Every finding on record at California Post Acute

Based on observation, interview, and record review, the facility failed to implement the comprehensive care plan for one of three sampled residents (Resident 1), by failing to provide Resident 1 with the assistance and supervision identified as necessary for toileting/activities of daily living (ADLs) on [DATE]. This failure resulted in Resident 1 getting out of bed without assistance at approximately 5:00 AM and subsequently being found unresponsive on the floor at approximately 6:00 AM on [DATE].During a review of Resident 1's admission Record, dated [DATE], indicated Resident 1 was admitted to the facility on [DATE] with diagnosis of Chronic Obstructive Pulmonary Disease (COPD - lung disease causing restricted airflow and breathing problems), shortness of breath, scoliosis (a medical condition where the spine curves sideways instead of running straight down the middle of the back), heart failure (the heart muscle isn't pumping blood as well as it should, failing to meet the body's needs for oxygen and nutrients, leading to fluid buildup and symptoms like shortness of breath and fatigue), and reduced mobility. During a review of Resident 1's Minimum Data Set (MDS- resident assessment tool) dated [DATE], indicated Resident 1 had intact cognitive (ability to think, remember and reason) skills for daily decision making. The MDS indicated Resident 1 required partial assistance for toileting, shower, lower body dressing, putting on taking off footwear, roll left and right, sit to lying, lying to sitting on side of bed, sit to stand, chair/bed to chair transfer, toilet transfer, and walk ten feet. The MDS indicated Resident 1 required supervision (Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) for upper body dressing and set up assistance (Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity) for eating and oral hygiene. During a review of Resident 1's Comprehensive Care Plan (CP) dated [DATE], indicated Resident 1 presents with trunk stability impairments, bilateral lower extremity strength/joint deficits, balance deficits, and decreased independence with functional mobility. The CP indicated interventions required by staff were to implement fall preventions, gait and wheelchair management training. The CP indicated Resident 1 was at risk for alteration in comfort related to diagnosis of respiratory failure with hypoxia, and interventions by staff included assist during transfers and positioning, assist resident with activities of daily living (ADL) tasks and mobility functions as needed. The CP indicated Resident 1 was at risk of fall related to history of fall and medication use. Interventions provided by staff included monitor resident for changes in gait, balance, strength, cognition (ability to make decisions), and safety awareness and remind the resident to use call light. During a review of Resident 1's Fall Risk assessment dated [DATE] indicated Resident 1 required the use of assistive devices for gait and balance, walking, and make a turn. During a review of Resident 1's Physical Therapy evaluation dated [DATE], indicated Resident 1 was fall risk, had well controlled HIV, severe scoliosis, asthma (a chronic lung disease that causes inflammation and muscle tightening of the airways, making it harder to breathe), and required partial/moderate assistance for sit to stand, walk 10 feet, and chair/bed to chair transfer. During a review of Resident 2's admission Record, dated [DATE], indicated Resident 2 was admitted to the facility on [DATE] with diagnosis of epilepsy (a chronic brain disorder characterized by recurrent, unprovoked seizures, which are sudden surges of abnormal electrical activity in the brain, causing temporary disruptions in behavior, movement, or awareness). During a review of Resident 2's MDS dated [DATE], indicated Resident 2 had intact cognitive skills for daily decision making. During an interview on [DATE] at 12:49 PM with Resident 2, Resident 2 laid down on his bed (bed-A- closest to the door) with his head elevated, and stated that on the morning of [DATE] at approximately 3 AM he heard Resident 1 who was his roommate (bed-B) get up to use the restroom unassisted by staff, making a lot of noise which woke him up, and returned to his bed a few minutes later. Resident 2 stated Resident 1 got up again on [DATE] at approximately 5 AM making a lot of noise, which was not unusual for Resident 1 as he always made a lot of noise when he was awake and tried to walk because Resident 1 had a problem with his equilibrium, had human immunodeficiency virus (HIV- a virus that attacks the body's white blood cells, weakening the immune system), and was physically and mentally shot. Resident 2 stated that the noise Resident 1 was making sounded a lot like he was bumping into the furniture and tv stand but he could not see Resident 1 because he was laying down trying to sleep. Resident 2 stated after five minutes of Resident 1 making noises, the noise eventually stopped. Resident 2 stated no staff came into the room between the hours of 3-5 AM to assist Resident 1 to get up and use the restroom or assist him back to bed. Resident 2 stated at approximately 6 AM, he heard the Certified Nursing Assistant 1 (CNA1) walk into the room to do her rounds before she left her shift and found Resident 1 unresponsive on the floor. Resident 2 stated the CNA1 and another Licensed Vocational Nurse 1 (LVN1) checked Resident 1's pulse and began doing cardiopulmonary resuscitation (CPR- It is a life-saving emergency procedure used when someone's heart stops beating or they stop breathing) on Resident 1. Resident 2 stated the Emergency Medical Technicians (EMTs) showed up a few minutes later and pronounced Resident 1 dead. Resident 2 stated three CNAs came to the room to place Resident 1 back on his bed and clean up his body. During an interview on [DATE] at 1:13 PM with CNA1 , CNA1 stated she was working at the facility on the night of [DATE] at 11PM through [DATE] at 7AM, and was assigned to care for Resident 1. CNA1 stated Resident 1 was independent with toileting and did not require staff assistance. CNA 1 stated Resident 1 seemed restless on the night of [DATE] and pressed the call light at least three times between the hours of 11PM through 12:30 AM. CNA1 stated Resident 1 requested ice, water, and oxygen. CNA1 stated at approximately 11:30 PM Resident 1 requested his blood sugar checked, so she reported to the Charge Nurse 1 (CN1) that Resident 1 looked restless and was asking for his blood sugar to be checked. CNA1 stated at approximately 12 AM, Resident 1 called again requesting oxygen, which CNA1 reported to CN1. CNA1 stated about 12:20 AM Resident 1 called again requesting his blood sugar be tested again, and she reported to the CN1. CNA1 stated she did not hear from Resident 1 from 12:30 AM through 5:30 AM as she checked on all her other residents since she had 14 residents assigned to her care that night. CNA1 stated at approximately 5:30 AM she returned to Resident 1's room to check on him and noticed he was sitting on the side of his bed, thinking. CNA1 stated she asked Resident 1 if he was okay, but Resident 1 did not answer her and CNA1 assumed Resident 1 was just thinking to himself, so she moved on to her next assignment without reporting to CN1. CNA1 stated at approximately 6AM, she was walking by Resident 1's room when she observed Resident 1 on the floor not breathing. CNA1 stated she called the CN1 and she began CPR on Resident 1. CNA1 stated CN1 and a second licensed nurse walked in the room to continue CPR until paramedics arrived and took over. CNA1 stated paramedics declared him dead at the facility. CNA1 stated she did not have any knowledge that Resident 1 was at risk for falls, and believed he was independent for ADLs. During an interview on [DATE] at 1:29 PM with CN 1, CN 1 stated that on the night of [DATE] she worked at the facility from 11PM to [DATE] at 7AM. CN1 stated between the hours of 12-2AM, CNA1 informed her that Resident 1 required assistance with his vital signs. CN1 stated Resident 1 always pointed his finger when he wanted his oxygen saturation checked. CN1 stated she went in to check Resident 1's oxygen saturation using a finger probe and Resident 1's oxygen saturation fell within normal range (96-98 percent). CN1 stated Resident 1 had an order for continuous oxygen via nasal cannula (a light, flexible plastic device used to deliver extra oxygen directly into a person's nose) and Resident 1 was wearing it that night. CN1 stated she explained to CNA1 that Resident 1 was requesting his oxygen levels be checked by pointing his finger not his blood sugar. CN1 stated she thought Resident 1 was okay and therefore did not notify the facility doctor. CN1 stated the last time she saw Resident 1 breathing was at approximately 4 AM when she walked around the facility, checking on residents. CN1 stated Resident 1 was in his room laying down in his bed and did not seem short of breath. CN1 stated CNA1 did a round to check on residents around 5 AM but nothing was reported, until 6 AM when CNA1 reported that Resident 1 was unresponsive on the floor, and Resident 1 looked cold and gray. CN1 stated she tried to feel for a pulse on Resident 1 but he did not have one so they started CPR until paramedics came and took over but essentially pronounced Resident 1 dead. During an interview on [DATE] at 2:53 PM with the Director of Nursing (DON), the DON stated the facility should take necessary precautions for residents who are at risk for falls by performing a fall risk assessment, use a star as an indicator to signal staff residents who are risk of falls, and put a risk band so that staff is aware of resident fall risk status. The DON stated residents who require partial/moderate assistance for toileting should be assisted by staff to transfer and use the toilet, as well as do more rounds on residents. The DON stated Physical Therapy evaluations should be communicated to nursing staff upon admission, and verbalize which residents will require partial assistance, such as residents who are at risk of falls. The DON stated Resident 1's fall could have been prevented by increasing the frequency of rounds for Resident 1, implementing the Care Plan to prevent falls, staff should have assisted Resident 1 with ADLs, and ensure resident care is specific for resident's level of care. The DON also stated that when a resident is asked whether they are okay and does not respond, staff should notify the charge nurse rather than leave the resident alone on the side of the bed, as well as communicate when residents are out of baseline with their behaviors such as looking restless to ensure assessment and follow up by licensed nurse. The DON stated upon facility investigation of Resident 1's fall and death that occurred on [DATE] through [DATE], the facility had not determined the root cause analysis that led to Resident 1's fall and subsequent death, leaving other residents at risk for injury and death.During a review of the facility's policy and procedure (P&P) titled Develop-Implement Comprehensive Care Plan dated [DATE], indicated the facility develops and implements a person-centered comprehensive care plan to meet each resident's preferences, goals, and address the resident's medical, physical, mental and psychosocial needs. The facility establishes, documents, and implements the care and services provided to each resident to assist in attaining or maintaining his or her highest practicable quality of life. Care plans shall describe the residents' needs and how the facility will assist in meeting these needs. Care plans shall include the discipline providing care or services, measurable objectives, and timeframes to evaluate the resident's progress toward his/her goal.

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) received adequate supervision and assistance to prevent accidents when Resident 1, who was assessed as requiring partial/moderate assistance (Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with toileting and walking, was allowed to get out of bed and walk without staff assistance.This failure resulted in Resident 1 experiencing an unwitnessed fall, was found unresponsive on the floor approximately one hour later by staff, and his death.During a review of Resident 1's admission Record, dated [DATE], indicated Resident 1 was admitted to the facility on [DATE] with diagnosis of Chronic Obstructive Pulmonary Disease (COPD - lung disease causing restricted airflow and breathing problems), shortness of breath, scoliosis (a medical condition where the spine curves sideways instead of running straight down the middle of the back), heart failure (the heart muscle isn't pumping blood as well as it should, failing to meet the body's needs for oxygen and nutrients, leading to fluid buildup and symptoms like shortness of breath and fatigue), and reduced mobility. During a review of Resident 1's Minimum Data Set (MDS- resident assessment tool) dated [DATE], indicated Resident 1 had intact cognitive (ability to think, remember and reason) skills for daily decision making. The MDS indicated Resident 1 required partial assistance for toileting, shower, lower body dressing, putting on taking off footwear, roll left and right, sit to lying, lying to sitting on side of bed, sit to stand, chair/bed to chair transfer, toilet transfer, and walk ten feet. The MDS indicated Resident 1 required supervision (Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) for upper body dressing and set up assistance (Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity) for eating and oral hygiene. During a review of Resident 1's Comprehensive Care Plan (CP) dated [DATE], indicated Resident 1 presents with trunk stability impairments, bilateral lower extremity strength/joint deficits, balance deficits, and decreased independence with functional mobility. The CP indicated interventions required by staff were to implement fall preventions, gait and wheelchair management training. The CP indicated Resident 1 was at risk for alteration in comfort related to diagnosis of respiratory failure with hypoxia, and interventions by staff included assist during transfers and positioning, assist resident with activities of daily living (ADL) tasks and mobility functions as needed. The CP indicated Resident 1 was at risk of fall related to history of fall and medication use. Interventions provided by staff included monitor resident for changes in gait, balance, strength, cognition (ability to make decisions), and safety awareness and remind the resident to use call light. During a review of Resident 1's Fall Risk assessment dated [DATE] indicated Resident 1 required the use of assistive devices for gait and balance, walking, and make a turn. During a review of Resident 1's Physical Therapy evaluation dated [DATE], indicated Resident 1 was fall risk, had well controlled HIV, severe scoliosis, asthma (a chronic lung disease that causes inflammation and muscle tightening of the airways, making it harder to breathe), and required partial/moderate assistance for sit to stand, walk 10 feet, and chair/bed to chair transfer. During a review of Resident 2's admission Record, dated [DATE], indicated Resident 2 was admitted to the facility on [DATE] with diagnosis of epilepsy (a chronic brain disorder characterized by recurrent, unprovoked seizures, which are sudden surges of abnormal electrical activity in the brain, causing temporary disruptions in behavior, movement, or awareness). During a review of Resident 2's MDS dated [DATE], indicated Resident 2 had intact cognitive skills for daily decision making. During an interview on [DATE] at 12:49 PM with Resident 2, Resident 2 laid down on his bed (bed-A- closest to the door) with his head elevated, and stated that on the morning of [DATE] at approximately 3 AM he heard Resident 1 who was his roommate (bed-B) get up to use the restroom unassisted by staff, making a lot of noise which woke him up, and returned to his bed a few minutes later. Resident 2 stated Resident 1 got up again on [DATE] at approximately 5 AM making a lot of noise, which was not unusual for Resident 1 as he always made a lot of noise when he was awake and tried to walk because Resident 1 had a problem with his equilibrium, had human immunodeficiency virus (HIV- a virus that attacks the body's white blood cells, weakening the immune system), and was physically and mentally shot. Resident 2 stated that the noise Resident 1 was making sounded a lot like he was bumping into the furniture and tv stand but he could not see Resident 1 because he was laying down trying to sleep. Resident 2 stated after five minutes of Resident 1 making noises, the noise eventually stopped. Resident 2 stated no staff came into the room between the hours of 3-5 AM to assist Resident 1 to get up and use the restroom or assist him back to bed. Resident 2 stated at approximately 6 AM, he heard the Certified Nursing Assistant 1 (CNA1) walk into the room to do her rounds before she left her shift and found Resident 1 unresponsive on the floor. Resident 2 stated the CNA1 and another Licensed Vocational Nurse 1 (LVN1) checked Resident 1's pulse and began doing cardiopulmonary resuscitation (CPR- It is a life-saving emergency procedure used when someone's heart stops beating or they stop breathing) on Resident 1. Resident 2 stated the Emergency Medical Technicians (EMTs) showed up a few minutes later and pronounced Resident 1 dead. Resident 2 stated three CNAs came to the room to place Resident 1 back on his bed and clean up his body. During an interview on [DATE] at 1:13 PM with CNA1 , CNA1 stated she was working at the facility on the night of [DATE] at 11PM through [DATE] at 7AM, and was assigned to care for Resident 1. CNA1 stated Resident 1 was independent with toileting and did not require staff assistance. CNA 1 stated Resident 1 seemed restless on the night of [DATE] and pressed the call light at least three times between the hours of 11PM through 12:30 AM. CNA1 stated Resident 1 requested ice, water, and oxygen. CNA1 stated at approximately 11:30 PM Resident 1 requested his blood sugar checked, so she reported to the Charge Nurse 1 (CN1) that Resident 1 looked restless and was asking for his blood sugar to be checked. CNA1 stated at approximately 12 AM, Resident 1 called again requesting oxygen, which CNA1 reported to CN1. CNA1 stated about 12:20 AM Resident 1 called again requesting his blood sugar be tested again, and she reported to the CN1. CNA1 stated she did not hear from Resident 1 from 12:30 AM through 5:30 AM as she checked on all her other residents since she had 14 residents assigned to her care that night. CNA1 stated at approximately 5:30 AM she returned to Resident 1's room to check on him and noticed he was sitting on the side of his bed, thinking. CNA1 stated she asked Resident 1 if he was okay, but Resident 1 did not answer her and CNA1 assumed Resident 1 was just thinking to himself, so she moved on to her next assignment without reporting to CN1. CNA1 stated at approximately 6AM, she was walking by Resident 1's room when she observed Resident 1 on the floor not breathing. CNA1 stated she called the CN1 and she began CPR on Resident 1. CNA1 stated CN1 and a second licensed nurse walked in the room to continue CPR until paramedics arrived and took over. CNA1 stated paramedics declared him dead at the facility. CNA1 stated she did not have any knowledge that Resident 1 was at risk for falls, and believed he was independent for ADLs. During an interview on [DATE] at 1:29 PM with CN1, CN1 stated that on the night of [DATE] she worked at the facility from 11PM to [DATE] at 7AM. CN1 stated between the hours of 12-2AM, CNA1 informed her that Resident 1 required assistance with his vital signs. CN1 stated Resident 1 always pointed his finger when he wanted his oxygen saturation checked. CN1 stated she went in to check Resident 1's oxygen saturation using a finger probe and Resident 1's oxygen saturation fell within normal range (96-98 percent). CN1 stated Resident 1 had an order for continuous oxygen via nasal cannula (a light, flexible plastic device used to deliver extra oxygen directly into a person's nose) and Resident 1 was wearing it that night. CN1 stated she explained to CNA1 that Resident 1 was requesting his oxygen levels be checked by pointing his finger not his blood sugar. CN1 stated she thought Resident 1 was okay and therefore did not notify the facility doctor. CN1 stated the last time she saw Resident 1 breathing was at approximately 4 AM when she walked around the facility, checking on residents. CN1 stated Resident 1 was in his room laying down in his bed and did not seem short of breath. CN1 stated CNA1 did a round to check on residents around 5 AM but nothing was reported, until 6 AM when CNA1 reported that Resident 1 was unresponsive on the floor, and Resident 1 looked cold and gray. CN1 stated she tried to feel for a pulse on Resident 1 but he did not have one so they started CPR until paramedics came and took over but essentially pronounced Resident 1 dead. During an interview on [DATE] at 2:53 PM with the Director of Nursing (DON), the DON stated the facility should take necessary precautions for residents who are at risk for falls by performing a fall risk assessment, use a star as an indicator to signal staff residents who are risk of falls, and put a risk band so that staff is aware of resident fall risk status. The DON stated residents who require partial/moderate assistance for toileting should be assisted by staff to transfer and use the toilet, as well as do more rounds on residents. The DON stated Physical Therapy evaluations should be communicated to nursing staff upon admission, and verbalize which residents will require partial assistance, such as residents who are at risk of falls. The DON stated Resident 1's fall could have been prevented by increasing the frequency of rounds for Resident 1, implementing the Care Plan to prevent falls, staff should have assisted Resident 1 with ADLs, and ensure resident care is specific for resident's level of care. The DON also stated that when a resident is asked whether they are okay and does not respond, staff should notify the charge nurse rather than leave the resident alone on the side of the bed, as well as communicate when residents are out of baseline with their behaviors such as looking restless to ensure assessment and follow up by licensed nurse. The DON stated upon facility investigation of Resident 1's fall and death that occurred on [DATE] through [DATE], the facility had not determined the root cause analysis that led to Resident 1's fall and subsequent death, leaving other residents at risk for injury and death. During a review of the facility's policy and procedure (P&P) titled Free of Accident Hazards/Supervision/Devices dated [DATE], indicated a fall is defined as unintentionally coming to rest on the floor/ground, an accident is any unexpected or unintentional incident which results in injury to a resident. An avoidable accident is defined as when an accident occurred because the facility failed to:Identify environmental hazards and or assess individual resident risk of an accident, including the need for supervision and or assistive devices.Evaluate/ analyze the hazards and risks and eliminate them, identify and implement measures to reduce the hazard risks as much as possibleImplement interventions including adequate supervision and assistive devices consistent with a resident's needs, goals, care plan, and current professional standards of practice in order to eliminate risk.Monitor the effectiveness of the interventions and modify the care plan as necessary. The P&P indicated an effective way for the facility to avoid accidents is to develop a culture of safety and commit to implementing systems that address resident risk and environmental hazards to minimize the likelihood of accidents. A facility with a commitment to safety:Acknowledges the high-risk nature of its population and setting.Develop effective communication, including a reporting system that does not place blame on the staff member for reporting resident risks and environmental hazards.Encourages the use of data to identify potential hazards, risks, and solutions related to specific safety issues that arise.Identification of hazards, including inadequate supervision, and a resident's risks of potentially avoidable accidents in the resident environment.Identify factors that may result in resident falls which include, but are not limited to poor lighting, balance disorders, medication side effects, underlying chronic medical conditions such as heart failure, and environmental hazards. During a review of the facility's P&P titled Fall Management Program dated [DATE], indicated the facility provides an environment that is free from accident hazards over which the facility has control and provide supervision and assistive devices to each resident to prevent avoidable accidents. An avoidable accident is an accident which occurred because the facility failed to implement interventions, including adequate supervision consistent with the resident's care plan and current professional standards of practice to eliminate the risk of an accident. The interdisciplinary team will complete a post fall evaluation to identify intrinsic and extrinsic factors resulting in the resident falling.

Based on interview and record review, the facility failed to ensure four of four sampled residents (Resident 5, Resident 11, Resident 43, and Resident 57) had a complete advance directive (a legal document indicating resident preference on end-of-life treatment decisions). This failure violated Resident 5, Resident 11, Resident 43, and Resident 57 and/or representative's rights to be fully informed of the option to formulate an advanced directive and had the potential not to follow the residents' wishes. Findings: a.During a review of Resident 5's admission Record, the admission Record indicated the facility admitted the resident on 6/12/2020 with diagnoses that included anemia (a health condition where your blood lacks enough healthy red blood cells or hemoglobin (the protein that carries oxygen), acute respiratory failure with hypoxia (a health condition when lungs suddenly cannot move enough oxygen into your blood), and essential hypertension (high blood pressure). During a review of Resident 5 's Advance Directive Acknowledgement Form dated 3/2/2025, the Advanced Directive Acknowledgement form indicated that Resident 5's acknowledgement statements were not initialed. The blank initial spaces indicated there was no documented acknowledgment that the resident received information regarding their right to accept or refuse medical treatment, the right to formulate an advance directive, and the understanding of the advanced directive information and options. During a review of Resident 5's Minimum Data Set (MDS, a resident assessment tool) dated 6/10/2026, the MDS indicated Resident 7 usually made herself understood and understood others. The MDS indicated Resident 5's cognitive functioning (mental processes that enable people to think, understand, make decisions, and complete tasks) was severely impaired. The MDS indicated Resident 5 was dependent from staff for activities of daily living (ADLs-bed mobility, surface transfer, eating, walk in room, dressing, toileting, and personal hygiene). During a review of Resident 5's History and Physical (H&P) dated 7/2/2026, the H&P indicated Resident 5 did not have the capacity to make complex health care decisions, however Resident 5 was able to decide for activities of daily living (ADL- basic self-care tasks that people do every day to live independently). b.During a review of Resident 11's admission Record, the admission Record indicated the facility admitted the resident on 5/7/2026 with diagnoses that included hyperkalemia (having too much potassium in your blood), hyperlipidemia (having too many fats, or lipids, in your blood) and essential hypertension. During a review of Resident 11's H&P dated 5/10/2026, the H&P indicated Resident 11 had the capacity to make medical decisions. During a review of Resident 11 's Advance Directive Acknowledgement Form dated 5/11/2026, the Advanced Directive Acknowledgement form indicated that Resident 5's acknowledgement statements space did not have initials. The blank initial spaces indicated there was no documented acknowledgment that the residents received information regarding their right to accept or refuse medical treatment, the right to formulate an advance directive, and the understanding of the advanced directive information and options. During a review of Resident 11's MDS dated [DATE], the MDS indicated Resident 11 made herself understood and understood others. The MDS indicated Resident 11's cognitive functioning was intact. The MDS indicated Resident 11 was dependent on staff for bed mobility, transfer, lower body dressing, toileting, and required maximum assistance from staff for personal hygiene, upper body dressing, and oral hygiene. c.During a review of Resident 57's admission Record, the admission Record indicated the facility admitted the resident on 4/22/2026, with diagnoses that included anemia (a health condition where your blood lacks enough healthy red blood cells or hemoglobin (the protein that carries oxygen), anxiety disorder (a mental health condition that causes extreme fear, worry, or nervousness), and essential hypertension. During a review of Resident 57's untitled history and physical document dated 6/23/2026, the untitled history and physical indicated Resident 57 did not have the capacity to understand and make decisions. During a review of Resident 57's Advance Directive Acknowledgement Form dated 6/11/2026, the Advanced Directive Acknowledgement form indicated that Resident 5's acknowledgement statements were not initialed. The blank initial spaces indicated there was no documented acknowledgment that the residents received information regarding their right to accept or refuse medical treatment, the right to formulate an advance directive, and the understanding of the advanced directive information and options. During a review of Resident 57's MDS dated [DATE], the MDS indicated Resident 7 usually made herself understood and understood others. The MDS indicated Resident 57's cognitive functioning (mental processes that enable people to think, understand, make decisions, and complete tasks) was severely impaired. The MDS indicated Resident 57 required moderate assistance on staff for ADLs. During a concurrent interview and record review on 8/4/2026 at 1:59 PM with the Admissions Coordinator (AC), the standard Advance Directive Acknowledgement form (in general) was reviewed. The AC stated that an advance directive allowed a resident (in general) to designate another person to inform the facility of the resident's (in general) healthcare wishes if the resident became unable to make medical decisions. The AC stated she (AC) assisted the social services director with completing the advance directive acknowledgement forms (in general). The AC stated the Advance Directive Acknowledgement form was required to be completed as part of the admission packet. The AC stated that advance directive acknowledgement form was necessary upon admission to provide residents with information regarding advance directives and to document the resident's acknowledgement of the information and available options. During a concurrent interview and record review on 8/4/2026 at 2:10 PM with the Social Service Director (SSD), Resident 5, Resident 11, and Resident 57's Advance Directive Acknowledgement Forms were reviewed. The SSD stated the forms were completed upon admission and readmission to provide residents (in general) with information and options regarding advance directives and was required by the state. The SSD stated the Advance Directive Acknowledgement forms for Resident 5, Resident 11 and Resident 57 were incomplete because the acknowledgement statements were not initialed. The SSD stated the blank initials indicated there was no documentation that the residents (Resident 5, Resident 11 and Resident 57) were provided with information regarding the right to formulate an advance directive or understood the advanced directive information the SSD stated the facility failed to complete the form in their entirety. During a concurrent interview and record review on 8/4/2026 at 2:10 PM with the Director of Nursing (DON), Resident 5, Resident 11, and Resident 57's Advance Directive Acknowledgement forms were reviewed. The DON stated that completed Advance Directive Acknowledgement form was part of the admission process and documented information was provided to residents (in general) regarding their right to formulate an advance directive in their understanding of information. The DON stated the Advance Directive Acknowledgement form instructed residents to place their initials after each acknowledgment statement. The DON stated the forms of Resident 5, Resident 11, and Resident 57 did not contain the required initials. The DON stated the facility failed to complete the advance directive acknowledgement form. The DON stated the absence of initials had the potential to prevent residents from exercising their right to formulate an Advance Directive. During a review of the facility's Advance Directive policy and procedure (P&P) dated 1/15/2026, the P&P indicated residents have the right to request, refuse and or discontinue treatment, to participate in or refuse to participate in experimental research and to formulate an advance directive. The P&P indicated Facility staff should attempt to determine the reason for the refusal of care, including whether a resident who was unable to verbalize their need is refusing care for another reason. The P&P indicated The facility is required to establish, maintain, and implement written policies and procedures regarding the residents right to formulate an advance directive, refuse medical or surgical treatment. The P&P indicated In addition, the facility management is responsible for ensuring that staff follow those policies and procedures. The P&P indicated the Facility honors residents' choices for care and does not treat the residential against his or her wishes. d.During a review of Resident 43's admission Record, the admission Record indicated the facility originally admitted Resident 43 on 12/22/2021 and was readmitted on [DATE] with diagnoses that included acute respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide), diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]) and depression (a mood disorder that causes persistent feeling of sadness and loss of interest). During a review of Resident 43's physician orders for life-sustaining treatment (POLST-medical order signed by a clinician that translates resident's personal choices about life support during an emergency) dated 1/18/2024, the POLST indicated Resident 43 did not have an advance directive. During a review of Resident 43's History and Physical (H&P) dated 2/12/2026, the H&P indicated Resident 43 had the capacity to understand and make decisions. During a review of Resident 43's MDS dated [DATE], the MDS indicated Resident 43 was on moderate assistance (helper does less than half the effort) to dependent (helper does all the effort) from staff for activities of daily living (ADLs-bed mobility, surface transfer, eating, walk in room, dressing, toileting, and personal hygiene). MDS also indicated Resident 43 did not have an advance directive. During a concurrent interview and record review on 8/5/2026 at 9:29 AM with the Social Service Director (SSD), Resident 43's advance directive acknowledgement form was reviewed. Advance directive acknowledgement form dated 1/17/2025, indicated Resident 43 did not have an advance directive. Advance directive acknowledgement form indicated missing Resident 43's initial indicating that Resident 43 was provided with written materials regarding resident's right to accept or refuse medical treatments, and rights to formulate an advance directive. The SSD stated that Resident 43's advance directive acknowledgement form was incomplete and added that it was best practice to make sure all documents were signed/initialed; and to document if a resident refused to sign or complete a form that he/she (resident) was provided with information/education regarding their (residents) advance directive rights. During an interview with Resident 43 on 8/5/2026 at 1:29 PM, Resident 43 stated that she (Resident 43) was not aware of what an advance directive was. During an interview with the Director of Nursing (DON) on 8/6/2026 at 2:43 PM, DON stated importance of completing the advance directive acknowledgement form and ensuring that residents were informed of or educated regarding advance directive rights. During a review of facility's P&P, titled, Advanced Directive, reviewed on 1/15/2026, P&P indicated that residents have the right to request, refuse, and or discontinue treatment, to participate in a or refuse to participate in experimental research, and to formulate an advance directive. P&P also indicated that the process of advance care planning is ongoing and integral aspect of the facility's comprehensive care planning process, assuring re-evaluation fo the resident's desires on a routine basis.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan (a plan of care that summarizes a resident's health conditions, specific care needs, and current treatments) to meet the needs of three of 15 sampled residents (Resident 3, Resident 13 and Resident 43) by failing to: 1.Develop and implement care plan for Resident 13's restorative nursing assistant (RNAnursing aide program that helps residents maintain their function and joint mobility) program for range of motion (ROMmeans the full movement potential of a joint) exercises on right lower extremity (leg). 2.Develop care plans for Resident 3's depression (a mood disorder that causes persistent feeling of sadness and loss of interest) disorder as manifested by verbalization of sadness and Ozempic (weight loss medication) use. 3. Develop care plan for Resident 43's Remeron (anti-depressant medication) use. These failures had the potential to result negative impact on Resident 3, Resident 13 and Resident 43's health, and the quality of care and services received.Findings: 1.During a review of Resident 13's admission Record, the admission Record indicated the facility admitted Resident 13 on 9/14/2023 with diagnoses that included but not limited to rhabdomyolysis (a serious medical condition where damaged muscle tissue breaks down rapidly), hyperlipidemia (having too many fats, or lipids, in your blood) and essential hypertension (high blood pressure that has no known, single medical cause). During a review of Resident 13's Physical Therapy (PT) Evaluation & Plan of treatment dated 9/14/2023 through 10/13/2023, the PT Evaluation & Plan of Treatment indicated objectives and goals that included, but we're not limited to, increasing resident 13's bilateral lower extremity strength, ability to stand, and balance. The PT evaluation and plan of treatment indicated resident 13's goal was to get stronger, walk again and return home. During a review of Resident 13's Physical Therapy (PT) Evaluation & Plan of treatment dated 10/14/2023 through 11/12/2023, the PT Evaluation & Plan of Treatment indicated objectives and goals that included, Resident 13 would safely ambulate using walker with functional balance. During a review of Resident 13's Rehab-Functional ROM and Voluntary Movement documents dated 3/25/2025 and 1/13/2026, the Rehab-Functional ROM and Voluntary Movement documents indicated on 3/25/2025 Resident 13 's RLE had no functional range of motion (ROM) limitations and no loss of voluntary movement. The Rehab-Functional ROM and Voluntary Movement documents indicated on 1/13/2026 Resident 13's RLE had functional ROM limitation and partial loss (resident is able to initiate and complete the task but movements are slow, spastic, uncoordinated, rigid, on one or both sides) of voluntary movement. During a review of Resident 13's (untitled) History and Physical (H&P) dated 6/17/2025, the H&P indicated that Resident 13 had the capacity to understand and make decisions. During a review of Resident 13's Care Plan Report dated 7/31/2025, the Care Plan Report indicated Resident 13 was receiving restorative care with a goal to achieve the highest level of optimal functioning by next review. The Care Plan Report indicated an intervention for AAROM (Active Assisted ROM) exercises to the RLE five times a week, with monitoring for pain before, during and after treatment. The intervention was initiated on 4/2/2026. During a review of Resident 13's Minimum Data Set (MDS- a resident assessment tool) dated 9/23/2025 (the formal release from a facility), the MDS indicated Resident 13 made himself usually understood and usually understood others. The MDS indicated Resident 13's cognitive functioning (mental processes that enable people to think, understand, make decisions, and complete tasks) is intact. The MDS indicated Resident 13 used a walker and wheelchair for out of bed mobility. The MDS indicated Resident 13 required supervision from staff with toileting, shower, upper and lower body dressing and personal hygiene. The MDS indicated Resident 13 required supervision from staff with transfers and positioning from sitting to standing. The MDS indicated Resident 13's physical therapy stop date was on 11/10/2023. During a review of Resident 13's Order Listing Report dated 8/7/2026, the Order Listing Report indicated on 2/20/2024, Resident 13 had an active restorative nursing service order of AROM on LLE (left lower extremities-left leg) five times per week every day with monitoring for pain before, during, and after treatment. The Order Listing Report indicated on 7/24/2025, Resident 13 had an active restorative nursing service order of AAROM on RLE five times per week every day with monitoring for pain before, during, and after treatment. During an interview on 8/3/2026 at 7:54 AM, in Resident 13's room, Resident 13 stated he (Resident 13) wanted physical therapy to become more active and improve his balance. Resident 13 stated he (Resident 13) was unsteady on his feet. During a concurrent interview and record review on 8/6/2026 at 10:01 AM with the Physical Therapy Supervisor (PTS), the Rehab -Functional ROM and Voluntary Movement documents dated 3/25/2025 and 1/13/2026 were reviewed. The PTS stated that Resident 13 completed physical therapy ([PT] a type of medical care that helps people move better, ease pain, and build strength after an injury, surgery, or illness) in 2023 and was transitioned to restorative nursing services. The PTS stated that the Rehab -Functional ROM and Voluntary Movement documents were annual screenings completed to assess Resident 13's ROM. The PTS stated The screening dated 1/13/2026 identified a decline in resident 13's right lower extremity. The PTS stated a plan of care was developed based on the residents (in general) affected body part and included specific exercise intervention to address the residents identified functional rehabilitation needs. The PTS stated the care plan for Resident 13 should be specific for his RLE decline and include the intervention of restorative nursing service ordered. During a concurrent interview and record review on 8/6/2026 at 11:30 AM with the Director of Staff Development (DSD), Resident 13's Care Plan Report dated 7/31/2025 was reviewed. The DSD stated she supervised the RNAs who provided restorative nursing services to residents. The DSD stated the new RLE AAROM order was added to the existing Care Plan as intervention and was not identified as a separate functional problem. The DSD stated a separate care plan for the new RLE AAROM program should have been developed to identify additional care and interventions to improve Resident 13's RLE function and mobility. During a concurrent interview and record review on 8/6/2026 at 1:30 PM with the Director of Nursing (DON) Resident 13's Care Plan Report dated 7/31/2025 was reviewed. The DON Stated the newly added lower extremity functional need needed to be addressed as a separate problem in the care plan because there was an order specific to the residents 13 are right lower extremity functional need. The DON stated a care plan specific to the right lower extremity would allow the facility to monitor the effectiveness of the intervention. The DON stated a care plan should have been developed for Resident 13's newly identified right lower extremity problem. During a review of the facility's Develop-Implement Comprehensive Care Plans policy and procedure (P&P) dated 1/15/2026, the P&P indicated that the facility develops a person-centered comprehensive care plan that are culturally competent' and trauma-informed, developed and implemented to meet each resident's preferences and goals, and address the resident's medical, physical, mental and psychosocial needs. The P&P indicated that the care plans shall describe the resident's needs and preferences and how the facility will assist in meeting these needs and preferences. The P&P indicated the comprehensive care plan describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The P&P indicated care plans shall describe the resident's needs and preferences and how the facility will assist in meeting these needs and preferences. The P&P indicated care plans shall include the discipline providing care or services, measurable objectives, and timeframes in order to evaluate the resident's progress toward his/her goal(s). During a review of the facility's Restorative Nurse Services P&P dated 1/15/2026, the P&P indicated the facility ensures that every resident receives restorative nursing services as determined by their comprehensive plan of care to assist them to maintain or restore their highest practicable level of physical, mental, functional, and psycho-social well-being. The P&P indicated restorative goals and objectives ore individualized and resident-centered and are outlined in each participating resident's plan of core. The P&P indicated Restorative goals may include but are not limited to supporting and assisting the resident in participating in the development and implementation of his slash her plan of care. 2.During a review of Resident 3's admission Record, the admission Record indicated the facility originally admitted Resident 3 on 3/20/2024 and was readmitted on [DATE] with diagnoses including diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]), obesity (having a high amount of excess body fat compared to bone and muscle) and depression. During a review of Resident 3's Order Summary Report dated 3/13/2026, the Order Summary Report indicated Resident 3 had a physician order for Escitalopram Oxalate (anti-depressant medication) 20 milligram (mg) one time a day for depression manifested by (m/b) verbalization of sadness. The Order Summary Report indicated Resident 3 had a physician order to monitor behavior episodes of: Depression m/b verbalization of sadness and tally with hashmarks for each episode on the medication administration record (MAR) every shift. During a review of Resident 3's History and Physical (H&P) dated 3/14/2026, the H&P indicated Resident 3 had the capacity to understand and make decisions. During a review of Resident 3's Minimum Data Set (MDS- a resident assessment tool) dated 6/23/2026, the MDS indicated Resident 3 had intact cognition (mental action or process of acquiring knowledge and understanding) for daily decision-making and from set up (helper sets up, resident completes activity) to maximal assistance (helper does more than half the effort)from staff for activities of daily living (ADLs-bed mobility, surface transfer, eating, walk in room, dressing, toileting, and personal hygiene). The MDS indicated Resident 8 had an active diagnosis of depression and DM, and as well as taking high risk drug medication such as antidepressants and hypoglycemic medications. During a review of Resident 3's Order Summary Report, dated 7/1/2026, the Order Summary Report indicated Resident 3 had physician orders for Ozempic 0.5 mg one time a day subcutaneous (subQ-insertion of medications beneath the skin using a needle) every Friday for 4 weeks from 7/31/2026 to 8/28/2026, Ozempic 1 mg subQ one time a day every Friday for 4 weeks from 8/28/2026 to 9/25/2026 and Ozempic 2 mg subQ one time a day every Friday starting 9/25/2026 for DM. During a concurrent interview and record review on 8/6/2026 at 2:11 PM with Registered Nurse 2 (RN 2), Resident 3's care plan was reviewed. Resident 3's care plans indicated missing depression behavior m/b verbalization of sadness and Ozempic use care plans. RN 2 stated Resident 3 needed to have care plans for depression m/b verbalization of sadness and for Ozempic use to be able to know how they can properly provide the specific care to Resident 3. During an interview on 8/6/2026 at 2:38 PM with Licensed Vocational Nurse 4 (LVN 4), LVN 4 stated the importance of having care plans for depression m/b verbalization of sadness and Ozempic use for Resident 3 and stated that he (LVN 4) would not know how to take care of a resident without a care plan. During an interview on 8/6/2026 at 2:57 PM with the Director of Nursing (DON), the DON validated and stated missing care plans for depression m/b verbalization of sadness and Ozempic use for Resident 3. The DON stated it was important to have care plans so they (facility staff) could provide individualized, specific care to the resident. During a review of facility's Policy and Procedure (P&P), titled, Develop-Implement Comprehensive Care Plans, reviewed on 1/15/2026, P&P indicated that facility developed a person centered comprehensive care plan that are developed and implemented to meet each resident's preferences and goals, and address the resident's medical, physical, mental and psychosocial needs. During a review of facility's P&P, titled, Behavioral Health Services, reviewed on 1/15/2026, P&P indicated that facility provided each resident with the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. 3. During a review of Resident 43's admission Record, the admission Record indicated the facility originally admitted Resident 43 on 12/22/2021 and was readmitted on [DATE] with diagnoses that included acute respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide), DM and depression. During a review of Resident 43's H&P dated 12/21/2025, the H&P indicated Resident 43 had the capacity to understand and make decisions. During a review of Resident 43's MDS dated [DATE], the MDS indicated Resident 43 was on moderate assistance (helper does less than half the effort) to dependent (helper does all the effort) from staff for ADLs. During a concurrent interview and record review on 8/6/2026 at 2:22 PM with RN 2, Resident 43's care plan was reviewed. Resident 43's care plans indicated missing Mirtazapine medication use care plan. RN 2 stated Resident 43 needed to have a care plan for Mirtazapine medication use to be able to know how they could properly provide the specific care to Resident 43. During an interview on 8/6/2026 at 2:36 PM with LVN 4, LVN 4 stated it was important to have a care plan for the use of Mirtazapine for Resident 43 and stated that without the care plan, they (facility staff) would not be able to provide the care that Resident 43 needed. During an interview on 8/6/2026 at 2:51 PM with the DON, the DON validated and stated missing Mirtazapine use care plan for Resident 43. The DON stated it was important to have a care plan for the use of the Mirtazapine so they (facility staff) can provide individualized plan of care to the resident. During a review of facility's P&P, titled, Develop-Implement Comprehensive Care Plans, reviewed on 1/15/2026, P&P indicated that facility developed a person centered comprehensive care plan that are developed and implemented to meet each resident's preferences and goals, and address the resident's medical, physical, mental and psychosocial needs. During a review of facility's P&P, titled, Behavioral Health Services, reviewed on 1/15/2026, P&P indicated that facility provided each resident with the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being, in accordance with the comprehensive assessment and plan of care.

Based on observation, interview and record review, the facility failed to ensure safe and sanitary food storage and food preparation in the kitchen by failing to: -Ensure the kitchen staff (in general) labeled the open bags of carrots and green peas inside freezer 1 (F1) and freezer 2 (F2) and opened lemon juice bottle inside the walk-in refrigerator were labeled. -Ensure the kitchen staff (in general) monitored and documented the temperature for F1 and F1, walk in refrigerator and dry storage rooms. -Ensure the kitchen staff (in general) monitored, cleaned, and documented the ice machines. -Ensure the kitchen staff (in general) discarded Resident 53's opened tortilla inside the resident refrigerator per facility policy. -Ensure Dietary Aid 1 (DA 1) and DA 4's hairs were fully secured within the hair nets. -Ensure the kitchen metal under the sinks were clean and without any rust. These failures had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to food borne illness in 55 out of 55 residents (unidentified) who received food from the facility and including residents who had food stored in the resident refrigerator. Findings:During a concurrent observation and interview with [NAME] 1 on 8/3/2026 at 7:50 AM, inside the kitchen, opened bags of carrots, inside F1 and opened bag of green peas, inside F2 were unlabeled without the opened date when carrots and green peas were opened. [NAME] 1 stated opened bags of carrots and green peas needed to have labeled date when it was received and opened. During a concurrent observation and interview on 8/3/2026 at 8:04 AM with DA 1 inside the kitchen, the lemon juice bottle opened inside the walk-in refrigerator was unlabeled without the open date. DA1 stated that when opening lemon juice bottle, they (staff) were supposed to label with date when it was opened. During a concurrent observation and interview with [NAME] 1 on 8/3/2026 at 8:11 AM, inside the kitchen, temperature logs for F1, F2, walk-in refrigerator and dry storage room were observed with missing temperature logs. The Ice machine was observed with missing cleaning log. [NAME] 1 stated unable to find the temperature logs for F1, F2, walk-in refrigerator and dry storage room and cleaning log for the ice machine. [NAME] 1 stated the previous Dietary Services Supervisor (DSS) too all of the kitchen binders including the logs. [NAME] 1 stated importance of checking, monitoring and documenting temperatures twice a day for F1, F2, walk-in refrigerator and dry storage room to make sure food does not get spoiled. [NAME] 1 stated they (staff) were supposed to clean daily and document when ice machine had been cleaned for possible contamination. During an interview with the (DSS) on 8/4/2026 at 9:50 AM, DSS stated that all food in the freezers and refrigerator needed to be labeled with date when it was received and opened. The DSS stated it was import to have documented logs for temperature monitoring of F1, F2, walk-in refrigerator, and dry storage room and as well as cleaning log for the ice machine due to risk of food borne illness.During a review of the facility's policy and procedures (P&P) titled, Food Storage, reviewed on 1/15/2026, P&P indicated all open food items would have an open date and used-by-date per manufacturer's guideline.A review of the 2022 U.S. Food and Drug Administration Food Code titled Ready to Eat, Time/Temperature control for safety food, Date Marking Code#3-501.17, indicated, Ready to eat, time temperature control for safety food prepared and packaged by food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed, sold, or discarded.During a review of the facility's P&P titled, Freezer and Refrigerator Temperatures, reviewed on 1/15/2026, P&P indicated refrigerator and freezer temperatures should be recorded on an appropriate log sheet on a daily basis.During a review of the facility's P&P titled, Food Receiving and Storage, reviewed on 1/15/2026, P&P indicated controlling temperature, humidity, and rodent and insect infestations helps prevent deterioration or contamination of the food in the dry food storage.During a review of the facility's P&P titled, Ice Machine and Storage Chest, reviewed on 1/15/2026, P&P indicated to clean and sanitize the ice machines according to the manufacturer's guidelines and facility would maintain a copy of the procedures including a cleaning log.During a concurrent observation and interview on 8/3/2026 at 10:29 AM with Activity Aid (AA), inside the activity room, opened bag of tortilla labeled with date, 7/27/2026, was observed inside residents' refrigerator. The AA stated that per the Fridge Rules posted in the residents' refrigerator, all food may only be kept in two days, and it would be thrown away after two days.During an interview on 8/3/2026 at 10:48 AM with Activities Director (AD), the AD stated that food stored in the residents' refrigerator was only good for two days due to risk of bad bacteria forming in the food.During a review of the facility's P&P titled, Use and Storage of Food Brought to Resident, reviewed on 1/15/2026, P&P indicated perishable foods older than two days will be discarded.During a concurrent observation and interview on 8/4/2026 at 3:33 PM with the DSS, observed DA 1 and DA 4's hair were hanging on the back of their (DA 1 and DA 4's) neck, and not fully secured by the hair nets. The DSS stated that everyone entering the kitchen needed to wear a hair net and to make sure that the hair was secured inside to prevent possible contamination of the food.During a review of the facility's P&P titled, Hair Nets and Personnel Permitted in Food and Nutrition Services Department, reviewed on 1/15/2026, P&P indicated all food and nutrition services staff were required to wear hairnets or caps or other suitable coverings to confine all hair when required to prevent contamination of food, equipment or utensils.A review of the 2022 U.S. FDA Food Code titled Hair Restraints Code#2-402.11.17, indicated, Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints and clothing that covers body hair, that are designed and worn to effectively keep their hair from contracting exposed food, clean equipment, utensils, and linens .During a concurrent observation and interview on 8/5/2026 at 12:03 PM with the DSS, observed under the kitchen metal sinks were uncleaned with orange, brownish rust and whitish black residues. DSS stated under the metal sink should be cleaned and without any rust making sure that the kitchen was sanitary and clean.During a review of the facility's P&P titled, Metal Shelving and shelves under tables reviewed on 1/15/2026, P&P indicated metal shelves under tables would be cleaned weekly.A review of the 2022 U.S. Food and Drug Administration (FDA) Food Code titled Cleaning of Equipment and Utensils Code#4-601.11, indicated, Equipment food-contact surfaces and utensils shall be clean to sight and touch and non-food contact surfaces shall be kept free of an accumulation of dust, dirt, food residue and other debris.

Based on observation, interview, and record review, the facility failed to ensure the trash stored in the dumpster areas was maintained in a sanitary manner by failing to:-Ensure the dumpster area was clean and without yogurt container, soiled bagged linens, pieces of paper, and gloves on the floor. -Ensure two recyclable trash bins were not overfilled with boxes, without a whole box on top and were left uncovered.These failures had the potential for harboring and feeding of pests.Findings:During a concurrent observation and interview on 8/3/2026 at 8:44 AM with the Director of Nursing (DON), outside the parking area, next to the dumpsters, a yogurt container, one soiled bagged linen, pieces of paper and gloves were observed on the floor. Two recyclable trash bins were observed overfilled with boxes, with a box on top and were left uncovered. The DON stated there should not be any trash on the floor and the trash bins needed to have the lid closed completely due to possible infection control issues.During an interview on 8/6/2026 at 11:05 AM with the Infection Preventionist Nurse (IPN), the IPN stated the dumpster area needed to be clean at all times for infection control purposes.During a review of the facility's policy and procedures (P&P) titled, Dispose of Garbage and Refuse, reviewed on 1/15/2026, P&P indicated that facility waste would be properly contained in dumpsters or compactors with lids covered and loading docks and hallways used for garbage disposals shall remain clean, and free of debris. P&P also indicated that garbage storage should maintained in a sanitary condition to prevent the harborage and feeding of pests.During a review of Food and Drug Administration (FDA) Food Code 2022, code number 5-501.113 titled Covering receptacles, indicated: receptacles and waste handling units for refuse, recyclables, and returnable shall be kept covered with tight-fitting lids or doors if kept outside the establishment. The Food Code also indicated under code number 5-501.110 titled Storing Refuse, Recyclables, and Returnable indicated that refuse, recyclables, and returnable shall be stored in receptacles or waste handling units so that they are inaccessible to insects and rodents.

Based on observation, interview, and record review, the facility failed to maintain infection control measures necessary to prevent the spread of infections when: a. Bags of soiled linens were open, and on the floor next to the dumpster area. b. Residents' (unidentified) clothing and linens were not machine-washed at a temperature of at least 160 Fahrenheit ( F, a unit of measure for temperature). These failures had the potential to result in the spread of pathogens (harmful microorganisms) to residents, visitors, and staff throughout the facility. Findings: a. During a concurrent observation and interview on 8/3/2026 at 8:44 AM with the Director of Nursing (DON), outside the parking area, next to the dumpsters, opened bagged soiled linens were observed inside two of three sampled bulk linen carts and one bagged soiled linen was on the floor. The DON stated that all soiled linens must be completely bagged, unopened, and inside the bulk linen carts due to possible infection control issues. During an interview on 8/6/2026 at 11:05 AM with the Infection Preventionist Nurse (IPN), the IPN stated all soiled linens must be bagged and not on the floor due to infection control. During a review of the facility's policy and procedures (P&P) titled, Linens, reviewed on 1/15/2026, P&P indicated that all soiled linens will be bagged/placed in a laundry container and should not be placed on the floor. b. During a concurrent observation and interview on 8/5/2026 at 10:22 AM with Laundry Aide (LA) 1 in the laundry room, the thermometer gauge connected to the washing machine indicated a water temperature of 75 degrees F. LA 1 stated the water temperature of the washing machine must be high, at 150 degrees F, to kill the bacteria and effectively clean linens. LA 1 stated the facility used a bleach-free laundry detergent. During a concurrent observation and interview on 8/5/2026 at 10:46 AM with the Maintenance Supervisor (MS) in the laundry room, the MS used a digital thermometer to manually check the water temperature. The digital thermometer stick indicated the washing machine water temperature was 145 degrees F. The MS stated the water temperature must be at least 140 degrees F during the washing cycle to kill the bacteria on residents' (in general) clothes. During a concurrent observation and interview on 8/5/2026 at 11:01 AM with the MS in the boiler room, the thermostat dial for the water heater used for both the laundry and kitchen was set at B. The MS stated the water heater was set at a temperature of 140 degrees F. During a record review of the Thermostat Adjustment – ICON System Electronic Gas Control, undated, the document indicated to adjust the temperature by turning the thermostat dial. The document indicated setting B was 140 degrees F. During an interview on 8/6/2026 at 9:47 AM with the MS, the MS stated residents' clothes must be washed at 140 degrees F, not 160 degrees F because residents' clothes were not considered linen. The MS stated 160 degrees F was too hot to wash the residents' clothing in. The MS stated a high temperature could cause dyes to fade and fabric shrinkage. During a review of the facility's Laundry Hot Water Log, the log indicated a temperature of 150 degrees F on the following dates: 1/1/2026 to 1/6/2026, 5/1/2026, 5/4/26 to 5/8/2026, 5/11/2026 to 5/15/2026, 5/18/2026 to 5/20/2026, and 8/1/2026 to 8/5/2026. The log did not indicate additional documentation of water temperatures for the remaining months. During a review of the facility's Laundry Aide Job Description, undated, the job description indicated an essential job function to sort, count, and wash soiled laundry, linens, and garments in accordance with established procedure. During a concurrent interview and record review on 8/6/2026 at 11:24 AM, the facility's policy and procedure (P&P) titled, Linens, revised January 2025, was reviewed with the MS. The MS reviewed the P&P and stated staff (in general) were required to wash the laundry at 160 degrees F. The MS stated improperly laundered items were unhygienic and was an infection control issue. During a review of the facility's P&P titled, Linens, revised January 2025, the P&P indicated if a facility chooses to process laundry using a hot water temperature environment, the temperature maintained for 25 minutes should be 160 degrees F. The P&P defined laundry as resident's personal clothing, linens, towels, washcloths, and items from departments.

Based on observation, interview and record review, the facility failed to provide timely pain management for one of one sampled resident (Resident 1), by failing to: -Ensure timely administration of prescribed PRN (as needed) pain medication after Resident 1 reported pain and was assessed with pain level of ten out of ten (a pain scale used to measure the severity of pain, where 0 means no hurt at all and 10 means the worst hurt you can imagine).-Ensure timely intervention when Resident 1 exhibited pain and discomfort evidenced by facial grimacing and audible moaning.This failure had the potential to prolong Resident 1's severe pain and delay effective pain relief affecting Resident 1's comfort. Finding:During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 3/17/2026 with diagnoses that included but not limited to chronic ulcer (an open sore or wound on the skin or inside the body that breaks down and fails to heal within a normal timeframe) to left & right lower leg, anxiety disorder (a mental health condition marked by extreme, ongoing fear and worry), and acute kidney failure (kidneys suddenly stop working). During a review of Resident 1's History and Physical (H&P) dated 7/13/2026, the H&P indicated Resident 1 lacked the capacity to make medical decisions. During a review of Resident 1's Minimum Data Set (MDS a resident assessment tool) dated 7/6/2026 (the formal release from a facility), the MDS indicated Resident 1 made himself usually understood and usually understood others. The MDS indicated Resident 1's cognitive functioning (mental processes that enable people to think, understand, make decisions, and complete tasks) is severely impaired. The MDS indicated Resident 1 received PRN pain medication. During a review of Resident 1's Order Summary Report dated 8/6/2026, the Order Summary Report indicated on 6/29/2026 the physician ordered to monitor Resident 1's pain using Pain scale (0-No pain, 1-3 mild pain, 4-7 moderate pain, and 8-10 severe pain) and medicate as ordered. The Order Summary Report indicated on 7/14/2026 the physician ordered Hydrocodone-Acetaminophen Oral Tablet 5-325 as needed for severe pain. During an observation on 8/5/2026 at 8:06 AM, in Resident'1 room, Licensed Vocational Nurse (LVN) 5 entered Resident 1's room and assessed Resident 1's level of pain. Resident 1 stated his level of pain was at 10 and was pointing to his lower bilateral (both) legs with dressing. Observed Resident 1's facial grimacing and audible moaning. Observed LVN 5 checked the electronic Medication Administration Record (MAR) and stated out loud Resident had Hydrocodone-Acetaminophen Oral Tablet 5-325 as PRN every eight hours order for severe pain, last received was on 8/4/2026 at 9 PM. Observed LVN 5 told Resident he can have the pain medication. During an observation on 8/5/2026 at 8:11 AM, outside Residet1's room, LVN 5 put on PPE and took Resident 1's blood pressure. Observed LVN doff PPE and prepared morning medications to administer Resident 1. During an observation on 8/5/2026 at 8:17 AM, by the door of Resident 1's room, LVN 5 performed hand hygiene and went to Resident 1's bedside to administer prepared medications. During an interview on 8/5/2026 at 8:34 AM with LVN 5, LVN 5 Stated he could not administer the pain medication when he did not have the narcotic book with him on the medication cart and cannot leave Resident 1's prepared morning medications unattended. LVN 5 stated there was more than a 20-minute delay in addressing resident one's pain level of 10 and that the pain medication should have been administered promptly. LVN 5 stated he could have obtained the narcotic book from the nurse's station first and administered Residents 1's pain medication for severe pain in a timely manner then followed by the routine morning medications. LVN 5 stated that the administration of pain medication was time sensitive and that delay had the potential to cause Resident 1's to experience increased pain in the lower legs. During a concurrent interview and record review on 8/6/2026 9 AM with Registered Nurse (RN) 1, Resident 1's Medication Administration Record (MAR), dated 8/1/2026 to 8/31/2026, was reviewed. RN 1 stated the MAR indicated Resident 1 had a pain level of 10 on 8/5/2026 and received Hydrocodone-Acetaminophen Oral Tablet 5-325, one tablet at 8:32 AM. RN 1 stated the after Resident 1's pain was assessed, the expectation was for LVN 5 to administer the pain medication promptly without further delay. RN 1stated that the delay in pain medication administration could worsen Resident 1's pain and affect the resident's comfort when pain management was not prioritized. During an interview on 8/5/2026 at 8:34 AM with the Director of Nursing (DON), the DON stated pain management was to ensure residents (in general) pain was addressed and residents were kept as comfortable as possible. The DON stated the facility used the numeric pain scale to assess pain: 0-No pain, 1-3 mild pain, 4-7 moderate pain, and 8-10 severe pain. The DON stated LVN1 should have prioritized the administration of pain medication to Resident 1. The DON stated the facility failed to promptly address Resident 1's severe pain as ordered. During a review of the facility's Pain Assessment and Management Policy & Procedure (P&P) dated 1/15/2026, the P&P on pain recognition indicated that the facility strives to recognize and address pain promptly. The P&P indicated examples of possible indicators of pain include but are not limited to facial expressions of grimacing, frowning, fright or clenching of the jaw. During a review of the facility's Administering Medications Policy & Procedure (P&P) dated 1/15/2026, the P&P indicated the purpose of P&P was to provide employees with guidelines for the safe and timely administration of medications per physician order. The P&P indicated medications must be administered in accordance with the orders.

Based on interview and record review, the facility failed to ensure assessment in the Minimum Data Set (MDS-a resident assessment tool) accurately reflected the residents' status for two of 15 sampled residents (Resident 13 and 43) by failing to: -Ensure Resident 13's MDS under smoking was accurately assessed. -Ensure Resident 43's MDS under cognitive (ability to think and process information) pattern was accurately assessed. These failures had the potential to negatively affect the plan of care and the delivery of necessary care and services to Resident 13 and Resident 43. Findings: a. During a review of Resident 13's admission Record, the admission Record indicated the facility admitted Resident 13 on 9/14/2023 with diagnoses that included but not limited to rhabdomyolysis (a serious medical condition where damaged muscle tissue breaks down rapidly), hyperlipidemia (having too many fats, or lipids, in your blood), and essential hypertension (high blood pressure that has no known, single medical cause). During a review of Resident 13's (untitled) History and Physical (H&P) dated 6/17/2025, the H&P indicated that Resident 13 had the capacity (ability) to understand and make decisions. During a review of Resident 13's Minimum Data Set ([MDS] a standardized assessment tool) dated 9/23/2025 (the formal release from a facility), the MDS indicated Resident 13 made himself usually understood and usually understood others. The MDS indicated Resident 13's cognitive functioning (mental processes that enable people to think, understand, make decisions, and complete tasks) is intact. The MDS indicated Resident 13 required supervision with mobility. The MDS indicated Resident 13 did not use tobacco. During a review of Resident 13's Progress Notes dated 6/4/2026, the Progress Notes indicated that the Activities Director (AD) met with Resident 13 and provided education for the storage of smoking materials. During a review of Resident 13's MDS dated [DATE], the MDS indicated no tobacco use assessment. During an interview on 8/5/2026 at 12:30 PM with Resident 13, Resident 13 stated he (Resident 13) had been smoking at the facility since 2024 and smoked at the patio as instructed by facility staff During a concurrent interview and record review on 8/5/2026 at 1:45 PM with Minimum Data Set Coordinator (MDSC), Resident 13's MDS dated [DATE] and MDS dated [DATE] were reviewed. The MDSC stated that MDS was a comprehensive assessment of a resident's (in general) actual health status and condition. The MDSC stated Resident 13 was an active smoker and included on the facility's smoking list. The MDSC stated that the MDS assessment on 9/23/2025 indicated Resident 13 was not a tobacco user and the MDS assessment on 6/22/2026 did not include an assessment of Resident 13's tobacco use. The MDSC stated that the MDS assessment dated [DATE] did not accurately reflect Resident 13's tobacco use. During a concurrent interview and record review on 8/5/2026 at 2:03 PM, with the Director of Nursing (DON), Resident 13's MDS Assessments dated 9/23/2025 and 6/22/2026 were reviewed. The DON stated that MD's assessments were completed upon admission with the change in condition, quarterly and annually. The DON stated that MDS assessments must be accurate to ensure appropriate reimbursement and prevent discrepancies. The DON stated that Resident 13's MDS assessment dated [DATE] was inaccurate and that the MD's assessment dated [DATE] did not include a tobacco use assessment. The DON stated that the facility did not accurately assess Resident 13's tobacco use. During a concurrent interview and record review on 8/5/2026 at 3:30 PM, with the Administrator (ADM), Resident 13's MDS dated [DATE] was reviewed. The ADM stated MDS was a comprehensive assessment of residents (in general). The ADM stated that facility's goal was for the MDS to accurately reflect the residents' health conditions. The ADM stated Resident 13 was a smoker and smoked at the patio. The ADM stated that the MDS assessment on 9/23/2025 indicated Resident 13 was not a tobacco user. The ADM stated that the facility did not accurately assess Resident 13's tobacco use. During a review of the facility's Policy & Procedure (P&P) titled Accuracy of Assessments last reviewed on 1/15/2026, the P&P indicated that the MDS assessment was to ensure each resident receives an accurate assessment by staff qualified to assess relevant care areas. The P&P indicated that the assessment must represent an accurate picture of the resident's status during the observation period of the MDS. During a review of the facility's MDSC Job Description, the job function indicated ensuring all MDS assessments are accurate, completed, encoded and exported per state and federal requirements. During a review of the facility's Policy & Procedure (P&P) titled Smoking Policy last reviewed on 1/15/2026, the P&P indicated that residents who express a desire to smoke will be assessed for deficits and capabilities to smoke safely. Assessments will be completed on admission and quarterly and as the residents' needs or capabilities change. b.During a review of Resident 43's admission Record, the admission Record indicated the facility originally admitted Resident 43 on 12/22/2021 and was readmitted on [DATE] with diagnoses that included acute respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide), diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]) and depression (a mood disorder that causes persistent feeling of sadness and loss of interest). During a review of Resident 43's H&P dated 2/12/2026, the H&P indicated Resident 43 had the capacity to understand and make decisions. During a review of Resident 43's MDS dated [DATE], the MDS indicated Resident 43 was on moderate assistance (helper does less than half the effort) to dependent (helper does all the effort) from staff for activities of daily living (ADLs-bed mobility, surface transfer, eating, walk in room, dressing, toileting, and personal hygiene). During a concurrent interview and record review on 8/6/2026 at 8:48 AM with the MDSC, Resident 43's MDS dated [DATE] was reviewed. The MDS indicated that Resident 43 had a BIMS (Brief Interview for Mental Status-a quick test to check person's memory, attention and basic thinking skills) summary score of 6 (severely impaired). The MDSC stated Resident 43 could not fully complete the BIMS at the time of the assessment, triggering Resident 43 to be at a low score. During an interview on 8/6/2026 at 9:50 AM with the MDSC, the MDSC stated inconsistency between the BIMS and H&P. The MDSC stated that when she (MDSC) was assessing Resident 43, Resident 43 could not fully complete the BIMS, the MDSC stated she (MDSC) needed to move onto the next section under Staff Assessment of Mental Status (BIMS alternative) rather than stopping on at the BIMS section to be able to accurately assess Resident 43's cognition. The MDSC stated it was important to accurately assess the resident's cognition and notify the doctor for any issues or decline. During an interview on 8/6/2026 at 2:43 PM with the Director of Nursing (DON), the DON stated and verified that Resident 43 could make decisions and was self-responsible. The DON also stated importance of accurate assessment via MDS so they (facility) can provide the right care specific for the residents. During a review of facility's P&P, titled, Accuracy of Assessment, reviewed on 1/15/2026, P&P indicated that facility would ensure each resident receives an accurate assessment, reflective of the resident's status, by staff qualified to assess relevant care areas and are knowledgeable about the resident's status, needs, strengths and areas of decline. During a review of facility's job description (JD), titled, MDS Coordinator, reviewed on 1/15/2026, JD indicated that MDS coordinator oversees the patient care assessment of each resident in accordance with all laws, regulations and facility company standards. JD indicated MDS informs team members of the requirements for accuracy and completion of the MDS. JD also indicated that MDS meets with and solicits advice from department concerning the resident assessment/care plan functions of the community. During a review of Centers for Medicare & Medicaid Services' (CMS-U.S federal healthcare agency) manual, titled, Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.20.1 (LTCF RAI manual), dated 10/2025, LTCF RAI manual indicated that the rules for stopping the BIMS before it is complete was if all responses have been nonsensical (any response that is unrelated, incomprehensible, or incoherent: not informative with respect to the item being rated); there has been no verbal or written response to any of the question or both responses has been either no verbal or written response to some question and resident has given a nonsensical response. LTCF RAI manual indicated that if the interview was stopped for BIMS, complete the Staff Assessment for Mental Status. LTCF RAI manual also indicated that occasionally, a resident can communicate but choose not to participate in the BIMS and therefore does not attempt to answer, it would be considered an incomplete interview, enter 99 for C0500 (BIMS Summary Score) and complete the Staff Assessment for Mental Status.

Based on interview and record review, the facility failed to ensure to conduct an antibiotic stewardship surveillance (tracks how medical providers prescribe antibiotics, alongside monitoring resistant infection patterns) for one of five sampled residents (Resident 44) by failing to:-Ensure the facility licensed nurses (in general) notified the physician that Resident 44 did not meet the criteria for infection prior to prescribing antibiotics. This failure had the potential to increase Resident 44's risk for antibiotic resistance (when bacteria evolve to survive the drugs designed to kill them, making infections harder to treat) associated with the inappropriate use of antibiotic therapy.Findings: During a review of Resident 44's admission Record, the admission Record indicated the facility readmitted the resident on 7/16/26, with diagnoses that included Non-Hodgkin lymphoma (a blood cancer that starts in the lymphatic system, which helps the body fight germs), pneumonia (an infection/inflammation in the lungs), and alcoholic liver cirrhosis (late, permanent stage of liver disease where heavy, long-term alcohol use replaces healthy liver tissues with hard scar tissue). During a review of Resident 44's Care Plan Report dated 4/26/2026, the Care Plan Report indicated an intervention to document and report signs of secondary infection related to antibiotic therapy such as oral thrush (white coating in mouth, tongue) and persistent diarrhea. During a review of Resident 44's Order Summary Report dated 7/16/2026, the Order Summary Report indicated a physician order for levofloxacin (antibiotic) 500 milligrams (mg, a unit of measure) oral tablet, to give one tablet by mouth one time a day for infection prophylaxis (means measures to prevent disease or harm) related to chemotherapy (is a treatment that uses medicines to destroy cancer cells). During a review of Resident 44's Order Summary Report dated 7/16/2026, the Order Summary Report indicated a physician order for valacyclovir (antiviral medication) 500 mg oral tablet, to give one tablet by mouth two times a day for antiviral prophylaxis related to chemotherapy. During a review of Resident 44's Minimum Data Set (MDS, a resident assessment tool), dated 7/20/2026, the MDS indicated Resident 44 was severely cognitively impaired (significant difficulty with memory, orientation, and recalling information). During a concurrent interview and record review on 8/5/2026 at 8:50 AM, Resident 44's Surveillance Data Collection Form for levofloxacin and valacyclovir, both with a start date of 7/16/2026 were reviewed with the Infection Preventionist Nurse (IPN). The IPN reviewed both Surveillance Data Collection Form[s] and stated the physician must be notified when residents' (in general) did not meet the criteria for infection, to avoid unnecessarily prescribing antibiotics. The IPN stated prescribing antibiotics when the antibiotics were not needed would cause the germs to build resistance, making future infections harder to treat. During a review of Resident 44's Surveillance Data Collection Form for levofloxacin and valacyclovir, both with a start date of 7/16/2026, the Surveillance Data Collection Form indicated no documented date/time of when the physician was notified that Resident 44 did not meet the criteria for infection prior to prescribing the antibiotics. During a review of the facility's QAPI (Quality Assurance Performance Improvement), dated 5/21/2026, the QAPI indicated licensed nursing staff will be in-serviced regarding antibiotic stewardship to minimize unnecessary antibiotic use, resistance and adverse effects. During a concurrent interview and record review on 8/6/2026 at 10:42 AM, the facility's policy and procedure (P&P) titled, Documentation Policy, revised January 2025, was reviewed with the Director of Nursing (DON). The DON reviewed the P&P and stated nurses must notify the physician if infection criteria was not met and to document when the physician was notified. The DON stated if notification is delayed, residents' condition could worsen if continuously given inappropriate antibiotics. During a review of the facility's P&P titled, Documentation Policy, revised January 2025, the P&P indicated nurses should document physician communications. During a review of the facility's P&P titled, Antibiotic Stewardship, revised January 2025, the P&P indicated for the designee to audit new antibiotic orders to ensure all necessary documentation is completed.

Based on interview and record review, the facility failed to maintain accurate and complete medical records for one of 15 sampled residents (Resident 44) by failing to:-Ensure Resident 44's chemotherapy (treatment using powerful drugs to kill or stop from multiplying fast-growing cancer cells in the body) appointment on 6/15/2026 was documented when Resident 44 transferred out from the facility.This failure placed Resident 44 at risk of not receiving appropriate care due to inaccurate medical care information and the potential to result in confusion in the care and services provided to Resident 44.Findings: During a review of Resident 44's admission Record, the admission Record indicated the facility originally admitted Resident 44 on 4/22/2026 and was re-admitted on [DATE] with diagnoses including lymphoma (type of cancer), encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition-such as viral infection or toxins in the blood) and cirrhosis (chronic liver damage that can lead to scarring and liver failure). During a review of Resident 44's Care Plan Report dated 5/4/2026, the Care Plan Report indicated Resident 44 was receiving chemotherapy related to cancer with interventions that Resident 44 would be transferred to general hospital 1 (GACH 1) for chemotherapy on 6/15/2026. During a review of Resident 44's previous Physician Order dated 6/12/2026, the physician order indicated Resident 44 had a physician order for a chemotherapy appointment on 6/15/2026. During review of Resident 44's Minimum Data Set (MDS - a resident assessment tool), dated 7/20/2026, the MDS indicated Resident 44 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) for daily decision-making and with varying assistance from being moderate (helper does less than half the effort) to maximal (helper does more than half the effort) assistance from staff for activities of daily living (ADLs-bed mobility, surface transfer, eating, walk in room, dressing, toileting, and personal hygiene). During a concurrent interview and record review on 8/6/2026 at 10:11 AM with Registered Nurse 2 (RN 2), Resident 44's progress notes and transfer form were reviewed. Progress notes and transfer form indicated missing discharge documentation when Resident 44 was scheduled for chemotherapy on 6/15/2026. RN 2 stated and validated missing discharge documentation on 6/15/2026 and stated importance of documenting discharge information. RN 2 stated if it was not documented, they (facility staff) would not know what happened to Resident 44. RN 2 stated that it was best practice to document when a resident would go out from the facility and make sure documenting information such as where the resident was going, the reason for the discharge, and any relevant information such as assessment. RN2 stated any education provided and/or needed information was communicated to the receiving facility. During an interview on 8/6/2026 at 11:09 AM with the Director of Nursing (DON), the DON stated it was important to document discharge information related to Resident 44's scheduled chemotherapy. The DON stated that they (facility staff) needed to document relevant information such as assessment regarding resident's condition. During a review of the facility's policy and procedure (P&P) titled, Documentation Policy reviewed on 1/15/2026, the P&P indicated that it was the facility policy to document relevant findings in the clinical record. P&P also indicated that resident and/or family/responsible party/legal representative education and/or training, discharge summaries and discharge instructions were to be charted in nursing or other notes. During a review of facility's P&P, titled, Documentation of Discharge or Transferring Resident, reviewed on 1/15/2026, P&P indicated that facility ensured that the transfer or discharge of a resident was documented in the resident's medical record and appropriate information was communicated to the receiving hea

Based on interview and record review, the facility failed to clarify the physician orders for Vitamin C (supplement) as recommended by the facility's consultant pharmacist (a healthcare professional who provides specialized expertise to healthcare facilities, typically focusing on ensuring the safe and effective use of medications) during the monthly Medication Regimen Review (MRR, when a consultant pharmacist reviews and analyzes a resident's medication list, ensuring that the medications are appropriate, effective, and safe) for one of five sampled residents (Resident 43). This failure had the potential to result in adverse medication outcome (undesirable) and the possibility of providing unnecessary medication to Resident 43.Findings: During a review of Resident 43's admission Record, the admission Record indicated the facility originally admitted Resident 43 on 12/22/2021 and was readmitted on [DATE] with diagnoses that included acute respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide), diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]) and depression (a mood disorder that causes persistent feeling of sadness and loss of interest). During a review of Resident 43's History and Physical (H&P) dated 12/21/2025, the H&P indicated Resident 43 had the capacity to understand and make decisions. During a review of Resident 43's Minimum Data Set (MDS-resident assessment tool) dated 5/21/2026, the MDS indicated Resident 43 required moderate assistance (helper does less than half the effort) to dependent (helper does all the effort) from staff for activities of daily living (ADLs-bed mobility, surface transfer, eating, walk in room, dressing, toileting, and personal hygiene). During a concurrent interview and record review on 8/6/2026 at 2:22 PM with Registered Nurse 2 (RN 2), Resident 43's medical records were reviewed. Resident 43's Order Summary Report was reviewed and indicated Resident 43 had a physician order dated 7/7/2026 for Vitamin C 500 milligram (mg, a unit of measurement) by mouth one time a day for wound healing. Resident 43's Consultant Pharmacist's Medication Regimen Review (CPMRR) was also reviewed and indicated a recommendation dated 7/16/2026 for an order clarification request to clarify diagnosis for Vitamin C for wound healing to read: for supplement. Resident 43's Progress Notes dated 7/1/2026 to 8/6/2026 were reviewed and indicated no documentation of the CPMRR physician notification for Resident 43. RN 2 stated that CPMRR was supposed to be completed by now and was not sure why it was not completed. RN 2 stated that registered nurse supervisor (RNS) would get the list of CPMRR and notify the physician of the recommendation. RN 2 stated that depending on the physician's response, either agree or disagree of the recommendation, they (facility) needed to document the CPMRR physician notification. During an interview with the Director of Nursing (DON) on 8/6/2026 at 2:51 PM, the DON stated and validated missing notification of Resident 43's CPMRR to the physician. The DON stated the licensed nurses (in general) needed to notify and follow up the pharmacy recommendations with the physician. The DON stated it was important to be able to monitor, catch and/or prevent any issues or adverse consequences in regards with residents' medication usages. During a review of facility's Policy and Procedure (P&P), titled, Medication Regimen Review, reviewed on 1/15/2026, P&P indicated that the facility staff will encourage physician/prescriber of other responsible parties receiving the MRR and the DON to act upon the recommendations including acceptance or rejection; and provide an explanation as to why the recommendation was rejected. P&P also indicated that the DON/designees will alert the physician and medical director when MRRs are not addressed by the attending physician within a timely manner.

Based on observation, interview, and record review, the facility failed to ensure safe medication administration to meet the needs of one of five sampled residents (Resident 49) reviewed during medication administration by failing to: -Ensure Licensed Vocational Nurse 1 (LVN1) administered Resident 49's valproic acid (medication used as mood stabilizer) 250 milligram (mg) one capsule with meals on 8/5/2026 between 8:39 AM and 8:48 AM as indicated in Resident 49's physician order. This failure had the potential to result in reduced drug absorption (is the process by which a drug enters the bloodstream after administration) and possible risk of gastrointestinal (GI -referring to the digestive system including the stomach and intestines) symptoms such as GI irritation, nausea, vomiting, stomach pain and indigestion (heartburn) for Resident 49.Findings:During a review of Resident 49's admission Record, the admission Record indicated the facility admitted the resident on 4/30/2026 with diagnoses that included thoracic (mid back bone), lumbar (lower back bone) and left femur (thigh bone) fracture (broken bone), and bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive [period of feeling sad, hopeless or empty] lows to manic [being in a state of extreme, elevated energy and emotion] highs). During a review of Resident 49's History and Physical (H&P) dated 5/3/2026, the H&P indicated Resident 49 did not have the capacity to make medical decisions. During a review of Resident 49's Order Summary Report dated 5/1/2026, the Order Summary Report indicated for Resident 49 to receive valproic acid 250 mg by mouth two times a day with meals. During a review of Resident 49's Minimum Data Set (MDS- a resident assessment tool) dated 5/4/2026, the MDS indicated Resident 49 had mildly impaired cognition (mental action or process of acquiring knowledge and understanding) for daily decision-making and dependent (helper does all the effort) from staff for activities of daily living (ADLs-bed mobility, surface transfer, eating, walk in room, dressing, toileting, and personal hygiene). During a review of Resident 49's Medication Administration Record (MAR) dated from 8/1/2026 to 8/31/2026, the MAR indicated that valproic acid 250 mg one capsule 250 mg by mouth two times a day with meals was to be administered at 7:30 AM and 5:30 PM. During a review of facility's schedule of mealtimes undated indicated serving time was at 7:30 AM for breakfast, 12:30 PM for lunch and 5:30 PM for dinner. During a concurrent medication administration observation and interview on 8/5/2026 between 8:39 AM and 8:48 AM outside Resident 49's room with LVN 1, LVN1 prepared two medications that included but not limited to valproic acid 250 mg one capsule and was administered via mouth to Resident 49. Resident 49 was not observed having a meal during medication administration. LVN 1 stated that Resident 49 had already eaten breakfast today at around 7 to 8 AM. LVN 1 stated that she (LVN 1) needed to administer the medication with meals and added needing to follow the physician order when administering medications so Resident 49 would not have issues on absorbing the medication and/or have any GI symptoms. During an interview on 8/6/2026 at 2:43 PM with the Director of Nursing (DON), the DON stated the importance of administering medication as ordered by the physician to prevent any adverse reaction (undesirable and usually unanticipated event) outcome. During a review of facility's policy and procedure (P&P), titled, Administering Medication, reviewed on 1/15/2026, P&P indicated that medications must be administered in accordance with the orders.

Based on interview, and record review, the facility failed to ensure one of two sampled residents (Resident 6) reviewed under dialysis (also known as hemodialysis [HD], a medical treatment that acts as an artificial kidney, filtering waste products, toxins, and excess water from the blood when a person's kidneys can no longer perform these tasks properly) received dialysis services consistent with professional standards of practice by failing to: -Ensure hemodialysis communication records were completed and returned back to the facility when Resident 6 had hemodialysis on 7/2/2026, 7/4/2026, and 7/11/2026. This failure had the potential to negatively affect the plan of care and as well as the delivery of necessary care and services to Resident 6.Findings:During a review of Resident 6's admission Record, the admission Record indicated the facility originally admitted Resident 6 on 5/28/2026 and was readmitted on [DATE] with diagnoses including dependence on renal (kidney) dialysis, diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]), and chronic kidney disease (CKD-a longstanding disease of the kidneys leading to kidney failure). During a review of Resident 6's Care Plan Report dated 5/31/2026, the Care Plan Report indicated Resident 6 needed HD with nursing interventions under post dialysis care that upon return from HD center, the nursing staff would check the post (after) dialysis assessment form for any recommendations from dialysis center and making sure the recommendations were followed. During a review of Resident 6's Order Summary Report dated 6/10/2026, the Order Summary Report indicated Resident 6 had a physician order for dialysis-notify dialysis center of any abnormalities noted before and each dialysis treatment, obtain post dialysis weights from dialysis center and review post dialysis notes special instructions and new orders. During a review of Resident 6's History and Physical (H&P) dated 6/10/2026, the H&P indicated Resident 6 did not have the capacity to understand and make decisions. During a review of Resident 6's Minimum Data Set (MDS- a resident assessment tool), dated 6/13/2026, the MDS indicated Resident 6 had moderately impaired cognition (mental action or process of acquiring knowledge and understanding) for daily decision-making and mostly maximal assistance (helper does more than half the effort) from staff for activities of daily living (ADLs-bed mobility, surface transfer, eating, walk in room, dressing, toileting, and personal hygiene). The MDS indicated Resident 6 had been on dialysis since admission. During a review of Resident 6's Order Summary Report dated 6/16/2026, the Order Summary Report indicated Resident 6 was scheduled for dialysis on Tuesdays, Thursdays and Saturdays with dialysis time of 8:30 AM. During a review of Resident 6's Progress Notes dated 7/2/2026 and 7/4/2026, the Progress Notes indicated Resident 6 had dialysis. The Progress Notes indicated missing documentation if Resident 6 had dialysis on 7/11/2026. During a concurrent interview and record review on 8/5/2026 at 7:53 AM with Licensed Vocational Nurse 1 (LVN 1), Resident 6's Hemodialysis Communication Record form (HDCR form) was reviewed. Resident 6's HDCR form indicated missing on the following HD scheduled dates: 7/2/2026, 7/4/2026, and 7/11/2026. LVN 1 stated and validated missing HDCR forms. During an interview on 8/5/2026 at 12:40 PM with LVN 1, LVN 1 stated she (LVN1) was unsure how the HDCR forms were missing. LVN 1 stated that it was important to make sure that the HDCR form was returned back to the facility with the residents. LVN 1 stated that HDCR form was a form of communication between the facility and the HD center in regards with Resident 6's dialysis care. During an interview on 8/6/2026 at 2:45 PM with the Director of Nursing (DON), the DON stated that they (facility staff) needed to make sure that the HDCR form was sent back to them with the resident (in general) after the HD and that they (facility staff) would check the form for any issues or concerns during the HD. The DON stated that it (HDCR form) was being used as a communication between the facility and the HD center. During a review of facility's Policy and Procedure (P&P), titled, Dialysis Management, reviewed on 1/15/2026, P&P indicated that facility would assure that each resident receives care and services for the provision of HD consistent with professional standards of practice including the ongoing assessment of the resident's condition and monitoring for complications before and after HD treatments received at a certified dialysis facility; and ongoing communication and collaboration with the dialysis facility regarding dialysis care and services.

Based on interview and record review, the facility failed to evaluate the effectiveness of restorative nursing services (nursing aide program that helps residents maintain their function and joint mobility) for one of one sampled resident (Resident 13) by failing to:-Conduct and document progress evaluations for Resident 13's left lower extremity (LLE) active range of motion (AROM- moving a joint yourself using your own muscles) restorative nursing program, as indicated in Resident 13's care comprehensive care plan. - Conduct and document progress evaluations of Resident 13's right lower extremity (RLE) Active-Assisted Range of Motion (AAROM is a type of physical therapy movement where you use your own muscles to move a joint, with partial help) restorative nursing program as ordered. This failure had the potential to result in identified functional decline and missed opportunities to timely modify or progress restorative interventions necessary to maintain or improve Resident 13's highest practicable level of functioning.Findings: During a review of Resident 13's admission Record, the admission Record indicated the facility admitted Resident 13 on 9/14/2023 with diagnoses that included but not limited to rhabdomyolysis (a serious medical condition where damaged muscle tissue breaks down rapidly), hyperlipidemia (having too many fats, or lipids, in your blood) and essential hypertension (high blood pressure that has no known, single medical cause). During a review of Resident 13's Physical Therapy (PT) Evaluation & Plan of treatment dated 9/14/2023 through 10/13/2023, the PT Evaluation & Plan of Treatment indicated objectives and goals that included increasing Resident 13's bilateral (both) lower extremity strength, ability to stand, and balance. The PT evaluation and plan of treatment indicated Resident 13's goal was to get stronger, walk again, and return home. During a review of Resident 13's Rehab-Functional ROM and Voluntary Movement documents dated 3/25/2025 and 1/13/2026. On 3/25/2025, the Rehab-Functional ROM and Voluntary Movement documents indicated Resident 13's LLE had functional ROM limitations and partial loss (resident was able to initiate and complete the task but movements are slow, spastic, uncoordinated, rigid, on one or both sides) of voluntary movement while the RLE had no functional range of motion limitations and no loss of voluntary movement. The Rehab-Functional ROM and Voluntary Movement documents indicated on 1/13/2026 Resident 13's LLE had no functional ROM limitation and no loss of loss of voluntary movement while the RLE had a new functional range of motion (ROM) limitations and partial loss of voluntary movement. During a review of Resident 13's (untitled) History and Physical (H&P) dated 6/17/2025, the H&P indicated that Resident 13 had the capacity to understand and make decisions. During a review of Resident 13's Care Plan Report dated 7/31/2025, the Care Plan Report indicated Resident 13 was receiving restorative care. The Care Plan included interventions to evaluate Resident 13's progress every month and as needed (PRN) and to keep the physician and responsible party (RP) informed of resident's progress. During a review of Resident 13's Minimum Data Set (MDS a resident assessment tool) dated 9/23/2025 (the formal release from a facility), the MDS indicated Resident 13 made himself usually understood and usually understood others. The MDS indicated Resident 13's cognitive functioning (mental processes that enable people to think, understand, make decisions, and complete tasks) was intact. The MDS indicated Resident 13 used a walker (is a type of mobility aid that offers stability and support while walking) and wheelchair for out of bed mobility. The MDS indicated Resident 13 required supervision from staff with toileting, shower, upper and lower body dressing and personal hygiene. The MDS indicated Resident 13 required supervision from staff with transfers and positioning from sitting to standing. The MDS indicated Resident 13's physical therapy stop date was on 11/10/2023. During a review of Resident 13's Order Listing Report dated 8/7/2026, the Order Listing Report indicated on 2/20/2024, Resident 13 had an active restorative nursing service order of AROM on LLE five times per week every day with monitoring for pain before, during, and after treatment. The Order Listing Report indicated on 7/24/2025, Resident 13 had an active restorative nursing service order of AAROM on RLE five times per week every day with monitoring for pain before, during, and after treatment. During a review of Resident 13's RNA Weekly Summary documentation dated 7/2/2026,7/9/2026, 7/16/2026,7/23/2026 , 7/30/2026 and 8/6/2026, the RNA Weekly Summaries indicated progress comments that Resident 13 participated in the LLE AROM and RLE AAROM restorative nursing programs five times a week or as tolerated, with no change of condition (COC) or pain after ten to 15 minutes of treatment. During an interview on 8/3/2026 at 7:54 AM, in Resident 13's room, Resident 13 stated he (Resident 13) wanted physical therapy to become more active and improve his balance. Resident 13 stated he was unsteady on his feet. During a concurrent interview and record review on 8/5/2026 at 3:57 PM with the Director of Staff Development (DSD), Resident 13's Care Plan Report dated 7/31/2025 was reviewed. The DON stated the care plan intervention indicated to evaluate progress every month and to keep the physician informed of resident's progress. Stated there was no documentation of monthly progress evaluation. The DSD stated the progress notes should have documented effectiveness of the specific restorative nursing services for Resident 13. During a concurrent interview and record review on 8/5/2026 at 4:01PM with the DSD, Resident 13's RNA Weekly Summary documents dated 7/2/2026,7/9/2026, 7/16/2026,7/23/2026, 7/30/2026 and 8/6/2026 were reviewed. The DSD stated the weekly summaries contained narrative progress comments indicating Resident 13 had no change of condition and no pain. The DSD stated the RNA Weekly Summary documents did not contain evaluations to determine whether resident13's strength and balance had improved or declined or whether the restorative nursing orders needed to be modified or progressed. The DSD stated providing information on evaluation was necessary for the physical therapy team to determine and discuss appropriate restorative care options with Resident 13. During a concurrent interview and record review on 8/5/2026 at 4:15 PM with the Director of Nursing (DON) Resident 13's Care Plan Report dated 7/31/2025 was reviewed. The DON stated Resident 13 was transitioned from PT care to Restorative Nursing Assistants ([RNAs]- a certified nursing assistant with extra training who helps patients regain or keep their physical strength and mobility) care. The DON stated the care plan indicated ordered RNA programs and interventions included an intervention to evaluate resident 13's progress every month. The DON stated there was no documentation of resident's progress evaluation for the ordered restorative care services. The DON stated Resident 13 was not re-evaluated for effectiveness of the restorative needed better interventions to meet the goal of residents maximum optimal functioning. The DON stated the facility did not follow up on Resident 13's bilateral lower extremity improvement and problems. During a concurrent interview and record review on 8/6/2026 at 10:01 AM with the Physical Therapy Supervisor (PTS), the Rehab -Functional ROM and Voluntary Movement documents dated 3/25/2025 and 1/13/2026 were reviewed. The PTS stated that Resident 13 completed physical therapy ([PT] a type of medical care that helps people move better, ease pain, and build strength after an injury, surgery, or illness) in 2023 and was transitioned to restorative nursing services. The PTS stated that the Rehab -Functional ROM and Voluntary Movement documents were annual screenings completed to assess Resident 13's ROM. The PTS stated that the screening on 3/25/2025 and 1/13/2026 identified significant changes in Resident 13'LLE & RLE. The PTS stated monthly evaluations were important to determine the effectiveness of the restorative nursing services and whether the restorative nursing program required modification. The PTS stated If the resident demonstrated a decline, the restorative nursing interventions could be modified, and if the resident was tolerating and progressing with the program, the restorative nursing services could be advanced to the next level such as adding weights. During an interview on 8/6/2026 at 12:20 PM, with Restorative Nursing Assistant (RNA) 1, RNA 1 stated she was the assigned RNA to Resident 13. RNA 1 stated she completed the RNA Weekly Summaries dated 7/2/2026,7/9/2026, 7/16/2026,7/23/2026, 7/30/2026 and 8/6/2026, which was reviewed by the DSD. RNA 1 stated her progress comments were limited to documenting Resident 13's specific restorative care orders for the RLE and LLE, no change of condition and no pain. RNA 1 stated her weekly summaries did not document details of Resident 13's progress in balance, strength or coordination. During a review of the facility's Restorative Nurse Services policy and procedures (P&P) dated 1/15/2026, the P&P indicated the facility ensures that every resident receives restorative nursing services as determined by their comprehensive plan of care to assist them to maintain or restore their highest practicable level of physical, mental, functional, and psycho-social well-being. During a review of the facility's Documentation P&P dated 1/15/2026, the P&P indicated it is the policy of this facility to document relevant findings in the clinical record. The P&P indicated the facility utilizes assessment sheets flow sheets progress notes, care plans and other mandated assessments as required by state and federal regulations. The P&P indicated narrative format charting will be used for entries that ore not supported by flow sheets and assessment forms. During a review of the facility's Develop-Implement Comprehensive Care Plans policy and procedure (P&P) dated 1/15/2026, the P&P indicated the comprehensive care plan describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

Based on observation, interview, and record review, the facility failed to provide necessary treatment and services to minimize the risk of development and worsening of pressure ulcers/injuries (PU/PI, injuries to the skin and underlying tissue resulting from prolonged pressured on the skin) for one of one sampled resident (Resident 7) reviewed for PU/PI by failing to: - Ensure Resident 7's low air loss mattress (LALM, a pressure relieving mattress used to prevent and treat PU/PIs) was maintained at the correct weight setting. This failure had the potential to place Resident 7 at risk for further skin breakdown and the development of PU/PIs.Findings:During a review of Resident 7's admission Record, the admission Record indicated the facility readmitted the resident on 8/13/2023 with diagnoses that included quadriplegia (paralysis from the neck down, including legs and arms, usually due to a spinal cord injury), malnutrition, and Stage 4 PU (full thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) of the sacrum (the large, triangular bone at the base of the spine and back of the pelvis). During a review of Resident 7's Minimum Data Set (MDS, a resident assessment tool) dated 6/24/2026, the MDS indicated the resident was dependent (resident does none of the effort to complete the activity, the helper does all of the effort) on staff to complete activities of daily living (ADLs, activities a person performs daily such as bathing, dressing, and toileting). During a review of Resident 7's Braden Scale Assessment (a scale used for predicting pressure sore risk), dated 6/24/2026, the Braden Scale Assessment indicated Resident 7 was very high risk for developing PU/PIs. During a review of Resident 7's Monthly Weight dated 7/2026, the Monthly Weight indicated Resident 7's weight was 89 pounds (lbs., a unit of weight/mass). During a review of Resident 7's Order Summary Report dated 7/9/2026, the Order Summary Report indicated a LALM for wound management every evening and night shift. During a review of Resident 7's Order Summary Report dated 7/10/2026, the Order Summary Report indicated LALM for wound management every dayshift. During a review of Resident 7's Weekly Pressure Ulcer Record dated 7/20/2026, the Weekly Pressure Ulcer Record indicated Resident 7's sacral PU resolved. During a concurrent observation and interview on 8/3/2026 at 8:47 AM with Restorative Nursing Assistant1 (RNA 1) in Resident 7's room, Resident 7's LALM weight setting was set at 150 lbs. The sticker on the LALM indicated Resident 6's weight was 89 lbs., as of 7/1/2026. RNA 1 stated certified nursing assistants (CNAs in general) were not allowed to manipulate the LALM settings. During an interview on 8/4/2026 at 11:03 AM with the Treatment Nurse (TXN), the TXN stated Resident 7's LALM weight setting of 150 lbs., and that the setting was way off and must be set as close to 89 lbs., as possible. The TXN stated it was important to maintain the correct LALM weight settings to effectively offload pressure off the residents' bony prominences. During a concurrent interview and record review on 8/5/2026 at 4:10 PM with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Low Air Loss Mattresses, revised November 2024. The DON reviewed the P&P and stated the P&P was not followed. The DON stated instead of being a preventative measure, incorrect LALM weight settings increase the risk for developing PUs because the LALM was too firm. During a review of the facility's P&P titled, Low Air Loss Mattresses, revised November 2024, the P&P indicated the facility shall follow the manufacturer's guidelines for maintenance, cleaning, settings and care. During a review of Resident 7's Med-Air 8 Alternative Pressure Mattress Replacement System with Low Air Loss user manual undated, the user manual indicated to adjust the analog pressure dial to correspond to the residents' appropriate weight setting. During a review of the facility's P&P titled, Treatment Services to Prevent/Heal Pressure Ulcers, dated January 2025, the P&P indicated PU/PIs may develop where pressure has impaired the circulation to the tissues such as from use of medical devices applied for therapeutic purposes.

Based on observation, interview, and record review, the facility failed to ensure the care and services provided met professional standards of clinical practice for two of five sampled residents (Resident 32 and Resident 43) by failing to:-Ensure the licensed nurses (in general) informed Resident 32's physician of Resident 32's improved eating functional abilities.-Ensure Resident 43 did not have padded siderails (are adjustable metal or rigid plastic bars that attach to the bed) without an appropriate assessment.These failures had the potential not to meet Resident 32 and Resident 43's needs. Findings:a. During a review of Resident 32's admission Record, the admission Record indicated the facility admitted the resident on 4/23/2026, with diagnoses that included spinal stenosis (a narrowing of the space within the spine that puts pressure on the spinal cord and nerves), central cord syndrome (an incomplete spinal cord injury that causes weakness and loss of fine motor control in the arms and hands), and post spinal fusion (surgery to connect two or more bones in any part of the spine). During a review of Resident 32's History and Physical (H&P) dated 5/9/2026, the H&P indicated the resident had the capacity to make medical decisions. During a review of Resident 32's Functional ROM (range of motion, means the full movement potential of a joint) and Voluntary Movement dated 5/29/2026, the Functional ROM Abilities and Voluntary Movement indicated Resident 32 was able to initiate and complete tasks but movements were slow, uncoordinated, and rigid on both upper and lower extremities (arms and legs). During a review of Resident 32's Order Summary Report dated 5/29/2026, the Order Summary Report indicated Resident 32 required one-to-one assistance with all meals. During a review of Resident 32's Minimum Data Set (MDS, a resident assessment tool), dated 6/2/2026, the MDS indicated Resident 32 required maximum assistance (helper does more than half the effort) from staff with eating. During a review of Resident 32's Nutritional/Dietary Services Progress Note dated 6/18/2026, the Nutritional/Dietary Services Progress Note indicated Resident 32 required one-to-one assistance with meals. During a review of Resident 32's Quarterly/Annual Participation Review dated 7/30/2026, the Quarterly/Annual Participation Review indicated Resident 32 preferred to be independent. During a review of Resident 32's Functional Abilities and Goals dated 8/4/2026, the Functional Abilities and Goals indicated Resident 32 required setup assistance (helper assists only prior to the activity) from staff with eating. During an observation on 8/3/2026 at 9:49 AM in Resident 32's room, a strict aspiration (when something enters the airway or lungs by accident) precaution sign was posted at the head of the bed. The strict aspiration precaution sign included an intervention of one-to-one supervision/feeding assistance as needed. During an observation on 8/3/2026 at 12:48 PM in the dining room, a staff member (unidentified) assisted Resident 32 with setting up the lunch meal tray. Resident 32 ate independently, with no one-to-one assistance from staff. Resident 32 was able to swallow food and liquid without choking or coughing. During a concurrent observation and interview on 8/4/2026 at 12:43 PM with Resident 32 in Resident 32's room, Resident 32 ate independently with no assistance or supervision from staff. Resident 32 stated when he (Resident 32) first got admitted , he (Resident 32) needed help to hold the utensils but now he (Resident 32) could eat without help from staff. During an interview on 8/4/2026 at 1:56 PM with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated Resident 32 needed one-to-one assistance when Resident 32 was newly admitted . CNA 1 stated Resident 32 got stronger and could eat without staff assistance. During an interview on 8/4/2026 at 2:04 PM with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated the diet order needed to be updated to reflect Resident 32's current functional abilities. LVN 1 stated the importance of updating orders to ensure staff provided the correct care to residents (in general) making sure residents' needs were properly met so residents (in general) could have the best optimal outcome. LVN 1 stated the aspiration precaution sign posted at Resident 32's head of the bed (HOB) was from Resident 32's admission and Resident 32 was no longer on strict aspiration precautions. During a concurrent interview and record review on 8/6/2026 at 10:35 AM with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Develop-Implement Comprehensive Care Plans, revised January 2025 was reviewed. The DON reviewed the P&P and stated nursing staff (in general) must notify the physician of the resident's improved functional abilities to get updated orders. The DON stated physician orders were resident specific and were the foundation for resident-centered care. During a review of the facility's P&P titled, Develop-Implement Comprehensive Care Plans, revised January 2025, the P&P indicated the facility establishes, documents, and implements the care and services provided to each resident to assist in attaining or maintaining his/her highest practicable quality of life. During a review of the facility's P&P titled, Quality of Care, revised January 2025, the P&P indicated the facility must review and/or revised care plan goals and treatment choices as the residents' status changes. b.During a review of Resident 43's admission Record, the admission Record indicated the facility originally admitted Resident 43 on 12/22/2021 and was readmitted on [DATE] with diagnoses that included acute respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide), diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]) and depression (a mood disorder that causes persistent feeling of sadness and loss of interest). During a review of Resident 43's History and Physical (H&P) dated 2/12/2026, the H&P indicated Resident 43 had the capacity to understand and make decisions. During a review of Resident 43's MDS dated [DATE], the MDS indicated Resident 43 required moderate assistance (helper does less than half the effort) to dependent (helper does all the effort) from staff for activities of daily living (ADLs-bed mobility, surface transfer, eating, walk in room, dressing, toileting, and personal hygiene). During a concurrent observation and interview on 8/3/2026 at 9:09 AM with Licensed Vocational Nurse 2 (LVN 2) in Resident 43's room, Resident 43's right upper side rail was padded with black foam while left upper side rail unpadded with black foam hanging up in the left side rail. LVN 1 stated that Resident 43 needed to have the side rails padded for safety and that the padding needed to be secured to the side rails. During a concurrent interview and record review on 8/4/2026 at 2:07 PM with Licensed Vocational Nurse 1 (LVN 1) Resident 43's Order Summary Report was reviewed as of 8/4/2026. Resident 43's Order Summary Report indicated no physician order for the padded side rails. Resident 43's care plan was also reviewed as of 8/4/2026, Resident 43's care plan indicated no care plan regarding Resident 43 needing to have padded side rails. LVN 1 stated not being aware of the reason why Resident 43 had padded side rails and added that if there was no need for padded side rails, Resident 43 should not have the paddings on Resident 43's bilateral side rails. During an interview on 8/5/2026 at 3:11 PM with the Director of Nursing (DON) the DON stated Resident 43 did not need padded side rails. The DON stated she (DON) was not aware of the reason why Resident 43 had the padded rails and stated that Resident 43 should not have the padded side rails. The DON stated that staff (facility) should completely assess residents' needs and provide care in accordance with professional standard of practice. During a review of facility's policy and procedure (P&P), titled, Quality of Care, reviewed on 1/15/2026, P&P indicated that the facility ensured that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the resident's choices, based on the comprehensive assessment of the resident.

Based on interviews and record review, the facility failed to update and revise the comprehensive care plan for one of three sampled residents (Resident 57) with a diagnosis of dementia (a progressive state of decline in mental abilities) by failing to:-Ensure Residents 57's dementia care plan included individualized interventions.-Ensure Resident 57's dementia care plan address dementia related needs, including cognitive status, behavioral symptoms, psychosocial and emotional needs, communication needs, individualized approaches to care, safety needs, and the level of monitoring and supervision necessary to provide person centered venture care.This failure had the potential to delay the identification and provision of appropriate individualized care and interventions for Resident 57's dementia-specific needs. Findings:During a review of Resident 57's admission Record, the admission Record indicated the facility admitted the resident on 4/22/2026, with diagnoses that included unspecified dementia, anxiety disorder (a mental health condition that causes extreme fear, worry, or nervousness), and essential hypertension (high blood pressure). During a review of Resident 57's Care Plan (Plan of health needs, sets recovery goals, and explains the exact actions for caregivers or doctors) Report for dementia dated 4/30/2026, the Care Plan Report indicated interventions limited to administer meals as ordered, monitor and report any changes to the physician, and redirect resident as needed. During a review of Resident 57's Minimum Data Set (MDS, a resident assessment tool) dated 6/10/2026, the MDS indicated Resident 57 usually made herself understood and understood others. The MDS indicated Resident 57's cognitive functioning (mental processes that enable people to think, understand, make decisions, and complete tasks) was severely impaired. The MDS indicated Resident 57 required moderate assistance on staff for activities of daily living (ADLs-bed mobility, transfer, eating, shower, lower body dressing, toileting, and personal hygiene). During a review of Resident 57's untitled history and physical document dated 6/23/2026, the untitled history and physical indicated Resident 57 did not have the capacity to understand and make decisions. During a concurrent interview and record review on 8/6/2026 at 1:20 PM with Minimum Data Set Coordinator (MDSC), Resident 57's Care Plan Report dated 9/23/2025 was reviewed. The and MDSC stated The MDSC stated a care plan addressed the resident's (in general) identified needs and was specific to the resident's condition, including medications, procedures, activities of daily living (ADL), nutrition and activities. The MDSC stated resident 57's care plan needed to be updated to address the residents' dementia - specific needs. The MDSC stated dementia interventions for Resident 57 needed to address memory impairment and forgetfulness, agitation, providing reminders and redirection, allowing additional response time, and repeating instructions as needed. The MDSC stated resident 57's care plan was not updated to address the resident's dementia diagnosis and included only three general interventions that were not person centered to resident 57's dementia related needs. The MDSC stated the lack of dementia specific approaches had the potential to delay appropriate care in addressing resident 57's dementia related needs. During a concurrent interview and record review on 8/6/2026 at 1:53 PM with LVN 5, Resident 57's Care Plan Report dated 9/23/2025 was reviewed. LVN 5 stated dementia was a mental condition in which residents could exhibit forgetfulness, wandering, and communication challenges. LVN 5 stated resident 57's current care plan included only three general interventions. LVN5 stated resident 57's care plan needed to included intervention such as reality inter orientation, redirection, visual checks, explaining care and meals as provided, and approaching Resident 57 in a calm manner. LVN 5 stated Resident's 57 safety was also important because residents with dementia (in general) could wander (leave the facility unsupervised) and be at risk for elopement. LVN 5 stated resident 57's care plan needed to be updated because nurses (in general) followed the care plan for specific interventions on how to provide care and address Resident 57's current mental and health care Resident 57's care plan was not comprehensive and person centered to Resident 57's needs. During a concurrent interview and record review on 8/6/2026 at 2:14 PM with the Director of Nursing (DON), Resident 57's Care Plan Report dated 9/23/2025 was reviewed. The DON stated resident 57's care plan was not comprehensive and did not include dementia specific interventions. The DON stated a care plan addressed care specific to the residents' diagnoses and health conditions and that a dementia diagnosis required a specific care plan. The DON stated resident 57's care plan was missing multiple dementia specific interventions, including assistance with reorientation, monitoring for decline, administering medications for dementia, obtaining psychiatric follow-up as needed, and monitoring for agitation, confusion, and wandering. The DON stated the lack of dementia specific interventions had the potential to result in the facility not addressing resident 57's dementia related safety needs. The DON stated the facility did not update Resident 57's care plan. During a review of the facility's Develop-Implement Comprehensive Care Plans policy and procedure (P&P) dated 1/15/2026, the P&P indicated that he facility develops a person-centered comprehensive care plan that are culturally competent' and trauma-informed, developed and implemented to meet each resident's preferences and goals, and address the resident's medical, physical, mental and psychosocial needs. The P&P indicated that the care plans shall describe the resident's needs and preferences and how the facility will assist in meeting these needs and preferences. During a review of the facility's Caring for a Resident with Dementia policy and procedure (P&P) dated 1/15/2026, the P&P indicated that the facility has a systematic approach for caring for residents with dementia with dedicated dementia care programming. specially trained staff, a safe and supportive environment designed for individuals with dementia, and detailed assessment procedures to identify individual needs. The P&P indicated the staff, and physician will review the current physical, functional, and psychosocial status of each individual with dementia to formulate an accurate overall picture of the individual's condition, related complications, and functional impairments. The P&P indicated for the individual with confirmed dementia, the staff and physician will identify a plan to maximize the remaining function and quality of life. The P&P indicated the staff will monitor the individual with dementia for changes in condition and decline in function and will report these findings to the physician.

Based on interviews and record review, the facility failed to develop and implement an effective discharge planning process for one of the three sampled residents (Resident 1) who was bedridden (a person is forced to stay in bed because of severe illness, injury, weakness, or old age) and was dependent on staff for feeding via his G-Tube (Gastrostomy tube - a small, flexible medical device inserted directly through the abdomen into the stomach) by failing to:1. Developing a care plan which focuses on the Resident 1's discharge goals.2. Verify that Resident 1 had 24-hour caregiving services and providing orientation. This deficient practice resulted in Resident 1 being left alone from 4/16/2026 approximately 3 pm to 4/17/2026 at approximately 8 am.A review of Resident 1's admission record indicated that Resident 1 was originally admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy (a temporary change in brain function caused by a chemical imbalance, illness, or organ malfunction elsewhere in the body), ileostomy (a surgical procedure that creates an opening in the belly for waste to leave the body), and dementia (a loss of memory, language, reasoning, and other thinking abilities that are severe enough to interfere with daily life). During a review of Resident 1's history and physical (H&P) dated 2/8/2026 indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1 ' s Minimum Data Set (MDS - a assessment tool) dated 2/9/2026, the MDS indicated Resident 1 had severe cognitive impairment (a person has profound difficulties with thinking, remembering, and making decisions). The MDS indicated Resident 1 was dependent on staff for all of his Activities of Daily Living (ADLs such as oral hygiene, toileting hygiene, shower/bathe self, upper and lower body dressing, putting on/taking off footwear, personal hygiene, lying to sitting onside of bed, and chair/bed to chair transfer). During a review of a physician's order dated 4/16/2026 indicated, Resident may discharge on [DATE] to Home. The same order indicated tube feeding, Jevity [fiber-fortified liquid formula primarily used as a medical food for tube-feeding] 1.2 [1.2 calories] 400ml [milliliter - unit of measure] 4 times a day (8am, 12pm, 4pm, 8pm) flush [push] with 60ml water before and after each feeding. start with 1/2 the volume for the first couple feeds if switching right away. During a concurrent interview and record review of Resident 1's chart on 5/20/2026 at 11:57 am with the Director of Nursing (DON), the DON stated that Resident 1 did not verbally communicate but utilized communication boards (a simple, visual tool that helps people with limited or no speech express their thoughts, needs, and choices). The DON stated that Resident 1 previously resided at a senior living facility (independent specialized housing and lifestyle communities designed for older adults) and was constantly asking to return. The DON stated that they postponed the discharge because it was not safe which is why they had arranged for Resident 1 to be discharged with Home Health (HH - skilled medical care provided in your home to treat an illness, injury, or chronic condition by licensed professionals such as nurses) and Resident 1's caregiver (CG). The DON stated that nursing staff had provided caregiver training to CG which included G-Tube feedings and ADL care but was unable to provide documented evidence. The DON stated that the importance of documentation was to show and prove that said teachings were provided. The DON stated that there could be certain things that could be missed when caregiver training is not provided which could worsen resident's health condition. The DON confirmed that there was no individualized discharge care plan developed which should have included continuation of services such as G-Tube feeding. During an interview with Resident 1's caregiver (CG) on 5/20/2026 at 3:21 pm stated she (CG) had worked with Resident 1 prior to being admitted to the facility. CG stated that she had received a call from the facility staff asking her if she was going to continue working with Resident 1 as his caregiver. CG stated that she had made it clear to the facility staff that she would continue working the hours that she worked previously, which was from 8 am to 3 pm. CG stated that on 4/16/2026, Resident 1 was discharged to his apartment and CG stayed with him until 3 pm and left as per agreement. CG stated that when she returned the following day at 8 am, Resident 1 appeared unwell. CG stated that Resident 1's colostomy bag was full and leaking around the site and that there was brownish-foul smelling discharge from his mouth which CG thought was fecal matter. CG stated that she called Resident 1's case manager who then instructed her to call 911 (lines designated for emergencies such as crime, fire, or request for an ambulance). During a follow up interview with the DON on 5/21/2o26 at 11 am, the DON acknowledged that HH services are not initiated the day of discharge meaning that Resident 1 would not have received the skilled services at least the day after his discharge on [DATE]. The DON confirmed that Resident 1 required 24 and depended on staff for all ADLs. During a review of a policy and procedure (P&P) titled, TRANSFER AND DISCHARGE, with a review date of 1/2025, indicated the facility transfers and discharges in a safe manner which ensures that discharge needs, needed support, and resources required by the residents are met. The same P&P indicated the discharge process addressed each resident's goals and needs which included caregiver support and referrals which must include the resident if applicable, resident representative and the interdisciplinary team in developing a discharge plan. The same P&P indicated under the discharge planning process that the discharge must be consistent with the resident's rights which included:- Consider caregiver/support person availability and the resident's or caregiver's/supportperson(s) capacity and capability to perform required care, as part of the identificationof discharge needs.- Involve the resident and resident representative in the development of the dischargeplan and inform the resident and resident representative of the final plan.The same P&P indicated under discharge summary:i. When the facility anticipates a resident's discharge, the resident shall have a dischargesummary that includes, but is not limited to, the following:- A post-discharge plan of care that is developed with the participation of the resident and,with the resident's consent, the resident representative(s), which will assist the resident toadjust to his or her new living environment.- The post-discharge plan of care must indicate where the individual plans to reside, anyarrangements that have been made for the resident's follow up care and any postdischargemedical and non-medical services.

Based on interview and record review the facility failed to implement the nursing interventions according to the care plan for two of four sampled residents (Resident 1 and Resident 2). 1.For Resident 1, the facility failed to monitor and record food intake after each meal.2. For Resident 1 and Resident 2, the facility failed to specify in the care plan the frequency of obtaining their weight, what time of day the weight should be taken and specify the scale that would be used to obtain their weights.These deficient practices had the potential for the facility not meet Resident 1's and Resident 2's needs to maintain ideal body weight.1.During a review of the admission Record indicated the facility admitted Resident 1 on 12/22/21 and re-admitted on [DATE] with diagnoses including diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing) dysphagia (difficulty swallowing) and pneumonitis (inflammation of the lungs [breathing organ]).During a review of the Minimum Data Set (MDS, resident assessment tool) dated 11/21/25 indicated Resident 1 had moderately impaired cognition. Resident 1 was dependent on staff for shower/bathe self, lower body dressing, putting on/taking off footwear; substantial assistance (helper does more than half the effort) with oral hygiene, toileting hygiene, upper body dressing, personal hygiene and partial assistance with eating.During a review of Resident 1's care plan initiated on 12/31/25 indicated Resident 1 had unplanned/unexpected weight loss related to poor oral intake and episodes of refusal of food. The care plan goal indicated Resident 1 will not have further weight loss for three months. The care plan interventions included monitor and record food intake at each meal and weigh at the same time and record (Frequency), weighed at (time) using (specify scale). The frequency, time and scale were not specified. During a review of Resident 1's Meal Intake indicated Resident 1's meal intake was monitored as follows:1/8/26 - 9 a.m. and 1 p.m.1/9/26 - 8:43 a.m. and 6:04 p.m.1/15/26 -2:33 p.m. and 6:15 p.m.1/22/26 -2:09 p.m. and 8:11 p.m.1/24/26 - 9:21 a.m. and 5:29 p.m.1/27/26 - 8:18 a.m. and 6:10 p.m.1/28/26 - 8:08 a.m. and 6:08 p.m.1/31/26 - 2:34 p.m. and 9:57 p.m.2/1/26 1:16 p.m. and 10:04 p.m. 2. During a review of the admission Record indicated the facility admitted Resident 2 on 8/14/23 and re-admitted on [DATE] with diagnoses including DM, protein calorie malnutrition and reduced mobilityDuring a review of the MDS dated [DATE], indicated Resident 2 had moderately impaired cognition. Resident 2 was dependent on staff for toileting hygiene, shower/bathe self, upper/lower body dressing and taking off footwear. Resident 2 needed substantial assistance with oral hygiene and partial assistance with eating.During a review of Resident 2's care plan initiated on 12/10/25 indicated Resident 2 had unplanned/unexpected wight loss of seven pounds in one week related to disease process. The care plan goal indicated Resident 2 will not have further weight loss for three months. The nursing interventions included weighing at same time of day and record (frequency) weighed at (time) using (specify scale). The frequency, time and scale were not specified.During a concurrent interview and record review on 2/6/26 at 12:57 p.m., Resident 1's meal intake and Resident 1's and Resident 2's care plan was reviewed with the director of nursing (DON). The DON stated monitoring of Resident 1's meal intake was inconsistent. The DON stated the purpose of monitoring Resident 1's meal intake is to know the pattern of Resident 1's meal intake and to prevent further weight loss. The DON stated mealtimes are at 7 a.m., 12 p.m. and 5 p.m. The DON stated Resident 1's meal intake should be recorded after each meal. During a review of the care plan for Resident 1 and Resident 2, the DON stated the frequency of taking Resident 1 and Resident 2's weight should be specified including what time and what scale was used to obtain the weights. The DON stated the care plan should be specific and thorough.During a review of the facility's policy and procedures titled Develop-Implement Comprehensive Care Plans reviewed on 1/25, the P&P indicated each resident will have a person-centered comprehensive care plan developed and implemented to meet his or her preferences and goals, and address the resident's medical, physical, mental and psychosocial needs. The facility establishes, documents and implements the care and services to each resident to assist in attaining or maintaining his or her highest practicable quality of life.During a review of the facility's policy and procedures titled Weight Management revised on 12/24, the P&P indicated the weight management committee will review and update the resident's care plan as indicated.

Based on interview and record review, the facility failed to ensure one of three sampled resident (Resident 61) for closed record review was immediately provided with cardiopulmonary resuscitation (CPR, a lifesaving emergency procedure for a victim who has signs of cardiac [heart] arrest [a situation when a victim becomes unresponsive, no normal breathing, and no pulse], consisting of a combination of chest compressions, mouth-to-mouth, or mechanical breathing [a device used to help someone breathe]) in accordance with the facility's policy and procedure titled, Cardiopulmonary Resuscitation (CPR) by failing to: 1. Verify Resident 1's code status (a set of instructions for medical staff about what to do or not do in a medical emergency) from the hospital record, dated 5/21/2025. The hospital record, dated 5/21/2025, indicated Resident 1 was full code (indicates a resident wishes to be revived when breathing and/or heart stops). 2. Ensure Certified Nursing Assistant 5 (CNA 5) and Licensed Vocational Nurse 3 (LVN 3) initiated and performed CPR to Resident 61, after the resident was found unresponsive on 6/20/2025 at 4:30 AM on his bed. 3. Ensure Resident 61 had a physician order specifying the resident's code status. 4. Implement the facility's policy and procedure (P&P), titled, Cardiopulmonary Resuscitation (CPR) by not providing Resident 61 CPR when he was found unresponsive on 6/20/2025 at 4:30 AM on his bed. These deficient practices resulted in delayed treatment and not providing lifesaving emergency procedures to Resident 61. Resident 61 died at the facility. Resident 61's Record of Death, dated 6/20/2025 record did not indicate the resident's time of death. On 7/25/2025 at 5:27 PM, while onsite at the facility, the California Department of Public Health (CDPH) identified an Immediate Jeopardy (IJ, a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death of a resident) regarding the failure to ensure CPR was immediately performed on Resident 61, after the resident was found unresponsive on 6/20/2025 at 4:30 AM. The survey team notified the Interim Director of Nursing (IDON) and the Administrator (ADM) of the IJ situation. On 7/26/2025 at 5:29 AM, the facility submitted an 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), but the IJ removal plan was not accepted. On 7/26/2025 at 4:45 PM, the survey team completed the recertification survey tasks and conducted an exit conference while onsite in the presence of the IDON with the IJ situation not removed. On 7/28/2025 at 4:02 PM, the IJ was removed in the presence of the ADM and the IDON after the facility submitted an acceptable IJ Removal Plan and the surveyor verified and confirmed onsite the facility's implementation of the IJ Removal Plan and that the IJ situation was no longer present. The IJ Removal Plan dated 7/27/2025 at 4:30 PM, included the following: 1. Resident 61 expired on June 20, 2025 (time not indicated) and LVN 3 notified the physician of the resident's death. 2. On 7/26/2025, the facility's IDON and Director of Staff Development (DSD) attended an in-service provided by an outside RN Consultant at the facility on F678 Personnel Provide Basic Life Support including CPR - Verification of Code Status and Performing CPR, Code Blue (an emergency code indicating a patient is experiencing cardiac or respiratory [breathing] arrest [sudden stop] and required immediate resuscitation [the process of restoring life, typically by restarting the heartbeat and breathing]) and Pronouncement of Death. The following process will be implemented as follows: a. The Licensed nurses will verify the code status by checking the written physician order in Point Click Care (PCC, a healthcare management software) and the completed and signed POLST (Physician Orders for Life Sustaining Treatment, a record signed by the resident or representative and a physician that indicates the types of medical treatment they want to receive during serious illness) by resident/responsible party (RP) and physician. b. Licensed nurses will call code blue and initiate CPR after confirming the resident is nonresponsive, with no pulse or rise and fall of chest and will remain with the resident. c. If CPR is unsuccessful, a Registered Nurse (RN) or 911 (an emergency telephone number) will validate the resident's death and inform a physician for the pronouncement of death and will be documented in the nursing progress notes. 3. On 7/26/2025, the IDON provided on- on-one in-service on F678 Personnel Provide Basic Life Support including CPR - Verification of Code Status and Performing CPR, Code Blue and Pronouncement of Death to LVN 3. 4. On 7/26/2025, the facility's DSD checked 52 nursing staff (RN, LVN, CNA) CPR certification records and verified them to be current. 5. On 7/26/2025, the IDON performed skills competency to facility's licensed nurses (RN and LVN) with focus on Performing CPR and Performing Code Blue. 6. On 7/26/2025, the IDON performed skills competency with focus on Performing CPR and Performing Code Blude to LVN 3. 7. On 7/26/2025, CNA 5 was identified and per employee's record review, was discharged on 7/7/2025. 8. On 7/26/2025, the facility's Director or Medical Records (DMR) completed an audit of 54 residents' advance directives and POLST, and no other residents were found to be affected. 9. On 7/26/2025, the facility's Social Worker, IDON, and DMR reviewed and audited residents' advance directives and POLST, preferences for CPR and their physician orders for resuscitation matched. 54 residents found with code status physician orders utilizing an audit tool for adherence to ensure residents are not affected by the deficient practice utilized for the identification of other residents. 10. On 7/26/2025, the facility's DSD completed an employee files audit for CPR certification and verified they were active. The facility's 34 CNAs, 26 LVNs, three RNs, and two respiratory therapists (RT) staff CPR certifications are current. 11. Effective 7/26/2025, the facility's IDON and RN consultant initiated an in-service on F678 Personnel Provide Basic Life Support including CPR - Verification of Code Status and Performing CPR, Code Blue and Pronouncement of Death to the nursing staff (CNA, LVN, and RN). There were 25 out of 52 nursing staff that received the in-service. The remaining 27 will be provided in-services at the start of the next scheduled shift. 12. Effective 7/25/2025, the POLST form will be completed by the admitting nurse in collaboration with the assigned primary physician of the resident. Completion will be verified by the admitting nurse and will be reflected on the physician orders within 72 hours. 13. Effective 7/25/2025, the facility's interdisciplinary team (IDON, Social Workers, and DMR) will review resident advance directives, physician code status order, and or POLST 24 to 72 hours after admission and as needed to verify it is signed by the resident and/or responsible party including their assigned primary physician. 14. Effective 7/26/2025, the licensed nurses will review and validate completion of POLST form, code status physician orders, and/or advance directive availability of each resident upon admission, transfer, or significant change in condition within 72 hours. 15. Effective 7/26/2025, the facility's DSD and IDON will provide skills competency to nursing staff (CNA, LVN, and RN) with focus on Performing CPR and Performing Code Blue. There were 35 out of 52 nursing staff who completed and received their skills competency. The remaining 27 will be provided with skills competency upon the start of the next scheduled shift. 16. Effective 7/25/2025, licensed nurses will review residents' advance directives and POLST to verify code status and verify physician code status orders within 72 hours of admission. Any findings will be corrected immediately by the licensed nurse assigned and report to the IDON. 17. Effective 7/25/2025, the IDON and Social Service Director (SSD) will review three residents daily (Monday through Friday) for four weeks and monthly thereafter for three months to ensure residents' advance directives and POLST to verify code status from hospital physicians, physician's orders available that specify code status, and PCC code status. 18. Effective 7/25/2025, the facility's Administrator (ADM) will review three random new employee files for CPR certification and verify they are current, check completion of skills competency assessments with focus on Performing CPR and Performing Code Blue. This will be completed weekly for four weeks and monthly for three months.Findings: During a review of Resident 61's Face Sheet (admission record), the Face Sheet indicated the facility admitted the resident on 5/21/2025 from a General Acute Care Hospital, with diagnoses that included cerebral infarction (a condition where blood flow to brain is blocked, causing weakness and paralysis (loss of muscle function) on the left side of the body, end stage renal disease (irreversible kidney failure), severed protein-calorie malnutrition (inadequate intake of food that leads to fatigue and loss of muscle), and adult failure to thrive (a condition characterized by weight loss, decreased appetite, and poor nutrition). During a review of Resident 61's admission Cover Sheet, dated 5/21/2025, the admission Cover Sheet indicated Resident 61 received dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidneys have failed) every Wednesday. The facility was not able to provide a copy of Resident 61's Physician Orders for Life Sustaining Treatment (POLST, a record signed by the resident or representative and a physician that indicates the types of medical treatment they want to receive during serious illness). During a concurrent interview and record review on 7/24/2025 at 2:13 PM with LVN 5, Resident 61's clinical records were reviewed. LVN 5 stated she could not locate a physician's order for Resident 61's code status nor Resident 61's POLST. LVN 5 stated Medical Director 1 (MD 1) should have written Resident 61's order for code status upon the resident's admission to the facility or as soon as the resident's wishes changed. LVN 5 stated having a physician order for code status was important, so the staff would know the resident's or family's wishes for actions to be taken in the event the resident was found unresponsive. LVN 5 stated if a resident did not have a POLST, the staff should assume that the resident is a full code and should immediately perform CPR if found unresponsive. During a concurrent interview and record review, on 7/25/2025 at 11:06 AM, with the IDON, Resident 61's Progress Notes and clinical records were reviewed. The IDON stated the Progress Notes, dated 6/18/2025 at 10:50 PM, authored by LVN 5, indicated Resident 61 missed his original dialysis appointment time of 12:30 PM (on 6/18/2025) and arrived at the dialysis center at 4:15 PM. The Progress Notes indicated when Resident 61 arrived at the dialysis center, the dialysis staff called the facility and stated they were refusing to do dialysis on Resident 61 due to him feeling weak and having shortness of breath (SOB). The Progress Notes indicated the dialysis staff recommended sending Resident 61 to the hospital. During the interview, on 7/25/2025 at 11:06 AM, the IDON stated Resident 61's Progress Notes, dated 6/18/2025 at 10:50 PM, authored by LVN 5, indicated Resident 61 was feeling weak and having SOB at the dialysis center. The IDON stated Resident 61's nurse should have called 911 immediately upon Resident 61's return to the facility. The IDON stated a change of condition note should have been documented for Resident 61's symptoms and the resident's change of condition should have been monitored 72 hours after the symptoms were first identified. The IDON stated there was no documentation in Resident 61's progress notes of the resident's monitoring of change of condition and his symptoms on 6/18/2025 from 3 PM to 11 PM, from 6/18/2025 11 PM to 6/19/2025 7 AM, 6/19/2025 from 7 AM to 3 PM, and 6/19/2025 from 3 PM to 11 PM. During the interview, on 7/25/2025 at 11:06 AM, the IDON stated Resident 61's Progress Notes, dated 6/18/2025 at 10:50 PM, authored by LVN 5, indicated MD 1 was notified of Resident 61's condition and MD 1 ordered for Resident 61 to be transfer out to General Acute Care Hospital (GACH). The IDON stated the Progress Notes indicated Resident 61 was not transferred out to GACH because the hospital was full and the earliest time the resident would be able to be transported (to GACH) was the following day, 6/19/2025. The IDON stated Resident 61 remained in the facility and was not transferred out. The IDON stated Resident 61 did not have a physician's order to transfer Resident 61 to GACH on 6/18/2025. The IDON stated Resident 61 should have a written transfer order because it was an intervention requested by MD 1 to address Resident 61's change of condition. During the interview on 7/25/2025 at 11:06 AM, with the IDON, the IDON stated when Resident 61 was not accepted by GACH for transfer, the nurse should have informed MD 1 and should have called 911 to transfer Resident 61 to another hospital. The IDON stated Resident 61 was not transferred out to GACH and stayed at the facility. During a concurrent interview and record review, on 7/25/2025 at 11:30 AM, with the IDON, Resident 61's transfer documentation from GACH (upon admission to the facility), dated 5/20/2025, was reviewed. The GACH transfer documentation indicated Resident 61 had a code status of full code when the facility admitted the resident. During a concurrent interview and record review, on 7/25/2025 at 11:40 AM, with the IDON, Resident 61's Progress Notes, dated 6/20/2025 at 6:11 AM, authored by LVN 3, was reviewed. The Progress Notes indicated CNA 5 went (to Resident 61's room) to clean Resident 61 at 4:10 AM and the resident was alert and cooperative. The Progress Notes indicated at 4:30 AM, CNA 5 reentered Resident 61's room and found the resident unresponsive. The Progress Notes indicated CNA 5 alerted LVN 3 who then assessed Resident 61 and found the resident to be unresponsive with no pulse. The IDON stated CPR was not initiated by LVN 3 and CNA 5 when Resident 61 was found unresponsive on 6/20/2025 at 4:30 AM. During the interview, on 7/25/2025 at 11:40 AM, The IDON stated CPR should have been attempted immediately when Resident 61 was found unresponsive because Resident 61 was considered to have a status of full code. The IDON stated when a resident is found unresponsive, an LVN should first assess for a pulse. If the resident had no pulse, CPR must be started immediately until it is verified that the resident is DNR (Do Not Resuscitate, a medical order, typically documented by the physician, that instructs healthcare providers not to perform CPR if a person's heart stops beating or they stop breathing) through the physician order, Advance Directive (a legal document that outlines a resident's wishes for medical care should they become unable to make decisions for themselves), or POLST. During a telephone interview on 7/25/2025 at 2:18 PM, with MD 1, MD 1 stated 911 should have been called immediately when Resident 61 arrived at the facility with symptoms of feeling weak and SOB. MD 1 stated the staff should not have waited for Resident 61 to be directly admitted to GACH. MD 1 stated if the facility was unaware of a resident's code status, the default status should be full code. MD 1 stated the facility should do everything possible to resuscitate a resident, when needed lifesaving intervention, if the resident has a full code status. During a concurrent interview and record review on 7/25/2025 at 5:05 PM with the IDON, Resident 61's Record of Death, dated 6/20/2025 and signed by RN 1 at 11:15 AM, was reviewed. The Record of Death did not indicate Resident 61's time of death. The IDON stated there was no time of death documented. IDON stated LVN 3 pronounced the death of Resident 61. During a review of the facility's policy and procedure (P&P) titled, Cardiopulmonary Resuscitation (CPR), revised January 2025, the P&P indicated, If a resident experiences a cardiac or respiratory arrest and does not show obvious clinical signs of irreversible death. a facility staff member shall provide basic life support, including CPR, prior to the arrival of emergency medical services:- In accordance with the resident's advance directives and any related physician order, such as a code status, or- In the absence of advance directives or a DNR order.

Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 61) who required hemodialysis (HD, a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney[s] have failed) received HD care and services in accordance with Resident 61's Medical Director 1 (MD1) orders, care plan, and the facility's policies and procedures by failing to: -Ensure the licensed nurses (in general) and the Social Services Director (SSD) had ongoing communication and collaboration with Dialysis Center 1 (DC1) to coordinate Resident 61's HD care and services when the transportation did not pick up Resident 61 as scheduled on [DATE] at 11 AM. -Ensure Licensed Vocational Nurse 5 (LVN5) and other licensed nurses (in general) assessed Resident 61 prior to Resident 61 being transported to DC1 on [DATE] at 4:45 PM. -Ensure LVN5 and other licensed nurses (in general) assessed and monitored Resident 61's signs and symptoms of weakness and shortness of breath upon Resident 61's return to the facility on [DATE] (time unknown) from DC1 (missed HD). -Ensure LVN5 and other licensed nurses (in general) transferred Resident 61 to a General Acute Care Hospital (GACH) for a missed HD on [DATE] as ordered by MD1 upon Resident 61's return to the facility from DC1 (DC1 closed at 5PM on [DATE] and did not perform HD to Resident 1). -Ensure the licensed nurses (in general) informed MD1 that GACH 1 could not accept Resident 61 on [DATE] for HD. As a result of these failures, Resident 61 did not receive HD care and services and did not receive medical interventions for the shortness of breath and weakness. On [DATE] at 4:30 a.m., Certified Nursing Assistant 5 (CNA 5) and Licensed Vocational Nurse 3 (LVN 3) found Resident 61 unresponsive (not reacting or moving at all) with no pulse (the number of times the heart beats) inside Resident 61's room. Resident 61 expired at the facility. On [DATE] at 5:27 PM, the Department called an Immediate Jeopardy Situation (IJ, a situation in which the provider's non-compliance with one or more requirements of participation has caused, or likely to cause, serious injury, harm impairment, or death to a patient) in the presence of the facility's Administrator (ADM) and the Interim (temporary) Director of Nursing (IDON) related to the failures to ensure Resident 61 received HD care and services in accordance with Resident 61's MD1's orders, care plan, and the facility's policies and procedures. The above failures resulted in Resident 61 not receiving HD care and services, and/or medical interventions to treat Resident 61's shortness of breath and weakness. These failures also placed four residents who received dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) (Resident 8, Resident 33, Resident 37, Resident 53) at risk for harm and potential death. On [DATE] at 4:45PM, the facility was unable to submit an acceptable IJ removal plan (IJRP, includes all actions the facility has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment, or death likely). On [DATE] at 4:45PM, the Department completed the survey tasks and conducted an exit conference while onsite in the presence of the IDON, the Director of Staff Development (DSD), and the Activity Director (AD). On [DATE] at 4:19 PM, the Department removed the IJ situation while onsite after the surveyors verified the facility's implementation of the IJ removal plan through observation, interview, and record review, which included: -On [DATE] Resident 61 expired. -On [DATE] the SSD, IDON, and the Medical Record Director reviewed the dialysis communication records for four residents who resided at the facility and who received dialysis. The four residents did not miss dialysis and did not have a change of condition (COC, a sudden clinically important deviation from a patient's baseline in physical, cognitive [ability to think and process information], behavioral, or functional domains [categories or areas of focus that describe different aspects of human behavior and mental processes]) from [DATE] to [DATE]. -On [DATE] an outside consultant (a person who provides expert advice professionally) provided in-services to the IDON, DSD regarding dialysis resident management/change of condition. -On [DATE] the IDON in-serviced LVN5 regarding dialysis/resident management/COC. -On [DATE] the IDON performed skills competency assessments to LVN5 regarding dialysis management. -On [DATE] the IDON initiated the in-services to the licensed nursing staff regarding dialysis resident management/COC. Findings: During a review of Resident 61's admission Record, the admission Record indicated the facility admitted Resident 61 on [DATE] with diagnoses that included hemiplegia (total paralysis of the arm, leg, and truck on the same side of the body), hemiparesis (mild or partial weakness or loss of strength on one side of the body)following cerebral infarction (stroke, loss of blood flow to a part of the brain), end stage renal disease (ESRD, irreversible kidney failure), dependence on renal (kidney) dialysis, dysphagia (difficulty swallowing), paroxysmal atrial fibrillation (an irregular heartbeat), and adult failure to thrive (a decline caused by diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity). During a review of Resident 61's Minimum Data Set (MDS, a resident assessment tool) dated [DATE], the MDS indicated the resident had moderately impaired cognition (some impairment in the ability to think, understand, and reason). The MDS indicated Resident 61 received dialysis. During a review of Resident 61 Care Plan Report dated [DATE], the Care Plan Report indicated Resident 61 had a need for hemodialysis and was dependent on dialysis. The Care Plan Report indicated Resident 61 was at risk for complications such as shortness of breath, chest pains, elevated blood pressure, edema (swelling caused by excess fluid trapped in the body's tissues), weight fluctuation (instability), and dehydration (occurs when the body loses more fluids than it takes in, leading to a deficiency of water and other essential fluids). The Care Plan Report indicated a goal for Resident 61 was to have no complications related to hemodialysis. The Care Plan Report indicated interventions for Resident 61 included communicating with the dialysis center for progress or any problems, coordinating with the dialysis center regarding the resident's care and treatment, monitoring the resident for any changes of condition and reporting promptly (no delay) to the physician, performing post (after) dialysis care upon the resident's return from the dialysis center, checking the Post Dialysis Assessment Form for any recommendations from the dialysis center, making sure recommendations are carried out, and taking the resident's vital signs (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions) pre (before) and post dialysis. During a review of Resident 61's Physician Order dated [DATE], the Physician Order indicated Resident 61's scheduled dialysis day was on Wednesdays at 12:30 PM. The Physician Order indicated Resident 61 was to be picked up by Transportation Service 1 (TS 1) at 11 AM. During a review of Resident 61's Hemodialysis Communication Record dated [DATE], the Hemodialysis Communication Record indicated it was to be completed by the facility's licensed nurses (in general) for residents on dialysis prior to hemodialysis treatment. The Hemodialysis Communication Record indicated it was to be completed by the certified dialysis facility following dialysis treatment. The Hemodialysis Communication Record indicated it was to accompany the resident on return to the facility post (after) hemodialysis. The Hemodialysis Communication Record indicated it was to be completed by the facility's licensed nurses (in general) post hemodialysis treatment. During a review of Resident 61's SBAR (Situation, Background, Assessment, Recommendation, a communication tool used by healthcare workers when there is a change of condition among the residents) Summary for Providers progress note dated [DATE] at 2:24 PM, the SBAR Summary for Providers progress note indicated Resident 61 missed dialysis on [DATE] due to transportation not showing up. The SBAR Summary for Providers progress note indicated Resident 61's dialysis was rescheduled for [DATE]. The SBAR Summary for Providers progress note indicated transportation was rescheduled for [DATE]. The SBAR Summary for Providers progress note indicated Resident 61's MD1 was notified and recommended to monitor the resident. During a review of Resident 61's Nursing Progress Note dated [DATE] at 2:32 PM, the Nursing Progress Note indicated Resident 61 missed dialysis on [DATE] due to transportation not showing up. The Nursing Progress Note indicated Resident 61's insurance did not authorize transportation for Resident 61. The Nursing Progress Note indicated Resident 61's dialysis and transportation were rescheduled for [DATE]. During a review of Resident 61's DC1's Nurses Note dated [DATE] at 4:46 PM, the DC1's Nurses Note indicated Resident 61 had a transportation issue on [DATE]. The Nurses Note indicated Resident 61 arrived at DC 1 at 4:45 PM on [DATE]. The Nurses Note indicated Resident 61 stated I do not feel good, I feel very weak and tired. The Nurses Note indicated DC1's Physician (MD2) was notified and ordered to send Resident 61 to the hospital. The Nurses Note indicated that the facility (Skilled Nursing Facility) was notified. During a review of Resident 61's Nursing Progress Note dated [DATE] at 10:51 PM, the Nursing Progress Note indicated Resident 61 missed dialysis. The Nursing Progress Note indicated Resident 61 was rescheduled to go to dialysis later in the day at 4:15 PM. The Nursing Progress Note indicated once Resident 61 got to DC1, DC1 called and stated they (DC1) refused to do dialysis on Resident 61 due to Resident 61 feeling weak and had shortness of breath. The Nursing Progress Note indicated DC1 recommended sending Resident 61 to the hospital. The Nursing Progress Note indicated DC1 could not reschedule Resident 61 for dialysis the following day because they (DC1) were booked up. The Nursing Progress Note indicated Resident 61's MD1 was made aware of the situation. The Nursing Progress Note indicated Resident 61's MD1 provided physician orders to send Resident 61 to GACH 1 for dialysis. The Nursing Progress Note indicated that the coordinator (unidentified) was contacted about setting up transportation and transfer Resident 61 to GACH1. The Nursing Progress Note indicated the coordinator (unidentified) stated GACH 1was saturated (full). The Nursing Progress Note indicated the coordinator (unidentified) would keep the facility updated. The Nursing Progress Note did not indicate Resident 61's MD1 was notified GACH 1 was saturated. During a review of Resident 61's Physician Orders, the Physician Order indicated there was no Physician Order dated [DATE] to transfer Resident 61 to the hospital. During a review of Resident 61's Nursing Progress Note dated [DATE] at 6:11 AM, the Nursing Progress Note indicated at approximately 4:30 AM on [DATE] a Certified Nursing Assistant (CNA5) noticed Resident 61 was unresponsive and called the charge nurse (LVN3). The Nursing Progress Note indicated the charge nurse (LVN3) went to assess Resident 61 and found him unresponsive with no pulse. The Nursing Progress Note indicated the charge nurse (LVN3) was unable to obtain Resident 61's vital signs. The Nursing Progress Note indicated Resident 61 was provided with postmortem care (the procedures performed on a deceased person's body after death), and Resident 61's MD1 was made aware. During a concurrent interview and record review on [DATE] at 2:13 PM, Resident 61's SBAR Summary for Providers progress notes and Nursing Progress Notes dated [DATE] were reviewed with LVN 5. LVN 5 stated she (LVN5) worked with Resident 61 on [DATE]. LVN 5 stated Resident 61 initially missed dialysis on [DATE] at 11 AM because transportation did not show up. LVN 5 stated Resident 61 was sent on a rescheduled dialysis appointment later in the day on [DATE] (unidentified time). LVN5 stated the dialysis center (DC1) refused to do dialysis because Resident 61 had shortness of breath. LVN 5 stated the dialysis center (DC1) sent Resident 61 back to the facility. LVN 5 stated the dialysis center (DC1) recommended Resident 61 to go to the hospital because he (Resident 61) was having shortness of breath. LVN 5 stated Resident 61's physician (MD1) was made aware of the situation. LVN 5 stated if a resident (in general) missed dialysis, a change of condition form must be done. LVN 5 stated it was the charge nurse's or Registered Nurse's (in general) responsibility to complete a change of condition form. LVN 5 stated Resident 61's physician (MD1) should also be made aware of the change of condition. LVN 5 stated a change of condition must also be completed for residents who have shortness of breath. LVN 5 stated if a resident (in general) had symptoms of shortness of breath, she (LVN5) would have to call 911 (emergency phone number) or arrange for a direct admission to the hospital if non-emergent (non urgent). LVN 5 stated she (LVN5) did not call 911 for Resident 61 because Resident 61's vitals and respirations looked normal. LVN 5 stated once a change of condition was started, the resident should be monitored for 72 hours. LVN 5 stated there should be documentation for the resident's change of condition every shift. LVN 5 stated there were no progress notes documented for Resident 61 on [DATE]. LVN 5 stated there should have been monitoring notes for Resident 61 on [DATE] for the 11 PM to 7 AM shift, 7 AM to 3 PM shift, and the 3 PM to 11 PM shift following Resident 61's change of condition on [DATE]. LVN5 stated there were no assessment nursing notes from [DATE] to [DATE] for Resident 61. During a telephone interview on [DATE] at 8:27 AM with the DC1's Admin Assistant (AA), AA stated she (AA) was the AA at DC 1. AA 1 stated DC 1 was Resident 61's dialysis center. AA 1 stated Resident 61 arrived at the dialysis center on [DATE] at 4:45 PM. AA 1 stated DC 1 was going to close at 5 PM on [DATE]. AA 1 stated Resident 61 was on isolation precautions (is the act of separating a sick individual with a contagious disease from healthy individuals without that contagious disease). AA 1 stated DC1 was about to close, and the isolation chair was not available. AA 1 stated DC 1 was unable to dialyze Resident 61. AA 1 stated Resident 61 arrived at DC1 late because the facility had transportation issues. AA 1 stated Resident 61 stated I don't feel good, I feel weak and tired. AA 1 stated the physician (MD2) at the dialysis center recommended for the facility to transfer the resident to the hospital. AA 1 stated Resident 61 was not dialyzed on [DATE]. During an interview on [DATE] at 10:31 AM with the SSD, the SSD stated she (SSD) handled the dialysis transportation for the residents at the facility. The SSD stated transportation was arranged by insurance. The SSD stated she was not aware of Resident 61's transportation issues on [DATE]. The SSD stated Admissions might have been informed of Resident 61's transportation issues. During an interview on [DATE] at 10:40 AM with Admissions staff, Admissions staff stated the SSD handled Residents 61's transportation to dialysis. Admissions stated she (Admissions) was not made aware Resident 61 had any transportation issues on [DATE]. During a concurrent interview and record review on [DATE] at 11:06 AM, with the IDON, Resident 61's Physician Orders, SBAR Summary for Providers progress notes dated [DATE], Nursing Progress Notes dated [DATE], and Resident 61's physical chart were reviewed. The IDON stated Resident 61 would receive dialysis once a week. The IDON stated a change of condition note would be completed if the resident was experiencing something out of the ordinary, such as shortness of breath. The IDON stated the charge nurse and RN supervisors (in general) had the responsibility to follow up on the resident's COC. The IDON stated every nurse was responsible for monitoring the resident's COC. The IDON stated there should be documentation on the monitoring of the resident's COC at least once per shift. The IDON stated the resident's COC should be monitored for 72 hours unless a solution is found or the resident improves. The IDON stated she (IDON) would have called 911 immediately because Resident 61 was feeling weak and short of breath and missed HD. The IDON stated weakness and shortness of breath were not normal symptoms. The IDON stated, I don't see a physician order to transfer the resident to the hospital. The IDON stated Resident 61 needed to have a physician order for his transfer to the hospital. The IDON stated the licensed nurse was responsible for ensuring Resident 61's physician order for the transfer to the hospital was in place. The IDON stated the physician order to transfer the resident to the hospital was an intervention that was requested by the resident's physician (MD1) for the resident's change of condition.The IDON stated Resident 61 did not have a written physician order to transfer Resident 61 to the hospital. The IDON stated if she did not see the physician's order she (IDON) would call MD1 for an order. The IDON stated if the hospital was full the LVN (LVN5) should have called 911 to attempt another way to transfer Resident 61. The IDON stated that shortness of breath was a symptom of decline. The IDON stated it was important that Resident 61 received dialysis because he (Resident 61) could decline. The IDON stated shortness of breath could have been a complication from missed dialysis.The IDON stated a COC should have been done for the resident's symptom of shortness of breath. The IDON reviewed Resident 61's physical chart and stated she did not see a pre and post dialysis communication form for [DATE]. The IDON stated the charge nurse was responsible for ensuring the pre and post dialysis communication form was completed. The IDON stated transportation must be ensured, checked, and followed up on by the SSD. The IDON stated if there was no transportation, ambulance services could be used. The IDON stated the licensed nurse could have followed up on the Resident's transportation to dialysis. The IDON stated the licensed nurse could have let the SSD know to follow up on Resident 61's transportation arrival. The IDON stated that the Nursing Progress Notes did not let the dialysis center know that Resident 61 would be late for dialysis. The IDON stated licensed nurses can also organize transportation to dialysis.The IDON stated according to Resident 61's record, it did not seem like the resident's physician (MD1) was notified the hospital was saturated and could not accept the resident. The IDON stated the licensed nurse should have called and informed Resident 61's physician (MD1) that the hospital was saturated. The IDON stated Resident 61's physician (MD1) could have had other orders for how the resident could have been dialyzed. During a telephone interview on [DATE] at 2:18 PM with MD 1, MD 1 stated he was the facility's Medical Director and Resident 61's primary physician. MD 1 stated he (MD 1) remembered Resident 61. MD 1 stated Resident 61 was on limited dialysis once a week but did not remember the reason why. MD 1 stated he (MD1) did not recall a phone call or voice message from the facility stating GACH1 was full on [DATE]. MD 1 stated if he (MD 1) knew GACH1 was full, he (MD 1) would have recommended the facility to send Resident 61 to any other hospital that could accommodate the resident. MD 1 stated if Resident 61 was already stating he (Resident 61) was experiencing shortness of breath and weakness, he (MD 1) would have called 911. During a review of the facility's P&P titled Dialysis Management dated 1/2025, the P&P indicated To provide residents who require dialysis care, services consistent with professional standards of practice, a comprehensive person-centered care plan which meets the residents' goals and preferences.To ensure the facility assures that each resident receives care and services for the provision of hemodialysis and/or peritoneal dialysis (is a way to remove waste products from the blood a cleansing fluid flows through a tube into part of the stomach area) consistent with professional standards of practice including the: Ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility. Ongoing assessment and oversight of the resident before, during, and after dialysis treatments, including monitoring the resident's condition during treatments, monitoring for complications, implementing appropriate interventions, and using appropriate infection control practices; and ongoing communication and collaboration with the dialysis facility regarding dialysis care and services.Procedure: The facility has an agreement with contracted Dialysis Units (s) which operates in accordance with current standards of practice, including communication and collaboration. The Dialysis Units (s) and facility staff coordination the development and implementation of the dialysis care plan, including ongoing provision of assessment of the resident and care plan revision, as necessary. The facility employs qualified nursing staff to care for residents receiving dialysis treatment, including assessment and communication of dialysis related concerns. The facility has a qualified social services representative who assists the dialysis resident and their representative with dialysis related financial concerns, transportation needs, psychosocial needs, and advanced directives.The licensed nurse shall notify the physician and dialysis representative of resident symptoms including but not limited to uncontrolled chills, shaking, fever, vomiting, headache, dizziness, muscle weakness, skin flushing, diarrhea, hyper (high blood pressure)/hypotension(low blood pressure), hemolysis, and anemia(is a problem of not having enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissues. Hemoglobin is a protein found in red cells that carries oxygen from the lungs to all other organs in the body). During a review of the facility's Policy & Procedure (P&P) titled Transportation, Social Services dated 3/2023, the P&P indicated Our facility shall help arrange transportation for residents as needed. Social services will help the resident as needed to obtain transportation.Inquiries concerning transportation should be referred to social services. During a review of the facility's P&P titled Notification of Changes dated 1/2025, the P&P indicated The facility informs the resident, the resident's physician, and the resident's representative when there is an accident resulting in injury, changes involving life threatening conditions, adverse treatment consequences or transfer or discharge the resident.the facility notifies the physician and resident representative of: a. An accident involving the resident which results in injury and has the potential for requiring physician intervention; b. A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); c. A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or d. A decision to transfer to discharge the resident from the facility.

Based on observation, interview and record review, the facility failed to ensure one of five sampled residents (Resident 6) reviewed for pressure ulcer (an injury to the skin and underlying tissue caused by continuous pressure on the skin) care area did not develop a pressure ulcer by failing to: 1. Ensure that the Certified Nurse Assistant (CNA) monitored and documented the repositioning of Resident 6, who was assessed for a high risk of developing a pressure ulcer. 2. Include the Registered Dietitian (RD, a healthcare professional who has a special training in diet and nutrition) in the interdisciplinary team (IDT, a group of professionals from different fields who collaborate for a common goal) to discuss and implement interventions for promoting the healing of Resident 6's unstageable (when the full extent of the skin damage cannot be determined because there is dead tissue present) at the sacrococcyx (an area of the body where the lower end of the spine meets the tailbone). 3. Ensure Licensed Nursing Staff followed up with RD on the referral as requested on the Weekly Pressure Ulcer Record, dated 6/18/2025. 4. Communicate to Resident 6's physician the resident's lab results, dated 7/18/2025, which showed an albumin (reflects the nutritional status of a patient. Low albumin level can impair the body's ability to heal wounds, including pressure ulcers. Normal albumin levels range from 3.5 to 5.5 grams per deciliter) level of 2.6 grams per deciliter (g/dl, a unit of measurement) and hemoglobin (a protein in the red blood cells that carries oxygen to the body, which is vital for tissue repair and healing. Normal levels range from 12 to 15.5 g/dl) level of 8.6 g/dl. These failures resulted in Resident 6 developing an unstageable pressure ulcer on the sacrococcyx extending to the left and right buttock measuring 10.1 centimeters (cm, a unit of measurement) in length and 14.0 cm in width.Findings: During a review of Resident 6's Face sheet (admission Record) dated 7/24/2025, the Face sheet indicated the facility admitted Resident 6 on 8/14/2023 with diagnosis that included hemiplegia and hemiparesis (a condition where there is paralysis or severe weakness on one side of the body) and anemia (a condition where the blood does not have enough red blood cells to carry oxygen throughout the body). During a review of Resident 6's admission Assessment, dated 7/3/2024, the admission Assessment did not indicate Resident 6 was assessed for skin breakdown. During a review of Resident 6's Braden Scale (a tool used to assess a person's risk of developing pressure ulcers), dated 4/30/2025, the Braden Scale indicated Resident 6 was at a moderate risk to develop a pressure ulcer. During a review of Resident 6's Braden Scale reassessment, dated 6/18/2025, the [NAME] Scale reassessment indicated Resident 6 was at a high risk to develop a pressure ulcer. During a review of Resident 6's Wound Care Specialist note, dated 6/27/2025, the Wound Care Specialist note indicated Resident 6 had an unstageable pressure induced tissue damage on the sacrococcyx, extending to left and right buttock, measuring 10.1 cm in length and 14.0 cm in width. During a review of Resident 6's Minimum Data Set (MDS, a resident assessment tool used for screening of clinical and functional status), dated 7/25/2025, the MDS indicated Resident 6 had impaired function on one upper extremity, impaired function on both lower extremities, and required staff assistance to roll from lying on their back to the left and right side and return to back-lying position in bed. The MDS did not indicate Resident 6 had a pressure ulcer/injury. During an observation on 7/23/2025 at 12:03 p.m. in Resident 6's room, Resident 6 was positioned onto his back after wound care treatment. During an observation on 7/23/2025 at 2:10 p.m. in Resident 6's room, Resident 6 was observed to be lying on his back. During an interview on 7/23/2025 at 1:23 p.m. with Certified Nursing Assistant 11 (CNA 11), CNA 11 stated that CNAs were unable to chart whether a resident is repositioned to the left or right side. CNA 11 mentioned that there is no set schedule for offloading or repositioning residents, but CNAs clicks on the yes/no at the daily task list if they perform it. During an interview on 7/23/2025 at 12 p.m. with Treatment Nurse (TN), TN stated Resident 6 had a reopened pressure ulcer (a pressure ulcer that was once healed and now has opened again). TN stated Resident 6 had been free from skin breakdown for one year since Resident 6 was readmitted on [DATE] and the reopened pressure ulcer was obtained in the facility. TN stated that during the readmission [DATE]) of Resident 6 in the facility there are no skin issues identified. During a concurrent interview and record review on 7/24/2025 at 9:19 a.m. with TN, the Documentation Survey Report for turn and reposition, dated 6/2025, was reviewed. The Documentation Survey Report did not indicate the staff repositioned Resident 6. TN stated there should be documentation indicating the staff repositioned the resident and the blank spaces on the report indicate that it was not done. TN stated pressure ulcers are avoidable when interventions are implemented. TN stated that the care plan was generalized and not specific to the needs of Resident 6 like the repositioning every two hours was not implemented as an intervention. During a concurrent interview and record review on 7/24/2025 at 11:27 p.m. with the Interim Director of Nursing (IDON), Resident 6's Documentation Survey Report for 6/2025 and 7/2025, for monitoring the residents' turning and repositioning, were reviewed. The Documentation Survey Report indicated a N (for not turned) was documented on the following dates and times:1.On 6/1/2025 at 8 a.m., 10 a.m., 12 p.m., and 2 p.m.2.On 6/3/2025 at 4 p.m., 6 p.m., 8 p.m., and 10 p.m.3.On 6/6/2025 at 4 a.m. 4.On 6/7/2025 at 12 p.m.5.On 6/8/2025 at 8 a.m., 10 a.m., 12 p.m., and 2 p.m.6.On 6/14/2025 at 8 a.m., 10 a.m., 12 p.m., and 2 p.m.7.On 6/15/2025 at 8 a.m., 10 a.m., 12 p.m., and 2 p.m. 8. On 6/18/2024 at 8 p.m.9.On 6/20/2025 at 12 a.m., 2 a.m., 4 a.m., and 6 a.m. 9.On 6/21/2025 at 8 a.m., 10 a.m., 12 p.m., and 2 p.m. 10.On 6/23/2025 at 12 a.m., 2 a.m., 4 a.m., and 6 a.m.11. On 6/25/2025 at 12 a.m., 2 a.m., 4 a.m., and 6 a.m.12.On 6/28/2025 at 8 a.m., 10 a.m., 12 p.m., and 2 p.m.13.On 6/29/2025 at 12 a.m., 2 a.m., 4 a.m., and 6 a.m., 8 a.m., 10 a.m., 12 p.m., and 2 p.m.14.On 6/30/2025 at 12 a.m., 2 a.m., 4 a.m., and 6 a.m.15.On 7/1/2025 at 12 a.m., 2 a.m., 4 a.m., and 6 a.m.16.On 7/2/2025 at 12 a.m., 2 a.m., 4 a.m., and 6 a.m.17.On 7/7/2025 at 2 a.m., 4 a.m., and 6 a.m. 18.On 7/8/2025 at 12 a.m., 2 a.m., 4 a.m., and 6 a.m.19.On 7/9/2025 at 12 a.m., 2 a.m., 4 a.m., and 6 a.m. During a concurrent observation and interview on 7/24/2025 at 11:37 a.m. in Resident's 6 room, Resident 6 was lying on his back. 2. During a concurrent interview and record review on 7/24/2025 at 9:19 a.m., of the Weekly Pressure Ulcer Record dated 6/18/2025 with the TN. The Weekly Pressure Ulcer Record indicates a Registered Dietitian (RD) review was requested. Resident 6's records did not indicate the RD evaluated the resident. TN stated it was important for RD to be involved because the RD could make recommendations for nutritional supplements (vitamins, minerals, or protein that can help aid in tissue repair). TN stated that RD did not see or assess Resident 6. During a review of the Registered Dietitian's (RD) recommendation monthly visit, dated 6/19/2025, the RD recommendation monthly visit did not indicate the RD visited Resident 6. During an interview on 7/24/2025 at 11:27 a.m. with IDON, the IDON stated the interdisciplinary team (IDT) meeting was held on 6/18/2025 and the RD should have been involved in the IDT meeting and there were no notes from the RD indicating she was in the IDT meeting. IDON stated the importance of involving the RD to evaluate Resident 6's nutrition and hydration status. If necessary, the RD should consider adding a supplement to support wound healing. IDON stated that nurses must follow up on consultations, and Resident 6 was overlooked. 3. During a concurrent interview and record review on 7/24/2025 at 11:10 a.m. with TN, Resident 6's Lab Results Report, dated 7/18/2025 was reviewed. The Lab Results Report indicated a level for albumin of 2.6g/dl and hemoglobin 8.6 g/dl. The TN stated the albumin level should be between 3.5 g/dl and 3.7 g/dl and low albumin levels are associated with delayed tissue repair and impaired healing. TN stated the hemoglobin level should be between 13.7 g/dl and 17.5 g/dl and reduced levels can impair oxygen deliver to tissues, contributing to delayed wound healing. TN stated the physician may prescribe supplements to help improve hemoglobin levels and support the healing process. TN stated the lab results report was not communicated to the MD for follow-up. During a concurrent interview and record review on 7/24/2025 at 11:27 a.m. with IDON, Resident 6's Lab Results Report, dated 7/18/2025, was reviewed. The Lab Results Report indicated a level for albumin of 2.6g/dl and hemoglobin 8.6 g/dl. IDON stated the resident's albumin was low at 2.6 g/dl and can indicate inflammation and the facility protocol required the RD to be notified so she could make supplement recommendations for healing but there was no documentation indicating the RD was notified and there was no documentation indicating the low albumin level was addressed. IDON stated the care plan should also include notifying MD of lab results since this is an important factor for wound healing. During a review of Resident 21's Order Summary Report, dated 7/24/2025, the Order Summary Report did not indicate the resident was on supplements (something added to enhance something else) that could help promote wound healing or increase hemoglobin level. According to the nationally recognized Journal of Clinical Nursing, an article retrieved from https://onlinelibrary.[NAME].com/doi/full/10.1111/jocn.14691 titled, The Standardized Pressure Injury Prevention Protocol nurses working in health care settings must address pressure ulcer development prevention. The early intervention to prevent pressure injury is required and be integrated into the workflow process. During a review of the facility's policy and procedure (P&P) titled, Treatment Services to Prevent/Heal Pressure Ulcers, dated 1/2025, the P&P indicated, The purpose is to promote healing.and prevent the development of additional pressure ulcer/injury. The P&P indicated prolonged or excessive pressure can lead to injury, the facility did not do the initiation of appropriate, individualized interventions and ongoing evaluation of their effectiveness, and residents identified as at risk may be more vulnerable to developing pressure ulcers or injuries when in one position for an extended duration. The P&P indicated clinicians may use laboratory tests to evaluate potential nutritional deficiencies in residents with pressure ulcers.

Based on interview and record review, the facility failed to protect the resident's right to be free form sexual abuse (deliberate, aggressive, or violent behavior with the intention to cause harm) for one of three sampled residents (Resident 2), who was subjected to Resident 1's sexual aggression, who had diagnoses of schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior). The facility failed to: -Implement the facility's policy and procedure titled, Abuse Prevention Program-Abuse Prohibition, revised May 2024, which indicated the facility shall uphold resident's right to be free from sexual and physical abuse. -Implement the facility's policy and procedure titled, Behavior Assessment, Intervention, and Monitoring, revised May 2024, to ensure the interdisciplinary team would thoroughly evaluate Resident 1's new or changing behavioral symptoms, which occurred on 1/7/2025, in order to identify underlying causes and address any modifiable factors that may have contributed to the resident's change in condition. -Ensure Social Services provided Resident 1 a psychosocial visit for 72 hours after Resident 1 displayed a new aggressive behavior and punched a staff member on 1/7/2025. As a result, five days later, on 1/12/2025 at about 9 PM, Resident 1 sexually abused Resident 2 (the roommate) when Resident 2's incontinent brief was removed by Resident 1. Resident 1 used her left hand signaling to Resident 2 to stop crying and Resident 1 placed her right fingers in Resident 2's vagina. Resident 2 cried loudly and was angry with distress (a state of emotional suffering). This deficient practice resulted in Resident 2 being subjected to physical and sexual abuse by Resident 1 while under the care of the facility. Based on the Reasonable Person Concept (the usual behavior of an average person under the same circumstances), due to Residents 2's severely impaired cognition (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering) and medical condition, an individual subjected to physical and sexual abuse may have physical pain, psychological (mental or emotional) effects including feelings of hopelessness (a feeling or state of despair or lack of hope), helplessness (the belief that there is nothing that anyone can do to improve a bad situation), and humiliation (the feeling of being ashamed or losing respect for own self). Findings: A review of Resident 1's Admission Record indicated the facility admitted the resident on 6/17/2024 with diagnoses including schizoaffective disorder, depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and mild cognitive impairment of uncertain or unknown etiology (problems with a person's ability to think, remember, use judgement). A review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 12/24/2024, indicated the resident's problems with ability to think, remember and use judgement had declined and now had moderate cognitive impairment for daily decision making. The MDS indicated the resident did not have any behaviors of hallucinations (seems to see, hear, feel, or smell something that does not exist) or delusions (false belief that someone holds onto, even when there was evidence that it was not true), physical behavioral symptoms directed towards others (hitting, kicking, grabbing, abusing others sexually) or verbal behavioral symptoms towards others (treating others, screaming at others, cursing at others). A review of the Change in Condition Evaluation dated 1/7/2025, indicated Resident 1 had physical aggression towards an employee and Resident 1 punched the employee's left upper arm. The note indicated Resident 1's family and physician were notified. A review of Resident 1's Behavior Problem care plan dated 1/7/2025 with a focus on physical aggression (patient punched nurse) indicated the goal was for Resident 1 to verbalize understanding of need to control physical / verbal / social / sexual inappropriate behavior for three months. The care plan interventions indicated to share with the resident other options for dealing with feelings, and when resident becomes agitated: intervene before agitation escalates; guide away source of distress; engage calmly in conversation; if response was aggressive -walk calmly away, and approach later. According to a review of Resident 1's Change of Condition (COC) Evaluation dated 1/12/2025 (five days later), there was an allegation of sexual abuse as Resident 1 inappropriately touched (any physical contact that was unwanted) Resident 2's (the roommate) pelvic area, which was witnessed by the assigned certified nursing assistant (CNA) 1. A review of the COC findings indicated at approximately 9 PM on 1/12/2025, CNA 1 heard a noise inside room [ROOM NUMBER]'s room, immediately went to the room, and witnessed Resident 1 touching the pelvic area of Resident 2. CNA 1 removed Resident 1 and took the resident to the nurses station. Resident 1 was transferred to another room for increased visual monitoring. A review of Resident 2's Admission Record indicated the facility admitted the resident on 7/22/2015 with diagnoses including hemiparesis (condition that causes weakness or an inability to move on one side of the body) following cerebral infarction (occurs as a result of disrupted blood flow to the brain) affecting left non-dominant side and unspecified dementia (a progressive state of decline in mental abilities). The Admission Record indicated the facility's Bioethics Committee (a group of people who ensure that human rights are respected) was Resident 2's responsible party. A review of Resident 2's MDS dated [DATE], indicated the resident had severe cognitive impairment for daily decision making and did not have any behaviors of hallucinations or delusions, physical behavioral symptoms directed towards others or verbal behavioral symptoms towards others. The MDS indicated the resident required supervision or touching assistance with toileting and had impairment on both sides of the upper extremity (shoulder, elbow, wrist, hand) and lower extremity (hip, knee, ankle, foot). A review of Resident 2's COC Evaluation dated 1/12/2025, indicated Resident 2 was a victim of abuse (sexual) and a skin and psychosocial evaluation were done. The COC indicated Resident 2's skin was intact and showed no signs of emotional distress or psychosocial decline. During an interview with the Director of Nursing (DON) on 1/15/2025 at 10:11 AM, the DON stated Resident 1's behavior of punching the staff member on 1/7/2025 was a new behavior. During a concurrent review of the facility's policy titled, Behavioral Assessment, Intervention, and Monitoring, the DON stated per policy, the interdisciplinary team (IDT) should have thoroughly evaluated Resident 1's new or changing behavioral symptoms. The DON stated there was no documentation indicating the IDT met after Resident 1's physical aggression incident on 1/7/2025. The DON stated it was important to have the IDT meet and develop individualized interventions to address Resident 1's specific behavior. The DON stated there was a potential for physical or verbal altercation since Resident 1's new behavior was not addressed. The DON stated Resident 1 also should have been visited by Social Work for a psychosocial evaluation and emotional support for 72 hours. The DON stated and confirmed based on documentation, Resident 1 was not visited by the Social Work Department after the incident on 1/7/2025. During an interview on 1/15/2025 at 12:57 PM, the Social Service Director (SSD) stated she was not aware of Residents 1's aggressive behavior from 1/7/2025 and did not conduct a psychosocial visit for Resident 1. The SSD stated it was important a psychosocial visit for 72 hours was conducted to check on Resident 1 to see if there was any emotional distress or any other changes in behavior. The SSD stated when a resident displayed a new behavior like aggression, there should be an IDT meeting to discuss the behavior. During an interview on 1/15/2025 at 1:41 PM, the Quality Assurance Nurse (QA), stated it was important the IDT met to identify causes and come up with interventions on how to manage and monitor the Resident 1's new behavior. The QA stated it was important to have new interventions to ensure safety of Resident 1, staff, and other residents. The QA stated Resident 2 was a vulnerable resident because she was bedbound and could not speak for herself and could answer mostly yes or no questions. The QA stated if IDT would have met, IDT would have considered doing a room change for Resident 1 with a resident that was alert and oriented, could speak for themselves, and verbalize any concerns. On 1/15/2025 at 2:26 PM during an interview, the DON stated the allegation of Resident 1 touching Resident 2 inappropriately was a concern for sexual abuse. The DON stated Resident 2 was a vulnerable resident because she was bedbound and had dementia. The DON stated using a reasonable person concept she would have been emotionally distressed, uncomfortable, and felt unsafe if she was touched inappropriately. The DON stated it was important that all residents were free from abuse because it was the residents right. During an interview on 1/15/2025 at 3:02 PM CNA 1 stated between 8:30 to 9 PM on 1/12/2025 she was charting at the front desk near Resident 2's room when she heard Resident 2 screaming and crying. CNA 1 stated she rushed to Resident 2's room and saw Resident 2's privacy curtain closed. CNA 1 stated when she walked to the foot of Resident 2's bed and saw Resident 1 using her left hand to make a motion with one finger over her mouth telling Resident 2 to stop crying and Resident 1's right hand touching Resident 2's vagina. CNA 1 stated Resident 2's diaper was off, and the blankets were open (not covering Resident 2). CNA 1 stated Resident 2's expression was angry because she was crying very loud. CNA 1 stated she immediately removed Resident 1 from the room and informed the charge nurse (Licensed Vocational Nurse, LVN) 1 what she observed. CNA 1 stated she observed the charge nurse (LVN 1) ask Resident 1 if it was true what she (CNA 1) had said CNA 1 heard Resident 1 respond yes, she (Resident 2) likes to be touched. During a phone interview on 1/15/2025 at 3:22 PM, LVN 1 stated on 1/7/2025 at about 9:10 PM, she asked Resident 1 why she had removed Resident 2's diaper and touched Resident 2's private area. LVN 1 reported Resident 1 responded, Because she (Resident 2) wanted her (Resident 1) to. During an interview on 1/16/2025 at 9:22 AM, the Administrator (Admin) stated he learned about the allegation of Resident 1 inappropriately touching Resident 2 on 1/12/2025. Admin stated there was a concern for sexual abuse and based on his investigation Resident 1 was the perpetrator and Resident 2 was the victim. Admin stated based on the reasonable person concept, he would feel terrible if someone touched him inappropriately because it was demeaning. Admin stated all residents and staff have a right to be free from abuse because it was part of resident dignity and respect. A review of the facility's policy and procedure titled, Abuse Prevention Program-Abuse Prohibition, revised May 2024, indicated the facility shall uphold resident's right to be free from sexual, physical, and mental abuse, and involuntary seclusion. A review of the facility's policy and procedure titled, Behavior Assessment, Intervention, and Monitoring, revised May 2024, indicated the interdisciplinary team would thoroughly evaluate new or changing behavioral symptoms in order to identify underlying causes and address any modifiable factors that may have contributed to the resident's change in condition. The policy indicted the interdisciplinary team would evaluate behavioral symptoms in residents to determine the degree of severity, distress and potential safety risk to the resident, and develop a plan of care accordingly. Interventions and approaches would be based on a detailed assessment of physical, psychological, and behavioral symptoms and their underlying causes, as well as the potential situational and environmental reasons for the behavior. The care plan would include, as a minimum: a description of the behavioral symptoms, including: frequency, intensity, duration, outcomes, location, environment and precipitating factors or situation, targeted and individualized interventions for the behavioral and/or psychosocial symptoms, the rationale for the interventions an approaches, specific and measurable goals for targeted behaviors; and how the staff would monitor for effectiveness of the interventions. The policy indicated the SSD / Designee would conduct a psychosocial visit with the resident for 72 hours to ensure their needs were being met and they were adhering to the established care plan.

Based on observation, interview, and record review, the facility failed to provide safe and accident-free environment for one of three sampled residents (Resident 1), who had visual impairment (blindness, difficulty seeing), a left above the knee amputation (AKA - surgical removal of the portion of the leg above the knee), and had history of fall with injury, by failing to: - Follow the Physician's Order dated 4/15/2024 for Resident 1 to receive visual hourly safety checks for fall prevention. -Review and update the At Risk for Falls Care Plan after a fall and change in condition on 4/15/2024, including implementation of individualized care and maximizing the resident's safety. -Assist Resident 1 with mobility and repositioning around 7:30 PM on 12/19/2024, when the roommate (Resident 2) informed Licensed Vocational Nurse 1 that Resident 1 was on the edge of the bed and was going to fall. As a result, Resident 1 had another fall off her bed on 12/19/2024, was screaming, crying, and the facility staff called 911 (emergency phone number for immediate medical assistance via ambulance). Resident 1 was transferred to General Acute Care Hospital (GACH) 1 where she moaned in pain, sustained a 5-centimeter (cm) laceration (a cut or tear in the skin that is caused by an injury) to her forehead and on 12/20/2024 was admitted to the intensive care unit for acute stroke. Findings: A review of Resident 1's Admission Record, indicated the facility originally admitted the resident on 12/22/2021 with diagnoses including a left above the knee amputation (AKA, surgical removal of the portion of the leg above the knee), schizophrenia (a serious mental disorder in which people interpret reality abnormally, may result in delusions and behavior that impairs daily functioning, may have grandiose delusions [strong beliefs of things that are untrue]), and visual impairment (blindness in one eye). A review of Resident 1's At Risk for Falls care plan initiated 8/19/2022, related to diagnoses of visual impairment and impulsive behavior (acting without thinking of the consequences), lack of awareness, left AKA, muscle weakness, and right heel wound/pain indicated the goal was for Resident 1 to minimize the risk for falls. The care plan interventions indicated to maintain the call light within reach, to remind the resident to use the call light, and to remove hazards from the resident's environment. The care plan indicated the interventions were initiated on 8/19/2022 and had not been updated since 8/19/2022. A review of Resident 1's Actual Fall care plan dated 4/11/2024, indicated the resident fell from the wheelchair while in the resident's room. The care plan was revised on 4/15/2024 which indicated Resident 1 rolled out of bed in the covers and fell on to the floor to the right side of the bed. The care plan indicated interventions for visual hourly safety checks and to continue interventions on the at-risk plan. A review of the Physician's Order dated 4/15/2024 indicated to visually and hourly check Resident 1 for fall monitoring. A review of the Minimum Data Set (MDS, a resident assessment tool) dated 11/22/2024 indicated Resident 1 had mildly impaired cognitive skills (problems or difficulty with memory, thinking, and following instructions, but it did not usually interfere with daily tasks). The MDS indicated Resident 1's functional abilities (dependent on help, for personal hygiene, putting on / taking off footwear, lying to sitting on the bed, bed to chair transfer, and ability for Resident 1 to ambulate at least 10 feet once standing) were not assessed. A review of Resident 1's MDS dated [DATE], indicated the resident had modified independence of cognitive skills for daily decision making (some difficulty in new situations only). The MDS indicated Resident 1 was dependent on help (helper did all of the effort) for personal hygiene, putting on / taking off footwear, lying to sitting on the bed, and bed to chair transfer. The MDS indicated the ability for Resident 1 to ambulate at least 10 feet once standing was not attempted and Resident 1 did not perform this activity. The MDS indicated Resident 1 was always incontinent (having no or little control) of urine and bowel and had one fall with injury (skin tears, abrasions, lacerations, superficial bruises, hematomas, and sprains; or any fall-related injury that causes the resident to complain of pain) since admission / entry, reentry, or the prior assessment. According to a review of Resident 1's Fall Risk assessment dated [DATE], the resident was at a high risk for potential falls with a score of 14. The assessment indicated Resident 1 had intermittent confusion, no falls in the past three months, was chair bound, had poor vision with or without glasses, required the use of assistive devices (i.e. cane, w/c, walker, furniture), had no noted blood pressure drop between lying and standing, had a loss of limb, and was taking hypoglycemics (medication to lower blood sugar levels), narcotics (medication used to treat pain), and psychotropics (medication that affects behavior, mood, thoughts, or perception). A review of the At Risk for Fall Care plan indicated there were no updates or revisions to include Resident 1's current status of high risk for falls with intermittent confusion. A review of Resident 1's Change of Condition documentation dated 12/19/2024 at 8:08 PM, indicated the resident had a fall. The documentation indicated at 7:40 PM, Resident 1 fell out of her bed and fell on to the floor. The documentation indicated Resident 1 was found to have a gash (a long deep slash, cut, or wound) on their forehead and was bleeding from area. The documentation indicated 911 was called and the paramedics decided to transfer Resident 1 to General Acute Care Hospital (GACH) 1. The documentation further indicated Resident 1's physician was notified. A review of Resident 1's Medication Administration Record (MAR) dated 12/1 - 12/31/2024 indicated to perform visual hourly safety checks for fall precaution. The MAR indicated to document in MAR Y=Yes that the visual check was completed checking on the resident every hour. The MAR indicated the documentation of 2 referred to Drug Refused. The MAR documentation on 12/8 - 12/11/2024 indicated LVN 1 documented 2, drug refused, from midnight to 7 AM for a total of 32 times. The MAR dated 12/19/2024 from 5 PM to 11 PM indicated LVN 1 documented 2. Further review of the December MAR indicated 2 was documented a total of 71 times by LVN 1. A review of Resident 1's Health Status Note documented by Licensed Vocational Nurse (LVN) 1 dated 12/19/2024 at 8:30 PM, indicated LVN 1 went on a break at 7:30 PM and returned at 7:50 PM. The health status note indicated that according to LVN 2, Resident 1 was heard falling at 7:40 PM. LVN 2 went straight to the room and found Resident 1 on the floor with a gash on the forehead, and 911 was called. The note indicated Resident 2 had reported to LVN 1 that Resident 1 was at risk for falling at 6 PM. According to a review of Resident 1's Emergency Documentation (ED) from GACH 1 dated 12/19/2024, the resident was found on the floor from falling out of her bed striking her forehead on the floor and sustaining a laceration. The ED indicated Resident 1 was moaning in pain and had a 5-centimeter horizontal shallow laceration to the forehead. A review of Resident 1's GACH 1 History and Physical (H&P) dated 12/20/2024 indicated the resident had a magnetic resonance imaging (MRI, a noninvasive medical imaging test that used radio waves and strong magnetic fields to create detailed pictures of the inside of the body) scan done on 12/20/2024 for a head injury. The MRI indicated Resident 1 had a small region of acute infarct (a medical emergency that occurs when an organ or body part has a sudden interruption of blood supply, resulting in cell death and tissue damage due to and lack of oxygen, in the context of stroke) along the left corona radiata (a bundle of nerve fibers that carries information between the brain stem and cerebral cortex, or the outer layer of the brain). The H&P indicated Resident 1 was initially admitted to the intensive care unit, was later downgraded to telemetry, and was administered aspirin and statin (a class of medications that reduce the risk of stroke and heart attack) for her acute stroke with a neurology consult. During a concurrent observation and interview on 1/6/2025 at 11:10 AM, in Resident 1's room, the resident was observed lying in bed with an adaptable call light within reach. Resident 1 was observed with the bed low and floor mats to the left and right side of the bed. Resident 1 was observed wearing a yellow wristband that indicated fall risk to their right wrist. Resident 1 stated they did not remember falling or hitting their head in the facility. Resident 1 stated they did not remember anything about falling. A review of Resident 2's Admission Record indicated the facility admitted the resident on 3/20/2024 with diagnoses including muscle weakness, anxiety disorder, and depression. A review of Resident 2's MDS dated [DATE], indicated the resident was cognitively intact (the ability to think, understand, and reason). During an interview on 1/6/2025 at 12:38 PM, in Resident 2's room, Resident 2 stated she knew Resident 1 and she was roommates with Resident 1 since being admitted to the facility 3/2024. Resident 2 stated she remembered when Resident 1 fell on [DATE] around 8 PM. Resident 2 stated before Resident 1 fell she saw the resident close to the edge of her bed. Resident 2 stated she called LVN 1 and told LVN 1 Resident 1 was about to fall. Resident 2 stated LVN 1 told her, Don't worry. Resident 1 was not going to fall. Resident 2 stated LVN 1 stood at the door and told her not to worry and walked away. Resident 2 stated, LVN 1 did not come into the room at all. Resident 2 stated shortly after notifying LVN 1, Resident 1 fell and landed close to Resident 2's bed. Resident 2 stated after Resident 1 fell , the resident was crying and screaming. Resident 2 stated LVN 1 came into the room after the paramedics came. Resident 2 stated Resident 1, Needed a lot of help doing things, she only had one leg, and she had fallen from the wheelchair before. During a telephone interview on 1/6/2025 at 2:37 PM, Certified Nursing Assistant (CNA) 1 stated he was Resident 1's CNA the night the resident fell . CNA 1 stated Resident 1 was always confused and shouted a lot at night. CNA 1 stated Resident 1 was always moving left and right and needed special pillows on the bed. During an interview on 1/6/2024 at 3:31 PM, LVN 2 stated she was working the 3 PM to 11 PM shift on 12/19/2024. LVN 2 stated she was at the nursing station doing documentation when she heard a noise and Resident 2 yelling for help. LVN 2 stated she went to Resident 1 and 2's room and saw Resident 1 on the floor. LVN 2 stated she saw Resident 1 had blood on her head. LVN 2 stated she asked Resident 1 what had happened, and the resident told her she fell , hit her head, and was in pain but could not provide their pain level. LVN 2 stated she called 911. LVN 2 stated Resident 1 hit the right side of her head and had a smear of blood on their face. LVN 2 further stated LVN 1 was assigned to take care of Resident 1 that night. On 1/7/2024 at 8:57 AM, during a telephone interview, LVN 1 stated on 12/19/2024 he was working the 3 PM to 11 PM shift and was taking care of Resident 1. LVN 1 stated he did not see Resident 1 fall. LVN 1 stated he went on break from 7:30 PM to 8 PM that night. LVN 1 stated he came back early from break because he was called and informed Resident 1 had fallen. LVN 1 stated when he got back to the facility Resident 1 was already in the ambulance. LVN 1 stated Resident 1 had some behaviors that were concerning such as leaning on the side of the bed, crying a lot, and behaviors that make you think the resident might have an accident. LVN 1 stated at baseline Resident 1 was confused and did not know much of what was going on. LVN 1 stated Resident 1 was at risk of falling and he could not remember if Resident 1 had floor mats the night the resident fell on [DATE]. During a concurrent interview and record review on 1/7/2025 at 9:32 AM, Resident 1's care plans, MAR dated 12/1 - 12/31/2024, and electronic health care record (EHR) were reviewed with Registered Nurse (RN) 1. RN 1 stated Resident 1 was unpredictable and had periods of confusion but could make their needs known. RN 1 stated Resident 1 was dependent on staff and required total care. RN 1 reviewed Resident 1's EHR and stated prior to the resident's fall on 12/19/2024, the resident fell previously on 4/15/2024. RN 1 stated Resident 1's at risk for falls care plan was not updated after the resident fell on [DATE]. RN 1 stated Resident 1's at risk for falls care plan was last updated on 8/19/2022. RN 1 stated after a resident had a fall, staff refer to the at-risk for falls care plan and update the care plan with additional interventions. RN 1 stated after a resident had a fall, an actual fall care plan should also be created. RN 1 stated care plans were updated with a change of condition, quarterly, and as needed. On the same interview, RN 1 reviewed Resident 1's December MAR. RN 1 stated and confirmed that on 12/19/2024 from 5 PM to 11 PM, 2 was documented for visual hourly safety checks for fall prevention. RN 1 stated 2 indicated Drug Refused. RN 1 stated the documentation on the MAR was incorrect. RN 1 stated, I don't know how you can refuse a visual check; I can't deny what my eyes are seeing. RN 1 stated a visual check means seeing if Resident 1 was good, the resident may refuse a drug, but a visual check was not a drug. RN 1 stated you can visually see where Resident 1 was by just looking or passing by a room. RN 1 stated the documentation on Resident 1's MAR indicated that a visual check was not done. RN 1 stated if the visual check was done the documentation would indicate a Y which it did not. During a concurrent telephone interview and record review on 1/7/2025 at 10:03 AM, Resident 1's MAR dated 12/1- 12/31/2024 was reviewed with LVN 1. LVN 1 stated that on 12/19/2024 from 5 PM to 11 PM, he documented a 2 for visual hourly safety checks for fall prevention. LVN 1 stated the 2 indicated Drug Refused. LVN 1 stated the documentation on the MAR was incorrect and he made a mistake. LVN 1 stated that night he was informed by Resident 2 that Resident 1 was on the edge of the bed and might fall. LVN 1 stated he did not enter the room because he could see that Resident 1 was centered in the bed. LVN 1 stated he did not reposition Resident 1 when he was notified of Resident 2's concern because the resident was centered in the bed. During an interview on 1/7/2025 at 10:45 AM, Resident 1's Physician's Orders were reviewed with RN 1. RN 1 stated Resident 1 had floor mats to prevent falls placed after the fall on 12/19/2024 after she returned to the facility from GACH 1. RN 1 stated Resident 1 did not have any physician's orders for floor mats prior to the resident's fall on 12/19/2024. RN 1 stated there were no care plan interventions for floor mats on Resident 1's at risk for falls or actual fall care plans. RN 1 further stated Resident 1's laceration could have been prevented if the resident had floor mats in place when they fell on [DATE]. During a concurrent interview and record review on 1/7/2025 at 11:31 AM, Resident 1's care plans, MAR dated 12/1 - 12/31/2024, and EHR were reviewed with the DON. The DON stated Resident 1 had a previous fall on 4/15/2024. The DON reviewed Resident 1's at risk for fall care plan, the left AKA care plan, and the Self Care Deficit care plan and stated the care plans had not been updated since 2022. The DON stated when a resident has a fall, the at risk for falls care plan should be updated to include additional and new interventions to help prevent further falls. The DON stated appropriate care plans should be updated with any change in condition and quarterly with specific and person-centered interventions that are based on the resident's assessments. During the same concurrent interview and record review of Resident 1's MAR, and the DON stated that on 12/19/2024 from 5 PM to 11 PM, a 2 was documented for visual hourly safety checks for fall prevention. The DON stated the 2 indicated Drug Refused. The DON stated the documentation on the MAR was incorrect and indicated a visual check was not done. The DON stated if the visual check was done the documentation would indicate Y for yes. The DON stated Resident 1 had floor mats placed to the sides of her bed when she returned to the facility after their fall on 12/19/2024. The DON stated floor mats could have helped prevent Resident 1 from sustaining a laceration when she fell on [DATE]. The DON further stated an updated at risk for falls care plan and hourly visual checks would have prevented Resident 1 from falling off their bed. A review of the facility's policy and procedure titled, Fall Risk Assessment, revised 1/2024, indicated the nursing staff, in conjunction with the attending physician, consultant pharmacist, therapy staff, and others, will seek to identify and document resident risk factors for falls and establish a resident-centered falls prevention plan based on relevant assessment information. The attending physician and nursing staff will evaluate the resident's vital signs, assess the resident for medical conditions (such as those that cause dizziness or vertigo) or sensory impairments (such as decreased vision and peripheral neuropathy) that may predispose falls. Assessment data shall be used to identify underlying medical conditions that may increase the risk of injury from falls (such as osteoporosis). The staff will seek to identify environmental factors that may contribute to falling, such as lighting and room layout. The staff and attending physician will collaborate to identify and address modifiable fall risk factors and interventions to try to minimize the consequences of risk factors that are not modifiable. A review of the facility's policy and procedure titled, Care Plans, Comprehensive Person-Centered, revised 5/2024, 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 interdisciplinary Team must review and update the care plan: when there has been a significant change in the resident's condition; when the desired outcome is not met; when the resident has been readmitted to the facility from a hospital stay; and at least quarterly, in conjunction with the required quarterly MDS assessment. A review of the facility's policy and procedure titled, Assessing Falls and Their Causes, revised 5/2024, indicated the purposes of this procedure was to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall. Review the resident's care plan to assess any special needs of the resident. Falling may be related to underlying clinical or medical conditions, overall functional decline, medication side effects, and/or environmental risk factors. Residents must be assessed upon admission and regularly afterward for potential risk of falls. Relevant risk factors must be addressed promptly. When a resident falls, the following information should be recorded in the resident's medical record. Appropriate interventions taken to prevent future falls.

This is a Repeated Deficiency from 10/8/2024 and 12/3/2024. Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1), who had a history of falls, was a high fall risk, and was dependent on staff for toilet transfer, received the care and services necessary to prevent accident and falls by failing to assist Resident 1 for transfer to the toilet every two hours, per the Bowel and Bladder Incontinence care plan. As a result, on 11/28/2024 approximately at 11:30 PM, Resident 1 tried to go to the bathroom by himself and fell . Resident 1 was transferred to the General Acute Care Hospital (GACH) for further evaluation where he was diagnosed with a displaced intertrochanteric (where hip and thigh meet) fracture (a partial or complete break in a bone) of right femur (the thigh bone). Cross Reference F690 Findings: A review of Resident 1's admission record indicated the resident was readmitted to the facility on [DATE], with diagnoses including generalized muscle weakness, cognitive communication deficit (a person's inability to think learn, remember, use judgement, and make decisions), and chronic kidney disease (damaged kidneys cannot filter blood as needed causes risks of high blood pressure and heart disease). A review of the Bowel and Bladder Incontinence care plan initiated 3/9/2023 indicated the interventions to assist Resident 1 to the bathroom toilet every two hours and when needed, to encourage the resident to ask for assistance during toileting program and to encourage the resident participation in bowel and bladder re-training program for seven days. There was no revision or review date indicated on the care plan. A review of Resident 1's Fall Risk assessment dated [DATE] indicated the resident had a history 1 -2 falls in the past three months, required use of assistive devices, and that for level of consciousness the resident was disoriented. The assessment indicated Resident 1 had a score of 17, as a score of 10 or greater indicated a high risk for potential falls. A review of Resident 1's Minimum Data Set (MDS, a mandated federal assessment tool) dated 11/15/2024, indicated Resident 1 was moderately confused, unable to make decisions, or follow instructions. The MDS indicated Resident 1 was dependent on a manual wheelchair for mobility, and required partial assistance from another person for indoor ambulation. The MDS indicated Resident 1 had a fall in the last 2-6 months prior to admission and was dependent on staff for toilet transfer, . A review of the At Risk for Fall care plan initiated 12/7/2020 indicated the resident had gait / balance problems, attempts to stand unassisted, and was unaware of safety needs. The care plan goal indicated the resident would not sustain injuries for 90 days. The care plan interventions indicated to anticipate and meet the resident's needs, assist with all transfers or ambulation, and that the resident needed a safe environment. Further review of the At Risk for Fall care plan indicated a resolved date of 9/18/2023. This indicated there was no active Fall care plan for Resident 1. A review of Resident 1's CNA tracking log titled, Toilet transfer: The ability to get on and off a toilet or commode, dated 11/26/2024 indicated at 2:25 PM the resident had supervision or touching assistance to get on and off the toilet. At 8:30 PM indicated 'not applicable' for the activity. On 11/27/2024 at 8:41 PM, the log indicated 'not attempted due to environmental limitations, i.e., lack of equipment.' On 11/28/2024 at 2:34 PM, Resident 1 had supervision for the activity and at 6:58 PM, there was no attempt for Resident 1 to be assisted on and off the toilet due to medical condition or safety concerns. A review of the Physician's Order Summary Report dated 11/29/2024, indicated to transfer Resident 1 to the GACH for further evaluation and treatment of status post fall. According to a review of the facility document received to the Department on 12/2/2024, Resident 1 had a fall on 11/28/2024 around 11 PM. Resident 1 was found on the floor by the closet and stated he was trying to go to the bathroom. The facility document indicated the physician was notified, ordered an X-ray of the right hip and the technician reported there was a dislocation. A review of the Progress Notes dated 12/2/2024 indicated Resident 1 was screaming because of pain during the x-ray performed on 11/29/2024. A review of Resident 1's re-admission record dated 12/2/2024 indicated Resident 1 had a new diagnosis of a displaced intertrochanteric (the area between the greater and lesser bone, where hip and thigh meet) fracture (a partial or complete break in a bone) of right femur (the thigh bone, the longest and strongest bone in the body), initial encounter for closed fracture. A review of Resident 1's post fall Interdisciplinary Team (IDT) note dated 12/2/2024 indicated Resident 1 fell on [DATE] approximately 11 PM during shift change. The IDT note indicated Resident 1 had periods of confusion and required supervision during activities of daily livings (ADLs). During an interview on 12/2/2024 at 2:45 PM, Resident 2 (Resident 1's roommate) stated Resident 1 fell around the bathroom door while trying to go to bathroom on Thanksgiving Day. Resident 2 stated Resident 1 was yelling for help. I got out of my bed and tried to get help, staff came and assisted Resident 1. During an interview on 12/3/2024 at 6:24 AM, Licensed Vocational Nurse (LVN) 3 stated, I assist Resident 1 daily. Resident 1 was confused and very dependent on staff for mobility and ADLs. During a concurrent interview and record review on 12/3/2024 at 10:45 AM with Director of Staff Development (DSD), Resident 1's At Risk for Fall and Incontinence care plans, 12/7/2020 and 3/9/2023 respectively, were reviewed. The DSD stated Resident 1 had mobility and cognitive deficiencies that contributed to his fall. The DSD stated, after review of Resident 1's At Risk for Fall care plan and Incontinence care plan that the quarterly care plans for June 2024 was not reviewed or revised and was missing. The DSD stated the importance of reviewing and revising the care plans was to provide accurate direction and guidance to staff and to meet the resident's needs. During an interview on 12/4/2024 at 12:27 PM with MDS coordinator, Resident 1's care planning revisions were reviewed. The MDS coordinator stated and acknowledged there was a deficiency in updating the At Risk for Fall and Incontinence quarterly care plans for Resident 1. On 12/5/2024 at 1:38 PM, during a telephone interview, Certified Nursing Assistant (CNA) 3 stated he was assigned to care for Resident 1 on the night Resident 1 fell while trying to go to bathroom. CNA 3 stated he heard a loud bang near Resident 1's room and went to check the noise. CNA 3 stated he found Resident 1 lying flat on his back in front of the bathroom and assisted the charge nurse to place Resident 1 back to his bed. CNA 3 stated Resident 1 was screaming and was assessed with no visible injury noted. CNA 3 stated Resident 1 was not consistent with using call lights because he gets confused. CNA 3 stated Resident 1 did not have routine schedules to assess for toileting needs, staff conducted hourly or random checks. During an interview on 12/5/2024 at 2:06 PM, the Director of Nursing (DON) stated Resident 1 required frequent reminders to call for assistance and was dependent on staff for ambulating. The DON stated Resident 1 was checked and changed by staff for bathroom needs. Staff conducted frequent rounds, but they were not documented. When the DON was asked about the bowel bladder incontinence care plan intervention regarding Resident 1 required assistance every two hours for transfer to the bathroom, the DON stated the facility did not document the two hourly rounds for Resident 1 because that was not the process. A review of the facility's policy and procedures (P&P) titled, Fall Risk Assessment, revised January 2024, indicated the staff with the support of the attending physician, would evaluate functional and psychological factors that may increase fall risk, including ambulation, mobility, gait, balance, excessive motor activity, Activities of Daily Living (ADL) capabilities, activity tolerance, continence, and cognition. The staff and attending physician would collaborate to identify and address modifiable fall risk factors and interventions to try to minimize the consequences of risk factors that were not modifiable. A review of the facility's Policy and Procedures (P&P) revised January 2024, titled, Care Plans, Comprehensive Person-Centered, 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 interdisciplinary team must review and update the care plan: a. when the desired outcome is not met; d. At least quarterly, in conjunction with the required quarterly MDS assessment.

Based on interview and record review, the facility failed to protect the resident's right to be free from physical and mental abuse (deliberate, aggressive, or violent behavior with the intention to cause harm) for two of five sampled residents (Resident 4 and Resident 2) when: On 4/5/2024, Resident 5 threw urine from his urinal on to Resident 4 (the roommate) and both residents were engaged in a verbal altercation. On 4/7/2024, after Resident 5 was moved to a different room, Resident 5 poured urine from his urinal onto the side of his bed, which splashed onto Resident 2 (the new roommate) and both residents were engaged in a verbal altercation. These deficient practices resulted in Resident 2 and Resident 4 being subjected to physical and mental abuse and psychosocial harm (harm that causes mental or emotional trauma or that causes behavioral change or physical symptoms) by Resident 5, while under the care of the facility. Resident 2 reported feelings of anxiety and feeling more depressed, and Resident 4 reported increased feelings of depression. Findings: a. A review of Resident 5's Admission Record indicated the facility initially admitted Resident 5 on 9/28/2023, with diagnoses including hemiplegia (one-sided muscle paralysis or weakness), hemiparesis (weakness or the inability to move on one side of the body), anxiety disorder, and major depressive disorder (a common and serious medical illness that negatively affects how you feel, the way you think and how you act). A review of Resident 5's History and Physical, dated 10/26/2023, indicated the resident had the capacity to understand and make decisions. A review of Resident 5's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 1/9/2024, indicated that the resident's cognitive skills (ability to understand and make decisions) were intact and the resident was dependent on two or more-person assistance for showering, dressing, personal hygiene, and rolling left to right in bed. According to a review of the Change in Condition Evaluation (CIC- when there a sudden change in resident health), dated 4/5/2024, timed at 1:23 P.M., Resident 5 was found yelling, cursing, and throwing things at his roommate (Resident 4). A review of Resident 5's Social Services Note, dated 4/5/2024 at 6:04 P.M., indicated Resident 4 and Resident 5 threw ice, water, and urinals at each other. The note indicated housekeeping had to clean the room and bedsheets of both residents. The Social Service note indicated both residents were placed on 1:1 supervision until a room change occurred and the Administrator spoke to both residents. A review of Resident 5's Care Plan, initiated on 4/5/2024, indicated the resident had an altercation with another resident (Resident 2) and the goal indicated to minimize emotional distress daily. The care plan interventions included to have a psychiatric consult, monitor, document and report sign of emotional distress every shift, anticipate care needs and provide them before the resident became overly stressed, and when resident becomes agitated to intervene before agitation escalates. A review of Resident 5's Order Summary Report, dated 4/12/2024, indicated there was a physician's order to transfer Resident 5 to General Acute Care Hospital (GACH 1) on 4/8/2024 related to verbal aggression towards a resident. A review of Resident 4's Admission Record indicated the facility initially admitted Resident 4 on 9/18/2021 with a readmitted [DATE]. Resident 4's diagnoses included chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body), chronic pain syndrome (a long lasting pain that persist beyond the usual recovery period), anxiety disorder (persistent and excessive worry that interferes with daily activities), major depression (a common and serious medical illness that negatively affects how you feel, the way you think and how you act), and insomnia (a condition when a person is not sleeping enough or having trouble falling or staying asleep). A review of Resident 4's History and Physical, dated 9/15/2023, indicated the resident had the capacity to understand and make decisions. A review of Resident 4's MDS, dated [DATE], indicated the resident's cognitive skills were intact and needed supervision for showering, dressing, oral and toileting hygiene, eating, and walking 10 feet. The MDS indicated Resident 4 was feeling down, depressed, or hopeless. According to a review of Resident 4's Medication Administration Record (MAR) from 4/1/2024 to 4/10/2024, the resident was on monitoring for episodes of anxiety manifested by an inability to relax and on monitoring for major depression manifested by verbalization of feeling hopeless. A review of Resident 4's Change in Condition Evaluation (CIC), dated 4/5/2024, timed at 1:33 P.M., indicated the resident had behavioral changes manifested by verbal aggression and was found yelling, cursing, and throwing things at his roommate (Resident 5). A review of Resident 4's Psychiatric Consultation, dated 4/9/2024, indicated that Resident 4 has a history of anxiety, depression, and insomnia. It also indicated that Resident 4 was seen regarding a recent altercation with another resident and no changes to his medication were made. On 4/12/2024 at 9:31 A.M. during an interview, Resident 4 stated that a few days ago around lunch time his roommate, Resident 5, splashed him and his bed with urine. Resident 4 stated that Resident 5 was yelling F-words and threatening him. Resident 4 further stated that this incident increased his anxiety, and for four days he was not able to perform his usual activities like walking, reading books and watching movies. During an interview, on 4/12/2024 at 12:15 P.M., Certified Nursing Assistant 2 (CNA 2) stated that on 4/5/2024 Resident 5 refused his diaper change at 7:45 AM and a few more times during that morning. CNA 2 stated that when she came back during lunch time with a lunch tray, Resident 5 asked her to change his diaper to which she responded that she would do it after lunch. Resident 5 then got upset and threw his lunch tray against the door. CNA 2 stated that Resident 5 and his roommate (Resident 4) started yelling, cursing, and throwing things (not specifically mention what are those things) at each other. b. A review of Resident 2's Admission Record indicated the facility readmitted the resident on 12/13/2021, with diagnoses including hemiplegia (one-sided muscle paralysis or weakness), hemiparesis, major depressive disorder, and insomnia (a condition when a person is not sleeping enough or having trouble falling or staying asleep). A review of Resident 2's History and Physical, dated 11/26/2023, indicated the resident had fluctuating capacity to understand and make decisions. According to a review of Resident 2's MDS dated [DATE], the resident had mildly impaired cognition (a slight decline in mental abilities, memory and completing complex tasks) and was dependent on two or more-person assistance for showering, dressing, personal hygiene, eating and rolling left to right in bed. A review of Resident 2's Change in Condition Evaluation (CIC) dated 4/8/2024 indicated that on 4/7/2024 (two days after the first incident on 4/5/2024) Resident 5 threw a urinal bottle filled with urine at Resident 2 and that Resident 2 then threw a bottle with water at Resident 5 in retaliation. Resident 2 was visibly soiled in urine and required cleaning after incident. A review of Resident 2's Care Plan initiated on 4/8/2024, indicated that the resident was at risk for emotional distress due to an altercation with another resident (Resident 5). On 4/12/2024 at 9:07 A.M. during an interview, Resident 2 stated that on 4/7/2024 around 11:30 P.M., he asked Resident 5 to lower the volume of his cell phone because it was too loud. Resident 2 stated that Resident 5 did not want to lower the volume on his cell phone and instead he opened his urinal and threw urine on the edge of his bed which splashed onto Resident 2. When asked how the incident made him feel, Resident 2 stated he felt more depressed. On 4/12/2024 at 1:02 P.M. during an interview, the Director of Nursing (DON) stated that Resident 5 was involved in an emotional and verbal altercation with Resident 2 on 4/5/2024 and with Resident 4 on 4/7/2024 and it should not have occurred according to the Abuse policy. On 4/12/2024 at 2:15 P.M. during a phone interview, Licensed Vocational Nurse 3 (LVN 3) stated that on 4/5/2024, she reported altercation between Resident 5 and Resident 4 to Resident 5's physician and received an order to transfer Resident 5 to the GACH for a psychiatric evaluation. LVN 3 stated she did not follow up on the physician's order to make sure that the transfer was arranged as soon as possible, as a result Resident 5 was transferred to a GACH after the second altercation on 4/8/2024. LVN 3 stated that it was her mistake not to follow the physician's order for Resident 5 on 4/5/2024. During an interview on 4/26/2024 at 9:48 A.M., the DON stated the Physician's Order for Resident 5 to be transferred for a psychiatric evaluation was received on 4/5/2024 (after the first altercation). The DON stated Resident 5 was transferred to a GACH on 4/8/2024 after second altercation but did not go for the psychiatric evaluation, per the physician's order. The DON stated that she could not explain why the nursing staff did not follow the physician's order to transfer Resident 5 for a psychiatric evaluation on 4/5/2024. A review of the facility's Policy and Procedure (P&P) titled, Abuse Prevention Program, revised December 2016 indicated residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This included but not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse.

Based on interview and record review, the facility failed to ensure residents environment remained free of accident hazards for one of three sampled residents (Resident 1) and by failing to: 1. Monitor and supervise Resident 1 after Resident 1 lit an incense using a lighter inside a drawer and the drawer caught fire on 11/19/2023 at 11:45 a.m. and had another two fire incidents on 11/20/23 at 12 a.m. and 12:30 a.m. The facility was aware Resident 2 (Resident 1's roommate) was on continuous oxygen therapy on 11/19/2023 and 11/20/2023. 2. Inspect and inventory Resident 1's belongings and investigate the fire incident on 11/19/2023 at 11:45 a.m by Resident 1 to prevent another resident caused fire incident in the facility. 3. Conduct an inventory for contrabands including lighters on all residents including residents who smoke after Resident 1 started three fires on three different occasions. These three fire incidents had the potential for fire related accidents including, serious harm, smoke inhalation, explosion, and death for 57 and 60 residents in house including Resident 1 who were in the facility on 11/19/2023 and 11/20/2023. Residents 2 and 3 stating that they feared for their lives. On 12/6/2023 at 12:11 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 facility's [NAME] President of Operations (VPO) and Assistant Director of Nursing (ADON), and the Administrator (ADM) was on the phone because of the seriousness related to the facility's failure to ensure Resident 1 did not start three fires on 11/19/2023 and 11/20/2023. On 12/7/2023 at 7 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 12/7/2023 at 7:47 p.m. in the presence of the ADM and ADON. A review of the IJ removal plan included the following: 1. On 12/6/2023, the department heads completed new inventories for 57 of 59 residents on 12/6/2023. Documentation and education completed for two non-compliant residents. Social Services Director (SSD) will complete and verify inventories for all new residents upon admission and for residents readmitted to the facility and every month for the first three months. 2. On 12/7/2023, Director of Staff Development (DSD) conducted an in-service (education) to certified nursing assistants (CNAs) and licensed nurses about smoking schedule and policies on smoking. Activities department will keep lighters, smoking devices or spark producing items and will monitor residents during smoke hours/breaks. The charge nurses will be responsible to keep all smoking items locked after hours. Interdisciplinary Team (IDTs - a group of professionals from various disciplines who work in collaboration to address a patient needs) will be held and education conducted for residents who elect to keep cigarettes, e- cigarettes, pipes, tobacco and other smoking articles in their possession. In the event of a new fire incident, the facility will immediately place the involved resident(s) on one to one (1:1- constant observation to help prevent a fall or redirect a patient from engaging in a harmful act) monitoring, conduct a thorough search of belongings to ensure resident safety, and immediately notify the attending physician and the medical director. 3. On 12/7/2023, the facility conducted new smoking assessments on all ten who smoke. 4. On 12/6/2023 and on 12/7/2023, a fire safety instructor hired by the facility, conducted fire drill training for 75 of 84 facility staff on night shift (11 Pm to 7 AM), day shift (7 a.m. to 3 p.m.) and evening shift (3 p.m. to 11 p.m.). The fire drill training included: 4.1. P.A.S.S (Pull the pin, Aim, Squeeze the handle and Sweep the base of the fire from side to side and working the way up), 4.2. SAFE (Safely rescue and/or remove, Activate/Alert/Alarm, Fight the Fire if necessary and safe to do so, and Evacuate), 4.3. RACE (Rescue, Alarm, Contain, Extinguish), Stop (Stop, Drop, and Roll), ---Evacuations, 4.4. Classifications of fire & extinguishers, 4.4.1. Class A (ordinary combustibles [able to catch fire and burn easily]), 4.4.2. Class B (Flammable Liquids [easily set on fire]), 4.4.3. Class C (Electrical Fires). The facility will complete fire drill training for remaining nine staff members by 12/22/2023. DSD will ensure Staff Competencies are conducted quarterly effective 12/7/2023. 5. Effective 12/7/2023, SSD, with the assistance of the Receptionist, will track all packages delivered to residents. SSD will complete new inventories monthly for all residents receiving packages. Residents who do not receive outside packages will have inventories completed quarterly. 6. Effective 12/7/2023, the facility Receptionist, will educate visitors and resident family members upon arrival on smoking articles (cigarettes, tobacco, cigarettes, e-cigarettes, and pipes). Resident family members and visitors will be educated that only disposable safety lighters are permitted in the facility and all other forms of lighters, including matches, are prohibited. Resident family members and visitors will be encouraged to leave smoking articles with activities department/staff member to ensure resident safety. 7. Effective 12/7/2023, care plans will be updated for residents that are non-compliant with storing smoking articles with activities department/staff, new smoking assessments completed, and the resident will be provided with a copy of the facility's smoking policy. 8. Effective 12/8/2023, SSD will report any contraband(s) identified in a resident's possession, and immediately followed up by IDTs meeting on Monday to Friday during stand-up huddle/meeting. Any incidents or contraband found during the weekend will be immediately reported to Administrator. Any required follow-up will be reported to the monthly Quality Assurance and Performance Improvement (QAPI - is a process used to ensure services are meeting quality standards and assuring care reaches a certain level) Committee meetings. The QAPI Committee will provide written recommendations to the Administrator. The Administrator will review QAPI recommendations and act accordingly. Findings: A review of the facility's census dated 11/19/2023 indicated the facility had 60 residents in house. A review of the facility's census dated 11/20/2023 indicated the facility had 57 residents in house. On 11/20/2023, the facility reported to California Department of Public Health (CDPH) that on 11/19/2023 at 11:45 a.m., Resident 1 stated a fire in his room. Resident 1 roommates included Resident 2 and Resident 3. A review of Resident 1's admission record indicated Resident 1 was readmitted to the facility on [DATE], with diagnoses not limited to secondary malignant neoplasm (cancer) of the liver and intrahepatic bile duct (small tubes that carry bile [yellow-green fluid produced by the liver] inside the liver), dyspnea (an intense tightening in the chest, difficulty breathing, breathlessness or a feeling of suffocation), and kidney failure (when your kidneys no longer work properly). A review of Resident 1's history and physical (H&P) dated 7/22/23, indicated Resident 1 had fluctuating capacity to understand and make medical decisions. A review of Resident 1's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 10/13/2023, indicated Resident 1 had intact cognition (mental ability to make decisions of daily living). The MDS indicated Resident 1 required staff to support or hold Resident 1's limbs (arms and legs) or trunk (upper body) during shower/bathe, upper and lower body dressing, and putting on /taking off foot wear. Resident 1 used a wheelchair for mobility. A review of Resident 2's admission record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including history of other mental and behavioral disorders, and injury at unspecified level of cervical spinal cord. A review of Resident 2's H&P (illegible date), indicated Resident 2 had the capacity to understand and make decisions. A review of Resident 2's Medication Administration Record (MAR) for the month of 11/2023, indicated effective 11/4/2023, to administer oxygen at two liter per minute (2L/min) via nasal cannula (soft flexible tubing used to administer oxygen through the nose) for Resident 2. A review of Resident 2's MDS dated [DATE], indicated Resident 2 had intact cognition. A review of Resident 2's Resident's Clothing and Possessions document (illegible date), indicated Resident 2 did not have any belongings. A review of Resident 2's Change in Condition (COC - a deterioration in health, mental, or psychosocial status in either life-threatening circumstances or clinical) dated 11/19/2023 at 11:55 a.m., indicated, Resident 2's roommate [Resident 1] lit incense in the room, placed the incense inside the top drawer of Resident 1's bedside nightstand and the drawer was smoldering. A charge nurse (unidentified) called for help, removed the drawer and placed it in the outside patio adjacent to Resident 2's room and used a fire extinguisher to put out the fire. A review of Resident 3's admission record indicated Resident 3 was admitted to the facility on [DATE] with diagnoses including generalized muscle weakness, abnormalities of gait (manner of walking) and mobility, acquired absence of left leg below knee, depression (a common but serious mood disorder that affects how a person feels, thinks, and handles daily activities, such as sleeping, eating, or working), anxiety (a mental disorder in which a person is often worried about many things and finds it hard to control the feeling of being worried). A review of Resident 3's COC dated 11/19/2023 at 11:51a.m., indicated, Resident 2's roommate [Resident 1] lit incense in the room, placed the incense inside the top drawer of Resident 1's bedside nightstand and the drawer was smoldering. A charge nurse (unidentified) called for help, removed the drawer and placed it in the outside patio adjacent to Resident 2's room and used a fire extinguisher to put out the fire. A review of Resident 3's MDS dated [DATE], indicated Resident 3 had intact cognition. Resident 3 required maximal assistance for sitting to lying position on side of bed, surface transfer from chair to bed and bed to chair, getting off and on a toilet or commode (portable toilet), and to get in and out of a tub/shower. A review of the facility's incident report (FRI) to the California Department of Public Health (CDPH) received on 11/19/2023 at 11:08 p.m., which the facility updated on 11/20/2023, indicated that on: a. 11/19/2023 at 11:45 a.m., Resident 1 lit incense in his room and placed it the top drawer of his night stand while ignited. A nurse (unidentified) smelled smoke, inspected Resident 1's room and found the incense burning inside Resident 1's bedside drawer. The nurse removed the drawer on fire and placed it drawer outside. The nurse used a fire extinguisher to extinguish any smoldering. Resident 1's belongings were searched, additional lighters found., and all lighters were confiscated for Resident 1's safety. b. 11/20/2023 at approximately 2:30 a.m., a nurse (unidentified) smelled something burning and found a towel inside an electric device near his [Resident 1's] bed. The FRI indicated Resident 1 said it was an accident and that he had not used anything to ignite the fire. c. 11/20/2023 at 3:30 a.m., a pad was found (unidentified person) with burnt marks. No physical harm done to any residents. Resident 1 was sent out to a general acute care hospital (GACH). A review of the facility's undated conclusion investigation report indicated that on 11/19/2023, Resident 1 allegedly lit incense in his room and placed it inside the top drawer of the nightstand causing smoldering and smoke. Upon smelling the smoke and ensuring the resident's safety, staff (unidentified) removed the smoldering top drawer and extinguished it outside. Resident 1 was apologetic and said, I did not mean to cause any harm. I just wanted my incense. Resident 1 was in no apparent distress, denied feeling sad, depressed, agitated, or anxious. Resident 1 agreed to search his belongings, and four lighters were removed. Resident 1 verbalized understanding of the dangers of using open flames inside the facility and continued to be apologetic. Resident 1 continued the remainder of the shift and the afternoon shift without further incident. The same facility's undated conclusion investigation report indicated that on 11/20/2023, at approximately 2:30 am, Resident 1 was found to have an electrical device with smoke near the head of the bed with smoke. The nurse (unidentified) was able to extinguish it with minimal smoke and without causing harm to Resident 1 or his roommates. (Residents 2 and 3). Resident 1 repeated, It was an accident. I don't know what happened. Resident 1 denied attempting to ignite a fire and denied having anything to ignite a fire. When staff (unidentified) attempted to ask to search his belongings, Resident 1 declined, stating, Don't touch my stuff. I already told you. I don't have anything. I don't know how that happened. The nurse (unidentified) called 911, and when the fire department/ paramedics (medical professionals who specialize in emergency treatment) arrived, paramedics declined to take Resident 1 to GACH and instead recommended calling the police department and the Psychiatric Emergency Team (PET - mobile teams operated by psychiatric hospitals approved by the Department of Mental Health to evaluate a person for mental illness). While waiting for police arrival, staff (unidentified) smelled smoke from the room again. Upon inspection, the staff (unidentified) found a chuck on the floor with smoke. The nurse attempted to extinguish the fire with a fire blanket, but Resident 1 became irate yelling at the staff and using profanity and attempting to stop the efforts of the staff to extinguish the chuck. Once the fire was extinguished, the nurse (unidentified) attempted to search a bag Resident 1 was holding, but the resident yelled at staff and did not allow anyone to touch him. The nurse (Unidentified) called 911. While the nurse was on the phone, Resident 1 called 911 to report a sudden onset of acute abdominal pain and reporting that he needed to go to GACH. Resident 1 was transferred to GACH on 11/20/2023, at approximately 5 am. During an interview with Resident 2 on 12/5/2023 at 11:30 a.m., Resident 2 stated that on 11/19/2023 and 11/20/2023, he was in the room with Resident 1 when Resident 1 started a fire. Resident 2 stated he did not see Resident 1 start the fire because the privacy curtain was pulled around Resident 1's bed. Resident 2 stated the room was full of smoke. Resident 2 stated he was receiving oxygen when Resident 1 started the fire. Resident 2 stated he feared for his life, because the room was smokey especially since I'm on oxygen. During an interview with Resident 3 on 12/5/2023 at 11:55 a.m., Resident 3 stated on 11/19/2023 at around 12:13 pm, he saw the flames and yelled for facility staff to help. Resident 3 stated he saw the flames/fire through the curtains near the head of the bed for Resident 1head. Resident 3 stated Resident 1 lit a total of three fires on 11/19/2023 and 11/20/2023. Resident 3 stated he called 911 because the staff did not call 911. Resident 3 stated he, called 911 on 11/19/2023 at 12:17 p.m. for the big fire. Resident 3 stated the facility fire alarms did not sound/trigger. Resident 3 stated he was afraid and feared for his safety and that is why he called 911. During an interview with CNA 1 on 12/5/23 at 1:36 p.m., CNA 1 stated she was working on 11/20/2023, the day of the fire incident. CNA 1 stated that on 11/19/2023 at approximately 12:20 p.m., a housekeeper (unable to recall the name) used a fire extinguisher to put out the fire in Residents 1, 2 and 3's room. CNA 1 stated she was working on 11/19/2023, the day of the fire incident. CNA 1 stated a housekeeper (unable to recall housekeeper's name) put out the fire using a fire extinguisher. CNA 1 stated Resident 3, started screaming fire, fire. CNA 1 stated Licensed Vocational Nurse 1 (LVN 1) ran into Resident 3's room and evacuated (removed) Residents 1, 2 and 3. CNA 3 stated LVN 1 assessed Residents 1, 2 and 3. CNA 3 stated the fire department and paramedics were called. CNA 1 stated Resident 1 did not answer LVN 1 when asked how the fire started. CNA 1 stated she had never witnessed Resident 1 smoking cigarettes and that Resident 1 never verbalized to her that he smokes cigarettes. During an interview with ADON on 12/5/23 at 2:26 p.m., ADON stated she did not know how Resident 1 obtained the cigarette lighters. ADON stated Resident 1 told her that he did not intentionally set the drawer on fire. ADON stated he lit an incense inside the drawer and that is how the fire started. ADON stated none of the staff knew where and how Resident 1 got the cigarette lighters. ADON stated the bottom of drawer is the only thing that was burnt. ADON stated LVN 1 checked Resident 1's belongings and found four cigarette lighters after the first fire on 11/19/2023. ADON stated Resident 1 never said that he smoked cigarettes since being admitted to the facility. ADON stated, after the first fire incident, facility staff placed Resident 1 close to the nurses' station to closely monitor Resident 1. ADON stated, that on 11/20/2023 night, LVN 1 contacted and notified the Administrator of the two fire incidents started by Resident 1 on 11/20/2023. The ADON stated LVN 1 moved Resident 1 close to the nurses' station for close monitoring. The ADON stated neither the Administrator nor the ADON went to the facility to check on the residents and staff after Resident 1 started the second and third fires on 11/20/2023 night. During an interview with CNA 2 on 12/6/23 at 6:17 a.m., CNA 2 stated she was working on 11/20/2023, the day of the fire incident. CNA 2 stated that on 11/20/23 at approximately 12 a.m., LVN 5 (Charge Nurse) smelled something burning in Residents 1, 2 and 3's room. CNA 2 stated LVN 5 told her that when LVN 5 entered Resident 1's room and saw a bed pad burning on Resident 1's bed. CNA 2 stated LVN 5 told her that LVN 5 put the fire out with a cup of water and did not call 911. CNA 2 stated that on 11/20/2023 at about 12:30 a.m., she heard Resident 2 and Resident 3, call out fire. CNA 2 stated she took a fire extinguisher and ran to Residents 1, 2, and 3's room but by the time she got to the room, LVN 5 had already put out the fire out with a cup of water. CNA 2 Stated Resident 1's room was smoky from the fire. CNA 2 stated CNA 2 stated she and LVN 5 evacuated Residents 1, 2, and 3 from their room and into the hallways for safety and opened the patio door to let the smoke out and then LVN 5 called 911. When asked why she did not call the Fire Department after the fire incident on 11/20/2023 at 12 a.m., CNA 2 stated she thought LVN 5 was going to call. CNA 2 stated Resident 1 set fire on a bed pad and again set fire on a blanket. CNA 1 stated after Resident 1 set the fires, neither her nor LVN 5 did not check Resident 1's belongings for hazardous materials. CNA 2 stated she was not aware Resident 1 had started a fire in his room on 11/19/2023. CNA 2 stated she has never witnessed Resident 1 smoke cigarettes. CNA 2 stated Residents 1, 2, or 3 did not have any visible injuries. CNA 2 stated Resident 2 or Resident 3 did not complain of any breathing problems. CNA 2 stated she nor LVN 5 suffered any injuries. CNA 2 stated she assisted LVN 5 evacuate Residents 1, 2, and 3 from the room to prevent smoke related injuries. LVN 5 was not available for interview. A review of the facility's policy and procedures (P&P) titled Fire Safety and Prevention dated 12/6/23, indicated, all personnel must learn methods of fire prevention and must report conditions that could result in a potential fire hazard. Fire prevention is the responsibility of all personnel, residents, visitors, and general public. Whoever identifies a fire hazard, or other conditions that could develop into a fire hazard, must report the situation to the department director or maintenance director as soon as practical. A review of the facility P&P titled Hazardous Areas, Devices and Equipment dated 12/6/23, indicated, all hazardous areas, devices and equipment in the facility will be identified and addressed appropriately to ensure resident safety and mitigate accident hazards to the extent possible. Resident-specific interventions may include changes to the plan of care and/or increased supervision. Monitoring to ensure that recommendations are implemented consistently and correctly will be the safety and accident prevention program. The safety committee will assess the effectiveness of interventions and make changes as necessary based on monitoring data.

Based on interview and record review, for two of four sampled residents (Resident 1 and Resident 2) the facility failed to: 1. Protect Resident 1's right to be free from verbal (the act of harassing, labeling, insulting, scolding, rebuking, or excessive yelling towards an individual) abuse and mental (controlling another person by using emotions to criticize, embarrass, shame, blame, or otherwise manipulate that person) abuse on 10/17/2023 at approximately 1:20pm, Certified Nursing Assistant 1 (CNA 1) yelled at Resident 1, told Resident 1 to shut up and [Q** J** (vulgar word(s)] in CNA 1's native language. CNA 1 continued to argue with Resident 1, after Licensed Vocational Nurse 1 (LVN 1) told CNA 1 to leave Resident 1's room. Resident 1 kept asking LVN 1 and CNA 1 to provide with incontinence (inability for a person to control the evacuative functions of urination or defecation) care for Resident 2 on 10/17/2023 from 8:30am to 1:20pm. 2. Protect Resident 2's (Resident 1's roommate) right to be free from neglect when CNA 1 neglected to provide incontinence care for Resident 2 on 10/17/2023 from 8:30am to 1:20pm. Resident 2's cognition was impaired and was dependent on staff for activities of daily living (ADL - locomotion, toileting, feeding, grooming, and transfers). On 10/17/2023, CNA 1 resigned from the facility via telephone and was not available for an interview. As a result, 1. On 10/17/2023, Resident 1 endured the smell of urine and feces for four hours and 50 minutes from 8:20am to 1:20pm. Resident 1 experienced pounding heart in her chest, stated she gets upset whenever she thinks of the incident with CNA 1. Resident 1 experienced anxiety (an emotion characterized by feelings of tension, worried thoughts, and physical changes like increased blood pressure, and increased heart rate), experienced difficulty sleeping and was fearful (an unpleasant emotion caused by the belief that someone or something is dangerous likely to cause pain, or a threat). Resident 1 did not eat breakfast on 10/17/2023. 2. On 10/17/2023, Resident 2 endured the smell of urine and feces and was left lying on urine and feces for four hours and 50 minutes from 8:20am to 1:20pm. Using a reasonable person's approach, Resident 2 experienced psychosocial (a person's mental, emotional, social, and spiritual health) harm including lowered self-esteem/self-worth, embarrassment, humiliation, discomfort, and lowered dignity. Findings: A review of Resident 1's admission record, indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included essential (primary) hypertension (HTN - high blood pressure), unspecified atrial fibrillation (afib - a condition that causes rapid heartbeats, that may cause chest pain, lightheadedness or shortness of breath), anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). A review of Resident 1's History and Physical (H&P) dated 2/4/2023, indicated Resident 1 had the capacity to understand and make decisions. A review of CNA 1's Job Description Responsibilities signed and dated by CNA 1 on 7/17/2023, indicated, Elimination/Toileting - Promptly assist residents to bathroom according to toileting . clean resident if resident is unable to clean self . A review of CNA 1's Skills Performance Checklist dated 7/24/2023, indicated CNA 1 attended and completed skills performance checklist that included incontinence care, and toileting . incontinent resident. A review of Resident 2's admission record, indicated Resident 2 was admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy (an alteration in consciousness caused due to brain disfunction, the inability to speak or understand speech) morbid obesity (if the body weight is more than 80 to 100 pounds above the ideal body weight) and generalized muscle weakness. A review of CNA 1's employee file indicated that on 9/7/2023, CNA 1 completed training on Sexual Harassment and Abusive Conduct Prevention Training. A review of Resident 2's MDS dated [DATE], indicated Resident 2 was rarely/never understood and was not able to repeat/recall words, and was not able to state the correct year/month/day of the weeks. Resident 2 required physical assistance from staff with ADL (bed mobility, walking, surface transfers, locomotion, personal hygiene, toileting, grooming, dressing, and eating). A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 10/12/2023, indicated Resident 1's cognition (a person's mental ability to think, learn, remember, use judgement, and make decisions) is intact. Resident 1 required one person assist only with activities of daily living (ADL- bed mobility, transfer, toilet use and one personal physical assist with toilet use and personal hygiene). A review of the facility's undated investigation conclusion letter indicated, While interviewing [Resident 1], [Resident 1] appeared visibly upset by the altercation (a noisy argument or disagreement). Resident 1 said, I do not understand why [CNA 1] would talk to me that way. [CNA 1's] statements supported Resident 1's version of events. The letter further indicated, Based on the investigation, resident interviews and staff interviews, IDT concluded that the alleged incident is substantiated, (the act of showing something to be true, or of supporting a claim with facts) and [CNA 1] will not return to the facility. An in-service with staff was done to educate all staff members on Staff to Resident Abuse and ways to de-escalate situations like the incident above. A review of Resident 1's psychiatric (the branch of medicine that focuses on mental, emotional, and behavioral disorders) consultation dated 10/23/2023, indicated Resident 1 had psychiatric consultation at the request of Resident 1's primary care physician to assess Resident 1's feelings regarding the abuse that occurred on 10/17/2023. The psychiatric consultation plan indicated to provide emotional support and increase socialization to prevent isolation for Resident 1. On 10/31/2023 at 8:15am, during an interview with Resident 1, Resident 1 stated that on 10/17/2023 at around 8:30am, during breakfast, she [Resident 1] told Licensed Vocational Nurse 2 (LVN 2) that Resident 2 (Resident 1's roommate and on bed next to Resident 1) needed to be cleaned because Resident 2 was smelling of urine and stool. Resident 1 stated LVN 2 told Resident 1 that she would inform CNA 1 to clean Resident 2 and that CNA 1 was assigned to provide care to Resident 2. Resident 1 stated that on 10/17/2023at around 8:50 am, she [Resident 1] asked CNA 1 to please clean Resident 2. Resident 1 stated that she could not eat breakfast because her room was smelling of urine and feces (stool). Resident 1 stated CNA 1 came and told her [Resident 1] that she [CNA 1] would clean Resident 2 in a few minutes. Resident 1 stated CNA 1 did not return to the room to clean Resident 2 for over one hour. Resident 1 stated CNA 1 later returned to her [Resident 1's] room on 10/17/2023 at around 9:55am., at that time she [Resident 1] asked CNA 1 again to please clean Resident 2. Resident 1 stated CNA 1 again told her [Resident 1] that she [CNA 1] would return in a moment and clean Resident 2 and then CNA 1 left the room at 10am without cleaning Resident 2. Resident 1 further stated that on 10/17/2023 after 1pm, CNA 1 returned to clean Resident 2. Resident 1 stated that on 10/17/2023 from 8:30am to after 1pm, she [Resident 1] had to endure the smell of urine and feces from Resident 2. Resident 1 stated CNA 1 finally returned, closed the door to Resident 1's room and started cleaning Resident 2. Resident 1 stated the smell in the room got worse after CNA 1 closed the door. Resident 1 stated she told CNA 1 to open the door because the smell was too bad and to please hurry up and clean Resident 2. Resident 1 stated CNA 1 told Resident 1 in a language that Resident 1 spoke and understood [Q** J**]. Resident 1 stated that in addition to the negative statement made by CNA 1, she [CNA 1] also told her [Resident 1] to, shut up. Resident 1 stated she too told CNA 1 to, shut up. Resident 1 stated CNA 1 continued with verbal insults directed at her [Resident 1] which made Resident 1 become very upset and that she too started yelling at CNA 1. Resident 1 stated that she demanded an apology for being disrespected by CNA 1. Resident 1 stated she has a heart condition, and she felt her heart pounding in her chest because she was so upset and disappointed that CNA 1 disrespected her. Resident 1 stated she became afraid because of her [Resident 1's] heart condition. Resident 1 stated CNA 1 continued to yell at her [Resident 1] until LVN 2 came into the room and stopped CNA 1 from yelling at her [Resident 1]. Resident 1 stated that CNA 1 was young enough to be her great grandchild. Resident 1 stated no one should speak to her in that manner and that she [Resident 1] gets very upset when she thinks about the incident with CNA 1. Resident 1 stated she felt safe, did not want CNA 1 terminated but felt that young people should respect the elderly. On 10/31/2023 at 10:10am during an interview with LVN 2, LVN 2 stated that on 10/17/2023 at around 8:30am, Resident 1 told her [LVN 2] that there was a bad smell in the room and asked LVN 2 to clean Resident 2 who was next to Resident 1. LVN 2 stated she informed Resident 1 that she [LVN 2] would tell CNA 1 to clean Resident 2. LVN 2 stated that on 10/17/2023 at approximately 8:35am, she informed CNA 1 to clean Resident 2. LVN 2 stated CNA 1 told her [LVN 2] that she [CNA 1] would take care of it (clean Resident 2) right away. LVN 2 stated that on 10/17/2023 at approximately 1:20pm, she heard Resident 1 yelling and went into the room to check on Resident 1. LVN 2 stated she asked Resident 1 what had happened. LVN 2 stated Resident 1 said CNA 1 told her [Resident 1] to shut up. Resident 1 stated she [Resident 1] deserves respect, and no one should say shut up to her [Resident 1]. LVN 2 stated she asked CNA 1 what had happened, and she [CNA 1] told LVN 2 that she [CNA 1] told Resident 1 to shut up because Resident 1 kept telling her [CNA 1] to hurry up and clean Resident 2 when she [CNA 1] was already cleaning Resident 2. LVN 2 stated she immediately told CNA 1 that, yelling at and telling a resident to shut up, was verbal abuse and she [LVN 2] told her [CNA 1] to please leave the room now. LVN 2 stated CNA 1 told her [LVN 2] that she [CNA 1] did not care if it was abuse and continued to argue with Resident 1. LVN 2 stated she ordered CNA 1 to stop arguing with Resident 1 and again asked CNA 1 to leave Resident 1's room. LVN 2 stated a few moments later she [CNA 1] complied and left Resident 1's room. On 10/31/2023 at 11:05am, during an interview with the Assistant Director of Nursing (ADON), the ADON stated that on 10/17/2023 at around 1:30pm, she [ADON] heard Resident 1 yelling at someone inside Resident 1's room. The ADON stated she [ADON] went to check on Resident 1, however, LVN 2 was already in the room. The ADON stated that on 10/17/2023 at approximately 1:35pm, she spoke with LVN 2 about the incident with Resident 1. The ADON stated she spoke with CNA 1 about the incident involving Resident 1. The ADON stated she asked CNA 1 if she [CNA 1] told Resident 1 to shut up. The ADON stated CNA 1 confirmed she [CNA 1] told Resident 1 to shut up and also told Resident 1 [Q** J** (vulgar word)], because it was not Resident 1's business to tell CNA 1 to clean anyone. The ADON stated she [ADON] spoke and understood CNA 1's native language. The ADON stated she informed CNA 1 that CNA 1 had verbally abused Resident 1. The ADON stated CNA 1 told her [ADON] that she [CNA 1] did not care if the incident with Resident 1 was abuse. The ADON stated CNA 1 stated residents should not be allowed to talk to staff any way that they wished. The ADON stated CNA 1 was suspended pending investigation and that CNA 1 resigned from the facility via telephone on 10/17/2023. A review of the facility's undated policy and procedures titled, Abuse Prevention Program, indicated, Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. The abuse prevention program policy interpretation and implementation continues to state the following: As part of the resident abuse prevention, the administration will: 1. Protect our residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual. A review of the facility's In-service (a professional training or staff development effort, where professionals are trained and discuss their work with others in their peer group.) titled: Abuse and Neglect Clinical Protocol, dated 10/17/2023, indicated, neglect is defined the failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental, anguish, or emotional distress.

Cross Reference F689 Based on interviews and record review, for one of three residents (Resident 2 [Resident 1's roommates]), the facility failed to protect Resident 2's right to be free from verbal and mental abuse by Resident 1 in accordance with the facility's undated policy and procedures titled Abuse Prevention Program. On 9/3/2023 at 5:38 AM, Resident 1 became upset after Licensed Vocational Nurse 1 (LVN 1) confiscated Resident 1's lighter torch, (a portable device used to create a controlled flame) and incense (an aromatic material that releases fragrant smoke when burnt). Resident 1 walked over to Resident 2's bed and threatened to beat up Resident 2. This deficient practice resulted in Resident 2 not feeling safe in the facility, experienced increased anxiety (an emotion characterized by feelings of tension, worried thoughts, and physical changes like increased blood pressure), difficulty sleeping and feared for his life. Resident 2's Ativan (a medication used to treat anxiety) dose was increased from 0.5 milligrams (mg - unit dose measurement) to 1 (one) mg and Klonopin (medication used to treat anxiety and panic disorder) was increased from 0.5 mg to one mg for anxiety. Findings: A review of Resident 2's admission record, indicated Resident 2 was admitted to the facility on [DATE] with the most recent readmission to the facility on [DATE] with diagnoses including viral pneumonia (an infection of the lungs caused by a virus), respiratory failure (a serious condition that makes it difficult to breathe on your own), anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life) and insomnia (difficulty sleeping). A review of Resident 2's History and Physical (H&P) dated 12/22/2022, indicated Resident 2 had the capacity to understand and make decisions. A review of Resident 2's Physician order dated 4/24/2023, indicated Resident 2 to receive oxygen (odorless gas that is present in the air and necessary to maintain life) two liters per minute via nasal cannula (a medical device used to deliver oxygen from the oxygen machine to a person) to keep oxygen saturation (the amount of oxygen that's circulating in a person's blood) above 92 percent (%). A review of Resident 2's Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 6/15/2023, indicated Resident 2's cognition (a person's mental ability to think, learn, remember, use judgement, and make decisions) was intact. Resident 2 required staff set up assistance with bed mobility, surface transfer, walking in and off unit, and eating. Resident 2 required one staff physical assist with toilet use and personal hygiene. A review of Resident 1's admission record indicated Resident 1 was admitted to the facility on [DATE] from a General Acute Care Hospital (GACH) with diagnoses that included end stage renal disease (a condition in which the kidneys lose the ability to remove waste and balance fluids) with dependance on dialysis (a treatment to clean your blood when your kidneys are not able to), type 2 diabetes (chronic condition that affects the way the body processes blood sugar), dyspnea (shortness of breath) and schizophrenia, (serious mental illness that affects how a person thinks, feels, and behaves). A review of the nursing progress note dated 8/30/2023, indicated Resident 1 was on monitoring for 72 hours for change of condition (a sudden clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domain) as a new admission to the facility. Resident 1 was alert and oriented to his name, place, time, and situation. A review of the nursing progress note dated 9/3/2023, indicated that on 9/3/2023 at 5:38 AM, Certified Nursing Attendant 1 (CNA 1) called LVN 1 to Resident 1 and Resident 2's [roommates] room. LVN 1 and CNA 1 observed Resident 1 with lighter torch and incense in Resident 1's hands. Resident 1 was trying to light the blow torch to light the incense and LVN 1 right away stopped Resident 1. LVN 1 told Resident 1 that he could not light incense in the room, it is not allowed and also his roommate (Resident 2) is on oxygen which is a hazard which could cause flames because the oxygen . Resident 1 then walked over to Resident 2, who was in bed, and yelled at Resident 2, I can do whatever the *** I want. I need to clean up my stuff and put away my clothes. The progress notes indicated LVN 1 told Resident 1 that Resident 2, is trying to sleep and to please allow Resident 2 to sleep. A review of Resident 2's nursing progress note dated 9/3/2023, LVN 1 documented that on 9/3/2023 at 5:38 AM, Resident 2 and Resident 1 got into an argument because Resident 1 was playing loud music and trying to light incense. Resident 2 was yelling at Resident 1 and told Resident 1 that, you cannot do this [use the blow torch in the resident room] in here you are going to blow me up [burn Resident 2]. Resident 2 told Resident 1, you have not let me sleep all night. The progress notes indicated Resident 2, is very agitated and stated that he needed something [medication] for his agitation. The progress note indicated LVN 1 notified a physician who gave an order to increase Ativan to one mg by mouth and to administer Ativan one mg by mouth for Resident 2. A review of Resident 2's Physician order dated 9/3/2023, indicated Resident 2 to receive Ativan one mg by mouth one time for increased anxiety. A review of Resident 2's Medication Administration Record (MAR), for the month of 9/2023, indicated Resident 2 received Ativan one mg tablet by mouth for anxiety on 9/3/2023 at 7:14 AM. A review of Resident 2's psychiatric (the branch of medicine that focuses on mental, emotional, and behavioral disorders) consultation (comprehensive evaluation intended to meet a patient's mental health treatment and goals) dated 9/6/2023, indicated Resident 2 had psychiatric consultation at the request of Resident 2's primary care physician to assess Resident 2's behaviors and review psychotropic medications (a group of drugs that treat a variety of conditions, they can affect a person's mood, behavior, perception, and thoughts). The psychiatric consultation plan indicated to increase Klonopin from 0.5mg to 1mg at hour of sleep. During an interview on 9/12/2023 at 9:55 AM with Resident 2, Resident 2 stated that on 9/3/2023 around 5 AM, the charge nurse (LVN 1) found Resident 1 using a blow torch (a portable device used to create a controlled flame) and incense in the room. I told the nurse [LVN 1] that I did not feel safe. Resident 2 stated LVN 1 took the blow torch and the incense away from Resident 1 and when the nurse left the room, [Resident 1] told me that he is going to beat me up and punch the nurse [LVN 1] who took his blow torch away. I informed the nurse that I was having increased anxiety and that I needed medication. Resident 2 stated LVN 1 contacted a physician, and I was given medication. I did not feel safe the entire time Resident 1 was my roommate, I had a friend sit with me in the room to make sure Resident 1 did not hurt me. I had to call the psychiatric doctor and tell him I had increased anxiety from my roommate [Resident 2] and the psychiatric doctor increased my Klonopin from 0.5mg to one mg. I feel the facility should have never put Resident 1 as my roommate. During an interview on 9/12/2023 at 1:14 PM with LVN 1, LVN 1 stated that on 9/3/2023 at around 5:30 AM, CNA 1 informed her that Resident 1 was sitting on his bed and had a blow torch and incense on his bed. LVN 1 stated, I went to the room [Resident 1 and 2's room] and Resident 1 wanted to light the incense. I informed him that he could not light the incense in the facility and that there was oxygen nearby. I confiscated the blow torch and the incense. LVN 1 stated Resident 2 was yelling at Resident 1 about having a blow torch in the room and that Resident 2 was on oxygen. LVN 1 stated Resident 1 went to Resident 2's bed and yelled at Resident 2. Resident 2 became upset and stated that he [Resident 2] needed medication due to increased anxiety. LVN 1 stated, I called the doctor and who gave an order to administer Ativan 1 mg by mouth, to Resident 2 for increased anxiety. LVN 1 stated both Resident 1 and Resident 2 declined room change. During an interview on 9/12/2023 at 2:50 PM with CNA 1, CNA 1 stated that on 9/3/2023 at around 5:30 AM, the call light for Resident 1 and 2's room was on. CNA 1 stated that Resident 2, informed me that [Resident 1] had a blow torch and incense. I saw the blow torch and the incense on Resident 1's bed and I went to get the charge nurse [LVN 1], who confiscated the blow torch and the incense from Resident 1. During an interview on 9/13/2023 at 10:48 AM with the Assistant Director of Nursing (ADON), the ADON stated LVN 1 informed her that Resident 1 had a blow torch and incense on his bed and that LVN 1 had confiscated them. The ADON stated, I was not informed that [Resident 1] went to Resident 2's bed and yelled at [Resident 2]. Nursing staff offered [Residents 1 and 2] a roommate change but they both declined. ADON stated nursing staff closely monitored Resident 1 and Resident 2 to ensure no further resident to resident altercation. During an interview on 9/13/2023 at 1PM, with Administrator (ADM), ADM stated he was not aware that Resident 1 had yelled at Resident 2 and that Resident 2 was experiencing increased anxiety regarding the incident with Resident 1. ADM stated, the incident between [Resident 1 and 2] is considered a resident-to-resident altercation. A review of the facility's undated policy and procedures titled Abuse Prevention Program, indicated, our residents have the right to be free from abuse, neglect misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. As part of the resident abuse prevention, the administration will, protect our resident from abuse from anyone including, but not necessarily limited to facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representations, friends, visitor or any other individual . Investigate and report any allegations of abuse within timeframes as required by federal requirements.

Based on observation, interview and record review, the facility failed to ensure meals did not contain a food allergen (a substance that causes an allergic reaction) for one of six sampled residents (Resident 1). Resident 1 was allergic to onions and he ate macaroni salad for dinner on 7/27/2023. The recipe for macaroni salad had onions. Resident 1 had a history of allergic reaction on 3/8/2023 after eating food with onions, on 7/3/2023 (allergen was unknown), and on 7/22/2023 after eating potato salad with onions. This deficient practice resulted in Resident 1 ' s top lip to swell (an allergic reaction), which had the potential to cause a life-threatening condition such as anaphylactic shock (severe allergic reaction including closure of airway), severe tachycardia (increased heart rate), cardiac arrest (sudden loss of heart function, breathing, and consciousness) and death. On 7/27/23 at 7:36 p.m., while onsite at the facility, the Assistant Director of Nursing (ADON), Licensed Vocational Nurse (LVN 1) and the Administrator (ADM), who joined by telephone, were verbally notified of an Immediate Jeopardy (IJ, a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death of a resident) situation regarding food and nutrition services. Resident 1 who was identified as having food allergy to onion, was served food with onions. On 7/28/23 at 5:16 p.m., the IJ was removed in the presence of the ADM 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 onsite the facility ' s implementation of the IJ Removal Plan. The IJ Removal Plan included: 1. Resident 1 was immediately assessed on 7/27/2023. The primary physician was notified and gave order to administer the Benadryl (a medication that relieves allergies) 25 milligrams (mg, a unit of measure), one tablet by mouth and was given to Resident 1 at 6:14 p.m. At 7:14 p.m. Resident 1 was re-assessed and the Benadryl was noted to be effective due to absence of swelling and itchiness of the lips. Resident 1 was monitored every two hours for 24 hours for any signs and symptoms of anaphylactic shock (severe, potentially life-threatening allergic reaction that can develop rapidly). 2. Licensed Nurses assessed all residents receiving meals on 7/27/23 to ensure accuracy of meals served for dinner. 3. Registered Dietitian (RD, health professionals with special training in the use of diet and nutrition to keep the body healthy) to reassess all residents ' nutritional status to ensure nutritional plan, dietary restrictions and food preferences are up to date. 4. RD provided in-service on 7/28/2023 to dietary staff that included the cooks, cook aides and assistant dietary supervisor about food handling process, meal preparation, food allergies and food preferences. Findings: During an interview on 7/27/2023 at 12:51 p.m. with (Resident 1), the resident stated he was allergic to onions and melons and the information was written on his diet card (card on meal tray that indicates diet types and specific preferences and restrictions). Resident 1 stated he was served onions and melons on 7/22/2023 (lunch) and had an allergic reaction to the potato salad he ate. The resident stated he reported to the Dietary Supervisor Assistant (ADS), he had allergic reaction to the food (potato salad) he ate on that day (7/22/2023). During an interview on 7/27/2023 at 4:08 p.m. with ADS, ADS stated, food allergies were on the diet card (placed on residents ' trays) and were as visible as possible to the dietary staff. The ADS stated there are recommendations that will be implemented in the future, because food preferences and food allergies were getting mixed up. The ADS stated, When a resident gets food which they are allergic to, the resident can get sick, vomit, have diarrhea or die because they cannot breathe. During an interview and record review of the Standardized recipe for macaroni salad, on 7/27/2023 at 5:34 p.m. with Cook 1, Cook 1 stated he prepared all the food today and that he followed the recipe for macaroni salad. A review of the facility ' s Standardized recipe for macaroni salad, undated, indicated the recipe included, onion, chopped one half (1/2 ) inch or less. During an observation and concurrent interview, on 7/27/2023 at 6:03 p.m., in Resident 1 ' s room, the resident ' s dinner tray had a sandwich with macaroni salad on the plate, and with diet card indicating no onions, melon or fish. Resident 1 stated his lip was swelling from food that he ate from the facility during dinner. During an interview on 7/27/23 at 8 p.m., Resident 1 stated he received Benadryl (a medication to relieve allergies) for his lip swelling. During an interview with the ADS on 7/28/2023 at 11:54 a.m., the ADS stated Resident 1 reported he had an allergic reaction on 7/22/2023; however, the resident did not tell her what food he ate or the type of reaction to the food. The ADS stated she was not aware what was done about it. ADS stated he did not replay the report the nurse on duty (Licensed Vocational Nurse [LVN] 2). During an interview with Resident 1 on 7/28/2023 at 12:39 p.m., Resident 1 stated he had an allergic reaction to the onions in the potato salad he ate on 7/22/2023. During an interview with Licensed Vocational Nurse (LVN) 2 on 7/28/2023 at 3:14 p.m., LVN 2 stated she worked on 7/22/2023 but did not recall any reported incident (regarding Resident 1 ' s allergic reaction to potato salad) on that day. A review of Resident 1 ' s Admission Record indicated the facility admitted the resident on 2/27/2023, with diagnoses that included pleural effusion (water on the lungs) and systolic congestive heart failure (a type of heart failure which makes the heart weak). A review of the facility ' s electronic document, eINTERACT Change in Condition Evaluation V4.2, dated 3/8/2023 at 12:10 p.m., indicated Resident 1 had an allergic reaction because the resident ate (an) allergen (onion). The document indicated Resident 1 was allergic to melon and onion. A review of Resident 1 ' s untitled electronic care plan initiated on 3/9/2023 indicated the resident had an allergic reaction to onion. The goal of the care plan was allergen will not be given at any time in the next 3 months. The interventions included monitor for sign and symptoms of allergic reaction, immediately notify the physician (MD) about any allergic reaction that occur, label MD order sheets, medication administration record (MAR), treatment sheets of resident ' s allergy, notify pharmacy of resident ' s allergy and place allergy sticker in front of the chart. A review of Resident 1 ' s Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 5/25/2023, indicated the resident had no cognitive (ability to think and make decisions) impairment. A review of the facility ' s electronic document eINTERACT Change in Condition Evaluation V4.2, dated 7/3/2023 at 12:30 p.m., indicated Resident 1 had an allergic reaction. There were no additional details what caused the allergic reaction. A review of Resident 1 ' s Progress Notes ' , dated 7/3/2023 at 12:40 p.m., indicated during lunch, the charge nurse was notified that the resident was complaining of an allergic reaction. The notes indicated the resident stated he was having an allergic reaction to something he ate and his tongue was swollen. The notes indicated the resident had minimal swelling to the upper lip. A review of Resident 1 ' s Progress Notes, dated 7/3/2023 at 1:54 p.m., indicated Diphen (Diphenhydramine, a medication to relieve allergies) oral tablet 25 milligrams (mg, a unit of measure) was given as needed for allergies. A review of Resident 1 ' s untitled electronic care plan initiated on 4/24/2023 indicated Resident 1 is allergic to melon and onion. The focus of the care plan indicated Resident 1 had an allergic reaction on 7/3/2023. The goal of the care plan was allergen will not be given to Resident at any given time in the next 3 months. A review of Resident 1 ' s Progress Notes, dated 7/27/2023 at 6:04 p.m., indicated the resident approached a certified nurse assistant and verbalized my top lip is getting swollen due to onion in my macaroni salad. A review of Resident 1 ' s medication administration record (MAR), for July 2023, indicated the resident had allergies to melon, onion, and Diphen oral tablet 25 mg; one tablet by mouth every four hours as needed for allergies, was administered on 7/27/2023 at 6:14 p.m. A review of the facility ' s electronic document eINTERACT Change in Condition Evaluation V4.2, dated 7/27/2023 at 6:12 p.m., indicated Resident 1 had an allergic reaction. There were no additional details what caused the allergic reaction. A review of the facility ' s Resident Council Minutes, dated 7/12/2023, indicated Supervisor met with residents; one out of 7 residents are still receiving food they are allergic to . A review of the facility ' s menu, Good For You Health Menus, dated 7/24/2023 to 7/30/2023, indicated for Thursday, 7/27/2023, the dinner foods were Turkey & Bacon Sandwich, Macaroni Salad, and Nilla Banana Pudding. A review of the facility ' s policy, Food Allergies, dated 2020, indicated, Appropriate food substitutions will be offered for foods the resident cannot eat.

Based on interview and record review, the facility failed to provide an effective discharge plan for one of two sampled residents (Resident 1). For Resident 1, who was diagnosed with [CONDITION(S)] (a brain disorder that distorts the way a person thinks, acts, expresses emotions, perceives reality, and relates to others), and had severe cognitive impairment (unable to make decisions), the facility failed to: -Ensure the Interdisciplinary Team (IDT-a group of healthcare professionals from diverse fields who work in a coordinated fashion towards a common goal for the patient) was involved in developing a discharge plan to reflect Resident 1's discharge needs and goals. -Provide effective and appropriate transition of care to the next care provider for Resident 1. -Develop an individualized discharge Plan of Care for Resident 1. As a result, on 4/15/2022, Resident 1 was discharged to an Assisted Living Facility, where Resident 1 eloped (left the facility, presenting an imminent threat to the resident's health and safety because resident was too impaired to make a decision to leave) two days later, was physically assaulted (being attacked) on the street, and was admitted to the General Acute Care Hospital (GACH) on 4/17/2022. Findings: A review of Resident 1's Admission Record (Face Sheet) indicated the facility admitted Resident 1, on 8/19/2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's admission Minimum Data Set (MDS- standardized assessment and care screening tool) dated 8/26/2021, indicated Resident 1 had severe cognitive impairment. A review of the discharge MDS dated [DATE], indicated Resident 1 had severely impaired cognition (never/rarely made decisions) and required limited staff assist with personal hygiene, toilet use, and dressing. A review of Resident 1's Discharge Summary dated 4/15/2022, indicated the facility discharged Resident 1 because his health had improved sufficiently and no longer needed the services provided by the facility. The Discharge summary was missing the recapitulation on the resident's stay, the reason for transfer and discharge, the discharge diagnoses, the Interdisciplinary Team (IDT) representative and physician signatures. A review of Resident 1's medical records indicated there was no documentation explaining how/why Resident 1's status had improved to be discharged to a lower level of care. A review of the facility's Notice of Proposed Transfer/discharge date d 4/15/2022, indicated Resident 1 signed the Notice of Proposed Transfer/Discharge upon discharge on 4/15/2022. According to a review of Resident 1's Medical Record, there was no IDT meeting held by the facility to discuss Resident 1's discharge planning. Further review of Resident 1's medical records indicated there was no communication between the facility and resident/responsible party regarding the final discharge plan and destination for Resident 1. A review of Resident 1's GACH History and Physical (H&P) Reports dated 4/18/2022, indicated Resident 1, with history of Huntington`s disease, presented via Emergency Medical Services (EMS) from the street with back pain in the setting of a physical assault. The H&P records indicated Resident 1 was oriented to self only with deficits in memory, consistent with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview with Certified Nurse Assistant 1 (CNA 1) on 4/23/2022 at 11:14 AM, CNA 1 stated, The resident was not fully oriented, was confused at times, did not have good balance, and required supervision when walking. CNA1 stated Resident 1, had episodes of incontinence (accidental leakage of urine or feces). At times, he would get confused and was not able to control himself. CNA 1 stated Resident 1 mumbled at times, and his speech was not clear. During an interview with CNA 2 on 4/23/2022 at 11:23 AM, CNA 2 stated, The resident was a high fall risk and had coordination issues. CNA2 stated, Resident 1 was not able to focus on one task. I showered him couple of times and I was there giving him instructions of what to do. He was not able to shower on his own. He needed directions for showering, and I had to do everything for him. His balance was off and mostly dependent. You had to tell him what to do, he would think about it, and he would get stuck. You need to tell him again and again so he could comprehend. During an interview and concurrent record review with Licensed Vocational Nurse 1 (LVN 1) on 4/23/2022 at 1:12 PM, LVN 1 stated, The discharge summary form is not normally in this format. LVN 1 confirmed that Resident 1`s Discharge Summary form was not completed properly and was not signed by the IDT representative and or the physician. LVN 1 confirmed that an IDT meeting was not conducted prior to Resident 1's discharge. LVN 1 stated in addition, staff did not initiate an individualize care plan for Resident 1`s discharge. On 4/23/2022 at 1:25 PM, during a telephone interview with Resident 1's Physician, the Physician stated [CONDITION(S)] was a progressive disease and that the resident's condition could get worse over time. The Physician stated if there was a Social Worker attached to the resident's profile, the facility's Social Worker needed to be in touch with the Physician and get approval before the resident was discharged . The Physician stated, My determination to deem Resident 1 as someone capable to make his own decisions in the History and Physical (H&P) form dated 8/19/2021 was based on his face sheet and his ability to answer my questions. The Physician stated if there was a change of condition in Resident 1's cognition, it should have been noted in his face sheet. The Physician stated, Resident's face sheet should always reflect the correct and current information regarding the resident's condition. During a telephone interview on 4/25/2022 at 10:15 AM, the Assisted Living Administrator stated Resident 1 was self-responsible and was admitted on [DATE] from the facility. The Assisted Living Administrator stated Resident 1 eloped two days after admission, on 4/17/2022, and that she was not aware Resident 1 had a Court Mandated Treatment Team (CMTT) involved in the resident's care. During an interview with the Director of Social Services (DSS) on 4/25/2022 at 11:14 AM, the DSS stated Resident 1 was self-responsible and had outside services that would come visit with the resident in the facility. The DSS stated the CMTT monitored Resident 1's behavior while he was in the facility. The DSS confirmed that Resident 1 had severe cognitive impairment and that a resident with severe cognitive impairment does not have the capacity to make decisions or sign discharge papers. The DSS stated, I should have updated Resident 1's face sheet that he is not self-responsible. The DSS stated, No IDT meeting was conducted before Resident 1's discharge. The DSS stated, it was my first time working with the CMTT and I did not have much information about them. I learned more during the resident's stay in the facility. During a telephone interview with the CMTT Licensed Clinical Social Worker (LCSW) on 4/25/2022 at 11:55 AM, the LCSW stated their organization was a court-mandated treatment team pursuant to Sections 1608 and 1610 of the Penal Code and was committed under Penal Code 2972 Offender (a person who commits a crime) with Mental Health Disorders. The LCSW stated Resident 1 was not able to communicate his thoughts completely and his abilities were limited to simple sentence responses, and yes or no answers. The LCSW stated, It was very concerning that the Director of Social Services (DSS) at the facility did not fully acknowledge our involvement in Resident 1's treatment and care despite having provided her the information and on multiple occasions. The LCSW stated, I personally handed DSS a copy of Penal code 2972 and we sat down with DSS and had several conversations regarding our involvement in Resident 1`s care. The LCSW stated Resident 1's discharge to a lower level of care was not safe and the facility staff moved Resident 1 to an Assisted Living on 4/15/2022, without any consultation with our team. The LCSW stated the Assisted Living did not know that we were part of Resident 1's treatment team. On 4/25/2022 at 12 PM, during an interview, Registered Nurse 1 (RN1) stated, I discharged the resident (Resident 1) on 4/15/2022 and I was the one who asked him to sign the Notice of Proposed Transfer/Discharge paper. RN 1 stated, I explained to Resident 1 that he needs to sign. I told him you will be discharged to a lower level of care. I asked him if he can sign, and he said yes. During an interview on 4/25/2022 at 1:26 PM, the Administrator (ADM) stated the facility conducted discharge IDT meetings prior to discharging residents, and in this case an IDT meeting was not performed before Resident 1 was discharge. The ADM stated, A resident with severe cognitive impairment was not capable of making decisions for themselves and the resident did not have the cognitive ability to sign his discharge papers for himself. The ADM stated the Discharge Summary for Resident 1 was not completed and was missing recapitulation of Resident 1's stay, the reason for transfer and discharge, discharge diagnoses, the IDT representative, and physician's signatures. The ADM stated Resident 1's face sheet was not updated based on the resident's changing cognitive ability for decision-making and the staff failed to initiate an individualized care plan for discharge planning, and failed to follow the facility's policy and procedures for discharge. A review of the policy and procedures (P&P) titled, Discharge Summary and Plan, revised 12/2016 indicated, the discharge summary will include a recapitulation of the resident's stay at this facility and a final summary of the resident's status at the time of the discharge in accordance with established regulations governing release of resident`s information and as permitted by the resident. The discharge summary shall include the resident's current diagnosis, medical history, course of illness, treatment and/or therapy since entering the facility, current laboratory, radiology, consultations and diagnostic test results, physical and functional status, ability to perform activities of daily living. A member of the IDT will review the final post-discharge plan with the resident and family at least twenty-four (24) hours before the discharge is to take place. A review of the policy titled, Discharging the Resident, revised 12/2016 indicated, the resident should be consulted about the discharge. If discharging to another long -term care facility tell the resident: where the new facility is located, how large the facility is, what services it offers, that his or her family and visitors will be informed of the discharge and where the resident will be living and why the discharge is necessary. A review of facility's policy and procedure titled, Resident Assessments, revised 11/2019 indicated the Resident Assessment Coordinator was responsible for ensuring the Intradisciplinary Team conducts timely and appropriate resident assessment and reviews according to the following requirements: Discharge Assessment-conducted when a resident is discharged from the facility. A Significant Change in Status assessment (SCSA) is completed within 14 days of the interdisciplinary team determining that the resident meets the guidelines for major improvement or decline. Examples of decline from baseline include resident's decision-making ability has changed. All resident assessment completed within previous 15 months are maintained in the resident`s active clinical record. The results of the assessments are used to develop, review, and revise the resident`s comprehensive care plan. A review of facility's Director of Social Services Job Description updated on 9/2020 indicated, duties and responsibilities of Director of Social Services: develops and maintains plan of care in conjunction with facility interdisciplinary team. Determines legal status of residents upon admission, provides information and obtains copies of advanced directives. Identifies discharge potential/status (short or long term) at admission and throughout resident stay and follows through as indicated. Provides discharge planning services including referrals, arrangement for follow-up services, transfers to other facilities, and post discharge plan of care, orientation of residents and family regarding discharge.

Based on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five percent (%). Fourteen medication errors out of 29 total opportunities contributed to an overall medication error rate of 48.28 % affecting four of four sampled residents observed for medication administration (Residents 4, 9, 21, and 42.), by failing to: -Ensure Licensed Vocational Nurse 1 (LVN 1) did not crush and mix six medications for administration through a gastrostomy tube (g-tube - a surgically implanted tube used to deliver food or medication directly to the stomach) for Resident 4. -Ensure LVN 1 followed Resident 4's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . -Ensure LVN 1 and LVN 2 did not omit scheduled medications to Residents 4, 9 and 21 due to error or medication availability. -Ensure LVN 1 did not administer the incorrect form of aspirin (a medication used to treat blood clots) to Resident 9. -Ensure LVN 2 did not administer the incorrect strength of calcium supplement to Resident 42. These deficient practices of failing to administer medications in accordance with the attending physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . As a result, Resident 4's medication [MEDICATION(S)] (a medication used to treat or prevent seizures [a sudden uncontrolled electrical disturbance in the brain]), level (a laboratory blood test to check for therapeutic level of a specific medication) was less than two micrograms (mcg - a unit of measure for mass) per ml (reference range for therapeutic levels of [MEDICATION(S)] between 5 mcg/ml and 63 mcg/ml). The physician issued new orders to increase the dose of Resident 4's [MEDICATION(S)] to 750 milligrams (mg - a unit of measure for mass) via g-tube every 12 hours. On 3/9/2022 at 4 PM, the Department of Public Health (Department) called an Immediate Jeopardy situation (IJ - a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) in the presence of the Administrator (ADM), Director of Nursing (DON), and Director of Staff Development (DSD) for the facility's failure to ensure the medication error rate was less than 5 %, which threatened the health and safety of the residents. On 3/11/2022 at 11:26 AM, the IJ was lifted after the facility submitted an acceptable removal plan. The survey team verified and confirmed on-site the implementation of the removal plan through observation, interview, and record review. The IJ situation was removed in the presence of the Administrator, the DON, and the Clinical Mentor. The accepted removal plan included the following actions: a. The DON assessed Resident 4 for signs and symptoms of seizures or bleeding with none noted . b. Resident 4's physician was notified of the situation who gave a new lab order to check his [MEDICATION(S)] level. c. Resident 4's Responsible Party (RP) was notified regarding the situation and verbalized understanding. d. The DON requested the facility's consultant pharmacist to review Resident 4's medication regimen. e. The DON informed the facility's medical director regarding the situation who agreed with the facility's treatment plan. f. The Clinical Mentor provided one-on-one retraining to Licensed Vocational Nurse (LVN 1), LVN 2, and DSD on the facility's policy and procedure regarding medication administration and medication administration via the g-tube route. g. The Clinical Mentor conducted a skills competency assessment with LVN 1, LVN 2, and DSD regarding proper medication administration and medication administration via the g-tube route. h. The DON and licensed staff assessed all the facility's residents with g-tubes, or who were taking [CONDITION(S)] or anticoagulant medication for signs and symptoms of significant changes. i. The Clinical Mentor and DON started to provide in-service training and skills competency assessment to all other licensed staff regarding medication administration and medication administration via the g-tube route and developed a plan to periodically monitor competency on a regular basis moving forward. Findings: A review of Resident 42's Admission Record (a document containing resident diagnostic and demographic information), indicated the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] During an observation of medication administration on 3/8/2022 at 8:21 AM, LVN 2 was observed administering one tablet of calcium and vitamin D supplement 600 mg/5 mcg to Resident 42. Resident 42 was observed taking the calcium/vitamin D 600mg/5mcg with seven other medications by mouth with juice. A review of Resident 42's Order Summary Report (a comprehensive list of current physician orders), dated 3/9/2022, indicated Resident 42's physician prescribed calcium/vitamin D 500 mg/5 mcg on 1/29/2021. A review of Resident 21's Admission Record indicated he was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] During an observation and concurrent interview on 3/8/2022 at 8:29 AM, LVN 2 was observed preparing a total of eight medications for Resident 21. LVN 2 stated Resident 21 was to receive [MEDICATION(S)] otic solution (ear drops to aid removal of excess ear wax) but that she was unable to administer it this morning because the medication was unavailable in the cart. LVN 2 stated that according to the resident's clinical record, the last dose was given yesterday. LVN 2 stated she was unaware whether a refill order had been placed with the pharmacy to replace the [MEDICATION(S)]. A review of Resident 21's Order Summary Report, dated 3/9/2022 indicated Resident 21's physician prescribed [MEDICATION(S)] solution on 3/8/2022. During an interview on 3/8/2022 at 11:40 AM with LVN 2, LVN 2 stated [MEDICATION(S)] was not administered to Resident 21 because it was not available. LVN 2 stated she did not know why the medication was unavailable and had not yet had an opportunity to follow up with the dispensing pharmacy. LVN 2 also stated she gave the wrong strength of the calcium/vitamin D supplement to Resident 42. LVN 2 stated the strength of calcium called for in the order was 500 mg but the product she administered contained 600 mg. LVN 2 stated that if the product she had on hand and the order did not match, she was required to clarify the order with the physician prior to administering it. LVN 2 stated that giving the wrong strength of medications could cause residents harm or diminish their quality of life. A review of Resident 9's Admission Record indicated Resident 9 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .) During an observation and concurrent interview on 3/9/2022 at 8 AM with LVN 1, LVN 1 was observed preparing a total of five medications for Resident 9 including one chewable tablet of aspirin (a medication used to prevent blood clots) 81 mg. LVN 1 stated Resident 9 should also receive a dose of [MEDICATION(S)] (a medication used to help control blood sugar levels) this morning, but she was unable to administer it because it was unavailable in the cart. LVN 1 stated the last dose was given yesterday and although a refill order was placed with the dispensing pharmacy four days ago, it had not yet arrived. During an observation on 3/9/2022 at 8:10 AM, Resident 9 was observed taking five medications, including the chewable aspirin 81 mg tablet, by mouth with water. A review of Resident 9's Order Summary Report, dated 3/9/2022, indicated Resident 9's physician prescribed [MEDICATION(S)] 1000 mg to be taken by mouth with meals on 4/27/2018 and Resident 9's order for aspirin 81mg was for the [MEDICATION(S)] coated (EC- a special tablet coating that protects the stomach from irritation) form. During an observation and concurrent interview on 3/9/2022 at 8:22 AM with LVN 1, LVN 1 was observed preparing the following medications for Resident 4: -Seven and a half (7.5) milliliters (ml - a unit of measure for volume) of [MEDICATION(S)] sulfate (an iron supplement) [MEDICATION(S)] 220 mg/5 ml. -Thirty milliliters of [MEDICATION(S)] (a [MEDICATION(S)]) 10 grams (g - a unit of measure for mass) per 15 ml -Five milliliters of [MEDICATION(S)] (a medication used to prevent seizures) 100 mg/ml -One tablet of [MEDICATION(S)] (a medication used to prevent blood clots) 5 mg -One capsule of [MEDICATION(S)] (a mediation used to reduce stomach acid) 30 mg -One tablet of a multivitamin (a vitamin supplement) -One tablet of acetaminophen (a medication used to treat mild pain) 325 mg -One tablet of vitamin C (a vitamin supplement) 500 mg -One tablet of [MEDICATION(S)] (a medication used to treat mental illness) 10 mg. LVN 1 stated Resident 4 had a g-tube and his medications must be crushed or in liquid form to administer. During an observation on 3/9/2022 at 8:38 AM, LVN 1 was observed combining six medications ([MEDICATION(S)], [MEDICATION(S)], the multivitamin tablet, acetaminophen, vitamin C, and [MEDICATION(S)]) into one small plastic bag and using a crushing device to crush them all together. LVN 1 was then observed pouring this mixture into a plastic water cup. LVN 1 was then observed pouring the [MEDICATION(S)] sulfate [MEDICATION(S)], the [MEDICATION(S)] solution, and the [MEDICATION(S)] solution out of their medication dosage cups and into plastic water cups separately. During an observation and concurrent interview on 3/9/2022 at 8:42 AM with LVN 1, LVN 1 was observed pouring ice water from Resident 4's bedside canteen into the plastic water cup containing the [MEDICATION(S)] solution. LVN 1 stated she realized she was not supposed to mix ice water with the resident's medications and will return to the medication cart to prepare the [MEDICATION(S)] again. LVN 1 was observed leaving the other medications unattended at the resident's bedside and returning to the medication cart in the hallway. LVN 1 was observed returning to the resident's room with water from the cart and then diluting each liquid medication ([MEDICATION(S)] sulfate, [MEDICATION(S)], and [MEDICATION(S)]) separately in plastic water cups with an unknown amount of water (estimated 90 - 120 ml.) LVN 1 was then observed diluting the crushed mixture of six medications ([MEDICATION(S)], [MEDICATION(S)], the multivitamin tablet, acetaminophen, vitamin C, and [MEDICATION(S)]) with an unknown amount of water (estimated 90-120 ml) in a plastic water cup. LVN 1 was observed drawing up a portion of the diluted [MEDICATION(S)] solution into a 60 ml syringe and attempting to inject it through Resident 4's g-tube without first checking for placement or residual volume. LVN 1 was then stopped by the surveyor before the medication was administered and advised to discuss the medication preparation with the surveyor in the hallway. During an interview on 3/9/2022 at 8:52 AM with LVN 1, LVN 1 stated she crushed six medications ([MEDICATION(S)], [MEDICATION(S)], the multivitamin tablet, acetaminophen, vitamin C, and [MEDICATION(S)]) and mixed them together. LVN 1 stated, according to facility policy, each medication must be crushed individually and administered separately through a g-tube to ensure she was able to tell the medications apart. LVN 1 stated she forgot to crush the medications separately today because she was nervous. LVN 1 stated she then mixed the crushed medication mixture and the other three liquid medications ([MEDICATION(S)] sulfate, [MEDICATION(S)], and [MEDICATION(S)]) with an unknown amount of water. LVN 1 stated that she was supposed to flush each medication with 30 ml of water after administration through the g-tube per Resident 4's physician order. LVN 1 agreed based on visual inspection that she added significantly more water than 30 ml to each medication. LVN 1 stated she was not really trained well on administration of medications to residents via the g-tube route. During an interview on 3/9/2022 at 9 AM, the DON stated medications for g-tube administration should be crushed and administered separately to be able to tell the medications apart, to give the resident the right to refuse medications individually, to ensure there were no physical or chemical incompatibilities between the medications, and to ensure the mixture would not clog the g-tube. The DON stated each medication should then be administered separately and flushed with the amount of water specified in the physician order. The DON stated that liquid medications should be administered directly through the g-tube and flushed with water between each one per the resident's physician order. During an observation and concurrent interview on 3/9/2022 at 9:06 AM, LVN 1 was observed discarding the initial preparation of Resident 4's medication and preparing the medications again under the supervision of the DSD. LVN 1 stated she would prefer to have the DSD supervise her second attempt to administer Resident 4's medications via g-tube. During an observation and concurrent interview on 3/9/2022 at 9:22 AM, LVN 1 and the DSD were observed repositioning Resident 4 for administration of medications via the g-tube. Neither the DSD nor LVN 1 were observed checking Resident 4 for g-tube placement or residual volume. LVN 1 and the DSD were observed drawing up medications into a 60 ml syringe and attempting to administer the medications through Resident 4's g-tube by pushing the plunger on the syringe once connected to the g-tube. The DSD was observed pulling back on the syringe while it was still attached to Resident 4's g-tube and drawing already administered medication back up into the syringe chamber. After intervention from the surveyor, the DSD stated she will remove the plunger from the syringe and attempt to administer the medications via gravity and use a slow push to aid administration only if the g-tube becomes stuck. During an observation on 3/9/2022 at 9:51 AM, LVN 1 and the DSD were observed completing the administration of all medications to Resident 4 via the g-tube route. A review of Resident 4's Admission Record, dated 3/8/2022, indicated Resident 4 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 4's Order Summary Report, dated 3/9/2022, indicated on 10/27/2021 the attending physician gave the following enteral (through the stomach) feed orders: -Check residuals every shift and hold tube feedings if residuals above 100 ml. Resume after one hour if residuals were less than 100 ml. If still more than 100 ml, call MD. -Check tube for placement/patency every shift before initiation of formula, medication administration, and flushing-tube. -Crush all crushable medications given via feeding-tube every shift. Use a slow push to facilitate consumption. -Flush tube with 30-50 ml of water pre and post medication administration via tube every shift. A review of Resident 4's Order Summary Report, dated 3/9/2022, indicated between 10/27/2021 and 2/17/2022 the attending physician gave the following prescription orders: -[MEDICATION(S)] 10 mg via g-tube once daily for depression (a psychiatric condition characterized by changes in mood and lack of interest in activities) manifested by episodes of crying for no apparent reason -[MEDICATION(S)] 5 mg via g-tube once daily for [CONDITION(S)] (DVT) prophylaxis (to prevent blood clots forming in the legs which may break loose, travel to the lungs, and cause a pulmonary embolism). -[MEDICATION(S)] Sulfate 220 mg/5ml [MEDICATION(S)]. Give 7.5 ml per g-tube once daily for [CONDITION(S)] (a blood condition caused by low iron levels) -[MEDICATION(S)] ([MEDICATION(S)]) 20 gm/30 ml. Give 30 ml via g-tube once daily for bowel management -[MEDICATION(S)] 30 mg via g-tube every morning for GERD ([CONDITION(S)] - a medical condition characterized by frequent heartburn). -[MEDICATION(S)] 100 mg/ml. Give 5 ml via g-tube every 12 hours for seizures with minerals tablet. Give one tablet via g-tube once daily for supplement -Sodium chloride 1 g via g-tube three times daily for [CONDITION(S)] (low sodium level) -Acetaminophen 325 mg. Give two tablets via g-tube once daily for pain management -Vitamin C 500 mg via g-tube once daily for supplement. A review of Resident 4's care plan for [CONDITION(S)] disorder, dated 5/31/2021, the care plan indicated to give medications as ordered. monitor/document for effectiveness and side effects. A review of Resident 4's care plan for DVT prophylaxis, dated 1/13/2022, indicated to administer anticoagulant medications as ordered by physician. Monitor for side effects and effectiveness every shift. During an interview on 3/9/2022 at 11:12 AM, LVN 1 stated she gave the wrong form of aspirin to Resident 9. LVN 1 stated Resident 9's order for aspirin was for the EC and the form she administered was the chewable form. LVN 1 stated that not giving the EC form of aspirin may cause irritation to Resident 9's stomach. LVN 1 stated she failed to administer Resident 4's sodium chloride tablet this morning because she failed to double check all the orders that were due at that time. LVN 1 stated she failed to check or follow the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . LVN 1 stated she was nervous about her medication pass being observed and it caused her to make more mistakes than she normally would have such as crushing and mixing multiple medications together or diluting them with more water than allowed by the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . LVN 1 stated she had four residents with g-tubes on her medication administration assignment today. LVN 1 stated although there were orders to check Resident 4's g-tube placement and residual prior to medication administration, neither she nor the DSD checked for proper placement of Resident 4's g-tube or residual level prior to administering the medications this morning. LVN 1 stated she did not know what she should do if the residual level was too high and was not confident in her ability to check g-tube placement or residual properly prior to administering medications via the g-tube. LVN 1 stated that if a g-tube becomes dislodged, administering food or medications through it could cause medical complications [MEDICAL RECORD OR PHYSICIAN ORDER] . LVN 1 stated the DSD was probably the one who assessed her competence at g-tube medication administration during her initial training but does not remember exactly. During an interview on 3/9/2022 at 11:29 AM the DSD stated it was her responsibility to train newly hired licensed staff on administering medications according to facility policies and professional standards and assess their competence to do so independently prior to allowing them to perform those duties unsupervised. The DSD stated that she trained LVN 1 on proper medication and g-tube administration and signed her off as competent on 9/10/2201 but stated LVN 1 was a challenge to train because she had an attitude. The DSD stated she had not reassessed LVN 1 formally since her initial training but checked in on her from time to time. The DSD stated that she also failed to check residual level or placement of Resident 4's g-tube this morning while she was assisting the LVN with the g-tube medication administration or follow the facility's policy regarding administration of medication via the g-tube route. The DSD stated that placement and residual must be checked for every resident with a g-tube prior to the administration of food or medication, and medications must be prepared for g-tube administration properly according to the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the laboratory report for the [MEDICATION(S)] level for Resident 4, dated 3/10/2022, indicated Resident 4's [MEDICATION(S)] level was less than two micrograms (mcg - a unit of measure for mass) per ml and the reference range for therapeutic levels of [MEDICATION(S)] was between 5 mcg/ml and 63 mcg/ml. Further review of the laboratory report indicated based on the results of the [MEDICATION(S)] level, the physician issued new orders to increase the dose of Resident 4's [MEDICATION(S)] to 750 mg via g-tube every 12 hours. A review of the facility's policy titled, Administering Medications, dated April 2019, indicated medications were administered in accordance with prescriber orders, and the individual administering the medications checks the label three (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. A review of the facility's policy titled, Administering Medications through an Enteral Tube, dated November 2018, the policy indicated to administer each medication separately and flush between medications, verify placement of feeding-tube, stop feeding and flush tubing with at least 15 ml warm purified water (or prescribed amount), dilute medication: a) Remove plunger from syringe. Add medication and appropriate amount of water to dilute b) Dilute crushed (powdered) medication with at least 30 ml purified water (or prescribed amount) c) Dilute liquid medication with 30 ml or more (depending on viscosity) with purified water. Administer each medication separately. Reattach syringe (without plunger) to the end of the tubing. Administer medication by gravity flow a) pour diluted medication into the barrel of the syringe while holding the tubing slightly above the level of insertion b) open the clamp and deliver the medication slowly c) Begin flushing before tubing drains completely.

Based on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 4) observed for medication administration was free of significant medication errors by failing to administer [MEDICATION(S)] (a medication used to treat or prevent seizures [a sudden uncontrolled electrical disturbance in the brain]), [MEDICATION(S)] (an anticoagulant medication used to prevent blood clots) and sodium chloride (medication used for low salt level) according to physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -Ensure Licensed Vocational Nurse 1 (LVN 1) crushed the medications individually, including [MEDICATION(S)], and administered separately through a gastrostomy tube (g-tube , a surgically implanted tube used to deliver food or medication directly to the stomach) for Resident 4. -Ensure LVN 1 flushed each medication, including [MEDICATION(S)], with 30 milliliters (ml - a units of measure for volume) of water after administration through the g-tube, per Resident 4's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -Ensure LVN 1 administered Resident 4's sodium chloride tablet 1 gram (gm - a unit of measure for mass) via g-tube three times daily for [CONDITION(S)] (low sodium level) and double check all the orders that were due at that time. -Ensure LVN 1 and the Director of Staff Development (DSD) checked for proper placement of Resident 4's g-tube and residual level prior to administering the medications. These deficient practices of failing to administer [MEDICATION(S)], [MEDICATION(S)], and sodium chloride in accordance with the attending physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . As a result, Resident 4's [MEDICATION(S)] level (a laboratory blood test to check for therapeutic level of a specific medication) was less than two micrograms (mcg - a unit of measure for mass) per ml (reference range for therapeutic levels of [MEDICATION(S)] between 5 mcg/ml and 63 mcg/ml). The physician issued new orders to increase the dose of Resident 4's [MEDICATION(S)] to 750 milligrams (mg - a unit of measure for mass) via g-tube every 12 hours. On 3/9/2022 at 4 PM, the Department of Public Health (Department) called an Immediate Jeopardy situation (IJ - a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) in the presence of the Administrator (ADM), Director of Nursing (DON), and the Director of Staff Development (DSD) for the facility's failure to administer Resident 4's medications in accordance with the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] On 3/11/2022 at 11:26 AM, the IJ was lifted after the facility submitted an acceptable removal plan. The survey team verified and confirmed on-site the implementation of the removal plan through observation, interview, and record review. The IJ situation was removed in the presence of the Administrator, the DON, and the Clinical Mentor. The accepted removal plan included the following actions: a. The DON assessed Resident 4 for signs and symptoms of seizures or bleeding with none noted. b. Resident 4's physician was notified of the situation who gave a new order to check the resident's [MEDICATION(S)] level. c. Resident 4's Responsible Party (RP) was notified regarding the situation and verbalized understanding. d. The DON requested the facility's consultant pharmacist to review Resident 4's medication regimen. e. The DON informed the facility's medical director regarding the situation who agreed with the facility's treatment plan. f. The Clinical Mentor provided one-on-one retraining to Licensed Vocational Nurse 1 (LVN 1) and the DSD on the facility's policy and procedure regarding medication administration and medication administration via the g-tube route. g. The Clinical Mentor conducted a skills competency assessment with LVN 1 and the DSD regarding proper medication administration and medication administration via the g-tube route. h. The DON and licensed staff assessed all the facility's residents with g-tubes, or who were taking [CONDITION(S)], anticoagulant, [CONDITION(S)] medication for signs and symptoms of significant changes. i. The Clinical Mentor and DON started to provide in-service training and skills competency assessment to all other licensed staff regarding medication administration and medication administration via the g-tube route and developed a plan to periodically monitor competency on a regular basis moving forward. Findings: During an observation and concurrent interview on 3/9/2022 at 8:22 AM, LVN 1 was observed preparing the following medications for Resident 4: - Seven and a half (7.5) ml of [MEDICATION(S)] sulfate (an iron supplement) [MEDICATION(S)] 220 mg/5 ml. - 30 milliliters of [MEDICATION(S)] (a [MEDICATION(S)]) 10 gm/15 ml. - Five milliliters of [MEDICATION(S)] 100 mg/ml. - One tablet of [MEDICATION(S)] 5 mg. - One capsule of [MEDICATION(S)] (a mediation used to reduce stomach acid) 30 mg. - One tablet of a multivitamin (a vitamin supplement). - One tablet of acetaminophen (a medication used to treat mild pain) 325 mg. - One tablet of vitamin C (a vitamin supplement) 500 mg. - One tablet of [MEDICATION(S)] (a medication used to treat mental illness) 10 mg. LVN 1 stated Resident 4 had a g-tube and his medications must be crushed or in liquid form to administer. During an observation on 3/9/2022 at 8:38 AM, LVN 1 was observed combining six medications ([MEDICATION(S)], [MEDICATION(S)], the multivitamin tablet, acetaminophen, vitamin C, and the [MEDICATION(S)]) into one small plastic bag and using a crushing device to crush them together. LVN 1 was then observed pouring this mixture into a plastic water cup. LVN 1 was then observed pouring the [MEDICATION(S)] sulfate [MEDICATION(S)], the [MEDICATION(S)] solution, and the [MEDICATION(S)] solution out of their medication dosage cups and into plastic water cups separately. During an observation and concurrent interview on 3/9/2022 at 8:42 AM, LVN 1 was observed pouring ice water from Resident 4's bedside canteen into the plastic water cup containing the [MEDICATION(S)] solution. LVN 1 stated she realized she was not supposed to mix ice water with the resident's medications and will return to the medication cart to prepare the [MEDICATION(S)] again. LVN 1 was observed leaving the other medications unattended at the resident's bedside and returning to the medication cart in the hallway. LVN 1 was observed returning to the resident's room with water from the cart and then diluting each liquid medication ([MEDICATION(S)] sulfate, [MEDICATION(S)], and [MEDICATION(S)]) separately in plastic water cups with an unknown amount of water (estimated 90-120 ml.) LVN 1 was then observed diluting the crushed mixture of six medications ([MEDICATION(S)], [MEDICATION(S)], the multivitamin tablet, acetaminophen, vitamin C, and [MEDICATION(S)]) with an unknown amount of water (estimated 90-120 ml) in a plastic water cup. LVN 1 was observed drawing up a portion of the diluted [MEDICATION(S)] solution into a 60 ml syringe and attempting to inject it through Resident 4's g-tube without first checking for placement or residual volume. LVN 1 was then stopped by the surveyor before the medication was administered and advised to discuss the medication preparation with the surveyor in the hallway. During an interview on 3/9/2022 at 8:52 AM, LVN 1 stated she crushed six medications ([MEDICATION(S)], [MEDICATION(S)], the multivitamin tablet, acetaminophen, vitamin C, and [MEDICATION(S)]) and mixed them together. LVN 1 stated, according to facility policy, each medication must be crushed individually and administered separately through a g-tube to ensure she was able to tell the medications apart. LVN 1 stated she forgot to crush the medications separately today because she was nervous. LVN 1 stated she then mixed the crushed medication mixture and the other three liquid medications ([MEDICATION(S)] sulfate, [MEDICATION(S)], and [MEDICATION(S)]) with an unknown amount of water. LVN 1 stated that she was supposed to flush each medication with 30 ml of water after administration through the g-tube per Resident 4's physician order. LVN 1 agreed based on visual inspection that she added significantly more water than 30 ml to each medication. LVN 1 stated she was not really trained well on administration of medications to residents via the g-tube route. During an interview on 3/9/2022 at 9 AM, the DON stated medications for g-tube administration should be crushed and administered separately to be able to tell the medications apart, to give the resident the right to refuse medications individually, to ensure there were no physical or chemical incompatibilities between the medications, and to ensure the mixture would not clog the g-tube. The DON stated each medication should then be administered separately and flushed with the amount of water specified in the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation and concurrent interview on 3/9/2022 at 9:06 AM, LVN 1 was observed discarding the initial preparation of Resident 4's medication and preparing the medications again under the supervision of the DSD. LVN 1 stated she would prefer to have the DSD supervise her second attempt to administer Resident 4's medications via g-tube. During an observation and concurrent interview on 3/9/2022 at 9:22 AM, LVN 1 and the DSD were observed repositioning Resident 4 for administration of medications via the g-tube. Neither the DSD nor LVN 1 were observed checking Resident 4 for g-tube placement or residual volume. LVN 1 and the DSD were observed drawing up the [MEDICATION(S)] solution into a 60 ml syringe and attempting to administer the medications through Resident 4's g-tube by pushing the plunger on the syringe once connected to the g-tube. The DSD was observed pulling back on the syringe while it was still attached to Resident 4's g-tube and drawing already administered medication back up into the syringe chamber. After intervention from the surveyor, the DSD stated she would remove the plunger from the syringe and attempt to administer the medications via gravity and use a slow push to aid administration if the g-tube becomes stuck. During an observation on 3/9/2022 at 9:51 AM, LVN 1 and the DSD were observed completing the administration of all medications to Resident 4 via the g-tube route. A review of Resident 4's Admission Record, dated 3/8/2022, the Admission Record indicated Resident 4 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 4's Order Summary Report, dated 3/9/2022, indicated on 10/27/2021 the attending physician gave the following enteral (through the stomach) feed orders: - Check residuals every shift and hold tube feedings if residuals above 100 ml. Resume after one hour if residuals are less than 100 ml. If still more than 100 ml, call MD. - Check tube for placement/patency every shift before initiation of formula, medication administration, and flushing-tube. - Crush all crushable medications given via feeding-tube every shift. Use a slow push to facilitate consumption. - Flush tube with 30-50 ml of water pre and post medication administration via g-tube every shift. A review of Resident 4's Order Summary Report, dated 3/9/2022, indicated between 10/27/2021 and 2/17/2022 the attending physician gave the following prescription orders: - [MEDICATION(S)] 10 mg via g-tube once daily for depression (a psychiatric condition characterized by changes in mood and lack of interest in activities) manifested by episodes of crying for no apparent reason. - [MEDICATION(S)] 5mg via g-tube once daily for [CONDITION(S)] (DVT) prophylaxis (to prevent blood clots forming in the legs which may break loose, travel to the lungs, and cause a pulmonary embolism). - [MEDICATION(S)] Sulfate 220 mg/5 ml [MEDICATION(S)]. Give 7.5 ml per g-tube once daily for [CONDITION(S)] (a blood condition caused by low iron levels). - [MEDICATION(S)] ([MEDICATION(S)]) 20 g m/30 ml. Give 30 ml via g-tube once daily for bowel management. - [MEDICATION(S)] 30 mg via g-tube every morning for GERD ([CONDITION(S)] - a medical condition characterized by frequent heartburn). - [MEDICATION(S)] 100 mg/ml. Give 5 ml via g-tube every 12 hours for seizures. - Multivitamin with minerals tablet. Give one tablet via g-tube once daily for supplement. - Sodium chloride 1 gm via g-tube three times daily for [CONDITION(S)] (low sodium level). - Acetaminophen 325 mg. Give two tablets via g-tube once daily for pain management. - Vitamin C 500 mg via g-tube once daily for supplement. A review of Resident 4's care plan for [CONDITION(S)] disorder, dated 5/31/2021, indicated to give medications as ordered. Monitor/document for effectiveness and side effects. A review of Resident 4's care plan for DVT prophylaxis, dated 1/13/2022, indicated to administer anticoagulant medications as ordered by physician. Monitor for side effects and effectiveness every shift. During an interview on 3/9/2022 at 11:12 AM, LVN 1 stated she failed to administer Resident 4's sodium chloride tablet this morning because she failed to double check all the orders that were due at that time. LVN 1 stated she failed to check or follow the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . LVN 1 stated she was nervous about her medication pass being observed and it caused her to make more mistakes than she normally would have such as crushing and mixing multiple medications together or diluting them with more water than allowed by the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . LVN 1 stated, although there were orders to check Resident 4's g-tube placement and residual prior to medication administration, neither she nor the DSD checked for proper placement of Resident 4's g-tube or residual level prior to administering the medications this morning. LVN 1 stated she did not know what she should do if the residual level was too high and stated that if a g-tube becomes dislodged, administering food or medications through it could cause medical complications [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 3/9/2022 at 11:29 AM, the DSD stated it was her responsibility to train newly hired licensed staff on administering medications according to facility policies and professional standards and assess their competence to do so independently prior to allowing them to perform those duties unsupervised. The DSD stated that she trained LVN 1 on proper medication and g-tube administration and signed her off as competent on 9/10/2021 and she had not reassessed LVN 1 formally since her initial training but had checked in on her from time to time. The DSD stated that she also failed to check residual level or placement of Resident 4's g-tube this morning while she was assisting LVN 1 with the g-tube medication administration or follow the facility's policy regarding administration of medication via the g-tube route. The DSD stated that placement and residual must be checked for every resident with a g-tube prior to the administration of food or medication, and medications must be prepared for g-tube administration properly according to the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] A review of the laboratory report for the [MEDICATION(S)] level for Resident 4, dated 3/10/2022, indicated that the Resident 4's [MEDICATION(S)] level was less than two micrograms (mcg - a unit of measure for mass) per ml (reference range, therapeutic levels was between 5 mcg/ml and 63 mcg/ml). Further review of the laboratory report indicated based on the results of the [MEDICATION(S)] level, the physician issued new orders to increase the dose of Resident 4's [MEDICATION(S)] to 750 mg via g-tube every 12 hours. A review of the facility's policy titled, Administering Medications, dated April 2019, indicated medications are administered in accordance with prescriber orders and the individual administering the medications checks the label three (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. A review of the facility's policy titled, Administering Medications through an Enteral Tube, dated November 2018, indicated to administer each medication separately and flush between medications, verify placement of feeding-tube, stop feeding and flush tubing with at least 15 ml warm purified water (or prescribed amount). Dilute medication: a) Remove plunger from syringe. Add medication and appropriate amount of water to dilute b) Dilute crushed (powdered) medication with at least 30 ml purified water (or prescribed amount) c) Dilute liquid medication with 30 ml or more (depending on viscosity) with purified water. Administer each medication separately. Reattach syringe (without plunger) to the end of the tubing. Administer medication by gravity flow a) pour diluted medication into the barrel of the syringe while holding the tubing slightly above the level of insertion b) open the clamp and deliver the medication slowly c) Begin flushing before tubing drains completely.

Based on interview and record review, the facility failed to identify and evaluate accident risks and hazards and did not modify care plan interventions when necessary for one of three sampled residents (Resident 1). For Resident 1, who was identified as prone to spontaneous fracture from lifting or turning, required two person physical assistance with transfers, and had a history of [REDACTED]. This deficient practice resulted in CAN 1 attempted to solely transfer Resident 1 and wrapped her arms around Resident 1's chest and guided her to the floor. Resident 1 developed swollen face and right upper chest. Resident 1 was transferred to the general acute hospital (GACH) and was found to have broken ribs and pneumothorax (presence of air or gas in the cavity between the lungs and the chest wall causing collapse of the lungs). Findings: A review of the Admission Record indicated Resident 1 was admitted to the facility, on 12/5/18 and readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS - an assessment and care planning tool), dated 9/10/19, indicated Resident 1 was rarely and never understood. Resident 1 had short and long term memory problems. Resident 1 needed two person physical assistance with transfers and one person physical assistance with rest of activities of daily living (ADLs). A review of the physician progress notes [REDACTED]. The Progress Note indicated Resident 1 had a reduced bone density (decreased minerals in the bones increasing the susceptibility to fracture) and x-rays that indicated Resident 1 had [MEDICAL CONDITION] that makes her prone to fracture even with spontaneous movements or from lifting or turning. According to a review of the care plan, dated 3/18/19, indicated Resident 1 had potential for wandering and restlessness making the resident at risk for falls and injuries. The care plan goal indicated Resident 1 would be safe from falls / injuries for 90 days. The care plan intervention indicated to approach resident calmly and unhurriedly, attempt to refocus attention, and provide reminder to resident. The care plan did not have any update and was cancelled on 11/30/19. A review of the care plan, dated 10/11/19, indicated Resident 1 had an actual fall related to unsteady gait and inability to stay in bed. The care plan goal indicated Resident 1 would not suffer any additional injury related to fall and the care plan intervention indicated to provide a 1:1 sitter and to provide adequate monitoring or supervision by making rounds every hour as needed. The care plan interventions did not address the level of assistance during transfer and the resident's risk for spontaneous fracture to prevent accident and injuries. A review of the Change of Condition (C[NAME]) form, dated 11/28/19, at 8:36 a.m., indicated Resident 1 had increased agitation, restlessness and hitting staff. Resident 1 stood up quickly and CNA 1 wanted Resident 1 to sit on the bed. Due to Resident 1's unbearable weight and continuous hitting CNA 1 cautiously assisted Resident 1 down to the floor and called for help. The C[NAME] form indicated Resident 1 was found lying on her side on the floor mat, beside the bed. Skin check was done and there were no bruising, discoloration or open areas. There was no visible head injuries. The C[NAME] form indicated Resident 1 did not complain of pain and was able to stand up with assistance. Resident 1 was assisted back to her bed. A review of the Progress Notes, dated 11/28/19, at 9:50 a.m., (less than two hours later) indicated Resident 1 had swelling of the face and right upper chest. The MD ordered to transfer Resident 1 to the GACH. According to a review of the GACH emergency room (ER) report, dated 11/28/19, at 10:08 a.m., indicated Resident 1 had mild bilateral periorbital (around the eyes) swelling. There was swelling on the right chest wall and presence of subcutaneous crepitus (crackling feel to touch when air gets into the tissues under the skin) from the clavicle (collarbone) to the rib cage. A review of the GACH chest x-ray, dated 11/28/19, at 10:57 a.m., indicated Resident 1 had fractures of the right eight to eleventh ribs, 20% pneumothorax (presence of air or gas in the cavity between the lungs and the chest wall, causing collapse of the lungs), large pnuemomediastinum (presence of air or another gas in the center of the chest between the lungs) and large subcutaneous [MEDICAL CONDITION] (trapped air or gas under the skin) of the right chest wall. A review of the ER Report, dated 11/28/19, at 11:19 a.m., indicated the swelling around the eyes were due to the subcutaneous [MEDICAL CONDITION] caused by the rib fractures and pneumothorax. The ER Report indicated a chest tube (a flexible plastic tube that is inserted through the chest wall) was inserted to remove the air. During a telephone interview, on 12/18/19 at 12:32 p.m., the certified nursing assistant 1 (CNA 1) stated she was the sitter for Resident 1 on 11/28/19 during the night shift. CNA 1 stated at approximately 5 a.m., Resident 1 was restless and was getting out of bed saying, I have to go. CNA 1 stated she tried to calm down Resident 1. Resident 1 suddenly got out of bed and grabbed the side rails. CNA 1 stated she grabbed Resident 1's waist from behind and hugged her to place Resident 1 back to her bed. CNA 1 stated Resident 1 was heavy so she guided Resident 1 to the floor mat beside Resident 1's bed. During an interview and record review, on 12/31/19 at 1:45 p.m., the Director of Nursing (DON) stated the nurse practitioner documented on the MD notes that Resident 1 was prone to fractures. The DON stated there were no care plans addressing Resident 1 was prone to fractures. A review of Resident 1's clinical record indicated there was no care plan found. During a telephone interview and concurrent record review on 1/15/20, at 9:56 a.m., the MD progress notes and the care plan was reviewed with the registered nurse supervisor (RNS). RNS stated there was no care plan addressing Resident 1's prone to fractures. RNS stated the facility did not see the MD notes. During a telephone interview, on 1/16/20 at 8:29 a.m., CNA 1 stated no one informed her that Resident 1 was prone to fractures. CNA 1 stated if she had known, I would not be turning Resident 1 by myself and would always ask for assistance. A review of the facility's policy titled, Care Plans, Comprehensive Centered, revised 12/2016, indicated a comprehensive person-centered care plan that included measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs was developed and implemented for each resident. The care plan would describe the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being.

Based on observation, interview and record review, the facility's nursing staff failed to ensure the safety for three of 15 sampled residents (Residents 1,8, 9 and 16). Resident 16 was not provided supervision and eloped from the facility on March 25, 2014. Resident 16 was missing for 3 days and found on March 28, 2014, in the General Acute Care Hospital, (GACH). Resident 16 was diagnosed in the GACH with an altered level of consciousness, dehydration and [DIAGNOSES REDACTED]. Failure to provide supervision for residents who elope out of the facility had a potential for harm to the resident. Residents 1 and 8, had orders for a tab alarm, (an alert for the staff when the resident gets up unassisted), while in bed or in a wheel chair to prevent falls. This deficient practice had a potential for a resident to suffer a fall with injury. The facility's maintenance staff failed to ensure the safety of residents by ensuring one oxygen tank found inside of a storage room, located directly next to residents rooms was turned off. The facility failed to ensure the safety of residents by not turning off the oxygen tank in a storage room located next to residents rooms. The facility maintenance staff failed to provide a safe interior for residents by not securing televisions and other heavy objects to prevent them from falling. This deficient practice placed residents at risk for injury. The facility's staff failed to provide medical treatment and care in a safe and clutter free environment free from hoarding. This deficient practice had the potential to put these residents and others at risk for fire hazards. Findings: 1. During an observation on August 16, 2014, at 12:30 p.m., one resident was observed walking out of the facility. A Certified Nurse Assistant (CNA) was seen leaving out of the facility to return the resident to the facility. On August 17, 2014, at 2:10 p.m., 5 residents were seen sitting in the entrance hallway without staff supervision. One resident got up and stated, "I need to leave" and attempted to leave the facility. A facility staff was informed regarding the resident' s statement and brought the resident back inside. During an observation on August 15, 2014, from 5 p.m. to 9 p.m. and on August 16, 2014, from 7 a.m. to 5 p.m. and again on August 17, 2014, from 7:30 a.m. to 4 p.m., there was no facility staff assigned to supervise the front entrance of the skilled nursing facility. During an interview on August 17, 2014, at 11:45 a.m., with the facility's Administrator when asked about the lack of staff supervising the front entrance door she stated, there are video cameras constantly being used to monitor the front entrance door. The administrator also stated, the facility's staff are suppose to supervise the front door. During an interview with the Assistant Administrator on August 17, 2014 at 1:10 p.m., when asked if any residents eloped, he stated Resident 16 was missing from the facility on March 25, 2014, but was found on March 28, 2014, at the General Acute Care Hospital (GACH). A review of the GACH records indicated, Resident 16 was found 3 days later with [DIAGNOSES REDACTED] (low sugar, with altered level of consciousness (confused) dehydrated, with difficulty breathing and was taken by paramedics to GACH. A review of the Admission record indicated Resident 16 was admitted on [DATE], with [DIAGNOSES REDACTED]. According to the Licensed Nursing Notes, on March 25, 2014, at 3:10 p.m. , Resident 16 was seen standing at the entrance of the dining room. At 4:20 p.m., a Certified Nurse Accident (CNA) was unable to locate the resident. At 7 p.m., the police department was informed (missing persons division was notified). At 8 p.m., the facility's administrator was notified at 8:10 p.m., the conservator was notified; and at 8:15 p.m., the primary physician was notified. A review of the policy and procedure undated and titled, "Policy: Missing Resident," directed that, to assure missing residents are located quickly, two or more staff will search the neighborhood and after an hour the facility will notify: the police; administrator and DON, physician and family. There was no policy and procedure to protect residents from leaving the facility unsupervised. The facility failed to supervise and prevent Resident 16 from leaving the facility and suffering harm. 2. During an initial tour on August 15, 2014 at 6 p.m., Resident 9's bed had approximately 2 feet of piled brown paper bags filled with food items such as; cookies, chips, packaged foods, biscuits, clothing items, cookies, newspapers, toiletries, toothpaste, toothbrush, soap, and clothing items lying against the walls, and on top of the night stand. During an interview, Resident 9 was asked if she had any difficulty getting out of her bed, the resident stated no. There were many items observed stacked along the bedside obstructing a clear pathway to and from the bathroom. A review of an Admission record indicated, Resident 9 was admitted on [DATE], with a [DIAGNOSES REDACTED]. A review of Resident 9's care plan, Interdisciplinary Team (IDT) notes and the Licensed Nurses Notes did not address the hoarding problem or the cluttered and unsanitary living environment. A review of Resident 9's medical record indicated, the social service notes revealed, there was no documentation to show an attempt was made to counsel or help the resident with relocating some of the personal items. A review of the Licensed Nursing Notes indicated, there were no entries written to address this resident's risk for falls and that the room was not safe for the resident. During an interview with the Director of Nursing (DON) on August 8, 2014 at 12:15 p.m., when the surveyor asked for documentation addressing Resident 9's excessive accumulation of items and the hazard it could create, the DON stated, there was none available. During an interview with the social worker on August 16, 2014 at 10:45 a.m., when the surveyor asked why there were piles of paper bags in Resident 9's room she stated, these were the resident's belongings and extra supplies of food, that resident kept in her room. She further indicated, these items were brought to the facility by her family during their visits. 3. On August 16, 2014 at 8:40 a.m., during a medication pass, Licensed Vocational Nurses (LVN) 1 was observed giving medication to Resident 6. On a table next to Resident 6's bed there was a water pitcher, a half empty bottle of energy drink, coffee in a glass decanter, several containers of cookies and packages of food. The floor beside the resident's bed was cluttered with newspapers, magazines and boxes of food items, one walking cane, shoes, and a leg brace. There was not a cleared area observed around Resident 6's bedside. 4. During an observation on August 16, 2014, at 4 p.m., in the entrance hallway Resident 13 was observed sitting in a wheelchair with a table in front of her, and eating. On the table were: 4 cans of ensure, 4 bottles of water and three foil covered plates of food. Beside Resident 13 was a two shelf metal cart full of fruit and packages of food wrapped in napkins in plastic bags. When the surveyor asked the resident why she was eating in the hallway, the resident became very agitated and started yelling. During an interview, on August 17, 2014, at 9:45 a.m., the social worker stated, Resident 13 refuses to eat in the dining room or in her room. According to the social worker the resident does not eat food prepared by the facility. The social worker indicated, Resident 13 prefers to eat in her room and insists on eating in the hall way by the building entrance. The resident also insists on keeping food for hours and shares the food with other residents. The social worker said, the resident becomes violent and will throw food items at the staff when she is asked to participate in groups or to eat in the dining room, or when asked by the facility staff to not share food with other residents. A review of Resident 13's Admission record indicated, she was admitted on [DATE], with [DIAGNOSES REDACTED]. According to the medical record, Resident 13 refuses medical treatment, blood sugar checks, medication, laboratory tests, and food from the facility. Resident 13 keeps food for hours that the family brings to the facility including canned food and shares with other residents. There was no documentation of evaluation and treatment of [REDACTED]. A review of the facility's policy and procedure undated, titled "Unmanageable Residents," indicated, uncooperative residents can be transferred and an incident report will be filed in the medical records. A review of the facility policy and procedure undated, titled" refusal of Medications and Treatment" states that "repeated refusal shall be reported to the DON and the Attending physician. There was no policy and procedure for clutter free environment or hoarding. The facility's staff failed to provide medical treatment and care in a safe and cluttered free environment. 5. A review of a physician's order, dated April 11, 2014, indicated, Resident 1 was to have a "tab alarm" while in bed and when up in the wheel chair, to alert staff when the resident gets up unassisted. A review of Resident 1's Admission record, dated June 3, 2009, indicated he was readmitted to the facility with [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS) (an assessment screening tool), dated June 24, 2014, the resident was assessed with [REDACTED]. During the survey from August 14 through 17, 2014, Resident 1 was observed with no "tab alarm" either attached to the resident's bed or wheel chair. On August 16, 2014 ,at 8:30 a.m., during an interview the Certified Nurse Assistant (CNA) 1 stated, he was not aware the resident was supposed to have a tab alarm on his bed. On August 16, 2014, during an interview, the Director of Nurses (DON) stated, she was not aware the resident should have a tab alarm on his bed. 6. A review of the admission record indicated Resident 8 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), dated [DATE], indicated the resident was independent with his cognitive skills for daily decision making and required extensive assistance by staff with activities of daily living (ADL - bed mobility, transfer, walking, locomotion, dressing, toilet use, personal hygiene and bathing). The Fall Risk Assessment, dated March 6, 2014, indicated the resident had a fall risk score of 10 indicating that he was a high risk for fall. There was a physician's order dated, March 6, 2014, to provide a tab alarm while in the wheelchair for fall management prevention. A review of Resident 8's March 6, 2014, at 12:30 a.m., indicated the resident was seen at the front lobby sitting on the floor next to his wheelchair. The resident fell from his wheelchair but had no injury noted. On August 14, 2014 at 6 p.m., the resident was observed seating in his wheelchair next to his bedside. The resident's wheelchair did not have a tab alarm attached. A review of the resident's Nursing Clinical Notes dated August 12, 2013, at 1 p.m., revealed that Resident 5 fell out from his wheelchair and was found on the floor. The licensed nurse documented that the staff failed to provide the resident a soft waist belt when he was sitting in his wheelchair. The resident did not sustain an injury from the fall. During an interview with the director of nursing (DON) on August 14, 2014, at 7 p.m., he stated, the resident should have a tab alarm while in the wheelchair. A care plan dated March 6, 2014, for an actual fall had an intervention for staff to provide a tab alarm while the resident was up in the wheelchair. 7. On August 12, 2014, at 5:08 p.m., during the initial tour of the facility the following was observed: a. Water was water observed leaking from the ceiling skylight in the hallway near the nursing station. There was a small trash can observed in the floor to catch the water, however there was a large puddle of water on the floor beyond the small trash can which was a fall potential for residents, visitor and staff. b. In Rooms 1, 10, 12, 14, 16, 18 and 24 there were multiple televisions varying in size and other miscellaneous items, i.e., antennas, on bedside tables and other surfaces that were either not secured or were secured but were to large for the surface on which they sat. c. On August 16, 2014, during general observation of the facility in the presence of the maintence supervisor, there was large oxygen cylinder with a valve attached to the cylinder that had the oxygen on and set to 2 liters. The administrator and the director of nursing was informed of the finding. On the same day during an interview with the director of nursing he stated, "there were no residents in the facility currently on oxygen".

Based on observation, interview and review of records, the facility's nursing, maintenance and administrative staff failed to ensure the safety of residents by not securing (locking and alarming) the front door of the building, not maintaining a functioning door that completely closed and latched shut when accessed, and by not following up to ensure the door was repaired and the building was secure after learning of the theft of Resident 13's property. On April 14, 2013, at approximately 10:30 p.m., a stranger (thief) entered the facility through an unlocked, unalarmed, opened front door. While in the facility the thief entered Resident 13's room, without the knowledge of the staff or resident, and stole his fanny pack, which contained $325 cash, a credit card, check book, cell phone, access card and Medi-Cal card. On April 20, 2013, at 5 p.m., two Evaluators, the administrator and the assistant business office manager tested the door while it was in a locked and unlocked position. It was determined that the door did not self-close, latch (click shut) and/or remained ajar when allowed to close without manual assistance. On the same day a review of the video surveillance tape clearly showed staff who were working in the facility, the night of the theft (April 14, 2013), did not lock the front door, activate the door alarm, or monitor the entrance, with the door left ajar. A review of the Face Sheets of 15 residents, whose rooms were located along the hallway of Unit One and were directly adjacent and in view of the building's malfunctioning front door, revealed vulnerable residents that were mostly dependent upon staff for assistance with care needs, resided in the rooms. These rooms were away from and out of the view of the nursing station, making the residents at a higher risk of abuse by strangers unknowingly entering the building through an unsecured door, at night and in a high-crime area. A situation of Immediate Jeopardy (IJ) was declared by the survey team on April 21, 2013, at 7:24 a.m. The facility's administrator, director of nursing (DON), director of staff development (DSD) and the assistant business office manager were immediately notified of the seriousness of the survey team's findings. The facility's staff formulated a written plan of correction (POC), which included calling a company to repair the door, in-servicing staff on locking the doors at night, activating the alarm system and designating someone to sit at and monitor the door after 7 p.m., until the repairs were made. On April 22, 2013, at 5:30 p.m., a monitoring visit revealed the front door still did not shut/lock properly, and the IJ remained in effect. On April 23, 2012, at 4:45 p.m., after ensuring the front door of the facility worked properly, the administrator was informed the IJ was lifted. The facility also failed to ensure the residents' environment was free of hazards, by not securing their television set and/or cable boxes, placing the residents at risk of injury in the event the televisions were to fall over. Findings: a. On April 20, 2013, at 2 p.m., an Entity Reported Incident (ERI) regarding a stranger entering the facility and stealing Resident 13's property was investigated during the survey. On April 20, 2013, at 2 p.m., during a resident group meeting, Resident 13 reported his property had been stolen by a stranger entering the facility through the front door of the building. He stated when he had returned to the facility after 10 p.m. on separate occasions, the front door would often be open (ajar) because it did not work properly. He stated, on several occasions, prior to his property being stolen, he had reported to the nurses on the evening shift, the assistant business office manager and in the resident council meeting that the front door of the facility was broken, but nothing was done about it. A non-sampled resident attending the group meeting stated she had documented in the meeting notes regarding the broken door. A review of the Residents' Council Minutes, dated January 17, 2013, February 26, 2013, and March 21, 2013, indicated there were no resident concerns. There were no notes about a broken door as indicated by the non-sampled resident. On April 20, 2013, at 3:40 p.m., during an interview Resident 13 stated he was out of the facility on April 14, 2013, Sunday, and returned at approximately 10:30 p.m. He stated he noticed the front door of the facility was open at an approximate 45 degree angle. He entered the building and saw a black gentleman standing in the hallway. He asked him who he was and what he was doing there and was told by the stranger that he was there visiting someone. Resident 13 stated he went to his room, was assisted by a nurse, and then went to the activity/dining room, but realized he did not have his fanny pack. He returned to his room to look for his fanny pack, but could not find it. After he and the staff searched for his fanny pack he realized the stranger he had encountered in the hallway had taken it. He said the facility viewed the video on April 15, 2013, Monday, and it was confirmed the stranger in the hallway had in fact taken his belongings Resident 13 stated he had reported, on several occasions over a 2 to 3 month period, to the evening shift nurses and the Assistant Business Office Manager that the front door was not operating correctly, but no one had repaired it. A review of Resident 13's Minimum Data Set (MDS), an assessment and care screening tool, dated March 26, 2013, revealed he was originally admitted to the facility on [DATE]. He was assessed as alert and oriented to person, place, and time, and he utilized a wheelchair for mobility. On April 20, 2013, at 4:33 p.m., during an interview, the administrator stated when she came to work on April 15, 2013, the front door was ajar. She stated she interviewed the evening shift staff, who worked the night of the incident, and they told her the door was locked at 8 p.m., and no one had reported to her that the door was broken. She reviewed the video surveillance tape and it clearly showed a stranger entering the facility and walking out of Resident 13's room with his fanny bag. She called a company to repair the door and when the company left the faciity on Tuesday, April 16, 2013, she assumed the door had been repaired. She did not attempt to follow up with the repair company until the doors were tested by the Evaluators on April 16, 2013, and found they still were not self-closing/latching properly. During the interview, when asked who was responsible for viewing the video monitor, the administrator stated the assistant business office manager reviews the video the day after it records, Monday through Friday. She stated the camera viewed the front doors and the common areas of the facility. She stated that the monitor is locked in the office, and is not available to staff because she doesn't want them to spend all of their time looking at the monitor. The office is locked on the weekends and after hours. On April 20, 2013, at 5:15 p.m., during interviews, the assistant business office manager, and two licensed vocational nurses (LVN 1 and LVN 2) stated no report was given to them regarding a broken door. The social service designee (SSD) stated after the incident occurred Resident 13 told her he had reported on several occasions to the nurses on the 3-11 shift, that the door needed to be repaired. The SSD stated she did not interview the evening shift nurses about the reports of the door not operating properly, but did report what the resident told her at one of their stand up meetings. At 5:20 p.m., the activity director (AD), after reviewing the resident council meeting notes, gave no explanation why the residents' concerns about the door had not been documented in the minutes. On April 20, 2013, at 5:30 p.m., the facility's video surveillance tape was viewed by two Evaluators, the administrator and the assistant business office manager. The video footage showed the front door of the facility had not been locked or the alarm activated on April 14, 2013, the evening of the theft. The front door was left ajar and at approximately 10:30 p.m., an African American man entered the facility, went into Resident 13's room and exited the facility through the front door, which was still ajar and unalarmed, with Resident 13's property under his arm. Staff working in the facility who were made aware that a stranger had entered the building were shown going to the front door closing it but not locking or alarming it. The video footage revealed that at 10:48 p.m., night shift staff entered the facility door, which was not locked, and after entering the building, the door did not shut, but remained ajar in an opened position. The Administrator stated she had only viewed the tape from the time the man entered the facility until he left with Resident 13's property. She had taken the word of her staff that they had locked the door at 8 p.m., and did not think to rewind further to determine if they had in fact locked the door or if the door operated properly, by self-closing and latching after it was accessed. She stated there was no written policy on locking/alarming the doors, but the staff knew they were to lock the doors after 8 p.m. for security reasons. On April 20, 2013, at 6 p.m., during an interview, the assistant business office manager stated the repair company came to the facility on [DATE]. He stated he left the building before the repairs were complete and when he returned to the facility on Wednesday, April 17, 2013, he tested the doors, which he thought were working properly at the time. He stated he did not receive an invoice or work order from the repair company and assumed the work was completed, and they would be billed for the work done. On April 20, 2013, when it was determined the front door of the building still did not self-close or latch properly, and on the direction of the Administrator, he called another repair company. On April 22, 2013, at 5:30 p.m., during a monitoring visit, the front doors of the building were tested several times, but still did not self-close or latch properly. This was after the repair company had supposedly completed repairs on the door earlier that day. On April 23, 2013, at 9:10 a.m., during another interview, the assistant business office manager clarified that the initial company that attempted to repair the door, had to order parts and could not complete the repair work on April 16, 2013. On April 23, 2013, at 3:45 p.m., during an interview, LVN 3 stated she was aware the door was not catching (closing properly) prior to the incident on April 14, 2013. She stated Resident 13 had told her a few times during the last 2 to 3 weeks and had found that the front door was not catching and the back door would blow open because it also did not shut properly. She stated she knows she is supposed to lock the doors every night, and usually does so between 7:30 p.m. and 8 p.m. She was not sure if she documented it but stated she reported it to the night shift charge nurse, and both of them would go together to the back door and lock it to keep it from blowing open. On April 23, 2013, after the repair company returned to the facility and it was verified the repairs were complete and the front door functioned properly, the IJ was lifted at 4:45 p.m. One April 24, 2013, a review of the staff endorsement book and the maintenance log revealed there was no written report of any doors not working properly. b. On April 18, 2013, at 6 p.m. during the initial tour of the facility the following was observed: In Rooms 1 Bed C, 2 Beds A, B, 3 Bed A, 6 Bed C, 7 Bed A, 8 Bed A, 9 Bed B, C, 10 Bed A, B, 11 Bed A, B, C, 12 Bed A, B, televisions were observed sitting on resident's bedside tables, night stands and rolling television stands. On top of some of the televisions were cable boxes and/or radios. The televisions were manually moved and it was determined they were not secured to the furniture on which they sat. The televisions ranged in size from 19 inch to 50 inch. Some were relatively light (flat screens) and others were the large box type televisions. On April 18, 2013, at 6 p.m., during an interview, the director of nursing stated the televisions should be secured because in the event of an earthquake they could fall and injure the residents.

Based on observation, interview, and review of records, the facility's administrative staff failed to implement written policies and procedures to prevent misappropriation of all residents' property, including Resident 13, by not securing (locking and alarming) the front door of the building. They also failed to maintain a functioning door that completely closed and latched shut when accessed, and by not following up to ensure the door was repaired and the building was secure after learning of the theft of a resident's property. On April 14, 2013, at approximately 10:30 p.m., a stranger (thief) entered the facility through an unlocked, unalarmed, opened front door. While in the facility the thief entered Resident 13's room, without the knowledge of the staff or the resident, and stole his fanny pack, which contained $325.00 in cash, a credit card, check book, cell phone, access card and Medi-cal card. On April 20, 2013, at 5 p.m., two Evaluators, the administrator and the assistant business office manager, tested the door while it was in a locked and an unlocked position. It was determined that the door did not latch (click shut) and/or remained ajar when allowed to close without manual assistance. On the same day a review of the video tape clearly showed staff who were working in the facility, the night of the theft (April 14, 2013), did not lock the front door, activate the door alarm, or monitor the entrance (the door was left ajar) to ensure the residents were safe. A review of the Face Sheets of 15 residents, whose rooms were located along the hallway of Unit One and were directly adjacent and in view of the building's malfunctioning front door, revealed vulnerable residents that were mostly dependent upon staff for assistance with care needs. These rooms were away from and out of the view of the nursing station, making the residents at a higher risk of abuse by strangers unknowingly entering the building through an unsecured door, at night and in a high-crime area. A situation of Immediate Jeopardy (IJ) was declared by the survey team on April 21, 2013, at 7:24 a.m. The facility's administrator, director of nursing (DON), director of staff development (DSD) and the assistant business office manager were immediately notified of the seriousness of the survey team's findings regarding the inoperable front door. The facility's staff formulated a written plan of correction (POC), which included calling a company to repair the door, in-servicing staff on locking the doors at night, activating the alarm system and designating someone to sit at and monitor the door after 7 p.m., until the repairs were made. On April 22, 2013, at 5:30 p.m., a monitoring visit found the front door still did not self-close/latch or lock properly, and the IJ remained in effect. On April 23, 2013, at 4:45 p.m., after ensuring the front door of the facility self-closed, latched and locked properly, the administrator was informed the IJ was lifted. Findings: On April 20, 2013, at 2 p.m., an Entity Reported Incident (ERI) regarding a stranger entering the facility and stealing Resident 13's property was investigated during the survey. On April 20, 2013, at 2 p.m., during a resident group meeting, Resident 13 reported his property had been stolen by a stranger entering the facility through the front door of the building. He stated when he had returned to the facility after 10 p.m. on separate occasions, the front door would often be open (ajar) because it did not work properly. He stated, on several occasions, prior to his property being stolen, he had reported to the nurses on the evening shift, the assistant business office manager and in the resident council meeting that the front door of the facility was broken, but nothing was done about it. A non-sampled resident attending the group meeting stated she had documented in the meeting notes regarding the broken door. A review of the Residents' Council Minutes, dated January 17, 2013, February 26, 2013, and March 21, 2013, indicated there were no resident concerns. There were no notes about a broken door as indicated by the non-sampled resident. On April 20, 2013, at 3:40 p.m., during an interview Resident 13 stated he was out of the facility on April 14, 2013, Sunday, and returned at approximately 10:30 p.m. He stated he noticed the front door of the facility was open at an approximate 45 degree angle. He entered the building and saw a black gentleman standing in the hallway. He asked him who he was and what he was doing there and was told by the stranger that he was there visiting someone. Resident 13 stated he went to his room, was assisted by a nurse, and then went to the activity/dining room, but realized he did not have his fanny pack. He returned to his room to look for his fanny pack, but could not find it. After he and the staff searched for his fanny pack he realized the stranger he had encountered in the hallway had taken it. He said the facility viewed the video on April 15, 2013, Monday, and it was confirmed the stranger in the hallway had in fact taken his belongings Resident 13 stated he had reported, on several occasions over a 2 to 3 month period, to the evening shift nurses and the Assistant Business Office Manager that the front door was not operating correctly, but no one had repaired it. A review of Resident 13's Minimum Data Set (MDS), an assessment and care screening tool, dated March 26, 2013, revealed he was originally admitted to the facility on [DATE]. He was assessed as alert and oriented to person, place, and time, and he utilized a wheelchair for mobility. On April 20, 2013, at 4:33 p.m., during an interview, the administrator stated when she came to work on April 15, 2013, the front door was ajar. She stated she interviewed the evening shift staff, who worked the night of the incident, and they told her the door was locked at 8 p.m., and no one had reported to her that the door was broken. She reviewed the video surveillance tape and it clearly showed a stranger entering the facility and walking out of Resident 13's room with his fanny bag. She called a company to repair the door and when the company left the faciity on Tuesday, April 16, 2013, she assumed the door had been repaired. She did not attempt to follow up with the repair company until the doors were tested by the Evaluators on April 16, 2013, and found they still were not self-closing/latching properly. During the interview, when asked who was responsible for viewing the video monitor, the administrator stated the assistant business office manager reviews the video the day after it records, Monday through Friday. She stated the camera viewed the front doors and the common areas of the facility. She stated that the monitor is locked in the office, and is not available to staff because she doesn't want them to spend all of their time looking at the monitor. The office is locked on the weekends and after hours. On April 20, 2013, at 5:15 p.m., during interviews, the assistant business office manager, and two licensed nocational nurses (LVN 1 and LVN 2) stated no report was given to them regarding a broken door. The social service designee (SSD) stated after the incident occurred Resident 13 told her he had reported on several occasions to the nurses on the 3-11 shift, that the door needed to be repaired. The SSD stated she did not interview the evening shift nurses about the reports of the door not operating properly, but did report what the resident told her at one of their stand up meetings. At 5:20 p.m., the activity director (AD), after reviewing the resident council meeting notes, gave no explanation why the residents' concerns about the door had not been documented in the minutes. On April 20, 2013, at 5:30 p.m., the facility's video surveillance tape was viewed by two Evaluators, the administrator and the assistant business office manager. The video footage showed the front door of the facility had not been locked or the alarm activated on April 14, 2013, the evening of the theft. The video footage showed the front door was left ajar and at approximately 10:30 p.m., an African American man entered the facility, went into Resident 13's room and exited the facility through the front door, which was still ajar and unalarmed, with Resident 13's property under his arm. Staff working in the facility who were made aware that a stranger had entered the building were shown going to the front door closing it but not locking or alarming it. Video footage at 10:48 p.m., indicated night shift staff entering the facility door. They opened the front door, which was not locked, and after entering the building, the door remained in ajar in an opened position. The administrator stated she had only viewed the tape from the time the man entered the facility until he left with Resident 13's property. She had taken the word of her staff that they had locked the door at 8 p.m., and did not think to rewind further to determine if they had in fact locked the door or if the door operated properly, by self-closing and latching after it was accessed. She stated there was no written policy on locking/alarming the doors, but the staff knew they were to lock the doors after 8 p.m. for security reasons. On April 20, 2013, at 6 p.m., during an interview, the assistant business office manager stated the repair company came to the facility on [DATE]. He stated he left the building before the repairs were complete and when he returned to the facility on Wednesday, April 17, 2013, he tested the doors, which he thought were working properly at the time. He stated he did not receive an invoice or work order from the repair company and assumed the work was completed, and they would be billed for the work done. On April 20, 2013, when it was determined the front door of the building still did not self-close or latch properly, and on the direction of the Administrator, he called another repair company. On April 22, 2013, at 5:30 p.m., during a monitoring visit, the front doors of the building were tested several times, but still did not self-close or latch properly. This was after the repair company had supposedly completed repairs on the door earlier that day. On April 23, 2013, at 9:10 a.m., during another interview, the assistant business office manager clarified that the initial company that attempted to repair the door, had to order parts and could not complete the repair work on April 16, 2013. On April 23, 2013, at 3:45 p.m., during an interview, LVN 3 stated she was aware the door was not catching (closing properly) prior to the incident on April 14, 2013. She stated Resident 13 had told her a few times during the last 2 to 3 weeks and had found that the front door was not catching and the back door would blow open because it also did not shut properly. She stated she knows she is supposed to lock the doors every night, and usually does so between 7:30 p.m. and 8 p.m. She was not sure if she documented it but stated she reported it to the night shift charge nurse, and both of them would go together to the back door and lock it to keep it from blowing open. On April 23, 2013, after the repair company returned to the facility and it was verified the repairs were complete and the front door functioned properly, the IJ was lifted at 4:45 p.m. One April 24, 2013, a review of the staff endorsement book and the maintenance log revealed there was no written report of any doors not working properly.