarter-sized and redness noted to the left harm. The Nursing Progress Note also indicated that neurological checks (a series of simple, painless physical tests that check how well your brain, spinal cord, and nerves are working) were initiated every 15 minutes and remained within normal limits until the Emergency Medical Service (EMS) arrived. Patient remained alert and oriented x3, expressed concerns, able to understand the situation, and verbalized understanding. Physician was notified and ordered to transfer Resident 1 to the ER via 911 (emergency medical response telephone number) for further evaluation. During a review of Resident 1's Emergency Department's (ED) Triage Note indicated Resident 1 arrived in the ED on 7/13/2026 at 10:18 PM. The Triage Note, documented by GACH 1 Registered Nurse (GRN) 1 created on 7/13/2026 at 10:46 PM indicated, Resident 1 reported that, another resident put a towel around [Resident 1's] neck, dragging [Resident 1] to the ground from [Resident 1's] bed. GRN 1 also indicated Resident 1's pain level was 2/10 to the right-sided neck and shoulder pain, and had notable bruising to the right arm. GRN 1 indicated that Resident 1 was alert and able to account and communicate what happened to [Resident 1].The same ED Triage Note under Emergency Provider (physician) Note indicated [Resident 1] does complain of right-sided neck pain, right shoulder pain, and right rib and flank pain. The Emergency Provider note also indicated Resident 1 appeared anxious.had right lateral (toward the side) neck tenderness to palpation (when a healthcare provider presses on a specific body part), no midline (an imaginary line dividing the body down the exact center into matching left and right halves) tenderness and right lateral shoulder tenderness to palpation, posterior rib tenderness to palpation, and right lower back pain. During a review of Resident 1's Change of Condition (COC) - a significant change in a resident's health or functional status) dated 7/13/2026 at 11:59 PM, the COC indicated Resident 1 was assaulted by fellow resident on 7/13/2026 at night (time not indicated). The COC also indicated Resident was on the floor crying and in distress and that Resident 2 was holding Resident 2's shoes ready to hit [Resident 1] on the floor. The COC further indicated that Resident 1 complained of back pain, neck pain, and wrist pain.noted discoloration on back with abrasion. The COC indicated that Resident 1's primary physician (PP) was notified who ordered to send Resident 1 to a GACH for further evaluation. During a review of Resident 1's Social Services Note dated 7/14/2026 at 9:02 PM, documented by the facility Social Services Assistant (SSA - supports the facility's social work team, interview residents and families to gather psychosocial histories, assist with care and discharge planning, and connect residents with community resources), the SSA note indicated that Resident 1 stated feeling upset and shaken up following the incident of 7/13/2026 around 10 PM where Resident 1 was physically assaulted by Resident 2. During a review of Resident 1's Social Services Note dated 7/15/2026 at 3:47 PM, written by SSA indicated that Resident 1 reported didn't sleep well last night and had some pain. During a review of Resident 1's Nursing Progress Note dated 7/15/2026 at 4:44 PM, the Progress Note indicated Resident 1 shows signs of pain due to facial grimacing and [Resident 1] pointing to [Resident 1's] right lower back. During a review of Resident 1's Nursing Progress Note dated 7/15/2026 at 10:57 PM, the Progress Note indicated Resident 1 had complain of pain of the sacral (a portion of the spine between the lower back and tailbone) area. During a review of Resident 1's Psychological Service Note dated 7/16/2026 indicated, Resident 1 had a Recent incident in which pt was aggressed (first attacked) against by another resident who has since been removed from facility; Patient has some residual pain from incident as well as anxiety. During a review of Resident 1's Social Services Note dated 7/16/2026 at 6:23 PM, written by SSA stated that Resident 1 reported still has little trouble sleeping at times. During a review of Resident 1's Skin Issues Note date 7/22/2026 at 3:39 PM, the Note indicated that Resident 1's sacral abrasion (a superficial wound or scrape located over the triangular bone at the base of the spine, and right above the tailbone) still present, ongoing treatment for skin issue. During a review of Resident 2's (Perpetrator) AR, the AR indicated the facility admitted Resident 2 on 5/18/2022, and readmitted on [DATE] with the following diagnoses: degenerative disease of the basal ganglia (a rare progressive brain disorder where nerve cells die and areas of the brain shrink); intervertebral disc degeneration, lumbar region (gradual wear and tear of the cushions between the lower spine bones); cervical disc degeneration, unspecified cervical region (the natural breakdown of the cushion-like discs between your neck bones); neurocognitive disorder with Lewy bodies dementia (a progressive brain disorder caused by abnormal protein deposits called Lewy bodies building up in nerve cells); depression (a common but serious mood disorder that causes a persistent feeling of sadness and loss of interest); and visual hallucinations (seeing things that are not real, it happens while you are awake). During a review of Resident 2's CP , the CP indicated Resident 2 had an alteration in behavior pattern related to psychotic disorder (a group of symptoms where a person loses touch with reality, having core signs which included delusions [false beliefs], hallucinations, and visual hallucination initiated on 6/13/2024, and revised on 6/15/2026, with a target date of 9/11/2026. The CP goal included for Resident 2 to have reduced episode of visual hallucination of seeing dead people resulting into unrealistic fear through the next review date to 0 (zero) to 1. The CP's interventions included:(a) Determine cause of the change in Resident 2's behavior;(b) Observe for trigger events of behavior and redirect as needed;(c) Evaluate comfort level, check for presence of pain and provide intervention as indicated; and(d) Assess resident to process feelings and find positive outcomes. A review of Resident 2's MDS dated [DATE] indicated Resident 2 had moderately impaired cognition (make poor decisions, cues and supervisions required). The MDS also indicated that Resident 2 required partial/moderate assistance from staff with toileting, dressing, and personal hygiene. MDS also indicated Resident 2 required supervision or touching assistance from facility staff related to mobility (ability to move freely, purposefully, and independently). MDS indicated Resident 2 used a wheelchair for mobility. During a review of Resident 2's Care Plan (CP), Resident 2 had exhibited agitation and physical aggression towards staff members initiated on 3/29/2026, and revised on 6/15/2026, and a target date of 9/11/2026. The CP's goal included Resident 2 will demonstrate reduced episodes of physical aggression and effective coping skills through the review date. The CP's interventions included(a) Analyze times of day, places, circumstances, triggers, and what de-escalates behavior and to document; (b) To assess and address for contributing sensory deficits; (c) Modify environment, such as reduce noise, place familiar objects in room, keep door closed);(d) Document observed behavior and attempted interventions in behavior log;(e) Monitor resident closely for signs of agitation or escalation; and(f) Monitor/document/report as necessary, any signs and symptoms of Resident 2 posing danger to self and others. A review of Resident 2's Nursing Progress Notes dated 6/24/2026 at 3:20 PM under Mood and Behavior, indicated, Resident 2 wanders at night. During a review of Resident 2's Psychological Service Note dated 6/25/2026 indicated, Resident 2 presented ongoing symptoms of adjusting to illness/decrease in functioning, hopelessness, depression, irritable, tangential thinking, visual hallucination, and paranoid delusions. The Psychological Service Note indicated under Comment/Recommendations/Notes section, Resident 2 was talkative, confused; however, able to be redirected when touching items at nursing station. During a review of Resident 2's Nursing Advanced Skilled Evaluation dated 6/29/2026 at 11:11 AM, Resident 2 was observed to have chronic (on going) confusion, disorganized thoughts, and short-term memory loss. The Nursing Advanced Skilled Evaluation under Mood and Behavior heading indicated that Resident 2 had a change in [Resident 2's] depression. However, the Nursing Advanced Skilled Evaluation did not indicate what changes were observed on Resident 2. During a review of Resident 2's Psychological Service Note dated 7/02/2026 indicated, Resident 2 presented ongoing symptoms of hopelessness, depression, tangential thinking, visual hallucination, and paranoid delusions. The Note indicated under Comment/Recommendations/Notes section, Resident 2 had tangential thinking and difficulty participating in dyadic (an interaction between two people) conversation today; hyperverbal (talking a lot or using too many words). During a review of Resident 2's Physician's Progress Note dated 7/07/2026, the Note indicated Resident 2 had recent depressed mood. During a review of Resident 2's Psychological Service Note dated 7/09/2026 indicated, Resident 2 presented ongoing symptoms of hopelessness, depression, tangential thinking, visual hallucination, and paranoid delusions. The Note indicated under Comment/Recommendations/Notes section, Resident 2 had paranoid ideation, tangential thinking, hyperverbal, wanders in wheelchair at times, however, staff intervenes as needed. Patient reminded to stay out of other (residents) rooms. A review of Resident 2's Psychological Consult (an initial or follow-up meeting with a mental health professional to discuss your concerns, review your history, and determine the best treatment or testing plan) dated 7/09/2026 indicated, Resident 2 had visual hallucinations, paranoid delusions (fixed, false beliefs that you are being harmed, watched, or plotted against by others), hyperverbal (talking a lot or using too many words), and tangential thinking (a communication and thought pattern where a person wanders off-topic and never returns to the original point). The psychological consult notes also indicated Resident 2 wanders in wheelchair at times. and was reminded to stay out of others (residents) rooms. During a review of Resident 2's GACH 2 records from the Emergency Department (ED) Note dated 7/13/2026 indicated Resident 2 was accompanied by the police on a 5150 (an involuntary 72-hour hold psychiatric detention) arrived in the ED on 7/13/2026 at 11:52 PM. The ED Note, under the heading Initial Physician Contact indicated, Resident 2 was brought in from the facility after physically assaulting another patient. The Initial Physician Contact section indicated that it was reported that [Resident 2] dragged another patient from the bed onto the floor and choked the patient with a towel.patient states does not remember this incident. The ED Note also indicated that Resident 2 correctly provided [Resident 2's] name and date of birth but when asked where Resident 2 was, Resident 2 stated at [my] . house. Resident 2 reported having a headache for the last week and was currently at 9/10 pain level. A computed tomography scan (CT/CAT scan- is a medical imaging test that uses a rotating X-ray machine and a computer to create detailed, cross-sectional slices of the inside of the body) of the brain was ordered to rule out (to stop considering something as a possibility, to eliminate an option) intracranial hemorrhage or mass (a critical, life-threatening medical emergency requiring immediate evaluation). The ED Notes continued to indicate that Resident 2 was admitted to the psychiatric unit (a specialized inpatient ward within a general hospital or a standalone psychiatric facility that provides 24-hour medical evaluation, observation, and intensive treatment for individuals experiencing acute mental health crises, severe psychiatric disorders, or active risks of self-harm) on 7/14/2026 at 6:17 PM. During a review of Resident 3's AR Resident 3 was admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses not limited to schizophrenia (a serious and severe mental disorder that affects how a person thinks, feels, and behaves); bipolar disorder a mental health condition. It causes extreme shifts in mood, energy, and activity levels); depression; and insomnia (difficulty falling and or staying asleep). During a review of Resident 3's H&P dated 4/30/2026, H&P indicated Resident 3 had the capacity to understand and make decisions. During a review of Resident 3's MDS dated [DATE], MDS indicated Resident 3 had intact cognition (the mental ability to make decisions of daily living). The MDS also indicated Resident 3 did not have signs and symptoms of delirium, and no potential indicators of psychosis. A review of the facility's Daily Huddle 3rd floor included residents who needed assistance with meals, high risk for falls, however, there was no documented evidence of residents with wandering behaviors for the following dates:3/27/20266/4/20266/18/2026 A review of the facility's Daily Huddle dated 6/1/2026, 6/7/2026,6/10/2026, 6/13/2026, 6/18/2026, and 6/19/2026, included special needs and the following daily reminders to ensure patient safety, however, there was no documented evidential reminders to monitor/supervise the whereabouts of residents with wandering behaviors:1. Call lights within reach at all times2. Toileting and Incontinent Care3. Proactive supervision and assistance4. Low bed, landing pads, and supportive position5. Items within reach- water, phone, remote, etc.6. Report any pain or change of condition7. Monitor fall risk patients (residents) During an interview on 7/23/2026 at 9:32 AM with Resident 3 (Resident 1's Roommate), Resident 3 stated that on 7/13/2026 it was very late, around nighttime, Resident 2 entered Resident 3's room without permission nor an invitation. [Resident 2] just entered our room.it was nighttime.I was reading my book. All the residents were asleep. Resident 3 stated that Resident 3 witnessed Resident 2 go straight to Resident 1's bed. Resident 3 stated there was a curtain pulled close between the Resident 1 and Resident 3 beds so Resident 3 did not see why Resident 1 started screaming and then somehow Resident 1 got out of bed. Resident 3 stated Resident 3 witnessed Resident 2 hitting my roommate (Resident 1) on the head with Resident 2's shoe and that Resident 3 screamed to get a staff's attention. Resident 3 stated, My roommate (Resident 1) was moaning and crying. Several staff came in right away and took Resident 2 out of our room. Resident 3 stated that on previous occasions, Resident 2 had been in Resident 1 and Resident 3's room twice before during the night but [Resident 2] never came inside our room, just outside the door. [Resident 2] never hurt me or my roommate (Resident 1) before until that day. I was surprised [Resident 2] walked into our room that day. During an interview on 7/23/2026 at 2:59 PM with CNA (Certified Nursing Assistant) 1, CNA 1 stated Resident 2 is a wanderer (a person who travels or moves from place to place without a fixed home, permanent job, or specific destination). [Resident 2] walks around all the time, every day. [Resident 2] would stand on someone else's rooms. I know [Resident 2] stood by the doorway of other residents' rooms. I saw [Resident 2] do this a lot (did not state specific times). CNA 1 stated that on 7/13/2026 around 10 or 10:30 at night CNA 1 was caring for another resident next door to Resident 1 and 3's room when CNA 1 heard someone scream for help. CNA 1 ran out to the other room and saw Resident 1 on the floor, sitting, screaming and crying, both arms to Resident 1's side. CNA 1 wheeled Resident 2 out of the room. CNA 2 asked Resident 2 what happened, Resident 2 stated well, [Resident 1] was the one who started it. CNA 1 stated CNA 1 separated Resident 2 from the scene and took Resident 2 back to Resident 2's assigned room. CNA 1 stated that it is common knowledge to the staff that Resident 2 goes to other residents' rooms. CNA 1 stated that Resident 1 may feel scared that the incident with Resident 2 may happen again to Resident 1. CNA 1 stated that Resident 2 is verbally aggressive and that every once in a while Resident 2 is aggressive with staff and pulls staff hair. During an interview on 7/23/2026 at 3:32 PM with CNA 2, CNA 2 stated Resident 2 walks around the facility hallway over and over daily. [Resident 2] just stands outside other residents' doors and stares at the residents. I've been called to residents rooms many times to remove [Resident 2] from other residents' room and return [Resident 2] back to Resident 2's assigned room. CNA 2 stated Resident 1 may feel angry, scared and feels [Resident 1] cannot trust the staff to keep her safe following the incident with Resident 2 During an interview on 7/23/2026 at 3:47 PM with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 2 is a wanderer, wanders, and goes around the facility. LVN 1 also stated LVN 1 has witnessed Resident 2 enter other residents' rooms. LVN 1 stated Resident 1 may feel anger and fear that Resident 2 might cause harm again to Resident 1. LVN 1 further stated, Yes, I saw [Resident 2] wander through their (other residents) belongings. LVN 1 was asked how Resident 1 felt after getting physically assaulted by Resident 2, LVN 1 stated afraid, angry at [Resident 2] for hurting [Resident 1]. During a concurrent interview and record review on 7/24/2026 at 2:22 PM with LVN 2, Resident 2's section E0900 - Wandering and Frequency of the MDS dated [DATE] was reviewed, LVN 2 stated Resident 2 wanders almost every day, day and night, but never witnessed [Resident 2] entered other residents' rooms. was reviewed with LVN 2, LVN 2 stated a code of zero, indicating behavior is not exhibited was entered. LVN 2 stated the code entered was incorrect because Resident 2 was always wandering. LVN 2 stated LVN 3 completed the MDS Assessment but LVN 2 did not check/verify the MDS for accuracy before posting the MDS Assessment in the Point Click Care (PCC - an electronic health record technology platform that specializes in providing software solutions for the senior care industry, particularly skilled nursing facilities and assisted living facilities), LVN 2 added that the Social Services Director (SSD - manages and coordinates social service programs [ex. housing, mental health, healthcare] and organizations that provide assistance to people in need) completed the MDS Section E0900 for Resident 2 and that the SSD is not a licensed nurse. LVN 2 also stated that LVN 2 was ultimately responsible for the accuracy of Section E0900 of the MDS. LVN 2 searched the facility's PCC but was unable to locate for Resident 2's Wandering Risk Assessment but was not able to locate the and stated, I can't find anything (wandering risk assessment). LVN 2 also stated Wandering Risk Assessment is completed to help assess [Resident 2's] level of risk for leaving the facility, to ensure there is a care plan in place and interventions like monitoring to make sure [Resident 2] doesn't go outside the building or go to other residents' rooms. LVN 2 stated if the Wandering Risk Assessment is not completed on admission and when needed, we are not doing any monitoring and [Resident 2's] wandering and whereabouts are not being addressed. LVN 2 stated that Resident 2 is a .when [Resident 2] goes into other residents' rooms, [Resident 2] might become aggressive towards other residents and invading their privacy. A review of Nursing Progress Note dated 6/24/2026 at 3:20 PM with LVN 2, LVN 2 read [Resident 2] wanders at night. LVN 2 stated Resident 1 felt anger and fear that Resident 2 might come back to hurt [Resident 1] again. During a concurrent interview and record review on 7/24/2026 at 3:04 PM with Registered Nurse Supervisor (RNS), RNS 1 kept Resident 2 on the facility's 3rd floor in nurse's station 1 to keep [Resident 2] busy instead of just wandering. RNS 1 reviewed Resident 2's MDS Assessment Section E0900 dated 6/12/2026 in the facility's PCC. RNS 1 stated the zero-code entered in section E0900 on the MDS for Resident 2 is incorrect because [Resident 2] wanders around. RNS 1 stated there is no Wandering Risk Assessment on [Resident 2]. RNS 1 stated Wandering Risk Assessment should have been completed on admission and when there was a change in condition related to Resident 2's wandering behavior so that, we (licensed nurses) can have a plan of care ongoing for [Resident 2]. If the Assessment was not completed then the nurses are not aware of that (wandering), of [Resident 2] going to other patients' rooms.During the same interview and record review with RNS 1, Resident 2's Nursing Progress Note dated 6/24/2026 at 3:20 PM with RNS 1, RNS 1 read, confirmed and stated that [Resident 2] wanders at night. RNS 1 stated Resident 1 felt scared and angry that Resident 2 might harm Resident 1 again following the incident with Resident 2 on 7/13/2026. During a concurrent interview and record review on 7/24/2026 at 3:48 PM with the Director of Nursing (DON), the DON reviewed Resident 2's MDS Assessment Section E0900 dated 6/12/2026 in the facility's PCC. The DON stated Resident 1 wanders around the facility every day, down the hallway. The DON confirmed and stated that the facility marked Section E0900 of Resident 2's MDS assessment dated [DATE] with the code zero was not accurate, because we (facility) all know [Resident 2] wanders around a lot. During the same interview and record review with DON, DON stated, there is no Wandering Risk Assessment found for Resident 2. DON stated it is important to complete a Wandering Risk Assessment upon a resident's admission and when necessary so we (nurses) can write our plan of care (for the resident) and make sure the plan of care and interventions are current and ongoing. DON stated Resident 1 must have felt scared, angry at staff for not keeping [Resident 1] safe.might felt traumatized, not eat, isolate self, not trusting staff. During a phone interview on 8/07/2026 at 12:54 PM with the Administrator (ADM), the ADM stated that Resident 2 physically assaulted Resident 1 when Resident 2 pulled Resident 1's legs off the bed and Resident 2 attempted to hit Resident 1. The Adm stated that the Adm checked the facility camera video footage the next morning, on 7/14/2026. The ADM further stated that, On that video, [Resident 2] was on the wheelchair going in and out of the dining room. [Resident 2] passed by nurse's station 2, The Adm stated that CNA 3 saw Resident 2 because CNA 3 was facing Resident 2 when Resident 2 passed by. The ADM stated Resident 2 then went down the hall and entered [Resident 1's] room. The call light came on. I saw CNA 3 go that way to [Resident 1 and Resident 3's] room, and just before CNA 3 went to [Resident 1 and Resident 3's] room, Resident 3 called out for LVN 4 by name, CNA 3 ran the rest of the way and into Resident 1 and Resident 3's room. CNA 1 came from running from another room and followed CNA 3 into Resident 1 and Resident 3's room. The ADM stated that CNA 3, told me that the call light came on from [Resident 1's] bed CNA 3 thought it strange because Resident 1 never uses the call light during that time because Resident 1 usually goes to bed around 7 PM. The Adm stated that, Our call light will tell us which bed needs assistance. The ADM stated that the video was no longer available to view because It was not saved. It's only saved for a couple of days. During an interview on 8/07/2026 at 2:25 PM with the Medical Records Director (MRD), MRD was asked why so many of the daily huddle days for the months of June and July 2026 were missing, MRD stated, that's all we have in our binder so I copied everything for June and July 2026. During a concurrent interview and record review on 8/07/2026 at 3 PM with the DON, when asked why the facility's had six days of the facility daily huddle for the month of 6/2026 and 13 days for the month of 7/2026, the DON stated, I don't know, we need to check with the MRD. When the DON was told what MRD stated earlier, the DON stated, Oh, I guess that is all we have, I thought we have more than that. During a review of the facility's policy and p

Based on interview, and record review, the facility failed to ensure the assessment entry in Section E0900 Wandering - Presence and Frequency (records the presence and frequency of wandering [occurs when a person with loss of memory, thinking, or reasoning roams around and becomes lost or confused about their location] during the 7-day look-back period) under the Minimum Data Set (MDS - a federally mandated resident assessment tool) was accurately documented according to the facility's policy and procedure (P&P - policy explains the rules and presents them in a logical framework while procedures outline the step-by-step implementation of various tasks) titled Wandering, Unsafe Resident with a reviewed date of 01/2026 for one of the five sampled residents (Resident 2). This deficient practice had the potential to negatively affect the plan of care and delivery/provision of necessary care and services for Resident 2.Findings: Cross Reference F600 & F656 A review of Resident 2's admission Record (face sheet - a document containing demographic and diagnostic information) indicated the facility admitted Resident 2 on 5/18/2022, and readmitted on [DATE] with the following diagnoses: degenerative disease of the basal ganglia (a rare progressive brain disorder where nerve cells die and areas of the brain shrink); intervertebral disc degeneration, lumbar region (gradual wear and tear of the cushions between the lower spine bones); cervical disc degeneration, unspecified cervical region (the natural breakdown of the cushion-like discs between your neck bones); neurocognitive disorder with Lewy bodies dementia (a progressive brain disorder caused by abnormal protein deposits called Lewy bodies building up in nerve cells); depression (a common but serious mood disorder that causes a persistent feeling of sadness and loss of interest); and visual hallucinations (seeing things that are not real, it happens while you are awake). A review of Resident 2's MDS dated [DATE] indicated, Resident 2 had moderately impaired cognition (make poor decisions, cues and supervisions required). The MDS also indicated that Resident 2 required partial/moderate assistance from staff with toileting, dressing, and personal hygiene. MDS also indicated Resident 2 required supervision or touching assistance from facility staff related to mobility (ability to move freely, purposefully, and independently). MDS indicated Resident 2 used a wheelchair for mobility. A review of Resident 2's Nursing Progress Notes (captures the details of a patient's health status, treatment progress, and any changes in their condition over time) dated 6/24/2026 at 3:20 PM under Mood and Behavior, indicated, Resident 2 wanders at night. A review of Resident 2's Psychological Consult (an initial or follow-up meeting with a mental health professional to discuss your concerns, review your history, and determine the best treatment or testing plan) dated 7/09/2026 indicated, Resident 2 had visual hallucinations, paranoid delusions (fixed, false beliefs that you are being harmed, watched, or plotted against by others), hyperverbal (talking a lot or using too many words), and tangential thinking (a communication and thought pattern where a person wanders off-topic and never returns to the original point). The Note also indicated that Resident 2 wanders in wheelchair at times. and was reminded to stay out of others rooms. During an interview on 7/23/2026 at 9:32 AM with Resident 3, Resident 3 stated Resident 2 entered Resident 3's room without permission nor an invitation. [Resident 2] just entered our room.it was nighttime.I was reading my book and all the residents were asleep. According to Resident 3, Resident 3 witnessed Resident 2 going straight into Resident 1's bed. Resident 3 stated there was a curtain pulled close between the two roommates' beds so Resident 3 did not see why Resident 1 started screaming then got out of bed. Resident 3 stated witnessing Resident 2 hitting my roommate on the head with [Resident 2's] shoe. Resident 3 screamed to get a staff's attention. My roommate was moaning and crying. Several staff came in right away and took Resident 2 out of our room. Resident 3 stated that Resident 2 had been in their room twice before during the night but [Resident 2] never came inside our room, just outside the door. [Resident 2] never hurt me or my roommate before until that day. I was surprised [Resident 2] walked into our room that day. During an interview on 7/23/2026 at 2:59 PM with CNA (Certified Nure's Aide) 1, CNA 1 stated Resident 2 was a wanderer (a person who travels or moves from place to place without a fixed home, permanent job, or specific destination). Resident 2 walks around all the time, every day. [Resident 2] would stand on someone else's rooms. I know [Resident 2] stood by the doorway of other residents' rooms. I saw [Resident 2] do this a lot. According to CNA 1, CNA 1 was caring for another resident next door to Resident 1 and 3's room when CNA 1 heard someone scream for help. CNA 1 ran out to the other room and saw Resident 1 on the floor, sitting, screaming and crying, both arms to the side. CNA 1 stated Resident 2 said well, [Resident 2] was the one who started it. CNA 1 stated separating Resident 2 from the scene and took Resident 2 back to Resident 2's assigned room. CNA 1 stated that it was common knowledge to the staff that Resident 2 would go to other residents' rooms. CNA 1 stated Resident 1 may feel scared that the alleged incident with Resident 2 may happen again. During an interview on 7/23/2026 at 3:32 PM with CNA 2, CNA 2 stated Resident 2 walks around the hallway over and over daily. Resident 2 just stands outside other residents' doors and stares at the residents. I've been called to the rooms many times to get [Resident 2] removed from other residents' room and return [Resident 2] back to Resident 2's assigned room. CNA 2 stated Resident 1 may feel angry, scared and feels [Resident 1] cannot trust the staff to keep her safe. During an interview on 7/23/2026 at 3:47 PM with LVN (Licensed Vocational Nurse) 1, LVN 1 stated Resident 2 wanders and goes around the facility. LVN 1 also stated witnessing Resident 2 going to other residents' rooms. LVN 1 stated Resident 1 may feel anger and fear that Resident 2 might allegedly cause harm again. During a concurrent interview and record review on 7/24/2026 at 2:22 PM with LVN 2, LVN 2 stated Resident 2 wanders almost every day, day and night, but never witnessed [Resident 2] entered other residents' rooms. Section E0900 - Wandering and Frequency under MDS dated [DATE], was reviewed with LVN 2, LVN 2 stated a code of zero, indicating behavior is not exhibited was entered. LVN 2 stated the code entered was incorrect because Resident 2 was always wandering. LVN 2 stated LVN 3 completed the MDS Assessment but LVN 2 did not check the MDS for accuracy before posting the MDS Assessment in the PCC. LVN 2 added that Social Services Director (SSD - manages and coordinates social service programs [ex. housing, mental health, healthcare] and organizations that provide assistance to people in need), who was not a licensed nurse, completed Section E0900. LVN 2 also stated that LVN 2 was ultimately responsible for the accuracy of this Section in the MDS. LVN 2 was asked to locate Resident 2's Wandering Risk Assessment using the facility's electronic health record called Point Click Care (PCC - an electronic health record technology platform that specializes in providing software solutions for the senior care industry, particularly skilled nursing facilities and assisted living facilities), LVN 2 stated can't find anything. LVN 2 also stated Wandering Risk Assessment is completed to help assess [Resident 2's] level of risk for leaving the facility, to ensure there is a care plan in place and interventions like monitoring to make sure [Resident 2] doesn't go outside the building or go to other residents' rooms. LVN 2 stated if the Wandering Risk Assessment was not completed on admission and when needed, we are not doing any monitoring and [Resident 2's] wandering and whereabouts are not being addressed. LVN 2 added Resident 2 was a high risk for elopement.when [Resident 2] goes into other residents' rooms, [Resident 2] might become aggressive towards other residents and invading their privacy. A review of Nursing Progress Note dated 6/24/2026 at 3:20 PM with LVN 2, LVN 2 read [Resident 2] wanders at night. LVN 2 stated Resident 1 felt anger and fear that Resident 2 might come back to hurt [Resident 1] again. During a concurrent interview and record review on 7/24/2026 at 3:04 PM with RN Supervisor (RNS), RNS kept Resident 2 on the 3rd floor in nurse's station 1 to keep [Resident 2] busy instead of just wandering. RNS reviewed Section E0900 of the MDS assessment dated [DATE], RNS stated the zero code entered was incorrect because [Resident 2] wanders around. RNS stated Wandering Risk Assessment should have been completed on admission and when there was a change in condition related to [Resident 2's] wandering.so we (licensed nurses) can have a plan of care ongoing for [Resident 2]. If the Assessment was not completed then the nurses are not aware of that (wandering), of [Resident 2] going to other patients' rooms. A review of Nursing Progress Note dated 6/24/2026 at 3:20 PM with RNS, RNS read [Resident 2] wanders at night. RNS stated Resident 1 felt scared and angry that Resident 2 might harm Resident 1 again. During a concurrent interview and record review on 7/24/2026 at 3:48 PM with the Director of Nursing (DON), the [NAME] stated Resident 1 wandered around every day, down the hallway. DON confirmed that Section E0900 under the MDS assessment dated [DATE] with the code zero was not accurate because we all know [Resident 2] wanders around a lot. After doing a record review with the DON, DON stated there is no Wandering Risk Assessment found for Resident 2. DON stated Wandering Risk Assessment was important to be completed upon admission and when necessary so we (nurses) can write our plan of care and make sure the plan of care and interventions are current and ongoing. DON stated Resident 1 must have felt scared, angry at staff for not keeping [Resident 1] safe.might felt traumatized, not eat, isolate self, not trusting staff. During a review of the facility's Job Description (a written explanation that outlines the essential responsibilities and requirements for a specific position) titled Resident Assessment/Care Plan Coordinator with a revision date of year 2003 indicated, inform all assessment team members of the requirements for accuracy and completion of the resident assessment (MDS). During a review of the facility's policy and procedure (P&P - policy explains the rules and presents them in a logical framework while procedures outline the step-by-step implementation of various tasks) titled Wandering, Unsafe Resident with a review date of 1/2026 indicated: Policy Statement: The facility will strive to prevent unsafe wandering while maintaining the least restrictive environments for residents who are at risk for elopement.Policy Interpretation and Implementation:The staff will identify residents who are at risk for harm because of unsafe wandering (including elopement).The staff will assess at-risk individuals for potentially correctable risk factors related to unsafe wandering.

Based on interview and record review, the facility failed to develop a care plan for one of five residents (Resident 2) who had wandering behavior and entering other residents rooms without permission/authorization This deficient practice had the potential to for the Resident 2 not receive the necessary and appropriate care and services and suffer physical and psychological harm/injury. Findings: Cross Reference F600 & F641 During a review of Resident 2's admission Record (AR), the AR indicated the facility admitted Resident 2 on 5/18/2022, and readmitted on [DATE] with the following diagnoses: degenerative disease of the basal ganglia (a rare progressive brain disorder where nerve cells die and areas of the brain shrink); intervertebral disc degeneration, lumbar region (gradual wear and tear of the cushions between the lower spine bones); cervical disc degeneration, unspecified cervical region (the natural breakdown of the cushion-like discs between your neck bones); neurocognitive disorder with Lewy bodies dementia (a progressive brain disorder caused by abnormal protein deposits called Lewy bodies building up in nerve cells); depression (a common but serious mood disorder that causes a persistent feeling of sadness and loss of interest); and visual hallucinations (seeing things that are not real, it happens while you are awake). During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2 had moderately impaired cognition (make poor decisions, cues and supervisions required). The MDS also indicated that Resident 2 required partial/moderate assistance from staff with toileting, dressing, and personal hygiene. MDS also indicated Resident 2 required supervision or touching assistance from facility staff related to mobility (ability to move freely, purposefully, and independently). MDS indicated Resident 2 used a wheelchair for mobility. During a review of Resident 2's Nursing Progress Notes dated 6/12/2026 at 6:13 PM, the Nursing Progress Notes indicated, thatResident 2 definitely needs a 1 to 1 sitter 24 hours a day due to her roaming around the facility. During a review of Resident 2's Nursing Progress Notes dated 6/24/2026 at 3:20 PM under Mood and Behavior, the Nursing Progress Notes indicated that Resident 2 wanders at night. During a review of Resident 2's Psychological Consult (an initial or follow-up meeting with a mental health professional to discuss your concerns, review your history, and determine the best treatment or testing plan) Note dated 7/09/2026, the Psychological Consult Note indicated that Resident 2 had visual hallucinations, paranoid delusions (fixed, false beliefs that you are being harmed, watched, or plotted against by others), hyperverbal (talking a lot or using too many words), and tangential thinking (a communication and thought pattern where a person wanders off-topic and never returns to the original point). The Psychological Consult Note also indicated that Resident 2 wanders in wheelchair at times. and was reminded to stay out of others rooms. During an interview on 7/23/2026 at 9:32 AM with Resident 3, Resident 3 stated Resident 2 entered Resident 3's room without permission nor an invitation. [Resident 2] just entered our room.it was nighttime.I was reading my book and all the residents were asleep. According to Resident 3, Resident 3 witnessed Resident 2 going straight into Resident 1's bed. Resident 3 stated there was a curtain pulled close between the two roommates' beds so Resident 3 did not see why Resident 1 started screaming then got out of bed. Resident 3 stated witnessing Resident 2 hitting my roommate on the head with [Resident 2's] shoe. Resident 3 screamed to get a staff's attention. My roommate was moaning and crying. Several staff came in right away and took Resident 2 out of our room. Resident 3 stated that Resident 2 had been in their room twice before during the night but [Resident 2] never came inside our room, just outside the door. [Resident 2] never hurt me or my roommate before until that day. I was surprised [Resident 2] walked into our room that day. During an interview on 7/23/2026 at 2:59 PM with CNA (Certified Nursing Assistant) 1, CNA 1 stated Resident 2 was a wanderer (a person who travels or moves from place to place without a fixed home, permanent job, or specific destination). Resident 2 walks around all the time, every day. [Resident 2] would stand on someone else's rooms. I know [Resident 2] stood by the doorway of other residents' rooms. I saw [Resident 2] do this a lot. CNA 1 stated that CNA 1 was caring for another resident next door to Resident 1 and 3's room when CNA 1 heard someone scream for help. CNA 1 ran out to the other room and saw Resident 1 on the floor, sitting, screaming and crying, both arms to the side. CNA 1 stated Resident 2 said well, [Resident 2] was the one who started it. CNA 1 stated that CNA 1 separated Resident 2 from the scene and took Resident 2 back to Resident 2's assigned room. CNA 1 stated that it was common knowledge to the staff that Resident 2 would go to other residents' rooms. CNA 1 stated Resident 1 may feel scared that the alleged incident with Resident 2 may happen again. During an interview on 7/23/2026 at 3:32 PM with CNA 2, CNA 2 stated Resident 2 walks around the hallway over and over daily. Resident 2 just stands outside other residents' doors and stares at the residents. I've been called to the rooms many times to get [Resident 2] removed from other residents' room and return [Resident 2] back to Resident 2's assigned room. CNA 2 stated Resident 1 may feel angry, scared and feels [Resident 1] cannot trust the staff to keep [Resident 1] safe. During an interview on 7/23/2026 at 3:47 PM with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 2 wanders and goes around the facility. LVN 1 also stated LVN 1 further stated, Yes, I saw [Resident 2] wander through their (other residents) belongings. LVN 1 stated Resident 1 may feel anger and fear that Resident 2 might allegedly cause harm again. During a concurrent interview and record review on 7/24/2026 at 2:22 PM with LVN 2, LVN 2 stated Resident 2 wanders almost every day, day and night, but never witnessed [Resident 2] entered other residents' rooms. LVN 2 reviewed all of the care plans found in the PCC. LVN 2 stated a care plan for Resident 2's wandering behavior was not found. LVN 2 was asked what happens to Resident 2 if a care plan for Resident 2's wandering behavior was not completed, LVN 2 stated we (nurses) might not be addressing resident's current concerns. During a concurrent interview and record review on 7/24/2026 at 3:04 PM with RN Supervisor (RNS), RNS kept Resident 2 on the 3rd floor in nurse's station 1 to keep [Resident 2] busy instead of just wandering. When RNS was asked to locate a wandering care plan for Resident 2 in the PCC, RNS stated none were found. RNS stated it was important that a wandering care plan was completed to make sure all of the residents' needs are met and if the wandering care plan was not completed for Resident 2, then we are jeopardizing [Resident 2's] care and that [Resident 2] will not get the care Resident 2 needed. During a concurrent interview and record review on 7/24/2026 at 3:48 PM with the Director of Nursing (DON), the DON stated Resident 1 wandered around every day, down the hallway. DON confirmed a care plan for wandering behavior for Resident 2 none found in the PCC. DON stated a wandering behavior care plan was important to complete to meet [Resident 2's] needs, to provide up to date interventions. DON added if the wandering behavior care plan was not competed they Resident 2's health and well-being might be jeopardized. [Resident 2] may not get the care Resident 2 needs. During a review of the facility's policy and procedures (P&P) titled Wandering, Unsafe Resident with a reviewed date of 1/2026 indicated the following: Policy Statement: The facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement. Policy Interpretation and Implementation: 1. The staff will identify residents who are at risk for harm because of unsafe wandering (including elopement).2. The staff will assess at-risk individuals for potentially correctable risk factors related to unsafe wandering. 3. The resident's care plan will indicate the resident is at risk for elopement or other safety issues. Interventions to try to maintain safety, such as a detailed monitoring plan will be included. During a review of the facility's P&P titled Care Plans, Comprehensive Person-Centered with a reviewed date of 1/2026 indicated the following: Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.Policy Interpretation and Implementation: 2. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment.8h. The comprehensive, person-centered care plan will incorporate risk factors associated with identified problems.

Based on record review and interviews the facility failed to follow the physician's order to perform physical therapy (PT- is a healthcare specialty that evaluates and treats movement dysfunctions, pain, and physical limitations) five times a week for 60 days for one of three sampled residents (Resident 1). This deficient practice had the potential to cause a decline in functioning for Resident 1.Findings: On 6/1/2026 The California Department of Public Health (CDPH) received a complaint alleging that the facility would not resume PT because Resident 1 needed preauthorization for Medicare Part B (Is the outpatient medical insurance that primarily covers outpatient care, doctor visits, preventive services, and durable medical equipment) because Resident 1 was from out of state. A review of resident 1's admission record indicated the facility admitted Resident 1 on 1/9/2026 with diagnoses including cerebral infarction (CI-stroke, loss of blood flow to a part of the brain), abnormalities of gait, weakness, adult failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity), hypertension (HTN-high blood pressure), benign prosthetic hyperplasia (BPH-enlarged prostate gland), repeated falls, and glaucoma (a group of eye diseases). A review of Resident 1's Minimum Data Set (MDS-a resident assessment tool) dated 4/15/2026, indicated Resident 1's cognition (mental ability to make decisions for daily living) was moderately impaired. The MDS indicated Resident 2 required moderate assistance (helper does less than half the effort to complete the activity) with ambulation using a walker. A review of Resident 1's SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents) dated 4/16/2026 indicated new onset tremors and subsequent transfer to the general acute care hospital (GACH). A review of Resident 1's physician order dated 4/24/2026 indicated Physical Therapy evaluation for strengthening and conditioning. A review of Resident 1's PT evaluation dated 4/26/2026 indicated the reason for referral (Resident 1) sent to GACH for altered level of consciousness (ALOC- is a state of consciousness where an individual is not as awake, alert, or able to understand or react normally) and new onset tremors, referred to skilled PT by physician dues to decline in function. A review of Resident 1's clarified PT order dated 4/26/2026, indicated (Resident 1)to perform therapeutic exercises, therapeutic activities, gait (walk) training, patient education and care giver training every day for 60 days. During a telephone interview on 6/11/2026 at 10:58 am with the Family Member (FM) 1, FM 1 stated, Resident 1, is just lying there getting weaker, I asked for more therapy, and two people there told me no preauthorization was needed so why isn't (Resident 1) getting therapy? FM 1 stated Resident 1, is just in bed everyday and already a fall risk; I am concerned (Resident 1) will get weaker before (Resident 1) is ready to come home. During a concurrent interview and record review on 6/11/2026 at 11:15am with the Licensed Vocational Nurse (LVN), Resident 1's insurance authorization (insurance company reviews Resident 1's PT eval and notes and determines if criteria is met for further therapy and determines the duration and number of sessions.) request for PT dated 4/27/2026 was reviewed. Resident 1's insurance authorization request for PT indicated a written request for coverage of additional therapy services under Medicare Part B. The LVN stated FM 1 called after Resident 1 had a decline in health and was transferred to GACH so as to request for additional PT and that is why the request for authorization was sent. The LVN stated the insurance company informed the facility that preauthorization was not needed for Resident 1 for services under Medicare Part B and that the insurance company instructed the facility to perform PT on Resident 1 and then bill the insurance company for reimbursement. The LVN stated, That is not our usual practice; We usually get preauthorization then perform the PT. Since I had encountered this, I involved the business office manager (BOM). During an interview on 6/11/2026 at 11:52am with the BOM. the BOM stated that the insurance company instructed the facility to call the provider services. The BOM stated that provider services was called and who told again the facility that there was no preauthorization needed for additional PT under Medicare Part B for Resident 1. The BOM stated that historically under traditional Medicare preauthorization would not be needed; the facility can do the evaluation and then submit a claim for reimbursement. The BOM stated that, however, Resident 1 had a managed plan which required preauthorization and that the BOM was also not familiar with this process. The BOM stated the facility submitted a claim to the insurance company for the PT evaluation that was done on 4/26/2026 for Resident 1 and the facility had not been reimbursed. During a concurrent interview and record review on 6/11/2026 at 12:02pm with the BOM, Resident 1's insurance preauthorization request for PT dated 5/12/2026 was reviewed. Resident 1's preauthorization request for PT indicated a request for coverage under Medicare Part B for additional PT. The BOM stated after this was sent the facility still did not hear back from the insurance company, so they called and spoke with the case manager at the insurance company. The BOM asked the case manager for a policy to support the process of filing a claim for reimbursement but never received. The BOM stated, I sent an email to the team (PT, the Administrator (Adm) and the LVN) to inform them of this after (FM 1) called to follow up on 5/28/2026. The BOM stated, As far as I know (Resident ) is not receiving any PT services. During a concurrent interview and record review on 6/11/2026 at 1:23 pm with the physical therapist (PT) 1, Resident 1's PT evaluation dated 4/26/2026 was reviewed. Resident 1's PT evaluation indicated referred to skilled PT by physician due to decline in function. The PT stated, Resident 1 was not very motivated and not getting out of bed. I thought PT would be a vehicle do get Resident 1 out of bed more and come down to the therapy room; I did not really notice a decline, but this was 2 months ago I would need to re-evaluate to determine Resident 1's strengths and goals. During an interview on 6/11/2026 at 2:43pm with the director of Nursing (DON), the DON stated, there is no approval or denial as of now for (Resident 1's) additional therapy. I placed(Resident 1) on Restorative Nurse Assistant (RNA- is a certified nursing assistant (CNA) with specialized training in rehabilitation skills who assists the restorative team with supervised and delegated restorative programs) so (Resident 1) will not decline. During an interview on 6/11/2026 at 3:17pm with the Adm, the Adm stated Adm was not aware of the insurance company not needing preauthorization and not aware of Resident 1 not receiving PT. A review of the facility policy and procedures titled, Resident/patient referrals Rehabilitation Services, dated 12/12/2017 indicated , Rehabilitation services are provided only upon a written or verbal referral transcribed to the medical record by allowable clinical professional from a resident/patient's physician.Therapy orders are to be filed in the medical record in Physician Order Section on the day the order is created. This includes any type of order created by therapy (e.g. initial therapy clarification order, re-clarification order, continuation order, discharge order, and/or RNA order). These services are provided under a written treatment program that is regularly evaluated. The treatment must be beneficial to the stated treatment diagnosis Requirements for Physician Therapy Orders Physician therapy orders must be specific and timely. Therapy orders must include the following: Specific type of order Initial Clarification Continuation Re-Clarification Discharge Specific discipline (PT, OT, ST) Specific procedure/service to be provided to resident (i.e. gait training, therapeutic activity, treatment of swallowing dysfunction) Specify frequency and duration (i.e. 3 times a week times 2 weeks) Include the discipline related TREATMENT ICD-10 diagnosis with description (i.e. M62.81 Muscle Weakness; R13.12 dysphagia, oropharyngeal phase; R26.2 difficulty in walking).

Based on observation, interview, and record review, the facility failed to implement its policy and procedures (P&P) titled Self-Administration for Medications revised 1/2026 for three of three residents sampled (Residents 24, 48 and 91) by failing to ensure there was documented assessment for self-administration before:1. Allowing Resident 91 to self-administer 2 (two) medications.2. Leaving unidentified medications at Resident 48's bedside.3. Leaving a medicine cup with thick, smooth and rich white substance on Resident 24's nightstand. This deficient practice had the potential for:1. Incorrect medication of administration that may or may not result in medication error, and / or negative outcome to resident's health condition.2. Unauthorized access/ingesting to the medications by confused and wandering residents(s) resulting in anaphylaxis, choking, unnecessary hospitalization, and/or death.Findings: A. During an observation on 3/05/2026 at 9:34 AM outside of Resident 91's room with the licensed vocational nurse (LVN 1), LVN 1 was preparing 17 medications for Resident 91. Two of 17 medications were as followed: Symbicort (a combination inhaler of budesonide/formoterol, used for the long-term maintenance treatment of asthma and chronic obstructive pulmonary disease or COPD, a type of inflammatory lung disease causing obstructed airflow, to improve breathing and reduce flare=ups) 80/4.5 milligrams (mg, unit to measure mass) Spiriva HandiHaler (tiotropium bromide powder in capsule, used to relax airway muscles to improve breathing. LVN 1 placed 1 cap in the inhaler and primed the inhaler. During the medication administration observation on 3/05/2026 at 9:55 AM, Resident 91 requested to self-administer Symbicort and Spiriva, and Resident 91 proceeded to pick up the Symbicort inhaler from a tray on the table in front of the resident. Resident 91 shook inhaler and inhaled 1 puff, waited about 10 seconds, then took another puff by mouth. Next, Resident 91 placed the Symbicort inhaler in the tray and picked up Spiriva and self-administered 1 puff. During an interview on 3/05/2026 at 9:57 AM, LVN 1 stated Resident 91 was alerted and oriented, and the resident would sometime prefer to self-administer certain medications. During an interview on 3/05/2026 at 2:38 PM, LVN 1 stated she could not find Resident 91's self-administration of medication assessment. During a concurrent review of Resident 91's care plans, LVN 1 stated she didn't see a care plan to monitor proper self-administration of medication. Also, LVN 1 could not find a physician order for self-administration. During an interview on 3/05/2026 at 2:54 PM, with the facility Quality Assurance nurse (QA) and the assistant director of nursing (ADON), ADON stated there should be a physician order stating resident could self-administer and a nurse completed a self-administration medication assessment form, before the resident can self-administer medications. QA confirmed resident 91 did not have a physician order. During a review of the facility policy and procedures, Self-Administration of Medications (dated 1/2026), the policy indicated . the staff and practitioner will assess each resident's mental and physical abilities to determine whether self-administering medications is clinically appropriate for the resident. The staff and practitioner will perform a more specific skill assessment. will document their findings and residents who are able to self-administer medications. B. A review of Resident 48's admission record indicated Resident 48 was originally admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses that include osteomyelitis of Vertebra (infection in the spine.), Type 2 diabetes (high blood glucose (sugar) levels, which are caused by the body's inability to properly use insulin), end stage renal disease (ESRD- permanent, irreversible kidney failure), metabolic encephalopathy (neurologic disorders characterized by an alteration in mental status) and dependence on renal dialysis (life sustaining medical treatment to remove waste and excess fluid from the blood). A review of Resident 48's Minimum Data Set (MDS - a resident assessment tool) dated 2/6/2026 indicated the resident 48's cognition (The mental ability to make decision of daily living) was moderately impaired. The MDS indicated Resident 48's required supervision/touching assistance for eating and oral hygiene, partial/moderate assistance with upper body dressing, and substantial/maximal assistance with toileting/hygiene, shower/bathe, lower body dressing and putting on/taking off footwear. During a facility tour on 3/2/2026 at 8:51 AM, Resident 48's bedside drawer was observed to have 2 (two) medicine cups with unknown tablets in each cup. During an interview on 3/2/2026 at 8:59 am Assistant Director of Nursing (ADON) stated Resident 48 had temporarily left the facility for dialysis. ADON also stated she did not know the purpose and nature of medication tablets that were in the medication cups left at bedside. ADON further stated Residents are required to take their medications as soon as they are administered and it is not safe to leave medications unattended at bedside because a confused Resident could wander into t Resident 48's room, consume the medications which could resulting in anaphylaxis, choking, unnecessary hospitalization, poor overall outcomes and/or death. During an interview on 3/6/2026, at 10:50 am, the Director of Nursing (DON) stated Residents are only allowed for have Meds at bedside if they have been assessed to be cognitive and physically demonstrated they can safely able to do so and have a physician approval, DON stated medication at bedside should be in a locked container. The DON further stated medications should not be left at bedside, because of the risk of duplicity that can lead to an overdose, a confused wandering Resident may consume the medications which could lead to an adverse reactions, unnecessary hospitalization and possible poor outcomes, A review of the facility's policy and procedures (P&P) titled Self-Administration of Medication dated 01/2026 indicated, .Residents have the right to self-administer medications if the interdisciplinary team (IDT- a group of health care professionals with various areas of expertise who work together toward the goals of the Resident), has determined that it is clinically appropriate and safe for the resident to do so. As part of their overall evaluation, the staff and practitioner will assess each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the Resident. Self-administered medications are stored in a safe and secure place, which is not accessible by other Residents. C. A review of Resident 24's admission Record indicated the facility admitted Resident 24 on 2/9/2026 with diagnoses including chronic obstructive pulmonary disease (COPD - a chronic lung disease causing difficulty in breathing), atrial fibrillation (Afib - heart condition causing an irregular, often rapid heart rate), and diabetes (DM -a disorder characterized by difficulty in blood sugar control and poor wound healing). A review of Resident 24's MDS dated [DATE], indicated Resident 24 is cognitively intact (when a person has no trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 24 required setup/clean up to partial/moderate assistance from staff with Activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily) care. During a concurrent observation and interview on 3/3/2026, at 10:03 A.M., with Resident 24, in Resident 24's room, a thick, smooth and rich white substance was in a medicine cup on Resident 24's nightstand. Resident 24 stated that the white cream in the medicine cup was cream for his legs that the nurse gave to him. During a concurrent observation and interview on 3/3/2026, at 11:21 A.M., with LVN 1, in Resident 24's room, a white thick, smooth and rich substance was on Resident 24's nightstand. LVN 1 stated that the white substance in the medicine cup was resident 24's cream, LVN 1 stated she could not tell the surveyor what the cream was, she would have to ask the treatment nurse to say what it exactly was. LVN 1 stated that the cream should definitely not be on the residents' nightstand because a confused resident can walk and ingest the medications. LVN 1 stated potential adverse outcome if another resident ingests the medication is that they may get adverse reactions to the medications. During a concurrent observation and interview on 3/3/2026, at 11:28 A.M., with LVN 2 in the hallway with LVN 2 holding the medicine cup with the cream in her hands. LVN 2 stated that the cream in the medicine cup was Amlactin (cream that is a moisturizer and a chemical exfoliant to soften dry, rough or bumpy skin) which should not be left be left at the resident's bedside unattended. LVN 2 stated that if cream is left at the bedside unattended, a confused resident can eat it and put the medication where is should not be maybe in their eyes which can cause irritation and an allergic reaction if they are allergic to it. LVN 2 stated the cream should not be left at the bedside and application should be done by the treatment nurse. During a concurrent interview and record review on 3/5/2026, at 9:145 A.M., with the DON, Resident 24 electronic medical record was reviewed. the DON stated the facility process for residents to have their medication at the bedside is that if the residents is cognitively able to self-administer their own medication, a medication self-medication assessment is completed and if the resident's assessment states they are able to safely self-administer their medication, their medication is to be locked in the nurses cart or locked at the residents bedside. The DON stated that resident 24 did not have a medication self-administration assessment completed prior to medication being found at the resident bedside, facility completed one on 3/3/2026 after surveyor requested for the assessment. The DON stated that resident's medication should not be left unattended at the bedside because if there is a resident that is not cognitively aware, they may take that medication and depending on the medication, it can affect the patient's health adversely and possibly lead to hospitalization. A review of the Facility P&P titled Self-Administration for Medications revised 1/2026, indicated that: Policy Statement Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. Policy Interpretation and Implementation 1. As part of their overall evaluation, the staff and practitioner will assess each resident's mental and physical abilities to determine whether self-administering medications is clinically appropriate for the resident. 2. In addition to general evaluation of decision-making capacity, the staff and practitioner will perform a more specific skill assessment, including (but not limited to) the resident's: a. Ability to read and understand medication labels; b. Comprehension of the purpose and proper dosage and administration time for his or her medications; c. Ability to remove medications from a container and to ingest and swallow (or otherwise administer) the medication; and d. Ability to recognize risks and major adverse consequences of his or her medications. 8. Self-administered medications must be stored in a safe and secure place, which is not accessible by other residents. If safe storage is not possible in the resident's room, the medications of residents permitted to self-administer will be stored on a central medication cart or in the medication room. Nursing will transfer the unopened medication to the resident when the resident requests them. A review of the Facility P&P titled Medication Administration revised 1/2026, indicated that: Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. A review of the Facility P&P titled Hazardous Areas, Devices and Equipment revised 1/2026, indicated that: Identification of Hazards 1. A hazard is defined as anything in the environment that has the potential to cause injury or illness. Examples of environmental hazards include, but are not limited to: . g. Access to toxic chemicals; Assessment and Analysis of Hazards.

Based on observation, interview and record review, the facility's staff and practitioner failed to ensure medications were not left at the bed side unattended for two out of two sampled residents (Residents 24 and 48) according to the facility's policy and procedures (P&P) titled Medication Storage In The Facility with a reviewed date of 1/2026. This deficient practice had the potential for confused residents and residents with wandering behavior to gain access and ingest the medications which could result in anaphylaxis reaction (undesirable), choking, unnecessary hospitalization and/or death.Findings: 1. A review of Resident 48's admission record indicated Resident 48 was originally admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses that include osteomyelitis of Vertebra (infection in the spine.), Type 2 diabetes (high blood glucose (sugar) levels, which are caused by the body's inability to properly use insulin), end stage renal disease (ESRD- permanent, irreversible kidney failure), metabolic encephalopathy (neurologic disorders characterized by an alteration in mental status) and dependence on renal dialysis (life sustaining medical treatment to remove waste and excess fluid from the blood). A review of Resident 48's Minimum Data Set (MDS - a resident assessment tool) dated 2/6/2026 indicated the resident 48's cognition (The mental ability to make decision of daily living) was moderately impaired. The MDS indicated Resident 48's required supervision/touching assistance with activities of daily (ADL - eating and oral hygiene, partial/moderate assistance with upper body dressing, and substantial/maximal assistance with toileting/hygiene, shower/bathe, lower body dressing and putting on/taking off footwear). During a facility tour on 3/2/2026 at 8:51 AM, Resident 48's bedside drawer was observed to have 2 (two) medicine cups with unknown tablets in each cup. During an interview on 3/2/2026 at 8:59 am Assistant Director of Nursing (ADON) stated Resident 48 had temporarily left the facility for dialysis. ADON also stated she did not know the purpose and nature of medication tablets that were in the medication cups left at bedside. ADON further stated Residents are required to take their medications as soon as they are administered and it is not safe to leave medications unattended at bedside because a confused Resident could wander into t Resident 48's room, consume the medications which could resulting in anaphylaxis, choking, unnecessary hospitalization, poor overall outcomes and/or death. During an interview on 3/6/2026, at 10:50 am, the Director of Nursing (DON) stated Residents are only allowed for have Meds at bedside if they have been assessed to be cognitive and physically demonstrated they can safely able to do so and have a physician approval. The DON stated medication at bedside should be in a locked container. The DON further stated medications should not be left at bedside, because of the risk of duplicity that can lead to an overdose, a confused wandering Resident may consume the medications which could lead to an adverse reactions, unnecessary hospitalization and possible poor outcomes, A review of the facility's policy and procedures (P&P) titled Medication Storage In The Facility with a reviewed date of 1/2026, indicated, Policy: Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized. 2. A review of Resident 24's admission Record indicated the facility admitted Resident 24 on 2/9/2026 with diagnoses including chronic obstructive pulmonary disease (COPD - a chronic lung disease causing difficulty in breathing), atrial fibrillation (Afib - heart condition causing an irregular, often rapid heart rate), and diabetes (DM -a disorder characterized by difficulty in blood sugar control and poor wound healing). A review of Resident 24's MDS dated [DATE], indicated Resident 24 is cognitively intact. The MDS indicated Resident 24 required setup/clean up to partial/moderate assistance from staff with ADLs (activities such as bathing, dressing and toileting a person performs daily) care. During a concurrent observation and interview on 3/3/2026, at 10:03 A.M., with Resident 24, in Resident 24's room, a thick, smooth and rich white substance was in a medicine cup on Resident 24's nightstand. Resident 24 stated that the white cream in the medicine cup was cream for his legs that the nurse gave to him. During a concurrent observation and interview on 3/3/2026, at 11:21 A.M., with LVN 1, in Resident 24's room, a white thick, smooth and rich substance was on Resident 24's nightstand. LVN 1 stated that the white substance in the medicine cup was resident 24's cream, LVN 1 stated she could not tell the surveyor what the cream was, she would have to ask the treatment nurse to say what it exactly was. LVN 1 stated that the cream should definitely not be on the residents' nightstand because a confused resident can walk and ingest the medications. LVN 1 stated potential adverse outcome if another resident ingests the medication is that they may get adverse reactions to the medications. During a concurrent observation and interview on 3/3/2026, at 11:28 A.M., with LVN 2 in the hallway with LVN 2 holding the medicine cup with the cream in her hands. LVN 2 stated that the cream in the medicine cup was Amlactin (cream that is a moisturizer and a chemical exfoliant to soften dry, rough or bumpy skin) which should not be left be left at the resident's bedside unattended. LVN 2 stated that if cream is left at the bedside unattended, a confused resident can eat it and put the medication where is should not be maybe in their eyes which can cause irritation and an allergic reaction if they are allergic to it. LVN 2 stated the cream should not be left at the bedside and application should be done by the treatment nurse. During a concurrent interview and record review on 3/5/2026, at 9:145 A.M., with the DON, Resident 24 electronic medical record was reviewed. the DON stated the facility process for residents to have their medication at the bedside is that if the residents is cognitively able to self-administer their own medication, a medication self-medication assessment is completed and if the resident's assessment states they are able to safely self-administer their medication, their medication is to be locked in the nurses cart or locked at the residents bedside. The DON stated that resident 24 did not have a medication self-administration assessment completed prior to medication being found at the resident bedside, facility completed one on 3/3/2026 after surveyor requested for the assessment. The DON stated that resident's medication should not be left unattended at the bedside because if there is a resident that is not cognitively aware, they may take that medication and depending on the medication, it can affect the patient's health adversely and possibly lead to hospitalization. A review of the Facility P&P titled Self-Administration for Medications revised 1/2026, indicated that: Policy Statement Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. Policy Interpretation and Implementation 1. As part of their overall evaluation, the staff and practitioner will assess each resident's mental and physical abilities to determine whether self-administering medications is clinically appropriate for the resident. 2. In addition to general evaluation of decision-making capacity, the staff and practitioner will perform a more specific skill assessment, including (but not limited to) the resident's: a. Ability to read and understand medication labels; b. Comprehension of the purpose and proper dosage and administration time for his or her medications; c. Ability to remove medications from a container and to ingest and swallow (or otherwise administer) the medication; and d. Ability to recognize risks and major adverse consequences of his or her medications. 8. Self-administered medications must be stored in a safe and secure place, which is not accessible by other residents. If safe storage is not possible in the resident's room, the medications of residents permitted to self-administer will be stored on a central medication cart or in the medication room. Nursing will transfer the unopened medication to the resident when the resident requests them. A review of the Facility P&P titled Medication Administration revised 1/2026, indicated that: Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. A review of the Facility P&P titled Hazardous Areas, Devices and Equipment revised 1/2026, indicated that: Identification of Hazards 1. A hazard is defined as anything in the environment that has the potential to cause injury or illness. Examples of environmental hazards include, but are not limited to: . g. Access to toxic chemicals; Assessment and Analysis of Hazards.

Based on observation, and interview, the facility failed to observe and maintain their infection control measures according to their Policy and Procedure (P&P), titled Infection Prevention & Control Program Policy, reviewed 10/2026, for one of one sampled residents (Resident 24) when Resident 24's nebulizer (a small electric machine that turns liquid medication into fine mist) mask was on Resident 24's night stand not stored in a plastic bag according to their P&P titled Administering Medication through a small Volume (Handheld) Nebulizer, reviewed 1/2026. This deficient practice had the potential to cause infection and/or hospitalization for Resident 24. Findings: A review of Resident 24's admission Record indicated the facility admitted Resident 24 on 2/9/2026 with diagnoses including chronic obstructive pulmonary disease (COPD - a chronic lung disease causing difficulty in breathing), atrial fibrillation (Afib - heart condition causing an irregular, often rapid heart rate), and diabetes (DM -a disorder characterized by difficulty in blood sugar control and poor wound healing). A review of Resident 24's Minimum Data Set (MDS - resident assessment tool) dated 2/13/2026, indicated Resident 24 is cognitively intact (when a person has no trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 24 required setup/clean up to partial/moderate assistance from staff with Activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily) care. During a concurrent observation and interview on 3/3/2026, at 10:03 A.M., with Resident 24, in Resident 24's room, a nebulizer machine was on Resident 24's nightstand, with the nebulizer mask was placed on top of the nebulizer machine and not in a bag. Resident 24 stated that he had COPD and uses the nebulizer machine as needed (PRN) and that the last time he used the nebulizer machine was last night. During a concurrent observation and interview on 3/3/2026, at 11:21 A.M., with Licensed Vocations Nurse 1 (LVN1), in Resident 24's room, a nebulizer machine was on Resident 24's nightstand, with the nebulizer mask was placed on top of the nebulizer machine and not in a bag. LVN 1 stated that resident 24's nebulizer mask had been used and left on top of the nebulizer machine. LVN 1 stated that resident 24's nebulizer mask should be cleaned and placed in a bag to keep it clean, prevent contamination of the nebulizer mask which may cause the resident to have an infection. LVN 1 stated she would get a new mask and place it in a bag to make sure that resident 24 has a clean mask. During an interview with on 3/5/2026, at 9:45 A.M., with the Director of Nursing (DON), the DON stated that the nebulizer mask when not in use needs to be stored in a plastic to keep it clean and non-contaminated. The DON stated that if the nebulizer machine is not stored in a plastic bag, it may place residents at risk for bacterial contamination when not store properly and possibly lead to hospitalization. A review of the Facility P&P titled Infection Prevention and Control Program, reviewed 1/2026, indicated that:Policy statement:An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. A review of the Facility P&P titled Administering Medication through a small Volume (Handheld) Nebulizer, reviewed 1/2026, indicated that .27. Rinse and disinfect the nebulizer equipment according to facility protocol, or:a. Wash pieces with warm, soapy water;b. Rinse with hot water;c. Place all pieces in a bowl and cover with isopropyl (rubbing) alcohol. Soak for five minutes);d. Rinse all pieces with sterile water (NOT tap, bottled, or distilled); ande. Allow to air dry on a paper towel.29. When equipment is completely dry, store in a plastic bag with the resident's name and the date on it.

Based on interview and record review, the facility failed to ensure the interdisciplinary team (IDT team, a collaborative group of professionals-including doctors, nurses, social workers, and therapists-who work together to create and implement a unified, patient-centered care plan) assess and evaluate the ability to self-administration medications for one (1) of 3 residents sampled for medication administration observations (Resident 91).This deficient practice had the potential to cause incorrect or unsafe medication administration that may or may not cause a negative outcome to resident's health condition. Findings: During a review of Resident 91's admission record, Resident 91 was admitted on [DATE] with diagnoses included but not limited to: chronic obstructive pulmonary disease (or COPD, a type of inflammatory lung disease causing obstructed airflow, to improve breathing and reduce flare-ups), disorder of muscle, and abnormalities of gait and mobility. During an observation on 3/05/2026 at 9:34 AM outside of Resident 91's room with the licensed vocational nurse (LVN 1), LVN 1 was preparing 17 medications for Resident 91. Two of 17 medications were as followed:Symbicort (a combination inhaler of budesonide/formoterol, used for the long-term maintenance treatment of asthma and COPD) 80/4.5 milligrams (mg, unit to measure mass)Spiriva HandiHaler (tiotropium bromide powder in capsule, used to relax airway muscles to improve breathing. LVN 1 placed 1 cap in the inhaler and primed the inhaler. During the medication administration observation on 3/05/2026 at 9:55 AM, Resident 91 requested to self-administer Symbicort and Spiriva, and Resident 91 proceeded to pick up the Symbicort inhaler from a tray on the table in front of the resident. Resident 91 shook inhaler and inhaled 1 puff, waited about 10 seconds, then took another puff by mouth. Next, Resident 91 placed the Symbicort inhaler in the tray and picked up Spiriva and self-administered 1 puff. During an interview on 3/05/2026 at 2:54 PM, with the facility Quality Assurance nurse (QA) and the assistant director of nursing (ADON), and a concurrent review of Resident 91's interdisciplinary team (IDT team, a collaborative group of professionals, including doctors, nurses, social workers, and therapists, who work together to create and implement a unified, patient-centered care plan) notes (dated 9/19/2025 and 12/23/2025), QA stated IDT notes did not document discussion of self-administration of medications. During a review of the facility policy and procedures, Self-Administration of Medications (dated 1/2026), the policy indicated Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. The staff and practitioner will periodically (for example, during quarterly MDS reviews) reevaluate a resident's ability to continue to self-administer medications.

Based on interview and record review, the facility failed to ensure that the Minimum Data Set (MDS - resident assessment tool) was accurately documented according to their policy and procedure (P&P) titled Certifying Accuracy of the Resident Assessment reviewed 1/2026 for two of two sampled residents (Residents 66 and 127). This deficient practice resulted in Resident 66 and Resident 127's medical records being inaccurate and missing vital information of services being rendered to the resident.Findings: A. During a review of Resident 127's admission Record indicated the resident was originally admitted to the facility on [DATE], and was readmitted on [DATE], with diagnoses of, but not limited to, generalized muscle weakness, hydrocephalus, diabetes mellitus type 2 (a group of diseases that result in too much sugar in the blood), major depressive disorder, hypertension (HTN-high blood pressure), prostate cancer, failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity), cerebrovascular accident (CVA-stroke, loss of blood flow to a part of the brain), and dementia (a progressive state of decline in mental abilities). During a review of Resident 127's MDS, dated [DATE], Section B indicated Resident 127 had the ability to make herself understood and understand others; Section C, Brief Interview for Mental Status (BIMS) is 4 out of 15 which indicated Resident 127's cognition level is severely impaired. During a review of Resident 1's Care Plan, dated 2/28/2026, indicated the resident has impaired cognitive function or impaired thought processes related to dementia and a communication deficit related to his hearing impairments. The interventions consisted of using a communication board, giving access to pencil and paper for writing needs, and enhancing spoken words with gestures, actions, pictures, or other non-verbal methods. During an interview on 3/5/2026 at 12:40 p.m. with the Minimal Data Set Director (MDSD), the MDSD stated all of Section B of the MDS must be reassessed because it does not reflect the resident's current health status. During a concurrent interview and record review on 3/5/2026 at 10:49 a.m. with the Director of Nursing (DON), MDS dated [DATE] was reviewed. Section B of the MDS indicated, Resident 127 had the ability to make herself understood and understand others. The DON stated, the MDS is not correct because Resident 127 does not always understand and staff cannot always understand Resident 127. The DON stated, a reassessment must be done to correct the problem or Resident 127 will risk having an incorrect individualized plan of care. During a review of the facility's policy and procedure (P&P) titled, Certifying Accuracy of the Resident Assessment, reviewed 1/2026, indicated All personnel who complete any portion of the Resident Assessment (MDS) must sign and certify the accuracy of that portion of the assessment. During a review of the facility's policy and procedures (P&P) titled Resident Assessment Instrument dated 10/1/2023, indicated, The MDS Nurse / Coordinator / UM Nurse will be responsible to update assessment schedule manually or electronically (in EHR) for reference of members of the IDT whenever applicable. B. A review of Resident 66's admission Record indicated the facility admitted Resident 66 on 1/26/2026 with diagnoses including chronic obstructive pulmonary disease (COPD - a chronic lung disease causing difficulty in breathing), emphysema (a chronic, progressive lung disease—part of COPD where the alveoli [tiny air sacs]in the lungs are damaged and lose their elasticity, causing them to break and form larger, less efficient pockets), and hypothyroidism (a condition where the butterfly-shaped gland in the neck does not produce enough thyroid hormones). A review of Resident 66's MDS dated [DATE], indicated Resident 66 is cognitively impaired (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 66 required partial/moderate assistance to dependency on staff with Activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily) care. The MDS indicated in section O, under check all that apply, the hospice section was blank and below it none of the above was checked off. A review of Resident 66's physician's order dated 2/6/2026 indicated that patient admitted to hospice (specialized, compassionate care for people with terminal illnesses (typically with less than 6 months to live) . diagnosis COPD . During a concurrent interview and record review, on 3/5/2026, at 9:20 A.M., with MDS Director (MDSD), Resident 66's electronic chart was reviewed. The MDSD stated that a significant change of condition (SCOC) in the MDS id done when a resident has had either a decline or improvement in two areas that affect the resident as a whole. MDSD stated that hospice requires a SCOC in the MDS. The MDSD stated that resident 66 was on hospice however, the MDS indicated no/blank and should have indicated yes/mark with an X. The MDSD stated that it is important that the MDS indicates accurate information that will determine the proper care that the resident needs to be provided. The MDSD stated that if the MDS is inaccurate, the resident may not get the proper care that they require. During an interview on 3/5/2026, at 10:21 A.M., with the DON, the DON stated that the MDS assessments is utilized to derive a plan of care and/or to tailor the appropriate plan of care for the resident according to the assessment performed. The DON stated that an inaccurate MDS assessment may affect the plan of care for the resident and the residents care may not be individualized for them. A review of facility's P&P titled Certifying Accuracy of the Resident Assessment, reviewed 1/2026 indicated that: Policy Statement All personnel who complete any portion of the Resident Assessment (MDS) must sign and certify the accuracy of that portion of the assessment. A review of the CMS RAI Version 3.0 dated 10/2025, indicated, . For these sections, the person signing the attestation must review the information to assure accuracy and sign for those portions on the date the review was conducted. For sections requiring resident interviews, the person signing the attestation for completion of that section should interview the resident to ensure the accuracy of information and sign on the date this verification occurred.

Based on observation, interview, and record review, the facility failed to provide Resident 127 with a communication tool that was accessible in the resident's language, easily readable, and within reach according to the resident's Care Plan, dated 2/28/2026, the Care Plan on communication deficit related to hearing impairments, and facility's policy and procedures (P&P) titled Communication-Cognitive Deficit, reviewed 1/2026. This failure had the potential to result in Resident 127's inability to communicate with staff his needs, preferences, and requests. Findings: During a review of Resident 127's admission Record indicated the resident was originally admitted to the facility on [DATE], and was readmitted on [DATE], with diagnoses of, but not limited to, generalized muscle weakness, hydrocephalus, diabetes mellitus type 2 (a group of diseases that result in too much sugar in the blood), major depressive disorder, hypertension (HTN-high blood pressure), prostate cancer, failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity), cerebrovascular accident (CVA-stroke, loss of blood flow to a part of the brain), and dementia (a progressive state of decline in mental abilities). During a review of Resident 127's Quarterly Minimum Data Set (MDS- a resident assessment tool) dated 2/26/2026, indicated the resident had severe cognitive impairment with significant limitations in memory, orientation, and attention. The MDS indicated Resident 127 needs substantial/maximal assistance with putting on and off footwear, dressing, toilet use, bathing. The MDS indicated Resident 127's had clear speech, makes himself understood, was able to understand others and preferred language is Farsi. During a review of Resident 127's Physician Orders, dated 3/5/2026, the Physician Orders, did not indicate an order for a communication board/tool. During a review of Resident 127's admission Record, dated 3/5/2026, indicated that Resident 127's primary language is Persian. During a review of Resident 127's Care Plan, dated 2/28/2026, the Care Plan indicated due to Resident 127's communication deficit related to hearing impairments, the facility to provide the resident with a communication board with gestures, actions, and pictures. During an observation on 3/2/2026, at 9:45 a.m., during the initial tour of the facility, Resident 127 was observed in his room, sitting in a wheelchair, awake, alert but unable to respond to verbal commands with the call light behind him on the bedside dresser. Multiple attempts was made to ask about the call light, however, Resident 127 was unable to verbally communicate or respond. During an observation on 3/2/2026 at 9:50 a.m., a stack of papers containing both clear and unclear images labeled Persian was seen on the resident's bedside drawer next to the call light. Additionally, a single-page document with unclear images and no translation was found pinned on a board across Resident 127's bed below the television. During an interview on 3/2/2026, at 10 a.m. with the CNA (Certified Nurse Assistant) 1, CNA 1 stated, he uses one worded commands because Resident 127 does not ask for assistance, so we just keep an eye on him. During an interview on 3/2/2026 at 10:25 a.m. with the Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 127 does not have any communication boards to assist with communication with staff and visitors. During an interview on 3/6/2026 at 10:49 a.m. with the Director of Nursing (DON), the DON stated that the facility provides communication folders for residents that have difficulty communicating with staff. The DON stated the folders/tools include photos with translations, making them simple to use for those who have trouble communicating. The DON stated each communication folder/tool should be kept on the resident's wheelchair or bedside table, so it is always easily accessible. During a review of the facility's policy and procedures titled, Communication-Cognitive Deficit, reviewed 1/2026, indicated, Residents shall receive communication support consistent with their primary language and communication abilities.

Based on observation, interview, and record review, the facility failed to ensure the call light was within reach for one of two sampled residents (Resident 127) according to the facility's policy and procedures (P&P) titled, Call Lights: Accessibility and Timely Response, revised on 10/2025. This deficient practice had the potential to result in staff delay in meeting Resident 127's needs for hydration, toileting, and activities of daily living. Findings: During a review of Resident 127's admission Record indicated the resident was originally admitted to the facility on [DATE], and was readmitted on [DATE], with diagnoses of, but not limited to, generalized muscle weakness, hydrocephalus, diabetes mellitus type 2 (a group of diseases that result in too much sugar in the blood), major depressive disorder, hypertension (HTN-high blood pressure), prostate cancer, failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity), cerebrovascular accident (CVA-stroke, loss of blood flow to a part of the brain), and dementia (a progressive state of decline in mental abilities). During a review of Resident 127's Quarterly Minimum Data Set (MDS- a resident assessment tool) dated 2/26/ 2026, indicated the resident had severe cognitive impairment with significant limitations in memory, orientation, and attention. The MDS indicated that Resident 127 needs substantial/maximal assistance with putting on and off footwear, dressing, toilet use, bathing. The MDS indicated Resident 127's has clear speech, makes himself understood, is able to understand others and his preferred language is Farsi. During a review of Resident 127's admission Record dated 3/5/2026, indicated that Resident 127's primary language is Persian. During a review of Resident 127's Health and Physical (H&P), dated 3/2/2026, the H&P indicated patient occasionally said yes/no to some questions but was mostly non-verbal. During an observation on 3/2/2026, at 9:45 a.m., during the initial tour of the facility, Resident 127 was observed in his room, sitting in his wheelchair, awake, alert but unable to respond to verbal commands with the call light behind him on the bedside dresser. Multiple attempts were mad to ask Resident 127 about his call light, however, Resident 127 was unable to verbally communicate or respond. During an interview on 3/2/2026, at 10 a.m. with the CNA (Certified Nurse Assistant) 1, CNA 1 stated, he uses one-word commands because Resident 127 does not ask for assistance, so we just keep an eye on him. CNA 1 stated Resident 127, does not know how to use the call light, so I just put it behind him, so it's out in the open. If the call lights fall or break, they are expensive as hell. During an interview on 3/2/2026 at 11 a.m. with the LVN (Licensed Vocational Nurse) 1, LVN 1 stated it should always be placed in front of Resident 127 and within easy reach, but it was not positioned in front of Resident 127. LVN 1 stated the call light should always be in front of the Resident 127 if he needs to call for help. During a concurrent observation and interview on 3/5/2026 at 12:10 p.m. with the Social Services Assistant (SSA) in the dining room, Resident 127 was observed nodding yes to two out of five questions when spoken to in Farsi. Resident 127 was able to verbalize that he preferred to speak in Farsi. During an interview on 3/6/2026 at 10:49 a.m. with the Director of Nursing (DON), the DON stated that call lights are meant for residents to request staff help and should always be in their dominant hand for easy access. The DON stated if a call light is out of reach or not visible, residents could fall or miss needed assistance. The DON stated that for Resident 127, the call light was behind him, making it inaccessible. During a review of the facility's policy and procedures (P&P) titled, Call Lights: Accessibility and Timely Response, revised on 10/2025, indicated, Staff should facilitate call light placement within reach of resident and secure it as needed.

Based on interview and record review, the facility failed to ensure Certified Nursing Assistant (CNA) 1 did not violate the resident's rights to be treated with respect and dignity and did not subject the resident to humiliation (the feeling of being ashamed or losing respect for yourself) for one of eleven sampled residents (Resident 1) by failing to ensure: 1. CNA 1 did not record a video of Resident 1 without Resident 1 and/or Resident 1 Responsible Party 1's (RP 1) consent.2. CNA 1 did not post a video of Resident 1 on social media.These deficient practices violated Resident 1's right to be treated with respect and dignity and the potential to subject Resident 1 to humiliation (the act of being made to feel ashamed, embarrassed, or worthless, often publicly). Based on the reasonable person concept (used to determine how an average, rational individual would act or respond in a given situation) due to Resident 1's impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses), an individual subjected to humiliation can have lifetime physical and psychological (refers to the impact of psychological trauma [emotional damage] on mental health, both at an individual and community level) effects including feelings of embarrassment, negatively affect self-esteem, confidence, and overall well-being.Findings:During a review of the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnosis including human metapneumovirus pneumonia (HMPV - a type of virus that mostly affects the nose, throat, and lungs. Like the common cold, it can cause symptoms like coughing, wheezing, and a runny nose), dysphagia (difficulty swallowing) and congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling).During a review of the Minimum Data Set (MDS - a resident assessment tool) dated 5/19/2025, indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired (having a condition or problem that significantly limits a person's physical or mental ability to perform basic work activities or daily functions). The MDS indicated Resident 1 required moderate to maximal assistance from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The MDS also indicated, Resident 1 had a total of 12 severity score (moderate depression symptoms) during his mood interview and had mood disturbance such as little interest or pleasure in doing things and feeling down, depressed, or hopeless several days in a week. During a review of an anonymous complaint submitted to District Office, received on 6/5/2025 at 11:45 a.m., a complaint received regarding CNA 1 who posted a video of Resident 1 on social media with two photos attached to the complaint intake.During an interview with CNA 1 on 6/5/2025 at 2:30 p.m., CNA 1 stated, she (CNA 1) did not take a photo of Resident 1, and she did not share any photos of him on her social media. CNA 1 stated, it is not okay to share residents' personal information as is it against the rules. CNA 1 further stated, she worked from 7 a.m. to 11 p.m. (double shift) on 6/4/2025 and will also work double shift today (6/5/2025).During an interview with DON on 6/5/2025 at 2:47 p.m., DON, reviewed photos that was attached to the complaint sent to District Office, and DON stated and confirmed, Photo #1 was of CNA 1 and Photo #2 was of Resident 1. DON stated, there has been a breach on Resident 1's privacy. The DON identified and stated the pictures were that of Resident 1. The DON confirmed and stated taht CNA 1 did not follow the facility's policies and procedures regarding:1. Videotaping, Photographing, and Other Imaging of Residents dated 1/2025 which indicated Staff may not take or release images or recordings of any resident without explicit written consent. Written consent must be obtained from the resident or representative prior to obtaining images or recordings of the resident for any purposes other than investigation of abuse, neglect or emergencies, and photography obtained for personal/family use at the verbal request of the resident or family.2. Resident Rights dated 1/2025, which indicated, Unauthorized release, access, or disclosure of resident information is prohibited. All release, access, or disclosure of resident information must be in accordance with current laws governing privacy of information issues. 3. Protected Health Information (PHI - any information about a person's health or healthcare that can be used to identify them), Management and Protection of dated 1/2025, which indicated Protected Health Information (PHI) shall not be used or disclosed except as permitted by current federal and state laws.During a follow-up interview with CNA 1 on 6/5/2025 at 2:50 p.m., CNA 1 stated, Yesterday (6/4/2025), she (CNA 1) was with Resident 1, and he (Resident 1) was making jokes, she (CNA 1) then posted a story on Instagram with him (Resident 1), and I (CNA 1) shouldn't have done that. CNA 1 stated, she did not tell (Resident 1) that everyone would see it (video clip). CNA 1 further stated, she (CNA 1) was texting her friends on Instagram while she was in his (Resident 1's) room in which she Facetime called and posted on her (CNA 1)'s Instagram story. CNA 1 stated having video called (FaceTime) with friends and posting Resident 1's picture on her (CNA1's) personal social media.During an interview with Resident 1 on 6/5/2025 at 3:03 p.m., Resident 1 stated, he did not know that someone took a video of him, and it was posted on social media. Resident 1 stated, Why would she pick on me like that?. Resident 1 stated, he had been trying to keep his stay in the facility low key (a term used by someone who wants to hide or not draw further attention) and no other people know he was in the facility or why he was there, only him and his RP 1. During a telephone interview on 6/6/2025 at 7:30 a.m., Resident 1's Responsible Party (RP 1) stated on 6/5/2025 at 4:30 p.m. the facility called RP 1 to inform RP 1 of an incident in which CNA 1 posted pictures of herself (CNA 1) and Resident 1 in the background on CNA 1's personal social media account. RP1 reported feeling stunned by the incident and did not understand why CNA 1 was in Resident 1's room and why facility staff were allowed to take pictures of residents. RP1 stated HIPAA rights were supposed to protect residents from incidents such as these. RP1 visited Resident 1 on 6/5/2025 after the facility called and stated Resident 1 reported being interviewed the night prior by a staff member. RP 1 was not sure what the extent of damage was as RP1 was not informed how many people saw the picture or what the purpose of posting the picture was. RP1 denied being informed the picture posted was a direct picture of Resident 1. RP 1 stated it was one thing to post a picture of someone in the background and another to post a direct shot of the person. During the same interview on 6/6/2025 at 7:30 a.m., RP 1 further stated Resident 1 was a very private person and did not ever have social media and would not want to be displayed in such a vulnerable condition to the public. The RP 1 stated Resident 1's rights to privacy, dignity, and respect were violated by the facility and was concerned as to who had access to the Resident 1's unauthorized images. RP 1 stated The rule of thumb is once you put it up on social media it is there forever., it is in the cloud, it is out there forever even if you take it down. RP1 stated Resident 1 was not able to understand or give consent to having a picture taken or posted on social media. RP 1 stated Resident 1 was a very private person and did not have social media or allow pictures to be taken by family/friends. RP1 stated Resident 1 did not wish to be seen in his current condition. RP 1 stated Resident 1 was an accomplished person and to be made a mockery of and shown in current condition was harmful and degrading to all, Resident 1 is well accomplished person. RP1 stated Resident 1's dignity was violated and stated any reasonable person would feel violated that can negatively affect their self-esteem.During an interview with Social Services Assistant 1 (SSA 1) and Social Services Assistant 2 (SSA 2) on 6/6/2025 at 11:32 a.m., SSA 1 and SSA 2 stated, it is not allowed to take photos and videos of residents without proper consents. SSA 2 stated, it is a violation of residents' privacy and disrespectful to take photos and videos of residents without a proper form of consents.During an interview with SSD on 6/6/2025 at 12:06 p.m., SSD stated, it is very important and on top of their priority to protect residents' privacy. SSD stated, residents should not be photographed and video recorded without their consents. SSD stated the ADM showed her a short video clip of CNA 1 and Resident 1, in which she was told that it was posted on CNA 1's Instagram story. During an interview with DSD on 6/6/2025 at 12:35 p.m., on 6/5/2025 towards the end of morning shift (7 am - 3:30 p.m.), the DSD stated she was made aware of the incident that CNA 1 took photo and video of Resident 1 and shared it on her social media. DSD stated, they have to investigate what happened and CNA 1 went home after that morning shift. DSD reviewed CNA 1's staffing assignment which indicated, CNA 1 worked double shift (morning shift to evening shift [3 p.m. - 11 p.m.) on 6/5/2025. DSD stated, she was not aware that CNA 1 continued working on 6/5/2025 after knowing that CNA 1 posted a video of Resident 1 on her social media. During a review of the video clip sent by the ADM on 6/6/2025 at 3:27 p.m., the video clip showed CNA 1 waving with Resident 1 inside Resident 1's room.During a review of Resident 1's Medical Record for consents and email received from the Medical Records Director (MRD) on 6/16/2025 at 5:25pm, as of 6/7/2025, there was no written consent signed by Resident 1 and/or RP 1 regarding release of images or recordings.During a review of the facility's P&P titled, Videotaping, Photographing, and Other Imaging of Residents, dated 1/2025, the P&P indicated, Residents will be protected from invasion of privacy and/or abuse that might occur from photographs, videotapes, digital images, and recordings during resident care or other facility activities . Staff may not take or release images or recordings of any resident without explicit written consent. Written consent must be obtained from the resident or representative prior to obtaining images or recordings of the resident for any purposes other than investigation of abuse, neglect or emergencies, and photography obtained for personal/family use at the verbal request of the resident or family. Transmitting unauthorized images of any resident through email, internet or social media is considered a violation of resident rights. Any image or recording taken that may be construed as humiliating or demeaning to a resident or residents is considered resident abuse and will be reported and investigated as such.During a review of the facility's P&P titled, Resident Rights, dated 1/2025, the P&P indicated The unauthorized release, access, or disclosure of resident information is prohibited. All release, access, or disclosure of resident information must be in accordance with current laws governing privacy of information issues. All inquiries concerning the release of resident information should be directed to the HIPAA compliance officer.During a review of the facility's P&P titled, Telephone, Employee Use of, dated 1/2025, the P&P indicated, Cellular phones may be used for personal calls and text messaging ONLY when the employee is on authorized meal and break periods. Employee cell phones will remain off and/or silent during all other work hours.During a review of the facility's P&P titled, Protected Health Information (PHI), Management and Protection of, dated 1/2025, the P&P indicated, Protected Health Information (PHI) shall not be used or disclosed except as permitted by current federal and state laws . It is the responsibility of all personnel who have access to resident and facility information to ensure that such information is managed and protected to prevent unauthorized release or disclosure.

Based on interview and record review, the facility failed to provide sufficient preparation and orientation for one of four sampled residents, (Resident) 1 with a safe and orderly discharge planning by failing to: 1. Follow-up on the Interdisciplinary Team (IDT - a group of dedicated healthcare professionals who work to bring knowledge together to help residents receive the care they need) Care Conference meeting regarding Resident 1 ' s discharge planning during admission. 2. Ensure Resident 1 ' s are provided with necessary care and services upon discharge to home. These deficient practices resulted in incomplete and ineffective discharge planning that may lead to lack of necessary care, accident and possible injury after discharge. Findings: During a review of Resident 1 ' s admission Record, it indicated Resident 1 was admitted to the facility on [DATE] with diagnosis including infrarenal abdominal aortic aneurysm (AAA - is a bulge or weakening in the main blood vessel that runs through the belly, specifically below the arteries that supply blood to the kidneys), type II diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), muscle weakness (weakening, shrinking, and loss of muscle), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). The admission Record also indicated, Resident 1 was discharged home on 4/28/2025. During a review of the Minimum Data Set (MDS – resident assessment tool) dated 4/12/2025, indicated Resident 1 ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were moderately impaired. The MDS indicated Resident 1 required moderate assistance from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident ' s History and Physical, dated 4/9/2025, it indicated that, Resident 1 has fluctuating capacity to understand and make decisions – risk for delirium ((a serious disturbance in a person's mental abilities that results in a decreased awareness of one's environment and confused thinking). The H&P also indicated, Patient (Resident 1) lives at home alone . Resident 1 ' s majority of family in Central California and concerned about him (Resident 1) living alone . He (Resident 1) has been declining, but on the surface still appears to manage adequately and is able to compensate and mask deficits. However, they know he is not safe and has had more memory loss and cognitively also has had more deficits. During an interview with General Acute Care Hospital Social Worker 1 (GACH SW1) on 5/1/2025 at 8:44 a.m., GACH SW 1 stated, Resident 1 was discharged home alone from the facility on 4/28/2025 without a CG. GACH SW 1 stated, they have recommended Resident 1 to be discharged to an Assisted Living Facility (ALF - a type of housing that provides both housing and personal care services to people who need assistance with daily living activities, but who don't require the medical care of a nursing home) as he (Resident 1) was not safe to be home alone because of his comorbidities and home situation. During a review of Resident 1 ' s Care Plan (CP) for discharge, initiated on 4/10/2025, the CP indicated a goal of, Resident (1) will be able to verbalize/communicate required assistance post-discharge and the services required to meet needs before discharge. During a review of Resident 1 ' s Discharge Planning Review, dated 4/10/2025, it indicated that, Resident (1) lives alone . concerns are including: will need a Caregiver (CG). During a review of Resident 1 ' s IDT Care Conference Meeting, dated 4/22/2025, the IDT Care Conference indicated that, Plan: Recommended home health follow-up and CG for safety . Resident (1) was provided with different brochures for Caregiver Agencies since CG are recommended upon discharge . Resident (1) lives alone on an apartment . During a review of Resident 1 ' s Discharge summary, dated [DATE], it indicated that, Resident (1) was discharged to home with Home Health, ADL: independent. The DC summary does not indicate if Resident 1 was provided with a CG. During an interview with SSA 1 on 5/1/2025 at 3:22 p.m., SSA 1 stated, Resident 1 was discharged home on 4/28/2025 with Home Health. SSA1 stated that there was no information about if Resident 1 was discharged with a CG at home. During an interview with SSA 2 on 5/1/2025 at 3:55 p.m., SSA 2 stated, Resident 1 was given brochures regarding CG agencies as he was recommended to go home with a Home Health Provider and a CG. SS2 stated Resident 1 was provided with CG agencies, but Resident 1 stated, he cannot afford a CG. SSA2 stated that no information was provided to Resident 1 regarding ALF as an option for discharge planning. During a concurrent interview with the Social Services Director (SSD) on 5/1/2025 at 4:16 p.m., SSD stated, if a resident was given a recommendation to be discharged with a CG and/or be transferred to an ALF during discharge planning, they need to follow-up on the recommendation by providing resources and information and documenting it on the medical record. SSD stated, if not, this may negligibly affect the residents as Resident 1 may not be safe to be home alone. During a review of the facility ' s policy and procedure (P&P), titled, Transfer or Discharge, Resident-Initiated, revised on 1/2025, the P&P indicated that, For resident-initiated discharges, the medical record contains: Documentation: a. documentation or evidence of the resident's or resident representative's verbal or written notice of intent to leave the facility; b. a discharge care plan; and c. documented discussions with the resident or, if appropriate, his/her representative, containing details of discharge planning and arrangements for post-discharge care.

Based on interview and record review, the facility failed to develop a comprehensive care plan that met the care/services based on the resident's individual assessed needs for one of five sampled residents (Resident 1) by failing to develop an individualized Care Plan (CP) for Resident 1 ' s behavior of removing his own wound dressing. This deficient practice had the potential to have a negative impact on residents ' health and safety, as well as the quality of care and services received. Cross Reference F686. Findings: During a review of the Admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnosis including surgical aftercare following surgery on the circulatory system (body's network of blood vessels and heart that delivers oxygen and nutrients to cells and removes waste products), Type II diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), peripheral vascular disease (PVD - a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), and chronic (a condition that persists for a long time, generally lasting three months or more) non-pressure ulcer (open sores on the skin that are not caused by pressure on the skin) of right ankle. The Admission Record also indicated Resident 1 was discharged /transferred to General Acute Care Hospital 1 (GACH 1) on 4/4/2025. During a review of the Minimum Data Set (MDS - resident assessment tool) dated 3/28/2025 indicated Resident 1 ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions was severely impaired. The MDS indicated Resident 1 required moderate assistance to maximal assistance from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 1 ' s Care Plan as of 4/29/2025, there was no CP developed regarding Resident 1 ' s behavior of removing his own wound dressings. During a concurrent interview and record review with TXN 2 on 4/29/2025 at 1:17 p.m., TXN 2 stated Resident 1 had a behavior removing his own wound dressings and leaving it open to air. TXN 2 stated he would come during the day shift and the wound dressing from the previous day would already been removed. TXN 2 further stated, Resident 1 verbalized, he removed the old wound dressing because it was itchy. TXN 2 stated that the licensed nurses assigned to Resident 1 should have changed the dressing if it was removed by residents. TXN 2 further stated, there was no CP developed for Resident 1 ' s behavior. During an interview with Director of Nursing (DON) on 4/29/2025 at 2:21 p.m., DON stated, any licensed nurses can perform skin treatment at any shift and a CP should be developed on Resident 1 ' s behavior so that may address his behavior. DON stated, if a resident removed the wound dressing on his own, it puts the resident at risk of infection as he might scratch the wound and bleed. DON further stated, it should have been documented in the progress notes as well and notified the physician. During a review of facility ' s policy and procedure (P&P), titled, Care Plans, Comprehensive Person-Centered, reviewed on 1/2025, the P&P indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . The comprehensive, person-centered care plan will: a. Include measurable objectives and timeframes; b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; c. Describe services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment. During a review of facility ' s P&P titled, Nursing Care of the Resident with Diabetes Mellitus, reviewed on 1/2025, the P&P indicated, Skin should be kept as dry and clean as possible.

Based on interviews and record review, the facility failed to: 1. Obtain a wound consultation in the management of wound and maintain skin integrity for one of five sampled residents (Resident 1). 2. Ensure Resident 1 ' s Treatment Administration Record (TAR) were documented accurately per facility ' s policy and procedure (P&P) titled, Charting and Documentation. 3. Ensure Resident 1 ' s wound dressings are monitored and kept clean and dry per physician ' s order. These deficient practices had the potential to delay the provision of necessary care and services and deterioration of residents ' current wounds. Findings: A. During a review of the Admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnosis including surgical aftercare following surgery on the circulatory system (body's network of blood vessels and heart that delivers oxygen and nutrients to cells and removes waste products), Type II diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), peripheral vascular disease (PVD - a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), and chronic (a condition that persists for a long time, generally lasting three months or more) non-pressure ulcer (open sores on the skin that are not caused by pressure on the skin) of right ankle. The Admission Record also indicated Resident 1 was discharged /transferred to General Acute Care Hospital 1 (GACH 1) on 4/4/2025. During a review of the Minimum Data Set (MDS - resident assessment tool) dated 3/28/2025 indicated Resident 1 ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions was severely impaired. The MDS indicated Resident 1 required moderate assistance to maximal assistance from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 1 ' s Order Summary Report, dated 3/25/2025, the OSR indicated the following: i. Right dorsal foot (refers to the top or upper side of the foot, opposite the sole or bottom) arterial (blood vessels that distribute oxygen-rich blood to the entire body) wound - cleanse with normal saline (NS - a mixture of salt and water that can be applied directly to the wound site). Pat dry. Apply xeroform (a non-adhering, occlusive gauze dressing [a type of dressing used in wound care that creates a sealed environment to protect the wound and promote healing]), cover with ABD pad (used to absorb discharges) then wrap with kerlix (gauze rolls with open-weave design that provides fast wicking action, aeration and absorbency) every day ii. Right femoral (thigh bone) area incision site - cleanse with NS. Pat dry then cover with ABD pad, every day iii. Right foot wound: cleanse with NS. Pat dry then apply mupirocin (used to treat some skin infections), 2 percent (% - unit of measurement) and gentamycin (treat skin infections caused by certain bacteria) 0.1% topical daily. During a review of Resident 1 ' s Medical Record, as of 4/29/2025, there was no consultation and assessment by a Wound Provider Specialist (WPS). During a review of Resident 1 ' s Weekly Non-pressure Ulcer Observation Tool, dated 4/2/2025, Treatment Nurse 1 (TXN 2) documented, Resident (1) was supposed to be seen by wound specialist today, but resident (1) was not in the room. WPS will see resident next visit. During a concurrent interview and record review with TXN 2 on 4/29/2025 at 1:17 p.m., TXN 2 stated, WPS comes in the facility once a week, usually on Wednesdays, but they may also come anytime for new admit residents and if a resident needs a wound consultation. TXN 2 stated, according to Resident 1 ' s medical record, Resident 1 has not been seen by WPS since admitted and Resident 1 ' s wound and skin integrity was not evaluated by WPS. TXN 2 further stated Resident 1 had a behavior removing his own wound dressings and leaving it open to air. TXN 2 stated he would come during the day shift and the wound dressing from the previous days have been removed. TXN 2 further stated, Resident 1 verbalized, he removed the old wound dressing because it was itchy. TXN 2 stated that the licensed nurses assigned to Resident 1 should have changed the dressing if it was removed by residents. TXN 2 further stated, there was no CP developed for Resident 1 ' s behavior. During an interview with Director of Nursing (DON) on 4/29/2025 at 2:08 p.m., DON stated, resident with any skin integrity such as surgical wounds and non-pressure ulcer, there should be a wound assessment and consultation by a WPS upon resident ' s admission so they can validate if the current treatment orders for wounds are appropriate for the residents. DON stated, a WPS can come any day if needed. DON further stated, if a licensed nurse noticed the wound dressing was removed by Resident 1, they need to change and cover the wound and surgical sites to keep it clean and dry as ordered by the physician. B. During a review of Resident 1 ' s TAR on 4/7/2025, the TAR indicated, Licensed Vocational Nurse 1 (LVN 1) documented, all skin treatment was documented as given. During a concurrent interview and record review with DON on 4/29/2025 at 2:21 p.m., DON stated, Resident 1 ' s TAR was not accurately documented and charted as Resident 1 was transferred to GACH 1 on 4/4/2025 and was not in the facility on 4/7/2025. DON further stated, Resident 1 ' s TAR documentation was fraudulent. During a review of facility ' s P&P, titled, Consulting Physician, reviewed on 1/2025, the P&P indicated, It is the policy of this facility that primary physician will be aware of all consulting physician orders. During a review of facility ' s P&P titled, Nursing Care of the Resident with Diabetes Mellitus, reviewed on 1/2025, the P&P indicated, Skin should be kept as dry and clean as possible. During a review of facility ' s P&P titled, Charting and Documentation, reviewed on 1/2025, Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. During a review of facility ' s P&P titled, Podiatry/Food Services, reviewed on 1/2025, the P&P indicated, Podiatric services are provided for those residents who need such service for a specified reason and at a frequency determined by the needs of the individual residents; provided in a manner to prevent infections, and consistent with the facility ' s infection control policies and practices.

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) remained free of recurrent falls by failing to provide supervision of Resident 1 who is a high fall risk. This deficient practice resulted in Resident 1 had an unwitnessed fall on 2/5/2025, and 3/19/2025 while trying to ambulate to bathroom. Findings: A review of Resident 1 ' s admission record indicated, Resident 1 was originally admitted to the facility on [DATE] with a diagnosis that includes multiple fractures of ribs, dysphagia (difficulty swallowing), history of falls, personal history of transient ischemic attack (TIA-a temporary disruption of blood flow to the brain), unspecified dementia (loss of cognitive functioning, thinking, remembering, and reasoning). A review of Resident 3 ' s Morse Fall Risk Screen (assessment tool for prediction of a patient's potential for experiencing a fall while in a facility) dated 9/30/2023 Indicated Resident 1 had a history of falling, have more than one diagnosis. A review of Resident 1 ' s Minimum Data Set (MDS- a resident assessment screening tool), dated 1/22/2025, indicated, Resident 1 ' s cognition (the mental ability to understand and make decisions of daily living) was severely impaired, limitations with daily functions affecting lower extremity (hip, knee, ankle, foot) and uses a walker to ambulate. A review of Resident 1 ' s care plan (CP-a plan of care that summarizes a resident ' s health conditions, specific care needs, and current treatment) for High risk falls and injury created on 1/31/2025 indicated, the CP goal for Resident 1included to utilize call lights for assistance during transfers and ambulation until next review date. Resident 1 will not have more than 1 fall incident until next review date.The CP interventions (specific care and services facility staff need to provide a resident to promote healing and prevent a worsening of condition) for Resident 1 indicated to orient Resident 1 to person, place, time, routine and event, re-iteratet the importance of using call lights for assistance, and provide assistance needed with ADL (Activities of Daily Living). A review of Resident 1 ' s Morse Fall Risk Screen (assessment tool for prediction of patient ' s potential for experiencing a fall while in a facility) dated 2/5/2025 indicated, Resident 1 had a history of falling, have more than one diagnosis, and impaired gait, overestimates or forgets limits. A review of Resident 1 ' s History and Physical (H&P) dated, 2/7/2025, indicated, Resident 1 was admitted to General Acute Care Hospital (GACH) from 2/5/2025 to 2/6/2025 after falling at thenSkilled Nursing Facility. During an interview on 2/24/2025 at 11:25 AM with Licensed Vocational Nurse (LVN) 1 stated, Resident 1 is confused, sometimes uses hand signal to eat or go to bathroom, does not communicate even with his primary language. LVN 1 stated Resident 1 had falls in the past and injured himself. LVN 1 stated, He [Resident 1] had frequent falls; he just gets up and go to bathroom or go out he does not ask for assistance. A review of Resident 1 ' s Physical Therapy Evaluation and Plan of Treatment dated 3/11/2025, indicated, short term goal plan was for Resident 1 to safely ambulate 100 feet using a two-wheeled walker wit supervision or touching assistance with ability, long term goal safely ambulate 150 feet, and prior cognitive assistance constant supervision needed. A review of Resident 1 ' s SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents) dated 3/19/2025 indicated, Resident 1 was found by a desk nurse on the floor next to restroom floor in his room. A review of Resident 1 ' s physician ' s order dated 3/19/2025, indicated, Resident 1 may transfer to emergency room via 911 (emergency medical services or ambulance that are dispatched for emergency to provide immediate transport to a hospital). During an observation in front of Resident 1 ' s room on 3/24/2025 at 11:25 AM, Resident 1 suddenly got up from his bed sat at the edge of bed, attempted to get up and go to bathroom, LVN 1 immediately went in Resident 1 ' s room and prevented a fall, assisted Resident 1 sit on a wheelchair to ambulate to bathroom. During an interview on 3/24/2025 at 11:56 with Registered Nurse (RN) stated, Resident 1 is a long-term resident of the facility, confused, uses wheelchair for ambulation, able to stand and walk but not for long time he loses his balance. He does not follow instructions he does not ask for assistance. A one-to-one/sitter observation likely will help to prevent his falls. During an interview on 3/24/2025 at 1:07 PM with Director of Rehabilitation (DOR) stated, Resident 1 has been in the physical therapy program. DOR stated that in the past Resident 1 benefited from the program physically but not psychosocially because the resident has impaired cognition. DOR stated Resident 1 does does not ask for help when the resident gets up and go which leads to falls. DOR stated Resident 1 can benefit from a sitter or having alert enough roommate who can call on the resident's behalf when the resident gets up. During an interview on 3/24/2025 at 1:45 PM with the Director of Nursing (DON) stated, Resident 1 has dementia, confusion, language barrier, is very independent does not like to get help, and likes to do things on his own. The DON stated Resident 1 lately has been refusing physical therapy, the physical therapy helps him maintain strength and the resident's last two falls were unwitnessed. The DON stated tat Bed alarms are not utilized in the facility. The DON stated the facility will establish anticipatory recognition for further fall prevention interventions. The DON stated the next plan to prevent falls is to have a sitter outside Resident 1's room because the resident does not like to have a sitter in the room. A review of the facility policy and procedures (P&P) titled Falls and Fall Risk, managing reviewed 1/2025, indicated, Resident conditions that may contribute to the risk of falls include: delirium and other cognitive impairment; functional impairment, lower extremity weakness; and incontinence. Monitoring subsequent falls and fall risk, if interventions have been successful in preventing falling, staff will continue the interventions or reconsider whether these measures are still needed if a problem that required the intervention (e.g., dizziness or weakness) has resolved. If the resident continues to fall, staff will re-evaluate the situation and weather it is appropriate to continue or change current interventions. As needed the attending physician will help the staff reconsider possible causes that may not previously have been identified.

Based on observation, interview, and record review, the facility failed to protect and safeguard the residents personal and medical records according to the facility's policy and procedures (P&P), titled, confidentiality of information and personal privacy, reviewed 1/2024 for 11 of 13 sampled residents (Residents 11, 31, 44, 59, 65, 78, 142, 242, 343, 345, and 346). This deficient practice violated the resident's rights for privacy. Findings: A review of Resident 11's Admission Record indicated the facility admitted Resident 11 on 11/17/2024 with diagnoses including atrial fibrillation (a heart condition where the upper chambers of the heart beat irregularly and rapid causing racing sensation), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety disorder (a mental health condition that causes a person to experiences excessive and intense feelings of fear, worry, dread, and uneasiness). A review of Resident 31's Admission Record indicated the facility admitted Resident 31 on 12/18/2019 and readmitted Resident 31 on 3/5/2024 with diagnoses including end stage renal disease (ESRD - irreversible kidney failure), diabetes mellitus (DM -a disorder characterized by difficulty in blood sugar control and poor wound healing), and hypothyroidism (a condition where the thyroid gland doesn't produce enough thyroid hormone). A review of Resident 44's Admission Record indicated the facility admitted Resident 44 on 9/2/2024 with diagnoses including hypothyroidism (a condition where the thyroid gland doesn't produce enough thyroid hormone), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety disorder (a mental health condition that causes a person to experiences excessive and intense feelings of fear, worry, dread, and uneasiness). A review of Resident 59's Admission Record indicated the facility admitted Resident 59 on 9/9/2023 and readmitted Resident 59 on 11/15/2024 with diagnoses including diabetes mellitus (DM -a disorder characterized by difficulty in blood sugar control and poor wound healing), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety disorder (a mental health condition that causes a person to experiences excessive and intense feelings of fear, worry, dread, and uneasiness). A review of Resident 65's Admission Record indicated the facility admitted Resident 65 on 3/1/2024 with diagnoses including hypothyroidism (a condition where the thyroid gland doesn't produce enough thyroid hormone), insomnia (a common sleep disorder that makes it difficult to fall or stay asleep, or get to quality sleep), and history of falling. A review of Resident 78's Admission Record indicated the facility admitted Resident 78 on 11/7/2024 with diagnoses including metabolic encephalopathy (imbalance in the body's chemical causing the brain not to work properly), atrial fibrillation (a heart condition where the upper chambers of the heartbeat irregularly and rapid causing racing sensation), and acute kidney failure (kidneys suddenly stop working properly). A review of Resident 142's Admission Record indicated the facility admitted Resident 142 on 12/12/2024 with diagnoses including hypertension (HTN -high blood pressure), chronic obstructive pulmonary disease (COPD -a chronic lung disease causing difficulty in breathing), and bronchiectasis (a chronic lung condition that occurs when the airway in the lungs become damaged, widened, and scarred). A review of Resident 242's Admission Record indicated the facility admitted Resident 242 on 8/28/2024 and readmitted Resident 242 on 12/14/2024 with diagnoses including diabetes mellitus (DM -a disorder characterized by difficulty in blood sugar control and poor wound healing), depression (a mental health condition that involves a persistent low mood and loss of interest in activities that a person normally enjoys), and anxiety disorder (a mental health condition that causes a person to experience excessive and intense feelings of fear, worry, dread, and uneasiness). A review of Resident 343's Admission Record indicated the facility admitted Resident 343 on 12/10/2024 with diagnoses including Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), anxiety disorder (a mental health condition that causes a person to experience excessive and intense feelings of fear, worry, dread, and uneasiness), and chronic kidney disease (CKD -gradual damage to the kidneys so they cannot filter waste from the blood properly causing a buildup of toxins in the body). A review of Resident 345's Admission Record indicated the facility admitted Resident 345 on 12/9/2024 with diagnoses including hypertension (HTN -high blood pressure), depression (a mental health condition that involves a persistent low mood and loss of interest in activities that a person normally enjoys), and history of falling. A review of Resident 346's Admission Record indicated the facility admitted Resident 346 on 12/3/2024 with diagnoses including depression (a mental health condition that involves a persistent low mood and loss of interest in activities that a person normally enjoys), hypertension (HTN -high blood pressure), and history of falling. During an initial tour of the facility on 12/16/2024, at 10:10 A.M., Resident 141's family member (FM) approached surveyor with a stack of documents and stated, I found these documents in Resident 141's room, I think they are all medical records and they do not belong to Resident 141. During a concurrent interview and record review of the documents found in Resident 141's room, on 12/16/2024, at 10:12 A.M., with the Social Services Director (SSD), the SSD was within an ear shot of the conversation that this surveyor had with Resident 141's FM, SSD confirmed that the records that were found by Resident 141's FM were other residents medical records and that they should have not been in Resident 141's room for confidentiality reasons and that it was a violation on Health Insurance Portability and Accountability Act (HIPAA - federal standards protecting sensitive health information from disclosure without patient's consent). During an interview on 12/19/2024, at 10:06 A.M., with the Case Manager (CM), the CM stated the documents found in Resident 141's room were his and that those documents belonged to other residents and not Resident 141. The CM stated the documents included but were not limited to other residents' information from the hospital, resident demographics, resident financial information, residents' insurance information, residents' clinical information and residents living information, overall, a brief summary of their (residents) house and personal information. CM stated residents' medial information should not be in the residents' rooms due to HIPAA, medical records should not be accessible to other residents or their responsible party. The CM states exposure of the residents' medical records to unauthorized individuals will cause residents to feel unsafe, due to the invasion of their privacy and lead to other individuals discussing their (residents) personal information. During an interview 0n 12/19/2024, at 9:57 A.M., with the Facility Administrator (FA), the FA stated residents' medical information should not be in other residents' room, it is a violation of HIPAA. The FA stated the facility has already reported the incident to their HIPAA compliance officer and a case was opened. A review of the facility's P&P, titled, Confidentiality of Information and Personal Privacy, revised 1/20214, indicated Policy Statement: Our facility will protect and safeguard resident confidentiality and personal privacy . 1. The facility will safeguard the personal privacy and confidentiality of all resident personal and medical records. 2. The facility will strive to protect the resident's privacy regarding his or her: a. Medical treatment; 3 4. Access to resident personal and medical records will be limited to authorized staff and business associates.

Based on observation, interview, and record review, the facility failed to ensure the standardized recipes for lunch menu was followed on 12/16/24 when: 1.25 residents on mechanical soft diet (for resident who experience chewing or swallowing limitations) received Cajun country rice with sliced turkey instead of the Cajun country rice with ground turkey per menu and spreadsheet (food production guide includes food portion and serving guide). One resident on Dysphagia diet (for people with difficulty swallowing- food is moist, mechanical altered easily mashed, or pureed requires little chewing) received baked fish instead of ground fish, received regular Cajun Country rice instead of pureed rice per food production guides (food portion and serving guide). This deficient practice had the potential to result in meal dissatisfaction, decreased nutritional intake, weight loss and increased risk of choking for the residents who were on mechanical soft and dysphagia diet. Findings: According to the facility lunch menu for mechanical soft diet on 12/16/24, the following items will be served: Flaked and moist with fish fillet with tarragon sauce 3 ounces (3oz.); Cajun Country Rice with ground ham/turkey; creamed spinach with soft carrots, chopped corn salad, fruit Bavarian cream and beverage. For Dysphagia diet: Ground fish fillet with pureed tarragon sauce, Pureed Cajun country rice, Mashable and chop to 1/2 inch creamed spinach; pureed corn salad, Bavarian cream and beverage. During an observation of the tray line service for lunch on 12/16/24 at 12:00PM, the mechanical soft diet for Cajun Country Rice had large slices of turkey. During the same observation for lunch service on 12/16/24 one resident who was on dysphagia diet received baked fish that was flaked instead of ground and regular rice instead of pureed rice per the menu. During an interview with Cook1 on 12/16/24 at 12:30PM, Cook1 stated he used turkey slices instead of ham in the Cajun country rice because some residents don't like ham. Cook1 stated he chopped the turkey into 1 inch slices and he served the same rice to residents on regular diet and mechanical soft diet. During a concurrent review of the spreadsheet (food portions and serving guide), Cook1 stated he made a mistake, and he should have used ground turkey in the Cajun rice and not chopped pieces. Cook1 also stated one resident who is on the dysphagia diet should receive puree rice and ground fish. Cook1 stated when the pieces are large chops and it's the wrong texture residents can choke from the food. During a taste test of the mechanical soft and dysphagia diet on 12/16/24 at 12:40PM the pieces of the turkey in the Cajun country rice for the mechanical soft diet were large chopped into 1 inch and not ground. The Dysphagia diet received regular rice and not puree, and the fish was flaked instead of ground. During an interview with Dietary Supervisor (DS) on 12/16/24 at 12:45PM, DS stated residents on mechanical soft diet should receive rice with ground turkey or ham and residents on dysphagia diet should receive puree rice and ground fish. DS stated cooks should always follow the menu and to be careful with texture modified diets are important to prevent choking. During an interview with Registered Dietitian (RD1) on 12/17/24 at 10:00AM, RD1 stated the ham or turkey in the rice should be ground for the mechanical soft diet per the menu and the fish has to be ground and rice is pureed per the menu for dysphagia diet. RD1 stated mistakes had potential for residents choking. A review of facility policy and procedures titled Regular Mechanical soft diet (dated 2023) indicated, Meats poultry and fish allowed need to be ground with meat juices, gravy or sauce. A review of facility recipe for Fish with Tarragon Sauce indicated for dysphagia diet grind the fish and serve with pureed sauce. A review of facility recipe for the Cajun Country Rice indicated for mechanical soft Ham needs to be ground and the vegetables soft, for dysphagia diet puree the rice.

Based on observations, interview, and record review, the facility failed to: 1. Ensure the facility received and reviewed daily activity and discrepancy reports of the Cubex system (a computerized system that stores, dispenses, and tracks medications in healthcare setting), which was inconsistent with the facility policy for at least 11 months. 2. Ensure non-controlled drug dispositions (the process of returning or destroying unused medications) were performed and recorded by two licensed nurses as per policy for at least 8 months. 3. Ensure outdated medication are discarded and not stored in a medication cart. These deficient practices had the potential for medication errors, loss and/or diversion (transfer of medication from a lawful to an unlawful channel of distribution or use) of medications, and the potential for residents to receive outdated, deteriorated, and ineffective medication. Findings: 1. During an observation on [DATE] at 11:50 AM in a medication room on the 2nd floor, and a concurrent interview with a Licensed Vocation Nurse (LVN 2). There was an automated drug dispensing cabinet (Cubex, a computerized system that stores, dispenses, and tracks medications in healthcare setting) inside the medication room. There was a binder labeled inventory count next to the Cubex which indicated the facility pharmacist consultant performed inventory count once a month. LVN 2 stated the facility used Cubex for resident's first dose for new order and/or as oral emergency drugs supply. During an interview on [DATE] at 12:45 PM, the director of nursing (DON) could not pull activity report from Cubex. DON contacted the Cubex specialist (CS) of the facility pharmacy who stated the facility did not have access to reports. CS stated activity/transaction/discrepancy reports were sent to the DON daily via email. During a concurrent interview, DON stated the pharmacy took care of discrepancies. DON did not recall reviewing any Cubex reports. A review of the facility's policy and procedures titled Resolving Discrepancies Automated Drug Delivery Systems (dated ,d+[DATE]) indicated . Transaction and . Controlled Medication Discrepancy Report shall be generated and reviewed daily by the Director of Nursing . During an interview on [DATE] at 2:45 PM, the Quality Assurance Nurse (QA) stated Cubex was installed in [DATE]. During an interview on [DATE] at 3:02 PM, DON called the facility pharmacy personnel who stated the daily activity or transaction report of the Cubex was automatically generated by the system and automatically emailed to the facility designated person. During an interview on [DATE] at 3:14 PM, DON searched the email record and stated they had not received any reports from the pharmacy since the facility started using Cubex in [DATE]. During an interview on [DATE] at 3:31 PM, DON confirmed the facility did not have access or ability to generate reports from the Cubex. A moment later, the facility pharmacy emailed Cubex transaction occurred from September to November and from [DATE] to [DATE], to DON. During an interview on [DATE] at 9:40 AM, DON stated the facility pharmacy corrected the email address in the system and the facility received autogenerated email of the Cubex transaction report. 2. During an interview on [DATE] at 10:01 AM, DON presented non-controlled med disposition log, dated [DATE]. DON stated there was 1 (one) nurse's signature on the log. During an interview on [DATE] at 2:22 PM, DON reviewed a binder of medication disposition records from February 2024 to [DATE], DON stated only the disposition record of [DATE] had 2 nurses' signatures. During a concurrent review of the facility policy, Medication Destruction (dated [DATE]), DON stated the medication disposition should be done in the presence of 2 nurses. 3. During an observation on [DATE] at 1:53 PM with LVN 2 at Nursing Station 1 of floor 2 Medication Cart 1, there were 2 boxes of fluticasone Propionate and Salmeterol inhalers (an inhalation medication to treat certain lung disease or chronic conditions) for Resident 8 During an interview on [DATE] at 1:58 PM, LVN 2 reviewed the aforementioned inhalers and confirmed one of those inhaler boxes had an open date of [DATE] written on the label and the other inhaler had an open date on [DATE]. LVN 2 reviewed the instruction on the inhaler box and stated, Discard after 1 month of opening. LVN 2 stated the inhaler with an open date of [DATE] had expired and would bring it to DON for disposal. During an interview on [DATE] at 2:35 PM, DON reviewed the aforementioned inhaler with an open date of [DATE] and stated the inhaler should have been removed from the medication cart when it became outdated on [DATE], since it was opened on [DATE]. A review of the facility's policy and procedures titled Discontinued Medications (dated ,d+[DATE]), indicated . If a medication expires, . drug container shall be marked . and shall be stored in a separate location designated solely for this purpose .

Based on observation, interview and record review, the facility failed to ensure safe food handling practices when: 1.One of one ice scooper was not cleaned and sanitized daily in accordance with the facility policy and procedure (P&P) titled, Ice Procedures. The ice scooper was not stored in a sanitary condition, the ice scooper had red color stains on it and was sticky. This deficient practice 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 in101 out of 102 residents who received ice from the facility. Findings: During a concurrent observation and interview with Dietary Supervisor (DS) on 12/16/24 at 9:00AM the ice scooper was stored in the ice scoop container next to the ice machine. The Ice scooper had red stains on it and the stains were sticky to touch. DS stated it must be juice that is stuck on the ice scooper. DS stated the ice scooper is used to transfer ice from the ice machine and into water/juice pitchers for residents. DS stated the ice scoop is cleaned daily in the dishwasher and in the mornings. DS stated this must have happened after the daily cleaning. DS removed the ice scooper to the Dishwasher to wash. DS stated facility does not keep a log or a record of when the ice scooper is cleaned. DS stated when the scooper is dirty it can cross contaminate the ice. During a concurrent observation and interview with Dishwasher (DW) on 12/16/24 at 9:15AM, DW stated he works in the morning shifts. DW stated he washed the ice scooper today in the morning, he doesn't remember the time. DW stated he doesn't keep a record on days and time that he washes the scooper. During a review of the facility's policy and procedures (P&P) titled, Ice Procedures, (dated 2018) indicated, Ice scoops are to be washed in the dish machine daily by the PM Dishwasher or specify on the daily cleaning schedule who is to clean and when. A review of the 2022 U.S. Food and Drug Administration Food Code titled Equipment Food-Contact Surfaces and Utensils Code# 4-602.11, indicated, Surfaces of utensils and equipment contacting food that is not time/temperature control for safety food such as iced tea dispensers, carbonated beverage dispenser nozzles, beverage dispensing circuits or lines, water vending equipment, coffee bean grinders, ice makers, and ice bins must be cleaned on a routine basis to prevent the development of slime, mold, or soil residues that may contribute to an accumulation of microorganisms.

Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 3), who was assessed as a high risk was not left unattended in the bathroom unsupervised. This deficient practice resulted in Resident 3 falling while in the bathroom on 5/9/2024 at 6:45 p.m. and sustained a mild displaced comminuted subcapital (is a difficult hip injury that can have serious complications) fracture (a break in a bone) of the right femoral neck (right hip fracture). Resident 3 was transferred to General Acute Care Hospital (GACH) on 5/10/2024. Resident 3 underwent a closed reduction percutaneous fixation (a procedure to set [reduce] a broken bone without cutting the skin open) of the right femoral neck fracture resulting from a right non-displaced femoral neck fracture. Findings: A review of the Resident 3 ' s Admission Record indicated Resident 3 was originally admitted to the facility on [DATE] with a subsequent admission on 5/14/2024 with diagnoses that included atrial fibrillation (an irregular and often very rapid heart rhythm), congestive heart failure (CHF- A weakened heart condition that causes fluid buildup in the feet, arms, lungs, and other organs non-displaced fracture of the sixth and seventh cervical vertebra (C6 and C7-broken neck), low blood pressure, Benign Prostatic hyperplasia (BPH- enlarged prostate), abnormalities with walking and moving around and repeated falls. A review of Resident 3 ' s Morse Fall Risk Screen (assessment tool for prediction of a patient ' s potential for experiencing a fall while in a facility) dated 3/27/2024 Indicated Resident 3 had a history of falling and was at high risk for recurrent falls. A review of Resident 3 ' s history and physical (H&P) dated 3/28/2024 indicated, Resident 3 has limited capacity to understand and make decision depending on complexity of decisions that need to be made. Resident 3 required family assistance with making complex medical decisions. The same H & P indicated Resident 3 was admitted to the facility after recent hospitalization for cervical fracture due to recurrent falls in the facility. Assessment and plan included physical therapy (PT- is a healthcare profession, as well as the care provided by physical therapists who promote, maintain, or restore health through patient education, physical intervention, disease prevention, and health promotion) and occupational therapy (OT- a branch of health care that helps people of all ages who have physical, sensory, or cognitive problems. and fall precautions). The plan further included to always wear rigid cervical collar while in bed and in showers and wear cervical thoracic orthosis (CTO- neck brace with piece that extends down to protect the spine) brace when out of bed and during PT and OT. A review of Resident 3 ' Care Plan titled, High Risk for Fall created on 3/31/2024 indicated Resident 3 was at high risk for falls and injury related to limitation of mobility, repeated falls, and low blood pressure. Interventions to prevent falls included to provide assistance needed with toileting and do not leave the resident unattended in the room. A review of Resident 3 ' s Minimum Data Set (MDS-a standardized assessment and care planning tool), dated, 4/3/2024 indicated Resident 3 ' s cognition (mental ability to make decisions for daily living) was moderately impaired. Resident 3 was totally dependent (helper does all the effort) with toileting hygiene and transfers (moving between surfaces) from bed to chair. Resident 3 ' s ability to get on and off a toilet or commode was not attempted due to medical condition or safety concerns. A review of Resident 3 ' s Change in Condition Evaluation form dated 5/9/2024 at 6:45 p.m. indicated Resident 3 was found sitting on the bathroom floor wearing neck brace. Resident 3 was able to move both arms and legs and denied any pain. A review of Resident 3 ' s GACH X-Ray (are a form of electromagnetic radiation, similar to visible light) result of right femur (thigh) dated 5/10/2024 indicated a mild displaced mildly comminuted subcapital fracture of the right femoral neck. A review of Resident 3 ' s GACH orthopedic (focuses on injuries and diseases affecting your musculoskeletal system [bones, muscles, joints and soft tissues]) record dated 5/11/2024 indicated Resident 3 underwent a closed reduction percutaneous fixation (a procedure to set [reduce] a broken bone without cutting the skin open) of the right femoral neck fracture resulting from a right non-displaced femoral neck fracture. During an interview on 5/15/2024 at 11:10 a.m. Resident 5 (Resident 3 ' s roommate) stated on 5/9/2024 at unknown time an unknown staff member brought Resident 3 to his room in a wheelchair and left him (Resident 3) there watching television. Resident 5 stated he observed Resident 3 wheel himself into the bathroom and close the door. Resident 5 stated, after about 10 minutes, he became concerned because Resident 3 had not come out of the bathroom, so he pushed the call light. Resident 5 further stated an unknown staff responded to the call light and he informed the staff that Resident 3 had been in the restroom for a long time. Resident 5 further stated the unknown staff opened the bathroom door and found Resident 3 on the floor. During an interview on 5/15/2024 at 3:08 p.m. the Licensed Vocational Nurse 1 (LVN 1) stated on 5/9/2024 she had just finished rounding and left Resident 3 in his room sitting in the wheelchair eating dinner. LVN 1 stated after 10 minutes she returned to the nursing station and noticed the call light was on in the room. LVN 1 stated she went to the room and Resident 5 told her that Resident 3 wheeled himself to the bathroom. LVN 1 stated when she opened the bathroom door, she found Resident 3 sitting on the floor with both hands on the floor. LVN 1 further stated she then called for assistance to pick Resident 3 up and put back into the bed. LVN 1 further stated Resident 3 had a history of fall that resulted in a broken neck and required him to wear a neck brace. LVN 1 confirmed and stated Resident 3 required supervision with walking. During a concurrent interview and record review on 6/3/2024 at 12:53 p.m. with LVN 2, the Change in Condition Evaluation form dated 5/10/2024 was reviewed. The Change in Condition form indicated at 11p.m. the physical therapist informed LVN 2 Resident 3 was having pain in the right thigh and could not complete therapy session due to the pain. LVN 2 stated when she assessed Resident 3, he cried out in pain when she touched the areas, so she notified the Medical Director (MD) and received an order to transfer Resident 3 out to the GACH for evaluation. During an interview on 6/3/2024 at 2:48 p.m. Certified Nursing Assistant 1 (CNA 1) stated he was assigned to Resident 3 on 5/9/2024 from 3 p.m. to 11 p.m. CNA 1 stated he saw Resident 3 sitting in his wheelchair in his room when he started his shift at 3 p.m. CNA 1 added, he was in another room assisting a different resident to the bathroom when Resident 3 was found on the bathroom floor. CNA 1 did not recall the exact time, however, stated it was after dinner when he last saw Resident 3 still sitting in the wheelchair in his room talking with his roommate. CNA 1 stated it was his first-time taking care of Resident 3, so he was not too familiar with him. CNA 1 stated he was not aware Resident 3 was at risk for fall, but he made sure the call light was within his reach when he was last in the room. CNA 1 stated he asked LVN 1 about the level of assistance needed for Resident 3 and was told Resident 3 was able to stand and assist with transfers and he had in a neck brace. CNA 1 stated he asked because he did not know the resident and there was no huddle (verbal reports on status and needs of the residents) given before the shift. I did not know he was confused and started to sundown (a state on confusion that occurs in the late afternoon and lasts into the night) otherwise I would have checked on him more frequently. I did do more visual checks after the fall for the rest of the evening. CNA 1 further stated when he came out of the other room, he saw LVN 1 flagging him to come to the room and that is when he saw Resident 3 on the bathroom floor and assisted her with getting him up and to bed. During a concurrent interview and record review on 6/3/2024 at 2:50 p.m. with CNA 1, the assignment sheet dated 5/9/2024 3p.m.-11p.m. was reviewed. The assignment sheet indicated CNA 1 was assigned to 3 additional residents on top of his 8 residents for a total of 11 residents. The 3 additional residents indicated 7 p.m. next to the name of the CNA originally assigned to those residents. CNA 1 stated, Oh now I remember we were short on staff that evening so I had to cover those additional residents until the other CNA arrived at 7 p.m. so it must have happened before 7p.m. During a concurrent interview and record review on 6/3/2024 at 4 p.m. with the occupational therapist (OT), the Treatment Encounter Note dated 4/30/2024 was reviewed. The Treatment Encounter Note indicated Resident 3 required contact guard assist (the assisting person has one or two hands on your body but provides no other assistance to perform the functional mobility task) with minimal assist. Resident 3 required mod/max (moderate/maximum) assist for peri care (wipe and clean after using the bathroom) and brief management for safety due to limited balance. The OT stated, He was able to stand with me standing there on guard with minimal assistance because he has severe impairment in balance, so he needed to be cued to hold on to the grab bar while I pulled down his pants and wiped him after he was done. He required 50-75% (percentage) assistance from me and needed 50% rest breaks in between tasks because he would get tired and lose his balance. The OT further stated Resident 3 did follow commands, but he had periods of confusion and poor safety awareness overall due to his cognitive impairment. He required assistance from at least one person to use the bathroom. The Nursing Staff were made aware of this verbally and they have asked us to put our notes under the therapy tab in the electronic medical record system so they can access them and review at any time. During an interview on 6/6/2024 at 11:28 a.m. the Director of Nursing (DON), stated Resident 3 ' s cognition was severely impaired at admission, and he was admitted as a high fall risk. The DON stated Resident 3 required increase supervision due the high risk for fall, so he was moved closer to the nursing station after the unwitnessed fall incident on 5/9/2024. The DON could not state how the facility provided supervision and assistive devices to Resident 1 to prevent avoidable accidents. The DON further stated, When I did meet him after the fall, I saw that he was very confused and forgetful, so we decided to call the family to get a personal sitter to sit with him all day. During a concurrent interview and record review on 6/6/2024 at 12:28 p.m. with the DON; the OT Treatment Encounter Note dated 4/30/2024 was reviewed. The Treatment Encounter Note indicated Resident 3 required contact guard assist with minimal assist. Resident 3 required mod/max assist for peri care (wipe and clean after using the bathroom) and brief management for safety due to limited balance. The DON stated, this means he needed at least one person to assist with using the restroom and that one person would need to do most of the task. The DON further stated, The OT will verbally communicate these needs directly to the nursing staff so they will know how much assistance is needed. The DON further stated the resident ' s level of assistance that is needed should continue to be communicated to oncoming staff by outgoing staff and during huddle at change of shift. The DON stated, we should have done a better job of communicating to all staff that Resident 3 was moderately confused and required moderate assistance to use the bathroom that way we could have better anticipated his needs regarding safety and supervision. We could have provided more activities to keep him from getting out of bed unassisted. A review of the facility ' s policy and procedures (P & P) titled, Falls Management Program reviewed 1/2024 indicated: To provide residents with hazard free environment, adequate supervision and reduce risk factors leading to falls and injury .When a resident, family member or staff member said a fall occurred; When a person was found on the floor, regardless of whether any injury resulted; An occasion on which residents lowered themselves to the floor; When the resident had to be lowered to the floor by a staff member to prevent a fall . The same P & P indicated, It is the policy of this facility to provide residents with a safe environment which is free from accident hazard as is possible. The facility will provide residents with adequate supervision and assistive device to prevent accidents. It is also the policy of the facility to investigate the circumstances surrounding the resident fall and implement actions to reduce the incidence of additional falls and minimize potential for injury. The same P & P further indicated, 1. The Licensed nurse will observe the resident and review risk factors that may potentially contribute to the occurrence and reoccurrence of a fall on admission, quarterly thereafter, and following incident of fall and when a significant change of condition is identified to determine if he/she is at risk for falls using the Morse Fall Scale. 2.During schedule or unscheduled down time the Licensed Nurse will complete the Morse Fall Scale form in paper .4. The Licensed Nurse will initiate a plan of care within 24 hours from admission and readmission on residents identified as high risk for fall. The plan of care will be updated by the Licensed Nurse and Interdisciplinary Team as indicated; 5. The Interdisciplinary Team will reassess the risk factors contributing to falls and interventions to minimize recurrence of falls and injury during the initial, quarterly and annual assessment, post fall and when a significant change of condition is identified .

Based on interview, and record review, the facility failed to ensure Licensed Vocational Nurse 1 ( LVN 1) immediately initiated Cardiopulmonary Resuscitation (CPR- a medical procedure involving repeated compression of a patient's chest, performed to restore the blood circulation, and breathing of a person who has suffered cardiac arrest) for one of the three sampled residents (Resident 1) and did not leave Resident 1 unattended when LVN 1 found Resident 1 unresponsive (Unconscious, and possibly dead or dying) on [DATE] at 7:30 p.m. As a result, Resident 1 did not receive the necessary emergency life-saving services immediately. The paramedics (Healthcare professionals trained in the medical model, whose main role is to respond to emergency calls for medical help outside of a hospital) arrived at the facility on [DATE] at 7:39 p.m. Paramedics pronounced Resident 1 dead in the facility on [DATE] but did not indicate the time Resident 1 was pronounced (Officially state or declare) dead. Findings: A review of Resident 1's admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including cerebral infarction (CVA-also known as a stroke refers to damage to tissues in the brain due to a loss of oxygen to the area), metabolic encephalopathy (occurs when problems with your metabolism cause brain dysfunction), and Alzheimer's disease (A progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment). A review of Resident 1's Physician's Order of Life-Sustaining Treatment (POLST - a medical order that helps give people with serious illness more control over their care during a medical emergency), dated [DATE], indicated to attempt Cardiopulmonary Resuscitation (CPR - A emergency life-saving procedure that is done when someone's breathing, or heartbeat has stopped) and provide full treatment of prolonging life by all medical effective means. A review of Resident 1's care plan titled Dysphagia (Difficulty swallowing) ., initiated [DATE], indicated, Patient [Resident 1] will be free from aspiration (When food, liquid, or other material enters a person's airway and eventually the lungs) . A review of Resident 1's history and physical (H&P - The most formal and complete assessment of the patient and the problem) dated [DATE], indicated, Resident 1 was diagnosed with recurrent aspiration. A review of Resident 1's Minimum Data Set (MDS- a standardized assessment and care screening tool), dated [DATE], indicated Resident 1 had mild cognitive impairment (when a person starts to have problems with their memory or thinking). Resident 1 required one-person physical assist with bed mobility, dressing, toileting, and personal hygiene, and two-person physical assistance for surface transfer. A review of Resident 1's 911 (Emergency telephone number is any situation that requires immediate assistance from the police, fire department or ambulance) Run Sheet dated [DATE], indicated paramedics arrived at the facility on[DATE] at 7:39 p.m. Resident 1 was unresponsive, pulseless (no heartbeat), and apneic (not breathing) . Upon arrival violations assisted with Bag Valve Mask (BVM- non-rebreathing valve that directs fresh flow of oxygen to the patient and prevents exhaled gas re-entering the bag) and CPR. A review of Resident 1's Nurses Notes created on [DATE] at 1:13 a.m., indicated that on [DATE] at 7:30 p.m., LVN 1 found Resident 1 unresponsive. Resident 1 was placed on Oxygen 15 liters per min (L/min) via a nonrebreather mask (NRB - A device used to assist in the delivery of oxygen therapy which requires that the patient be able to breathe unassisted). During an interview with Family Members 1 and 2 (FM 1 and FM 2), on [DATE] at 11:33 a.m., FM 1 stated Resident 1 had other comorbidities (more than one disease or condition at the same time) such as Alzheimer's and weakness due to residual (Remaining after a disease or operation) from the CVA. FMs 1 and 2 stated Resident 1 was in his usual state of mind, full of joy and vivacious until [DATE] when FM 1 received a call from the facility that Resident 1 had passed (died ) away. FM 1 and FM 2 stated they were very shocked Resident 1 had died and could not understand what had happened to the resident. FM 1 stated he went to the facility on [DATE] the same night Resident 1 died . FM 1 stated upon inquiry, LVN 1 stated that on [DATE], Resident 1 was doing alright throughout the day, had dinner in bed and asked for water a while later. FM 1 further stated that LVN 1 told FM 1 that [LVN 1] peeked into Resident 1's room on [DATE] (unknown time) and noted that Resident 1 looked unwell. FM 1 stated LVN 1 told him that [LVN 1] left Resident 1 unattended and proceeded to administer medication/s to another resident in a different room. FM 1 stated that LVN 1 told him that [LVN 1] later returned to Resident 1's room and found Resident 1 unresponsive (unknown time). FM 1 and FM 2 stated that per Resident 1's Ear Nose and Throat (ENT- treats conditions affecting your ears, nose and throat) physician had emphasized to FM 1 that Resident 1 must always sit up in chair for meals and be reminded to sweep (running your finger through the choking person's mouth in an attempt to dislodge the food or other object that is blocking the airway) his mouth to prevent food pocketing (The act of storing food inside the mouth without swallowing) to prevent aspirating on food. FM 1 and 2 stated they believed Resident 1 aspirated on the noodle during dinner which was consistent with the postmortem (After death) autopsy (A specialized surgical procedure used to determine the cause and manner of death) report for Resident 1. During a telephone interview with LVN 1 on [DATE] at 3:44 p.m., LVN 1 confirmed and stated the facility identified Resident 1 as at risk for aspiration and that Resident 1 was on a mechanical soft diet (designed for people who have trouble chewing and swallowing). LVN 1 stated that on [DATE] at around 5:30 p.m., Resident 1 was set up for dinner in bed by CNA 1. LVN 1 stated that on [DATE] at around 7 p.m., Resident 1 yelled out and was asking for water to drink. LVN 1 stated that on [DATE] at around 7:30 p.m., while LVN 1 was at a Treatment Cart (Storage for medical or treatment supplies) which was right outside Resident 1's room, LVN 1 peeked in Resident 1's room and noted that Resident 1 Did not look good. His (Resident 1) eyelids were closed and the eyeballs moving underneath the closed eyelids. LVN 1 confirmed and stated she was, Going over to a room a few doors down to give certified nurse assistant 1 (CNA 1) a topical cream (To be applied to the skin to treat ailments) to be applied on another resident. LVN 1 confirmed and stated that when she [LVN 1] returned to Resident 1's room (time unknown), she found Resident 1 unresponsive, and that Resident 1 failed to respond to a sternal rub (involves using your knuckles to vigorously rub the breastbone to find out if a patient reacts to painful stimuli). LVN 1 stated she left Resident 1 unattended (time unknown), went to the nurses' station to ask for assistance and to call for Code Blue (Term used to describe the critical status of a patient/person) before she returned to Resident 1 and initiated CPR on Resident 1. LVN 1 further stated she [LVN 1] should have gone into Resident 1's room to assess what was happening when she (LVN 1) first noticed that something was wrong. LVN 1 further stated that she should not have left Resident 1 alone when she [LVN 1] found the resident unresponsive because any second wasted could cause irreversible (Incapable of being reversed) damage. LVN 1 also stated, It is important for a resident on aspiration precautions to sit resident up to prevent aspiration. LVN 1 stated she did not perform Heimlich maneuver (The manual application of sudden upward pressure on the upper abdomen of a choking victim to force a foreign object from the trachea [The airway that leads from the voice box to the bronchi which are large airways that lead to the lungs]) because she did not think that Resident 1 could have choked while eating. During a concurrent interview and record review with the Director of Nursing (DON) on [DATE] at 5:19 p.m., Resident 1's medical chart was reviewed. The DON confirmed and stated Resident 1 was on aspiration precautions (To ensure safe swallowing and prevent aspiration). The DON stated that LVN 1 should have checked on Resident 1 immediately when LVN 1 suspected Resident 1 had a change in condition (COC - a deterioration in health, mental, or psychosocial status which can be life-threatening). The DON stated staff need to respond immediately and immediately provide necessary treatment/measures whenever a resident develops a COC. The DON stated a resident could die if found unresponsive and necessary treatment/appropriate measures are delayed. The DON stated that nurses must always stay/remain with a resident whenever the resident is non-responsive while summoning for help by shouting help. The DON stated that other nurses should check the code status (the type of emergent treatment a person would or would not receive if their heart or breathing) of the resident and call 911. The DON confirmed and stated that Resident 1 should have been supervised during meals for safety. A review of the facility's policy and procedures (P&P) titled, Emergency Procedure - Choking Disaster Emergency Response, reviewed ,d+[DATE], indicated, Trained staff will assist the resident who is choking by attempting to expel the foreign body from the airway. The P&P indicated emergency procedure for chocking in an unconscious resident includes: - Call for help if assistance is not already present but do not leave the resident unattended. - Position the resident on his or her back with the arms at his or her side. - Perform abdominal thrusts as follows: a. Facing the resident, kneel and straddle the resident's upper thighs with your body. b. Place the heel of one hand on the resident's upper mid-abdomen, below the rib cage and above the navel and with fingers pointed toward the resident's chest. c. Place the other hand directly over the positioned hand. d. Bring your shoulders forward over your hands. e. Use your body weight to press your hands into the resident's upper abdomen with a quick upward thrust. - Perform abdominal thrusts as follows: a. Facing the resident, kneel and straddle the resident's upper thighs with your body. b. Place the heel of one hand on the resident's upper mid-abdomen, below the rib cage and above the navel and with fingers pointed toward the resident's chest. c. Place the other hand directly over the positioned hand. d. Bring your shoulders forward over your hands. e. Use your body weight to press your hands into the resident's upper abdomen with a quick upward thrust.

Based on observation, interview, and record review the facility failed to provide reasonable accommodations to meet resident needs for one of 27 sampled residents (Resident 387) by failing to assess the resident for call light accommodation needs and provide an appropriate call device that Resident 387 could use independently and without risk for injury or harm. 1. On 11/25/2023 at 6:22 PM Resident 387 was observed to have a silver bell with a black handle tightly tied to resident's left middle finger with a white gauze causing an indentation (area of skin that looks pushed in close to the bone of the finger) and redness, pain, and swelling to the resident's left middle finger. 2. On 11/25/2023 at 7:57 PM, the same bell was observed tied to Resident 387's left index finger. 3. On 11/26/2023 at 8:40AM, the same bell was observed tied to Resident 387's left index finger. The deficient practice denied Resident 387 independence to use an individualized call system, and the ability to prompt staff response. Resident 387 expressed feeling isolated and being a burden to staff. Resident 387 suffered swelling, redness, numbness, and pain to her left middle finger, placing the resident at increased risk for permanent harm and injury to the left middle finger. Cross Reference: F684 Findings: A review of Resident 387's admission record indicated Resident 387 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including intraspinal abscess (an accumulation of pus in the epidural space [space in between the bones of the spine] that can mechanically compress the spinal cord[long cord that is connected to the brain and send messages to and from the brain from the body]), spinal stenosis (is the narrowing of the spine which puts pressure on the spinal cord and nerves and can cause pain), depression (a common mental disorder that involves a depressed mood or loss of pleasure or interest in activities for long periods of time) and contractures (tightening and stiffening of joints) in both hands. A review of Resident 387's Minimum Data Set (MDS- a standardized assessment and care screening tool), dated 10/10/2023, indicated Resident 387 was cognitively intact (mental ability to make decisions of daily living) and required one-person physical assist with bed mobility, dressing, toileting, and personal hygiene. The MDS indicated Resident 387 required two-person physical assistance for surface transfer and was dependent on facility staff for all care and needs and had limited mobility to both arms with contractures (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) to both hands. A review of Resident 387's history and physical (H&P- a term used to describe a physician's examination of a patient. The physician obtains a thorough medical history from the patient, performs a physical examination, and then documents their findings) dated 11/15/2023, indicated Resident 387 had the capacity to understand and make decisions. A review of Resident 387's comprehensive care plan since admission (11/01/2023) indicated Resident 387 did not have a care plan in place for the resident's call light needs. A review of the General Acute Care Hospital (GACH) H&P dated 11/14/2023 indicated, Resident 387 presented with worsening neck pain and also noted numbness and tingling in her (Resident 387) hands. The H&P indicated Resident 387 reported that the numbness and tingling in her hand was chronic (ongoing) but more recently involved her right hand as well. The H&P indicated Resident 387 had to always wear a cervical collar (a device used to support the neck and spine and limit head movement after an injury to prevent a person from moving the head and neck until the injury heals). During an interview on 11/24/2023 at 12 PM, Resident 387 stated the nurses did not respond to her calls timely. Resident 387 stated when the nurses would eventually show up but would say things like what is it now? which made her feel like she was a burden to the nurses. Resident 387 stated she would often feel isolated because the nurses could not hear ring the ringing bell tied to the resident's left middle finger. Resident 387 stated the bell was the only way she could get a hold of facility staff. During a concurrent observation and interview with Resident 387 alongside the assisted Director of Nursing (ADON) on 11/25/2023 at 6:22 p.m.,Resident 387 was observed lying down in bed a bell with a black handle tied to the resident's left middle finger with white gauze. The black handle was tied to the resident's left middle finger with a white gauze wrapped around the bell handle and was tightly tied with a knot. The ADON confirmed and stated Resident 387's left middle finger was tied to the bell. The ADON was observed to immediately untie the gauze and removed the bell from Resident 387's middle finger. Resident 387's left middle finger was indented where the gauze had been tied/applied. The base of Resident 387's left middle finger and the left middle finger knuckle (joints of the fingers right) above the indentation was swollen with redness. Resident 387 verbalized feeling pain (resident refused to scale her pain, resident stated she just was in pain) and numbness to the left middle finger. Resident 387 stated the facility gave her the bell after she notified the staff that she was unable to push the button on the call light (an alerting device for nurses or other nursing personnel to assist a patient when in need). Resident 387 stated the bell was not loud and did not catch the attention of staff. During a follow up observation and interview in Resident 387's room with the ADON on 11/25/2023 at 7:57 p.m., Resident 387 was observed with the bell tied to the resident's left index (pointer) finger. The ADON confirmed and stated the resident had the bell tied to the left index finger and that the bell was placed on Resident 387's finger upon admission on 11/01/2023. The ADON was not aware that facility staff was tying the bell to the resident's finger. When asked if the facility had looked into other options for the resident to call the staff, the ADON stated the facility had not looked at alternative call devices for Resident 387. The ADON stated the tied call bell could potentially interfere with circulation to the resident's finger. When asked how facility staff were able to hear the bell tied to Resident 387's finger, the ADON confirmed and stated the facility staff were not within earshot when Resident 387 rang the bell. During an observation on 11/26/2023 at 8:40 AM, the bell was observed tied to Resident 387's left index finger. Resident 387 stated the bell was the only way she (Resident 387) could get a hold of facility staff. A review of Resident 387's Nursing Progress Notes dated 11/26/2023 at 11:19 a.m., indicated Resident 387 with swelling to the right middle finger. The nursing progress notes indicated Resident 387 experienced pain to the right hand and requested Excedrin (pain medication) for the swollen finger. The progress notes did not indicate the level of pain the resident was experiencing. There was no documented evidence on the nursing progress notes regarding Resident 387's left index finger or the left middle finger. During an interview with Certified Nursing Assistant (CNA) 5 on 11/26/2023 at 12:51 p.m., CNA 5 confirmed and stated the bell was wrapped around Resident 387's left middle finger for approximately one week when CNA 5 began caring for the resident. CNA 5 stated all the nurses were aware that the bell was tied to the resident's left index finger and left middle finger. A review of the facility's policy and procedures (P&P) titled Answering the Call Light reviewed 10/2023, indicated, The purpose of this procedure is to ensure timely responses to the resident's requests and needs. The P&P general guidelines were as follows: 1. Upon admission and periodically as needed, explain, and demonstrate use of the call light to the resident. 2. Ask the resident to return the demonstration. 3. Explain to the resident that a call system is also located in his/her bathroom. 4. Be sure that the call light is plugged in and functioning at all times. 5. Ensure that the call light is accessible to the resident when in bed, from the toilet, from the shower or bathing facility and from the floor. 6. Report all defective call lights to the nurse supervisor promptly. A review of the facility's P&P titled Accommodation of Needs reviewed 1/2023, indicated, Our facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving safe independent functioning, dignity and well-being. The resident's individual needs and preferences are accommodated to the extent possible, except when the health and safety of the individual or other residents would be endangered. The resident's individual needs and preferences, including the need for adaptive devices and modifications to the physical environment, are evaluated upon admission and reviewed on an ongoing basis.

Based on observation, interview, and record review, the facility failed staff responded to residents call light timely for three of five sampled residents (Residents 2, 4, and 5) in accordance with the facility's policy and procedures (P&P) n accordance with the facility's undated P&P titled, Answering the Call Light. The facility was aware Resident 2 was a high risk for fall and had disorders of bone density and structure (Osteoporosis is a bone disease that develops when bone mineral density and bone mass decreases, or when the quality or structure of bone changes). Residents 4 and 5 were dependent on staff for activities of daily living (ADL) As a result, 1. On 9/24/2023, Resident 2 pressed the call light waited for 50 minutes from for facility staff to respond to call light. On 9/24/2023 at 6:50 a.m., Resident 2 got up to use the bathroom fell and suffered right knee swelling and pain level of five out of 10 (5/10 - numerical pain assessment where zero is no pain and 10 is severe pain). On 9/24/2023 at 11:32 a.m., Resident 2 was transferred to General Acute Care Hospital 1 (GACH 1) where Resident 2 was diagnosed with right femur fracture (break in a bone). Resident 2 was diagnosed with acute (of sudden onset) nondisplaced fracture (a crack or a break in a bone but the bone retains its alignment) of the proximal anterior (front) and lateral (to the side of) femoral cortex (thigh bone) in the intertrochanteric region (located between the greater and lesser trochanters (a bony prominence on the side of the thigh bone) and acute distal (away from a specific area) lateral femoral fracture (fractures of the thighbone that occur just above the knee joint). 2. Resident 4 and Resident 5 both stated they waited for about 15 minutes for a staff member to answer their call lights and that the response to call lights was longer when staff are on break and during shift change. Resident 5 stated what can I do, I just have to wait. Findings: 1. A record review of Resident 2's Admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including urinary tract infection (UTI- an infection in any part of the urinary system, including the kidney [remove waste products from the blood and produce urine], bladder [A hollow organ in the lower abdomen that stores urine] or urethra[a canal that in most mammals carries off urine from the bladder]), centrilobular emphysema (lung condition that causes shortness of breath), disorders of bone density and structure and spinal stenosis (narrowing of the spaces within the spine, which can put pressure on the nerves that travel through the spine). A record review of Resident 2's Minimum Data Set (MDS - a standardized assessment and screening tool), dated 9/24/2023, indicated Resident 2's cognitive skill (mental action or process of acquiring knowledge and understanding) for daily decision-making were moderately impaired. The MDS indicated Resident 2 required one person staff physical assistance for activities of daily living (ADL - bed mobility, walking, locomotion (the act or the power of moving from place to place) on and off the unit, toileting, dressing, and grooming). The MDS indicated Resident 2 was not steady (ability to balance) for surface to surface transfers, walking, and seated to standing position. The MDS indicated Resident 2 used a wheelchair and a walker for mobility. A record review of Resident 2's Morse Fall Risk Screen (Fall Risk Assessment tool that predicts the likelihood that a patient will fall), dated 9/23/2023, indicated, Resident 2 had impaired (imperfect/weakened) gait. The fall risk assessment tool indicating Resident 2 was a high risk for falls. A record review of Resident 2's care plan on Limited Physical Mobility, created on 9/23/2023, indicated, the goal was that Resident 2 would remain free of complications related to immobility. The care plan interventions indicated Resident 2 required staff assistance to walk as necessary. A record review of Resident 2's care plan on High Risk for Falls and Injury, created on 9/24/2023, indicated interventions included to provide assistance as needed with transfer and ambulation . provide assistance as needed in toileting and to not leave Resident 2 unattended. The care plan indicated to pay attention to Resident 2's attempt to communicate needs. A record review of Resident 2's care plan on Impaired bladder function related to (R/T) Benign prostatic hyperplasia (BPH - is a condition in men in which the prostate gland [a gland in the male reproductive system that is located just below the bladder] is enlarged and not cancerous) initiated 9/24/2023, indicated to provide Resident 2 with assistance needed in toileting. A record review of Resident 2's Progress Notes dated 9/24/2023, indicated that on 9/24/2023 at 6:50 a.m., Registered Nurse 3 (RN 3) documented that Resident 2 had unwitnessed fall on 9/24/2023 at 5 a.m. Resident 2 was alert but confused . complained of 5/10 right knee pain, and pain medication administered. Resident 2's right knee was swollen, cold compress applied, texted attending physician . awaiting further orders . A review of Resident 2's document titled, Change of Condition (COC - a deterioration in health, mental, or psychosocial status) dated 9/24/2023 at 7:44 a.m., indicated Resident 2 had unwitnessed fall. patient pain level reduces. patient should be placed on more observation for any swelling or discomfort on the affected knee and that a physician was notified on 9/24/2023 at 5:45 a.m. who ordered to transfer Resident 2 to an emergency room (ER - a hospital room or area staffed and equipped for the reception and treatment of persons requiring immediate medical care). The COC document indicated Resident 2 received hydrocodone (controlled strong pain medication) and Tylenol for musculoskeletal (muscle and bone) pain for pain level of 5/10. The COC document indicated Resident 2 had marked localized bruising (skin discoloration from damaged, leaking blood vessels underneath your skin), swelling, or pain over joint or bone. A record review of Resident 2's Progress Notes dated 9/24/2023, indicated that on 9/24/2023 at 8:25 a.m., RN 1 documented that, Resident 2 was reassessed due to post fall with swollen with limited movement on right knee noted. The progress note indicated Resident 2 said that he received pain medication and did not have pain, but that his knee was getting more swollen. Noted to Attending Physician 1 regarding resident status . received order with x-ray (a picture which is taken using a form of radiation that is able to pass through the body to create a digital Xray image) immediately or transfer to emergency department to evaluate if unable to bear weight . Reassessed [Resident 2] and [Resident 2] with movement more limited noted at this time. Re-informed Attending Physician 1 and clarified order with transfer to GACH 1 for further evaluation after fall with right knee swelling. A review of Resident 2's Order Summary Report, indicated that on 9/24/2023, the facility received a physician's orders an order was received STAT (now) Xray of the right knee status post (s/p - after) fall with swelling and to transfer to GACH 1 ER for further evaluation s/p fall with right knee swelling. A record review of Resident 2's Nurses Notes Note dated 9/24/2023 at 11:32 a.m., indicated non-emergency ambulance transferred Resident 2 to GACH 2 ER for further evaluation in stable condition and the right knee pain level was 3/10. A record review of GACH 1 Orthopedic Surgery Trauma/General Consult notes for Resident 1 dated 9/24/2023 at 12:03 p.m., indicated that: a. Resident 2 was admitted to GACH 1 on 9/24/2023 and the chief complaint was right knee pain. The Orthopedic Surgery Trauma/General Consult notes indicated Resident 2, with severe right knee pain . lost his balance while walking and sustained a ground-level fall landing on his right knee. Resident endorses feeling immediate 10/10 pain in the right knee, which was made worse with movement and improved with rest . b. X-ray of the right femur, right knee, right tibia fibula (the two long bones located in the lower leg) and right ankle for Resident 2, completed on 9/24/2023, revealed, moderate to large right knee lipohemarthrosis (a mixture of fat and blood in a joint cavity following trauma) with a probable minimally impacted fracture of the lateral tibial plateau (an injury in which you break your bone and injure the cartilage that covers the top end of your tibia (bottom part of your knee). c. Computed tomography (CT scan - is a diagnostic imaging procedure that uses a combination of X-rays and computer technology to produce images of the inside of the body) right knee for Resident 2, collected on 9/25/2023, revealed the following: i. Interval development (the change that occurs in the interval between two scans) of acute nondisplaced fracture of the proximal anterior and lateral femoral cortex in the intertrochanteric region terminating just distal to anterior (a position in a limb that is farther from the point of) intertrochanteric area. ii. Acute distal lateral femoral shaft fracture (fractures are high energy injuries to the femur that are associated with life-threatening injuries) extending to metaphyseal junction (a type of bone fracture that occurs in the metaphysis, the wider part of the bone near the growth plate) with femoral condyles (the smooth surface area at the end of a bone, forming part of a joint). On 10/25/2023 at 9:10 a.m., during an interview with Family Member 3 (FM 3), FM 3 stated, that on 9/24/2023 at approximately 5:25 a.m., Resident 2 fell in the facility while trying to go to the bathroom. FM 3 stated Resident 2 told FM 3 that he used the call light for staff assistance to go to the bathroom, but the facility staff did not respond to his call light. FM 3 stated Resident 2 then got up on his own to go to the bathroom but fell and hit his knee on the floor. FM 3 stated that on 9/24/2023 at 6 a.m., RN 3 telephoned and informed her that Resident 2 fell down. FM 3 stated she went to the facility right away and found Resident 2 complaining of pain on the right knee and Resident 2 had an ice pack on the right knee. On 10/25/2023 at 9:10 a.m., during an interview, FM 3 stated, RN 3 called and left message for Resident 2's physician but since it was a Sunday and early morning, the facility might not get a return call until the next business hours.FM 3 stated RN 3 suggested that FM 3 to go home, but FM 3 refused to go home. FM3 stated RN 3 did not follow up with Resident 2's physician about Resident 2's fall and that Resident 2 was complaining of right knee pain. FM 3 stated RN 1 (working the 7 am to 3 pm shift) reported to work and informed FM 3 that the Resident 2 will be transferred to a GACH because of the right knee pain and swelling. FM 3 stated GACH 1 diagnosed Resident 2 with a fractured right femur and that GACH 1 applied a cast on Resident 2's right leg. On 10/25/2023 at 4:01 p.m., during an interview with RN 3, RN 3 stated that on 9/24/2023 at 5 a.m., Resident 2 had an unwitnessed fall and that she [RN 3] found Resident 2 on the floor next to Resident 2's bed. RN 3 stated, if a resident falls, then complains of swelling and pain, the resident may have sustained a fracture. RN 3 stated that her documentation on 9/25/2923 regarding Resident 2 falling, indicated that Resident 2 may have suffered a fracture after the fall. RN 3 stated she was not able to get a hold of a physician and get an order for an X-ray to rule out a fracture. RN 3 stated, she left a message for Resident 2's attending physician after she found Resident 2's on the floor. On 10/25/2023 at 4:01 p.m., during an interview RN 3 stated, but they (facility) usually do not get a return call from a physician until the next business hours. When asked if there was any other physician that the facility could contact, RN 3 stated, Yes. They [facility] can call the Medical Doctor (MD). However, RN 3 stated, she did not know who the MD was or how she could contact the MD because she did not work in the facility often. RN 3 stated, she did not document that she followed up with Resident 2's attending physician after leaving a message, and did not try to contact the facility's MD. On 10/26/2023 at 6:50 p.m., during an interview with Director of Nursing (DON), DON stated a physician should follow up with residents following unwitnessed fall and had symptoms of pain and swelling after the fall, to rule out injury(ies) such as fractures. DON stated licensed nurses are responsible to contact the facility's MD if a resident's attending physician was unavailable. 2a. A record review of Resident 4's Admission Record indicated Resident 4 was admitted to the facility on [DATE] with diagnoses including scoliosis (sideway curvature of the spine [back bone]), intervertebral disc degeneration (age-related wear and tear on discs, causing pain and instability) and abnormalities of gait (a person's manner of walking) and mobility. A record review of Resident 4's dated 9/29/2023, indicated Resident 4's cognitive skill for daily decision-making was intact. The MDS indicated Resident 4 required extensive assistance to total dependence from staff for ADL (bed mobility, surface to surface transfers, toilet use and personal hygiene). On 11/15/2023 at 11:44 a.m., during an interview with Resident 4, Resident 4 stated, he pressed the call light because he needed assistance and was wanted to request for a new incontinent brief (a piece of absorbent material wrapped around a person's bottom and between the legs to absorb and retain urine and feces. Resident 4 stated, he had waited for more than 10 minutes for facility staff to answer his call light. 2b. A record review of Resident 5's Admission Record indicated Resident 5 was admitted to the facility on [DATE] with diagnoses including aftercare (the care of people after they have left a hospital) following joint replacement surgery (a procedure done to realign or replacing a joint in the body with a prosthesis (a device designed to replace a missing part of the body or to make a part of the body work better), disorder of muscle, and abnormalities of gait and mobility. A record review of Resident 5's dated 11/2/2023, indicated Resident 5's cognitive skill for daily decision-making was intact. The MDS indicated Resident 5 required moderate to maximum assistance from staff for ADL (sitting to lying, toileting, showering). On 11/15/2023 at 11:33 a.m., during an observation, the call light for Resident 4 and Resident 5 was on, and the call light was buzzing and could be heard at the nursing station. On 11/15/2023 at 11:43 a.m., during a concurrent observation, Licensed Vocational Nurse 6 (LVN 6) entered Resident 4 room and then entered Resident 5's room to answer the call lights. During a concurrent interview, LVN 6 stated, some of the staffs were on lunch break and she had to attend to residents' call lights. Resident 4 stated, he pressed the call for staff to clean his room. Resident 4 stated he waited for about 15 minutes for someone to answer the call light. Resident 4 stated staff delay in responding to call lights during breaktime and change of shift. On 11/15/2023 at 12:04 p.m., during an interview with Resident 5, Resident 5 stated, she pressed the call light because she wanted to request for Tylenol (pain medication) and needed assistance for someone to clean her room. Resident 5 stated, she had come from physical therapy and was in pain in her legs. Resident 5 stated she waited for about 15 minutes for someone to answer the call light. Resident 5 state, what can I do, I just have to wait. Resident 5 stated staff delay in responding to call lights during breaktime and change of shift. On 11/15/2023 at 4:45 p.m., during an interview with RN 1, RN 1 stated, all staffs are responsible to answer residents' the call light. RN 1 stated, when staff are on break, another staff must cover for them (staff on break). RN 1 stated, call light should be answered timely especially for residents who are on fall risk. A review of the facility's policy and procedures (P&P) titled, Fall and Fall Risk, Managing, revised 1/2023, indicated, The staff will monitor and document each resident's response to interventions intended to reduce failing or the risks of falling . A review of the facility's P&P titled, Fall Prevention Policy, reviewed and updated on 1/2023, indicated, Facility is dedicated to providing a safe and secure environment for residents, employees, and visitors. The prevention of falls is of utmost importance to ensure the well-being and safety of our residents . clinical staffs to implement fall prevention interventions based on individualized care plans . ensure that staff members are trained in responding to falls and providing appropriate care. A review of the facility's undated P&P titled, Answering the Call Light, indicated the purpose of this procedure is to ensure timely responses to the resident's requests and needs.

Cross Reference F600 Based on interview, and record review, for 35 of 35 caregivers, the facility failed: 1. To make reasonable efforts to ensure contracted workers received training in elder and dependent adult abuse protocols and abuse prevention in accordance with the facility's undated Prohibition of Abuse, Neglect and/or Misappropriation of Resident Property and Mandated Reporting, Orientation Program for Newly Hired Employees, Transfers, Volunteers revised on 5/2019, and Caregiver, Non-Staff Reviewed on 1/2023, 2. To provide orientation program for all contracted caregivers in accordance with the facility's policy and procedures titled Orientation Program for Newly Hired Employees, Transfers, Volunteers, revised on 5/2019, by failing to: a. Ensure all caregivers attended a 10-hour orientation program within their first five (5) days of hire. b. Maintain written record of 35 of 35 care givers participation of orientation program. c. Maintain orientation records that includes date reviewed, caregiver's initials, subject matter reviewed, and other information deemed necessary or appropriate. d. Maintain records of caregivers personnel file upon completion of orientation program. e. Ensure all non-staff care givers adhere to facility's policy and State/Federal regulations. These deficient practices resulted in caregiver 1 (CG1) hitting Resident 1 and had the potential for further undetected abuse by 35 caregivers in the facility and severe psychosocial harm for Resident 1 and 19 identified residents assigned to the 35 caregivers. On 10/13/2023 at 2:39 p.m. while onsite, the State Survey Agency (SSA) called an Immediate Jeopardy (IJ - a situation in which the facility's non-compliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death of a resident) in the presence of the Administrator (ADM), Director of Nursing (DON), Assistant Director of Nursing (ADON), Minimum Data Set coordinator (MDS), Medical Records Director (MRD) and Assistant Social Services Director (ASSD) because of the seriousness related to the facility 's failure to protect Resident 1 from abuse from CG1 on 10/11/2023. On 10/15/2023 at 3:28 p.m., the facility provided acceptable IJ Removal Plan (interventions to correct the deficient practice). While onsite, the survey team confirmed implementation of the IJ corrective actions through interview, and record review. The SSA removed the IJ on 10/13/2023 at 2:39 p.m. in the presence of the ADM and DON. A review of the IJ removal plan indicated that: 1. On 10/11/2023, the Social Services Director (SSD) and RN1 reported the allegation of abuse to the Ombudsman, SSA and police department. 2. On 10/11/23, ADON initiated a Change in Condition (COC- a major decline or improvement in a resident's status that will not normally resolve itself without intervention from staff) for Resident 1 regarding the abuse allegation. Resident 1's condition was monitored for physical, emotional and/or mental distress and COC since 10/11/2023. Resident 1's comprehensive care plan was updated to reflect the physical abuse and incident and in-service education on abuse prevention and mandatory background checks were completed on R1's all of caregivers as corrective actions prevent recurrence and to ensure Resident 1 will continue to feel safe and secure in the facility. Resident 1 continues to be totally dependent for bed mobility, dressing, eating, toilet use and personal hygiene and expressed feeling safe and secure. 3. On 10/11/2023, CG1 was immediately escorted out of the facility with assistance of police. The facility notified CG1s employer of the witnessed physical abuse inflicted by CG1 on Resident 1. CG1 will never return to the facility and that CG1's services were no longer needed. 4. On 10/11/2023, SSD conducted a follow up visit with Resident 1 at bedside for psychosocial distress from the incident being hit by a caregiver on her right thigh. 5. On 10/11/2023, the DON and Director of Staff Development (DSD) initiated the following: a. Criminal background checks on all 35 caregivers in the facility. b. Issued Identification Badges that indicated the name and title of all caregivers in the facility. c. Provided In-service training on Abuse reporting and Abuse preventions to all caregivers inside the facility. 6. The DON conducted one to one (1:1- teaching that takes place directly between a single student and teacher) caregiver in-service education to DSD regarding abuse training, screening/ background checks, orientation and onboarding per facility policy and procedures on orientation Program for newly hired employees/transfers/volunteers/contractors/caregivers. 7. On 10/13/2023, the ADM informed the Medical Director about the IJ in the facility. 8. On 10/14/2023, a psychologist (a professional trained and qualified to address emotional and behavioral issues) visited Resident 1. 9. On 10/14/2023, the DSD conducted a screening/background verification review on all 35 caregivers in the facility. The facility determined that there were no negative findings noted. 10. On 10/14/2023, the ADM and/ or Designee conducted an in-service on abuse to the facility's Interdisciplinary team (IDT- a group of health care professionals with various areas of expertise who work together toward the goals of their clients) with emphasis on: a. Types and prohibition of Abuse b. Neglect and misappropriation of property c. Mandated reporting d. Onboarding and orientation procedures per policy and procedures e. Background checks and screenings to all newly hired employees/transfers/caregivers/contractors/vendors Findings: A review of facility's in-services dated 6/6/2023, indicated the facility provided training to all staff on resident rights, reporting elder and dependent adult Abuse. A review of Resident 1's admission record indicated Resident 1 was admitted in the facility on 8/29/2023 with diagnoses including dementia (a loss of memory, language, problem-solving and other thinking abilities that interfere with daily life), fracture of the left femur (a break in the left thigh bone), dysphagia (difficulty swallowing- taking more time and effort to move food or liquid from your mouth to your stomach) and anxiety disorder (persistent and excessive worry that interferes with daily activities). A review of Resident 1's care plan initiated on 8/30/2023, related to altered thought process, indicated Resident 1 had short term memory problem, was unable recall conversations after 5 minutes, had long term memory impairment, was unable to make decision, is Poor at decision making, has Problems understanding others, had problem making needs known, . had periods of confusion and disorientation (when a person is confused about the time, location or identity), . The interventions included explaining all procedures to Resident 1, anticipate Resident 1's needs, . pay attention to resident's attempt to communicate needs. A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 8/31/2023, indicated Resident 1 had moderately impaired cognition (the mental ability to understand and make decisions of daily living), was non-ambulatory (unable to walk), and was totally dependent on staff for bed mobility, dressing, eating, toilet use and personal hygiene. A review of Resident 1's Progress Notes dated 10/11/2023 at 11:40 a.m., indicated that on 10/11/2023 at around 6 a.m., morning, Registered Nurse (RN1) reported to the DON and the ADM that he [RN1] witnessed CG1 hit Resident 1 when CG1 was providing care to Resident 1. RN1 intervened immediately and escorted CG1 outside Resident 1's room and notified police. RN1 ensured Resident 1 was safe and treatment nurse 1 (TX1) together with RN1 performed a thorough performed body check on Resident 1. The progress notes indicated, no . discomfort and/or injuries were discovered on Resident 1 and that Resident 1's Power of Attorney (POA- a someone that makes decisions about a person health care in case the person is not able to make decisions) and the primary physician were informed of the abuse incident. A review of Resident 1's Physician Order Summary dated 10/11/2023, indicated effective 10/11/2023, the facility to provide witnessed care on every shift for Resident 1. On 10/12/2023 at 1:05 p.m., during a telephone interview with CG1, CG1 stated she works for a staffing agency and has been a private caregiver for R1 for the past six (6) years. CG1 stated she has been Resident 1's caregiver since Resident 1 was admitted to the facility on [DATE]. CG1 stated while in the facility she feeds, bathes, changes bed linen, makes the bed and cleans Resident 1. CG1 stated she ensures Resident 1 is always comfortable. CG1 stated on 10/11/2023 at around 6 a.m., she had just completed a bed bath and while repositioning Resident 1, Resident 1 kicked her [CG1] in the chest. CG1 stated Resident 1 was yelling help help. CG1 stated she held Resident 1's legs down so Resident 1 would not kick her again. CG1 stated RN1 opened the door to Resident 1's room and immediately asked did you hit her [Resident 1]?. CG1 stated she told RN1, no I did not hit [Resident 1]. CG1 stated she told RN1 that Resident 1 had just kicked her in the chest, and that she was holding Resident 1's legs down on the bed to prevent Resident 1 from kicking her again. CG1 stated she was about to place a cover on Resident 1 when she heard RN1 say that is elderly abuse and that RN1 was going to call the police. CG1 further stated Resident 1 had lower extremity leg fracture and would always yell when being repositioned. CG1 stated she repositioned Resident 1 to prevent Resident 1 from developing of pressure ulcer (Injury to skin and underlying tissue resulting from prolonged pressure on the skin.). CG1 stated two police officers arrived at the facility and that one of police officer interviewed her CG1 while the other police officer went to Resident 1's room. CG1 stated RN1 told the two police officers that CG1's services were no longer needed in the facility. The police officers helped her retrieve her belongings at Resident 1's bedside, then she went home. CG1 stated the facility had never asked her for her background check and had never required caregivers to have/wear any form of identification. CG1 stated the facility had never provided her any orientation/inserviced her on abuse prevention or reporting prior to and/or during the time she was providing care to Resident 1. CG1 stated she received abuse training through the staffing agency that hired her on 4/5/2023. On 10/12/2023 at 2:47 pm during an interview with DSD, DSD stated the facility had 35 caregivers who provided direct care to 19 residents respective at different times of the day. DSD stated all the 35 caregivers were either hired privately by the residents' family members or by the facility through staffing agencies to provide care to residents in the facility. DSD further stated the facility did not have any documentation/personal files for all the 35 caregivers in the facility. DSD stated the facility did not have any background checks documentation nor conducted any background searched for all 35 caregivers in the facility. DSD stated all 35 caregivers did not have form identification and the facility did not provide any abuse training for all 35 caregivers in the facility. DSD stated she did not know (was not aware) the work hours (schedule) for all 35 caregivers in the facility. DSD further stated the facility should have ensured all 35 caregivers had background checks, identification, abuse training prior to entering the facility and providing care to residents. DSD stated background searches and personal files would ensure that all 35 caregivers had no criminal history such as resident abuse and had received required training to safely provide care to the residents in the facility. DSD further stated, that effective 10/11/2023, the facility initiated the process of compiling information for all 35 caregivers after the abuse incident was reported for Resident 1. On 10/12/2024 at 4:47 p.m., during a telephone interview with RN1, RN1 stated he heard noise opened the closed door to Resident 1's room. RN1 stated he observed CG1's back was towards the door and that CG1 was facing Resident 1. RN1 further stated he observed CG1's left hand in up and down motion and heard slapping noise. RN1 stated he heard CG1 tell Resident 1 to stop hitting me. RN1 stated he then asked CG1 what are you doing, and CG1 told RN1 that Resident 1 had just kicked her in the chest. RN1 asked CG1 who is hitting who and CG1 did not say anything to RN1. RN1 stated he separated CG1 from R1 and asked CG1 to leave and told CG1 this is physical abuse. RN1 stated he called the police, the police came and interviewed RN1 and CG1. The Police retrieved CG1s belongings (her purse and jacket ) from Resident 1's bed side table and escorted CG1 off the premises. RN1 stated he told CG1 not to return to the facility and that CG1 services would not be needed. RN1 stated he immediately notified the DON and ADM and reported the incident to CDPH. On 10/14/2023 at 1:30 p.m., during an interview with the ADM and DON, the ADM and DON stated there were a total of 35 private caregivers in the facility at any given time that provide direct care to 19 residents in the facility. The ADM and DON stated the facility did not have any background or performed any background checks on all 35 caregivers. The ADM and DON stated the facility had not conducted in-services on abuse to all 35 caregivers. The ADM and DON further stated Background checks and abuse in-services ,should have been done prior to the caregivers working in the facility. The DON stated the reason for conducting background checks and providing abuse in-services training was to prevent resident abuse and to ensure caregivers understood and were competent in their roles and responsibilities, knew their limitations and adhered to the facility's policies and procedures on Abuse prevention and reporting. On 10/14/2023 at 1:35p.m., during an interview with the DON, the DON stated State and Federal regulations require that the facility provide . background checks, . for all caregivers, . DON stated facility should implement background checks and provided in-service training on abuse for all the 35 caregivers prior to having them provide caregiving services to the facility residents. The DON further stated the DSD must be clear all caregivers before providing care to any resident in the facility. A review of facility's undated policy and procedures title Prohibition Of Abuse, Neglect and/or Misappropriation of Resident Property and Mandating Reporting, indicated, All residents shall be free from mistreatment, neglect, abuse, exploitation and misappropriation of resident property by anyone, including, but not limited to, facility staff, other residents, consultants, contractors or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends or other individuals who provide care and services to residents on behalf of the facility. The facility shall make reasonable efforts to ensure that contracted workers provided by temporary placement agencies or contracted health services providing care have received training in elder and dependent adult abuse protocols and abuse prevention. Such efforts may include, but not be limited to: a. Contract clauses specifying abuse training has been provided. b. Verification of agency's employee orientation checklist and/or training programs c. Verification of agency's employment screening policies and procedures d. Distribution of the facility's policies and procedures regarding abuse prohibition. e. Participation in the facility's abuse prevention training programs. A review of facility's policy and procedures titled Caregiver, Non-Staff Policy & Procedure revised on 1/2023 indicated, It is the policy of this facility to allow non-staff care givers (family members, private duty and other care givers) to assist in the provision of care to residents within the scope of State and Federal regulations and according to the provisions of this policy. The Policy further states all non-staff caregivers will adhere to facility policy and state and federal regulations. A review of facility's policy and procedures titled Orientation Program for Newly Hired Employees, Transfers, Volunteers, revised on 5/2019 indicated, An orientation program shall be conducted for all newly hired employees, transfers from other departments, those providing services under contractual arrangements, and volunteers. All newly hired personnel/volunteers/transfers/contractors must attend a 10-hr orientation program within the first five (5) days of hire. Facility orientation program includes but is not limited to: a. A tour of the facility, which includes: (1) An overview of the resident's daily routine; and . An introduction to resident care procedures, which includes, but is not limited to: (2) A review of the facility's In-Service Training Program. b. An introduction of our administrative structure, which includes: (1) A review of resident rights; and (2) A review of personnel policies.

Based on interviews and record review, the facility failed to protect the rights of one of four sampled residents (Resident 1) to be free from physical abuse (any intentional act not limited to slapping, pinching, choking, kicking, shoving) by caregiver 1 (CG1) in accordance with the facility's undated policy and procedures titled Prohibition Of Abuse, Neglect and/or Misappropriation of Resident Property and Mandating Reporting by failing to: 1. Ensure CG1 did not hit and slap Resident 1 on the leg on 10/11/2023 at 6 a.m. Resident 1's diagnoses included dementia (progressive, persistent loss of intellectual functioning, especially with impairment (significant disturbance in an individual's cognition, emotional regulation, or behavior) of memory and abstract thinking). 2. Screen and conduct criminal background searches for four of 35 caregivers before hire and before being allowed to provide direct care to four of four residents (Resident 1, Resident 5, Resident 6, Resident 7). 3. Ensure CG1, CG2, CG3, CG4, CG5 and CG6 received abuse training prior to hire, and providing care and having direct contact with Resident 1, Resident 5, Resident 6, and Resident 7. 4. Secure a contract with the care givers staffing agency prior to hiring the caregivers. These deficient practices resulted in CG1 hitting Resident 1 on the right leg with CG1's open left hand with the potential for Resident 1 to suffer physical pain and psychosocial (to do with mental, emotional, social, and spiritual health) harm, mental anguish, and emotional distress and had the potential to result in abuse of (Resident 1, Resident 5, Resident 6, and Resident 7). On 10/11/2023 at around 6 a.m., Registered Nurse 1 (RN1) heard Resident 1, who had a diagnosis of dementia, who was dependent on staff for activities of daily living (ADL- mobility, eating, personal hygiene, toileting, personal grooming, surface transfers), scream loudly for help. Upon entering Resident 1's room, RN 1 witnessed CG1 hit Resident 1 on the right thigh with her left hand. CG1 told RN1 that Resident 1 kicked CG1 on the chest. On 10/13/2023 at 2:39 p.m. while onsite, the State Survey Agency (SSA) called an Immediate Jeopardy (IJ - a situation in which the facility's non-compliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death of a resident) in the presence of the Administrator (ADM), Director of Nursing (DON), Assistant Director of Nursing (ADON), Minimum Data Set coordinator (MDS), Medical Records Director (MRD) and Assistant Social Services Director (ASSD) because of the seriousness related to the facility 's failure to protect Resident 1 from abuse from CG1 on 10/11/2023. On 10/15/2023 at 3:28 p.m., the facility provided an acceptable IJ Removal Plan (interventions to correct the deficient practice). While onsite, the survey team confirmed implementation of the IJ corrective actions through interview, and record review. The SSA removed the IJ on 10/13/2023 at 2:39 p.m. in the presence of the ADM and DON. A review of the IJ removal plan indicated that: 1. On 10/11/2023, the Social Services Director (SSD) and RN1 reported the allegation of abuse to the Ombudsman (a person usually appointed by the government who investigates, reports on, and helps settle complaints), SSA and police department. 2. On 10/11/23, the ADON initiated a Change in Condition (COC- a major decline or improvement in a resident's status that will not normally resolve itself without intervention from staff) for Resident 1 regarding the abuse allegation. Resident 1's condition was monitored for physical, emotional and/or mental distress and COC since 10/11/2023. Resident 1's comprehensive care plan was updated to reflect the physical abuse and incident and in-service education on abuse prevention and mandatory background checks were completed on all of Resident 1's caregivers as corrective actions to prevent recurrence and to ensure Resident 1 will continue to feel safe and secure in the facility. Resident 1 continues to be totally dependent for bed mobility, dressing, eating, toilet use and personal hygiene and felt safe and secure. 3. On 10/11/2023, CG1 was immediately escorted out of the facility with assistance of the police. The facility notified CG1s employer [staffing agency] of the witnessed physical abuse inflicted by CG1 on Resident 1. CG1 will never return to the facility and that CG1's services were no longer needed. 4. On 10/11/2023, SSD conducted a follow up visit with Resident 1 at the bedside for psychosocial distress regarding the incident of being hit by a caregiver on her right thigh. 5. On 10/11/2023 the DON and Director of Staff Development (DSD) initiated the following: a. Criminal background checks on all 35 caregivers in the facility. b. The facility issued Identification Badges which included the names and titles of all caregivers in the facility. c. The facility provided in-service training on abuse reporting and abuse preventions to all caregivers in the facility. 6. The DON conducted one to one (1:1- teaching that takes place directly between a single student and teacher) caregiver in-service education with the DSD regarding abuse training, screening and background checks, orientation and onboarding per facility policy and procedures on Orientation Program for newly hired employees/transfers/volunteers/contractors/caregivers. 7. On 10/13/2023, the ADM informed the Medical Director about the IJ in the facility. 8. On 10/14/2023, a psychologist (a professional trained and qualified to address emotional and behavioral issues) visited Resident 1. 9. On 10/14/2023, the DSD conducted a screening and background verification review on all 35 caregivers in the facility. The facility determined that there were no negative findings noted. 10. On 10/14/2023, the ADM and/ or Designee conducted an in-service on abuse with the facility's Interdisciplinary team (IDT- a group of health care professionals with various areas of expertise who work together toward the goals of their clients) with emphasis on: a. Types and prohibition of Abuse b. Neglect and misappropriation of property c. Mandated reporting d. Onboarding and orientation procedures per policy and procedures e. Background checks and screenings to all newly hired employees, transfers, caregivers, contractors, and vendors Findings: A review of the facility's in-services dated 6/6/2023, indicated the facility provided training to all staff on resident rights, reporting elder and dependent adult Abuse. A review of Resident 1's admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included dementia, fracture of the left femur (a break in the left thigh bone), dysphagia (difficulty swallowing- taking more time and effort to move food or liquid from your mouth to your stomach) and anxiety disorder (persistent and excessive worry that interferes with daily activities). A review of Resident 1's care plan initiated on 8/30/2023, related to altered thought process, indicated Resident 1 had short term memory problem, was unable to recall conversations after five minutes, had long-term memory impairment, was unable to make decisions, is poor at decision making, has problems understanding others, had problem making needs known, . had periods of confusion and disorientation (when a person is confused about the time, location or identity), . The interventions included explaining all procedures to Resident 1, anticipate Resident 1's needs, . pay attention to resident's attempt to communicate needs. A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 8/31/2023, indicated Resident 1 had moderately impaired cognition (the mental ability to understand and make decisions of daily living), was non-ambulatory (unable to walk), and was totally dependent on staff for bed mobility, dressing, eating, toilet use and personal hygiene. A review of Resident 1's Progress Notes dated 10/11/2023 at 11:40 a.m., indicated on 10/11/2023 at around 6 a.m., RN1 reported to the DON and the ADM that he [RN1] witnessed CG1 hit Resident 1 when CG1 was providing care to Resident 1. RN1 intervened immediately and escorted CG1 outside Resident 1's room and notified police. RN1 ensured Resident 1 was safe and treatment nurse 1 (TX1) together with RN1 performed a thorough body check on Resident 1. The progress notes indicated, No . discomfort and/or injuries were discovered on Resident 1 and that Resident 1's Power of Attorney (POA- a someone that makes decisions about a person health care in case the person is not able to make decisions) and the primary physician were informed of the abuse incident. A review of Resident 1's Physician Order Summary report dated 10/11/2023, indicated effective 10/11/2023, the facility to provide witnessed care on every shift for Resident 1. A review of the facility's investigation report dated 10/23/2023, indicated the facility initially substantiated (proved) the abuse incident on Resident 1. However, the facility later unsubstantiated the allegation because there was only one witness (RN1). A review of Resident 5's admission record indicated Resident 5 was admitted to the facility on [DATE] with diagnoses of right femur fracture major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), chronic obstructive pulmonary disease (COPD-common lung disease causing restricted airflow and breathing problems) and dysphagia (difficulty swallowing). A review of Resident 5's MDS dated [DATE], indicated Resident 5 had severely impaired cognition and required extensive staff assistance with bed mobility, transfers, dressing, eating, toilet use and personal hygiene. A review of Resident 6's admission record indicated Resident 6 was admitted to the facility on [DATE] with diagnoses of fracture of left femur dementia (progressive, persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking) hypertension (blood pressure that is higher than normal hyperlipidemia (abnormally high levels of fats (lipids) in the blood) A review of Resident 6's MDS dated [DATE], indicated Resident 6 had severely impaired cognition was non-ambulatory and requires limited staff assistance with personal hygiene and extensive staff assistance with bed mobility, dressing and toilet use. A review of Resident 7's admission record indicated Resident 7 was admitted to the facility on [DATE] with diagnoses that included hemiplegia (severe or complete loss of strength leading to paralysis on one side of the body) and hemiparesis (related conditions that cause weakness on one side of the body), atrial fibrillation (afib- an irregular and often very rapid heart rhythm), and hypothyroidism (a condition in which the thyroid gland [A large gland in the neck which secrets hormones that regulate growth and development] does not make enough thyroid hormone). A review of Resident 7's MDS dated [DATE], indicated Resident 7 was cognitively intact (ability to think and make decisions), is non- ambulatory and requires extensive assistance with bed mobility, transfers, dressing, eating, toilet use and personal hygiene. On 10/12/2023 at 11:45 a.m., during an interview with Resident 1, Resident 1 was unable to recall the incident on Resident 1 by CG1. When asked if she felt safe in the facility, Resident 1 stated, I don't know if I do or don't. On 10/12/2023 at 11:50 a.m., during an interview with CG2, CG2 stated she was hired by a staffing agency as a caregiver for Resident 1. CG2 stated she started caring for Resident 1 since 8/29/2023, after the facility admitted Resident 1. CG2 stated the facility never asked her for a background check prior to working in the facility and/or providing care to Resident 1. CG2 stated the facility never in-serviced her on abuse prevention and or abuse reporting during the time she provided care to Resident 1. On 10/12/2023 at 12:10 p.m., during an interview with CG3, CG3 stated she was the caregiver for Resident 5 since Resident 5's admission to the facility on [DATE]. CG3 stated the facility does not require caregivers to have an identification (ID) and the facility never in-serviced her on abuse. On 10/12/2023 at 1:05 p.m., during a telephone interview with CG1, CG1 stated she works for a staffing agency and has been Resident 1's caregiver for the past six (6) years and was unable to recall the exact dates. CG1 stated she has been Resident 1's caregiver since Resident 1 was admitted to the facility on [DATE]. CG1 stated while in the facility she feeds, bathes, changes bed linen, makes the bed and cleans Resident 1. CG1 stated she ensures Resident 1 is always comfortable. CG1 stated on 10/11/2023 at around 6 a.m., she had just completed a bed bath and while repositioning Resident 1, Resident 1 kicked her [CG1] in the chest. CG1 stated Resident 1 was yelling Help Help. CG1 stated she held Resident 1's legs down so Resident 1 would not kick her again. CG1 stated RN1 opened the door to Resident 1's room and immediately asked Did you hit her [Resident 1]?. CG1 stated she told RN1, No I did not hit [Resident 1]. CG1 stated she told RN1 that Resident 1 had just kicked her in the chest, and that she was holding Resident 1's legs down on the bed to prevent Resident 1 from kicking her again. CG1 stated she was about to place a cover on Resident 1 when she heard RN1 say That is elderly abuse and that RN1 was going to call the police. CG1 further stated Resident 1 had a lower extremity leg fracture and would always yell when being repositioned. CG1 stated she repositioned Resident 1 to prevent Resident 1 from developing a pressure ulcer (Injury to skin and underlying tissue resulting from prolonged pressure on the skin.). CG1 stated two police officers arrived at the facility and one of the police officers interviewed her, while the other police officer went to Resident 1's room. CG1 stated RN1 told the two police officers that CG1's services were no longer needed in the facility. The police officers helped her retrieve her belongings at Resident 1's bedside, then she went home. CG1 stated the facility had never asked her for a background check. CG1 stated the facility had never provided her any orientation or inserviced her on abuse prevention or reporting. CG1 stated she received abuse training through the staffing agency that hired her on 4/5/2023. On 10/12/2023 at 2:47 p.m. during an interview with the DSD, the DSD stated the facility had 35 caregivers who provided direct care to 19 residents at different times of the day. The DSD stated all the 35 caregivers were either hired by the residents' family members or by the facility through staffing agencies to provide care to residents in the facility. The DSD further stated the facility did not have any documentation or personal files on any of the 35 caregivers in the facility. The DSD stated the facility did not have or conducted any background searches, any identification, any abuse training of any of the 35 caregivers in the facility. The DSD stated she did not know the work hours (schedule) of any of the 35 caregivers in the facility. The DSD further stated the facility should have ensured all 35 caregivers had background checks, identification, and abuse training prior to entering the facility and providing care to residents. The DSD stated background searches and personal files would ensure that all 35 caregivers had no criminal history such as resident abuse and had received required training to safely provide care to the residents in the facility. The DSD further stated, that starting 10/11/2023, the facility initiated the process of compiling information on all 35 caregivers after the abuse incident was reported regarding Resident 1. On 10/12/2023 at 3:55 p.m., during an interview CG4, stated she has been providing care to Resident 5 for four (4) weeks. CG4 was unable to recall the exact dates. CG4 stated the facility never oriented, educated, or in-serviced her on abuse. On 10/12/2024 at 4:47 p.m., during a telephone interview with RN1, RN1 stated he heard a noise and opened the closed door to Resident 1's room. RN1 stated he observed CG1's back was towards the door and that CG1 was facing Resident 1. RN1 further stated he observed CG1's left hand moving in an up and down motion and heard a slapping noise. RN1 stated he heard CG1 tell Resident 1 to Stop hitting me. RN1 stated he then asked CG1 What are you doing, and CG1 told RN1 that Resident 1 had just kicked her in the chest. RN1 asked CG1 Who is hitting who? and CG1 did not say anything to RN1. RN1 stated he separated CG1 from Resident 1 and asked CG1 to leave and told CG1 This is physical abuse. RN1 stated he called the police, the police came and interviewed RN1 and CG1. The Police retrieved CG1s belongings (her purse and jacket ) from Resident 1's bed side table and escorted CG1 off the premises. RN1 stated he told CG1 not to return to the facility and that CG1's services would not be needed. RN1 stated he immediately notified the DON and ADM and reported the incident to CDPH. On 10/13/2023 at 12:17 p.m., during an interview with CG5, CG5 stated she has been Resident 6's caregiver since the last week of 8/2023. CG5 stated she works for 12 hours in the facility on Monday to Friday from 7 a.m. to 7 p.m. CG5 stated the facility never oriented, educated, or in-serviced her on abuse prevention and/or reporting. On 10/13/2023 at 12:30 p.m., during an interview CG6, CG6 stated he provided care to Resident 7 for 24 hours a day. CG6 states he provided care to Resident 7 each week from Tuesday to Saturday. CG6 stated the facility never oriented, educated, or in-serviced him on abuse prevention and/or reporting. On 10/13/2023 at 1:35p.m., during an interview with the DON, the DON stated, state and federal regulations require that the facility provide . background checks, . for all caregivers, . The DON stated the facility should implement background checks and provided in-service training on abuse for all the 35 caregivers prior to having them provide caregiving services to the facility residents. The DON further stated the DSD must clear all caregivers before providing care to any resident in the facility. The DON stated the facility did not have any documented evidence of signed contracts with staffing agency(ies for the 35 caregivers. On 10/14/2023 at 1:30 p.m., during an interview with the ADM and DON, the ADM and DON stated there were a total of 35 caregivers in the facility at any given time that provide direct care to 19 residents in the facility. The ADM and DON stated the facility did not have any or performed any background checks on all 35 caregivers since the caregivers started proving care to residents in the facility. The ADM and DON stated the facility had not conducted in-services on abuse to all 35 caregivers. The ADM and DON further stated background checks and abuse in-services, Should have been done prior to the caregivers working in the facility. The DON stated the reason for conducting background checks and providing abuse in-services training was to prevent resident abuse and to ensure caregivers understood and were competent in their roles and responsibilities, knew their limitations and adhered to the facility's policies and procedures on abuse prevention and reporting. A review of facility's undated policy and procedures titled Prohibition Of Abuse, Neglect and/or Misappropriation of Resident Property and Mandating Reporting, indicated, All residents shall be free from mistreatment, neglect, abuse, exploitation and misappropriation of resident property by anyone, including, but not limited to, facility staff, other residents, consultants, contractors or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends or other individuals who provide care and services to residents on behalf of the facility. The facility shall make reasonable efforts to ensure that contracted workers provided by temporary placement agencies or contracted health services providing care have received training in elder and dependent adult abuse protocols and abuse prevention. Such efforts may include, but not be limited to: a. Contract clauses specifying abuse training has been provided. b. Verification of agency's employee orientation checklist and/or training programs c. Verification of agency's employment screening policies and procedures d. Distribution of the facility's policies and procedures regarding abuse prohibition. e. Participation in the facility's abuse prevention training programs. A review of the facility's policy and procedures titled Caregiver, Non-Staff Policy & Procedure revised on 1/2023 indicated, It is the policy of this facility to allow non-staff care givers (family members, private duty and other care givers) to assist in the provision of care to residents within the scope of state and federal regulations and according to the provisions of this policy. The Policy further indicated All non-staff caregivers will adhere to facility policy and state and federal regulations. A review of facility's policy and procedures titled Orientation Program for Newly Hired Employees, Transfers, Volunteers, revised on 5/2019 indicated, An orientation program shall be conducted for all newly hired employees, transfers from other departments, those providing services under contractual arrangements, and volunteers. All newly hired personnel/volunteers/transfers/contractors must attend a 10-hr orientation program within the first five (5) days of hire. Facility orientation program includes but is not limited to: a. A tour of the facility, which includes: (1) An overview of the resident's daily routine; and . An introduction to resident care procedures, which includes, but is not limited to: (2) A review of the facility's In-Service Training Program. b. An introduction of our administrative structure, which includes: (1) A review of resident rights; and (2) A review of personnel policies.

Based on interview and record review, the facility failed to administer as needed (PRN) glucagon (a lifesaving medication for low blood glucose [BG-sugar]) per physician order for one of 22 sampled residents (Resident 1) who was found on bed, with difficulty to arouse (wake up) and a BG of 44 milligrams per deciliter (mg/dl-unit measure that shows concentration of a substance in a fluid) on 8/8/2023 at 5:30 a.m. This deficient practice delayed prompt treatment care resulting in Resident 1 ' s BG dropped from 44 mg/dl to 34 mg/dl upon paramedics ' arrival to the facility on [DATE] at 5:40 a.m. and Resident 1 ' s hospitalization on [DATE], which had the potential to cause a life-threatening condition such as seizure (a sudden, uncontrolled electrical disturbance in the brain), coma (period of prolonged unconsciousness brought on by an illness or injury) and death. On 8/10/2023 at 2:45 p.m., while at the facility, an Immediate Jeopardy (IJ, a situation in which the facility ' s non-compliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified in the presence of facility ' s Director of Nursing (DON) and Assistant Director of Nursing (ADON) regarding the facility ' s failure to ensure PRN glucagon was administered per physician order when Resident 1 was found on bed, difficulty to arouse and a blood sugar of 44 mg/dl. On 8/12/2023 at 10:29 a.m., the IJ was removed in the presence of the DON and ADON after the facility submitted an acceptable IJ Removal Plan (a plan that identifies all actions the facility will take to immediately address the noncompliance that has resulted in the IJ situation) and the surveyor verified and confirmed through observation, interview, and record review onsite the facility ' s implementation of the IJ Removal Plan. The acceptable removal plan included the following actions: 1.On 8/8/2023, the Facility Administrator (FA) and the DON conducted disciplinary action counselling to Licensed Vocational Nurse 5 (LVN 5) for failure to follow physician order during Resident 1 ' s hypoglycemic (low blood sugar) episode. 2.On 8/8/2023 to 8/10/2023, the DON and ADON conducted an in-service to all nursing staff on handling hypoglycemic emergencies and diabetic protocols including glucagon locations, proper administration, and resident assessments. 3.On 8/10/2023, the DON and Medical Record Staff (MRS) conducted a medical record audit for all residents with diagnosis of diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]) to make sure these residents have fingerstick blood glucose monitoring in place or a recent hemoglobin A1C (HbA1C-a blood test that indicates average blood glucose level over the past two to three months) laboratory test. 4.The MRS will print all new physician orders for the last 24 hours and provide to the DON for review beginning 8/11/2023. 5.On 8/11/2023, facility staff notified primary physicians(MDs) and received physician order for either fingerstick blood glucose monitoring or HbA1C blood tests for all the Residents with history of DM. 6.On 8/10/2023, the Director of Staff Development (DSD) conducted a competency and skills check test to facility staff on administering via intramuscular injections (IM). 7.On 8/10/2023 to 8/14/2023, the DSD in-serviced facility licensed nurses on locations, usages, and replacements of emergency medication kit (Ekit). 8.On 8/10/2023, the facility generated an emergency tracking log to monitor status of Ekits and DSD conducted an in-service to the licensed nurses from 8/10/2023 to 8/14/2023. 9.On 8/10/2023 to 8/14/2023, the DSD in-serviced licensed nurses on medication administration according to the physician orders. 10.On 8/14/2023, the Pharmacy Consultant (PC) conducted an in-serviced with all the licensed nurses to review on glucagon administration, diabetic protocols, handling hypoglycemic emergencies and following physician orders. 11.On 8/10/2023 to 8/14/2023, the DON, ADON, DSD and Director of Clinical Services (DCS) conducted an in-serviced regarding accurately following physician orders as written. 12.The facility initiated a QAPI (Quality Assurance and Performance Improvement) implementing ordering a baseline HbA1C upon admission for all residents with DM on 8/14/2023. 13.Starting 8/14/2023, DON, ADON and of the DSD will initiate automatic education and competencies check for medication administration according to physician orders for all licensed nurses who are currently on leave of absence prior to start of the next scheduled working shift. Cross Referenced F726 Findings: During a review of Resident 1 ' s Admission Record, indicated the facility admitted Resident 1 on 8/4/2023 , with diagnoses including sacral (area at the bottom of the spine [backbone]) pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin), DM, urinary tract infection (UTI-infection in the urinary system [kidneys, bladder, or urethra-opening by which urine is removed out of the body]) and kidney transplant. During a review of Resident 1 ' s Physician ' s Order (PO), dated 8/4/2023, PO indicated a medication order of glimepiride (medication that treats DM by enhancing the release of body ' s natural insulin [regulate the body ' s energy supply]) one milligram (mg) to be given via mouth daily for DM management. Resident 1 ' s PO also indicated on 8/5/2023, that if the resident is unresponsive, and the BG is below 70 mg/dl, or less than the physician order parameter: Immediately administer one mg glucagon IM or give 25 mg IV Dextrose 50 percent (D50%-medication given for severe hypoglycemia) and notify MD for further orders. PO also indicated that if the resident remains unresponsive, call 911. During a review of Resident 1 ' s Care Plan (CP), dated 8/5/2023, CP indicated Resident 1 was at risk for hypoglycemia with an intervention for facility staff to immediately administer glucagon 1 mg via IM or give 25 mg IV (intravenous- administering fluid medication through a needle or tube inserted into a vein) D50% and notify MD for further orders when Resident 1 is unresponsive and a BG of less than 70 mg/dl. CP also indicated if Resident 1 remains unresponsive, call 911 (emergency number for medical assistance). During a review of Resident 1 ' s History and Physical (H&P), dated 8/6/2023, the H&P indicated Resident 1 has a capacity to make decisions. During a review of Resident 1 ' s Medication Administration Record (MAR), dated 8/7/2023 at 9 a.m., MAR indicated glimepiride medication was administered. Resident 1 ' s MAR, dated 8/8/2023, also indicated as needed glucagon was not administered when Resident 1 had an episode of BG of 44 mg/dl. During a review of Resident 1 ' s Documentation Survey Report (DSR), dated 8/7/2023 at 9:38 p.m., indicated Resident 1 did not have a bedtime snacks prior to an episode of Resident 1's BG of 44 mg/dl. During a review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 8/8/2023, the MDS indicated one to two persons assist from staff for activities of daily living (ADLs-bed mobility, transfers, locomotion on and off the unit, dressing, eating, toilet use, and personal hygiene). MDS also indicated Resident 1 was diabetic. During a review of Resident 1 ' s SBAR (situation, background, appearance and review/notify- structured tool for healthcare provider that provides communication between members. Also, being used as documentation for any changes of condition) Communication Form and Progress note (SBAR Notes), dated 8/8/2023, SBAR Notes indicated Resident 1 had a BG of 44 mg/dl, difficult to be aroused and other nurse (Licensed Vocational Nurse 7 [LVN 7]) was attempting to find a glucagon. During a review of the Paramedic Report (PR) dated 8/8/2023, indicated Paramedics received a call at 5:30 a.m. from Resident 1 ' s facility for the complaint of hypoglycemia. PR indicated that Paramedics arrived at Resident 1 at 5:40 a.m., noting Resident 1 was non-verbal with Glasgow Coma Scale (GCS -estimates coma severity from 15 to 3; 15 means fully awake and 3 completely unresponsive) of three. PR also indicated a BG of 34 mg/dl per arrival. PR also indicated that facility staff was not able to find glucagon medication, unable to administer medication. PR indicated Resident 1 was transported to GACH (General Acute Hospital) for further evaluation. During an interview on 8/9/2023 at 4:19 p.m., with the DON, DON stated that she (DON) came in early on 8/8/2023. DON stated that she (DON) was made aware that LVN5 was not able to administer glucagon before Resident 1 was taken to GACH. DON also stated that she (DON) was the person that found the glucagon located in the emergency kit. During an interview on 8/10/2023 at 11:11 a.m. with LVN 5, LVN 5 stated, on 8/8/2023 at approximately 5:30 a.m., Certified Nursing Assistant 3 (CNA 3) notified LVN 5 that Resident 1 was not her (Resident 1) usual condition when Resident 1 was not assisting CNA 3 on bed turning. LVN 5 stated that she (LVN 5) immediately assessed Resident 1. LVN 5 stated that Resident 1 was snoring loudly and with her (LVN 5) multiple attempts on waking Resident 1, Resident 1 was still not arousable. LVN5 stated upon turning, Resident 1 ' s pillow was wet, and she (LVN 5) immediately checked Resident 1 ' s MD orders. LVN 5 stated that upon checking Resident 1 ' s chart, LVN 5 found out that Resident 1 was diabetic with no orders for routine BG checks. LVN 5 stated that Resident 1 had an order for as needed glucagon via IM and/or D50% IV. LVN5 stated checking Resident 1 ' s BG was at around 43-44 mg/dl. LVN 5 stated that she (LVN 5) and LVN 7 were not aware where the location of the glucagon medication, unable to find glucagon immediately, LVN 5 decided to call 911 instead at around 5:40 a.m., and paramedics came in and took Resident 1 to GACH. During an interview on 8/10/2023 at 11:59 a.m., with the DON, DON stated that LVN 5 failed to follow as needed physician order for glucagon administration when Resident 1 was found difficult to arouse and a BG of 44 mg/dl. During an interview on 8/14/20232 at 11:37 a.m., with the Medical Director (MDR), MDR stated importance of following physician order as prescribed, and facility staff should act on the hypoglycemia protocol right away to give as needed medication per physician order. A review of the facility ' s policy and procedures (P&P) titled, Administering Medications, dated 1/2023, was conducted with the DON. The P&P indicated, Medications are administered in a safe and timely manner, and as prescribed. A review of the facility ' s P&P titled, Management of Hypoglycemia, dated 1/2023, indicated, If a resident has Level 3 hypoglycemia (altered mental and/or physical status requiring assistance for treatment of hypoglycemia) and is unresponsive, to administer glucagon (intranasal [route via nasal], IM or as provided). A review of the facility ' s P&P titled, Nursing Care of the Older Adult with DM, dated 1/2023, indicated, Facility will manage hypoglycemia according to protocols and provider orders. A review of facility ' s P&P titled, Diabetes-Clinical Protocol, dated 1/2023, indicated, Facility staff and physician will manage hypoglycemia appropriately for someone who is lethargic but not comatose, treatment might include oral glucose paste rubbed onto the buccal mucosa, IM glucagon, or IV 50% dextrose.

Based on observation, interview and record review, the facility failed to implement interventions to prevent and control the spread of COVID-19 (Coronavirus disease, a severe respiratory illness caused by virus and spread from person to person) in accordance to the facility's infection control policies and the Mitigation Plan (MP, a plan to reduce loss of life and impact of COVID-19 in the facility) for 11 of 11 sampled residents (Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, and 11) by failing to: 1. Implement a screening process, including checking for signs and symptoms of COVID-19, history of travel, and contact with positive COVID-19 persons upon entering and exiting the facility. 2. Ensure Certified Nursing Assistants 5 and 6 (CNAs 5 and 6), Caregivers 1 and 2 (CG 1 and 2), and Licensed Vocational Nurse 1 (LVN 1) followed infection control practices while donning (putting on) personal protective equipment (PPE, equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses such as goggles, head/shoe covers, masks, gowns, gloves, and face shields) to provide care to Residents 6, 7, 8, 9, 10, and 11, who were in the Yellow Zone (area where patients under investigation for COVID-19 are allocated). Receptionist 1 did not perform hand hygiene before taking the temperature of one visitor during screening for COVID-19 (screening includes asking for signs and symptoms, history of contact with COVID-19 infected persons, recent travels to other states and countries, and checking body temperature). CNAs 5 and 6, CG 1, and LVN 1 did not perform hand hygiene before or after providing care to Residents 6, 7, 10, and 11, who were on droplet isolation (precaution used for diseases or germs that are spread in tiny droplets caused by coughing and sneezing) and were persons under investigation (PUI) for COVID-19. 3. Ensure soiled linen and waste bins were located inside the rooms of residents on droplet isolation precautions. 4. Ensure LVN 1 disinfected a glucometer (a medical device for determining the approximate concentration of sugar in the blood) after using it with Resident 9, who was on droplet isolation precautions. 5. Ensure CGs 1 and 3 were properly fit tested (a respirator fit test checks whether a respirator properly fits the face of someone who wears it. It tests the seal between the respirator's facepiece and the face (around the nose and mouth) to prevent air leak) for an N95 (a particulate-filtering facepiece respirator that meets the U.S. National Institute for Occupational Safety and Health (NIOSH) and filters at least 95% of airborne particles). CNAs 7 and 9, LVNs 1, 2, and 4, and Operations Manager 2 (OM2) did not wear and were not provided N95 mask at the beginning of the shift. 6. Ensure newly admitted Residents 1, 2, 3, 4, and 5 were tested for potential COVID-19 upon admission to the facility. These deficient practices had the potential to result in the spread of COVID-19 placing all 75 residents in the facility and staff at risk to be infected with COVID-19 and becoming seriously ill, leading to hospitalization and/or death. On 10/29/2020 at 4:48 p.m., an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified in the presence of the facility's OM 1, the Assistant Director of Nursing (ADON), and the Infection Preventionist (IP) Nurse for the facility's failure to implement interventions to prevent the transmission of COVID-19 infection that threatened the health and safety of the residents and staff. The Administrator was also present at 4:56 p.m. On 10/31/2020 at 7:10 p.m., the IJ situation was lifted after the facility submitted an acceptable Plan of Action (POA, interventions to correct the deficient practices); the surveyor verified and confirmed the implementation of the POA while onsite through observations, interviews and record review. The IJ situation was removed in the presence of the Administrator (ADM), ADON, IP, OM 1, the Regional Director of Operations (RDO), and the Regional Director of Clinical Services. The accepted POA included the following actions: a. The front door entrance to the lobby area was designated as the sole point of entry and exit to the facility. A staff was assigned to monitor and screening of all persons entering and exiting the facility. b. Staff was in-serviced about the proper use of PPE, hand hygiene, proper donning and doffing of PPE. c. Staff assigned to do the screening of individuals entering the facility were provided training in screening, use of disinfectants, sanitizers, and PPE. d. IP provided in-service education and competency skills checklist procedure to the licensed nurses on proper disinfection of the glucometers. e. Soiled linen and waste bins were placed inside the rooms of residents on droplet isolation precautions. f. Staff who were previously fitted for N95 mask were provided with the correct model and size. The staff not fit tested will undergo testing. g. All newly admitted residents will be tested for COVID-19 on the day of admission, will be placed in quarantine (a state, period, or place of isolation in which people that have arrived from elsewhere or been exposed to infectious or contagious disease are placed) for 14 days and will be re-tested at the end of the quarantine. Findings: A review of the facility's census during onsite visits conducted on 10/6/2020, 10/26/2020, and 10/29/2020, indicated facility had 81, 64, and 75 residents in-house, respectively. 1. On 10/6/2020 at 2:30 p.m., during the entrance to the main lobby from the elevator, an observation of the lobby and reception area indicated there was no receptionist at the reception counter. There were two people standing at the lobby area. The facility front door was unlocked, and a male with a face covering entered the facility without having to request for a staff member to grant access for entry and without undergoing COVID-19 screening. Receptionist 1 was observed sitting at a desk in the office located behind the reception counter outside of direct visual access to the elevators or front door entrance. Receptionist 1 had to be prompted to screen persons that were in the lobby. When asked about the persons in the lobby, Receptionist 1 stated she did not know. The male who entered the facility left without being screened. Receptionist 1 proceeded to screen one of the two visitors standing at the lobby. Receptionist 1 did not perform hand hygiene before taking the temperature of the visitor. On 10/6/2020 at 4:07 p.m. during an interview, ADM and DON stated there were no visitors allowed, the front door should be locked, and Receptionist 1 should be screening for COVID-19 signs and symptoms and persons upon entering the facility. On 10/26/2020 from 6:35 a.m. to 7 a.m., during observation of the end of the healthcare workers (HCWs) shift (11 p.m. to 7 a.m.) assigned to the third and fourth floors (where residents on droplet isolation precautions were located), it was noted the HCWs were not screened at the end of the shift. At the end the observation, during an interview, the ADON stated that it was the facility's policy to screen at the beginning of shift only. The DON did not provide the Evaluator with the policy. On 10/26/2020 during observation from 11:25 a.m. to 11:40 a.m., a female wearing street clothes, a surgical mask, and no name badge was noted walking through the hallway and the dining area of the third floor. The female approached the elevator and waited for it to arrive. During the same observation, CNA 8 and LVN 3 were conversing at the nursing counter located in front of the elevators. At 11:30 a.m., upon interview, CNA 8 and LVN 3, could not identify the person. The female walked briskly toward the side door to the stairway and exited through the main lobby without being screened for COVID-19. At that time, Receptionist 1 was at the reception counter assisting other persons. The doors and the gate to the facility parking garage were wide open. At 11:40 a.m., an unidentified person was observed exiting the facility unnoticed by the numerous staff and without being screening for COVID-19. On 10/26/2020 at 11:43 a.m., a review of the facility's surveillance camera footage of the unidentified female, with Maintenance Supervisor (MS) and OM 1, was conducted. Upon concurrent interview, MS and OM 1 were unable to identify the female and stated she was not part of the staff or an essential visitor. OM 1 stated the facility is closed to visitors and acknowledged Receptionist 1 should be monitoring the entrance/exit and screening for COVID-19 persons entering and exiting the facility. 2. On 10/6/2020 at 4:34 p.m., during an observation in the Yellow Zone, CNA 5 was providing care to Resident 6 without wearing N95 mask and a face shield. CNA 5 did not perform hand hygiene prior to donning her PPE and after removing the gloves. At the end of the observation, during an interview, ADON acknowledged CNA 5 was not wearing the needed N95 mask and face shield. The ADON stated CNA 5 had to perform hand hygiene before providing care to Resident 6. On 10/6/2020 at 4:44 p.m., CG 1 was observed entering Resident 7's room and not performing hand hygiene upon entering the room and prior to provide care to Resident 7. In addition, CG 1 was not wearing an N95 mask, gown, gloves, goggles/face shield when providing care to Resident 7. Resident 7 was in the Yellow Zone (PUIs on droplet isolation precautions for COVID-19). On 10/6/2020 at 4:45 p.m., an observation was conducted of CG 2 and LVN 1 going to the room Residents 8 and 9 shared. The room was in the Yellow Zone (PUIs on droplet precaution). LVN 1 and CG2 were not wearing N95 mask, gown, goggles or face shield while providing care to the residents. On 10/30/2020 at 3:58 p.m., LVN 1 was observed in the Yellow Zone (for PUIs and on droplet isolation precaution) by the medication cart, outside Resident 10's room, preparing medications. LVN 1 proceeded to enter Resident 10's room to administer the resident medications. LVN 1 was not wearing N95 mask and gown. LVN 1 did not perform hand hygiene before donning gloves. On 10/31/2020 at 1:44 p.m. CNA 6 was observed in the Yellow Zone (for PUIs and on droplet precautions) providing care to Resident 11. CNA 6 isolation gown was not tied, and CNA 6 was alternatively holding the gown and providing care to Resident 11. CNA 6 did not perform hand hygiene after being in contact with Resident 11. 3. On 10/6/2020 at 4:45 p.m. and on 10/26/2020 at 7:10 a.m., during observations of the Yellow Zone, it was noted that outside the rooms of Residents 6, 7, 8, and 9, there were soiled linen and waste bins outside the rooms instead of inside the rooms. 4. A review of Resident 9's Admission Record indicated the facility admitted the resident on 6/20/2020 with [DIAGNOSES REDACTED]. On 10/6/2020 at 4:50 p.m. LVN 1 was observed leaving Resident 9's bedside after checking the blood sugar using a glucometer. LVN 1 did not disinfect the glucometer after its use and returned it back inside the medication cart. At the time of the observation, during an interview, LVN 1 stated and acknowledged that she had not disinfect the glucometer. The glucometer was not for individual use but used with other residents who needed blood sugar checks. 5. On 10/19/2020 at 3:17 p.m., during a telephone interview, IP stated staff were fit tested for the appropriate respirator on 9/8/2020 and staff should be wearing the specific N95 mask brand and model fitted when in the Yellow Zone rooms. On 10/26/2020 at 7 a.m., during an observation of the Yellow Zone (for PUIs and on droplet isolation precautions), LVN 2 was wearing a green universal N95 mask and a face shield. At the time of the observation, during an interview, LVN 2 stated she was fit tested , but the facility did not provide the N95 mask she needed. The facility only provided one green universal N95 mask for every five shifts. On 10/26/2020 at 8:11 a.m., during an interview, ADON stated, One mask is for five days. Daily is not in our plan. On 10/29/2020 at 3:50 p.m., OM 2 was observed on the second floor (designated for PUI residents, Yellow Zone) wearing a green universal N95 mask, no goggles or face shield. The mask was loose, leaving a gap on the nose area, and going down the mouth when OM 2 was speaking. At 3:55 p.m., during an interview, OM 2 stated having a fit testing in 9/2020 but did not get the mask brand and model tested for. On 10/29/2020 at 4:15 p.m., during observation of the Yellow Zone (PUIs on droplet isolation precautions), LVNs 1 and 4 were wearing green universal masks. During concurrent interview, LVNs 1 and 4 stated the green universal masks were not the N95 masks they were fit tested for, but the facility did not provide them with the masks fitted for them. On 10/29/2020 at 4:56 p.m., during an interview, the ADM stated, We have the same set of masks (green universal masks) for everyone. We provide those masks every five days; extended use is five days. On 10/30/2020 at 3:36 p.m., CNA 9 was observed wearing a green universal mask prior to entering a droplet isolation room. During a concurrent interview, CNA 9 stated the facility provides one green universal N95 mask every week. On 10/30/2020 at 3:52 p.m., during an observation of the Yellow Zone CNA 7 was wearing a green universal mask. During a concurrent interview, CNA 7 stated the green universal mask was not the mask that he was fit tested for. On 10/30/2020 at 4:35 p.m., during an observation of the Yellow Zone CG 3 was wearing a green universal mask. During a concurrent interview, CG 3 stated she was not fit tested for an N95 respirator. On 10/30/2020 at 4:45 p.m., during an observation of the Yellow Zone, CG 1 was wearing a green universal N95 mask. During a concurrent interview, CG 1 stated she was given one green mask every Monday. CG 1 uses the same mask for the week. CG 1 stated she was not fit tested . On 10/31/2020 at 7:15 p.m., upon interview, the ADM was unable to provide documented evidence CG 1 and 3 were fit tested for an adequate respirator (N95). A review of the Los Angeles County Department of Public Health (LAC DPH) PPE Updates to SNF (Skilled Nursing Facilities) COVID-19 Guidance, updated 10/2/2020 indicated N95 respirators should be used for all yellow cohorts (Yellow Zone, residents under investigation are places in the same area), fit testing required, and re-use is no longer allowed, but extended use is still allowed. Extended use is the use of PPE for more than one patient. N95 respirator extended use is allowed, maximum 8- to12-hour shift. Re-use is the use of PPE on multiple days. N95 respirator re-use is no longer allowed per the Division of Occupational Safety and Health (CAL-OSHA), as of 8/6/2020. 6. a. A review of Resident 1's Admission Record indicated the facility admitted the resident on 9/14/2020, with [DIAGNOSES REDACTED]. A review of Resident 1's COVID-19 test result collected 8/27/2020 at the general acute care hospital (GACH) indicated negative for COVID-19. A review of Resident 1's clinical record indicated no documentation of COVID-19 test conducted upon admission to the facility. A review of Resident 1's COVID-19 test, dated 10/1/2020 (over two weeks since admission), indicated Resident 1 was positive for COVID-19. A review of Resident 1's Nursing Progress Note dated 10/7/2020 indicated Resident 1 was transferred to a GACH via by emergency transport (paramedics) due to shortness of breath. A review of Resident 1's GACH Death Record dated 10/9/2020 indicated the cause of death as hypoxic [MEDICAL CONDITION] (a condition in which not enough oxygen passes from the lungs into the blood) secondary to COVID-19 Pneumonia. On 10/26/2020, at 2:40 p.m., the ADM and DON confirmed Resident 1 was not tested for COVID-19 within 72 hours from admission to the facility. 6b. A review of Resident 2's Admission Record indicated an admission to the facility dated 9/30/2020 with [DIAGNOSES REDACTED]. A review of Resident 2's COVID-19 test dated 10/6/2020 (one week after admission) indicated Resident 2 was positive for COVID-19. On 10/31/2020 at 7:23 p.m., Administrator stated Resident 2 should have been tested for COVID-19 on admission. 6c. A review of Resident 3's Admission Record indicated the facility readmitted the resident on 9/29/2020 with [DIAGNOSES REDACTED]. A review of Resident 3's COVID-19 test dated 10/4/2020 (six days from admission), indicated Resident 3 was positive for COVID-19. 6d. A review of Resident 4's Admission Record indicated a re-admission to the facility dated 9/30/2020 with [DIAGNOSES REDACTED]. A review of Resident 4's COVID-19 test dated 10/2/2020 indicated Resident 4 was positive for COVID-19. 6e. A review of Resident 5's Admission Record indicated Resident 5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 5's COVID-19 test, dated 10/5/2020, indicated Resident 5 was positive for COVID-19. On 10/26/2020 at 7 a.m., during an interview, LVN 2 stated the facility was not testing residents upon admission. On 10/31/2020 at 7:23 p.m., during an interview, the ADM stated Resident 5 should have been tested for COVID-19 on admission. A review of the All Facilities Letter (AFL) 20-53.3, dated 9/12/2020, indicated if hospital does not test patient within 72 hours, the SNF must test resident upon admission. Residents newly admitted from hospital should quarantine for 14 days from date of last potential exposure and re-tested . A review of facility's policy and procedures titled, Infection Prevention and Control: Novel Coronavirus (COVID-19), revised 9/15/2020 and 10/2/2020, indicated it was the policy of the facility to, Minimize exposures to respiratory pathogens and promptly identify residents with clinical features and an epidemiologic risk for the COVID-19 and adhere to Standard Contact and Airborne Precautions. Procedures: 1. Resident Care: Facility will follow Standard, Contact, Droplet and/or Airborne Precaution. Facility will use dedicated patient-care equipment for residents suspected COVID-19 infection. If equipment must be used for more than on resident clean and disinfect it before use on another resident, according to manufacturer's recommendation. Limit only essential personnel to enter the room with appropriate PPE and respiratory protection. For the disposable PPEs; gown gloves, staff must remove before leaving the resident's room. Hand hygiene using ABHS (Alcohol-Based Hand Sanitizer) before and after all contact with residents, and before and after removal of PPE, including gloves. Trash receptacles will be accessible inside the resident's rooms. Employees will be instructed to obtain temperature twice a day at least 12-hour intervals. II. COVID-19 Testing: Testing Plan for Residents and Staff: Facility staff includes caregivers who provide care and services to residents on behalf of the facility. Testing of all admissions and readmissions: the facility will follow the transfer rule guidance for newly admitted residents or readmissions. Testing newly admitted residents prior to admission, including transfers from hospitals. If hospital does not test the resident within 72 hours of transfer, the facility must test upon admission. The resident will be placed in quarantine for 14 days. III. Cohorting: 2. Yellow Cohort (Mixed-Quarantine). Residents in yellow zone will be treated with standard, contact and droplet precautions (N95 mask or higher) until the resident meets the time criteria or symptom-based criteria to return to the green sections (Green Zone, residents free from COVID-19 infection) based on current Centers for Disease Control and Prevention (CDC) guidance for the removal of transmission-based precautions. IV. Personal Protective Equipment and Supplies: Extended use of PPE: 4. N95 Respirators: when [MEDICATION NAME] extended use of N95 respirators, the maximum recommended extended use period is 8-12 hours. Respirators (N95 masks shall not be used for multiple work shifts and not reused after extended use. VIII. Visitors: The facility will actively verify absence of fever and absence of any signs and symptoms consistent with COVID-19 infection of any person upon entering the facility with the use of Visitor Screening tool for COVID-19. Resuming Other Visitation: Facility experiencing an outbreak (i.e. one or more confirmed positive cases) will not resume visitation. Indoor Visitations: the facility will accommodate and support indoor visitation, based on the following guidelines: a) there has been no new onset of COVID-19 cases in the last 14 days and the facility is not currently conducting outbreak testing; b) visitors should be able to adhere to the principles of infection prevention and staff should provide monitoring for those who may have difficulty adhering to the infection prevention; d) the facility will limit movement in the facility. Visitors will not be allowed to walk around in different halls of the facility. Visitors will be instructed to go directly to the resident's room or designated area. Addendum to Policy: Implementation of Universal Masking Protocol, dated 4/6/2020, revised 10/2/2020 indicated the universal masking protocol is intended to be used in conjunction with the facility's policy and procedure for COVDI-19. This does not replace the infection prevention and control guidelines specified in the policy. Requisites: to be successful, this new approach requires the following; strict adherence to extended use/reuse of facemasks, as indicated in the COVID-19 policy. A review of the facility's undated policy and procedure titled, COVID-19 Prevention and Control indicated, Facility leadership and clinical staff are implementing all reasonable measure to protect the health and safety of residents and staff during the current outbreak of COVID-19. Policy Interpretation and Implementation: 16. At this time visitors are being limited to certain [MEDICATION NAME] care situations such as end of life. These situations are being determined on a case-by-case basis and include careful screening of the visitor for fever or respiratory symptoms. Visitors who are permitted, are required to restrict their visit to the resident's room. A review of the facility's Visitation Procedures dated 9/24/2020 indicated 1. Scheduling a. All visitation must be prescheduled when possible. 2. Entry a. Universal Masking is required and mandatory to apply your mask before entering the facility. b. once in the elevator you will proceed to the lobby level or designated screening zone where you will be greeted by facility receptionist. Receptionist will require apply alcohol-based hand sanitizer and then lead you through the screening process. 3. a. Once you have arrived in the lobby our receptionist will take your temperature and provide you with a COVID-19 Screening Questionnaire. Once this step is completed, you are now cleared to be escorted by our receptionist to the area where the visitation will take place. The facility's policy titled, Mitigation Plan, undated, indicated, To test residents prior to admission or re-admission, including transfers from hospitals or other healthcare facilities. If the hospital does not test the resident, the facility will test and quarantine the resident upon admission. Residents admitted should be tested prior to admission and if they test negative, should be quarantined for 14 days and then re-tested . If negative, the resident can be released from quarantine. Place residents into three separate cohorts based on the test results. Facility will cohort all unknown asymptomatic and untested residents in the Yellow Zone and will be treated with contact and droplet precautions until a negative test result can be achieved or the resident meets the time criteria to return to the Green Zone based on current Centers for Disease Control (CDC) guidance for removal of transmission-based precautions. Residents positive for COVID-19 are cohorted (group of residents with the same infection status) on the Red Zone (area for COVID-19 positive residents).

Based on observation, interview and record review, the facility failed to ensure one of 16 sampled residents (Resident 56) who was assessed at a high risk for fall received adequate supervision and assistance to prevent fall, including: 1. Failure to identify and developed a comprehensive plan of care that addressed resident bladder function and provide assistance to the restroom. 2. Failure to implement fall prevention policy by not taking precautions for a resident identified and verbalized of unable to hold her bladder and that her call light was not answered timely. 3. Failure to provide adequate supervision by not having enough staff at 11 p.m., to 7 a.m., shift to answer call light and provide care to the resident. As a result, on 5/22/18 at 1:30 a.m., and 5/25/18 at 11:25 p.m., Resident 56 sustained two falls in the facility, ten days after the resident was admitted to the facility. The first fall resulted in a right femur fracture with an open reduction internal fixation (ORIF, a surgical procedure to fix a severe bone fracture, or break), severe pain, decreased level of functioning and aggravated feelings of depression and anger. Findings: On 6/11/18 at 3:18 p.m., Resident 56 was observed lying in bed. During an interview with Resident 56 the resident stated that she had hip surgery and came to the facility for rehabilitation. The resident stated that after her hip surgery she had limited control over her bladder, which she made the staff aware. The resident could not remember which staff she had informed about her urinary incontinence. The resident stated she has had two falls since admission to the facility. The resident stated the first fall occurred on 5/22/18 at around 1 a.m., or 2 a.m., in the morning. Resident 56 stated she had pressed the call light for assistance but was waiting a long time for a response. The resident stated while she was waiting she had completely wet her bed, and after about 10 minutes of waiting for assistance, she got up because she did not want to sit on her urine. The resident stated that the floor was wet with her urine, when she got up; she slipped and fell to the floor. The resident stated there was pain to her right hip and leg after the fall. During the same interview on 6/11/18 at 3:32 p.m., the resident was observed with ice packs to the right upper leg. The resident stated that the surgery to her leg was invasive and caused swelling to her leg. During the interview with the resident, she stated, I feel pretty depressed about the prospect of being in bed for three to four months. The original hip surgery the doctors told me I could walk the first week, and I could be back to normal in six (6) weeks. I feel very angry. A review of the Resident 56's admission records (Face sheet) indicated the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 56's Fall Risk Evaluation dated 5/16/18 indicated a score of 14 (total score of 10 or above represents high risk for falls). A review of Resident 56's Activities of Daily Living Roster dated 5/16/18 to 5/21/18 indicated the resident required limited assistance one-person physical assist for toilet use. A review of Resident 56's five day Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 5/22/18 indicated the resident had no cognitive (ability to reason, think, decide and remember) impairment. A review of Resident 56's occupational therapy care plan (CP) dated 5/17/18 indicated the resident had problem with impaired mobility in activities of daily living (ADL) due to recent surgery for [REDACTED]. The concerns identified were decline in dressing skills and activity intolerance. The goals included to be able to perform dressing and toileting with minimal assistance. The approaches to the goals included initial assessment, progressive ADL re-training, therapeutic activities, therapeutic exercises and neuromuscular re-education. The care plan did not address how the resident will be assisted to the bathroom. A review of physical therapy (PT) Progress and Discharge Summary dated 5/22/18 for Resident 56, indicated sit to stand mobility required partial to moderate assistance (assistant lifts, holds, or supports trunk or limbs but provides half the effort). A review of Resident 56's daily skilled nursing notes dated 5/16/18 (on admission) indicated the resident required extensive assistance from a Certified Nurse Assistant (CNA) with toileting and transfers. A review of the daily skilled nursing notes dated 5/21/18 (the day prior to the resident's fall) indicated the resident was able to stand for transfers with limited assistance and required limited assistance in toileting. A review of the physician's orders [REDACTED]. A review of Resident 56's Non-emergency Transfer to Hospital form dated 5/22/18 at 1:51 a.m. indicated the following: 1. On 5/22/18 at 1:40 a.m. the resident's pain was 8 out of 10 (8/10) (using the 0 to 10 numeric pain scale, 10 being the worse pain and 0 being no pain). [MEDICATION NAME] (a pain medication used to treat moderate to severe pain) 10-325 milligrams (mg) was administered. 2. At 2:00 a.m., the resident was re-assessed and still had 8/10 pain. Tylenol 650 mg was administered. 3. At 2:20 a.m., the resident was re-assessed and still had 8/10 pain (unrelieved pain despite medications administered). The transfer form indicated the ambulance service arrived at 2:30 a.m. and transported the resident out of the facility at 2:55 a.m. Resident 56 was readmitted back to facility on 5/24/18 with [DIAGNOSES REDACTED]. A review of the resident's comprehensive MDS assessment dated [DATE], after her re-admission to the facility, indicated no cognitive impairment. A review of Resident 56's History and Physical dated 5/25/18 indicated the resident had the capacity to understand and make decisions. During an interview with the director of nursing (DON) on 6/14/18 at 2:24 p.m., she stated Resident 56 fell in her room on 5/22/18 at 1:30 a.m. There were no witnesses to the fall. The DON stated Registered Nurse 5 (RN 5) went into the resident's room because of the alarm (a device under the resident, that makes an audible sound only at the nurse's station) at the nurse's station. She went into the resident's room, found the resident on the floor between beds A, and bed B, lying on her right side. The DON stated the resident was last check at 12:10 p.m., prior to the fall. The DON stated the resident came to the facility for rehabilitation after right hip surgery and the plan was for her to be discharge home. The DON stated she had observed the resident coming out of the restroom without assistance the day prior to the fall and discussed with the rehabilitation department and the nurses regarding the resident behavior and determined the resident exhibited impulsive behaviors and not asking assistance from the nurses. The DON stated she spoke to the resident about moving her to a room closer to the nursing station to be able to check her status more frequently and explained to the resident although she can walk independently, she was observed to not call the nurses for assistance when going to the restroom. The resident stated she did not call the nurses because they took too long to assist her with her needs. The DON stated that the resident told her 10 minutes was too long for her to wait for assistance. The DON stated the facility policy did not have a specific time in answering call lights but she has been instructing her staff to answer call lights not more than 15 minutes. The DON stated that the resident was moved at around 4 p.m. on 5/21/18 and she fell a few hours after, at 1:30 a.m. on 5/22/18. During a telephone interview and record review with the DON on 6/20/18 at 4:20 p.m., she stated there was no bowel or bladder care plan for Resident 56 prior to the first fall on 5/22/18. The DON stated the resident was continent and went to the restroom herself and admitted she was aware that the resident stated 5 to 10 minutes was too long for her to wait to go to the restroom. There was no care plan to address how the resident was assisted to the bathroom despite requiring one-person assistance. During the same interview on 6/14/18 at 2:24 p.m., with the DON she stated the nurses started monitoring the resident every hour after the room transfer for 24-hours. A review of Resident 54's monitoring log with the DON indicated hourly monitoring up to 10 p.m., on 5/21/18. The DON was asked where the monitoring sheets were after 10 p.m., the DON was unable to provide the monitoring after 10 p.m. and stated may have been missed filed. A review of an undated baseline care plan prior to the fall on 5/22/18 indicated to transfer with one person assist but did not indicate whether the resident was weight bearing or not. b. During an interview on 6/11/18 at 3:32 p.m., the resident stated that her second fall happened in her room and they saw me fall. She could not recall the staff names present in the room. On 6/14/18 at 2:59 p.m., during an interview with the DON regarding Resident 56's second fall on 5/25/18, the DON stated the resident fell a few hours after coming back to the facility from the hospital. The DON stated she was aware the resident was a high fall risk but there was no extra staff available to watch the resident after 11 p.m. The DON stated she had enough staff to cover all the other residents on the floor but no extra staff to cover the resident. On 6/14/18 at 2:59 p.m., during an interview with the DON, she stated the resident's call light came on at 11 p.m. and the charge nurse, Registered Nurse 5 (RN 5) went into the room to assist the resident but knew she could not do it by herself. The DON stated RN 5 called for another staff to assist her and while she was waiting, started to prepare the resident by positioning her on the side of the bed and placed the resident's walker in front of the resident. While still waiting for the second staff to come into the room, RN 5 was moving the floor mat out of the resident's way, when the resident stood up and grabbed her walker. RN 5 did not have a chance to hold onto the resident, and the resident fell in front of her. The DON stated that the resident required 2-person assist and was non-weight bearing. A review of baseline care after the fall on 5/24/18 indicated the resident required two-person assist for transfer. The care plan had no specific intervention how the two-person assist will be done. The Activities of Daily Living (ADLs) care plan dated 5/25/18 did not indicate what type of assistance the resident needed for transfers. The care plan did not addressed how the resident will be assisted to the restroom. During an interview with Registered Nurse 5 (RN 5) on 6/22/18 at 8:10 a.m., , she stated she was working during the 11 p.m. to 7 a.m. shift when around change of shift, she observed Resident 56's call light was on and went to check on the resident. The resident wanted to use the bedside commode (portable toilet) and needed assistance out of bed. RN 5 stated that the resident required two-person assistance from bed to commode and she needed help to get the resident out of the bed. RN 5 stated the Certified Nurse Assistant 6 (CNA 6) was late and There was a shortage of CNAs, so I was waiting for the CNA to come. RN 5 stated while she was waiting, she sat the resident up and positioned her on the edge of the bed. RN 5 stated, There was a floor mat which I got out of the way to make space for the commode. I then placed the resident's walker (assistive device for standing and walking) in front of the resident. I made the resident aware I was waiting for the CNA to assist us. I went to get the commode from against the wall and while I was doing that, the resident got up and fell on to the floor mat. RN 5 stated there were no injuries from the fall and the resident denied any pain. A review of Nurse Staffing Assignment and Sign-in sheet dated 5/25/18 indicated CNA 6 was assigned to the night shift (11 p.m. to 7 a.m.) and signed in at 12:20 a.m. (one hour and 20 minutes later from start of the shift). The sign-in sheet indicated there was one licensed staff (RN 5) and one certified nurse assistant (CNA 7) on the fourth (4th) floor with 21 total residents. A review of an undated facility policy titled Fall Prevention indicated the policies and procedures are designed to provide a safe environment for the residents as well as reduce risk for resident falls. Fall can be prevented if precautions are taken seriously and potential sources of accidents are identified and exercised. A review of an undated facility policy titled Call Light System indicated the purpose of the system was to provide a method of communication between the nursing and the resident in bed, up in a chair at the bedside, and in some instances in the bathroom and to determine and meet the needs of the resident. All nursing personnel will answer the call lights promptly during whether an emergency or a non-emergency needs. Emergency calls are answered immediately and non-emergency calls are answered as quickly as possible. Based on interview and record review the facility failed to answer the call lights in a timely manner. This failure had the potential of the resident to wait long periods of time for help, with the possibility of the resident urinating on self and sustaining a fall with injury. Resident #272 Accidents During an interview on 06/11/18 at 2:45 PM with R#272 it was stated, Yesterday I waited 30 minutes for help to the restroom. It came real close to me peeing on myself. It was further stated the staff often take a long time to answer call lights. During an interview on 06/15/18 at 09:45 AM with assistant director of nursing (ADON), it was stated we are aware the residents have complained to us before that middle and early night the call lights take long time to get answered. Call lights should be answered within 5 to 10 minutes and if they can't answer the resident in that timeframe, they need to communicate with the resident. Review of the resident's face sheet indicated an admitted d of 06/05/18 with the [DIAGNOSES REDACTED]. Review of the history and physical from the general acute care hospital with encounter date 06/05/18 indicated the resident was alert and has the capacity to understand and make decisions. It listed the [DIAGNOSES REDACTED]. Review of the physician's admission orders [REDACTED]. physician's orders [REDACTED]. There was another order to give [MEDICATION NAME] (diuretic; medication that causes increased passing of urine) 40mg daily. Review of the fall risk evaluation completed by nursing on 06/05/18 indicated resident had a score of 12, which is High Risk for falls. Review of the care plan dated 06/05/18 with concern at risk for fall related to history of previous falls. The goal for the resident have no incident of falls/injury every shift. The approach to the plan was to assist with transfer/mobility as needed and encourage resident to ask for assistance if resident is able to, review medications for side effects that causes falls/dizziness and report to MD if side effects are noted. Review of the facility's undated policy and procedure titled, Call Light System, under purpose it stated, to determine and meet the needs of the residents. It further stated under procedure, All nursing personnel will answer call lights promptly during whether an emergency or a non-emergency needs. Emergency call lights are answered immediately. Non-emergency call lights are answered as quickly as possible. It continues to state, Proceed with attending the resident. If unable to care for the resident immediately explain where you are and when you will be back and then return on time as promised or send someone else in to the resident.

Based on interview and record review, the facility failed to consult immediately with the physician when there was a significant change in clinical condition and the need to alter the treatment significantly for one of three sampled residents (Resident 1), including, 1. Failure to notify Physician 1 when Resident 1 required more than two liters of oxygen per minute (2 L/min) as ordered on [DATE]. 2. Failure to notify Physician 1 immediately when Resident 1 became short of breath at 5:12 a.m. and the oxygen was increased to 5 L/min. 3. Failure to notify Physician 1 when Resident 1 became short of breath after providing respiratory treatment (giving inhaled medication) at 6:20 a.m. and the oxygen was increased to 10 L/min. 4. Failure to implement the Care Plan for Resident 1's risk for shortness of breath by not notifying the physician if any shortness of breath. 5. Failure to implement the facility's policy on Observing, Recording, and Reporting Condition Change of the Resident by not notifying Physician 1 of Resident 1's change of condition. As a result, on 7/7/17, at 8 a.m., one hour after arriving to the Emergency Department at GACH 1 Resident 1 was pronounced dead. Finding: On 3/20/18, at 7:30 a.m., an unannounced visit was conducted at the facility to investigate a complaint regarding Death. A review of the Admission Record indicated, Resident 1 was initially admitted to the facility on [DATE], with the most recent readmission from General Acute Care Hospital 1 (GACH 1) dated 7/4/17. Resident 1's [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS - standardized assessment and care-planning tool) dated 7/16/17 (from prior admission) indicated Resident 1 was able to communicate needs, make decisions, and needed extensive assistance with transfers, bed mobility, toilet use and personal hygiene. A review of History and Physical (H&P) exam completed by Physician 1 on 7/5/17, indicated Resident 1 had the capacity to understand and make decisions. Resident 1 was hospitalized from 7/1 to 7/4/17 due to bilateral lower extremity [MEDICAL CONDITION] (collection of fluid) she was found with fluid overload and was treated with intravenous (IV) [MEDICATION NAME] (a diuretic - medication to reduce water). Resident 1 was diagnosed with [REDACTED]. Physician 1 documented Resident 1 had a prior hospitalization from ,[DATE] to 6/30/17 due to abdominal pain and acute kidney failure complicated with aspiration (refers to the accidental sucking in of food particles or fluids into the lungs) pneumonia (lung infection) and [MEDICAL CONDITION]. Upon Physician 1's assessment, Resident 1 stated she felt tired, breathing is better, and she considers hospice care but not ready at this time. The oxygen saturation (blood oxygen level - a measure of how much oxygen the red blood cells are carrying to the body. Normal range between 94-99%) was 95% breathing room air (without additional oxygen). A review of Physician 1's order dated 7/4/18 indicated to give [MEDICATION NAME] 0.5% 0.5 milliliters (ml) by nebulizer (device for converting a medication in liquid form into a mist or fine spray which is inhaled) every six hours as needed for shortness of breath. A review of Physician 1's order dated 7/5/18 indicated to administer Resident 1 oxygen at two liters per minute (2 L/min) to keep oxygen saturation at 92% or above and to notify Physician 1 if Resident 1 required more than 2 L/min. The order did not indicate if the oxygen was to be administered via nasal cannula (flexible tube placed under the nose with two prongs that go inside the nostrils) or using a mask. A review of the Care Plan developed 7/5/18, for Resident 1's risk for shortness of breath due to diagnoses, had a goal for Resident 1 to be free of shortness of breath, [MEDICAL CONDITION], chest pain, and electrolyte (minerals in the blood) imbalance. The approaches included observe for shortness of breath, abnormal pulse, [MEDICAL CONDITION], cold, clammy (sweaty) skin, and notify the physician if any. Administer oxygen as needed per physician's order. A review of the Licensed Personnel Progress Notes dated 7/6/18 timed at 11:30 p.m., LVN 1 documented Resident 1 was asleep with not shortness of breath or sign of distress. The Licensed Personnel Progress Notes dated 7/7/18, timed at 5:12 a.m. documented by LVN 1, indicated documented Certified Nursing Assistant 1 (CNA 1) notified LVN 1 Resident 1 was having shortness of breath. LVN 1 took Resident 1's vital signs and the blood pressure was 146/74 mmHg (millimeters of Mercury, normal range 90/60 - 120/80), the heart rate was 83 beats per minute (normal range 60-100), and the respiration rate was 21 breaths per minutes (normal respiration rate 12-20). LVN 1 checked Resident 1's oxygen saturation, which was 87%. LVN 1 increased the oxygen administration to 5 L/min via mask and the oxygen saturation increased to 91%. LVN 1 instructed CNA 1 to call RN 1. At 5:20 a.m., LVN 1 documented RN 1 requested LVN 1 to give [MEDICATION NAME] breathing treatment, which was carried out. Resident oxygen saturation went from 84% to 92%. R1 took over Resident 1's care. At 5:50 a.m., R1 documented she stayed with Resident 1 for close monitoring. Resident 1 expressed to RN 1 she felt better after the breathing treatment. The oxygen saturation remained between 92% - 94%. Resident 1's vital signs were blood pressure 140/76 mmHg, heart rate was 73 beats per minutes, and respiratory rate was 24 breaths per minute. At 6:20 a.m., Resident 1 complained of shortness of breath, respirations were uneven and labored (difficult) using accessory muscles for breathing. Resident 1 had difficulty communicating due to shortness of breath. Oxygen saturation was 82% with 5 L/min oxygen. RN 1 increased the oxygen to 10 L/min via mask. The blood pressure was down to 105/68 and the respiratory rate was 25 breaths per minute. At 6:30 a.m., RN 1 documented Resident 1 was alert with shortness of breath, the respiratory rate was 27 breaths per minute, audible congestion with the use of a stethoscope (instrument used for listening to sounds produced in the body and especially those of the heart and lungs). Oxygen saturation was 90% - 94% on 10 L/minute of oxygen with a non-rebreather mask (enables the delivery of high concentrations of oxygen). Resident 1 nodded when asked if she had chest pain. Resident 1's blood pressure was 100/50 mmHg, heart rate was 74 beats per minutes, and respiratory rate was 27 breaths per minute. Physician 1 was called but not available, 911 (paramedics) was called and the paramedics arrived at 6:38 a.m. On 7/7/17, from 5:12 a.m. to 6:30 a.m., 78 minutes from the time Resident 1 had a change of condition, the licensed nurses, LVN 1 and RN 1, did not call Physician 1 as ordered on [DATE] and as indicated in the plan of care. At 5:12 a.m., Resident 1's oxygen saturation was below 92%, the oxygen administration was increased over 2 L/min, and Resident 1 had shortness of breath. A review of GACH 1 Emergency Department Service Report Resident 1 arrived on 7/7/17 at 7 a.m., was not verbal and was not moving. Resident 1 was diagnosed with [REDACTED]. A review of the Certificate of Death indicated Resident 1's immediate cause of death was [MEDICAL CONDITION] and the underlying cause was hypertension. During an interview on 3/20/18 at 1:05 p.m., the Director of Nursing (DON) stated the nurses did not call Physician 1 right away but were taking care of Resident 1's needs. According to the DON, the licensed nurses (LVN 1 and RN 1) should have called Physician 1 when Resident 1 first went into respiratory distress (5:12 a.m.). The DON confirmed there was no physician's order to increase Resident 1's oxygen and the nurses should have called to notify the physician and receive new orders. During an interview on 3/20/18 at 3:25 p.m., RN 1 stated Resident 1 was on 5 L/min when she arrived to her room and she increased the oxygen to 10 L/min due to Resident 1 still having breathing problems. A review of the undated facility's policy on Observing, Recording, and Reporting Condition Change of the Resident, indicated the purpose was to observe, record, and report any condition change to the attending physician so proper treatment will be implemented. After a condition change, monitor dyspnea (difficult breathing) or variations in respirations and notify the physician.

Based on interview and record review, the facility failed to ensure the resident environment was free of accident hazards and failed to provide adequate supervision and assistance devices to prevent fall accident for one of three sample residents (Resident 1), including: 1. Failure to implement the Care Plan on Resident 1's impaired cognition (is the mental process involved in knowing, learning, and understanding things) due to dementia, by not monitor and anticipating Resident 1's needs. 2. Failure to implement the Care Plan on Resident 1's fall risk by not assessing the degree of safety awareness to determine safety needs and by not assisting with transfer/mobility as needed. 3. Failure to develop specific interventions to prevent falls such as reinstating the use of personal alarms for Resident 1 which were effective in the past; developing a toileting schedule program to anticipate Resident 1's need to use the restroom; and specifying the level and frequency of supervision and monitoring Resident 1 required for safety. As a result, Resident 1 fell three times while getting out of bed unattended. The third unwitnessed fall, resulted in a left [MEDICAL CONDITION] (break), requiring transfer to General Acute Care Hospital 1 (GACH 1) where she underwent a surgical procedure to repair the [MEDICAL CONDITION], a percutaneous pinning of the lower extremity (this involves the insertion of pins through the skin to hold the bones in a proper position while they heal). Findings: On 2/15/18, at 7:35 a.m., an unannounced visit was made to the facility to investigate a complaint regarding Admission, Transfer and Discharge Rights. According to the Admission Record, Resident 1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. nerve and can result in vision loss and [MEDICAL CONDITION]). A review of Minimum Data Set (MDS - standardized assessment and care-planning tool) dated 6/29/17 indicated, Resident 1 was able to communicate her needs, had visual impairment, and required extensive assistance with one-person physical assist with bed mobility, transfers, walking, toilet use, and personal hygiene. Resident 1's balance during transitions and walking was unsteady and only able to stabilize with staff assistance. Resident 1 used a walker and a wheelchair as mobility devices. A review of the Fall Risk Evaluation form, dated 6/23/17, 9/28/17, and 12/28/17 indicated, Resident 1 was at high fall risk due to mental status, history of falls, unsteady gait and balance, medication use and diagnoses. The form indicated preventive protocol should be initiated immediately. A review of the physician's orders [REDACTED]. The alarm goes off when the resident gets out of bed). According to the Care Plan developed 6/23/17, for Resident 1's impaired cognition (reasoning) due to dementia, the approaches included to monitor and anticipate needs. The frequency of monitoring was not indicated. A review of the Care Plan developed 6/29/17, last revised on 12/17/17, for Resident 1's Fall Risk, indicated a goal for Resident 1 not to have incidents of falls or injuries. The interventions included assess degree of orientation, vision and safety awareness to determine safety needs, assist with transfer/mobility as needed and encourage Resident 1 to call for assistance. There were no specific interventions to prevent falls and no specific supervision and monitoring system to ensure Resident 1's safety. A review of the physician's orders [REDACTED]. A review of the Nurses Notes dated 10/13/17 indicated Resident 1 did not have a fall incident in 40 days and the use of safety devices (alarms) were discontinued. A physician order [REDACTED]. According to the Supervisor's Incident Report and Nurses Notes, dated 10/20/17, at 7:55 p.m., the Licensed Nurse heard Resident 1 yelling for help, and found Resident 1 in her room, sitting against her bed. Resident 1 stated she was going to the restroom, the floor was slippery, and her socks were slippery. Resident 1 stated she slid down slowly against the bed onto the floor. Resident 1 did not have injuries. The corrective action was to re-educate Resident 1 to call for assistance and application of a floor mat by Resident 1's bed. A review of the Nurse's Notes dated, 10/21/17 at 3 p.m., indicated Resident 1 had multiple episodes of getting out of bed. A review of the Supervisor's Incident Report and the Nurses Notes indicated on 1/16/18 at 8:55 a.m., Certified Nursing Assistant 1 (CNA 1), found Resident 1 in the restroom, on the floor, lying on the left side in front of the hand sink. CNA 1 had served breakfast to Resident 1. Resident 1 went to the restroom without assistance, pressed the called light but could not wait for a nurse to come, stood up and lost her balance. Resident 1 stated she felt dizzy. Resident 1's body was checked and was found to have redness to the left cheek and left shoulder. The corrective action was to re-educate the resident to call for assistance. A review of the Supervisor's Incident Report and the Nurses Notes indicated on 2/9/18, at 8:10 p.m., a loud sound was heard at the Nurses' Station, Resident 1 was found sitting on the restroom floor with her back against the wall. Resident 1 stated she went to use the restroom without assistance, lost her balance and fell while trying to use the toilet as she bent over to remove her soiled diaper. Resident 1 complained of pain to the left shoulder and hip. The physician was notified and order to transfer Resident 1 to GACH 1. At 10 p.m., Resident 1 was transported by ambulance. On 2/15/18 at 9:57 a.m., during an interview, the Director of Nursing (DON) while reviewing Resident 1's clinical record was unable to provide documentation that the plan of care was reviewed and revised after each fall. After the falls on 10/20/17 and 1/16/18, the plan of actions were to re-educate Resident 1 on calling staff for assistance; however, Resident 1 was confused and unable to remember to call for assistance. There was no documented evidence the interdisciplinary team (IDT) addressed Resident 1's repeated falls, lack of safety needs, and incontinent status. There was no toileting plan developed as Resident 1 fell while attempting to use the toilet on her own. There was no documentation addressing the need to develop and implement new safety measures including considering to use again the personal alarms in bed and wheelchair. A review of GACH 1 Hospitalist History and Physical, dated 2/10/18, indicated Resident 1 sustained a fall with a left femoral neck (the upper part of the long bone of the leg) fracture. Resident 1 underwent percutaneous pinning of the left hip. On 2/15/18, at 9:57 a.m., during an interview, the Director of Nursing (DON) stated she was aware Resident 1 was a high risk for fall and kept falling because she never asked for help. The DON stated alarms were used in the past, but discontinued because Resident 1 was doing better and the facility did not want to use the alarms. A review of an undated facility Policy and Procedure titled, Fall Prevention, indicated the policy was designed to provide a safe environment for the residents as well as reduce the risk of resident falls. Due to residents not able to guard themselves from falling, it was every staff member responsibility to ensure resident safety and promote a safe environment. As incidents were reviewed and discussed during meetings to ensure that measures were taken to avoid repeat. Falls are unexpected and unintended accidents that can cause injury to residents and can be prevented if potential sources of accidents are identified, implemented and taken seriously.