Every finding on record at Cedar Mountain Post Acute

Based on observation, interview, and record review, the facility failed to ensure that one of four Certified Nursing Assistants (CNA 1) knew how to respond effectively in the event of a power outage affecting residents who were dependent on ventilators (machine to assist residents who are too sick, weak, or injured to breathe well on their own). This failure posed a significant risk to the lives of fourteen clinically compromised residents who were on ventilators due to their clinical condition.Findings:During a concurrent observation and interview on July 22, 2026, at 1:30 PM, with the Respiratory Supervisor (Supervisor) and the Maintenance Director (Director), a tour of the subacute care unit (a transitional inpatient facility providing goal-oriented, specialized medical and rehabilitative care for residents who are stable enough to leave an acute-care hospital but remain too medically complex or fragile to safely return home) was conducted. It was noted that the subacute care unit can accommodate a maximum of 30 subacute resident beds, but only two rooms (Rooms 401A and 410A) were equipped with red emergency outlets (a specialized electrical socket connected to a backup generator or uninterruptible power supply), along with two red emergency outlets located in the hallway, totaling of four red emergency outlets. It was also noted that the ventilators for the fourteen residents in the subacute unit were not plugged into red emergency outlets.During an interview on July 22, 2026, at 1:38 PM, with Certified Nursing Assistant (CNA 1), CNA 1 stated she was assigned to subacute care unit. She was asked how to respond in the event of a power outage, specifically regarding residents on ventilators. CNA 1 stated she was not supposed to handle ventilators herself and would just contact the respiratory therapist. CNA 1 did not verbalize that she was expected to immediately assess the ventilator-dependent residents or to verify that the ventilators were connected to a designated red emergency outlet.During an interview on August 12, 2026, at 11:00 AM, with CNA 2, CNA 2 was asked what to do to residents who have ventilators in the event of power outages. CNA 2 stated that he would assess the residents and then take the extension cords to connect ventilator to the red emergency outlet.During an interview on August 12, 2006, at 11:29 AM, with CNA 3, CNA 3 was asked what she would do while caring for a resident on a ventilator during a power outage. CNA 3 stated she would bring an extension cord, plug it into the red emergency outlet, and call the respiratory therapist for assistance.During an interview on August 12, 2026, at 11:33 AM, with CNA 4, CNA 4 was asked what she would do for a resident on a ventilator during a power outage. CNA 4 stated she will plug the power extension cord into the red outlet, and check on all residents with ventilators and follow their emergency plansDuring a concurrent interview and record review on August 12, 2026, at 12:55 PM, with the Admin. the Admin reviewed and acknowledged the facility's policy and procedures (P&P) titled, Electrical Power Failure, with a revision date of December 7, 2018, was reviewed. The P&P indicated, In the event of a power outage, all ventilator-dependent residents will continue to receive uninterrupted respiratory support. Ventilators and other essential respiratory equipment will be connected to the facility's emergency power system through designated red emergency outlets. 1. Respiratory Therapy and nursing staff will immediately assess all ventilator-dependent residents when a power outage occurs. 2. Verify that each ventilator is operating on internal battery power and confirm that all ventilator settings, alarms, and resident parameters remain appropriate. 3. Each ventilator must be connected to a designated red emergency outlet as soon as possible. 4. When a red emergency outlet is not located close enough to the resident's ventilator, a facility-approved, hospital grade, grounded extension cord may be used to connect the ventilator to the red emergency outlet.

Based on interview and record review, the facility failed to implement their own policy regarding safety and supervision for one of three sampled residents (Resident 1) when Resident 1 had a fall incident during a transfer to a shower chair on March 14, 2026. This failure may have potentially contributed to Resident 1 sustaining acute mildly displaced fracture of the proximal tibia and proximal fibular shaft (a recent break in the upper neck of the knee and the thin shin bone). Findings: A review of Resident 1's admission RECORD indicated Resident 1 was last admitted to the facility on [DATE], with diagnoses of hemiplegia (a condition of not being able to move one side of the body) hemiparesis (a condition of weakness on side of the body affecting arms and legs, aphasia (a condition of not able to speak) and age-related cataract (a condition of the eye). A review of Resident 4's History and Physical dated, February 20, 2026, indicated, . OTHER PLAN: . Patient [Resident 1] is not able to make own decisions.A review of Resident 1's care plan dated December 5, 2025, indicated, Focus [Name of Resident 1] has an ADL (Activities of Daily Living [daily self-care tasks to remain healthy, safe and independent]) self-care performance deficit r/t (related to) right sided hemiplegia, . REQUIRES TOTAL ASSISTANCE WITH[the caregiver does all the work, such as lifting, movement and cleaning.] ADLs A review of Resident 1's care plan dated March 19, 2026, indicated, Focus The resident has had an assisted fall with injury mild fracture to left proximal tibia. A review of Resident 1's clinical record Radiology Results Report, indicated, Radiology March 19, 2026, 15:40 Left Knee, 1/2 views / Left Tibia and Fibula, two views .Impressions: . There is an acute mildly displaced fractures of the proximal tibia and proximal fibular shaft. A review of a facility provided record titled, Investigation Notes dated March 19, 2026, indicated, . [Name of CNA 2] reported that on 3/14/26 during a transfer to a shower chair in the resident's room, with assistance from [Name of CNA 3), the resident was unable to bear weight. The resident was lowered to the floor in a controlled manner. [Name of CNA 2] reported she continued her shift and did not report the incident to the charge nurse at that time. During an interview on April 2, 2026, at 1:34 PM, with the Director of Nursing (DON), the DON acknowledged Resident 1 had a fracture of the left knee and a recent fall incident. The DON further stated it was his third day at the facility and was reviewing residents' records. During a phone interview on April 8, 2026, at 2:34 PM, with the Clinical Consultant (CC), the CC stated Resident 1 had a fall incident on March 14, 2026, during care with two staff. The staff did not report the fall incident until an investigation was initiated because of an x-ray result that showed fracture of Resident 1's left knee. A review of a facility provided document titled, Summary of Incident dated, March 19, 2026, indicated, . Summary of Incident: On 03/19/2026, the facility initiated an investigation after a resident was identified with a fracture of unknown origin. Conclusion: Based on staff interviews and record review, findings indicate the resident experienced an assisted fall during a transfer. The event was not reported, which limited the ability for timely clinical assessment and intervention. During a concurrent phone interview and record review on April 15, 2026, at 2:00 PM, with the Administrator, the facility's P&P titled, Safety and Supervision of Residents, dated, April 15, 2026, was reviewed. The P&P indicated, Policy Statement Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. 4. Employees shall be trained on potential accident hazards and demonstrate competency on how to identify and report accident hazards and try to prevent avoidable accidents.A review of the facility's policy and procedure (P&P) titled, Falls and Fall Risk, Managing dated, April 8, 2026, indicated, .Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling.

Based on observation, interview, and record review, the facility failed to provide appropriate care and services, which were consistent with the resident's needs and choices, for residents who are unable to carry out Activities of Daily Living (those needed for self-care and mobility and include activities such as bathing, dressing, grooming, oral care, ambulation, toileting, eating, transferring, and communicating) independently for one of three sampled residents (Resident 1) when Resident 1, who was dependent for self-care and mobility, was repositioned by a Certified Nursing Assistant (CNA 1) in bed by himself, dishonoring Resident 1's Wife's preference for Resident 1 for a two-person assist (safe patient handling technique in healthcare where two trained caregivers help someone move, transfer, or perform daily activities when they can't do it alone). This failure resulted in Resident 1 to fall out of bed, posing a potential risk to Resident 1's health and safety.Findings: A review of Resident 1's face sheet (contains demographic and medical information) indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included anoxic brain damage (the brain is completely deprived of oxygen leading to severe damage), tracheostomy status (a patient has a surgically created opening in their neck leading to the windpipe to provide an airway), and gastrostomy status (a person has a tube (a G-tube) going through their belly directly into their stomach, creating a shortcut for food, liquids, and medicine).A review of Resident 1's Fall Risk Evaluation (a healthcare process to identify factors increasing someone's chance of falling), dated October 2, 2025, indicated a score of 11. (If the total score is 10 or greater, the resident should be considered at High risk for potential falls.)A Review of Resident 1's Care Plan for Activity Living, initiated on October 5, 2025, indicated Resident 1 .Requires Total Assistance ADLs Non-Ambulatory Wife Prefers 2 person assist: Bed mobility (turning/repositioning) transfers, and oob (out of bed). Further reviewed indicated TRANSFER: The resident is totally dependent on (2) staff for transferring.A review of Resident 1's MDS (Minimum Data Set - federally mandated process for clinical assessment of all residents in Medicare or Medicaid-certified nursing homes), dated October 9, 2025, under Section GG (specifically measures the resident's functional abilities, such as transfer, walking, and self-care), indicated Resident 1 had score of one (1) for self-care and mobility. (Score of 1 means the resident is dependent. Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity.)A review of Resident 1's SBAR (a written communication tool focused on Situation, background, assessment, recommendation), dated November 8, 2025, indicated, resident had witnessed fall and all 3 set of vitals were abnormal.A review of Resident 1's Nurse Notes, dated November 8, 2025, at 6:05 AM, indicated, at approximately 0545 (5:45 AM) nursing aid (CNA 1) approached the charge nurse and reported his resident is on the floor. Resident was sent out (transferred to the hospital) for witnessed fall, all 3 vitals were abnormal, B/P (Blood Pressure) 79/66, Pulse 124, Oxygen saturation 85%, notified family representative and MD (Medical Doctor).A review of Resident 1's General Acute Care Hospital (GACH) Discharge summary, dated [DATE], indicated, .Date of admission November 8, 2025.Patient was transferred from a post-acute facility after a witnessed fall from bed during transfer. It is unclear if the patient struck his head.A review of Resident 1's GACH Care Assessments, dated November 10, 2025, it indicated Safety recommendations 2 Person Total Assist for bed mobility.During interview on January 8, 2026, at 12:05 PM, with the Assistant Director of Nursing (ADON), the ADON stated Resident 1 had a fall incident on November 8, 2025, while being assisted solely by CNA 1.During a telephone interview on January 8, 2026, at 2:33 PM, with CNA 1, CNA 1 stated that on November 8, 2025, he was changing Resident 1's incontinence pad alone due to a lack of assistance and the impending end of his shift. He further stated he noted that Resident 1 was positioned very close to the edge of the bed, and when he turned Resident 1 onto his side, Resident 1 fell off the bed. He stated that the protocol requires a two-person assist for Resident 1, as he was total care. He acknowledged that it was incorrect for him to assist the resident alone. A review of the facility's policy and procedure (P&P), dated April 2025, titled Activities of Daily Living (ADLs), Supporting, indicated, .5. Appropriate care and services are provided for residents who are unable to carry out ADLs independently, with the consent of the resident, and in accordance with the plan of care.

Based on observation, interview, and record review, the facility failed to ensure three of three sampled residents (Resident 17, Resident 22, and Resident 25) were free from accident hazards when:a. The wheelchair arm rests for Resident 22 were peeled off with abrasive fragments and exposed cushion.b. Floor mats were not provided as ordered for injury prevention interventions for Resident 17. c. Floor mats were not provided as ordered for injury prevention interventions for Resident 25.These failures had the potential to compromise the safety of Residents 22, 17, and 25 and result in skin breakdown, accidents, and injuries.Findings: a. A review of Resident 22's admission Record, indicated Resident 22 was admitted to the facility on [DATE], with diagnoses that included cerebral palsy (a condition marked by impaired muscle coordination and/or other disabilities, typically caused by damage to the brain before or at birth), diabetes (a long term condition that causes high blood sugar levels), and paraplegia (loss of voluntary movement and/or sensation in the lower body, including the legs, caused by damage to the spinal cord) among others. During a concurrent observation and interview with Resident 22, on 9/22/25, at 9:35 AM, inside Resident 22's room, the cover for both armrests of Resident 22's wheelchair were observed peeled off, exposing the underlying cushion. The edges of the peeled off cover had rough and uneven surfaces. Resident 22 stated the armrest cover started peeling off six months ago. A review of Resident 22's Care Plan Report titled, .AT RISK for impairment in skin integrity r/t [related to] fragile skin., dated 8/26/21, indicated .Identify/document potential causative factors and eliminate/resolve where possible. During an interview with the Director of Rehabilitation Services (DOR), on 9/24/25, at 11:14 AM, the DOR stated the armrests of a wheelchair were high-contact points and residents used them for mobility purposes and to rest their arms. The DOR stated a torn cover of the armrest could potentially cause skin issues like abrasions and skin tears. During a concurrent interview and record review with the DON, on 9/26/25, at 3:00 PM, the facility's policy and procedure (P&P) titled, Compliance Risks-Resident Quality of Care and Quality of Life, dated January 2025, was reviewed. The P&P indicated, .Policy Interpretation and Implementation.2. The following quality of care/quality of life standards are recognized as high-risk areas and therefore are carefully monitored.Resident Safety.4. Residents are provided with a safe, clean, and comfortable environment that is free of accident hazards, and adequately supervised. The DON stated the armrest on Resident 22's wheelchair should have been in good working condition, and further stated the facility's policy was not followed. b. A review of Resident 17's admission Record, indicated Resident 17 was admitted to the facility on [DATE], with diagnoses of Parkinson's Disease (a progressive brain disorder affecting movement) and hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body) following a stroke. During an observation on 9/22/25, at 4:14 PM, in Resident 17's room, Resident 17 was observed in bed and there was no floor mat present. During a concurrent observation and interview with Licensed Vocational Nurse 3 (LVN 3), on 9/22/25, at 4:20 PM, in Resident 17's room, LVN 3 verified Resident 17 did not have a floor mat on the right or left side of the bed. During an observation and interview with Registered Nurse 1 (RN 1), on 9/22/25, at 4:28 PM, in Resident 17's room, RN 1 verified there was no floor mat on the floor next to Resident 17's bed. RN 1 stated a floor mat should be placed just below the bed to protect a resident from injury from a fall. A review of Resident 17's order entry, dated 8/15/25, indicated right floor mat to prevent injury in case of fall. A review of Resident 17's care plan for risk for falls, dated 9/22/25, indicated Fall mat while resident in bed to reduce risk of injury. During an interview with the Assistant Director of Nursing (ADON), on 9/24/25, at 10:40 AM, the ADON stated the purpose of floor mats was to protect residents in case of a fall, so they would not have major injuries from the fall. The ADON stated if the floor mat was ordered at the right side of the bed, it should be at the right side to protect Resident 17. During a concurrent interview and record review of Resident 17's order entry, dated 8/15/25, with the Director of Nursing (DON), on 9/25/25, at 3:38 PM, the DON verified there was an order for a right-side floor/fall mat for Resident 17. The DON stated the physician order was not followed and implemented. c. A review of Resident 25's admission Record, indicated Resident 25 was readmitted to the facility on [DATE], with diagnoses including muscle weakness, unsteadiness on feet, hemiplegia (paralysis or weakness on one side of the body) affecting right dominant side, other muscle spasm (involuntary contractions of a muscle), and history of falling.A review of Resident 25's Minimum Data Set (MDS – a standardized assessment tool), dated 8/15/25, indicated Resident 25's cognitive skills for decision making were intact. The MDS indicated Resident 25 had upper extremity impairment on one side of the body and lower extremity impairment on both sides of the body. The MDS further indicated Resident 25 had a fall in the last month prior to admission and a fracture related to a fall in the six months prior to admission. A review of Resident 25's Care Plan titled Fall Risk, dated 8/8/25, indicated interventions including a floor mat to left side to prevent injury. A review of Resident 25's Order Summary Report, dated 9/24/25, indicated an order on 9/23/25 for a floor mat to the left side of Resident 25's bed to prevent injury. During an observation on 9/23/25, at 8:36 AM, in Resident 25's room, there was no floor mat observed on the left side of Resident 25's bed. Resident 25 was observed with a fall risk band on the right wrist. During a concurrent observation and interview with Resident 25, in Resident 25's room, on 9/24/25, at 8:19 AM, there was no floor mat observed on the left side of Resident 25's bed. Resident 25 stated Resident 25 had not had floor mats since admission.During a concurrent observation and interview with LVN 4, in Resident 25's room, on 9/24/25, at 8:40 AM, LVN 4 identified Resident 25 as a fall risk and verified Resident 25 did not have a floor mat on the left side of the bed. LVN 4 stated it would be important for Resident 25 to have the floor mat in place to prevent falls and injury. During a concurrent interview and record review with the DON, on 9/25/25, at 2:45 PM, the DON stated a floor mat should have been in place on the left side of Resident 25's bed in accordance with the physician's order dated 9/23/25 and Resident 25's fall risk care plan dated 8/8/25. The DON acknowledged the intervention was not implemented as required and confirmed the absence of the floor mat placed Resident 25 at increased risk of potential injury. A review of the facility's policy and procedure (P&P) titled, Falls, undated, indicated The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. Cross reference to F656.

Based on observation, interview and record review, the facility failed to ensure dental services, including the timely provision and replacement of dentures, were provided to one of one sampled resident (Resident 84).This failure had the potential to result in impaired nutrition, oral pain and discomfort, difficulty eating, and decreased quality of life for Resident 84.Findings:A review of Resident 84's admission Record (a document containing a summary of basic information about the resident), indicated Resident 84 was admitted to the facility on [DATE] and readmitted to the facility on [DATE].A review of Resident 84's Minimum Data Set (MDS- a standardized assessment tool), dated 9/10/25, indicated Resident 84's cognitive (ability to think and reason) skills for decision making were intact. The MDS indicated Resident 84 had no natural teeth.A review of Resident 84's Treatment Sheet, dated 6/19/25, indicated a Treatment Plan including a referral for new dentures.A review of Resident 84's Care Plan titled Dental Status, dated 9/16/25, indicated interventions including to coordinate arrangements for dental care and to monitor/document/report any signs and symptoms of oral/dental problems needing attention.A review of Resident 84's Order Summary Report, dated 9/24/25, indicated orders for regular diet easy to chew texture and dental evaluation and treatment as indicated.During a concurrent observation and interview with Resident 84, in Resident 84's room, on 9/22/25, at 10:20 AM, Resident 84 was observed with no natural teeth. Resident 84 stated Resident 84 had dentures at the previous facility, but the current facility did not ask about dentures upon admission. Resident 84 stated it was difficult for Resident 84 to chew at times, and the staff must give Resident 84 chopped food, despite being on a regular diet. Resident 84 further stated Resident 84 would like to get new dentures.During a concurrent interview and record review with the Social Services Director (SSD), on 9/25/25, at 8:49 AM, the SSD verified Resident 84 did not have a referral for dental services after readmission. The SSD stated it was the responsibility of the SSD to complete and follow up on Resident 84's dentures and it should have been done. The SSD stated it was important to follow up on dental services for eating and dignity purposes.A review of the facility's Policy and Procedure (P&P), titled Dental Services, undated, indicated . Social services will assist residents with appointments and arrangements as needed . Lost or damaged dentures will be addressed per regulatory requirements.

Based on observation, interview and record review, the facility failed to implement infection prevention and control practices to provide a safe and sanitary environment to help prevent the transmission of spreadable diseases and infections when:1. One gray basin was found on the bathroom floor containing four food containers and two utensils.2. Respiratory Therapist 1 (RT 1) did not do hand hygiene after stepping out from Resident 58's room and after removing gloves.3. Three resident trash bins were full and overflowing.These deficient practices posed the risk for transmission of communicable diseases and infections to residents in the facility. Findings: 1. During an observation on 9/22/25, at 9:15 AM, in the bathroom between the rooms of Resident 6 and Resident 20, a gray basin containing food containers and utensils was found on the floor. During a concurrent observation and interview with Certified Nurse Assistant 1 (CNA 1), on 9/22/25, at 12:55 PM, CNA 1 was asked about the contents of the gray bin and stated there were four food containers and two forks. CNA 1 stated this was not common practice and these items should not be kept on the bathroom floor. During a concurrent interview and record review, with the Infection Preventionist (IP), on 9/26/25, at 3:15 PM, IP was asked if finding food containers and utensils on the bathroom floor in a resident's room was an expectation. IP stated it was not an expectation. IP added that she expected her staff to follow infection control protocols. The facility's policy and procedure (P&P) titled, Infection Prevention and Control Program was reviewed with the IP. The P&P indicated, an Infection Prevention and Control Program is established and maintained to provide safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. IP acknowledged the staff did not follow the policy when food containers were found on the floor. 2. A review of the facility census dated 9/21/2025, indicated Resident 58 was on Enhanced Barrier Precautions (EBP- an infection control precaution utilized to prevent the spread of multi-drug-resistant infectious disease to residents). During a concurrent observation and interview on 9/22/25, at 9:23 AM, RT 1 was observed putting on gloves upon entering Resident 58's room. RT 1 then changed a used yankauer (a handheld suction tip used in medical settings to clear secretions like blood and saliva from the airway or surgical sites) with a new one and exited the room. Then, RT 1 removed the gloves. RT 1 did not do hand hygiene after stepping out of the room or after removing the gloves. RT 1 stated the expectation was to do hand hygiene before and after entering a resident's room. RT 1 stated he did not do hand hygiene when he stepped out of Resident 58's room. During an interview with the IP on 9/26/25, at 3:26 PM, the IP stated Resident 58 was on EBP and the expectation was for staff to practice standard precautions (basic infection control practices in healthcare setting that includes hand hygiene and appropriate use of protective equipment) when entering and exiting the room if they did not provide high-contact resident care. The IP further stated RT 1 should have practiced hand hygiene upon entering and exiting Resident 58's room.A review of the facility's policy and procedure titled, Enhance Barrier Precautions, revised December 2024, indicated, .Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents. 15. Standard precautions apply to the care of all residents regardless of suspected or confirmed infection or colonization status. 3. During observations on 9/22/25, at 12:58 PM, the following were observed: a. The trash bin in Resident 12's room was full and overflowing.b. The trash bin in Resident 20's room was full and overflowing.c. The trash bin in Resident 88's room was full and overflowing. During a concurrent interview and record review with the IP on 9/26/25, at 3:26 PM, the facility's policy and procedure (P&P) titled, Infection Prevention and Control Program, revision date December 2023, was reviewed. The P&P indicated, . Policy Statement. An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The IP stated the overflowing trash bins were not consistent with maintaining a safe and sanitary environment.

Based on interview and record review, the facility failed to ensure an accurate assessment for one of four sampled residents (Resident 12) when the Minimum Data Set (MDS- a standardized assessment tool) assessment did not reflect the accurate status of Resident 12 who was receiving hospice (end of life care) services.This failure had the potential for unmet services necessary for Resident 12's hospice care.Findings:A review of Resident 12's admission Record, dated 9/26/25, indicated Resident 12 was admitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary disease (COPD- a progressive lung disease which blocks air flow making breathing difficult) and cirrhosis of the liver (scarring of the liver, caused by chronic injury or long-term liver disease) among others.A review of the facility document titled, Order Entry, a physician's order for Resident 12, dated 7/8/2025, indicated, May admit to (Name of company) Hospice under (name of physician) Dx (abbreviation for diagnosis): COPD.A review of the facility's Clinical Census, dated 9/26/25, indicated Resident 12 was under hospice services, with effective date 7/8/2025.During a concurrent interview and record review with the MDS Director (MDS 1), on 9/26/25, at 11:46 AM, the MDS Significant Change assessment Section O (Special Treatment, Procedures and Programs) was reviewed. MDS 1 stated she was responsible for the assessment under Section O where part of the assessment would indicate if a resident was under hospice care. MDS 1 stated she completed the Section O for Resident 12. A review of Resident 12's Section O indicated an entry of No for Hospice care. MDS 1 stated Resident 12 was under Hospice care and should have been coded as such under Section O.During a concurrent interview and record review with the Director of Nursing (DON), on 9/26/25 at 3:00 PM, the facility's undated policy and procedure (P&P) titled, Resident Assessment, was reviewed. The P&P indicated, .Policy Interpretation and Implementation.10. Assessments are completed by staff members who have the skills and qualifications to assess relevant care areas and who are knowledgeable about the resident's strengths and areas of decline.11. All persons who have completed any portion of the MDS resident assessment form must sign the document attesting to the accuracy of such information. The DON stated the assessment for Resident 12 was not accurate because the resident was not coded under hospice care, and further stated the policy was not followed.

Based on observation, interview and record review, the facility failed to develop and implement comprehensive and person-centered care plans for one of one sampled resident (Resident 25) when:a. There was no care plan addressing anticoagulant (medication that helps prevent blood clots) use for Resident 25.b. The facility did not implement injury prevention interventions identified in Resident 25's fall risk care plan.These failures had the potential to result in complications from anticoagulant therapy and injury from falls for Resident 25.Findings:a. A review of Resident 25's admission Record, indicated Resident 25 was readmitted to the facility on [DATE] with diagnoses including Unspecified Atrial Fibrillation (Afib - an irregular heartbeat that commonly causes poor blood flow).A review of Resident 25's Minimum Data Set (MDS- a standardized assessment tool), dated 8/15/25, indicated Resident 25's cognitive (ability to think and reason) skills for decision making were intact. The MDS indicated Resident 25 had a diagnosis of Atrial Fibrillation with medication including an anticoagulant.A review of Resident 25's Order Summary Report (a document that consolidates prescription information) dated 9/24/25, indicated Resident 25 had an order for Eliquis (an anticoagulant medication used to treat and prevent blood clots) Oral Tablet 2.5 milligrams (mg- a unit of measure) two times per day for Afib.During a concurrent interview and record review of Resident 25's Care Plans, with the Assistant Director of Nursing (ADON), on 9/24/25, at 12:24 PM, the ADON verified there was no care plan in place for Resident 25's use of an anticoagulant.During a concurrent interview and record review of Resident 25's Care Plans, with the Director of Nursing (DON), on 9/25/25, at 2:53 PM, the DON acknowledged the importance of developing a care plan for the use of anticoagulants to ensure Resident 25 was being monitored for discoloration, bleeding, and bruising. The DON stated if the care plan was not in place, the side effects would be overlooked.b. A review of Resident 25's admission Record, indicated Resident 25 was readmitted to the facility on [DATE] with diagnoses including muscle weakness, unsteadiness on feet, hemiplegia (paralysis or weakness on one side of the body) affecting right dominant side, other muscle spasm (involuntary contractions of a muscle), and history of falling.A review of Resident 25's MDS dated [DATE], indicated Resident 25's cognitive skills for decision making were intact. The MDS indicated Resident 25 had upper extremity impairment on one side of the body and lower extremity impairment on both sides of the body. The MDS further indicated Resident 25 had a fall in the last month prior to admission, and a fracture related to a fall in the six months prior to admission.A review of Resident 25's Care Plan titled Fall Risk dated 8/8/25, indicated interventions including floor mat to the left side to prevent injury.During an observation on 9/23/25, at 8:36 AM, in Resident 25's room, there was no floor mat observed on the left side of Resident 25's bed. Resident 25 was observed with a fall risk band on the right wrist. During a concurrent observation and interview with Resident 25, on 9/24/25, at 8:19 AM, in Resident 25's room, there was no floor mat observed on the left side of Resident 25's bed. Resident 25 stated Resident 25 had not had floor mats since admission.During a concurrent observation and interview with Licensed Vocation Nurse 4 (LVN 4), on 9/24/25, at 8:40 AM, LVN 4 identified Resident 25 as a fall risk and verified Resident 25 did not have a floor mat on the left side of the bed. LVN 4 stated it would be important for Resident 25 to have the floor mat in place to prevent falls and injury.During a concurrent interview and record review with the DON, on 9/25/25, at 2:45 PM, the DON stated a floor mat should have been in place on the left side of Resident 25's bed, as outlined in Resident 25's fall risk care plan. The DON confirmed the intervention had not been implemented as required and acknowledged that failing to follow the care plan placed Resident 25 at safety risk and risk for potential injury.A review of the facility's policy and procedure (P&P) titled, Care Planning - Interdisciplinary Team, undated, indicated comprehensive, person-centered care plans are based on resident assessments.A review of the facility's policy and procedure (P&P) titled, Falls, undated, indicated The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. Cross reference to F689.

Based on interview, and record review the facility staff failed to notify the physician for one of three sampled residents (Resident 2) when: 1. Resident 2 had twenty-four episodes of high blood pressure (blood pressure higher than 160) and were not reported to the doctor. This failure had the potential to cause Resident 2 to suffer complications. 2. Resident 2 had eight episodes of high blood sugars and were not reported to the doctor. This failure had the potential to cause Resident 2 to suffer complications. Finding: During a review of Resident 2's Admission Record (contains demographic and medical information) dated, August 21, 2023, indicated Resident 2 was admitted to the facility on [DATE], with diagnoses which included Diabetes Mellitus (high blood sugar) and Hypertensive Heart Disease (A condition of the heart caused by high blood pressure). During a review of Resident 2's Medication Administration Record (MAR) dated August 1, 2023, through August 30, 2023, it indicated, Hydralazine HCL (medication used to treat high blood pressure) Oral Tablet 100 mg: give 1 tablet by mouth three times a day for hypertension hold for SBP< 100 [systolic blood pressure of Blood Pressure less than 100] Order date June 10, 2023. Further review of Resident 2's MAR dated August 1, 2023, through August 30, 2023, it indicated, Isosorbide Dinitrate (medication used to treat high blood pressure) Oral Tablet 20 mg: give 1 tablet by mouth three times a day for hypertension hold for SBP [Systolic Blood Pressure less than 100] Started Date May 5, 2023. During a review of Resident 2's MAR on August 30, 2023, at 1:30 PM, there was no documented evidence the physician had been notified for the following blood pressure levels: August 9, 2023, at 1:00 PM BP [blood pressure] 190/100, August 9, 2023, at 5:00 PM BP 167/93 August 10, 2023, at 9:00 AM, BP 201/93, August 14, 2023, at 9:00 AM, BP 188/104, August 14, 2023, at 1:00 PM, BP 177/75, August 14, 2023, at 5:00 PM BP 162/89, August 15, 2023, at 9:00 PM, BP 191/97, August 15, 2023, at 1 PM, BP 181/79, August 18, 2023, at 9:00 AM, BP 163/75, August 18, 2023, at 1:00 PM, BP 188/93, August 19, 2023, at 9:00 AM, BP 198/94, August 19, 2023, at 1:00 PM, BP 168/67, August 19, 2023, at 5:00 PM, BP 198/94 August 20, 2023, at 9:00 AM, BP 178/91, August 20, 2023, at 1:00 PM, BP 166/87, August 20, 2023, at 5:00 PM, BP 190/90, August 23, 2023, at 9:00 PM, BP 167/88, August 23,2023, at 5:00 PM, BP 163/90, August 24, 2023, at 9:00 AM, BP 168/90, August 24, 2023, at 1:00 PM, BP 168/68, August 28, 2023, at 9:00 AM, BP 186/97, August 28, 2023, at 1:00 PM, BP 198/88, August 29, 2023, at 9:00 AM, BP 191/98 and August 29, 2023, at 1:00 PM, BP 165/95. During an interview on August 30, 2023, at 2:29 PM, with Clinical Resource Nurse, (CRN), the CRN stated her expectation from the nurses is if they notice a resident with an elevated blood pressure is to recheck BP in both arms to ensure accuracy, to notify the doctor and document in the change of condition which includes nurses progress notes. During a review of Resident 2's Nursing Notes dated from August 1, 2023, through August 30, 2023, there was no documented evidence Resident 2's physician was notified of elevated blood pressure. 2. During a review of Resident 2's MAR dated, August 1, 2023, through August 30, 2023, indicated, insulin NPH (A medication used to treat high blood sugar): Inject 8 units subcutaneously (under the skin) two times a day for Diabetes. Start Date May 19, 2023. During a review of Resident 2's MAR on August 30, 2023, at 1:30 PM, there was no documented evidence Resident 2's physician had been notified for the following blood sugars levels: 6:30 AM: August 1, 2023, blood sugar level 442 mg/dl , August 2, 2023, blood sugar level 400 mg/dl, August 6, 2023, blood sugar level 400 mg/dl, August 10, 2023, blood sugar level 450 mg/dl, and August 20, 2023, blood sugar 65 mg/dl 7:00 PM: August 20, 2023, blood sugar level 581 mg/dl, and August 29, 2023, blood sugar level 400 mg/dl During a review of Resident 2's MAR dated, August 1, 2023, through August 30, 2023, indicated, insulin Lispro (a medication used to treat high blood sugar) Injection Solution Unit/ML: inject 6 unit subcutaneously in the evening for Diabetes Mellitus: Give before meals. Started date: July 04, 2023. During a review of Resident 2's MAR on August 30, 2023, at 1:30 PM, there was no documented evidence Resident 2's physician had been notified for the following high blood sugars levels. 5:00 PM: August 5, 2023, blood sugar level 400mg/dl and August 20, 2023, blood sugar level 416 mg/dl During a review of Resident 2's, Care Plan dated, May 7, 2023, indicated, .focus potential for fluctuating glucose levels secondary to DM [Diabetes Mellitus] Date initiated May 7, 2023. Goal will no sign and symptoms of Glycemic reactions x 90 days. Blood sugar will be within normal limits with no symptoms of hypo/Hyperglycemia for 90 days, date initiated: May 7, 2023, target date: October 29, 2023, Interventions .Monitor for sign & symptoms of glycemic reactions qshift. [every shift] Monitor thirst, excessive appetite or voiding, change in level of consciousness .report to MD promptly. During a review of Resident 2's Nursing Notes dated from August 1, 2023, through August 30, 2023, there was no documented evidence Resident 2's physician was notified of elevated blood sugar or low blood sugar. During an interview on August 30, 2023, at 1:38 PM with Registered Nurse 1 (RN 1), RN 1 reviewed the MAR with elevated blood pressure and elevated blood sugars and agree that would be interpreted as physician was not notified. RN 1 further stated, she could not find any Nurses Progress Notes, or any documentation of the physician was notified. RN 1 further stated, The expectation is that MD gets notify, if the MD give an order to administer any additional insulin, then to recheck blood sugar an hour after, to document and to do a change of condition that includes monitoring for seventy-two hours. Same steps for elevated blood pressure. During an interview with License Vocational Nurse 1 (LVN 1), on September 6, 2023, at 5:31 PM, via telephone, LVN 1 stated she remembered on August 20, 2023, Resident 2 had a blood sugar level of 581mg/dl. She stated the reason the doctor was not notified was because she was busy. LVN 1 further stated that when the blood sugar is higher than 400 mg/dl the MD must be notified. During an interview with License Vocational Nurse 2 (LVN 2) on September 6, 2023, at 6:30 PM via telephone, LVN 2 stated, she did not remember if the MD was informed. She further stated if it was not documented on the nurse's progress notes, then the MD was not informed. LVN 2 further stated that when a resident's blood sugar is higher than 400 mg/dl, the MD must be notified, and documented in the nurse's progress notes. LVN 2 further stated, when the blood pressure is elevated, the MD must be notified, and nurses would document in the progress nurse's notes. During a review of the facility's policy and procedure titled, Insulin Administration dated, September 2014, indicated, .Reporting .2. Notify the physician if the resident has signs and symptoms of hypoglycemia that are not resolved if the resident has signs and symptoms of hypoglycemia .) During a review of the facility's policy and procedures titled, Hypertension-Clinical Protocol revised November 2018, indicated, .2. The physician will identify situation where hypertension should be treated and will try to individualize treatment goals and blood pressure targets. a. treatment goals and blood pressure target ranges should be individualized .

Based on observation, interview and record review, the facility failed to ensure one of three sample residents (Resident 1) was transferred from chair to bed by using a Hoyer lift (a device used for lifting and safely transfering residents) with a sling (an assembly which connects the load to the Hoyer lift). This failure resulted in harm when Resident 1 sustained bruises on right upper inside of the arm and left upper inside of arm. Findings: During a review of the clinical record for Resident 1 title, Admission Record, indicated Resident 1 was admitted to the facility on [DATE], with the admitting diagnosis of: Unspecified Fracture of T9 - T10 Vertebra (T9 Thoracic [midback] is Fracture is a serious injury that can lead to long term complications and T10 Thoracic vertebra fracture will be likely result in a limited or complete loss of use of lower abdomen muscles .), Seizures (uncontrolled burst of electrical activity in the brain) and Major Depressive Disorder (a mental condition characterized by a persistently depressed mood and long-term loss of pressure or interest in life). During an observation on June 16, 2023 at 1:45 PM in Resident 1's room, Resident 1 was on a sitting up position, with head of the bed elevated to 90 degrees angle. Resident 1 was awake, alert, and oriented and able to verbalize his needs. Resident 1 was wearing a C-collar (a device used to support and immobilize a patient's neck) and TLSO brace (a brace that limits movement in the spine form the midback to the low back). During an interview on June 16, 2023, at 1:45 PM, in Resident 1's room, Resident 1 stated that on Saturday June 10, 2023, while he was sitting on his chair, 2 staff Certified Nurse Assistants (CNA 1 and CNA 2) came to assist him back to his bed. Resident 1 told them he wanted them to use the Hoyer lift with a sling but instead CNA 1 lift him from his arms and CNA 2 grabbed his feet, and place him on bed. Resident 1 stated they left bruises on him under his upper arms area. During a Concurrent observation and interview on June 16, 2023, at 2:10 PM with Registered Nurse (RN 1), RN 1 identified the bruises on Resident 1's arms. RN 1 stated according to Resident 1, it occurred when CNA 1 and CNA 2 transferred him back to bed and did not used the Hoyer lift with a sling. RN 1 futher stated they knew Resident 1 need the Hoyer lift with a sling when transferring but CNA 1 and CNA 2, failed to use to Hoyer lift with a sling. During an interview on June 16, 2023, at 3:56 PM, via phone with Director of Nurses (DON), the DON stated that she was informed on June 13, 2023, that Resident 1 was handled out of his chair and back to bed by 2 staff members on Saturday night. It was reported to the DON that Resident 1 wanted to go back to bed, and that CNA 1 and CNA 2 transferred Resident 1 without using a Hoyer lift with a sling. The DON stated CNA 1 and CNA 2, did not give a reason of why they failed to use the Hoyer lift with a sling, while transferring Resident 1 back to bed. When DON did an assessment of Resident 1's skin, DON identified the bruises on Resident 1 arms. DON stated, that immediately suspended the CNA 1 and CNA 2 and then, both CNAs got terminated the following day. DON acknowledge that the CNA 1 and CNA 2, failed to follow the lifting policy while transferring Resident 1. During an interview on June 21, 2023, at 1:08 PM via phone with the administrator (ADM) , the ADM stated that she was informed about the incident on June 13, 2023, while doing her rounds. She was informed by Resident 1 about the bruises. ADM stated that she informed Resident 1 that she was going to have the DON to check on him immediately. ADM stated that after the investigation the two employees were terminated. ADM agreed that CNA 1 and CNA 2 failed to follow the facility's policy of using the Hoyer lift with a sling with Resident 1. During a review of clinical record title, Clinical Care Plan Detail, undated, indicated for intervention to: Utilize C collar brace per resident request of use, Use Hoyer, and proper sling to transfer . During a review of clinical record title, eINTERACT Change in Condition Evaluation - V 5.1, dated June 13, 2023, at 2:17 PM indicated, 1. Signs & Symptoms Identified 1. The change in condition, symptoms, or signs I am calling about is/ are: 36. Change in skin color or condition 2. This started on: June 10, 2023 .4. Summarize your observations, evaluation, and recommendations: Resident was lifted by 2 cna back to bed using his bil forearms to transfer and other cna had his feet resident had a sling under him and failed to use the Hoyer. CNA stood behind resident while he was in the wheelchair and grabbed his forearms . 2. Skin Status Evaluation 6a. Describe skin changes: 5. Discoloration Site Description nickel size red purple area to rt [Right] upper arm quarter quarter size red area with skin peeling to left upper inside of arm . During a review of the facility's policy and procedure title, Lifting Machine, using a Mechanical indicated the purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device .2. Mechanical lifts may be used for tasks that require transferring a resident from bed to chair .

Based on observation, interview and record review, the facility failed to follow proper sanitation and food safety practices to prevent foodborne illnesses as evidenced by food debris, black grime and dirt were observed under the kitchen stove and griddle. This failure had the potential to result in food contamination and foodborne illnesses to medically compromised population of 71 of 94 residents in the facility. Findings: During a concurrent observation and interview with the Kitchen Cook (KC 1) on March 13, 2023, at 8:35 AM, there were food debris, black grime and dirt seen under the kitchen stove and griddle. The KC 1 stated the floor should be kept clean and free from debris and dirt. During an interview with the Dietary Service Supervisor (DSS) on March 14, 2023, at 3:15 PM, the DSS stated they had designated staff assigned each day for mopping and sweeping the kitchen floor. The DSS stated the kitchen floors should be kept clean, otherwise it could potentially attract insects and rodents which could contaminate food. During a concurrent interview and record review with the Administrator (ADM) on March 16, 2023, at 1:00 PM, of the facility's policy and procedure (P&P), titled, General Appearance of Food and Nutrition Department, dated 2018, indicated, Floors, floor mats, and walls must be scheduled for routine cleaning and maintained in good condition .2 .Sweep the floor, pushing all debris forward. Use a dustpan to remove and dispose of debris as it accumulates The ADM stated the kitchen should be kept clean. The ADM further stated the facility did not follow their policy. In a review of the FDA ( Food and Drug Administration) Federal Food Code 2017, 4-402.12 titled, Fixed Equipment, Elevation or Sealing, indicated, The inability to adequately or effectively clean areas under equipment could create a situation that may attract insects and rodents and accumulate pathogenic microorganisms that are transmissible through food.

Based on observation, interview, and record review, the facility failed to accurately code the status of a pressure injury (a wound developed on bony prominences as a result of prolonged pressure) in the Minimum Data Set (MDS - a computerized clinical assessment) for Resident 31. This failure had the potential to inaccurately reflect Resident 31's status to the oversight agency (Center for Medicare and Medicaid Services - CMS), who provides funding for Resident 31. Findings: During a review of Resident 31's clinical record, the face sheet (contains admission and demographic information), indicated Resident 31 was admitted on [DATE], with diagnoses which included chronic respiratory failure (long term dysfunction or complications of the lungs), intestinal obstruction (a condition in which digested material is prevented from passing normally through the bowel), and chronic kidney disease (long term dysfunction or complications of the kidneys). Upon further review of the clinical record for Resident 31, the Admission assessment dated [DATE], indicated Resident 31's skin was assessed by a licensed nurse and no pressure injuries were noted upon admission. During an observation on March 14, 2023, at 3:08 PM, Resident 31 was observed in bed, with a foam wedge placed under the left side of her body, offloading weight from her sacral area. Resident 31 was observed on a low air loss mattress (an air mattress to help cushion a body's bony prominences, while letting out air very slowly through tiny holes to help keep the skin dry and free of moisture). During a concurrent interview and record review with a MDS Nurse (MDS 1) on March 15, 2023, at 9:35 AM, Resident 31's Quarterly MDS Assessment, dated February 13, 2023, and Skin Assessment - Pressure Ulcer, dated October 10, 2022, were reviewed. The skin assessment indicated a Sacrum Stage 4 (pressure injury is staged to specify depth - stage 4 indicates exposed muscle or bone) developed on October 4, 2021. The skin assessment also indicated the sacral pressure injury was not present upon admission. The Quarterly MDS Assessment's Section M: Skin Conditions indicated the pressure injury was coded as present upon admission/entry or reentry. After the review, MDS 1 confirmed this was not coded accurately, and should have been coded as not present on admission, since the pressure injury developed in the facility. During an interview with the Director of Nursing (DON) on March 16, 2023, at 3:35 PM, Resident 31's Quarterly MDS Assessment, dated February 13, 2023, and Skin Assessment - Pressure Ulcer, dated October 10, 2022, were reviewed. The DON confirmed the pressure injury was inaccurately coded in Section M: Skin Conditions, and should have been coded to reflect the pressure injury was not present upon admission. During a review of CMS's Long-Term Care Facility Resident Assessment Instrument [RAI] 3.0 User's Manual Version 1.17.1, revised October 2019, the RAI Manual indicated instructions for properly coding section M, .For each pressure ulcer/injury, determine if the pressure ulcer/injury was present at the time of admission/entry or reentry and not acquired while the resident was in the care of the nursing home .

Based on observation, interview, and record review the facility failed to submit an updated Preadmission Screening and Resident Review (PASRR - a federal screening requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care) after a diagnosis of Schizophrenia (a serious mental illness that affects how a person think, feels, and behaves, and is often characterized by symptoms of visual or auditory hallucinations) had been identified after admission for Resident 78. This failure had the potential for Resident 78 not to be accurately assessed by a qualified mental health professional, in order to ensure proper placement related to his mental illness. Findings: During a review of Resident 78's clinical record, the face sheet (contains admission and demographic information) indicated the resident was admitted on [DATE], with diagnoses which included acute necrotizing hemorrhagic encephalopathy (a central nervous system disease secondary to a viral infection, causing brain damage). A PASRR had been submitted upon Resident 78 admission to the facility, but did not indicate a mental illness diagnosis, or the need for further screening. Further review of the clinical record indicated Resident 78 had a psychiatry consult for further evaluation, on September 27, 2022, one month after he was admitted to the facility. The consult notes indicated .He [Resident] has history of schizophrenia and being in psychiatric hospitals in the past .Patient is having auditory hallucinations . During a concurrent observation and interview on March 13, 2023, at 8:22 AM, Resident 78 was observed lying in bed, mumbling, and talking to himself. No one else was at his bedside at the time. When interviewed, the resident was able to engage in simple conversation and answer questions but was noted to be very easily distracted and talkative about details not pertaining to the original conversation. During an interview with the Director of Nursing (DON) on March 14, 2023, at 3:27 PM, the DON stated the expectation was for a new PASRR to be submitted once a diagnosis of a mental illness had been identified, in order for Resident 78 to be properly referred to and evaluated by a qualified mental health professional. The DON confirmed another PASRR was not submitted for Resident 78 and stated it should have. During an interview with the Administrator (ADM), on March 14, 2023, at 4:30 PM, the ADM stated the facility did not have a policy to specifically address the resubmitting of the PASRR for a new diagnosis of mental illness. The ADM further stated the PASRR should have been resubmitted, to indicate a resident review and status change had occurred.

Based on observation, interview and record review, the facility failed to provide services to maintain and improve one of one sampled resident (Resident 36) ability to communicate her needs to the facility staff. This failure had the potential to cause Resident 36's needs to go unmet resulting in frustration, pain, and discomfort. Findings: A review of Resident 36's face sheet (a document that gives a summary of resident's information), undated, indicated Resident 36 was admitted to the facility on [DATE], with diagnoses that included: amyotrophic lateral sclerosis (ALS-a nervous system disease that weakens muscles and impacts physical function), quadriplegia (a symptom of paralysis that affects all a person's limbs and body from the neck down), tracheostomy (an incision in the windpipe made to relieve an obstruction to breathing), and dependence on respirator/ventilator (dependent on mechanical ventilation). During an observation and interview with Resident 36 on March 13, 2023, at 8 AM, Resident 36 was unable to speak. Resident 36 was able to mouth the words yes and no and make eye contact but nothing more. Resident 36 was unable to move any part of her body, not even her head to indicate yes or no. There were no communication aids available in Resident 36's room. During an interview with a Licensed Vocational Nurse (LVN 1) on March 13, 2023, at 3:43 PM, LVN 1 stated she read Resident 36's lips for yes and no and to determine what Resident 36 needed. LVN 1 stated if she could not understand what Resident 36 was trying to say she would conduct a Zoom meeting- using the webcam to engage in virtual meetings with Resident 36's husband who assisted with understanding what Resident 36 needed. During an observation and interview with LVN 1, a Certified Nursing Assistant (CNA 1), a Respiratory Therapist (RT 1) and Resident 36 on March 13, 2023, at 4:12 PM, CNA 1 stated he helped Resident 36 with repositioning and brief changes. CNA 1 stated he could sort of read Resident 36's lips. CNA 1 stated if he could not read Resident 36's lips he would get another staff person to try. LVN 1 and CNA 1 were in Resident 36's room and Resident 36 was trying to communicate mouthing multiple words. LVN 1 and CNA 1 were concentrating on Resident 36's mouth but could not understand what Resident 36 was trying to say. There was an alphabet/picture communication board lying on an overbed table positioned next to the far wall. LVN 1 and CNA 1 stated they did not use the alphabet/picture communication board (a communication visual aid. It was designed specifically to suit a person's needs, using an Alphabetical key and pictures depicting pain, hot, cold, etc . The resident used an eye gaze or partner assisted scanning to facilitate communication). LVN 1 stated RT 1 was very good at reading Resident 36's lips and she would get RT 1 to help read Resident 36's lips. RT 1 arrived in Resident 36's room. RT 1 stated she did not use the alphabet/picture communication board. RT 1 read Resident 36's lips. Through RT 1's translation, Resident 36 stated the staff did not use the alphabet/picture communication board. Resident 36 stated she would like the staff to use the alphabet/picture communication board, but they did not. During an observation and interview with Resident 36 and Resident 36's husband on March 14, 2023, at 10:41 AM, Resident 36's husband stated the staff could not understand Resident 36. Resident 36's husband stated he had been working with the facility's Social Services Director (SSD) to get a computer type communication device, but it had been three months and the SSD had not updated him on the progress. Resident 36's husband had his own alphabet/picture communication board and white board with a dry erase marker. Resident 36's husband used the alphabet/picture communication board to communicate with Resident 36 by pointing and reading aloud each letter of the alphabet. Resident 36 would mouth yes when he reached the correct letter and Resident 36's husband would write the letter on the white board, until he had enough of a sentence to understand what Resident 36 was trying to say. Using this method, Resident 36 stated there had been times she did not get the help she needed because the staff could not understand her. Resident 36's husband stated the staff should be using the alphabet/picture communication board and he thought they had been. During an interview with the SSD on March 14, 2023, at 3:33 PM, the SSD stated Resident 36's husband had made a request for a computer type communication device. The SSD stated she had been having trouble obtaining a physician's order for the device. A review of Resident 36's care plan, dated revised, February 5, 2023, indicated, Impaired communication r/t [related to] inability/difficulty to express self, related to tracheostomy status. Will be able to relate to others effectively daily. Speak clearly and enunciate distinctly. Use touch when approaching the resident. Notify MD as indicated. Communication board as indicated. There was no documented evidence to show care planning of the back-up communication method of Zoom, meetings with Resident 36's husband or the acquisition of a computer type communication device. During an interview and concurrent record review, with the Director of Nursing (DON) on March 14, 2023, at 3:54 PM, the DON stated it was unacceptable that the staff were not using the communication board or had a white board available to write Resident 36's responses. The DON stated LVN 1 should have updated the care plan to reflect using Zoom, meetings as a back-up communication plan with Resident 36's husband and had not. The DON stated the acquisition of the computer type communication device should have been care planned and had not. The DON reviewed Resident 36's care conference meetings from April 10, 2022, to March 14, 2023, and stated the acquisition of the computer type communication device should have been discussed in the care conference meetings and had not. A review of the facility's policy and procedure titled, Care Plans, Comprehensive Person-Centered, dated March 2022, indicated, Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. Each resident's comprehensive person-centered care plan is consistent with the resident's rights to participate in the development and implementation of his or her plan of care, including the right to: a. participate in the planning process, b. identify individuals or roles to be included; c. request meetings; d. request revisions to the plan of care; e. participate in establishing the expected goals and outcomes of care, f. participate in determining the type, amount, frequency and duration of care, g. receive the services and/or items included in the plan of care, and h. see the care plan and sign it after significant changes are made. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident problem areas and their causes, and relevant clinical decision making. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. The interdisciplinary team reviews and updates the care plan: a. when there has been a significant change in the resident's condition; b. when the desired outcome is not met, .

Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 36) was repositioned every two hours to promote healing of Resident 36's Stage IV pressure sore (an injury caused by prolonged pressure that is very deep, reaching into muscle and bone). This failure had the potential to cause Resident 36's Stage IV pressure sore to worsen or additional pressure sores to develop. Findings: A review of Resident 36's face sheet (a document that gives a summary of resident's information), undated, indicated Resident 36 was admitted to the facility on [DATE], with diagnoses that included: amyotrophic lateral sclerosis (ALS-a nervous system disease that weakens muscles and impacts physical function), quadriplegia (a symptom of paralysis that affects all a person's limbs and body from the neck down), tracheostomy (an incision in the windpipe made to relieve an obstruction to breathing), and dependence on respirator/ventilator (dependent on mechanical ventilation). A review of Resident 36's care plan, dated revised, February 5, 2023, indicated, at high risk or unavoidable for developing pressure sore, bruising, discoloration, and other types of skin breakdown related to impaired mobility, impaired cognition, fragile skin, . Minimize the risk of skin breakdown/bruising/pressure sore daily. Turn and position as needed when in bed or wheelchair. A review of Resident 36's Skin Assessment, dated March 14, 2023, indicated, left lateral (side) ankle, Stage IV pressure sore. During an observation of Resident 36 on March 13, 2023, at 8 AM, Resident 36 was in bed positioned on her back with both arms lying atop of the pillows. There were two wedge type cushions positioned on each side of Resident 36's head. A letter sized paper was positioned on top of Resident 36's blanket near the bottom of the bed and indicated not to move resident without husband present. Resident 36 was unable to speak. Resident 36 was able to mouth the words yes and no and make eye contact but nothing more. Resident 36 was unable to move any part of her body, not even her head to indicate yes or no. During an observation of Resident 36 on March 13, 2023, at 11:28 AM, Resident 36 was in bed positioned on her back with both arms lying atop of the pillows. There were two wedge type cushions positioned on each side of Resident 36's head. A letter sized paper was positioned on top of Resident 36's blanket near the bottom of the bed and indicated not to move resident without husband present. Three hours and 30 minutes had passed without Resident 36 changing position. During an interview with a Licensed Vocational Nurse (LVN 1) on March 13, 2023, at 3:43 PM, LVN 1 stated Resident 36's husband came in once per day from 8:30 AM to 2 PM. LVN 1 stated Resident 36's husband was concerned Resident 36 was not being repositioned properly and wanted to be present to ensure her position and comfort. LVN 1 stated she had spoken with Resident 36's husband explaining the resident needed to be changed and repositioned every 2 (two) hours and as needed and it was not possible for him to be present every time. LVN 1 stated the note on the bed was to accommodate the husband to some extent. LVN 1 stated the Certified Nursing Assistants (CNAs) should be repositioning Resident 36 every two hours. Resident 36 was in bed positioned on her back with both arms lying atop of the pillows. There were two wedge type cushions positioned on each side of Resident 36's head. During an observation of Resident 36 on March 14, 2023, from 7:36 AM to 10:41 AM, Resident 36 was in bed positioned on her back with both arms lying atop of the pillows. There were two wedge type cushions positioned on each side of Resident 36's head. A letter sized paper that indicated not to move resident without husband present had been removed. Three hours had passed without Resident 36 changing position. During an interview with Resident 36's husband on March 14, 2023, at 10:41 AM, Resident 36's husband stated the CNAs did not position her (Resident 36) comfortably and the night shift CNAs were the most difficult. Resident 36's husband had his own alphabet/picture communication board (a communication visual aid. It was designed specifically to suit a person's needs, using an Alphabetical key and pictures depicting pain, hot, cold, etc . The resident used an eye gaze or partner assisted scanning to facilitate communication) and white board with a dry erase marker. Resident 36's husband used the alphabet/picture communication board to communicate with Resident 36 by pointing and reading aloud each letter of the alphabet. Resident 36 would mouth yes when he reached the correct letter and Resident 36's husband would write the letter on the white board, until he had enough of a sentence to understand what Resident 36 was trying to say. Using this method, Resident 36 stated she did not want to be moved without her husband present because the staff hurt her when they moved her. Resident 36 stated her husband did it better. Resident 36's husband stated they needed three people to move her and they don't do it. Resident 36's husband stated the ventilator gets dislodged and she cannot breathe, and it scares her. During an interview with a Certified Nursing Assistant (CNA 2) on March 14, 2023, at 11:23 AM, CNA 2 stated she gave Resident 36 a shower every Tuesday and Friday. CNA 2 stated Resident 36 needed three CNAs and one Respiratory Therapist (RT) to move Resident 36 safely and comfortably. CNA 2 stated she did not know how the CNAs moved Resident 36 on the night shift. A review of Resident 36's care plan, dated revised, February 5, 2023, was conducted. There was no documented evidence to show an intervention for three CNAs and one RT to reposition Resident 36. During an interview with a Certified Nursing Assistant (CNA 5) on March 16, 2023, at 7:41 AM, CNA 5 stated she had cared for Resident 36 on March 15, 2023, and had been assigned to care for Resident 36 this morning (March 16, 2023). CNA 5 stated she was responsible for repositioning every two hours, but she repositioned every two hours only if Resident 36's husband was present. CNA 5 stated if Resident 36 was soiled she would change the resident even if the husband was not present. CNA 5 stated if she had a knowledgeable CNA to help her, she would reposition Resident 36 with two CNAs, if she had a CNA who did not know Resident 36 well, she would use three CNAs to reposition her. CNA 5 stated she did not chart repositioning Resident 36. During an interview with the Director of Nursing (DON) on March 16, 2023, at 8:11 AM, The DON stated there was no area where the repositioning was charted every two hours. The DON stated the previous DON had created a care plan where she accommodated Resident 36's husband's request not to reposition Resident 36 without him present. The DON stated she found out about this a week ago and it was completely unacceptable. The DON stated Resident 36 was in their care and must be repositioned every two hours for her own wellbeing. The DON stated she had begun addressing this issue and was informed by staff that Resident 36 refused to be repositioned and Resident 36's husband was adamant about not repositioning Resident 36 without him present. The DON stated she had directed the staff to reposition Resident 36 every two hours, but they had been indoctrinated (brain washed) into always waiting for the husband. The DON stated the previous DON should have investigated the concerns of Resident 36's husband and Resident 36 when they stated no repositioning without the husband present and the issues could have been addressed and care planned so Resident 36 could be repositioned every two hours. The DON stated Resident 36 should have been repositioned every two hours and was not. A review of the facility's policy and procedure titled, Repositioning, dated May 2013, indicated, Purpose: The purpose of this procedure is to provide guidelines for the evaluation of resident repositioning needs, to aid in the development of an individualized care plan for repositioning, to promote comfort for all bed- or chair-bound residents and to prevent skin breakdown, promote circulation and provide pressure relief for residents. General Guidelines: 1. Repositioning is a common, effective intervention for preventing skin breakdown, promoting circulation, and providing pressure relief. 2. Evaluation of a resident's skin integrity after pressure has been reduced or redistributed should guide the development and implementation of repositioning plans. Such plans should be addressed in the comprehensive plan of care consistent with the resident's needs and goals. 3. Repositioning is critical for a resident who is immobile or dependent upon staff for repositioning. 4. The care plan for a resident at risk of friction or shearing during repositioning may require the use of lifting devices for repositioning. 5. Positioning the resident on an existing pressure ulcer should be avoided since it puts additional pressure on tissue that is already compromised and may impede healing. Interventions: 1. A turning/repositioning program includes a continuous consistent program for changing the resident's position and realigning the body. The program is defined as a specific approach that is organized, planned, documented, monitored, and evaluated. 2. Frequency of repositioning a bed- or chair-bound resident should be determined by: a. The type of support surface used b. The condition of the skin; c. The overall condition of the resident; d. The response to the current repositioning schedule; and e. Overall treatment objectives. 3. Residents who are in bed should be on at least an every two hour (q2 hour) repositioning schedule.

Based on observations, interviews and record reviews, the facility failed to provide adequate supervision and a valid assistance device (fire extinguisher) to prevent accidents when: 1. Resident 50 was found smoking on the outside patio without one-to-one supervision. This failure had the potential for Resident 50 to have a smoking accident. 2. A fire extinguisher's inspection tag had expired, and the fire extinguisher was mounted in the smoking area for use. This failure had the potential for residents to be exposed to injuries for outdated equipment. Findings: During an observation on [DATE], at 1:30 PM, Resident 50 was seen smoking unsupervised on the outside patio under the rain. During an interview on [DATE], at 1:39 PM, with Resident 50, Resident 50 stated they have been smoking unsupervised for a long time. During a review of Resident 50's Face Sheet, (contains demographic information), undated, indicated Resident 50 was admitted on [DATE], with a diagnosis to include cerebral infarction (disrupted blood flow to the brain), lack of coordination and muscle weakness. During a review of Resident 50's medical record, Safe Smoking Evaluation (Smoking facility)- V2, dated [DATE], indicated, .B. Vision: 1. Does Resident have any visual deficit(s)? a. Yes . 2. Additional Comments: Unable to hold anything with hands for some time because of hemiplegia (weakness of one side of the body) from old CVA ( Cerebrovascular accident: loss of blood flow from a part to part of the brain) [AGE] years ago .C. Dexterity :1. Does Resident have dexterity problem(s): a.Yes 2. Additional comments: Unable to hold anything heavy with both hands .E. Safety: . Resident's need for adaptive equipment .c. One-on-one assistance. During a concurrent interview and record review, on [DATE], at 2:20 PM, with the Director of Nursing (DON), Resident 50's Safe Smoking Evaluation(Smoking facility)-V2, dated [DATE] was reviewed. The Safe Smoking Evaluation (Smoking facility)-V2 indicated Resident 50's need for adaptive equipment is to have one to one assistance. DON stated they did not provide one-to one assistance as stated in the smoking evaluation when they allowed Resident 50 to smoke unsupervised. During a concurrent interview and record review, on [DATE], at 2:20 PM with the DON, Smoking Policy - Residents, (undated) was reviewed. The policy indicated, .Policy Statement: This facility shall establish and maintain safe resident smoking practices. Policy Interpretation and Implementation: .11. Any resident with restricted smoking privileges requiring monitoring shall have the direct supervision of a staff member, family member, visitor, or volunteer worker at all times. DON stated her expectation is for staff to provide supervision as the policy indicated but it was not followed 35183 2. A review of Resident 43's medical record, Face Sheet, undated, indicated Resident 43 was admitted to the facility on [DATE], with a diagnosis of chronic obstructive pulmonary disease (COPD-a group of lung diseases that block airflow and make it difficult to breathe). During an observation with Resident 43 on [DATE], at 7:49 AM, Resident 43 was smoking in the designated smoking area on an outside patio. The patio contained four ashtrays, a fire blanket, and a fire extinguisher. A review of the fire extinguisher's inspection tag indicated the inspection years of 2017 through 2021. During an interview with a Maintenance Director (MD) on [DATE], at 9:49 AM, the MD stated he was responsible for the inspection of the fire extinguishers for the facility. The MD stated the facility contracted with a company to check the fire extinguishers once per year and he checked the fire extinguishers once per month. The MD verified the inspection tag on the fire extinguisher in the smoking area had expired. A review of the facility's Smoking Policy - Residents, dated [DATE], indicated, This facility has established and maintains safe resident smoking practices. A review of the facility's Fire Extinguisher Policy, undated, indicated, Local fire authorities, or other authorized agencies, will conduct a yearly inspection of all fire extinguishers, shall record the results of their findings on that agency's inspection record, and shall give the Administrator a copy of the inspection results.

Based on observations, interviews and record review, the facility failed to provide the necessary respiratory care when a Physicians order for Oxygen therapy was not followed for one of three residents (Resident 59). This failure had the potential for resident 59 to experience shortness of breath. Findings: During an observation on March 13, 2023, at 11:40 AM, in Resident 59's room, Resident 59 was receiving 4 Liters (L) (Liters= unit of measurement) of oxygen via nasal cannula (a tube placed in the nose to deliver oxygen). During a review of Resident 59's medical record, Face Sheet (contains demographic information), undated, indicated Resident 59 was admitted on [DATE], with a diagnosis to include Chronic Obstructive Pulmonary Disease (COPD-lung diseases that block airflow and make it difficult to breathe). During a concurrent observation and interview on March 13, 2023, at 12:00 PM, with Licensed Vocational Nurse (LVN1), LVN 1 was observed checking the amount of oxygen Resident 59 was receiving. LVN 1 stated Resident 59 was receiving 4L of Oxygen. LVN 1 reduced the oxygen level to 2 L. LVN 1 also stated she is responsible for making sure residents are receiving the correct oxygen therapy per the physician's order. LVN 1 further stated, I know the order is 2 - 4 L but I will check. During a concurrent interview and record review on March 13, 2023, at 12:02 PM with LVN1, Resident 59's physician's order for oxygen therapy was reviewed. The physician's order indicated, Oxygen at 2 L via nasal cannula continuously every shift for shortness of breath related to COPD. LVN 1 stated, Resident 59 had always received 4 L of oxygen instead of 2 L as ordered by the physician. LVN 1 also stated the physician's order was not followed. During a concurrent interview and record review on March 13, 2023, at 12:11 PM, with the Director of Nursing (DON) Resident 59's physician's order for oxygen therapy was reviewed. The physician's order indicated, Oxygen at 2 L via nasal cannula continuously every shift for shortness of breath related to COPD. DON stated the order was not followed. During a concurrent interview and record review on March 13, 2023, at 12:16 PM, with the DON, the facility policy, Oxygen Administration, (undated) was reviewed. It indicated, Preparation: 1. Verify that there is a physician's order .Review the physician's orders or facility protocol for oxygen administration. The DON stated the policy was not followed.

Based on interview and record review, the facility failed to monitor antipsychotic medication for effectiveness and adverse [harmful] side effects for one of one sampled resident (Resident 12). This failure had the potential to cause ineffective control of symptoms to go unrecognized and unaddressed. In addition, Resident 12 had the potential to suffer prolonged adverse side effects of the medication. Findings: A review of Resident 12's face sheet (a document that gives a summary of resident's information), undated, indicated Resident 12 was admitted to the facility on [DATE], with a diagnosis of bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs.) A review of Resident 12's physician's order dated February 23, 2023, indicated, Risperidone [an antipsychotic medication to treat bipolar disorder] Oral Tablet 3 [three] MG [milligrams-a unit of measurement] Give 1 [one] tablet via G-Tube [a tube inserted through the wall of the abdomen directly into the stomach] one time a day for bipolar disorder m/b [manifested by] mood swings causing irritability. A review of Resident 12's Physician's Progress Note, dated February 23, 2023, indicated, She [Resident 12] is seen for psychiatry evaluation as requested for her depression and bipolar disorder.Plan/Recommendations/Interventions: .Cont. [continue] Risperdal [Risperidone] 3 [three] mg qday [daily] for bipolar disorder m/b mood swings caused by irritability.Monitor for any changes in behavior/mood/symptoms. During an interview and concurrent record review with the Director of Nursing (DON) on March 16, 2023, at 9:11 AM, the DON reviewed Resident 12's Medication Administration Record (MAR). The DON stated the monitoring for the Risperidone's effectiveness for controlling symptoms and for any adverse side effects was supposed to be documented on the MAR and it was not. During an interview with the Nurse Practitioner (NP), who had ordered Resident 12's Risperidone, on March 16, 2023, at 9:24 AM, stated he had put into his order to monitor for the adverse side effects of the Risperidone and monitoring for the effectiveness of the medication. The NP stated it was his expectation that this monitoring was being done. A review of the facility's policy and procedure titled, Psychotropic Medication Use, dated July 2022, indicated, Residents, Families and/or the representative are involved in the medication management process. Psychotropic medication management includes: .adequate monitoring for efficacy [effectiveness] and adverse consequences; and preventing, identifying, and responding to adverse consequences.

Based on observation, interview, and record review the facility failed to ensure medications were properly given as ordered for two sampled residents (Resident 193 and 78) when: 1. Resident 193 did not receive the full dose of Amiodarone (a medication used to treat a fast or irregular heartbeat) as ordered by a physician. This failure had the potential to cause Resident 193 to experience symptoms or discomfort. 2. Resident 78 did not receive three doses of Seroquel (antipsychotic medication to treat mental illness) as ordered by a physician. This failure had the potential to cause an increase in hallucinations or other negative psychosocial effects for Resident 78. Findings: 1. A review of Resident 193's face sheet (a document that gives a summary of resident's information), undated, indicated Resident 193 was admitted to the facility on [DATE], with a diagnosis of Cardiomyopathy (a disease of the heart muscle that makes it harder for the heart to pump blood to the rest of the body). During a medication pass observation and interview with a Licensed Vocational Nurse (LVN 5) on March 15, 2023, at 8:43 AM, LVN 5 retrieved one 200 mg (milligram-a unit of measurement) tablet of amiodarone (a medication used to treat a fast or irregular heartbeat) from its package. LVN 5 crushed the tablet into a fine light pink powder and poured it into a pill cup for administration into Resident 193's j-tube (jejunostomy tube-a soft, plastic tube placed through the abdomen into the small intestine, for administering medication and nutrition). LVN 5 added a small amount of water to the pill cup and poured the contents into Resident 193's j-tube. LVN 5 did not mix the water with the fine pink powder or rinse the pill cup with additional water, resulting in a substantial amount of the medication remaining in the pill cup and Resident 193 not receiving the full dose of the medication. LVN 5 stated there was still some of the medication left in the pill cup and she should have rinsed the pill cup with additional water and poured it into Resident 193's j-tube. A review of Resident 193's physician's order dated March 2, 2023, indicated, Amiodarone . Oral Tablet 200 MG, Give 1 tablet via J-tube for arrhythmia . [irregular heartbeat]. During an interview with the Director of Nursing (DON) on March 15, 2023, at 9:47 AM, the DON reviewed the remaining medication in Resident 193's pill cup. The DON stated Resident 193 did not get her full dose of amiodarone and LVN 5 should have rinsed the cup with water to administer the full dose. A review the facility's policy and procedure titled, Administering Medications through an Enteral [involving or passing through the intestine] Tube, undated, indicated, Steps in the Procedure . 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 [milliliters-a unit of measurement] purified water (or prescribed amount). 46119 2. During a review of Resident 78's clinical record, the face sheet (contains admission and demographic information) indicated Resident 78 was admitted on [DATE], with current diagnoses which included schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves, and is often characterized by symptoms of visual or auditory hallucinations). Further review of the clinical record indicated the resident had a current physician's order for Seroquel Oral Tablet 50 mg [milligram - unit of measurement] .Give 1 tablet by mouth two times a day for schizophrenia m/b [manifested by] auditory hallucinations . During a concurrent observation and interview on March 13, 2023, at 8:22 AM, Resident 78 was observed lying in bed, mumbling, and talking to himself. No one else was at his bedside at the time. When interviewed, Resident 78 was able to engage in simple conversation and answer questions but was noted to be very easily distracted and talkative about details not pertaining to the original conversation. During a concurrent interview and record review with a Licensed Vocational Nurse (LVN 7) on March 15, 2023, at 6:15 AM, Resident 78's Medication Administration Record (MAR), dated March 2023, was reviewed. The MAR indicated the resident had missed three doses of Seroquel on three separate days, March 9, 2023, March 12, 2023, and March 13, 2023, for the scheduled 8:00 PM administration time. LVN 7 stated the doses were not given because the bubble pack (a card-like package) containing the medication for 8:00 PM had run out. LVN 7 stated she did not look in the emergency kit (kit containing medications for emergency use, or for instances when meds are not available from pharmacy yet), and stated she should have. LVN 7 further stated she did not notify the MD of the missed doses and should have. During an interview with the Director of Nursing (DON) on March 15, 2023, at 6:19 AM, the DON stated the expectations were for the licensed nursing staff to give the medications as ordered by a physician. The DON stated that if for any reason the medication was not available in the cart, the pharmacy should be contacted, and the emergency kits should be utilized so the resident does not miss a dose. The DON further stated another expectation was for the physician to be notified of any missed doses. The DON stated the potential for not giving medication doses as ordered was for the resident to experience symptoms or decreased effectiveness of the medication. A review of the facility's policy and procedure (P&P) titled Administering Medications, revised 2019, indicated .4. Medications are administered in accordance with prescriber orders, including any required time frame .6. Medication errors are documented, reported, and reviewed by the QAPI committee to inform process changes and or the need for additional staff training .

Based on interview and record review, the facility failed to identify mental disorders during the Preadmission Screening and Resident Review (PASARR-a screening to identify the presence of serious mental illness) for one of one sampled resident (Resident 61). This failure had the potential to cause Resident 61 not to receive specialized mental health services. Findings: A review of Resident 61's face sheet (a document that gives a summary of resident 61 information), undated, indicated Resident 61 was admitted to the facility on [DATE], with a diagnosis of schizophrenia (a serious mental condition of a type involving a breakdown in the relation between thought, emotion, and behavior) and anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear). A review of Resident 61's PASARR dated November 5, 2022, indicated, .Result of Level I Screening: Level I - Negative, . Reason Code: No Serious Mental Illness. Section III - Serious Mental Illness - Definition: 10. Does the Individual have a serious diagnosed mental disorder such as Depressive Disorder, Anxiety Disorder, Panic Disorder, Schizophrenia/Schizoaffective Disorder, or symptoms of Psychosis, Delusions, and/or Mood Disturbance? NO. Explain: 11. After observing the Individual or reviewing their records, do you believe the Individual may be experiencing serious depression or anxiety, unusual or abnormal thoughts, extreme difficulty coping, or significantly unusual behaviors or does the individual actively engage in community mental health services? NO. During an interview and concurrent record review with the Director of Nursing (DON) on March 15, 2023, at 1:49 PM, the DON reviewed Resident 61's clinical record and Resident 61's level I PASARR dated November 5, 2022. The DON stated the level I PASARR was filled out incorrectly and should have indicated Resident 61's diagnoses of schizophrenia and anxiety disorder. The DON stated since the level I PASARR was incorrect Resident 61 did not receive a level II PASARR assessment to identify specialized mental health services Resident 61 might need. A review of the facility's policy and procedure titled, PASRR Completion Policy, undated, indicated, Policy Statement: The Center will a make sure that all admissions have the appropriate Patient Assessment and Resident Review (PASRR) completed. PRACTICE GUIDELINES: 1. Center Administrator will designate either the Admissions Director, Social Worker, or designee to make sure that the PASSRR and/or Level of Care (LOG) is done on all potential residents. If the referral indicates anything which might constitute an SMI or ID, the PASRR must be completed prior to admission. If the resident is deemed hospital exempted that must be clearly documented in the transfer documents prior to admission from the acute care facility. 2. Administrator will also designate a backup in case the designated person is not available. 3. Administrator is accountable for monitoring the process of completing the necessary paperwork for the admission.

Based on observation, interview, and record review, the facility failed to provide supervision to one of 88 residents (Resident 1) on October 3, 2022, when the resident was left unattended by staff while on the facility ' s smoking patio which had an unlocked, unalarmed, and unmonitored access gate. Resident 1 had a diagnosis of Alzheimer ' s disease (a progressive disease affecting the memory and function of the brain) and had been identified by the facility as a high risk for elopement (leaving the premises or safe area without authorization or supervision to do so). This failure had the potential to result in serious harm or death to Resident 1 who eloped from the facility on October 3, 2022, by placing her at risk for exposure to environmental elements, accident hazards, or being without resources such as food, water, and shelter. Resident 1 was not located until two days later (October 5, 2022), when the car she had been in with an unidentified male, broke down (malfunctioned) on a mountain highway. Findings: During a review of Resident 1's clinical record, the Face sheet (contains medical and demographic information) indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included Alzheimer ' s disease and heart failure. The resident was also receiving hospice care (comfort care provided to an individual with a serious illness who is approaching the end of life). During a review of Resident 1's Minimum Data Set (MDS- an assessment of a residents functional and health status), dated July 21, 2022, the MDS section C - Cognitive Patterns (section used to determine a residents cognitive functioning status) indicated the resident had a Brief Interview for Mental Status score (BIMS score - a score of 0-15 used to determine cognitive functioning) score of 5 (severe impairment). Further review of the MDS in Section E0900. Wandering - Presence & Frequency (section used to determine a resident ' s wandering tendencies), indicated the resident had the behavior of wandering which occurred between 1 to 3 days during the review period. Section E1000. Wandering - impact (section used to determine the risk of wandering), indicated yes to the question, Does the wandering place the resident at significant risk of getting to a potentially dangerous place (e.g. stairs, outside of the facility)? During review of Resident 1's Wandering/Elopement Risk Assessment, dated July 18, 2022, indicated, High Risk for Wandering . The assessment also indicated the resident was disoriented, was on anti-anxiety and hypnotic medications (medications which can cause drowsiness and can alter balance and memory) and had independent mobility without requiring assistance. During review of Resident 1's IDT Follow Up (IDT-Interdisciplinary team composed of staff from various clinical disciplines), dated July 19, 2022, the document indicated, Follow up with the report on 7/18/2022 (July 18,2022), that [Resident 1] attempted to go outside the building in the facility parking lot .Resident is disoriented x3 [times three], has Alzheimer ' s Dse [disease] .Spoke to resident at this time and gave reality orientation related to attempt to elope .Resident is high risk for wandering/elopement . During a review of Resident 1's care plan (an individualized plan for the medical care of a resident), dated July 9, 2022, the care plan indicated, Moderate risk for wandering/elopement related to cognitive impairment secondary to Alzheimer?s [sic] dementia as evidenced by patient unable to find what she is seeking and pacing repetitively .Interventions .Staff to ensure the resident at risk for wandering distance from exits .staff to monitor resident often at least Q30 minutes and monitor whereabout . During an interview on October 4, 2022, at 12:01 PM, with the Director of Nursing (DON), the DON stated Resident 1 had eloped from the facility on October 3, 2022, and had not yet been found. The DON further stated throughout her investigation, it was her understanding that Resident 1 was seen socializing with Resident 2 on October 3, 2022, at 7:45 PM, while on the facility ' s smoking patio. The DON then stated on October 3, 2022, at 8:00 PM, Resident 2 informed a Certified Nursing Assistant 1 (CNA 1) that Resident 1 left the facility through the smoking patio gate. During an interview on October 4, 2022, at 12:46 PM, with Resident 2, Resident 2 stated she was with Resident 1 last night (October 3, 2022) on the smoking patio sometime in the evening (could not recall exact time) when Resident 1 told her she was going to leave the facility and go to her home in [name of mountain community] and proceeded to exit through the gate on the far side of the smoking patio. Resident 2 further stated Resident 1 disappeared from sight after the resident exited the gate and made a left. Resident 2 stated there were no other residents or staff present when Resident 1 left the facility. Resident 2 further stated about 10 minutes later, CNA 1 came to the smoking patio, and she (Resident 2) informed the CNA that Resident 1 had left. During an interview on October 4, 2022, at 1:30 PM, with CNA 2, CNA 2 stated he was familiar with Resident 1 and knew she was at risk for leaving the facility and recalled an instance where the resident had previously verbalized a desire to leave (CNA 2 could not remember when). CNA 2 stated he worked on the evening of October 3, 2022, from 3:00 PM to 11:00 PM and he was the nurse assistant assigned to care for Resident 1 during that shift. CNA 2 stated he last saw Resident 1 at 7:30 PM on the smoking patio with Resident 2 and then went on break 15 minute later. CNA 2 further stated he did not recall seeing any staff on the patio with Resident 1 and Resident 2. During an interview on October 4, 2022, at 1:58 PM, with the DON, the DON stated Resident 1 was at risk for elopement and was not supposed to be near or around exits without staff being present. The DON further stated Resident 1 was not supposed to be outside on the smoking patio without staff. During a follow up interview on October 4, 2022, at 2:00 PM, with CNA 2, CNA 2 stated he didn ' t think much about it when he saw Resident 1 on the patio because he had previously seen her (Resident 1) there on prior occasions with no issues. CNA 2 further stated on October 3, 2022, at 7:30 PM when he last saw Resident 1, he asked her if she wanted to come back in the facility and she said, No, and that she said she was catching some sun. CNA 2 then stated he proceeded to assist other residents and went on break 10 or 15 minutes later after informing CNA 3 that he was leaving on break. CNA 2 stated he was not aware that Resident 1 had a care plan intervention to, .ensure the resident at risk for wandering distance from exits. CNA 2 stated he should have either brought the resident inside prior to going on break or asked for assistance from the Licensed Vocational Nurse if the resident was getting anxious or didn ' t want to come in. He stated he did not do that in this case and left the resident outside and didn ' t recall seeing any other staff present on the patio. During an interview on October 4, 2022, at 3:16 PM, with CNA 3, CNA 3 stated she worked on the evening of October 3, 2022, but was not assigned to Resident 1. CNA 3 stated CNA 2 informed her that he was going on his break and asked her to watch his residents and she agreed. CNA 3 stated she last saw Resident 1 between 7:30 PM and 7:45 PM when she went to check on CNA 2 ' s assigned residents and stated Resident 1 was with Resident 2 on the patio and there were no other staff present. CNA 3 stated after visually checking on Resident 1 on the patio, she went back to assist her own assigned residents in the facility. During an interview on October 4, 2022, at 3:31 PM, with a Registered Nurse 1 (RN 1), RN 1 stated she worked on October 3, 2022, from 7:00 AM until 9:00 PM, and recalled seeing Resident 1 who on that day, demonstrated periods of alternating levels alertness and confusion while ambulating around the facility. RN 1 stated Resident 1 was at risk for elopement and CNA 2 was assigned to the resident that shift. RN 1 further stated the patio area was an area residents could go to get fresh air, but confused residents were supposed to be supervised by staff while on the patio. RN 1 further stated Resident 1 was confused most of the time and therefore was supposed to be supervised any time she was on the patio. RN 1 stated her expectation was if Resident 1 was on the patio at any time, the resident would be accompanied by staff. RN 1 further stated regarding who was responsible for supervision of the patio area, that whoever is assigned to the resident was expected to supervise them on the patio. RN 1 stated if a staff member is accompanying a resident on the patio that needs supervision and the staff is going to leave the area, they should inform the RN supervisor so the RN can assign someone else to monitor the resident. During an interview on October 4, 2022, at 3:46 PM, with CNA 1, CNA 1 stated she worked on October 3, 2022, from 3:00 PM to 11:00 PM and she was familiar with Resident 1. CNA 1 stated the supervision and monitoring that Resident 1 required was constant, because of her risk for elopement and that she thought Resident 1 should be supervised at all times until the resident went to bed. CNA 1 further stated there was a prior instance (CNA 1 could not recall when) where the resident pushed open an exit door and attempted to leave the facility and that there should be no instances where Resident 1 was left on the smoking patio without staff being present. CNA 1 stated she last saw Resident 1 on the patio on October 3, 2022, between 7:30 PM and 7:40 PM and then she (CNA 1) went to her lunch break. CNA 1 stated when she arrived back from her lunch around 8:10 PM, she went to smoke on the smoking patio when Resident 2 informed her that she had witnessed Resident 1 leave out the patio gate approximately 20 minutes earlier. CNA 1 stated when she went to look for the resident, she could not find her. During an observation on October 4, 2022, at 4:01 PM, of the facility ' s smoking patio, there is a glass door from within the facility which leads to an outside patio area where there are 3 tables. On the far side of the patio (west side), there is a white gate with a latch that is not locked, does not alarm when opened, and can be easily opened. The gate leads to an area near the rear of the facility where there is a parking lot. There is a camera in this area. During a telephone interview on October 5, 2022, at 11:40 AM, with [name of hospice company] Chief Operating Officer (COO), the COO stated he had hospice staff checking on the resident ' s home every hour due to concerns of her wellbeing. The COO further stated the police had dispatched a helicopter and K-9 (canine- police dog) units to aid in the search and the resident was ultimately found on the side of a mountain community highway, while broken down in a vehicle accompanied by an unidentified male. During an interview on October 5, 2022, at 12:33 PM, with the DON, the DON stated she started working at the facility since mid-July 2022, and the smoking patio camera was not working at that time and has not worked since then, at minimum. During a review of the facility's policy and procedure, titled, Emergency Procedure - Missing Resident, revised August 2018, the policy indicated, Resident elopement resulting in a missing resident is considered a facility emergency. Policy Interpretation and Implementation 1. Residents at risk for wandering and/or elopement will be monitored, and staff will take necessary precautions to ensure their safety . During a review of the facility's policy and procedure, titled, Wandering and Elopements, revised March 2019, the policy indicated, Policy Statement .The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. Policy Interpretation and Implementation 1. If identified as at risk for wandering, elopement, or other safety issues, the resident ' s care plan will include strategies and interventions to maintain the resident ' s safety . An Immediate Jeopardy (IJ - a situation that has threatened or is likely to threaten the health and safety of a resident) was called under F689 S483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents on October 5, 2022, at 3:45 PM, after it was determined that Resident 1 did not receive supervision and monitoring required to keep the resident safe on October 3, 2022, when the resident was found to have eloped from the facility. The IJ was called in the presence of the Director of Nursing (DON). A Corrective Action Plan (CAP-a plan which includes interventions to remove the potential or actual harm of an immediate jeopardy situation) was requested and a preliminary CAP was received on October 5, 2022, at 5:06 PM, and the revised CAP was received and approved on October 6, 2022, at 1:09 PM. A record review of the CAP conducted on October 6, 2022, at 1:49 PM, and included the following: Resident 1 had subsequently been found by the police department and was at a local hospital with no injuries An alarm was installed on the smoking patio gate A contracted staffing agency was contracted to provide the nursing facility with staff to monitor the smoking patio door 24 hours, 7 days each week until a more permanent key-pad alarm can be installed on the patio gate, a commercial door/gate service company was onsite on October 6, 2022 to evaluate the patio gate for a new keypad alarm system for the patio gate, and the camera system which provides video of the smoking patio was repaired. A Vendor was on site on October 6, 2022, to assess the patio gate and provide a proposal for the installation of a keypad alarm system. The proposal was received by the facility on October 7, 2022. The video surveillance camera that provides a video of the smoking patio was repaired. The facility indicated they would not knowingly admit future residents that have been identified as a wandering risk. Purple wristbands have been placed on residents assessed with moderate to high risk for wandering which will be monitored by licensed nursing staff every shift. Residents with a history of wandering or who IDT determined to be at moderate to high risk for wandering or elopement will have a photograph maintained in their medical record and in the Elopement/Wandering Monitoring Binder. The Director of Nursing and the Director of Staff Development will provide education to the nursing staff regarding facility policies and procedures to manage wandering behavior and maintain a safe environment including identifying all aspects of the wandering behavior management system, staff roles and responsibilities. The Director of Staff Development/Nursing Designee will monitor the nursing staff to ensure no gaps exist in the wandering behavior management system. Any concerns identified during the review will be addressed at the time of the review and additional training will be completed at that time. The quality of monitoring the wandering behavior management system will be completed 1x/week (one time each week) for four weeks and then 2x/month (two times a month) for two months or until compliance is met. Results of the reports will be presented in the Quality Assurance Performance Improvement (QAPI) meeting to ensure compliance and reassessed for further action. The acceptable corrective action plan was verified with the facility to be implemented through observation, interview, and record review. The IJ was lifted on October 10, 2022, at 12:20 PM, in the presence of the Operations Manager, the Director of Nursing, and the Clinical Resource.

Based on observation, interview, and record review, the facility failed to follow proper infection control guidelines for handling linen when the facility washing machines became inoperable as follows: 1. The facility did not ensure the required minimum amount of linen (three changes times the capacity of 99=297) was available in the facility to meet the needs of the residents for bathing and bed linen changes. 2. The facility did not ensure the linens were laundered by a laundry Vendor or laundered by facility staff at a public laundry mat following the Department of Health guidelines for sanitizing laundry. This failure had the potential to result in residents not being kept clean due to nursing staff not having adequate towels, wash cloths and bed linens to provide for residents' bathing and hygiene needs. In addition, when laundry is not properly sanitized prior to reuse there is a potential for infections to be spread throughout the facility in a universe of 87 residents. Findings: 1. An abbreviated survey was conducted on (MONTH) 19, (YEAR) at 2:17 PM, to investigate a complaint related to the facility washers being inoperable and the staff not having access to the necessary linens needed to bathe and change residents on all shifts throughout the facility. An observational tour and concurrent interview was conducted on (MONTH) 19, (YEAR) at 2:17 PM, with a certified nursing assistant (CNA 1). A linen cart located in front of the nurses station was observed to have 4 fitted sheets, 10 top sheets, no pillow cases and no blankets. The certified nursing assistant (CNA 1) confirmed the count. When asked if she had worked the previous weekend (June 16 and (MONTH) 17, (YEAR)), she stated, We haven't had any laundry. It (washer) hasn't been working for a while. We couldn't make beds. When asked if there had been enough linen to take care of her residents CNA 1 stated,No, I use a draw sheet (a short half sheet) as a sheet, low on pillowcases, they give us five (5) for each cart. They (the facility are) low most of the time on blankets, wash cloths and fitted sheets. During an interview with the Environmental Services Director (ESD) on (MONTH) 19, (YEAR) at 3:42 PM, he stated that he did not know how much linen the facility was required to have. The ESD further stated after stocking all of the linen carts on the floor, We put out what we have. It should last a couple of hours at least. An observation on (MONTH) 19, (YEAR) at 3:55 PM with the ESD was made of the facility's emergency linen supply: Three boxes of 24 pads each, one small box with hand towels (25), one medium box of top sheets (15), one medium box with fitted sheets (15) and pillow cases (20) and one small box of hand towels (25). On (MONTH) 19, (YEAR) at 4:41 PM, the linen on all seven linen carts was counted with the ESD and the combined total equaled: 18 blankets, 25 pillow cases, 56 top sheets and 32 fitted sheets. During an interview with the Housekeeping Supervisor (HS 1) at (Name of the nearby sister facility) on (MONTH) 20, (YEAR) at 10:14 AM, she stated she had delivered linens to the facility yesterday (June 19, (YEAR)). During a interview with the Administrator of (Name of nearby sister facility) on (MONTH) 20, (YEAR) at 10:38 AM he stated, They (facility) came over on Monday and we came over there from (Name of another sister facility) and gave linen. During an interview on (MONTH) 20, (YEAR) at 11:33 AM, the ESD displayed a Linen Inventory Matrix, he stated the amount of linen he should have is a count of 297 for each item (three complete bed changes for their maximum capacity of 99 beds as required). This is everything I have in the facility right now in the building. The Linen Inventory Matrix indicated the following, which included linen borrowed from two sister facilities and emergency stock: a. Fitted sheets = 185 of the required 297 (short 112 fitted sheets) b. Pillow cases = 209 of the required 297 (short 88 pillow cases) c. Under pads = 237 of the required 297 (short 60 underpads) d. Flat sheets = 184 of the required 297 (short 113 flat sheets) e. Blankets = 87 of the required 297 (short 210 blankets) During an interview with Resident A, on (MONTH) 20, (YEAR) at 12:21 PM, when asked about the linen supply, he stated, Last night they (nursing staff) said they were all gone (blankets). I take a blood thinner and it makes me real cold so I need a lot of blankets. The facility policy and procedure titled Disruption of Services undated, indicated Laundry Services: .it is required to keep a 3-day supply of linen on hand for emergency situations . Title 22, Chapter 3, Article 6, Section (f) indicated A supply of linen shall be provided sufficient for not less than three complete bed changes for the facility's licensed capacity. 2. During an interview with the certified nursing assistant (CNA 2) on (MONTH) 19, (YEAR) at 2:43 PM, CNA 2 stated, she had experienced not having enough linen to provide for residents needs (baths, incontinence care and linen changes)e. CNA 2 stated, that when the linens ran out this weekend (June 16 and (MONTH) 17, (YEAR)), We would get them (residents) up (out of bed), put a pad (protector, used for incontinence) on the wheelchair and then in one or two hours we would wait for the next shift, Then it (shortage of linen supplies) was their's (the next shift) to deal with. During a concurrent observation and interview with the Environmental Services Director (ESD) on (MONTH) 19, (YEAR) at 2:55 PM, he stated both washers have not been working since (MONTH) 16, (YEAR). The ESD then stated the linens were being washed at (Name of the sister facility) and they were using detergent and bleach to clean the linens. When asked to view his current laundry cleaning supplies, he went to the storage area and counted the bottles of laundry detergent, softener, booster and bleach then opened a box of sani-10% to display the disinfectant. The ESD stated, You guys (California Department of Public Health) told us to use that because our (water) temps (temperatures) were low but they're good, so we don't' use it. , During a follow-up interview with the ESD on (MONTH) 19, (YEAR) at 3:30 PM, he was asked how he sanitized the linens he stated, What do you mean? The ESD was not able to describe the sanitation process. A record review of the maintenance record for the washing machines was conducted with the ESD. There was no documented evidence that water temperatures was checked during maintenance. The ESD confirmed the water temperatures were not documented to demonstrate that they met the regulatory requirements to ensure sanitation of the laundry. In a consecutive interview with the ESD on (MONTH) 19, (YEAR) at 4:37 PM, he stated he sanitizes the linens with hot water at 130 degrees Fahrenheit (unit of measure). (The minimum water temperature to wash linens for high temperature processing is 160 degrees Fahrenheit for a minimum of 25 minutes). During an observation on (MONTH) 19, (YEAR) at 5:07 PM, in the laundry room, a laundry aide (LA 1) was seen with a basket full of wet linens positioned to the side of him while continuing to fold another set of linens on a table. LA 1 then stated, he had just came from the laundry mat in his privately owned vehicle with the facility's linens. When asked what he used to clean the linens he pointed at the hoses near the inoperable washers and said, detergent and bleach. During an interview at (Name of the sister facility) with the Housekeeping Supervisor (HS 1) and the laundry aide (LA 2) on (MONTH) 20, (YEAR) at 10:14 AM, they stated they had not seen anyone from any other facility come and do laundry there. During an interview with the ESD on (MONTH) 20, (YEAR) at 11:19 AM, he stated, The only way you could tell (if the linens at the laundry mat were sanitized) would be to put a thermometer in the washer and you can't do that. Realistically, you cannot tell the temperature of the water. The facility policy and procedure titled Departmental (Environmental Services) - Laundry and Linen dated (MONTH) 2014, indicated The purpose of this procedure is to provide a process for the safe and aseptic handling, washing, and storage of linen .Washing Linen and other Soiled Items. 1. Laundry may be processed in either low-temperature or high temperature cycles. a. For high-temperature processing, wash linen in water that is at least 160 degrees Fahrenheit (unit of measure), for a minimum of twenty-five minutes . An immediate jeopardy was called in the presence of the Director of Nursing and the Administrator on (MONTH) 20, (YEAR) at 6:15 PM. An amended corrective action plan was received and accepted on (MONTH) 21, (YEAR) at 5:02 PM, with the following information: a. Laundry was done at (Name of sister facility's) plus linens carts in each hall (2 linen carts per each hall.) b. Linen counts done to monitor linen inventory to ensure proper supply was on hand. c. The facility used some of the 3 days emergency supply of linen to replace all linen in the linen carts and in rooms. d. Additional linens were delivered by (Name of external linen company) linen and from (Name of industrial linen supplier) supplies which restocked all regular and emergency supply of linens. e. Washing machine was repaired. d. Laundry services resumed at facility in addition to laundry services being performed at additional facility. e. (Linen supply company), emergency contract vendor, picked up soiled linen to clean linens. f. Contracts in place for additional linen supply as well as emergency laundry services. g. Administrator in-service Laundry staff related to laundry policies and procedures, emphasizing maintaining proper infection control. The IJ was removed on (MONTH) 21, (YEAR) at 5:30 PM, in the presence of the Administrator, the Director of Nursing and the Nurse Consultant.

Based on observation, interview, and record review, the facility failed to ensure an environment that was free of potential accidents and hazards for 3 of 17 sampled residents (Residents 7, 8, and 5), and for 3 of 10 unsampled residents (Residents A, B, and J) . For Resident 7, the facility failed to ensure that her safety and well-being were protected, and that she received the necessary supervision from the staff to prevent accidents and injuries. This failure resulted in Resident 7 wandering out of the facility during the night time, having a fall while she was restrained in her wheelchair, and sustaining a nose fracture, a skin laceration requiring sutures, and multiple bruises, abrasions and swelling. For Residents 8, A, and B, the facility failed to ensure that the vinyl or plastic arm rests of their wheelchairs were not cracked and damaged which had the potential to cause skin injuries to the residents. For Resident J and Resident 5, the facility failed to ensure that these residents had an overhead bed light with safe and adequate covers and these failures had the potential to cause injury to the residents. The facility also failed to ensure that an exit door leading to an outside patio was closing and contacting properly for the door alarm to work in the event the door was opened after normal business hours. Findings: 1. Resident 7 was observed on 6/4/12, at 12:35 PM, in the main dining room eating her lunch. Resident 7 had a soft waist restraint on her (a cloth device that went around her waist and was tied securely with straps to the back of the wheelchair). During an interview with Resident 7 at that time, she was asked if she could remove the restraint that was around her waist. Resident 7 was not able to loosen or untie the waist restraint at that time. Resident 7 was alert with increased confusion. She was able to answer simple yes/no questions but would get lost in her conversations, and she had short and long term memory loss. During an observation of Resident 7 on 6/4/12, at 4:00 PM, she was propelling herself independently down the hallway towards her room using the handrails on the wall to pull her wheelchair along. Resident 7 was also using her feet to propel her wheelchair. Resident 7 had no observable skin injuries noted during observations of her on 6/4/12. During an observation of Resident 7 the following morning on 6/5/12, at 8:05 AM, Resident 7 was lying in bed with her eyes closed and was very sleepy. Resident 7 had swelling to her nose and cheeks with large amounts of purple/bluish bruising to her forehead, both her eyes, her nose, and cheek areas. She had a small abrasion (scraped area of skin) to the right side of her forehead and several small abrasions to her nose area. An interview was conducted with the Assistant Director of Nursing (ADON) on 6/5/12, at 8:07 AM. She stated that Resident 7 had fallen the night before, hit her head, and had to be sent to the emergency room for stitches to her leg. The ADON stated that staff were investigating the circumstances of the fall, and the ADON was not exactly sure what happened. The ADON stated that Resident 7 also had a broken nose due to her fall. The clinical records for Resident 7 were reviewed on 6/5/12, at 8:10 AM. Resident 7 was re-admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the most recent Minimum Data Set (MDS - a comprehensive assessment of a resident that reflects the resident's functional status) dated 5/27/12, indicated that Resident 7 was hard of hearing with decreased cognitive ability. Resident 7 required staff assistance with bed mobility, transfers, wheelchair mobility, ambulation, dressing, eating, toileting and hygiene. Resident 7 was also using a waist/trunk restraint. A review of Resident 7's care plan titled, "Safety Deficit: Falls," dated 5/12/12, showed documentation that Resident 7 was at risk for falls due to her history of falls, cognitive deficit, impulsivity or decreased safety awareness, impaired sitting and standing balance, abnormal gait, communication deficit, unable/does not call for assistance and possible adverse side effects to psychotropic medications. Further review of Resident 7's fall care plan showed documentation on 5/29/12 that read, "Do Not Leave Resident Unattended." A review of Resident 7's care plan titled, "Physical Restraint Use," dated 5/21/12, showed that Resident 7 required the use of a soft waist belt while in the wheelchair for safety due to poor trunk control and sliding or leaning out of her wheelchair. A review of Resident 7's physician's orders [REDACTED]. a. Risperidone 0.5 mg (milligrams) orally every day at 5:00 PM for psychosis manifested by yelling (an antipsychotic medication used to treat behavior and mental disorders). b. Donepezile (Aricept) 10 mg orally at bedtime for Alzheimer's disease (a medication used to treat Alzheimer's dementia). c. Ativan 0.5 mg orally twice per day as needed for anxiety and agitation (an antianxiety medication used to treat anxiety). A review of an IDT (Interdisciplinary Team) note dated 5/17/12, showed documentation that Resident 7 had fallen on 5/17/12 due to leaning forward in her wheelchair and fell to the floor. The IDT documented that Resident 7 had episodes of fidgeting while up in the wheelchair, and not sleeping. The IDT recommended initiating the use of a wedge cushion and foot rests while in her wheelchair to prevent sliding forward. A review of an IDT note dated 5/21/12, showed documentation that Resident 7 had fallen on 5/19/12 due to Resident 7 getting up from her wheelchair unassisted and being found on the floor by the staff. The IDT recommended initiating the use of a non-skid pad in the wheelchair, and a lap buddy in the wheelchair (a cushion device placed over a resident's lap while in the wheelchair). A review of an IDT note dated 5/25/12, showed documentation that Resident 7 had fallen on 5/25/12 by sliding out of her wheelchair underneath the lap buddy. The IDT recommended initiating the use of a soft waist restraint for Resident 7 while in the wheelchair. A review of an IDT note dated 5/26/12, showed documentation that Resident 7 was found on the floor by staff on 5/26/12 and had fallen by trying to get up from her wheelchair unassisted. Resident 7 tipped her wheelchair backwards, causing her to hit the back of her head. The IDT made a recommendation that Resident 7 was not be left unattended. The IDT also recommended that the maintenance department install anti-tipping devices to the back of her wheelchair to prevent her from tipping backwards. A review of a facility form titled, "Fall Risk Evaluation," showed that the form was updated 6 different times from 5/15/12 through 6/4/12 and reflected that Resident 7 was at high risk for falling during each evaluation. Further review of Resident 7's clinical records showed documentation that Resident 7 had episodes of increased confusion, agitation, yelling, cursing and combativeness toward staff. A review of the facility form titled, "Licensed Nurses Progress Notes," showed documentation by LVN 2 on 6/4/12, at 10:30 PM, that LVN 2 was informed by CNA 4 at 9:30 PM that Resident 7 had fallen outside of the building. LVN 2 documented that when CNA 4 came out of the bathroom at 9:30 PM, he heard Resident 7 calling for help. CNA 4 stated that he found that the resident had fallen on the pavement outside in front of the facility. LVN 2 responded to the scene and found Resident 7 lying on the ground on her left side with the soft waist belt still intact and still tied to the wheelchair. LVN 2 documented that Resident 7 sustained an open area to the middle of her nose, her forehead was swollen, and she sustained a deep tissue laceration to her right inner ankle measuring 4 cm (centimeters) by 3.5 cm. Bleeding was noted to both sites. When LVN 2 asked Resident 7 what happened, Resident 7 replied that she was going to her house and she tipped over in her wheelchair. LVN 2 documented that staff stated Resident 7 was last seen at the nurse's station around 9:15 PM. Resident 7 was brought back into the facility, her physician was called, and the physician gave orders to send Resident 7 to the emergency room (ER) for further evaluation. A review of the ER report dated 6/4/12, at 10:39 PM, indicated that Resident 7 had an altered level of consciousness, was asking for her "Mommy and Daddy," and was oriented to person only. The ER report indicated that a CT scan (Computed Tomography - a type of X-ray) was performed, which reflected that she had a nasal (nose) fracture. The ER reported also indicated that Resident 7 had a 4 cm laceration to her right ankle that was repaired with sutures by the ER staff. A review of the CT scan report dated 6/5/12, at 9:04 AM, showed that Resident 7 had a nasal fracture. An interview with the Director of Nursing (DON) was conducted on 6/5/12, at 10:25 AM. She stated that Resident 7 had fallen the night of 6/4/12, around 9:30 PM. Resident 7 was up in her wheelchair at that time and was able to propel herself around the facility. Resident 7 had a history of [REDACTED]. The DON stated that Resident 7 was last seen by the staff around 9:15 PM on 6/4/12 in her wheelchair at the nurse's station. At 9:30 PM, a male certified nursing assistant (CNA) had walked down to the front of the building near the main entrance of the facility to use the restroom and he heard a resident yelling for help. The CNA found Resident 7 outside of the building past the entrance doors tipped over in her wheelchair. The DON stated that Resident 7 had wandered out of the building through the front entrance door, had gotten the wheels of her wheel chair stuck on a concrete ledge, and tipped forward in the wheelchair hitting the front of her head. The DON stated that Resident 7 was still tied to the wheelchair with a waist restraint when she was found outside by the CNA. The DON stated that Resident 7 was immediately transported to the emergency room for further evaluation at that time. During an interview with Maintenance Staff 1 on 6/6/12, at 9:30 AM, he stated that the alarm system on the exit doors in the facility were supposed to be set and alarmed at 6:30 PM every night. Maintenance Staff 1 stated all doors, except the night entrance door, were locked every night from the outside and alarmed so that if a door was opened from the inside it would alarm to alert staff the door had been opened. Maintenance Staff 1 stated that the door alarms were disabled during the day due to multiple people, such as staff and visitors, going in and out of the facility, and the door alarms were set after 6:30 PM. A review on 6/5/12 of the facility's policy and procedure titled, "Building Security" (undated), which was located at the nurse's station, indicated the following documentation: "5:00 (PM) Front office locks front door (main entrance door). 6:30 (PM) RNA's lock all other doors and alarms those doors and front door. 8:30 (PM) Supervisor secures building by locking and alarming patio and 400 hall door. All doors checked. Any malfunctioning alarms or locks to be reported immediately to director of maintenance." A review on 6/5/12 of the facility's policy and procedure titled, "After Hours Building Security," Version 4.6.09, indicated the following documentation: "Procedure: 3. RNA's and or designated staff will alarm all doors at 6:30 PM nightly. 6. On weekday evenings, beginning at 5 PM Monday through Friday when the front lobby receptionist leaves, the front lobby entrance will be locked and (a sign) will direct visitors to use the night entrance located in the 400 hall entrance until 6:00 AM daily. 7. At 8:30 PM daily, under the supervision of the 3-11 RN, all main entrance doors are to be checked that they are locked and secured. 10. At 10:00 PM, under the supervision of the 3-11 RN, all exit doors will be checked to ensure the doors are secure and the red alarm boxes are turned to the "on" position. The electronic door alarm system will be automatically activated between 6:30 PM and 6:00 AM." During an interview with CNA 3 on 6/6/12, at 3:30 PM, he stated that he was the CNA in charge of Resident 7 on 6/4/12, during the 3-11 PM shift, however, he was at lunch during the time Resident 7 had fallen. CNA 3 stated that he had last seen Resident 7 around 9:00 PM on 6/4/12 before he went to lunch, and she was sitting in her wheelchair at the nurse's station. CNA 3 stated that he then left the building for lunch and did not return to the building until after 9:30 PM. CNA 3 stated that upon his return from lunch, Resident 7 had already fallen, was being assessed by the nurses, and was in the process of being sent out to the ER. CNA 3 stated that Resident 7 wandered in her wheelchair frequently and she was very confused most of the time. During an interview with LVN 2 on 6/6/12, at 3:45 PM, she stated that she was the LVN in charge of Resident 7 on 6/4/12, during the 3-11 PM shift. LVN 2 stated that she had last seen Resident 7 around 9:00 PM seated at her wheelchair at the nurse's station. LVN 2 was passing nighttime medications to other resident's at the back of the 200 hall (away from the nurse's station). LVN 2 was informed by CNA 4 around 9:30 PM that Resident 7 had gotten outside of the building and fell . LVN 2 rushed to check on the resident and noted that Resident 7 had sustained a deep skin laceration to her right inner ankle, and had cuts on her face. LVN 2 stated that the RN on duty made sure that the door alarms were set. LVN 2 stated that she did not hear any door alarm sound at the time Resident 7 had supposedly gotten outside. LVN 2 stated that all the door alarms were very sensitive and when the door alarms were set and working properly the alarms would sound the very second a door was opened. LVN 2 stated the door alarms were very loud and all staff would hear them when they sounded, however, no staff heard any door alarm when Resident 7 had gotten outside that night. LVN 2 further stated that Resident 7 was very restless and would have anxiety in the evening time. Resident 7 would often sit up in her wheelchair or propel herself in the wheelchair during the PM shift and night shift. LVN 2 stated that staff would try to keep Resident 7 at the nurse's station and give her things to do to keep her busy at the nurse's station during the evening and night time hours. During an interview with the RN Supervisor (RN 1) on 6/6/12, at 3:50 PM, she stated that she was the RN on duty the night of 6/4/12 from 3-11 PM. RN 1 stated that on 6/4/12, around 9:00 PM, she was doing paperwork at the nurse's station and Resident 7 was at the nurse's station in her wheelchair. RN 1 stated that Resident 7 frequently stayed up late at night and the staff would keep her busy at the nurse's station and give her things to do to occupy her time. RN 1 stated that around 9:15 PM, she had to go check on another resident down the hall that was a new admission and Resident 7 remained at the nurse's station at that time. RN 1 stated that Resident 7 was possibly by herself and unobserved by staff from 9:15 PM until 9:30 PM. RN 1 stated that she was alerted by staff at 9:30 PM that Resident 7 had gotten outside of the facility and had fallen. RN 1 then assisted with getting Resident 7 transferred out of the facility to the emergency room for further evaluation. RN 1 also stated that she checked the doors earlier in the shift and the alarms were set on all the doors, but the door alarm for the front entrance door did not sound/alarm when Resident 7 went out that door. RN 1 further stated that she did not hear any alarm sound between 9:15 PM and 9:30 PM. A telephone interview was conducted with CNA 4 on 6/6/12, at 4:15 PM. CNA 4 stated that he was the CNA that found Resident 7 outside around 9:30 PM on the night of 6/4/12. CNA 4 stated that he had walked down the front hallway near the front entrance of the building to use the restroom before 9:30 PM, and when he came out of the restroom at approximately 9:30 PM, he heard someone screaming "Help, Help." CNA 4 looked from a distance near the front entrance door, where he heard the screaming come from (approximately 80 feet away), and observed a wheelchair tipped over outside in the front driveway. CNA 4 stated that it was dark outside, but he could see the bottom of a wheelchair through the glass front entrance door, and could hear the resident yelling for help even with the glass door closed. When CNA 4 reached the front door, he observed Resident 7 tipped over in the wheelchair, lying on her left side, and she was still tied to the wheelchair with her waist restraint. CNA 4 stated that he then ran back to the nurse's station to get some help and alerted the charge nurse of the situation. CNA 4 stated that he did not hear any door alarm sounding from approximately 9:15 PM until the time he found Resident 7 at 9:30 PM. CNA 4 stated that when the door alarms would sound they were very loud and everyone would be able to hear them. CNA 4 stated that he did not think the entrance door alarm had been set because it would have sounded very loud when the front door had been open by Resident 7. CNA 4 further stated that if he had not gone to the restroom and heard Resident 7 yelling for help at that time, he did not know how long the resident could have possibly been outside on the ground before she was found by someone. During an interview with RNA 2 on 6/7/12, at 8:00 AM, she stated that she had worked on 6/4/12 until 6:30 PM, and she was responsible for ensuring that the door alarms were set per the facility protocol. RNA 2 stated that she was sure she set the door alarm for the front entrance door on 6/4/12, at 6:30 PM, before she left work. RNA 2 stated that it was possible that the door could have been disarmed later that evening if the door had been opened by someone and the alarm was not reset. RNA 2 further stated that the facility had some residents that wandered and would lose their way around the facility and accidentally go out of the building's exit doors. Resident 7 was observed on 6/7/12, at 10:45 AM, in her room with the accompanying treatment nurse (LVN 6), for the purpose of observing Resident 7's skin laceration to her right inner ankle area, which she obtained on 6/4/12 during her fall. Resident 7's right inner ankle was observed to have 9 sutures to the laceration. Resident 7 continued to have large amounts of red/purple bruising and swelling to her face. During an interview with the Maintenance Supervisor (MS) on 6/7/12, at 2:20 PM, he stated that he normally checked the door alarms for the facility 2-3 times per week. The MS stated that he came to work early in the mornings and randomly opened doors to see if they alarmed. The MS stated that he did not keep a record for which doors he tested and how often they were tested , he just randomly checked a door 2-3 times per week to see if it alarmed when opened from the inside. The MS stated that all doors in the facility were supposed to be locked on the 3-11 shift around 6:00 PM every night, except for the night entrance door that was kept open so that staff can enter and exit when changing shifts. The night entrance door was locked from about 12:00 AM until around 6:00 AM. The MS stated that when the doors were locked people could not get into the building from the outside but people could exit through the doors from the inside. The MS stated that the door alarms were supposed to be turned on around 6:30 PM every evening, and if someone opened one of the alarmed doors from the inside, the alarm will go off and the sound of the alarm was very loud. The MS further stated that a representative from the door alarm company had come to the facility on [DATE], tested all the door alarms to make sure they were all working, and all doors were functioning properly. 2. During the initial tour of the facility on 6/4/12, at 9:45 AM, with the accompanying ADON, Resident 8 was observed to be seated in his wheelchair, out in the hallway, near his bedroom. Resident 8 was alert, oriented and able to make his needs known. Resident 8's skin appeared to be dry and fragile. The armrests on Resident 8's wheelchair were noted to be covered with padded vinyl which were observed with multiple cracks and tears in the vinyl on both arm rests. There was also a clear layer of tape over the vinyl arm rests and the tape had multiple cracks in it as well. During an interview with the ADON at the time of the observation, she acknowledged that the arm rests needed to be replaced and that the cracked vinyl could potentially cause skin injuries to the resident's skin. The ADON further stated she would inform the maintenance department to repair the arm rests on the resident's wheelchair. 3. During the initial tour of the facility on 6/4/12, at 9:40 AM, with the accompanying ADON, Resident A was observed to be seated in his wheelchair, out in the hallway, near his bedroom. Resident A was alert, oriented and able to make his needs known. The left arm rest on Resident A's wheelchair was noted to be made of hard plastic. There was a large crack with sharp edges in the center of the armrest. During an interview with the ADON at the time of the observation, she acknowledged that the arm rest on the left side of Resident A's wheelchair was cracked, which could potentially cause skin injuries to the resident. The ADON stated that she would inform the maintenance department that the arm rest needed to be repaired. 4. During the initial tour of the facility on 6/4/12, at 10:05 AM, Resident B was observed to be lying in her bed with her eyes closed. Resident B's skin appeared to be dry and fragile. The armrests on Resident B's wheelchair were noted to be covered with padded vinyl which was observed with multiple cracks and tears in the vinyl on both arm rests. During an interview with the ADON at the time of the observation, she acknowledged that the arm rests on Resident B's wheelchair were cracked which could potentially cause skin injuries to the resident. The ADON stated that she would inform the maintenance department that the arm rest needed to be repaired. 5. During an observation on the environmental tour with the Maintenance Assistant (MA) on 6/4/12 at 12:40 PM, an observation was made of the door accessing the smoking patio that was not striking (closing and contacting properly) to allow sufficient electrical contacts for the door alarm to function. In a concurrent interview with the Maintenance Assistant he acknowledged the improperly functioning door and alarm system. During a follow up interview and observation with the Maintenance Director (MD) on 6/4/12 at 12:50 PM, he acknowledged the door was not closing to allow alarm function and began immediate repairs. 6. During an initial tour observation on 6/4/12 at 9:55 AM, Resident J had an overhead bed light whose cover was partially coming off on the right side, which could fall off and injure the resident. During an interview with LVN 5, on 6/4/12 at 9:56 AM, LVN 5 was shown Resident J's overhead bed light cover. LVN 5 stated, "I will let maintenance know." 7. During an interview with Resident 5 on 6/6/12 at 2:35 PM, Resident 5 pointed out that the overhead bed light cover was broken and missing a piece on the left side. Resident 5 stated, "It's broken and needs to get fixed." During a concurrent observation on 6/6/12 at 2:35 PM, in Resident 5's room, the overhead bed light cover was broken and missing a piece on the left side, approximately 5 inches wide, which could injure the resident. During an interview with Maintenance Supervisor 1, on 6/6/12 at 3:15 PM, Maintenance Supervisor 1 was shown the broken overhead bed light cover in Resident 5's room, and he stated, "Oh, I did not see that before. I don't know how I could have missed that. I'll take care of it now."