Every finding on record at Chestnut Ridge Post Acute LLC

Based on observation, interview, and record review, the facility failed to notify the resident's responsible party (RP) of a significant change in condition for one of three sampled residents (Resident 1), in accordance with the facility's policy titled Change in a Resident's Condition or Status. The facility did not notify Resident 1's RP when the resident was identified with blackish discoloration of the right third toe on 8/7/2026, and a Change of Condition (COC) assessment was not completed until 8/18/2026, eleven days later. The COC dated 8/18/2026 documented RP notification as self, and Resident 1's RP was never notified. This deficient practice violated Resident 1's right to timely communication regarding significant changes in condition and had the potential to result in delayed care, lack of coordination, and inadequate clinical follow up. Findings:During a review of Resident 1's admission Record (AR), the AR indicated that Resident 1 was initially admitted to the facility on [DATE] and recently readmitted on [DATE] with diagnoses including spinal stenosis (the narrowing of one or more spaces within spinal canal), dementia (a progressive state of decline in mental abilities), and chronic kidney disease (CKD- a condition in which the kidneys are damaged and can't filter blood as well as they should). The AR identified a family member as Resident 1's RP and first emergency contact. During a review of Resident 1's History and Physical (H&P) dated 6/7/2026, indicated that Resident 1 had fluctuating capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 6/8/2026, indicated that Resident 1 had no pressure ulcers (localized damage to the skin and/or underlying tissue usually over a bony prominence) or venous and arterial ulcers (shallow sores with uneven edges result from poor arterial circulation or venous disease). During a review of Resident 1's Nursing Progress Notes (NPN) dated 8/7/2026, the NPN indicated that Resident 1 reported pain on her right 3rd toe. The NPN indicated that Registered Nurse (RN) 1 assessed the toe as black/dark discoloration resembling bruising. The physician was notified on 8/7/2026 at 7:16 PM, and orders were received for an X-ray and wound care consultation. There was no documentation that Resident 1's RP was notified of this change. During a review of Resident 1's Physician's Order dated 8/7/2026, the Order indicated an order for X-ray for the right foot, third toe. During a review of Resident 1's Orders Summary Report (OSR) from 8/7/2026 to 8/17/2026, there was no documented evidence indicating that the wound care consultant was notified of Resident 1's order to refer to the wound care physician for consult and appropriate wound care treatment order. During a review of Resident 1's Final X-Ray Report dated 8/8/2026, the report indicated diffuse osteopenia (bone density loss) and mild cortical erosions (a small break, thinning, or minor loss of the hard outer surface of a bone) in the distal part of first metatarsal (any of five long bones found in each foot) During a review of Resident 1's Wound Care Note (WCN) dated 8/18/2026 (11 days after discovery), authored by the wound care consultant/specialist the WCN indicated a right third toe arterial was assessed to be 100 percent purple, had light serosanguinous (a combination of serous fluid and blood) drainage, and peri-wound was fragile, scarred, and discolored. The WCN also indicated the plan was to apply betadine (topical antiseptic wash) daily. During a review of Resident 1's COC dated 8/18/2026, the COC indicated that Resident 1 complained of pain and the right 3rd toe was noted with blackish skin discoloration. The COC Resident Representative Notification was documented timed 10:00 AM to self. during a later validation interview with TXN 1, TXN 1 stated RP 1 was not notified of Resident 1's 3rd toe blackish skin discoloration. During a review of Resident 1's Care Plan (CP) Impaired skin integrity related to altered tissue condition as evidenced by skin discoloration of the right third toe dated 8/18/2026, the CP indicated the goal as Resident 1's skin will remain intact with no development of blistering, ulceration, drainage, or necrosis. Right foot/toe will remain free from signs of infection. The CP interventions indicated the following: Assess and document the color, size, location, and appearance of the discoloration and monitor for changes. Assess the toe and affected foot for temperature, capillary refill, pulses/perfusion, swelling, sensation, and pain as appropriate. Monitor for skin breakdown, blistering, open areas, drainage, redness, warmth, or swelling. Inspect footwear and socks for areas of pressure, friction, or poor fit; encourage proper1y fitting footwear. Protect the toe from pressure, friction, and trauma. During a concurrent observation and interview on 8/19/2026 at 2:40 PM with Resident 1, Resident 1 stated she noticed some pain on her right 3rd toe since 8/7/2026 and she reported to the licensed nurse. Resident 1 stated it took more than a week for the licensed nurses to get the wound care consultant and just started treatment for her toe just about two days ago from 8/18/2026. During a concurrent record review and an interview on 8/19/2026 at 3:35 PM with Treatment Nurse (TXN) 1, Resident 1's COC was reviewed. TXN 1 stated that she was told by Resident 1 about the right 3rd toe skin ulcer on 8/12/2026 and she was never made aware by RN 1 that Resident 1's PCP ordered a referral for wound care evaluation to wound care consultant/specialist. TXN 1 stated she reported to RN 2, who stated will contact the resident's PCP. TXN 1 stated this was considered a significant change but she did not create a COC because she assumed RN 2 had. TXN 1 stated she had not notified Resident 1's RP 1 about the COC created on 8/18/2026. During a concurrent record review and an interview on 8/19/2026 at 5:00 PM with RN 3, Resident 1's clinical records were reviewed. RN 3 stated she was endorsed about the skin issue on 8/13/2026. RN 3 stated that she did not review and create a COC to trigger family notification and follow up wound care consult, because she assumed that was a previously identified issue. RN 3 stated she did not make a phone call and notify RP 1 after the resident's PA made round on 8/13/2026 and gave orders for vascular (having to do with the blood vessels and circulation) and podiatry (doctor of podiatric medicine and surgery who specializes in caring for the feet and ankles) consultations. During an interview on 8/20/2026 at 3:50 PM with the Director of Nursing (DON), the DON stated that licensed nursing staff are supposed to ensure that a resident's change in condition was notified to the physician and the RP. The DON stated that giving the RP a call and documenting about notification is very important because that is also resident's rights and it is necessary to update about plan of care or treatment regarding COC. During a telephone interview on 8/21/2026 at 3:45 PM with RN 1, RN 1 stated that she forgot to create a COC on 8/7/2026 and did not call Resident 1's RP. RN 1 stated that she should have notified Resident 1's RP regarding the skin issue on her right 3rd toe and PCP's recommendations. During a review of the facility's policy and procedures (P&P) titled Change in a Resident's Condition or Status in 6/2025, the P&P indicated that a significant change of condition is a major decline or improvement in the resident's status that will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions. The P&P also indicated that unless otherwise instructed by the resident, a nurse will notify the resident's representative when there is a change in the resident's physical, mental, or psychosocial status. The P&P also indicated that except in medical emergencies, notification will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status.

Based on interview and record review the facility failed to obtain and administer Rifaximin (a prescription medication used to reduce the risk of recurring brain function issues caused by severe liver failure (a life-threatening state where a large portion of the liver is permanently damaged and stops functioning)) for one of two sampled residents (Resident 5) in accordance with the facility's policy and procedures on Medication Orders and Receipt Record. This failure had the potential to result in rapid recurrence of debilitating neurological symptoms (persistent or intermittent physical and cognitive impairments) such as confusion, lethargy (state of abnormal drowsiness), or coma, which often leads to emergency hospitalization. Findings: During a review of Resident 5's AR, the AR indicated Resident 5 was admitted on [DATE] with diagnoses that included cirrhosis of the liver (a late stage, progressive liver disease where healthy liver tissue is permanently replaced by scar tissue), hepatic encephalopathy (brain dysfunction caused by advanced liver disease, such as cirrhosis) fatty liver (a condition where excess fat builds up inside your liver cells), and major depressive (a feeling of severe sadness and hopelessness that affects the activities of daily living) disorder. During a review of Resident 5's History and Physical (H&P), dated 6/23/2026, the H&P indicated Resident 5 had the mental capacity to understand and make medical decisions. During a review of Resident 5's MDS dated [DATE], the MDS indicated Resident 5 has moderate cognitive (ability to process thoughts and information) impairment. The MDS also indicated, Resident 5 requires a helper to do more than half the effort for toileting hygiene, shower/bathe self, lower body dressing and putting on/taking off footwear. Resident 5 requires a helper to provide verbal cues and/or touching/steadying and/or contact guard assistance for eating. During a review of Resident 5's Physician's Orders, dated 6/22/2026, the physician ordered to administer rifaximin 550 milligrams (mgs-a unit of measurement) one tablet by mouth two times a day for hepatic encephalopathy starting 6/23/2026. During a concurrent interview and record review of Resident 1's Medication Administration Record (MAR) and physician's order on 7/2/2026 at 9:42 am, with Assistant Director of Nursing (ADON) and the Quality Assurance Nurse (QAN), stated according to Resident 5's MAR, dated 6/1/2026 - 6/30/2026, Resident 5 did not receive rifaximin on three consecutive days (6/23/2026 - 6/25/2026). On a follow up interview on 7/2/2026 at 9:45 am, The QAN the explained the morning nurse on 6/23/2026 to the evening nurse assigned to Resident 1 on 6/25/2026, the nurses did not follow up with the dispensing pharmacy about rifaximin not delivered to the facility. The ADON further stated, not administering rifaximin to the resident could lead to the resident liver condition to worsen and have symptoms such as confusion. During a review of the facility's Policy and Procedure (P&P) titled, Medication Orders and Receipt Record, reviewed June 2025, the P&P indicated medications should be ordered in advance and the receiving nurse should verify each delivered medication to check off the order form. Any discrepancies should be reported to the dispensing facility.

Based on interview and record review, the facility failed to notify the physician for significant change in condition for two of two sampled residents (Resident 4 and Resident 5) in accordance with the facility's policy and procedures titled Administering Medications and Requesting, Refusing and/or Discontinuing Care or Treatment when: Resident 4 refused bedtime medications for 8 nights in June 2026. Resident 5 was unable to take medications because facility had not received the medications from pharmacy on 6/23/2026 - 6/25/2026. This failure had the potential to worsen residents' condition and not meet their highest potential. In addition, the physician can increase dosage of medications by not knowing the medications were not administered to the residents, leading to hospitalization or death. Findings: 1. During a review of Resident 4's admission Record (AR), the AR indicated Resident 4 was admitted on [DATE] with diagnoses that included major depressive (severe sadness and hopelessness) disorder, metabolic encephalopathy (a general term for brain dysfunction caused by an underlying systemic or chemical imbalance rather than a direct physical injury to the brain), hyperlipidemia (high cholesterol or elevated levels of fats in the blood), and hypertension (high blood pressure). During a review of Resident 4's History and Physical (H&P), dated 12/15/2025, the H&P indicated Resident 4 has the mental capacity to understand and make medical decisions. During a review of Resident 4's Minimum Data Set (MDS - a comprehensive resident assessment and screening tool) dated 4/10/2026, the MDS indicated Resident 4 requires a helper to provide verbal cues and/or touching/steadying and/or contact guard assistance for oral hygiene, toileting hygiene, shower/bathe self, upper/lower body dressing, putting on/taking off footwear, and personal hygiene. During a review of Resident 4's Order Summary Report, dated 7/2/2026, the report indicated the physician ordered to administer: trazodone 100 milligrams (mg - a measurement unit) two tablets by mouth at bedtime for depression manifested by sleeping poorly starting 3/31/2026. latanoprost Solution 0.0005%, on drop to both eyes at bedtime for ocular hypertension (high blood pressure in the eyes) starting 3/4/2026. atorvastatin calcium 10 mg, one tablet by mouth at bedtime for hyperlipidemia starting 3/31/2026. melatonin 3 mg, two tablets by mouth at bedtime for supplement regulate circadian rhythm (body's natural sleep-wake cycle) starting 3/31/2026. During a concurrent interview and record review on 7/2/2026 at 10:42 am, with Assistant Director of Nursing (ADON) and the Quality Assurance Nurse (QAN), Resident 4's Medication Administration Record (MAR), dated 6/1/2026 - 6/30/2026, was reviewed. The MAR indicated: trazadone was not given on eight nights (6/10/2026, 6/17/2026 - 6/20/2026, and 6/24/2026) by Licensed Vocational Nurse (LVN 2). latanoprost solution was not given on eight nights (6/10/2026, 6/17/2026 - 6/20/2026, and 6/24/2026) by LVN 2. atorvastatin was not given on eight nights (6/10/2026, 6/17/2026 - 6/20/2026, and 6/24/2026) by LVN 2. melatonin was not given on eight nights (6/10/2026, 6/17/2026 - 6/20/2026, and 6/24/2026) by LVN 2. During a follow-up interview and record review on 7/2/2026 at 10:42 am, The ADON and QAN stated every time a resident refused to take the prescribed medication, or the medication(s) were not given, it should be reported to the physician. The ADON and QAN further stated there was no documented evidence that LVN 2 inform the physician medications were not given and Resident 4 could have symptoms related to what the medications are treating such as elevated lab values and Resident 4 condition can worsen. 2. During a review of Resident 5's AR, the AR indicated Resident 5 was admitted on [DATE] with diagnoses that included cirrhosis of the liver (a late stage, progressive liver disease where healthy liver tissue is permanently replaced by scar tissue), fatty liver (a condition where excess fat builds up inside your liver cells), and major depressive disorder. During a review of Resident 5's History and Physical (H&P), dated 6/23/2026, the H&P indicated Resident 5 had the mental capacity to understand and make medical decisions. During a review of Resident 5's MDS dated [DATE], the MDS indicated Resident 5 has moderate cognitive impairment. The MDS also indicated, Resident 5 required a helper to do more than half the effort for toileting hygiene, shower/bathe self, lower body dressing and putting on/taking off footwear. Resident 5 requires a helper to provide verbal cues and/or touching/steadying and/or contact guard assistance for eating. During a review of Resident 5's Physician's Orders, dated 6/22/2026, the physician ordered to administer rifaximin 550 mg one tablet by mouth two times a day for hepatic encephalopathy (brain dysfunction caused by advanced liver disease, such as cirrhosis) starting 6/23/2026. During a concurrent interview and record review on 7/2/2026 at 9:42 am, with Assistant Director of Nursing (ADON) and the Quality Assurance Nurse (QAN), Resident 5's MAR, dated 6/1/2026 - 6/30/2026, was reviewed. The MAR indicated Resident 5 did not receive rifaximin on three days (6/23/2026 - 6/25/2026). The ADON and QAN stated Resident 5 did not receive rifaximin because the nurse was waiting for the medication to be delivered to the facility. The ADON and QAN further stated there was no documented evidence that LVN 2 inform the physician that the medication was not given, which should have been reported to the physician. The ADON further stated, not notifying the physician of missed doses of Rifaximin could lead to worsening liver damage and symptoms like confusion. During a review of the facility's Policy and Procedures (P&P) titled, Administering Medications, reviewed June 2025, the P&P indicated medications are administered in accordance with prescriber orders, including any required time frame. During a review of the facility's P&P titled, Requesting, Refusing and/or Discontinuing Care or Treatment, reviewed June 2025, the P&P indicated the physician must be notified of refusal of treatment in a timely manner.

Based on interview and record review the facility failed to resolve a grievance (any formal or informal, written or verbal expression of dissatisfaction with the operations, activities, or behavior of the facility) for one of six (6) sampled residents (Resident 4), who reported a concern on 6/8/2026 that the resident was not receiving medications correctly from Licensed Vocational Nurse (LVN) 2 by failing to: 1. Replace LVN 2 with another nurse to administer Resident 4's medication as indicated in the recommendation/corrective action for the resident's grievance report. 2. Ensure the Administrator in Training (AIT) followed up to ensure the corrective action was implemented and completed another grievance report form when Resident 4 continued to report her concerns that LVN 2 was not administering her medications correctly. These deficient practices resulted in Resident 4's refusing and not receiving her scheduled bedtime medications on 6/10/2026, 6/17/2026, 6/18/2026, 6/19/2026, 6/20/2026, and 6/24/2026 (a total of 8 nights). Findings: During a review of Resident 4's admission Record (AR), the AR indicated Resident 4 was admitted on [DATE] with diagnoses that included major depressive disorder (a mental health condition that causes persistent feelings of sadness, hopelessness, and a total loss of interest in activities), metabolic encephalopathy (a general term for brain dysfunction caused by an underlying systemic or chemical imbalance rather than a direct physical injury to the brain), hyperlipidemia (high cholesterol or elevated levels of fats in the blood), and hypertension (high blood pressure). During a review of Resident 4's History and Physical (H&P), dated 12/15/2025, the H&P indicated Resident 4 has the mental capacity to understand and make medical decisions. During a review of Resident 4's Minimum Data Set (MDS - a comprehensive assessment and screening tool) dated 4/10/2026, the MDS indicated Resident 4 requires a helper to provide verbal cues and/or touching/steadying and/or contact guard assistance for oral hygiene, toileting hygiene, shower/bathe self, upper/lower body dressing, putting on/taking off footwear, and personal hygiene. During a review of Resident 4's Order Summary Report, dated 7/2/2026, the report indicated the physician ordered to administer: Trazodone 100 milligrams (mg - a measurement unit) two tablets by mouth at bedtime for depression manifested by sleeping poorly starting 3/31/2026. Latanoprost Solution 0.0005%, one drop to both eyes at bedtime for ocular hypertension (high blood pressure in the eyes) starting 3/4/2026. Atorvastatin calcium 10 mg, one tablet by mouth at bedtime for hyperlipidemia starting 3/31/2026. Melatonin 3 mg, two tablets by mouth at bedtime for supplement regulate circadian rhythm (body's natural sleep-wake cycle) starting 3/31/2026. During a review of Resident 4's Medication Administration Record (MAR), dated 6/1/2026 - 6/30/2026, the MAR indicated LVN 2 did not administer trazodone, latanoprost solution, atorvastatin, and melatonin (total of 4 scheduled medications) to Resident 4 on 6/10/2026, 6/17/2026 - 6/20/2026, and 6/24/2026 (total of 8 nights) with the reason coded as drug refused. During a concurrent interview and record review on 7/2/2026 at 10:42 am, with Assistant Director of Nursing (ADON) and the Quality Assurance Nurse (QAN), Resident 4's MAR, dated 6/1/2026 - 6/30/2026, was reviewed. The ADON and QAN stated, LVN 2 was the only nurse that did not administer the bedtime medications to Resident 4 in the month of June, other nurses assigned to Resident 4 were able to administer scheduled bedtime medications as ordered. The ADON further stated, LVN 2's failure to administer Resident 4's bedtime medications could result in symptoms related to the conditions that the medications are intended to treat, such as elevated lab values, and could lead to worsening of Resident 4's overall condition. During a review of Resident 4's Grievance/Complaint Report Form, dated 6/8/2026, the form indicated Resident 4 reported her concerns about LVN 2 on 6/4/2026 approximately at 11:30PM that LVN 2 was not giving her medications correctly, and the recommendation/corrective action from the Grievance report on 6/8/2026 was to schedule a different nurse to perform the resident's medication pass. During a concurrent interview and record review on 7/6/2026 at 2:50 pm with the AIT, Resident 4's Grievance/Complaint Report Form, dated 6/8/2026, was reviewed. The form indicated, corrective action taken was to schedule different medication pass (nurse) for the resident. The AIT stated that they did not follow the recommendation and corrective action to remove LVN 2 immediately from Resident 4's care on 6/8/2026. The AIT stated, Resident 4 complained again about LVN 2, but she did not complete and file another grievance form. The AIT further stated, if the corrective action was followed sooner, Resident 4's grievance may have been resolved sooner. During a review of the facility's Policy and Procedure (P&P) titled, Grievances/Complaints, Recording and Investigating, reviewed June 2025, the P&P indicated all grievances and complaints filed with the facility will be investigated and corrective actions will be taken to resolve the grievance(s). The P&P also indicated corrective actions will be taken within five working days of filing the grievance or complaint.

Based on interview and record review, the facility failed to provide activity of daily living (ADL, the basic self-care tasks everyone performs daily to survive, such as like bathing, dressing, and eating) care for one of three sampled dependent residents (Resident 2), in accordance with the facility's Activities of Daily Living policy and Bath/Shower Tub by failing to: 1.Ensure Certified Nurse Assistant (CNA) 1 provided Resident 2 with a shower on her scheduled shower day of 6/30/2026. 2.Ensure CNA 1 reported Resident 2's missed shower to the licensed nurses for appropriate follow up and documentation. These deficient practices had the potential to result in body odor, uncomfortable skin rashes, and an increased risk of fungal or bacterial infections for Resident 2. Findings: During a review of Resident 2's admission Record, the AR indicated Resident 2 was admitted on [DATE] and readmitted on [DATE] with diagnoses that included functional quadriplegia (complete immobility affecting fall four limbs due to severe disability or frailty, occurring without any physical injury or damage to the brain or spinal cord), seizure disorder (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness), depression (a mood disorder that causes a persistent feeling of sadness and a loss of interest in activities) and urinary tract infection (UTI - an infection in the bladder/urinary tract). During a review of Resident 2's History and Physical (H&P) dated 3/9/2026, the H&P indicated Resident 2 had the mental capacity to make medical decisions. During a review of Resident 2's Minimum Data Set (MDS - a comprehensive assessment and screening tool), dated 6/15/2026, the MDS indicated Resident 2 required a helper to do all of the effort for toileting hygiene, shower/bathe self and chair to bed transfers. The MDS also indicated Resident 2 requires a helper to do more than half the effort for lower body dressing and putting on/taking off footwear. During a review of Resident 2's Shower/Bathe Record (SBR) for June 2026, the SBR indicated Resident 2 did not receive a shower on 6/30/2026. During an interview on 7/1/2026 at 2:30 PM with Resident 2, Resident 2 stated she has not received a shower in a long time. Resident 2 further stated she never received a shower from Certified Nursing Assistant (CNA) 1 whenever she is assigned to her. During an interview on 7/1/2026 at 3:30 PM with CNA 1, CNA 1 stated she did not give Resident 2 a shower yesterday (6/30/2026) on the resident's scheduled shower day. CNA 1 also stated she did not notify the charge nurse or registered nurse of a missed shower. During a concurrent interview and record review on 7/2/2026 at 10:00 AM with the Director of Staff Development (DSD), Resident 2's SBR for June 2026, was reviewed. The SBR indicated Resident 2 did not receive a shower on 6/30/2026. The DSD stated, when a shower is refused or not given on the resident's shower day, CNA 1 is responsible for reporting Resident 2's missed shower on 6/30/2026 to the licensed nurses for appropriate follow up and documentation. DSD further stated CNA 1's failure to provide a shower to Resident 2 on her regular shower day could lead to a delay in care and Resident 2's feeling uncomfortable. During a review of the facility's Policy and Procedures (P&P) titled, Activities of Daily Living (ADLs), Supporting, the P&P indicated: a) Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. b) Appropriate care and services will be provided for residents who are unable to carry our ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with hygiene (bathing, dressing, grooming, and oral care). During a review of the facility's P&P titled, Bath, Shower/Tub, reviewed 6/2025, the P&P indicated document to show why a shower was not given and any interventions taken to provide shower. The P&P also indicated to notify the supervisor of showers not being provided. During a review of the facility's Job Description (JD) for Certified Nursing Assistant, undated, the JD indicated, the CNA is responsible to provide each of the assigned residents with routine daily nursing care and services in accordance with the resident's assessment and care plan, and as may be directed by the supervisors.

Based on interview and record review, the facility failed to complete an annual Certified Nursing Assistant (CNA) performance review (a yearly, documented meeting between a nursing assistant and their supervisor to assess the CNA's quality of care, communication, and attendance over the past 12 months) for one of four sampled CNAs (CNA 1). This failure had the potential to result in CNA 1 being unable to provide quality care to the facility's residents, which could negatively impact their dignity, mental health, and physical comfort. Findings: During a review of CNA 1's employment record, the record indicated CNA 1 was hired on 12/15/2016. During a review of CNA 1's Nursing Assistant Orientation & Competency Evaluation, Nursing Skills Performance Satisfactory Completion (NSPSC), dated 9/10/2024, indicated CNA 1's last annual performance review was completed on 9/10/2024. During a concurrent interview and record review on 7/6/2026 at 12:50 PM with the Director of Staff Development (DSD), CNA 1's NSPSC, dated 9/10/2024, was reviewed. The NSPSC indicated, there was no documented evidence that a CNA performance review was completed for CNA 1 within 12 months. The DSD stated that she did not compete a NSPSC for CNA 1 in 2025. During an interview on 7/6/2026 at 12:50 PM with the DSD, the DSD stated, the performance evaluations should be done every year. The DSD stated, she is responsible to observe the CNA performing each task on the performance evaluation form to ensure the CNA is performing the tasks correctly. The DSD further stated if the CNA does not perform a task appropriately, she will provide immediate education. During a review of the facility's Policy and Procedures (P&P) titled, Performance Evaluations, dated 2024-2025, the P&P indicates job performance, and goals are discussed informally on a regular basis. Formal performance reviews are done on an ongoing 12-month cycle. During a review of the facility's Job Description (JD) for Director of Staffing Development, revised 3/21/2021, the JD indicated the DSD is to perform performance reviews in accordance with the facility's P&P on performance evaluations. During a review of the facility's JD for Certified Nursing Assistant, undated, the JD indicated, the CNA's job function included to participate in staff meetings and mandatory in-service as required.

Based on observation, interview and record review, the facility failed to provide one of five sampled residents (Resident 1), who had functional limitation on both sides of her upper extremities (shoulder, elbow, wrist, and hand), with a soft-touch pad call light (a communication tool in that allows the residents to request help from nursing staff) instead of a standard button call light to accommodate the resident's needs. This failure resulted in Resident 1 not able to call for help when the resident had pain and needed assistance from the nursing staff on 7/2/2026 at 6:48 AM. This failure had the potential to delay medical attention and increased the risk of the resident not able to maintain and/or achieve independent functioning, dignity, and well-being. Findings: During a review of Resident 1's admission Record, the AR indicated Resident 1 was admitted on [DATE] with diagnoses that included cerebral palsy (a lifelong physical disability caused by an abnormality or non-progressive injury to the developing brain), diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing), cerebral infarction (stroke, loss of blood flow to a part of the brain), and chronic pain syndrome (persistent or recurrent pain lasting longer than three months that occurs most days or every day). During a review of Resident 1's History and Physical (H&P), dated 6/12/2026, the H&P indicated Resident 1 has the capacity to understand and make medical decisions. During a review of Resident 1's Minimum Data Set (MDS-a comprehensive assessment and screening tool), dated 6/15/2026, the MDS indicated Resident 1 needs a helper to do all of the effort for eating, oral hygiene, toileting hygiene, shower/bathing, dressing and personal hygiene. The MDS indicated Resident 1's functional limitation in range of motion (the amount that your joints can bend and straighten without pain or discomfort) was impaired on both sides of upper extremities (shoulder, elbow, wrist, and hand). During a review of Resident 1's care plan (CP) titled, ADL self-care performance deficit related to activity intolerance, impaired balance, limited range of motion, musculoskeletal impairment, stroke, initiated 6/12/2026, the CP indicated an intervention to encourage the resident to use bell to call for assistance. During a review of Resident 1's CP titled, at risk for falls related to deconditioning, incontinence, psychoactive drug use, initiated 6/12/2026, the CP indicated an intervention to have call light within reach and promptly respond to all requests for assistance. During a concurrent observation and interview on 7/2/2026 at 6:45 AM with Resident 1, in Resident 1's room, Resident 1's right arm was under a blanket and unable to move, and her left hand was contracted (a condition where one or more fingers become stiff and curl inward toward the palm). There was a push button call light was next to Resident 1's left hand but the resident was unable to press it. Resident 1 stated that she had pain and needed pain medication but could not use the provided call light due to her condition. During a concurrent observation and interview on 7/2/2026 at 6:48 AM with Licensed Vocational Nurse (LVN) 1, in Resident 1's room, Resident 1 was unable to press the call light button. LVN 1 stated that the call light button is all the facility has at this time, maintenance person will have to come in later to change it to a soft-touch pad call light to accommodate the resident's needs. During an interview on 7/2/2026 at 8:15 AM with Resident 1's private companion (PC - a person not employed by the facility that provides non-medical support and supervision), the PC stated she has asked the facility to provide a more appropriate call light in the past but nothing was done. The PC stated that she presses the call button for Resident 1 whenever the resident needs assistance. During an interview on 7/2/2026 at 10:20 AM with the Assistant Director of Nursing (ADON), the ADON stated that Resident 1 needs an appropriate call light to ensure her needs are met. The ADON explained that Resident 1 requires a soft touch pad call light if she is unable to press the standard call light button. During a review of the facility's Policy and Procedures (P&P) titled, Call System, Resident, dated June 2025, the P&P indicated, Each resident is provided with a means to call staff directly for assistance from his/her bed. If the resident has a disability that prevents him/her from making use of the call system, an alternative means of communication that is usable for the resident is provided and documented in the care plan. During a review of the facility's P&P titled, Accommodation of Needs, dated June 2025, the P&P indicated adaptations will be made to accommodate individual needs to maintain safe independent functioning, dignity and well-being.

Based on observation, interview, and record review, the facility failed to ensure that the facility's two out of three shower rooms (SR) were clean and sanitary, in accordance with the facility's policy and procedure titled, Infection Prevention and Control. On 6/2/2026 SR 1 and SR 2 were observed to have brown-colored substances that were smeared on the floor and shower chairs (a specialized, waterproof seat designed to allow individuals to sit while bathing). This deficient practice had the potential to spread infection to all the facility's residents who use the shower rooms.During a review of Resident 1's admission Record (AR), the AR indicated, the resident was admitted on [DATE] with diagnoses that included metabolic encephalopathy (a brain dysfunction, leading to symptoms like confusion, personality changes), diabetes mellitus (a metabolic condition characterized by persistently high blood sugar (glucose) levels), and hyperlipidemia (elevated blood cholesterol level). During a review of Resident 1's History and Physical (H&P), dated 12/15/2025, the H&P indicated, the resident has the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 4/10/2026, the MDS indicated, the resident has intact cognition (the ability to process thoughts and emotions). The MDS also indicated, the resident requires supervision (the helper provides verbal cues and/or touching assistance as resident completes the activity) on activities such as oral hygiene, toileting hygiene, bathing, and dressing. The MDS also indicated, the resident requires setup assistance (the helper sets up or cleans up prior to or following the activity) on activities such as eating. During an interview on 6/2/2026 at 10:29 AM with Resident 1, Resident 1 stated the facility's shower rooms are always filthy. Resident 1 stated the nurses do not clean up the shower room after they shower residents. Resident 1 stated that whenever she uses the shower rooms, there are always feces on the floor and the shower chairs. Resident 1 added that when she went to the shower room on 6/1/2026, the shower room's floor had feces. During a concurrent observation and interview on 6/2/2026 at 11:17 AM with Housekeeper (HK), the facility's SR 1 was inspected. HK stated that there are brown stains or smudges that appear to be feces on the shower room floor and the shower chair's lower legs. During a concurrent observation and interview on 6/2/2026 at 11:23 AM with the Director of Nursing (DON), the facility's SR 3 was observed. The DON stated SR 3 floor has feces. The DON added the shower chair inside SR 3 appears to have feces on its bottom frame. The DON also stated the Certified Nursing Assistant's (CNA) are responsible for cleaning up the shower room after each resident use it. During an interview on 6/3/2026 at 3:12 PM with the facility's Infection Preventionist Nurse (IP), IP stated feces that are left in the shower rooms could potentially transmit infections to residents. IP stated, after a resident defecates in the shower room, the nurse should throw away the feces in the trash and disinfect the floor and equipment using disinfectant wipes. During an interview on 6/3/2026 at 3:45 PM with the DON, the DON stated CNAs and nurses must ensure that shower rooms are clean and free from feces after each resident use. The DON added, the shower room must be clean before another resident uses it to prevent the spread of infections. The DON further added teces that are left in the shower room could potentially cause infections on whoever uses the shower room. During a review of the facility's policy and procedure (P&P) titled, Infection Prevention and Control, dated 2001, the P&P indicated that infection prevention policies and procedures apply to all personnel. The P&P indicated that the objectives of the infection prevention and control policy include for the facility to maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public.

Based on observation, interview, and record review, the facility failed to ensure that the water filter was changed at least once a year for the facility kitchen's coffee maker and juice machine. This deficient practice had the potential to affect the residents' appetite and fluid consumption because of the water palatability of the facility-served coffee and juice.During a concurrent observation and interview on 6/2/2026 at 3:11 PM with Dietary Supervisor (DS), the facility's kitchen was inspected. During the inspection, the facility's water filter was observed with a label indicating that the filter was changed on 5/28/2025. DS stated the water filter supplies water to the facility's coffee maker and juice making sure the water, which is served for the residents. During a follow-up interview on 6/2/2026 at 3:32 PM with DS, DS stated, about one month ago at the beginning of the month of 5/2026, DS observed that the water filter had not been changed since 5/28/2025. DS stated he intended to contact the vendor of the water filter to change the filter, but DS forgot. DS added that the water filter needs to be changed timely because it supplies water to the facility's coffee maker and juice making sure the water is palatable or no after taste. During a concurrent interview and record review on 6/2/2026 at 3:35 PM with DS, the water filter's manufacturer's catalog (dated 2026) was reviewed. DS stated the manufacturer's catalog indicated that the water filter must be replaced at least once a year. DS added if the water filter was last changed on 5/28/2025, the filter should have been changed on or before 5/28/2026. During an interview on 6/3/2026 at 2:11 PM with Maintenance Supervisor, MS stated he did not know that it was his responsibility to ensure that the coffee and juice machine's water filter is replaced at least once a year. MS also stated he thought that the vendor would automatically go to the facility to change the water filter for the coffee and juice maker. MS further stated he did not know that he should call the vendor to remind the vendor to replace the water filter. During an interview on 6/3/2026 at 3:45 PM with the Director of Nursing (DON), the DON stated it is the responsibility of the MS to ensure that the coffee and juice maker's water filter is changed timely. The DON, added that failure to change the water filter on time could affect the water quality that the residents drink and could place the residents at risk of potential foodborne infections and/ or loss of appetite because the water was not palatable. During a review of the facility's policy and procedure (P&P) titled, Maintenance Service, reviewed 6/2025, the P&P indicated maintenance service shall be provided to all areas of the building, rounds, and equipment. The P&P indicated the maintenance personnel shall follow the manufacturer's recommended maintenance schedule. The P&P further indicated that the maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. The P&P also indicated that the maintenance personnel's functions include the maintenance of plumbing fixtures.

Based on observation, interview, and record review, the facility failed to ensure one (1) of three sampled residents (Resident 1) were administered medications, in accordance with the physician's order and facility's policy and procedure (P&P) titled, Administering Medications. This deficient practice placed Resident 1 at risk of complications associated with the possible mismanagement of the resident's diseases process.Findings:During a review of Resident 1's admission Record (AR), the AR indicated resident was admitted on [DATE] with diagnoses that included metabolic encephalopathy (a brain dysfunction, leading to symptoms like confusion, personality changes), diabetes mellitus (DM, a metabolic condition characterized by persistently high blood sugar (glucose) levels), and hyperlipidemia (elevated blood cholesterol level). During a review of Resident 1's History and Physical (H&P), dated 12/15/2025, the H&P indicated the resident has the capacity to understand and make decisions. The H&P also indicated that the resident had a history of suicide attempt by way of overdosing on lisinopril (a medication used to control high blood pressure). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 4/10/2026, the MDS indicated that the resident has intact cognitive (the ability to process thoughts and emotions) skills for daily decision making. The MDS also indicated Resident 1 required supervision (the helper provides verbal cues and/or touching assistance as resident completes the activity) on activities of daily living (ADL) such as oral hygiene, toileting hygiene, bathing, and dressing. The MDS also indicated Resident 1 required setup assistance (the helper sets up or cleans up prior to or following the activity) with eating. During a review of Resident 1's Physician's Orders as of 6/2/2026, the Physician's Orders included the following:Jardiance (a medication used to control DM) oral tablet 10 milligrams (MG, a unit of measuring weight) give 1 tablet by mouth in the morning for DM, ordered on 12/12/2025.Metformin Hydrochloride (a medication used to control DM) oral tablet 1000 MG give 1 tablet by mouth two times a day for DM with meals (Hold if blood sugar [BS, the amount of glucose {a type of sugar} present in the bloodstream, which is the body's main source of energy] [is less than] 100), ordered on 3/31/2026.Probiotic (a supplement) oral capsule give 1 capsule by mouth one time a day for digestive supplement, ordered on 5/19/2026.Venlafaxine Hydrochloride (a medication used to treat depression [a serious, common mood disorder characterized by a persistent feeling of sadness, emptiness, and a significant loss of interest in activities]) oral capsule extended release 24-hour 75 MG give 1 capsule by mouth one time a day for depression, ordered on 3/31/2026.Vitamin C oral tablet give 1000 MG by mouth one time a day for supplement, ordered on 5/19/2026.During a review of Resident 1's Medication Administration Record (MAR), for the month of 6/2026, the MAR included the resident's Jardiance, Probiotic, Venlafaxine, and Vitamin C are prescribed to be administered at 9AM. The MAR also indicated that Resident 1's Metformin is prescribed to be administered at 7:30 AM. All five medications were initialed as administered to Resident 1. During a review of Resident 1's Medication Audit Report from 6/1/2026 to 6/2/2026, the Report indicated that Resident 1's Venlafaxine, Jardiance, Vitamin C, and Probiotic were documented as administered on 6/2/2026 at 9:28 AM by Licensed Vocational Nurse (LVN) 1. The Report also indicated that Resident 1's Metformin was documented as administered on 6/2/2026 at 8:25 AM by LVN 1. During a review of Resident 1's assessment Note titled, Self-Administration of Medication, dated 5/19/2026, the Note indicated that the resident is not approved for the self-administration of medications. The Note also indicated that Resident 1 may not keep medications at the bedside. The Note further indicated that Resident 1 requires assistance in actions such as stating the time to take the medications, stating the proper dosage of the medications, dispensing the proper amount of the medications, documenting the self-administration of medications, and naming the medications and their prescribed use. During a review of Resident 1's Care Plan for skilled nursing care, initiated on 12/17/2025, the Care Plan indicated that the resident requires skilled nursing care related to the resident's need for medical management, cognitive impairment, and metabolic encephalopathy. The care plan interventions included were to assist the resident with ADLs and administer medications as ordered. During an interview and observation on 6/2/2026 at 10:47 AM inside Resident 1's room, Resident 1 was observed grabbing a medication cup from her bedside table. Resident 1 stated that there are 5 medications in the cup. Resident 1 was then observed taking one pill from the medication cup and proceeded to put it in her mouth. Resident 1 stated that she ingested one of the medications in the cup, and it was vitamin C. Resident 1 then stated that she does not know the other four pills in the medication cup. During a concurrent observation and interview on 6/2/2026 at 10:51 AM with Licensed Vocational Nurse (LVN) 1 inside Resident 1's room, LVN 1 stated that there is a medication cup with four pills on Resident 1's bedside table. LVN 1 stated that the medications are Resident 1's Jardiance, Probiotic, Venlafaxine, and Metformin. During a follow-up interview on 6/2/2026 at 10:54 AM with LVN 1, LVN 1 stated that that she gave the medications to Resident 1, but the resident stated she wanted to sleep. LVN 1 stated that she left the medication cup containing the medications at around 8:30 AM because the medications were due at that time. LVN 1 further added that the medications are now late and do not fall within one hour of the prescribed time of administration. During an interview on 6/5/2026 at 11:06 AM with Registered Nurse 1 (RN 1), RN 1 stated that nurse must not leave medications with the resident. RN 1 stated that if the resident chooses not to take the medications at the time, the nurse can offer the medications later. During the same interview on 6/3/2026 at 2:45 PM with the DON, the DON stated that the nurse must ensure that all medications are successfully swallowed by the resident before leaving the resident to ensure that the resident's medications are taken on time. The DON added that the resident's medication regimen is affected if the medications are not taken on time. The DON further added that if medications are not taken within one hour of its prescribed time, the resident's disease will not be effectively managed. During a review of the facility's P&P titled, Administering Medications, reviewed 6/2025, the P&P indicated that only persons licensed or permitted by this state to prepare, administer, and document the administration of medications may do so. The P&P also indicated that medications are administered within one (1) hour of their prescribed time. The P&P also indicated that the individual administering the medication initials the resident's [Medication Administration Record] on the appropriate line after giving each medication.

Based on interview and record review, the facility failed to provide a hazard free environment and device to prevent falls in accordance with the facility's policy and procedure (P&P) titled Falls and Fall Risk, Managing, and Smoking Policy or five of five sampled resident (Resident 2, 5, 6, 7, and 8) by failing to: 1. Supervise and implement intervention for Resident 2 who used a wheelchair instead of a Front Wheeled [NAME] (FWW-a mobility aid featuring two wheels on its front legs and rubber, non-slip tips on the back legs) plan for safety while ambulating. 2. Monitor, supervise compliance with Smoking Policy and implement intervention to promote safety for Resident 5 who smokes and found sharing cigarettes and carrying a lighter. 3. Complete Resident 6's Smoking and Safety Assessment (an assessment and evaluation form used by the facility to determine the resident's ability to smoke safely). 4. Complete Resident 7's Smoking and Safety Assessment, monitor, supervise compliance with Smoking Policy' and implement intervention to promote safety for Resident 7 who smoked cigarette and found carrying two lighters. 5. Complete Resident 8's Smoking and Safety Assessment, monitor, supervise compliance with Smoking Policy and conduct an interdisciplinary team (IDT) meeting and develop a care plan for Resident 8 who was found with marijuana (dry shredded mix of leaves, flowers, stems from the Cannabis plant that contained chemicals that interact with your body and brain altering your mood, senses) in the resident's belongings. These deficient practices had the potential to result for Resident 2 to have increased risk for fall and repeated falls that could result in major injuries. In addition, the deficient practice could result in Residents 5,6,7 and 8 to be at risk for smoking-related accidents, burns, and fire hazards that could affect the safety of the other residents, personnel and visitors in the facility. Findings: 1. During a review of Resident 2's admission Record, the admission Record indicated Resident 5 was admitted on [DATE] with diagnoses that included major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) with psychotic symptoms (a severe mental condition that indicate a loss of contact with reality), unsteadiness (lack of physical stability or balance) on feet, lack of coordination (inability to make smooth, precise physical movements), and dementia (a progressive state of decline in mental abilities). During a review of Resident 2's History and Physical (H&P) dated 5/12/2026, the H&P indicated Resident 2 does not have the mental capacity to make medical decisions. During a review of Resident 2's Minimum Data Set (MDS-a comprehensive assessment and screening tool) dated 5/5/2026, the MDS indicated Resident 2 needs a helper to do less than half the effort for sit to stand, chair/bed-to-chair transfer, toilet transfer, walk 10 feet and walk 50 feet with two turns. During a review of Resident 2's Fall Risk Evaluation dated 4/18/2026, the Fall Risk Evaluation indicated Resident 2 was chairbound (being permanently or temporarily confined to a wheelchair due to illness or physical condition) and could not walk. During a review of Resident 2's Fall Risk Evaluation dated 4/20/2026, the Fall Risk Evaluation indicated Resident 2 had a balance problem while standing or walking. No goals or interventions were indicated. During a review of Resident 2's Interdisciplinary Team (IDT-a group of healthcare professionals with different specialties who collaborate to evaluate, plan and deliver resident centered care) Conference – Post Fall, dated 4/21/2026, the IDT Conference indicated on 4/19/2026, Resident 2 lost balance while walking to the restroom and was found sitting on the floor. The IDT conference indicated Resident 2 will have hands-on-assistance with transfer and ambulation. During a review of Resident 2's Physical Therapy (PT) Notes dated 5/15/2026, the PT notes indicated instructions were given to the resident and caregiver for use of FWW with ambulation. During a review of Resident 2's PT Progress Report dated 5/15/2026, the PT Progress Report indicated patient (resident) will safely perform functional transfers with stand by assistance for correct use of assistive device. During an interview on 5/18/2026 at 3 PM with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 2 usually walks around the facility pushing a wheelchair like a FWW. During an interview on 5/19/2026 at 9:30 AM with CNA 2, CNA2 stated Resident 2 was on fall precautions so needs supervision when walking or getting up out of bed. CNA 2 stated she walks with Resident 2 when walking around the facility and pushing the wheelchair as if it was a FWW. During an interview on 5/19/2026 at 10:45 AM with Physical Therapy Assistant (PTA), PTA stated Resident 2 was very confused and impulsive. The recommendation from physical therapy was to supervise Resident 2 while walking at all times. The PTA also stated, the wheelchair being on four wheels can easily keep rolling causing the resident to fall. During a concurrent interview and record review on 5/19/2026 at 2:38 PM with the Director of Nursing (DON), the Care Plan for impaired mobility, initiated 5/1/2026, was reviewed. The Care plan indicated, Resident to be supervised with bed mobility, transfers, gait with FWW. The DON stated she will follow up with the physical therapist is needed to ensure safe usage of a wheelchair versus the FWW. The DON stated it is important to provide appropriate supervision and care to achieve resident's goal and provide safety from falls. During a review of the facility's Policy and Procedures (P&P) titled, Falls and Fall Risk, Managing, reviewed June 2025, the P&P 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. 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. 2. During a review of Resident 5's admission Record (AR), the AR indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing), and atherosclerotic heart disease (the narrowing or blockage of the artery that supplied blood to the heart). During a review of Resident 5's Smoking and Safety (a form used to evaluate the resident's safety while smoking) dated 1/30/2026 timed at 5:30 AM indicated that the resident used tobacco and followed the facility's designated smoking locations and times. The care plan goal was for the resident to comply with the facility's smoking policies, the interventions included conducting smoking safety evaluations as needed and providing education on smoking schedules and procedures. During a review of Resident 5's Minimum Data Set (MDS, a federally mandated resident assessment tool) dated 3/24/2026, the MDS indicated the resident's cognition was intact (sufficient judgement and self-control to manage the normal demands of the environment). The MDS did not indicate if Resident 5 was currently using tobacco products. During a review of Resident 5's clinical record indicated a comprehensive care plan was not developed a Smoking Care Plan for Resident 5 regarding interventions and safety measures to implement when the resident was smoking. During an interview on 5/19/2026 at 11:27 AM, Resident 5 stated he smoked cigarettes and did not smoke marijuana. Resident 5 stated other residents who live at the facility tried to give Resident 5 marijuana, but he refused. Resident 5 stated he would not give the names of the residents who tried to offer him marijuana. During a concurrent observation and interview in Resident 5's room on 5/19/2026 at 12:09 PM, Resident 5 handed Resident 6 two cigarettes, in return Resident 6 handed Resident 5 a one-dollar bill. Resident 5 stated he did not sell his cigarettes but gave them to my friends and if the other residents wanted to give Resident 5 one dollar I won't refuse. Resident 5 also stated he keeps a lighter in his possession and the resident a lighter out of his pocket to show the surveyor. 3. During a review of Resident 6's AR, the AR indicated the resident was admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses that included COPD, lack of coordination, and nicotine dependence - cigarettes. During a review of Resident 6's History and Physical (H&P) dated 9/12/2024 at 5:20 PM, the H&P indicated the resident had the capacity to understand and make decisions. A review of Resident 6's Chronic Smoker Care Plan, revised on 2/10/2026, identified goals for Resident 6 to avoid injury from unsafe smoking practices and to not smoke without supervision. The Care Plan included interventions to educate the resident on smoking risks and hazards, review the facility's smoking policies regarding approved locations, times, and safety procedures, and ensure staff supervision while the resident smokes. During a review of Resident 6's Smoking and Safety dated 3/20/2026 timed at 2:05 PM, the Smoking and Safety indicated the resident used tobacco products. The Smoking and Safety record did not include ca care plan or measures to implement and ensure safety. During a review of Resident 6's MDS dated [DATE], the MDS indicated the resident's cognition was intact. The MDS did not indicate if Resident 6 was currently using tobacco products. 4. During a review of Resident 7's AR, the AR indicated the resident was admitted to facility on 3/13/2026, with diagnoses that included COPD, unsteadiness on feet, and generalized muscle weakness. During a review of Resident 7's Smoking and Safety dated 3/13/2026, the Smoking and Safety indicated the resident used tobacco products and had balance problems while sitting or standing. The Smoking and Safety record did not include ca care plan or measures to implement and ensure safety. During a review of Resident 7's H&P dated 3/14/2026, the H&P indicated the resident had the capacity to understand and make decisions. The review of Resident 7's Smoking Care Plan, dated 3/16/2026 indicated a goal for the Resident 7 not to smoke without supervision. Interventions included educating Resident 7 about smoking risks and cessation, reviewing the facility's smoking policies regarding locations, times, and safety, and providing staff supervision while the resident smokes. During a review of Resident 7's MDS dated [DATE], the MDS indicated the resident's cognition was intact and currently using tobacco products. During an observation on 5/19/2026 at 11:45 AM, Resident 7 had two lighters and cigarettes within his possession. 5. During a review of Resident 8's AR, the AR indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included DM, unsteadiness on feet, and generalized muscle weakness. During a review of Resident 8's H&P dated 3/2/2026, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 8's Smoking Care Plan dated 3/5/2026, the Care Plan goal was for Resident 8 not to smoke without supervision. The Care Plan included interventions to instruct the resident about smoking risks/hazards and about smoking cessation, instruct the resident regarding the facility policy on smoking regarding locations, times, and safety concerns, and to supervise Resident 8 while smoking. During a review of Resident 8's Smoking and Safety dated 5/8/2026 at 4:50 AM, the Smoking and Safety indicated the resident was a smoker and smoked other for the products used by the resident. The list to choose from included: tobacco, other smoking material. The Smoking and Safety did not indicate what the other product was. The Smoking and Safety indicated a care planning goal for Resident 8 to adhere to the tobacco/smoking policies of the facility and interventions to conduct smoking safety evaluations as needed and to educate the residents to smoking times and procedures. During a review of Resident 8's MDS dated [DATE], the MDS indicated the resident's cognition was intact. The MDS did not indicate if Resident 8 was currently using tobacco products. During an interview on 5/19/2026 at 9:34 AM, Resident 8 stated another resident attempted to hand him a joint (marijuana) that went out before he could smoke the joint. Resident 8 stated he did not remember who the resident was. During an interview on 5/19/2026 at 11:52 AM, the Director of Nursing (DON) stated the residents at the facility were allowed to keep their own cigarettes but were not allowed to keep lighters. The DON stated the facility staff encourage the residents to keep their cigarettes with Activities Staff to avoid conflict of sharing lighters and cigarrettes, but if after an assessment the resident had capacity, the residents were allowed to keep the cigarettes with them. During an interview on 5/19/2026 at 1:41 PM, the Staff 1 stated residents were not allowed to share cigarettes for infection control issues to ensure there was no spread of sickness to the residents. Staff 1 stated residents were not allowed to have lighters in the facility because having a lighter was dangerous and raised safety concerns. Staff 1 stated if residents had their own lighters, they might smoke in their room, get burned, and the residents could hurt themselves. During a concurrent interview and record review of the facility's policy and procedure (P&P) titled Smoking Policy – Residents dated June 2025, on 5/19/2026 at 1:58 PM, Staff 1 stated the residents were not following the policy because residents were observed carrying a lighter. Staff 1 stated if the facility allowed the residents to have lighter, the residents they are not safe and could start a fire and burn themselves or others. During an interview on 5/19/2026 at 2:08 PM, Staff 1 stated she had never witnessed a resident smoking marijuana at the facility but smelled marijuana this morning in the patio. Staff 1 stated Resident 7 and Resident 8 were together huddled in the corner of the patio but they both stated they were not doing anything. During an interview on 5/19/2026 at 3:32 PM, Staff 2 stated when Resident 8 was discharged , the resident left his belongings and the facility staff saw marijuana within his belongings and when the resident returned, Resident 8 was asking specifically for his marijuana. Staff 2 stated she had never observed Resident 8 smoking marijuana. During a concurrent interview and record review on 5/19/2026 at 3:45 PM, Staff 2 stated there was no documented evidence within Resident 8's comprehensive (complete) clinical chart regarding the finding of the resident's marijuana. Staff 2 stated the facility's process was to conduct an IDT and implement a care plan but that was not done. Staff 2 stated this was the first time the facility had encountered something like this and the facility staff should have followed the process. Staff 2 stated if the facility did not follow the process the facility staff would not be able to prevent other similar cases from happening. During a concurrent interview and record review of the facility's policy and procedure (P&P) titled Smoking Policy – Residents dated June 2025 indicated This facility has established and maintained safe resident smoking practices. The P&P indicated Residents who have independent smoking privileges are permitted to keep cigarettes, electronic-cigarettes, pipes, tobacco, and other smoking items in their possession. Only disposable safety lighters are permitted. All other forms of lighters, including matches, are prohibited. Residents are not permitted to give smoking items to other residents. During a review of the facility's P&P titled Care Plans, Comprehensive Person-Centered dated June 2025, the P&P indicated A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The P&P indicated Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. When possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers. Assessments of resident are ongoing and care plan are revised as information about the residents and the resident's conditions change. The interdisciplinary team reviews and updates the care plan: when there has been a significant change in the residents condition or when the desired outcome is not met.

Based on interview and record review the facility failed to provide a hazard free environment, supervision and assistive device to prevent accidents and injuries to one of three sampled resident (Resident 1) in accordance with the resident's care plan, physician order and the facility's policy and procedure titled Assessing Falls and Their Causes. The facility failed to ensure: Resident 1's call light was always within Resident 1's reach.Application of the bed alarm (a pressure sensitive pads with a pad alarm (a device that alarms when pressure is relieved from the pad (by the patient 'getting up' from the chair or bed) the alarm will sound and assistance can be provided) in good functioning condition as ordered by the physician.To complete the Fall Risk Assessment to assess and implement interventions based on the resident's risk factor for fall.Thoroughly investigate the root cause of fall on 11/11/2025 to determine the appropriate inventions to prevent recurrent fall on 1/21/2026.Assess if Resident 1 could be placed on bowel and bladder program or incontinence (no control with bowel movement and urination) program (a structured, individualized plan designed to help residents regain or maintain continence, prevent skin breakdown, and promote independence. It relies on scheduled toileting, fluid management, pelvic floor exercises, and restorative nursing strategies rather than relying on adult briefs). These deficient practices resulted in Resident 1's fall on 11/11/2025 and was hospitalized due to a laceration (a jagged tear or deep cut in the skin and underlying soft tissues usually caused by blunt trauma or friction) on the forehead requiring sutures (stitch or medical device use to hold the tissues together) and right anterior (in front) scalp hematoma (a collection of blood trapped under the skin on the front-right side of the head) on 11/11/2025. In addition, Resident 1 had a recurrent fall and experienced pain and discomfort after the fall. Findings: During a review of Resident 1's General Acute Care Hospital (GACH) 1 Discharge Note dated 9/10/2025, indicated the resident's discharge diagnosis included sacral wound (a skin injury over the sacrum, the triangular bone at the very base of the spine, just above the tailbone) infection and foley catheter (a thin, flexible tube inserted into the bladder to drain urine) for urinary retention (the inability to completely empty your bladder, or in some cases, to pass any urine at all). The GACH 1 Progress Note indicated Resident 1 to have a bowel regimen (a routine or plan designed to help have regular, healthy bowel movements and prevent constipation). During a review of Resident 1's admission Record (AR), the AR indicated the resident was admitted to the facility on [DATE], with diagnoses that included Parkinson's Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements) with dyskinesia (a movement disorder defined by involuntary, erratic, and uncontrollable muscle movements), pressure ulcer of sacral region stage four (skin injury due to prolonged unrelieved pressure resulting in full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone), and unsteadiness on feet (a lack of balance, causing a wobbly, uneven, or unstable feeling while standing or walking). During a review of Resident 1's History and Physical (H&P) dated 9/10/2025 at 8:53 PM, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS, a federally mandated resident assessment tool) dated 12/8/2025, the MDS indicated the resident had moderate cognitive impairment (a person was experiencing noticeable and significant difficulties with thinking, learning, remembering, and other cognitive skills that impact their daily life), that required substantial/maximal assistance (helper did more than half the effort) for transfers and sitting to standing, toileting and (partial/moderate staff does less than half the effort) on sit to stand, chair/bed-to-chair transfer, and walking 10 (ten) feet. The MDS indicated Resident 1 was always incontinent of bowel and urinary and was not on a toileting program. The MDS indicated the resident had a fall since admission/entry or reentry or the prior assessment with one injury. During a review of Resident 1's Fall Risk Evaluation dated 9/11/2025 at 2:29 AM, the Fall Risk Evaluation indicated the resident was alert and oriented, bedbound (a person spending most or all of their time in bed because of illness, injury, weakness, or disability making them unsafe or too difficult to move around) and incontinent (the involuntary loss of bladder or bowel control) and recently hospitalized in the last 14 days. The Fall Risk Evaluation was incomplete and did not indicate the fall risk score (a score or number used by healthcare providers to predict how likely a person was to fall - a score of 10 or higher indicates the resident was at high risk of falls) and the interventions to prevent falls. In addition, the report was not signed and dated by the facility staff who initiated the report. During a review of Resident 1's At Risk for Fall Care Plan dated 9/13/2025, the Care Plan indicated to reduce the risk for Resident 1's falls in three months, the facility will keep the call light within reach and the staff to answer call light promptly, keep frequently used items within reach, and to keep the bed at a low position. During a review of Resident 1's Change in Condition (COC) Evaluation dated 11/11/2025 at 6:24 AM, the Evaluation indicated on 11/11/2025 at 3:57 AM, Certified Nursing Assistant (CNA) 1 found Resident 1 on the floor lying on her right side with a right forehead laceration. The laceration was cleansed with normal saline (a sterile mixture of salt and purified water), patted dry, and covered with sterile gauze (a clean woven cotton material used in first aid) with applied pressure to stop bleeding. The Evaluation indicated that the resident representative and physician were notified with orders to transfer Resident 1 to the GACH via 911 (an emergency number). A review of the Nursing Progress Notes dated 11/11/2025 at 9:34 AM, Resident 1 was transferred to GACH 2 for further assessment of the head injury on 11/11/2025 at 4:24 AM. During a review of Resident 1's GACH 2 indicated Resident 1 was admitted to the Emergency Department (ED) on 11/11/2025 due to complaint of head injury after rolling out of bed, arrived with laceration on the head. A review of the Diagnostic Report dated 11/11/2025 at 5:24 AM, the GACH 2 Report indicated Resident 1's Computed Tomography (CT, imaging test that combined a series of X-rays taken from various angles with a computer to create detailed cross-sectional slices of the bones, organs, and tissues) indicated Resident 1 has a right anterior (in front) scalp hematoma. During a review of Resident 1's Fall Risk Evaluation dated 11/11/2025 at 6:25 AM (completed after the fall on 11/11/2025 at 3:57 AM), the Fall Risk Evaluation indicated the resident did not have any falls in the past three months, was alert and orientated to name, place and time and was, chairbound (someone unable to walk on their own and depended on a wheelchair to get around)/incontinent. The Evaluation indicated the resident's fall risk score was seven (7) indicating the resident was not at high risk for fall. During a review of Resident 1's GACH 2 Emergency Department Physician's Notes dated 11/11/2025 at 6:27 AM, the Physician's Notes indicated Resident 1 received four 6-0 nylon sutures (ultra-fine, non-dissolvable surgical stitch) with close approximation of two centimeters stellate appearing laceration (a star-shaped or jagged, multi-pronged tear in the skin) to the right forehead. The Physician's Notes indicated suture removal approximately in seven days given the wound appearance. During a review of Resident 1's Post Fall Evaluation dated 11/11/2025 at 6:45 AM, the Post Fall Evaluation indicated Resident 1 had unwitnessed fall in the room attempting to self-toilet and sustained a right forehead laceration. The Post Fall Evaluation indicated contributing factors to fall included the resident was incontinent and using incontinent supplies (incontinent brief) at the time of the fall. Resident 1 complained of generalized moderate body pain after the fall and was given pain medications as needed. During a review of Resident 1's Interdisciplinary Team (IDT-a group of facility staff that meet to create a plan of care for residents) Conference Record - Fall Management Follow-Up dated 11/11/2025 at 2:59 PM, the Follow-Up indicated the resident was placed on neurological (brain function and mental status) checks, post fall monitoring, and post fall Rehabilitation (rehab) assessment was competed and interventions (completed an evaluation and provided direct, hands-on treatment) and provided re-education to the resident to use the call light when needing help, changing the call light to a tap call light (a bedside button resident's use to ask for help) for easier manipulation by the resident, continued treatment of the right forehead laceration until healed, and to continue monitoring the application of the resident's bed alarm. During a review of Resident 1's Actual Fall with Minor Injury Care Plan dated 11/11/2025, the Care Plan indicated the goal for the resident to resume usual activities without further incident and for the resident's right forehead laceration to resolve without complications. The Care Plan included intervention to apply bed alarm, continuing interventions from the At Risk for Falls Care Plan and checking vital signs in the first 24 hours. During a review of Resident 1's Comprehensive Medical Chart, the Medical Chart did not indicate the resident had a Rehabilitation Post Fall/Incident Assessment done on 11/11/2025. During a review of Resident 1's Actual Fall with Minor Injury Care Plan dated 1/21/2026, the Care Plan indicated a goal for the resident to resume usual activities without further incident. The Care Plan interventions included continuing interventions on the At Risk for Falls care plan, educate Resident 1 for use the call light for help, and to offer snacks and fluids during medication pass and activities of daily living care. During a record review of the Order Summary Report indicated the physician ordered on 11/12/2025 to place bed alarm for Resident 1. During a review of Resident 1's COC Evaluation dated 1/21/2026 at 4:25 AM, the COC Evaluation indicated the resident fell at night. The Care Plan did not include information such as the exact time of the fall, location, how the resident was found, who witnessed the fall, what happened before the fall, and immediate interventions provided. The Evaluation indicated Resident 1's representative, and the physicians were notified with no new orders. During a review of Resident 1's Comprehensive Medical Chart, the Medical Chart indicated Resident 1's Fall Risk Evaluation form was not completed after the fall on 1/21/2026. During a review of Resident 1's IDT Conference Record - Fall Management Follow-Up dated 1/21/2026 at 4 PM, the Follow-Up indicated the resident was placed on neuro checks, post fall monitoring, and a post fall Rehab Assessment was competed and innervations were provided. The Follow-Up was incomplete and interventions to prevent recurrent falls were not documented. The Fall Management Follow-Up did not include a facility staff member's signature or date of completion. During a review of Resident 1's Rehabilitation Post Fall/Incident assessment dated [DATE] at 2:14 PM, the Assessment indicated the resident was seen with no apparent distress, the resident stated she was reaching for something and fell from the left side of the bed, screamed for help and the staff found the resident on the floor. The Assessment indicated the resident did not demonstrate proper safety techniques during transferring or using the call light properly. During a concurrent interview and record review on 5/13/2023 at 4 PM with the MDS Nurse, Resident 1's Change in Condition Evaluation dated 1/21/2026 was reviewed. The MDS Nurse stated the Evaluation did not have information on what specifically happened regarding the fall on 1/21/2026. The MDS Nurse stated the COC Evaluation was not completed because pertinent information about what happened and what caused the fall was not included in the COC. The MDS Nurse explained without any information showing what was done for Resident 1 safety could mean there was no proof that the facility staff did anything to care for the resident. During a telephone interview on 5/13/2026 at 7:56 PM, Registered Nurse Supervisor (RNS) 1 stated, when she arrived in Resident 1's room on 11/11/2025, the resident was already back to bed, and she informed CNA 1 and Licensed Vocational Nurse (LVN) 1 to apply pressure to the resident's forehead laceration while RNS 1 called 911. RNS 1 stated after calling 911, she assessed Resident 1 and the resident's mental orientation was intact. RNS 1 stated Resident 1 informed her that the resident was trying to turn off the light and close the bathroom door. The RNS 1 stated Resident 1 did not call for help. During a telephone interview on 5/14/2026 at 11:56 AM, CNA 1 stated on 11/11/2025 at around 3 AM, while she was assisting another resident CNA 1 heard Resident 1 yelling for help. CNA 1 stated she went to Resident 1's room she found the resident sitting on the floor leaning against the side of the bed and was actively bleeding on her forehead. CNA 1 stated she called for assistance and waited for the LVN 1 to assess the resident before moving the resident back into bed. CNA 1 stated Resident'1s bed was not in a low position and the resident did not have a floor mat. CNA 1 stated Resident 1 had a bed alarm that was under the resident's back which did not alarm when the resident was found on the floor. CNA 1 stated You would be able to hear the bed alarm if the bed alarm went off because the bed alarm was so loud, but there was no bed alarm sound coming from the resident's (Resident 1's) room at the time of the fall. During a telephone interview on 5/14/2026 at 12:16 PM, LVN 1 stated, on 11/11/2025 after the fall she found Resident 1 in her room with hands and feet were on the floor, sitting down and actively bleeding from her head. LVN 1 stated Resident 1 was alert and oriented during the assessment. LVN 1 explained the bed was not at a low position and he was not sure if a floor pad was on the floor. LVN 1 stated he did not hear the bed alarm go off on the morning Resident 1 fell on the floor. During a concurrent interview and record review on 5/14/2026 at 12:47 PM, the Physical Therapist (PT) stated when a resident had a fall, the Rehab Department conducted a Post Fall Assessment every time to assess if the resident broke any bones, investigate what caused the fall to try and prevent future falls, and implement a treatment plan. The PT stated there was no documented evidence that a Post Fall Assessment was completed for Resident 1 on 11/11/2025. During a telephone interview on 5/18/2026 at 11:31 AM, Resident 1 stated, on 11/11/2025 she was unsure how she fell off the bed, but she recalled that she was dizzy and her forehead was pounding. Resident 1 stated she was yelling for help for more than 30 minutes, but nobody came to assist her. Resident 1 stated she did not have a floor mat and was unsure if she had a bed alarm. Resident 1 stated she was unable to reach the call light to call for help, it was not near her. Resident 1 stated because of her Parkinson's Disease she has unsteady gait. During a continued telephone interview on 5/18/2026 at 11:31 AM, Resident 1 stated she does not remember how she fell on 1/21/2026. Resident 1 stated that she tried to yell for help after the fall since she could not reach her call light, because the call light was too far from her, but nobody came to help her. Resident 1 stated the staff takes away the call light away from her. Resident 1 reported she was in a lot of pain and she received pain medication. During a review of the Weight and Vitals Summary indicated Resident 1's pain level ranged from 11/11/2025 at 5:30 AM to 11/15/2026 was from 3-8 out of 10 (pain scale 0-no pain and 10-severe pain). The pain level from 1/15/2026 to 1/21/2026 ranged from 0-8 on the pain scale. During a concurrent interview and record review of Resident 1's Fall Risk Evaluation dated 9/11/2025 on 5/18/2026 at 12:18 PM, the Director of Nursing (DON) stated the Fall Risk Evaluation should be completed to identify the residents risk for fall and develop a person-centered care plan with interventions based on the risk factors to prevent recurrent falls and prevent injury . The DON stated there was a possibility that the residents' fall could have been prevented if the Fall Risk Assessment was completed because then the facility staff could have based our interventions from our assessment to make the plan resident specific. During a concurrent interview and record review of Resident 1's Change in Condition Evaluation dated 11/11/2025 on 5/18/2026 at 12:35 PM, the DON stated a genitourinary (GU, assessment of the urinary tract such as kidney, bladder, ureters and reproductive organs)/urine assessment was not completed because Resident 1 had no issues with urinary and bowel elimination during the fall. During a concurrent interview and record review of Resident 1's IDT Conference Record - Fall Management Follow-Up dated 11/11/2025 on 5/18/2026 at 12:38 PM, the DON stated the IDT's recommendation was not implemented because the resident did not have a Post Fall Assessment on 11/11/2025 from Rehab because that was best practice to reassess the resident after the resident returned from the GACH. The DON stated that because Resident 1 was not assessed by the Rehab Department the care plan related to mobility needs of the resident was not developed to prevent recurrent fall. During a concurrent interview and record on 5/18/2026 at 12:47 PM of Resident 1's Post Fall Evaluation dated 11/11/2025 with the DON, the DON stated the facility staff should have conducted a GU/urine assessment in the Change of Condition Evaluation dated 11/11/2025 as the Post Fall Evaluation indicated contributing factors included incontinence. The DON stated the resident was not placed in a bowel/bladder program and the staff should have anticipated the needs of the resident by putting the residents personal items closer to the resident to prevent recurrent fall. During a concurrent interview and record review on 5/18/2026 at 12:53 PM of Resident 1's Actual Fall with Minor Injury Care Plan dated 11/11/2025, the DON stated there were no interventions that included the contributing factors for the fall in 11/11/2026. The DON stated the facility staff should have followed the interventions from the At Risk for Falls Care Plandated 9/13/2025 and had everything Resident 1 needed within reach to prevent the resident from reaching out to grab things and being unsafe. During a current interview and record review on 5/18/2026 at 1:12 PM with the DON Resident 1's Change in Condition Evaluation dated 1/21/2026, the DON stated the Evaluation was not completed to indicate what happened, how the resident fell and who was present during the fall. During a concurrent interview and record review of Resident 1's Post Fall Evaluation dated 1/21/2026 on 5/18/2026 at 1:18 PM, the DON stated there was no documented evidence that a Post Fall Evaluation was completed for Resident 1 on 1/21/2026 to ensure the resident was provided with the appropriate treatment. During a concurrent interview and record review of Resident 1's Fall Risk Evaluation on 5/18/2026 at 1:19 PM, the DON stated there was no documented evidence that a Fall Risk Evaluation was completed on 1/21/2026. During a concurrent interview and record review of Resident 1's clinical records on 5/18/2026 at 1:20 PM with the DON, the DON stated the facility did not conduct a complete internal investigation of Resident 1's falls on 11/11/2025 to identify the risk factors that contributed to falls. The DON stated a resident specific care plan was not developed to indicate interventions to prevent recurrent falls related to the risk factors identified, such as incontinence care, bladder and bowel program, after the fall on 11/11/2025. The DON explained there was no record to ensure the pad alarm was monitored to be in place and functioning, and no record to indicate that the residents' call light was always within reach for the resident to use when needed. The DON stated that without a completed internal investigation the facility staff would not be able to find out and identify the root cause of what happened and escalate interventions, so Resident 1 does not have recurrent falls. During a continued concurrent interview and record review of Resident 1's clinical records on 5/18/2026 at 1:20 PM with the DON, the DON stated the facility did not conduct an internal investigation of Resident 1's fall on 1/21/2026 to identify the risk factors that contributed to falls and a resident specific care plan was not developed to indicate interventions to prevent recurrent falls related to the risk factors identified, after the fall on 1/21/2026, there was no record to indicate the residents' call light was always within reach for the resident to use when needed. The DON stated that without an internal investigation the facility staff would not be able to find out and identify the root cause of what happened and escalate interventions, so Resident 1 did not have recurrent falls. During a review of the facility's policy and procedures (P&P) Assessing Falls and Their Causes reviewed in 6/2025, the P&P indicated the following: Within 24 hours of a fall, try to identify possible or likely causes of the incident,Evaluate chains of events or circumstance preceding a recent fall,Continue to collect and evaluate information until the cause of falling is identified or it is determined that the root cause cannot be found,Consult with the attending physician or medical director to confirm specific causes from among multiple possibilities. During a review of the facility's policy and procedures (P&P) Care Plans, Comprehensive Person-Centered reviewed in 6/2025, the P&P indicated that care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. The P&P also indicated that assessment of residents is ongoing, and care plans are revised as information about the residents and residents' condition change.

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1), who had a stage 4 (Full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone), pressure injury (PI localized damage to the skin and/or underlying tissue usually over a bony prominence) was provided care and services to prevent wound deterioration in accordance with the facility's policy and procedures titled Prevention of Pressure Injuries. This deficient practice placed Resident 1 at risk for delayed wound healing, infection, and negative outcome of Resident 1's prognosis.Findings: During a review of Resident 1's admission Record (AR) the AR indicated that Resident 1 was originally admitted to the facility on [DATE] and discharged on 2/11/2026 with diagnoses including PI of sacral region (shield-shaped bony structure at the base of spine) Stage 4 (Full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone), Parkinson's Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), and hypertension (high blood pressure). During a review of Resident 1's Minimal Data Set (MDS- a federally mandated resident assessment tool) dated 12/8/2025, the MDS indicated that Resident 1 was moderately cognitively impaired (decisions poor, supervision required). The MDS also indicated that Resident 1 required substantial/maximal assistance (helper does more than half the effort) on toileting hygiene, rolling left and right, and chair/bed-to-chair transfer. During a review of Resident 1's Braden Scale for Predicting Pressure Injury Risk dated 9/11/2025, indicated the total score was 16 (scale range 15 to 18 at risk for pressure injury). During a review of Resident 1's Skilled Evaluation Nurse Note (SEN) dated 9/11/2025, the SEN indicated pressure-reducing device for bed was checked off. The SEN did not indicate a checkmark to indicate that Resident 1 was turned and repositioned every two (2) hours. During a review of Resident 1's Care Plan Resident has sacrococcyx pressure injury Stage 4 dated 9/13/2025, the Care Plan indicated interventions included to cleanse with normal saline, pat dry, apply Santyl ointment (a topical medicine used to debride (remove) dead, necrotic tissue from chronic skin ulcers and severe burns to promote healing), cover with dry dressing then foam dressing daily. The Care Plan indicated to provide pressure relief and low air loss mattress (LAL-a mattress designed to prevent and treat pressure wounds), and to support good body alignment and position. The Care Plan did not indicate an individualized repositioning schedule, educate and remind residents of the importance of repositioning. During a review of Resident 1's Documentation Survey Report (DSR) dated from 11/1/2025 to 11/30/2025, the DSR indicated that Resident 1 was assisted to roll left and right every shift. The DSR did not indicate that Resident 1 was turned and repositioned every two (2) hours while in bed. The DSR did not indicate the frequency Resident 1's incontinence brief was checked and changed after each episode. During a review of Resident 1's Nursing Progress Notes (NPN) dated from 11/25/2025 to 11/27/2025, the NPN indicated that despite explaining to Resident 1 the purpose of a foley catheter (thin, flexible, indwelling tube inserted through the urethra into the bladder to drain urine into a collection bag) for a Stage four (4) Sacral PI wound healing, Resident 1 refused reinsertion of foley catheter. During a review of Resident 1's IDT (Interdisciplinary Team- a collaborative group of health professionals working together to manage patient care) Conference Record (IDTCR)- Wound Management dated 12/5/2025, the IDTCR indicated the following interventions utilized: Treatment per Physician's OrderMedication/Mineral/Vitamin SupplementsVitamin CLAL MattressPressure Reducing MattressLAL Mattress. There was no documentation in the IDTCR indicating that IDT identified incontinence (involuntary loss of bladder control, causing leakage) as one risk factor that could inhibit the healing process for Resident 1's stage 4 PI. There was no documentation in the IDTCR that indicated any new recommendations after Resident 1 refused reinsertion of foley catheter since 11/25/2025. During a review of Resident 1's Care Plan Resident has potential for injury, worsening in condition related to non-compliance as evidence by refusing to reinsert foley catheter dated 12/9/2025, the Care Plan did not include any wound protective measures or moisture preventive interventions. During a concurrent interview and a record review on 3/27/2026 at 3 PM with the Treatment Nurse (TXN), Resident 1's clinical records were reviewed. TXN stated since 11/25/2025 Resident 1 refused reinsertion of foley catheter the resident did not have a foley catheter prior to discharge. TXN stated she was not sure how often Resident 1 was turned/repositioned by staff. TXN stated she was not sure how frequent staff checked or changed Resident 1's incontinence brief. TXN stated that the facility did not develop or indicate on the Care Plan to ensure that Resident 1 was turned or repositioned at least every two hours. TXN also stated that the Care Plan regarding Resident 1 refusal of a foley catheter did not have effective measures to protect Resident 1's sacrococcyx PI. During an interview on 3/27/25 at 4PM with the Director of Nursing (DON), the DON stated that the staff were supposed to ensure that Resident 1 was turned at least every two hours and that Resident 1's wound dressing was protected from soiling by incontinence. The DON stated preventative measures like repositioning and moisture reduction were very important for Resident 1 to lower the risks for PI wound infection and deterioration, however IDT did not address this risk, therefore the Care Plan was not revised. During a review of the facility's Policy and Procedures (P&P) Prevention of Pressure Injuries reviewed in 6/2025, the P&P indicated the following: Keep the skin clean and hydrated,Clean promptly after episodes of incontinence,Use a barrier product to protect skin from moisture,Reposition all residents with or at risk of pressure injuries on an individualized schedule, Teach residents who can change positions independently the importance of repositioning. Provide support devices and assistance as needed. Remind and encourage residents to change positions.Review the interventions and strategies for effectiveness on an ongoing basis.

Based on observation, interview, and record review, the facility failed to identify interventions related to one (1) of three sampled residents (Resident 1's) specific risks and causes to try to prevent the resident from falling by failing to: Ensure that Resident 1 was frequently monitored and checked for safety and not to leave frequently used items unreachable for Resident 1;Ensure that IDT (Interdisciplinary Team- a collaborative group of health professionals working together to manage patient care) identified and evaluated specific factors and causes after Resident 1 fell on [DATE] and 1/21/2026;Ensure that staff obtained physician's order for floor mat and applied as recommended by IDT and as in the Care Plan. As a result, Resident 1 sustained a four (4)-centimeter laceration on the right forehead on 11/11/2025 requiring suture, and a second fall on 1/21/2026 during similar timeframe. These deficient practices also had potential risks to place other residents at risk for falls. Findings: During a review of Resident 1's admission Record (AR) the AR indicated that Resident 1 was originally admitted to the facility on [DATE] and discharged on 2/11/2026 with diagnoses including Pressure Ulcer (localized damage to the skin and/or underlying tissue usually over a bony prominence) of Sacral Region(shield-shaped bony structure at the base of spine), Stage 4 (Full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone), Parkinson's Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), and hypertension (high blood pressure). During a review of Resident 1's Minimal Data Set (MDS- a federally mandated resident assessment tool) dated 12/8/2025, the MDS indicated that Resident 1 was moderately cognitively impaired (decisions poor, supervision required). The MDS also indicated that Resident 1 required substantial/maximal assistance (helper does more than half the effort) on toileting hygiene, and partial/moderate assistance (helper does less than half the effort) on sit to stand, chair/bed-to-chair transfer, and walking 10 (ten) feet. During a review of Resident 1's Nursing Progress Notes (NPN) dated 11/11/2025, the NPN indicated Resident 1 was found on his right side on the floor at 4:05 AM and noted to have right forehead laceration (a tear or ragged cut in skin or flesh). The NPN also indicated that 911 was called at 4:11 AM, and Resident 1 was transferred to the general acute care hospital (GACH) 1 via 911 paramedics at 4:30 AM. During a review of Resident 1's GACH 1 Emergency Department (ED) Discharge Instruction Document dated 11/11/2025, the Discharge Instructions indicated that Resident 1 had a laceration to the forehead and would require suture removal. During a review of Resident 1's IDT Conference Record - Fall Management Follow-Up (IDTCR) dated 11/11/2025, the record indicated interventions that included Medication Regimen Review (MMR a comprehensive evaluation of a patient's medication list), bed in lowest position, landing floor mat, and applying bed alarm (a safety device to detect when a person attempts to leave their bed). There was no documented evidence that indicated the cause of Resident 1's fall. During a review of Resident 1's NPN dated 1/21/2026, the NPN indicated Resident 1 was found on the floor next to the left side of the bed at 4:10 AM. Resident 1 was lying on the floor and had a snack bag in her hand. The NPN indicated that Resident 1 was alert but forgetful and stated that she was trying to reach the snack bag from the bedside table and slide down from bed. The NPN indicated Resident 1 was observed with skin redness on left side of the forehead and that Resident 1 stated she hit bedside table. During a review of Resident 1's IDT Conference Record - Fall Management Follow-Up (IDTCR) dated 1/21/2026, the IDTCR was incomplete since there were no checkmarks by the IDT that indicated suggestive appropriate interventions. During a review of Resident 1's Physician's Orders dated from 9/10/2025 to 1/29/2026, the Physician Orders did not indicate an order for floor mats. During a review of Resident 1's Care Plan Resident presents with deficits in strength, safety awareness. dated 12/19/2025, the Care Plan did not indicate to provide supervision for safety when Resident 1 had poor safety awareness and not remembering to use call light. During a review of Resident 1's Care Plan Resident had an actual fall with minor injury dated 11/11/2025 and 1/21/2026, the Care Plan did not indicate to ensure bed alarm was functioning. During a concurrent interview and record review on 3/31/2025 at 10:30 AM with the MDS Nurse (MDSN 1), Resident 1's clinical records were reviewed. MDSN 1 stated Resident 1 fell on [DATE] and 1/21/2026 around the same time between 4 AM and 4:30 AM. MDSN stated Resident 1's IDTCR should have been completed and thorough, and should indicate the cause of Resident 1's fall. MDSN stated Resident 1's Care Plan interventions for fall precautions should have included frequent monitoring even though there was a bed alarm to alert the staff about resident's movement in bed. MDSN stated that finding the causes of a resident's fall was important because it was the first step to develop a resident-centered care plan and apply appropriate interventions tailored to Resident 1's specific needs. During an interview on 3/31/2026 at 2:45 PM with the Director of Nursing (DON), the DON stated that Resident 1 had Parkinson's Disease and was cognitively impaired. The DON stated Resident 1 did not have a care plan for supervision after Resident 1 sustained her first fall on 11/11/2025. The DON stated she was not sure why floor mat was recommended by the IDT but never ordered or applied to Resident 1. The DON also stated the staff failed to try to identify and document specific factors and causes of resident's fall and failed to implement a resident-centered Care Plan interventions. The DON stated since the cause of the fall was not identified and specific needs were not implemented for Resident 1, the DON stated Resident 1 could likely sustain another fall. During a review of the facility's policy and procedures (P&P) Assessing Falls and Their Causes reviewed in 6/2025, the P&P indicated the following: Within 24 hours of a fall, try to identify possible or likely causes of the incident, Evaluate chains of event or circumstance preceding a recent fall, Continue to collect and evaluate information until the cause of falling is identified or it is determined that the cause cannot be found,Consult with the attending physician or medical director to confirm specific causes from among multiple possibilities. During a review of the facility's policy and procedures (P&P) Care Plans, Comprehensive Person-Centered reviewed in 6/2025, the P&P indicated that care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. The P&P also indicated that assessment of residents are ongoing and care plans are revised as information about the residents and residents' condition change.

Based on observation, interview and record review, the facility failed notify the physician after a change in condition for one of three sampled residents (Resident 1) who was a diabetic (someone whose body cannot properly manage blood sugar levels) and had an episode of hypoglycemia (a condition where blood sugar drops below normal levels, typically under 70 mg/dL( unit of measurement used to show the concentration of a substance) on 3/6/2026 This deficient practice had the potential for Resident 1's hypoglycemic episode to recur resulting in weakness, confusion or even coma (unconsciousness) that could negatively affect Resident 1's quality of life.FINDINGS: During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 3/4/2026 with diagnoses that included type1 diabetes (a chronic autoimmune condition where the immune system destroys insulin-producing beta cells in the pancreas, leading to little or no insulin production), duodenal ulcer (ulcer that appears in the first part of the small intestine, called the duodenum), and muscle weakness. During a review of Resident 1's History and Physical Examination (H&P), dated 3/6/2026, the H&P indicated Resident 1 was alert and oriented to person and place. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 3/6/2026, the MDS indicated Resident 1's cognitive status (the mental process of thinking and understanding) was intact. The MDS indicated Resident 1 required set-up or clean-up assistance (helper sets up and clean up) with eating, and partial/moderate assistance (helper does less than half the effort) with toileting, bathing and dressing. During a review of Resident 1's facility document titled Order Summary Report (a physician order), dated 3/6/2026 -active orders, indicated the following orders:call provider immediately if resident is hypoglycemic (less than 70 mg/dl), call provider as soon as possible when blood glucose values are regularly 70- 100 mg/dl ( for possible regimen adjustment).Inject Insulin Glargine (long-acting insulin) subcutaneously (SC) (under the skin) 30 units (dose strength) at bedtime.Inject Insulin Lispro (rapid acting insulin) 11 units SC before breakfast and before dinner.Inject Insulin Lispro 14 units SC before lunch. During a review of Resident 1's Care Plan (CP) for Resident 1's diabetes, dated 3/5/2026, the CP intervention indicated to call provider immediately if resident was hypoglycemic (less than 70 mg/dl), call provider as soon as possible when blood glucose values are regularly 70- 100 mg/dl (for possible regimen adjustment). During a review of Resident 1's facility document titled Progress Notes (PN) dated 3/6/2026 timed at 3:49 PM, the PN indicated Resident 1's blood sugar before lunch was 371 mg/dL, and insulin was administered. The PN indicated after lunch Residents blood sugar was checked again and it was 60 mg/dL, then Resident 1 was given juice and a parfait. Resident 1s blood sugar was reassessed and the blood sugar increased to 72 mg/dL. Resident 1 was monitored with no signs of distress. The PN did not indicate that the medical doctor (MD) was notified regarding Resident 1's hypoglycemic episode. During an interview on 3/17/2026 at 11:30 AM with Licensed Vocational Nurse (LVN) 1, LVN 1 stated on 3/6/2026 around 11:30 AM, prior to lunch, Resident 1's blood sugar was 371mg/dL, so LVN 1 administered 14 units of insulin to Resident 1's as ordered, then LVN 1 rechecked Resident 1's blood sugar around 1 PM after lunch, and Resident 1's blood sugar was 60mg/dL. LVN 1 stated she gave Resident 1 some juice and a parfait as part of her nursing measure to increase Resident 1's blood sugar. LVN 1 stated Resident 1 was asymptomatic. LVN 1 stated she rechecked Resident 1's blood sugar and was 72mg/dL. LVN 1 continued to monitor Resident 1 for any distress. LVN 1 stated, she forgot to notify the MD of Resident 1's change of condition (COC). LVN 2 stated by not notifying the MD of Resident 1's COC, Resident 1 could potentially remain hypoglycemic. LVN 1 stated, if MD was made aware of the COC, MD could have made changes on Resident 1's insulin regimen to prevent another hypoglycemic episode. During a concurrent interview and record review, on 3/17/2026 at 12:30 PM with the Director of Nurses (DON), Quality Assurance nurse (QA) and medical record director (MRD), Resident 1's electronic health record (EHR) from admission on [DATE] until discharge on [DATE] was reviewed. The EHR did not indicate that MD was made aware of Resident 1's COC on 3/6/2026. MRD stated, she did not see any COC, and she did not see any documentation that MD was notified of Resident 1's COC. QA stated the MD should have been notified immediately regarding Resident 1 being hypoglycemic as ordered by the physician when Resident 1's blood sugar was less than 70mg/dL. QA stated there was no documentation in Resident 1's EHR that the MD was made aware of the hypoglycemic episode. DON stated, even though Resident 1 had a planned discharge later that day, MD still should have been notified that Resident 1 was hypoglycemic, so MD could make adjustments, if needed, to Resident 1's insulin regimen and to prevent the potential of the hypoglycemic episode to reoccur, which could lead to weakness, confusion or even coma. A review of the facility's policy and procedure (P&P) titled, Management of Hypoglycemia, dated 10/2025 indicated; a) classification of level 1 hypoglycemia : blood glucose less than 70 mg/dl, but greater than 54 mg/dl, b) for level 1 hypoglycemia give resident an oral form of rapidly absorbed glucose and notify the provider immediately. A review of the facility's policy and procedure (P&P) titled, Change in a Resident's Condition or Status, dated 5/2017, indicated: a) the facility shall promptly notify his or her attending physician of changes in the resident's medical condition, b) the nurse will notify the resident's attending physician or physician on call when there has been a specific instruction to notify Physician of changes in the resident's condition.

Based on interview and record review, the facility failed to provide care and services to ensure one of three sample residents (Resident 1) with blisters (a painful skin condition filled with fluid fills a space between layers of skin) due to shingles (an infection caused painful rash) was assessed, monitored and documented weekly for two weeks the skin condition in accordance with the facility's policy and procedures (P&P) titled, Wound Care. This deficient practice had the potential for Resident 1's to receive delayed care or no care when the resident's skin condition with blisters due to shingles to worsen, become infected, and could also spread to other vulnerable residents in the facility. Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility originally admitted Resident 1 on 5/20/2025 and readmitted on [DATE] with diagnoses that included anxiety disorder (a normal feeling of worry or fear in response to stress) and hypertension (high blood pressure). During a review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care planning screening tool), dated 12/24/2025, the MDS indicated Resident 1 had moderately impaired cognitive (ability to understand and make decisions) skills for daily decision making. The MDS indicated Resident 1 required partial/moderate assistance with eating, oral hygiene, personal hygiene and chair/bed-to-chair transfer, and substantial/maximal assistance with toileting hygiene and shower/bathe self. During a review Resident 1's Physician Order, dated 12/24/2025, the order indicated the physician ordered to cleanse the shingles rash on bilateral buttocks in the morning with normal saline, pat dry, and cover with foam dressing daily for 14 days. During an interview on 1/8/2026 at 1:02 PM with Certified Nursing Assistant (CNA) 1, CNA 1 stated she assisted the Treatment Nurse (TXN) to assess Resident 1's skin when the resident was admitted to the facility on [DATE]. CNA 1 stated she saw Resident 1 had some red closed dots on her low back area and Resident 1 complained it was painful in that area. During a concurrent interview and record review on 1/8/2026 at 2:55 PM with the TXN, Resident 1's medical record was reviewed. The TXN stated Resident 1 had shingles and she saw red blisters on Resident'1 lower back area when she assessed Resident 1 on 12/19/2025. The TXN stated the Registered Nurse (RN) supervisor was responsible with documenting Resident 1's skin condition related to blisters, but the RN supervisor did not document the condition of the blisters in the resident's clinical record. The TXN stated the there was no documentation in Residen1's clinical record that indicated the resident's blisters was assessed, documented and monitored for two weeks since 12/19/2025 The TXN stated she was off for the past two weeks and the covering nurses did not assess and complete the Weekly Skin Check for Resident 1 from 12/26/2025 and 1/2/2026. The TXN stated it was important to assess the skin and document the assessment on the admission and weekly afterwards, so they could monitor the healing progress of the shingles and evaluate the effectiveness of the current treatment. The TXN stated if Resident 1's blisters condition worsens compared to the previous assessment; they could intervene immediately to prevent the wound and the infection from getting worse. During a concurrent interview and record review on 1/8/2026 at 3:15 PM with the Infection Preventionist (IP), Resident 1's medical record was reviewed. The IP stated she was aware Resident 1 had shingles and blisters upon admission on [DATE]. The IP stated there was no documentation indicated Resident 1's skin condition due to shingles were assessed, documented and monitored since her admission on [DATE]. The IP stated the nurses should assess and document Resident 1's skin condition due to shingles upon admission and weekly afterwards, so she could monitor the healing status of Resident 1's shingles and prevent potential spread of shingles virus to other vulnerable residents in the facility. During an interview on 1/8/2026 at 3:33 PM with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she was covering for the TXN to provide wound care to Resident 1 for past two weeks, but she did not know and was not endorsed to assess and complete the Weekly Skin Check for Resident 1 for the past two weeks. During a concurrent interview and record review on 1/9/2026 at 3:00 PM with the Director of Nursing (DON), the facility's policy and procedures (P&P) titled, Wound Care, dated 10/ 2010, and admission Assessment and Follow Up: Role of the Nurse, dated 9/2012, were reviewed. The DON stated the RN supervisor did not assess and document Resident 1's shingles blisters condition on Skin Check upon admission on [DATE] and the nurses did not assess and document the Weekly Skin Check for Resident 1's blisters on 12/26/2025 and 1/2/2026. The DON stated it was important to assess and document Resident 1's shingles blisters upon admission, so they would know the baseline condition. The DON stated the facility's P&P did not indicate the frequency of follow up skin assessment, but as the facility's practice, the nurses should reassess and document the shingles blisters condition weekly so they could monitor the healing process of the blisters and determine when and how to intervene timely to promote wound healing and prevent the spread of shingles to other residents. During a review of the facility's P&P titled, Wound Care, dated 10/2010, the P&P indicated the nurse should record all assessment data obtained when inspecting the wound and any change in the resident's condition in the resident's medical record. During a review of the facility's P&P titled, admission Assessment and Follow Up: Role of the Nurse, dated 9/2012, the P&P indicated the nurse should conduct physical assessments, including skin assessment, and record all relevant assessment data obtained during the admission assessment in the resident's medical record.

Based on observation, interview and record review the facility failed to ensure proper and effective Basic Life Support (BLS-the level of care provided to victims of life-threatening illnesses or injuries until full medical care is available, including recognition of cardiac arrest and activation of the emergency response system), that included cardiopulmonary resuscitation (CPR, an emergency procedure combining chest compressions and rescue breaths to circulate blood and oxygen when the heart stops or breathing ceases). The facility did not continuously perform BLS for one of 66 identified full code (a resident who wants all possible life-saving measures used if their heart stops or they stop breathing, including CPR residents) (Resident 1) during a code blue (a life-threatening medical emergency requiring an immediate trained response for CPR) when Resident 1 was found unresponsive, pulseless, and not breathing by failing to ensure: 1. Certified Nursing Assistant (CNA) 1, Registered Nurse Supervisor (RN) 1, Licensed Vocational Nurse (LVN) 1, LVN 2, and LVN 5 immediately called a code blue when Resident 1 was found unresponsive on [DATE] between 3:05 PM to 3:10 PM, so that CPR could be initiated without delay. 2. CNA 1, RN 1, LVN 1, LVN 2, and LVN 5 were aware of Resident 1's code status (a medical order indicating the type of emergency treatment a person would or would not receive if their heart or breathing stopped) and were able to locate this information in the resident's medical record. LVN 1 stated that CPR was initiated by a licensed nurse on the resident's bed at 3:22 PM on [DATE], approximately 12 minutes after the resident was found unresponsive. 3. LVN 1 and CNA 2 placed Resident 1 on a firm, flat surface while performing CPR on the resident's bed and utilized a backboard available at the facility, designed to provide a rigid surface under the resident's back to prevent mattress compression and improve the depth and effectiveness of chest compressions during CPR. 4. LVN 1 and CNA 2 performed continuous and uninterrupted CPR on the resident's bed until emergency medical services (EMS- ambulance services or emergency services that provide treatment and stabilization for the patient) assumed care. As a result, Resident 1 was pronounced deceased (dead) on [DATE] at 3:48 PM by EMS crew after 20 minutes of CPR were performed on the floor. These failures placed the facility's identified 66 full code residents at risk to not receive adequate and proper life-saving measures during a code blue, potentially leading to greater harm and/or death to other residents residing in the facility. On [DATE] at 2:34 PM, an Immediate Jeopardy (IJ: a situation in which the facility's' noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified in the presence of the facility's Administrator (ADM) and the Director of Nursing (DON) regarding the facility's failure to ensure Resident 1 adequately and continuously received BLS, including CPR, resulting in Resident 1's death on [DATE]. On [DATE] at 4:13 PM, the Administrator (ADM) provided an acceptable IJ Removal Plan (a detailed plan to address the IJ findings). On [DATE] at 6:13 PM, while onsite and after the surveyor verified/confirmed the facility's full implementation of the IJ Removal Plan through observation, interview, record review, and determined that the IJ situation was no longer present, the IJ was removed onsite on [DATE] at 6:13 PM, in the presence of the ADM and the Director of Nursing (DON). After the IJ was removed, the surveyor verified that the facility's non-compliance remained at a lower scope of isolated (when one or a very limited number of residents are affected and/or one or a very limited number of staff are involved) and lower severity of Level 2 (noncompliance with the requirements for participation that results in the potential for no more than minimal physical, mental, and/or psychosocial harm to the resident, but has the potential to result in more than minimal harm that is not immediate jeopardy). On [DATE] at 6:13 PM, the IJ was removed, in the presence of the ADM and the DON after the facility submitted an acceptable IJ Removal Plan. The surveyor verified and confirmed the implementation of the IJ Removal Plan while onsite through observation, interview, and record review. The acceptable IJ Removal Plan included the following: On [DATE], Quality Assurance Nurse (QA) and the RN on duty initiated a review of the current residents' care profile in the facility's electronic health record (EHR) system, Code Status. The QA and the RN verified the residents' Code Status via Physician Orders for Life-Sustaining Treatment (POLST -a portable medical order form that helps seriously ill or frail individuals specify their end-of-life care wishes, such as CPR) forms and/or physician's orders for Code Status and input the data accordingly in the residents' care profile under Code Status so that the information is readily available for facility staff, including such events as a Code Blue to ensure all residents who have a full code status receive effective BLS, including CPR. Out of 100 current residents, 66 residents have Full Code status. On [DATE], a copy of the list of these Full Code residents was readily available to staff at the nurse's station for reference and will be updated by the Social Services Director (SW) 1/designee on every admission/readmission and as needed. On [DATE] and ongoing, the DON/Designee provided in-service education to nursing staff regarding the availability of the list of residents who are Full Code. On [DATE], the DON checked the EC and ensured that CPR backboard is available. The RN and/or Designated Licensed Nurse conducted inventory on the EC utilizing the Emergency Cart Checklist and ensure that CPR backboard is readily available. This was validated by the DON and/or Designee. The RN and/or Designated Licensed Nurse will conduct inventory of the EC utilizing the Emergency Cart Checklist every shift to ensure that all necessary items listed are readily available, including, but not limited to, the CPR backboard. On [DATE] and ongoing, the DON initiated immediate in-service to RNs, LVNs, and CNAs regarding ensuring a CPR backboard is readily available and used accordingly. On [DATE], the DON initiated immediate in-service to RNs, LVNs, and CNAs regarding providing rescue breathing (a type of first aid that's given to people who have stopped breathing), not placement of a non-rebreather mask (medical device that delivers high concentrations of oxygen to individuals who can breathe independently but have low blood oxygen). The DON will provide continued in-services for all of the facility's RNs, LVNs, and CNAs. On [DATE], the DON initiated immediate in-service to RNs, LVNs, and CNAs regarding effective and appropriate procedure for CPR, including performing adequate and appropriate chest compressions and rescue breathing, effective and continuous CPR, and ensuring a CPR backboard is readily available and used accordingly. The DON will provide continued in-services for all facility's Licensed Nurses and CNAs. On [DATE], the Director of Staff Development (DSD) reviewed employee files for all current Licensed Nurses and CNAs, specifically to validate that all CPR cards are up to date. There are currently 102 active Direct Care Staff employed at the facility with a total of 16 RNs, 25 LVNs, and 61 CNAs are currently employed at the facility. One LVN (LVN 2) and one CNA do not have a current CPR/BLS certification. On [DATE], the identified CNA attended the CPR certification training. The CNA will be put on temporary suspension until CPR certification is received as part of Direct Care Staff competency. The identified LVN that did not have a current CPR/BLS certification has been placed on suspension and will not be permitted to return to work without an active certification for CPR/BLS. Multiple attempts have been made to contact the LVN with no response at this time. Clinical Nurse Consultant provided 1:1 in-service education to the DSD regarding the importance and significance of monitoring and validating direct staff's BLS/CPR competencies and filing of CPR cards. On [DATE], the DON/Designee provided in-service to CNA 1, CNA 2, LVN 2, and RN 1 regarding the facility's policy and procedure titled Emergency Procedures - Cardiopulmonary Resuscitation with emphasis on immediate code activation and calling for help, hard surface/backboard placement before compression, BVM rescue breathing with appropriate rate/volume, and high-quality compressions including the rate, depth, recoil (allowing the chest to completely return to its normal, resting position between compressions) and minimal interruptions. DON/Designee will provide in-service to LVN 2 upon returning to work. LVN 2 will not be on the schedule until education/reeducation was provided regarding the facility's policy and procedure titled, Emergency Procedures - Cardiopulmonary Resuscitation. On [DATE], the DON/Designee provided in-service to LVN 5 regarding the facility's policy and procedure titled Emergency Procedures - Cardiopulmonary Resuscitation with the emphasize on immediate code activation and calling for help, hard surface/backboard placement before compression, BVM rescue breathing with appropriate rate/volume, and high-quality compressions including the rate, depth, recoil and minimal interruptions. On [DATE], a Certified CPR instructor came to the facility and provided mandatory re-education and training for all Licensed Nurses and CNAs which was also attended by the DON and DSD with return demonstration conducted. A series of ongoing CPR Certification Training sessions will be provided by a Certified CPR instructor until all current Licensed Nurses and CNAs have been provided re-education and training to ensure all residents who have a full code status receive effective BLS, including CPR when the needs arise and prevent greater harm and/or death. Additionally, a Code Blue drill (training) was initiated on [DATE] and will continue weekly, once per shift for 3 months and monthly thereafter for the purpose of Skills Check Validation through return demonstration of Licensed Nurses and CNAs response to Code Blue situations and providing effective BLS, including CPR. An RN is designated as the team leader for Code Blue emergencies. On [DATE], additional CPR training will be provided by a Certified CPR Instructor to provide mandatory (required) re-education and training for all Licensed Nurses and CNAs with return demonstration. Any Licensed Nurses or CNAs will not be permitted to work directly with patients if they do not complete the Certified CPR refresher course. Quality Assurance and Performance Improvement (QAPI, a mandatory facility program to systematically monitor and enhance the quality of care and life for residents) Monitoring Plan Effective [DATE]: The DSD/Designee will maintain a log for all Direct Care Staff of their active Certification for BLS/CPR. DSD/Designee will notify staff with BLS/CPR certification expiring within a month. DSD/Designee will present to the QAA Committee the monthly log for all Direct Care Staff Certification for monitoring and compliance on BLS/CPR certification. As part of QAPI and Compliance on BLS/CPR, no Direct Care Staff will be permitted to work directly with patients without an active BLS/CPR certification. QAA Committee, on a monthly basis, will review audit findings from the DSD/Designee on BLS/CPR Certification monitoring for further needed corrective actions. Cross referenced to F659 Findings: During a review of Resident 1's admission Record, (AR) the AR indicated the resident was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD, [a progressive lung condition making breathing difficult), chronic bronchitis (inflamed airways), emphysema (damaged air sacs), and respiratory failure (a serious condition when not enough oxygen passes from a person's lungs to the blood). During a review of Resident 1's POLST, dated [DATE], and signed by Resident 1, the POLST instructed staff to attempt CPR if Resident 1 had no pulse and is not breathing. During a review of Resident 1's History and Physical (H&P), dated [DATE], the H&P indicated the resident does not have the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (a resident assessment tool), dated [DATE], the MDS indicated that Resident 1 has severely impaired cognition (the ability to process thoughts and emotions). The MDS also indicated that the resident did not have a life expectancy of less than 6 months at the time of assessment. The MDS further indicated that the resident did not have a POLST in the resident's chart. During a review of Resident 1's Interdisciplinary Team (IDT) Conference Record Notes, dated [DATE], the IDT indicated that Resident 1's code status was Full code and that staff should attempt CPR when necessary. During a review of Resident 1's Physician Progress Notes, dated [DATE], the Notes indicated that Resident 1 had a code status of Full Code- Attempt CPR. The Notes also indicated a plan to continue regular breathing treatments as scheduled. During a review of Resident 1's Progress Notes for the month of [DATE], the Progress Notes indicated the following information: 1. On [DATE], timed at 4:10 PM, and signed by RN 1, the note indicated that at 3:15 PM, the charge nurse reported to [RN 1] that she saw [Resident 1] unresponsive during rounds (scheduled nurse visits to patient's bedside to assess, monitor and address patient needs). The note further indicated that RN 1 went to the resident's room to assess Resident 1 and could not obtain the resident's blood pressure. The note also indicated that RN 1 instructed one of the team members to start CPR right away. The note indicated that CPR was continued until the Emergency Medical Services crew from the local Fire Department (FD) arrived at 3:29 PM. The note further indicated that the resident was pronounced deceased at 3:48 PM. 2. On [DATE], timed at 4:47 PM, and signed by LVN 1, the note indicated that at 3:05 PM, the CNA [CNA1] reported [to LVN 1] that resident was unresponsive. The note indicated that Resident 1 did not have a pulse or blood pressure. The note also indicated chest compressions were performed until the EMS crew came and took over. The note further indicated that Resident 1's time of death was on [[DATE]] at 3:48 PM. During a review of a Statement of Declaration (SOD) titled, Declaration, signed by LVN 1, dated [DATE], the SOD indicated that at 3:17 PM, [CNA 1] told [LVN 1] that [Resident 1] is unresponsive. The SOD indicated LVN 1, RN 1, and RN 2 reported to the resident's room. The SOD stated that chest compressions started at 3:22 PM initially. The SOD also indicated that RN 2, LVN 1, and CNA 2 were performing chest compressions until the EMS crew arrived. The SOD indicated that compressions were performed [at] 30 [per minute]. The SOD indicated RN 1 and RN 2 went into the Nurse's Station to check for Resident 1's POLST. The SOD further indicated that Resident 1's POLST could not be found and [RN 1 and RN 2] stated to initiate CPR. The SOD indicated that when a resident is found to be unresponsive, the resident's POLST is checked, and after that, CPR is initiated. During a review of the SOD titled, Declaration, signed by RN 3, dated [DATE], the SOD indicated that before doing CPR [staff] [has] to check [the] code status of the resident. During a review of the facility's staffing schedule titled, Monthly Work Schedule, the staffing schedule indicated the following information: 1.For CNA 3, for the month of [DATE], the schedule indicated that CNA 3 started working at the facility on [DATE]. The facility staffing schedule indicated CNA 3 performed work and assigned to residents at the facility on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE],[DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and[DATE]. 2. For CNA 3, for the month of [DATE], the schedule indicated that CNA 3 performed work and assigned to residents at the facility on [DATE], [DATE], [DATE], [DATE], [DATE],[DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. 3. For LVN 2, for the month of [DATE], the schedule indicated that LVN 2 performed work and assigned to residents at the facility on [DATE], [DATE], [DATE], [DATE], [DATE],[DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. 4. For LVN 2, for the month of [DATE], the schedule indicated LVN 2 performed work at the facility on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. During a review of a facility document titled, Emergency Cart Checklist, dated for the month of [DATE], the document indicated a list of equipment and medication contents required to be included in the facility's EC. The checklist indicated that all the contents of the EC were marked off as present and the daily inventory for [DATE] was completed, which included an Adult Ambu-bag with connective tubing (a thin plastic tubing that attaches to an oxygen source). During a concurrent interview and record review of the facility's [DATE] Emergency Cart Checklist on [DATE] at 9:46 AM with RN 3, RN 3 stated that the check marks in the checklist indicated that the item was checked and available in the EC. RN 3 further stated that she completed the inventory of the EC and checked off the EC checklist for [DATE]. During a follow up observation of the EC on [DATE] at 9:46 AM, in the presence of RN 3, the EC contents were inspected for completeness. During the observation, the EC did not contain an Ambu-bag. During a concurrent interview on [DATE] at 9:46 AM with RN 3, RN 3 stated Ambu-bags are used for CPR during a code blue. RN 3 stated it was her responsibility to inspect the EC at the beginning of the shift at 7:30 AM. RN 3 stated she completed and signed the EC checklist but did not actually inspect the entire contents of the EC because she was busy. During a follow-up interview on [DATE] at 11:11 AM with RN 3, RN 3 stated the correct procedure when inspecting the EC is to go over the EC contents one-by-one to make sure everything is there. RN 3 further stated that the Ambu-bag is important because in order to perform an effective CPR, an Ambu-bag is used to give rescue breaths to the resident. RN 3 also stated that the Ambu-bag might have been taken out of the EC during the code blue on [DATE]. RN 3 stated the Ambu-bag was probably not replaced when it was taken out on [DATE] during the code blue situation. RN 3 further stated that the EC contents must be re-stocked by the licensed nurses when the contents are used, as soon as possible. During a follow-up interview with RN 3 on [DATE] at 11:11 AM, RN 3 stated that the rate of compression during a CPR is 30 compressions per minute. During an interview on [DATE] at 11:47 AM with LVN 1, LVN 1 stated he worked on [DATE] when Resident 1 was found unresponsive. LVN 1 stated that on [DATE], at around 3:15 PM, CNA 1 informed him that Resident 1 was unresponsive. LVN 1 stated that he and other nurses, including RN 1 and RN 2, assessed the resident and found that the resident was not breathing and did not have a pulse. LVN 1 stated that RN 1 and RN 2 went into the nurse's station to check Resident 1's records and locate Resident 1's code status. LVN 1 stated that RN 1 was the one who instructed staff (LVN 1 and CNA 2) to start CPR on Resident 1. LVN 1 stated he could not recall who first initiated chest compressions to Resident 1 and if anyone was giving rescue breaths. LVN 1 also stated he could not recall if a backboard was used during Resident 1's CPR while the resident was on the bed. During a phone interview on [DATE] at 12:27 PM, CNA 1 stated that on [DATE], at approximately 3:10 PM to 3:15 PM, she entered Resident 1's room and found Resident 1 sitting up in bed and unresponsive. CNA 1 reported that she attempted to shake Resident 1, but the resident remained unresponsive. CNA 1 further stated that she did not initiate CPR immediately; instead, she left the room to inform LVN 2, followed by LVN 1. During a phone interview on [DATE] at 12:43 PM with LVN 2, LVN 2 stated that on [DATE] at around 3:10 PM, she went inside Resident 1's room and observed that Resident 1 was pale and not breathing. LVN 2 stated she assessed Resident 1 by checking the pulses in both arms and neck and found that the resident did not have a pulse. LVN 2 stated that she went out of Resident 1's room and went to Nursing Station 1 to notify RN 1. LVN 2 stated she did not initiate CPR right away and could not remember who initiated chest compressions to Resident 1. LVN 2 stated she went back to Resident 1's room. LVN 2 added she could not remember if anyone put the backboard under Resident 1 and if the Ambu-bag was used to give Resident 1 rescue breaths. During a phone interview on [DATE] at 1:18 PM with RN 1, RN 1 stated that on [DATE], between the hours of 3:00 PM to 3:15 PM, she was at Nursing Station 1 when LVN 2 informed her that Resident 1 was unresponsive and had no pulse. RN 1 stated that she went to Nursing Station 3 to check Resident 1's records and look for Resident 1's code status. RN 1 stated that when she found out Resident 1 was full code, that was when she informed the other nurses (CNA 1, CNA 2, RN 1, LVN 1, LVN 2, and LVN 5) in the room to initiate CPR on Resident 1. RN 1 stated that the nurses that were inside Resident 1's room were waiting for her to check Resident 1's code status. RN 1 stated that she could not recall who initiated CPR on Resident 1, could not recall if the Ambu-bag was used, or if the backboard was placed under Resident 1. During another interview on [DATE] at 1:36 PM with LVN 1, LVN 1 stated that on [DATE] at around 3:15 PM, RN 1 and RN 2 searched for Resident 1's code status in Nursing Station 3. LVN 1 stated that when RN 1 and RN 2 could not find the code status, RN 1 and RN 2 instructed facility staff (CNA 1, CNA 2, RN 1, LVN 1, LVN 2, and LVN 5) to initiate CPR on Resident 1. During another phone interview on [DATE] at 2:38 PM with LVN 2, LVN 2 stated that on [DATE] when she found Resident 1 unresponsive, she activated code blue by going to Nursing Station 1 to notify RN 1. LVN 2 stated she did not stay with the resident to initiate CPR. During a phone interview on [DATE] at 2:51 PM with RN 2, RN 2 stated that on [DATE] at around 3:20 PM, she entered Resident 1's room and found LVN 1 and LVN 5 assessing Resident 1. RN 2 stated that LVN 1 and LVN 5 informed her that Resident 1 did not have a pulse. RN 2 stated that RN 1 instructed them to start and initiate CPR on Resident 1. RN 2 stated that CPR was started after RN 1 instructed them to initiate CPR (after RN 2's arrival in Resident 1's room at 3:20 PM). RN 2 stated she could not remember who provided rescue breaths to Resident 1. RN 2 stated she could not remember if a backboard was placed under Resident 1 because when the EMS crew arrived, the EMS crew placed Resident 1 on the floor and continued CPR on the floor. During another phone interview on [DATE] at 3:35 PM with RN 1, RN 1 stated that on [DATE] when Resident 1 was found unresponsive, she searched for Resident 1's code status and could not find it. RN 1 stated that when there is a resident that's unresponsive and pulseless, the facility staff must first search for the resident's code status because if the resident's code status is a DNR (Do not Resuscitate, allow natural death), they would not have to initiate code blue. During another phone interview on [DATE] at 3:44 PM with CNA 1, CNA 1 stated that when she found Resident 1 unresponsive on [DATE] at around 3:, she did not check Resident 1's pulse or respirations. CNA 1 stated she did not call for help by shouting code blue. CNA 1 added she did not initiate CPR. During a phone interview on [DATE] at 4:16 PM with EMS Crew, Paramedic (PC) 1, PC 1 stated that on [DATE], PC 1 and PC 2 responded to the facility's call to 911 (a phone number used to contact the emergency services) emergency services for a resident that was unresponsive. PC 1 stated that on [DATE] upon arriving in Resident 1's room, PC 1 stated the he observed Resident 1 on the bed and two facility staff members (unable to state the names and titles) were next to Resident 1, and one of the facility staff members (unable to state name and title) was performing CPR. PC 1 stated Resident 1 was wearing a non-rebreather mask and staff were not using an Ambu-bag. PC 1 stated that an oxygen mask like the non-rebreather mask was not an appropriate equipment to use while conducting a CPR. PC 1 stated that the Ambu-bag was observed right next to Resident 1's head of the bed but was not being used by the facility staff because PC 1 observed that it was not inflated (be filled or expanded with air) and not connected to an oxygen source. PC 1 also stated that the EMS crew had to move Resident 1 from the bed to the floor because Resident 1 was not placed under a backboard while on the bed. PC 1 stated that the EMS crew continued to perform CPR on Resident 1 for about 15 more minutes. During a phone interview on [DATE] at 4:43 PM with another EMS Crew, PC 2, PC 2 stated that on [DATE] when the EMS crew responded to the facility's 911 call, PC 2 observed one facility staff member (unable to state the name and title) perform CPR on Resident 1. PC 2 stated that the facility staff member was not performing adequate CPR because the rate was inconsistent and slow and described the facility staff's compressions as it would stop and go and stop. PC 2 further stated that during his observation, the facility staff member performing the CPR was only using one hand, instead of two hands during chest compressions. PC 2 stated that the facility staff performing the CPR was not using the Ambu-bag to provide rescue breaths because Resident 1 was placed on a non-breather mask. PC 2 further stated that the facility staff did not place Resident 1 on a backboard and performed CPR on the bed. During a review of an SOD titled, Declaration, signed by LVN 5, dated [DATE], the SOD indicated that on [DATE] at around 3:15 PM, LVN 5 heard CNA 1 informing LVN 2 that Resident 1 was unresponsive. The SOD indicated that LVN 5 observed LVN 2 ran towards [Nursing] Station 1. The SOD indicated that LVN 5 assessed Resident 1 and the resident looked pale, unresponsive, and pulseless. The SOD indicated that LVN 5 recalled how LVN 2 searched for Resident 1's code status in the resident's electronic records and could not find Resident 1's code status. The SOD indicated that LVN 5 recalled that LVN 2 asked the facility's Social Worker (SW 2) regarding Resident 1's code status, and SW 2 stated that Resident 1's code status was full code and started CPR. During an interview on [DATE] at 9:37 AM, LVN 5 stated that on [DATE] at around 3 PM, she heard CNA 1 informed LVN 2 that Resident 1 was unresponsive. LVN 5 stated she instructed LVN 2 to get the EC, however, LVN 2 went to Nursing Station 1. LVN 5 stated she assessed Resident 1 and the resident was unresponsive, pale, and pulseless. LVN 5 stated that LVN 1, RN 2, and SW 2 were inside Resident 1's room. LVN 5 stated she went out of Resident 1's room to search for Resident 1's code status in the resident's physical chart. LVN 5 stated she needed to know Resident 1's code status before starting CPR. During an interview on [DATE] at 10:24 AM with LVN 5, LVN 5 stated that if a resident is unresponsive and pulseless, staff must make sure that the resident is a full code before initiating CPR. LVN 5 added that the chest compression rate for an effective CPR is 30 compressions per minute. LVN 5 also added that a non-rebreather mask may also be used during CPR. During a phone interview on [DATE] at 10:29 AM with CNA 2, CNA 2 stated that on [DATE], he participated in performing CPR on Resident 1. CNA 2 stated he performed CPR at 80 compressions per minute because Resident 1 was fragile. CNA 2 stated that when the EMS arrived, CNA 2 and another LVN (LVN 2) were performing CPR on Resident 1 while the resident was on the bed. CNA 2 stated that he could not remember if an Ambu-bag was used on Resident 1. CNA 2 also stated that he could not recall if a backboard was placed under Resident 1. During an interview on [DATE] at 10:45 AM with LVN 4, LVN 4 stated that on [DATE], she was in Nursing Station 1 when LVN 2 informed her that Resident 1 was unresponsive. LVN 4 stated that she brought the EC into Resident 1's room. LVN 4 stated that RN 1 instructed the nurses to perform CPR on Resident 1. During an interview on [DATE] at 11:08 AM with RN 5, RN 5 stated that if a resident is found unresponsive and pulseless, she would initially check the resident's code status. RN 5 then stated that after confirming that the resident is full code, the emergency cart will be brought inside the resident's room and CPR will be initiated. During an interview on [DATE] at 11:47 AM with LVN 7, LVN 7 stated that if a resident is found unresponsive and pulseless, she would check the resident's code status first. LVN 7 stated that if the resident is full code, she will start CPR. LVN 7 stated that the rate of compression during a CPR is 30 compressions per minute. During a concurrent interview and record review on [DATE] at 2:00 PM with the DSD, the entire facility's direct care employee records were reviewed, including each staff member's BLS/CPR certification. The DSD stated that CNA 3 and LVN 2 do not have a BLS/CPR certification on file. The DSD stated that she was aware that CNA 3 and LVN 2 have not submitted their BLS/CPR certification During an interview on [DATE] at 3:07 PM with the DON, the DON stated that when a staff member finds that a resident is unresponsive, the staff member should check the resident's vital signs (are measurements of the body's most basic functions-temperature, pulse rate, respiration rate, and blood pressure), such as the pulse, blood pressure, and respirations. The DON stated that if the resident was found to be pulseless, not breathing, and unresponsive, the staff member should initiate Code Blue by shouting Code Blue to alert other staff members into the room then initiate CPR right away. The DON added that when CPR has been initiated, other staff members may call for 911 and verify the resident's code status. During the same interview on [DATE] at 3:07 PM with the DON, the DON stated that in order to deliver quality CPR, staff members must use a backboard and the Ambu-bag. The DON stated that the backboard is placed under the resident when performing CPR. The DON added that an Ambu-bag is used to provide the resident two rescue breaths after 30 compressions. The DON also added that CPR must be performed at a rate of 100 to 120 compressions per minute. During an interview on [DATE] at 3:15 PM with CNA 3, CNA 3 stated that she was hired by the facility in [DATE]. CNA 3 stated that she has not provided a copy of her CPR Certificate to the facility. CNA 3 stated that if she finds a resident who is unresponsive, she will put the resident's chin up and perform CPR at the rate of 15 compressions per minute. During an interview on [DATE] at 4:05 PM with the DSD, the DSD stated that it is her responsibility to ensure that all the facility's nursing staff have updated and non-expired licenses and certifications. The DSD confirmed that since [DATE], CNA 3 has[TRUNCATED]

Based on observation, interview, and record review, the facility failed to ensure that a physician's order for a resident's code status preference that included the resident's Provider Orders for Life-sustaining Treatment (POLST-a set of portable medical orders that communicate a patient's wishes for end-of-life intervention to health care facilities and providers) was readily retrievable and placed in the residents' current medical chart for 11 out of 100 sampled residents (Resident 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 and 11), in case of an emergency and in accordance to the facility's Policy and Procedure (P&P) titled, Advance Directive. This deficient practice had the potential to delay life sustaining measures during a medical emergency. Findings: During a review of Resident 1's admission Record, (AR) the AR indicated the resident was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD, [a progressive lung condition making breathing difficult), chronic bronchitis (inflamed airways), emphysema (damaged air sacs), and respiratory failure (condition where the lungs can't adequately oxygenate the blood or remove carbon dioxide). During a review of Resident 1's History and Physical (H&P), dated [DATE], the H&P indicated the resident does not have the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (a resident assessment tool), dated [DATE], the MDS indicated that Resident 1 has severely impaired cognition (the ability to process thoughts and emotions). The MDS also indicated that the resident did not have a life expectancy of less than 6 months at the time of assessment. The MDS further indicated that the resident did not have a POLST in the resident's medical chart. During a review of Resident 2's admission Record indicated the resident was admitted on [DATE] with diagnoses that included metabolic encephalopathy (when the brain has trouble working because of a chemical, or metabolic, problem in the body), hypertension (high blood pressure), and hyperlipidemia (high cholesterol level). During a review of Resident 2's History and Physical (H&P), dated [DATE], indicated the resident does not have the capacity to understand and make decisions. During a review of Resident 2's MDS dated [DATE], the MDS indicated that the resident has severely impaired cognition. The MDS also indicated that the resident had a POLST in the resident's medical chart. During a review of Resident 3's admission Record indicated the resident was originally admitted on [DATE], and readmitted on [DATE], with diagnoses that included chronic kidney disease (CKD, a disease characterized by progressive damage and loss of function in the kidneys), cardiomegaly (an enlarged heart), and dementia (progressive loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). During a review of Resident 3's History and Physical (H&P), dated [DATE], indicated that the resident has fluctuating capacity to understand and make decisions. During a review of Resident 3's MDS, dated [DATE], the MDS indicated the resident has severely impaired cognition. The MDS also indicated that the resident did not have a POLST in the resident's medical chart. During a review of Resident 4's admission Record indicated the resident was admitted on [DATE] with diagnoses that included pneumonia (a lung infection), muscle weakness, and dysphagia (difficulty swallowing). During a review of Resident 4's H&P, dated [DATE], the H&P indicated that the resident does not have the capacity to understand and make decisions. During a review of Resident 4's MDS, dated [DATE] the MDS, indicated that the resident has moderately impaired cognition. The MDS also indicated that the resident had a POLST in the resident's medical chart. During a review of Resident 5's admission Record indicated the resident was originally admitted on [DATE], and readmitted on [DATE], with diagnoses that included COPD, muscle weakness, and hypertension. During a review of Resident 5's H&P, dated [DATE], indicated that the resident does have the capacity to understand and make decisions. During a review of Resident 5's MDS, dated [DATE], the MDS, indicated that the resident has moderately impaired cognition. The MDS also indicated that the resident had a POLST in the resident's medical chart. During a review of Resident 6's admission Record indicated the resident was admitted on [DATE] with diagnoses that included osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and CKD. During a review of Resident 6's H&P, dated [DATE], the H&P indicated that the resident has fluctuating capacity to understand and make decisions. During a review of Resident 6's MDS, dated [DATE], the MDS indicated that the resident has moderately impaired cognition. The MDS also indicated that the resident had a POLST in the resident's medical chart. During a review of Resident 7's admission Record indicated the resident was admitted on [DATE] with diagnoses that included quadriplegia (paralysis affecting all four limbs and the torso, usually from a spinal cord injury in the neck but also from brain trauma or disease), muscle weakness, and hypertension. During a review of Resident 7's H&P, dated [DATE], the H&P indicated that the resident does have the capacity to understand and make decisions. During a review of Resident 7's MDS, dated [DATE], the MDS indicated that the resident has moderately impaired cognition. The MDS also indicated that the resident had a POLST in the resident's medical chart. During a review of Resident 8's admission Record indicated the resident was admitted on [DATE] with diagnoses that included COPD, bipolar disorder (a mental health condition causing extreme mood swings), and depression (a serious mood disorder causing persistent sadness, loss of interest, and impacting thoughts, feelings, and daily life). During a review of Resident 8's H&P, dated [DATE], the H&P indicated that the resident does have the capacity to understand and make decisions. During a review of Resident 8's MDS, dated [DATE], the MDS indicated that the resident has intact cognition. The MDS also indicated that the resident had a POLST in the resident's medical chart. During a review of Resident 9's admission Record indicated the resident was admitted on [DATE] with diagnoses that included CKD, dementia, and hypothyroidism (a condition where the thyroid gland doesn't make enough thyroid hormone). During a review of Resident 9's H&P, dated [DATE], the H&P indicated that the resident does not have the capacity to understand and make decisions. During a review of Resident 9's MDS, dated [DATE], the MDS indicated that the resident has moderately impaired cognition. The MDS also indicated that the resident had a POLST in the resident's medical chart. During a review of Resident 10's admission Record indicated the resident was admitted on [DATE] with diagnoses that included diabetes mellitus, muscle weakness, and endocarditis (a serious inflammation of the heart's inner lining and valves). During a review of Resident 10's H&P, dated [DATE], the H&P indicated that the resident does have the capacity to understand and make decisions. During a review of Resident 10's MDS, dated [DATE], the MDS indicated that the resident has severely impaired cognition. The MDS also indicated that the resident did not have a POLST in the resident's medical records. During a review of Resident 11's admission Record indicated the resident was admitted on [DATE] with diagnoses that included diabetes mellitus, intracerebral hemorrhage (bleeding in the brain), and hypertension. During a review of Resident 11's H&P, dated [DATE], the H&P indicated that the resident does have the capacity to understand and make decisions. During a review of Resident 11's MDS, dated [DATE], the MDS indicated that the resident MDS indicated that the resident has moderately impaired cognition. The MDS also indicated that the resident had a POLST in the resident's medical chart. During an interview on [DATE] at 11:47 AM with licensed vocational nurse (LVN) 1, LVN 1 stated that on [DATE] at around 3 PM to 3:15 PM, Registered Nurse (RN) 1 went into Nursing Station (NS) 3 to check Resident 1's medical chart and identify what Resident 1's code status was. LVN 1 stated that RN 1 could not locate Resident 1's POLST. LVN 1 stated that after not being able to find the resident's POLST, RN 1 instructed the nurses to initiate CPR. LVN 1 stated when a POLST or a code status order was not found, the resident was treated as full code (a patient wants all possible life-saving measures, including CPR [chest compressions, defibrillation], intubation [breathing tube], and mechanical ventilation, if their heart stops or they stop breathing). During a telephone interview on [DATE] at 1:18 PM with RN 1, RN 1 stated that on [DATE] at around 3 PM, LVN 2 informed her in NS 1 that Resident 1 was unresponsive and pulseless. RN 1 stated that she went from NS 1 to NS 3 to look for Resident 1's code status. RN 1 stated that she could not find Resident 1's POLST or code status in Resident 1's current medical chart. RN 1 stated that she instructed the nurses to initiate CPR since there was no POLST or code status, therefore Resident 1 was treated as full code. During an interview on [DATE] at 4:53 PM with the Director of Nursing (DON), the DON stated that the facility could not find Resident 1's POLST or Advance Directive (AD a written statement of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) in the current medical chart. DON stated that the POLST or AD might be in the resident's old chart, since the POLST or AD was not in Resident 1's current medical chart. During a concurrent interview and record review on [DATE] at 8:47 AM with the DON, Resident 1's POLST, dated [DATE], was reviewed. The DON stated that she had found Resident 1's POLST in the resident's previous medical chart. The DON stated that the document was still valid on [DATE] when Resident 1 was found unresponsive. The DON stated that the POLST was part of the resident's AD and the AD should have been placed in the resident's current chart since the nurses look for the POLST when a resident was found unresponsive to determine if CPR should be performed. The DON further stated that not having the POLST or AD in the chart could cause a delay in performing CPR during a medical emergency. During a concurrent interview and record review on [DATE] at 11:38 PM with RN 3, the electronic and current medical charts of the facility's 100 residents were reviewed for their completeness, including the presence of a POLST and AD. During the record review, the records of Resident 2, Resident 3, Resident 4, Resident 5, Resident 6, Resident 7, Resident 8, Resident 9, Resident 10, and Resident 11 did not include a POLST or AD. RN 3 stated that she could not find the residents' POLST or AD. RN 3 stated that the POLST or AD must be in the charts because the nurses need the POLST or AD during a medical emergency to ensure the residents wishes were performed and that facility staff follow the residents wishes. The RN 3 stated a medical emergency example was when a resident was found unresponsive and pulseless. During a concurrent interview and record review on [DATE] at 3:35 PM with Social Worker (SW) 1, Resident 2's records were reviewed. SW 1 stated Resident 2's POLST was on SW 1's email and not placed in Resident 2's medical chart. SW 1 stated that the POLST must be printed and in the resident's physical chart. During a concurrent interview and record review on [DATE] at 3:35 PM with SW 1, Resident 3's records were reviewed. SW 1 stated that Resident 3's POLST was not in the resident's records because the resident was transferred to a different facility prior to the most recent admission. SW 1 stated Resident 3's POLST was found in Resident 3's previous medical records and not placed in Resident 3's current medical chart. During a concurrent interview and record review on [DATE] at 3:35 PM with SW 1, Resident 4's records were reviewed. There was not POLST for Resident 4 found. SW 1 stated she did not know if Resident 4 has a POLST. During another concurrent interview and record review on [DATE] at 3:35 PM with SW 1, Resident 5's records were reviewed. Resident 5's POLST could not be found. SW 1 stated Resident 5's POLST might be in the resident's old records. During another concurrent interview and record review on [DATE] at 3:35 PM with SW 1, Resident 6's records were reviewed. Resident 6's POLST could not be found. SW 1 stated that she is not sure if Resident 6 had a POLST. During another concurrent interview and record review on [DATE] at 3:35 PM with SW 1, Resident 7's records were reviewed. SW 1 could not locate Resident 7's POLST and stated that Resident 7 was able to make decisions. During another concurrent interview and record review on [DATE] at 3:35 PM with SW 1, Resident 8's records were reviewed. SW 1 stated that Resident 8 was new to the facility and did not know if Resident 8 had a POLST. SW 1 stated that it was SW 1's responsibility to obtain the POLST for newly admitted residents. During another concurrent interview and record review on [DATE] at 3:35 PM with SW 1, Resident 9's records were reviewed. SW 1 stated that Resident 9 was new to the facility. Resident 9's POLST was not found in Resident 9's current medical chart. SW 1 stated she was unsure if Resident 9 was offered a POLST. During another concurrent interview and record review on [DATE] at 3:35 PM with SW 1, Resident 10's records were reviewed. Resident 10's POLST was not found in Resident 10's current medical chart. During another concurrent interview and record review on [DATE] at 3:35 PM with SW 1, Resident 11's records were reviewed. SW 1 stated Resident 11's POLST and AD were not in Resident 11's current medical chart. SW 1 stated that the POLST should be in the resident's chart and not in her office. During another concurrent interview record review on [DATE] at 3:56 PM with SW 1, the facility's policy and procedures (P&P) titled, Advance Directives, dated 9/2022, was reviewed. SW 1 stated that the P&P indicated that upon admission, the social workers must inquire about the resident's POLST or AD. SW 1 stated that the term upon admission means within 48 to 72 hours upon the resident's admission. SW 1 stated that the P&P indicated that if the resident has an AD or a POLST, the documents must be in the resident's medical records and is accessible to any facility staff, and not in her office. During an interview on [DATE] at 11:41 AM with the DON, the DON stated that it is the responsibility of SW 1 to obtain the residents' AD and POLST within 48 hours of admission to the facility. The DON stated that if there was a POLST, the POLST must be in the resident's current medical chart. The DON stated that facility staff use the POLST to identify if residents are full code, especially in an emergency such as when a resident is found unresponsive. During a review of the facility Job Description (JD) for a social worker titled, Social Services Designee, undated, the JD indicated that the SW works with residents to complete advance directive documentation. During a record review of the facility's P&P titled, Advance Directive, dated 9/2022, the P&P indicated that if the resident or representative has not established an advance directive for the resident, the facility staff will offer assistance in establishing advance directive. The P&P also indicated that information about whether or not the resident has executed an advance directive is displayed prominently in the medical record in a section that is retrievable by any staff. The P&P also indicated that if the resident has an advance directive, copies of these documents are obtained and maintained in the same section of the residents medical record and are readily retrievable by any facility staff.

Based on observation, interview, and record review, the facility failed to ensure that direct care staff were qualified to respond and perform cardiopulmonary resuscitation (CPR) for one out of 66 identified full code (a resident who wants all possible life-saving measures used if their heart stops or they stop breathing, including CPR residents) (Resident 1). After further investigation, it was determined the facility failed to ensure that: 1.On [DATE], CNA 1, Registered Nurse (RN) 1, LVN 1, LVN 2, and LVN 5 did not call a code blue immediately when Resident 1 was found unresponsive on [DATE] between 3:05 PM to 3:10 PM. 2. On [DATE], LVN 1 and CNA 2 did not place Resident 1 on a firm, flat surface while performing CPR. LVN 1 and CNA 2 did not use the backboard (a rigid board inserted under a patient's back to create a firm surface, preventing soft surfaces [like mattresses] from absorbing compression force, thereby improving the depth and effectiveness of chest compressions) that was available at the facility. 3. On [DATE], LVN 1 and CNA 2 did not perform rescue breaths on Resident 1 while performing CPR on [DATE], in accordance with professional standard of practice and the 2025 American Heart Association (AHA) Guidelines for CPR. 4.On [DATE], LVN 1 and CNA 2 did not perform continuous and appropriate chest compressions with the required depth on Resident 1, in accordance with professional standard of practice and the 2025 AHA Guidelines for CPR. As a result, Resident 1 was pronounced deceased (dead) on [DATE] at 3:48 PM by EMS crew after 20 minutes of CPR. As a result of these deficiencies, the facility placed 66 full code (a patient wants all possible life-saving measures if their heart or breathing stops, including CPR) residents at risk to not receive adequate and proper life-saving measures during a code blue, potentially leading to greater harm and/or death to other residents residing in the facility. Cross referenced to F678 Findings: During a review of Resident 1's admission Record, (AR) the AR indicated the resident was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD, [a progressive lung condition making breathing difficult), chronic bronchitis (inflamed airways), emphysema (damaged air sacs), and respiratory failure (condition where the lungs can't adequately oxygenate the blood or remove carbon dioxide). During a review of Resident 1's POLST (Physician Orders for Life-Sustaining Treatment, a portable medical order form that helps seriously ill or frail individuals specify their end-of-life care wishes, such as CPR), dated [DATE], and signed by Resident 1, the POLST instructed staff to attempt CPR if Resident 1 has no pulse and is not breathing. During a review of Resident 1's History and Physical (H&P), dated [DATE], the H&P indicated the resident does not have the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (a resident assessment tool), dated [DATE], the MDS indicated that Resident 1 has severely impaired cognition (the ability to process thoughts and emotions). The MDS also indicated that the resident did not have a life expectancy of less than 6 months at the time of assessment. The MDS further indicated that the resident did not have a POLST (---) in the resident's chart. During a review of Resident 1's Interdisciplinary Team (IDT) Conference Record Notes, dated [DATE], the IDT indicated that Resident 1's code status was Full code and that staff should attempt CPR when necessary. During a review of Resident 1's Physician Progress Notes, dated [DATE], the Notes indicated that Resident 1 had a code status of Full Code- Attempt CPR. During a review of Resident 1's Progress Notes for the month of [DATE], the Progress Notes indicated the following information: 1. On [DATE], timed at 4:10 PM, and signed by RN 1, the note indicated that at 3:15 PM, the charge nurse reported to [RN 1] that she saw [Resident 1] unresponsive during rounds (scheduled nurse visits to patient's bedside to assess, monitor and address patient needs). The note further indicated that RN 1 went to the resident's room to assess Resident 1 and could not obtain the resident's blood pressure. The note also indicated that RN 1 instructed one of the team members to start CPR right away. The note indicated that CPR was continued until the Emergency Medical Services crew from the local Fire Department (FD) arrived at 3:29 PM. The note further indicated that the resident was pronounced deceased at 3:48 PM. 2. On [DATE], timed at 4:47 PM, and signed by LVN 1, the note indicated that at 3:05 PM, the CNA [CNA1] reported [to LVN 1 that resident was unresponsive. The note indicated that Resident 1 did not have a pulse or blood pressure. The note also indicated chest compressions were performed until the EMS crew came and took over. The note further indicated that Resident 1's time of death was on [[DATE]] at 3:48 PM. During a review of a Statement of Declaration (SOD) titled, Declaration, signed by LVN 1, dated [DATE], the SOD indicated that at 3:17 PM, [CNA 1] told [LVN 1] that [Resident 1] is unresponsive. The SOD indicated LVN 1, RN 1, and RN 2 reported to the resident's room. The SOD stated that chest compressions started at 3:22 PM initially. The SOD also indicated that RN 2, LVN 1, and CNA 2 were performing chest compressions until the EMS crew arrived. The SOD indicated that compressions were performed [at] 30 [per minute]. The SOD indicated RN 1 and RN 2 went into the Nurse's Station to check for Resident 1's POLST. The SOD further indicated that Resident 1's POLST could not be found and [RN 1 and RN 2] stated to initiate CPR. The SOD indicated that when a resident is found to be unresponsive, the resident's POLST is checked, and after that, CPR is initiated. During a review of a Statement of Declaration (SOD) titled, Declaration, signed by RN 3, dated [DATE], the SOD indicated that before doing CPR [staff] [has] to check [the] code status of the resident. During a follow-up interview on [DATE] at 11:11 AM with RN 3, RN 3 stated that the rate of compression during a CPR is 30 compressions per minute. During an interview on [DATE] at 11:38 AM with LVN 1, LVN 1 stated that when a resident is found unresponsive, the responding staff should go straight for airway. LVN 1 stated the next step is to assess the resident's circulation by checking the resident's pulse. LVN 1 stated that chest compressions should be initiated if the resident is determined to be pulseless at a rate of 30 compressions per minute. During another interview on [DATE] at 11:47 AM with LVN 1, LVN 1 stated he worked on [DATE] when Resident 1 was found unresponsive. LVN 1 stated that on [DATE], at around 3:15 PM, CNA 1 informed him that Resident 1 was unresponsive. LVN 1 stated that he and other nurses, including RN 1 and RN 2, assessed the resident and found that the resident was not breathing and did not have a pulse. LVN 1 stated that RN 1 and RN 2 went into the nurse's station to check Resident 1's records and locate Resident 1's code status. LVN 1 stated that RN 1 was the one who instructed staff (LVN 1 and CNA 2) to start CPR on Resident 1. LVN 1 stated he could not recall who first initiated chest compressions to Resident 1 and who administered rescue breaths. LVN 1 also stated he could not recall if a backboard was used during Resident 1's CPR. During a phone interview on [DATE] at 12:27 PM with CNA 1, CNA 1 stated she went into Resident 1's room on [DATE] at around 3:10 PM to 3:15 PM and found Resident 1 sitting up in bed and unresponsive. CNA 1 stated that she shook Resident 1 and still unresponsive. CNA 1 stated she did not initiated CPR right away on Resident 1 but instead went out of the resident's room to inform LVN 2 then LVN 1. During a phone interview on [DATE] at 12:43 PM with LVN 2, LVN 2 stated that on [DATE] at around 3:10 PM, she went inside Resident 1's room and observed that Resident 1 was pale and not breathing. LVN 2 stated she assessed Resident 1 by checking the pulses in both arms and neck and found that the resident did not have a pulse. LVN 2 stated that she went out of Resident 1's room and went to Nursing Station 1 to notify RN 1. LVN 2 stated she did not initiate CPR right away and could not remember who initiated chest compressions to Resident 1. LVN 2 stated she went back to Resident 1's room. LVN 2 added she could not remember if anyone put the backboard under Resident 1 and if the Ambu-bag was used to give Resident 1 rescue breaths. During a phone interview on [DATE] at 1:18 PM with RN 1, RN 1 stated that on [DATE], at around 3:00 PM to 3:15 PM, she was at Nursing Station 1 when LVN 2 informed her that Resident 1 was unresponsive and had no pulse. RN 1 stated that she went to Nursing Station 3 to check Resident 1's records and look for Resident 1's code status. RN 1 stated that when she found out Resident 1 was full code, that was when she informed the other nurses (CNA 1, CNA 2, RN 1, LVN 1, LVN 2, and LVN 5) in the room to initiate CPR on Resident 1. RN 1 stated that the nurses that were inside Resident 1's room was waiting for her to check Resident 1's code status. RN 1 stated that she could not recall who initiated CPR on Resident 1, could not recall if the Ambu-bag was used, or if the backboard was placed under Resident 1. During another interview on [DATE] at 1:36 PM with LVN 1, LVN 1 stated that on [DATE] at around 3:15 PM, RN 1 and RN 2 searched for Resident 1's code status in Nursing Station 3. LVN 1 stated that when RN 1 and RN 2 could not find the code status, RN 1 and RN 2 instructed facility staff (CNA 1, CNA 2, RN 1, LVN 1, LVN 2, and LVN 5) to initiate CPR on Resident 1. During another phone interview on [DATE] at 2:38 PM with LVN 2, LVN 2 stated that on [DATE] when she found Resident 1 unresponsive, she activated code blue by going to Nursing Station 1 to notify RN 1. LVN 2 stated she did not stay with the resident to initiate CPR. During a phone interview on [DATE] at 2:51 PM with RN 2, RN 2 stated that on [DATE] at around 3:20 PM, she entered Resident 1's room and found LVN 1 and LVN 5 assessing Resident 1. RN 2 stated that LVN 1 and LVN 5 informed her that Resident 1 did not have a pulse. RN 2 stated that RN 1 instructed them to start and initiate CPR on Resident 1. RN 2 stated that CPR was started after RN 1 instructed them to initiate CPR (after RN 2's arrival in Resident 1's room at 3:20 PM). RN 2 stated she could not remember who provided rescue breaths to Resident 1. RN 2 stated she could not remember if a backboard was placed under Resident 1. RN 2 further stated that when the EMS crew arrived, the EMS crew placed Resident 1 on the floor and continued CPR on the floor. During another phone interview on [DATE] at 3:44 PM with CNA 1, CNA 1 stated that when she found Resident 1 unresponsive on [DATE] at around 3:, she did not check Resident 1's pulse or respirations. CNA 1 stated she did not call for help by shouting code blue. CNA 1 added she did not initiate CPR. During a phone interview on [DATE] at 4:16 PM with EMS Crew, Paramedic (PC) 1, PC 1 stated that on [DATE], PC 1 and PC 2 responded to the facility's 911 call for a resident that was unresponsive. PC 1 stated that on [DATE] upon arriving in Resident 1's room, PC 1 stated he observed two facility staff members were next to Resident 1, and one more facility staff member was performing CPR. PC 1 stated Resident 1 was wearing a non-rebreather mask and staff was not using an Ambu-bag. PC 1 stated that an oxygen mask like the non-rebreather mask was not an appropriate equipment to use while conducting a CPR. PC 1 stated that the Ambu-bag was observed right next to Resident 1's head of the bed but was not being used by the facility staff because it was not inflated and not connected to an oxygen source. PC 1 also stated that the EMS crew had to move Resident 1 from the bed to the floor because Resident 1 was not placed under a backboard while on the bed. PC 1 stated that the EMS crew continued to perform CPR on Resident 1 for about 15 more minutes. During a phone interview on [DATE] at 4:43 PM with another EMS Crew, PC 2, PC 2 stated that on [DATE] when the EMS crew responded to the facility's 911 call, PC 2 observed one facility staff member perform CPR on Resident 1. PC 2 stated that the facility staff member was not performing adequate CPR because the rate was inconsistent and slow and the facility staff's compressions would stop and go and stop. PC 2 further stated that during his observation, the facility staff member performing the CPR was only using one hand, instead of two hands during chest compressions. PC 2 stated that the facility staff performing the CPR were not using the Ambu-bag to provide rescue breaths because Resident 1 was placed on a non-breather mask. PC 2 further stated that the facility staff did not place Resident 1 on a backboard and performed CPR on the bed. During a review of a Statement of Declaration (SOD) titled, Declaration, signed by LVN 5, dated [DATE], the SOD indicated that on [DATE] at around 3:15 PM, LVN 5 heard CNA 1 informing LVN 2 that Resident 1 was unresponsive. The SOD indicated that LVN 5 observed LVN 2 ran towards [Nursing] Station 1. The SOD indicated that LVN 5 assessed Resident 1 and the resident looked pale, unresponsive, and pulseless. The SOD indicated that LVN 5 recalled how LVN 2 searched for Resident 1's code status in the resident's electronic records and could not find Resident 1's code status. The SOD indicated that LVN 5 recalled that LVN 2 asked the facility's Social Worker (SW 2) regarding Resident 1's code status, and SW 2 stated that Resident 1's code status was full code and started CPR. During an interview on [DATE] at 9:37 AM, LVN 5 stated that on [DATE] at around 3 PM, she heard CNA 1 informed LVN 2 that Resident 1 was unresponsive. LVN 5 stated she instructed LVN 2 to get the Emergency Cart, however, LVN 2 went to Nursing Station 1. LVN 5 stated she assessed Resident 1 and the resident was unresponsive, pale, and pulseless. LVN 5 stated that LVN 1, RN 2, and SW 2 were inside Resident 1's room. LVN 5 stated she went out of Resident 1's room to search for Resident 1's code status in the resident's physical chart. LVN 5 stated she needed to know Resident 1's code status before starting CPR. During an interview on [DATE] at 10:24 AM with LVN 5, LVN 5 stated that if a resident is unresponsive and pulseless, staff must make sure that the resident is a full code before initiating CPR. LVN 5 added that the chest compression rate for an effective CPR is 30 compressions per minute. LVN 5 also added that a non-rebreather mask may also be used during CPR. During a phone interview on [DATE] at 10:29 AM with CNA 2, CNA 2 stated that on [DATE], he participated in performing CPR on Resident 1. CNA 2 stated he performed CPR at 80 compressions per minute because Resident 1 was fragile. CNA 2 stated that when the EMS arrived, CNA 2 and another LVN (LVN 2) was performing CPR on Resident 1. CNA 2 stated that he could not remember if an Ambu-bag was used on Resident 1. CNA 2 also stated that he could not recall if a backboard was placed under Resident 1. During an interview on [DATE] at 10:45 AM with LVN 4, LVN 4 stated that on [DATE], she was in Nursing Station 1 when LVN 2 informed her that Resident 1 was unresponsive. LVN 4 stated that she brought the Emergency Cart into Resident 1's room. LVN 4 stated that RN 1 instructed the nurses to perform CPR on Resident 1. LVN 4 stated she could not remember who used the Ambu-bag. LVN 4 stated she could not recall who put the backboard under Resident 1. During an interview on [DATE] at 10:48 AM with LVN 6, LVN 6 stated that if a resident is found unresponsive and pulseless, she would call an RN. LVN 6 stated that after calling for an RN, call 911 and check for the resident's code status. LVN 6 stated that after those steps, she would initiate CPR by laying the resident flat and starting chest compressions. During an interview on [DATE] at 3:07 PM with the Director of Nursing (DON), the DON stated that when a staff member finds that a resident is unresponsive, the staff member should check the resident's vitals signs, such as the pulse, blood pressure, and respirations. The DON stated that if the resident was found to be pulseless, not breathing, and unresponsive, the staff member should initiate Code Blue by shouting Code Blue to alert other staff members into the room then initiate CPR right away. The DON added that when CPR has been initiated, other staff members may call for 911 and verify the resident's code status. During the same interview on [DATE] at 3:07 PM with the DON, the DON stated that in order to deliver quality CPR, staff members must use a backboard and Ambu-bag. The DON stated that the backboard is placed under the resident when performing CPR. The DON added that an Ambu-bag is used to provide the resident 2 rescue breathing in between 30 compressions. The DON also added that CPR must be performed at a rate of 100 to 120 compressions per minute. During a phone interview on [DATE] at 4:31 PM with Medical Doctor (MD) 1, MD 1 stated that when a resident is found to be unresponsive, facility staff are expected to initiate CPR right away. MD 1 stated that staff should not prioritize looking for the resident's code status because if CPR is not initiated immediately, the resident could suffer prolonged cardiac arrest and, eventually, death. During a concurrent interview and record review on [DATE] at 11:41 AM with the DON, Resident 1's medical records were reviewed, including the progress notes. The DON stated the progress notes indicated that on [DATE] at 3:05 PM, a CNA reported to LVN 1 that Resident 1 was unresponsive. The DON stated that at 3:15 PM, another nurse informed RN 1. The DON stated that RN 1 instructed staff to perform CPR. The DON stated that CPR was delayed and it should have been initiated right away. During the same concurrent interview and record review on [DATE] at 11:41 AM with the DON, the facility's policy and procedures (P&P) titled, Emergency Procedure- Cardiopulmonary Resuscitation, dated 2/2018, was reviewed. The DON stated that the P&P indicates that CPR must be initiated until the resident is determined to be DNR. The DON stated that the P&P indicates that CPR compressions must be at a rate of at least 100 compressions per minute. The DON stated that the P&P also indicates that supplies necessary for CPR must always be readily available. The DON added that the EC must contain a backboard and Ambu-bag. During a phone interview on [DATE] at 3:49 PM with MD 2, MD 2 stated that facility staff must follow the facility's P&P in the event of a code blue. MD 2 added that during a code blue, CPR must be initiated right away. During a review of the facility's job description (JD) for a CNA titled, Certified Nursing Assistant, undated, the JD indicated that a CNA's job function includes initiating CPR and assisting with code procedures. During a review of the facility's job description (JD) for an LVN titled, Charge nurse- LVN, undated, the JD indicated that a LVN's job function includes responding and directing care in emergency situations using good judgement and established policies and procedures. The JD also indicated that the LVN initiates CPR and directs code procedures. During a review of the American Heart Association's guidelines published on [DATE], titled, 2025 American Heart Association Guidelines for CPR and ECC, https://cpr.heart.org/en/resuscitation-science/cpr-and-ecc-guidelines/adult-basic-life-support, [site accessed on [DATE]], the guidelines indicated the following: 1.If a resident is found unconscious/unresponsive, with absent or abnormal breathing (ie, only gasping), the health care professional should check for a pulse for no more than 10 seconds and, if no definite pulse is felt, should assume the person is in cardiac arrest. 2. After identifying an adult in cardiac arrest, a lone responder should activate the emergency response system first, then immediately begin CPR, beginning with chest compressions. 3. In adult cardiac arrest, it is preferred to perform CPR on a firm surface and with the person in the supine position, when feasible and does not delay chest compressions. 4. During manual CPR, rescuers should perform chest compressions to a depth of at least 2 inches. 5. For adults in cardiac arrest, it is reasonable for rescuers to perform chest compressions at a rate of 100 to 120 [per minute]. 6. It is reasonable for lay rescuers and health care professionals to perform CPR with cycles of 30 compressions followed by 2 breaths before placement of an advanced airway. 7. Bag-mask ventilation is most effective when provided by 2 trained and experienced rescuers; 1 rescuer opens the airway and seals the mask to the face with both hands while the other rescuer (who might also be the chest compressor) squeezes the bag during the pauses in chest compression. During a review of the facility's P&P titled, Emergency Procedure- Cardiopulmonary Resuscitation, dated 2/2018, the P&P indicated that the following: 1.The chances of a resident surviving a cardiac arrest may be increased if CPR is initiated immediately. 2. If a resident is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR. 3. The facility's procedure for administering CPR shall incorporate the steps covered in the 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care or facility BLS training material. 4. Maintain equipment and supplies necessary for CPR/BLS in the facility at all times. 5. If an individual is found unresponsive, briefly assess for abnormal or absence of breathing. If sudden cardiac arrest is likely, begin CPR. 6. The BLS sequence of events is referred to as C-A-B (chest compressions, airway, breathing). 7. Chest compressions: Following initial assessment, begin CPR with chest compressions; Push hard to a depth of at least 2 inches (5 cm [centimeters, a unit of measuring length]) at a rate of at least 100 compressions per minute; Allow full chest recoil after each compressions; and Minimize interruptions in chest compressions. Airway: Tilt head back and lift chin to clear airway. Breathing: After 30 chest compressions provide 2 breaths via Ambu-bag or manually (with CPR shield). All rescuers, trained or note, should provide chest compressions to victims of cardiac arrest. Trained rescuers should also provide ventilations with a compression-ventilation ratio of 30:2. Continue with CPR/BLS until emergency medical personnel arrive.

Based on interview and record review, the facility failed to provide the necessary respiratory care and interventions in accordance with the resident's respiratory care needs, care plan, facility policy and professional standards of practice, the physician's order and facility's policy and procedure for one of two sampled residents (Resident 1) diagnosed of respiratory failure (a condition where the lungs cannot supply enough oxygen or remove carbon dioxide from the blood) with hypoxia (a life-threatening condition where the lungs fail to deliver enough oxygen to the blood, leading to dangerously low oxygen levels in the body), chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty breathing), emphysema (a lung disease where the air sacs [alveoli] in the lungs are damaged, making breathing difficult) and recurrent pneumonia (an infection/inflammation in the lungs) by failing to: 1. Administer respiratory medications consistently as ordered for Resident 1 for COPD, chest congestion and shortness of breath. The Medication Administration Record (MAR) indicated the following missed respiratory treatments: -Acetylcysteine Inhalation Solution 20% (a medication used to thin mucus in the lungs) 25 (twenty-five) scheduled times between [DATE] to [DATE]. -Budenoside Inhalation Suspension (a medication inhaled to reduce swelling in the airways) 31 (thirty-one) scheduled times between [DATE] to [DATE]. -Ipratropium-albuterol Inhalation Solution (a medication used in a nebulizer that combines two drugs to relax and open the airways) 60 (sixty) scheduled times between [DATE] to [DATE]. 2. Monitor Resident 1 for respiratory distress (life-threatening condition that causes severe difficulty breathing. It occurs when the lungs become inflamed and damaged, making it difficult for oxygen to reach the bloodstream) and change in respiratory condition, in accordance with the resident's care plan for COPD and emphysema when Nurse Practitioner (NP) 1 identified Resident 1 on [DATE] as having cough, congestion, abnormal lung sounds and respiratory distress with oxygen saturation of 93% at 3 liter of oxygen and Registered Nurse (RN) 5 received abnormal laboratory (lab) and chest Xray (CXR - (a type of imaging that uses electromagnetic radiation to view internal structures of the body) results on [DATE]. 3. Revise and implement Resident 1's care plan to assess or monitor Resident 1's respiratory status that included assessment of lung sounds and monitoring Resident 1's worsening cough and congestion to initiate nursing interventions, after receiving Resident 1's abnormal laboratory (lab) and CXR results on [DATE]. 4. Notify Medical Doctor (MD) 1 of Resident 1's elevated white blood cell (WBC - a blood cell that helps attack infection or injury in the body) count and abnormal chest x-ray results indicating mild patchy opacity (an area that appears white or dense on an x-ray) in the left lower lung which represented a potential indicator of lung infection. This deficient practice had the potential to result to medical and respiratory complications which included severe respiratory distress/failure, collapsed lungs, septicemia that may lead to hospitalization and/or death. Furthermore, these deficient practices delayed necessary medical evaluation and treatment of Resident 1's respiratory condition from [DATE] to [DATE]. On [DATE], Resident 1 was found unresponsive and pulseless at 3:05 PM. Cardiopulmonary Resuscitation (CPR) was performed and Resident 1 was later pronounced dead on [DATE] at 3:48 PM by Emergency Medical Services (EMS). Cross referenced to F678Findings: During a review of Resident 1's admission Record, the record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including COPD, emphysema, respiratory failure (a condition where the lungs cannot supply enough oxygen or remove carbon dioxide from the blood) with hypoxia (a condition in which body tissues do not receive enough oxygen to function properly), recurrent pneumonia (an infection/inflammation in the lungs) and vascular dementia (changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain). During a review of Residents 1's Minimum Data Sheet (MDS- a resident assessment tool) dated [DATE], the MDS indicated Resident 1 had significantly impaired cognition (the ability to process thoughts) and was dependent on staff for all cares such as eating, bathing, and rolling left and right in bed. During a review of Resident 1's Medication Administration Record (MAR) for the months of [DATE], [DATE], and [DATE], the MAR indicated the following orders: 1. Acetylcysteine Inhalation Solution 20% three mL (milliliter- a unit measure of volume) inhale orally two times a day for COPD, start date [DATE]. 2. Budenoside Inhalation Suspension 0.25 milligram (mg- a unit of measurement)/2 mL, inhale two mL orally every morning and at bedtime for COPD, start date [DATE]. 3. Ipratropium-Albuterol Inhalation Solution 0.5-2.5 mg (3 mg)/3 mL, inhale three mL orally four times a day for congestion/breathing treatment, start date [DATE]. During a continued review of resident 1's MAR for the months of [DATE], [DATE], and [DATE] indicated no documentation on the following days and times for Resident 1's Acetylcysteine Inhalation Solution: [DATE] at 6 PM, [DATE] at 6 PM, [DATE] at 6 PM, [DATE] at 6 PM, [DATE] at 6 PM, [DATE] at 6 PM, [DATE] at 6 PM, [DATE] at 9AM and 6 PM, [DATE] at 6 PM, [DATE] at 6 PM, [DATE] at 6 PM,[DATE] at 6 PM, [DATE] at 6 PM, [DATE] at 6 PM, [DATE] at 6 PM, [DATE] at 6 PM, [DATE] at 6 PM, [DATE] at 6 PM, [DATE] at 9AM and 6 PM, [DATE] at 6 PM, [DATE] at 6 PM, [DATE] at 6 PM, and [DATE] at 9 AM. The MAR for [DATE], [DATE], and [DATE] indicated a total of 25 undocumented administrations for Acetylcysteine between [DATE] and [DATE]. During a continued review of Resident 1's MAR for the months of [DATE] to [DATE] indicated no documentation on the following days and time for Resident 1's Budenoside Inhalation Suspension: [DATE] at 9 PM, [DATE] at 9 PM, [DATE] at 9 PM, [DATE] at 9 PM, [DATE] at 9 PM, [DATE] at 9 PM, [DATE] at 9 PM, [DATE] at 9 PM, [DATE] at 9AM and 9 PM, [DATE] at 9 PM, [DATE] at 9 PM, [DATE] at 9 PM, [DATE] at 9 PM, [DATE] at 9 PM, [DATE] at 9 PM, [DATE] at 9 PM, [DATE] at 9 PM, [DATE] at 9 PM, [DATE] at 9 PM, [DATE] at 9 PM, [DATE] at 9 PM, [DATE] at 9AM and 9 PM, [DATE] at 9 PM, [DATE] at 9 PM, [DATE] at 9 PM, [DATE] at 9 PM, [DATE] at 9 PM, [DATE] at 9 PM, and [DATE] at 9 AM . The MAR for [DATE] to [DATE] indicated a total of 31 undocumented administrations for Budenoside between [DATE] and [DATE]. During a continued review of Resident 1's MAR for the months of [DATE] to [DATE] indicated no documentation on the following days and time for Resident 1's Ipratropium-Albuterol Inhalation Solution: [DATE] at 5 PM and 9 PM, [DATE] at 5 PM and 9 PM, [DATE] at 5 PM and 9 PM, [DATE] at 5 PM and 9 PM, [DATE] at 5 PM and 9 PM, [DATE] at 5 PM and 9 PM, [DATE] at 5 PM and 9 PM, [DATE] at 5 PM and 9 PM; [DATE] at 9 AM, 12 PM, 5 PM and 9 PM; [DATE] at 5 PM and 9 PM; [DATE] at 5 PM and 9 PM, [DATE] at 5 PM and 9 PM, [DATE] at 5 PM and 9 PM, [DATE] at 9PM, [DATE] at 5 PM and 9 PM, [DATE] at 5 PM and 9 PM, [DATE] at 5 PM and 9 PM, [DATE] at 9 PM, [DATE] at 5 PM and 9 PM, [DATE] at 5 PM and 9 PM; [DATE] at 12 PM, 5 PM, and 9 PM; [DATE] at 9 AM, 12 PM, 5 PM, and 9 PM; [DATE] at 5 PM and 9 PM, [DATE] at 5 PM and 9 PM, [DATE] at 9 PM, [DATE] at 9 PM, [DATE] at 9 PM, [DATE] at 5 PM and 9 PM, [DATE] at 12 PM, [DATE] at 9 AM and 12 PM, and [DATE] at 12 PM. The MAR for [DATE] to [DATE] indicated a total of 60 undocumented administrations for Resident 1's Ipratropium-Albuterol between September and [DATE]. During a review of Resident 1's physician Progress Notes (PN) dated [DATE], authored by Nurse Practitioner (NP) 1, the PN indicated Resident 1 had diminished breath sounds, was on three liters of oxygen, no respiratory distress, and with a nonproductive cough at the time of the exam. Rales (crackling sounds in the lungs caused by air moving through fluid) and rhonchi (low, snoring-like lung sounds caused by air moving through mucus in larger airways) noted on respiratory exam. The PN further indicated, Plan is to continue regular breathing treatments as scheduled. During another review of Resident 1's PN dated [DATE], authored by Licensed Vocational Nurse (LVN) 8, the PN indicated, shortness of breath noted. Nurse observed shortness of breath (upon exertion). Right lung clear. Left lung clear. Oxygen via nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen). During a review of Resident 1's physician PN dated [DATE] and authored by Medical Doctor (MD) 3, the PN indicated, Rhonchi present, diminished lung sounds. During another review of Resident 1's PN dated [DATE], authored by Registered Nurse (RN) 5, the PN indicated, shortness of breath noted. Resident [1] reported shortness of breath (while lying flat). Nurse observed shortness of breath (while lying flat). Right lung clear, left lung clear. Oxygen via nasal cannula. During another review of Resident 1's PN dated [DATE], authored by RN 5, the PN indicated, shortness of breath noted. Resident [1] reported shortness of breath (while lying flat). Nurse observed shortness of breath (while lying flat). Right lung clear, left lung clear. Oxygen via nasal cannula. During another review of Resident 1's PN dated [DATE], authored by RN 5, the PN indicated, shortness of breath noted. Resident [1] reported shortness of breath (while lying flat). Nurse observed shortness of breath (while lying flat). Right lung clear, left lung clear. Oxygen via nasal cannula. During a review of Resident 1's physician PN dated [DATE] and authored by NP 1, the PN indicated Resident 1 was on three liters of oxygen with no respiratory distress noted. Plan was to continue regular breathing treatments as scheduled. During a review of Resident 1's physician Progress Notes dated [DATE], authored by NP 1, the note indicated NP 1 assessed Resident 1's medical condition at the facility. The note further indicated Resident 1's lung exam exhibited rales (abnormal crackling sounds in the lungs when breathing). The note indicated Resident 1 was on oxygen at 3 liters per minute (LPM- a unit measuring the flow rate of oxygen through a delivery device) with an oxygen saturation (O2 sat- a measurement of how much oxygen the blood is carrying as a percentage [normal for COPD is 88% to 92%]) level of 93%, with respiratory distress noted, and coughing. The note indicated to continue regular breathing treatments as scheduled, chest percussion therapy (CPT- a technique that uses rhythmic clapping on the chest and back to loosen and clear mucus from the lungs) two times a day with Mucomyst (Acetylcysteine- a medication used to thin mucus in the lungs), wean off of oxygen, chest x-ray, and labs that included CBC (complete blood count) and CMP (comprehensive metabolic panel) to rule out infection etiology. During a review of Resident 1's Orders Report for [DATE], the Report indicated the following physician orders: 1. Chest x-ray 2 view due to congestion and cough, ordered on [DATE] by MD 1 at 3:50 PM as confirmed by RN 5 2. CBC and CMP due to congestion and cough, ordered on [DATE] by MD 1 at 4:01 PM as confirmed by RN 5 3. Acetylcysteine Inhalation Solution 20% 3 mL (milliliter- a measure of volume) inhale orally two times a day for cough, CPT with [Acetylcysteine] 3 mL 20% solution, ordered on [DATE] by MD 1 at 4:17 PM as confirmed by RN 5 During a review of Resident 1's lab results dated [DATE], the results indicated WBC of 16.85 x10*3/ul (Normal range 4.0-11.0 x10*3/ul). The lab results indicated a collected date of [DATE] at 8:10 AM and a result date of [DATE] at 12:59 PM, faxed to the facility on [DATE] at 1:10 PM. During a review of Resident 1's Final X-ray report dated [DATE], the report indicated mild patchy opacity (an area that appears white or dense on an x-ray) in left lower lung represent infectious process and a suggestion for radiographic follow-up examination to look for resolution, faxed to the facility on [DATE] at 11:13 PM. During a review of RN 5's text messages (a standard for sending short, text-only messages between mobile phones) thread to NP 1 on [DATE] at 1:52 PM from the facility's cellular phone, the text thread indicated pictures of Resident 1's faxed lab results for the CBC and CMP drawn on [DATE] and the faxed chest x-ray results from [DATE]. The text messages did not indicate a confirmation of text message delivery or a text response from NP 1. During a review of Resident 1's Progress Notes for the month of [DATE], the Progress Notes indicated the following information: 1. On [DATE] timed at 10:36 PM, and signed by RN 5, the note indicated NP 1 came to see Resident 1 and ordered chest x-ray for congestion and cough, CBC and CMP for congestion and cough, and Acetylcysteine Inhalation Solution 20% 3mL inhale orally two times a day for cough, and CPT two times a day with Acetylcysteine. 2. On [DATE], timed at 4:10 PM, and signed by RN 1, the note indicated that at 3:15 PM, the charge nurse reported to [RN 1] that she saw [Resident 1] during rounds unresponsive. The note further indicated that RN 1 went to the room to assess Resident 1 and could not obtain the resident's blood pressure. The note also indicated that RN 1 instructed one of the team members to start CPR right away. The note indicated that CPR was continued until the Emergency Medical Services (EMS - a system that provides emergency medical care) crew from the local Fire Department (FD) arrived at 3:29 PM. The entry further indicated that the resident was pronounced deceased at 3:48 PM. The progress notes did not indicate MD 1 or NP 1 verbally confirmed receipt of Resident 1's abnormal and chest x-ray with left lung opacity, or that the results were discussed with Resident 1's providers by any licensed nurses. The progress notes also did not indicate a change in condition (CIC/SBAR- a communication tool used by healthcare workers when there is a change of condition among the residents) or assessment and monitoring by licensed nurses for cough and congestion after NP 1 ordered CBC, CMP, chest x-ray, and CPT with Acetylcysteine for Resident 1's cough and congestion. The PN also did not indicate a CIC/SBAR with assessment and monitoring for Resident 1's WBC 16.85 x10*3/ul and chest x-ray with left lung opacity. During a review of Resident 1's CP initiated on [DATE] and revised [DATE], the CP indicated Resident 1 had impaired gas exchange related to COPD. The CP indicated a goal for Resident 1 to maintain O2 sat within personal goal range. The CP indicated interventions to evaluate capillary refill, evaluate for change in level of consciousness, evaluate for restlessness, evaluate for use of accessory muscles while breathing, evaluate mental status, evaluate respiratory rate and effort, evaluate skin color, temperature and characteristics, monitor for changes in respiratory rate or shallow breathing, and monitor for use of accessory muscles. During another review of Resident 1's CP initiated on [DATE] and revised [DATE], the CP indicated Resident 1 had oxygen therapy related to respiratory illness. The CP indicated goals for Resident 1 not to have signs and symptoms of poor oxygen absorption. The CP also indicated to monitor for signs and symptoms of respiratory distress and report to the MD as needed: respirations, O2 sat, increased heart rate, restlessness, sweating, headaches, lethargy, confusion, atelectasis (partial or complete lung collapse), hemoptysis (coughing blood), cough, painful breathing, accessory muscle usage, and skin color. During further review of Resident 1's current care plans, the CPs did not include a revised/updated care plan for Resident 1's new onset or worsening cough and congestion that included at risk for infection related to the abnormally high WBC lab results and abnormal chest x-ray received on [DATE]. During an interview with RN 5 on [DATE] at 11:08 AM, RN 5 stated that Resident 1's lab and diagnostic results were faxed to the facility on [DATE], and the results were reviewed by the RN on shift. The RN was responsible for sending lab and diagnostic results to the MD and obtaining new orders. During the same interview with RN 5, RN 5 stated she was aware NP 1 came to facility on [DATE] and placed new orders for Resident 1 that included CBC, CMP, chest x-ray, and CPT with Acetylcysteine for Resident 1's worsening cough and congestion. RN 5 further stated that these new orders should have triggered her to initiate a CIC/SBAR and assess Resident 1's respiratory condition because it was a change in the resident's condition, but RN 5 stated that she did not initiate a CIC/SBAR to assess/monitor Resident 1's respiratory condition such as lung sounds or breathing to ensure Resident 1 was not in respiratory distress or experiencing shortness of breath. During another interview with RN 5 on [DATE] at 4:54 PM, RN 5 stated that when she received Resident 1's lab and x-ray results on [DATE] at 1:52 PM, RN 5 sent pictures of the lab and CXR result to NP 1's cellular phone but never received text message responses back from NP 1. RN 5 further stated that she also faxed Resident 1's lab and CXR results to MD 1's office on [DATE], but did not verify the lab results were received by MD 1's office. RN 5 stated she did not call MD1's office or NP 1's cellular phone to confirm receipt of Resident 1's lab and CXR results. RN 5 stated that she should have called MD 1's office or NP 1 to verify the receipt of Resident 1's lab and CXR results. RN 5 stated that elevated WBCs of 16.85 x10*3/ul and a chest x-ray with left lung opacities indicated an infectious process and not relaying the results to MD 1 or NP 1 delayed the provider's from providing orders to treat Resident 1's respiratory infection. During the same interview with RN 5 [DATE] at 4:54 PM, RN 5 stated that she should have also initiated a CIC/SBAR on [DATE] for Resident 1's elevated WBCs of 16.85 x10*3/ul and a chest x-ray with left lung opacities and assessed Resident 1 for signs of respiratory distress or shortness of breath, but she did not. During a concurrent record review and interview with RN 5 on [DATE] at 4:54 PM, Resident 1's Progress Notes for [DATE] was reviewed. RN 5 stated she did not document that she notified MD 1 or NP 1 of Resident 1's abnormal lab results indicating elevated WBC and abnormal CXR. RN 5 stated that there was no documentation in the progress notes of any licensed nurses discussing the WBC or chest x-ray results with NP 1 or MD 1. RN 5 also stated there was no documentation of a CIC/SBAR or assessment and monitoring by licensed nurses for cough and congestion after [DATE] after NP 1 ordered CBC, CMP, CXR, and CPT with Acetylcysteine for Resident 1's cough and congestion in the progress notes. RN 5 also stated the progress notes did not contain documentation of a CIC/SBAR with assessment and monitoring for Resident 1's WBC of 16.85 x10*3/ul and CXR with left lung opacity. During an interview with MD 1 on [DATE] at 11:23 AM, MD 1 stated that Resident 1's WBC of 16.85 x10*3/ul and chest x-ray results with left lung opacities were not received by her office. MD 1 also stated that the facility did not have NP 1 or MD 1's direct cellphone numbers, thereby making it impossible for any residents' results to be received via text message. MD 1 further stated the facility's nurses had a practice of documenting lab and diagnostic results were faxed to her office, even if the lab and diagnostic results were not confirmed as received. MD 1 elaborated that the facility's nurses would document physician notified without actual notification. MD 1 stated that the facility's nurses should have called her practice to verify receipt of lab and diagnostic results. During an interview with RN 3 on [DATE] at 12:51 PM, RN 3 stated she was familiar with Resident 1. RN 3 stated the text messages to NP 1 would not work because the number used was actually the direct line to MD 1's operator and would not be able to receive text messages. RN 3 stated that Resident 1's lab and CXR results should have been faxed to MD 1's office, with verbal confirmation from MD1's office staff by phone. During the same interview with RN 3 on [DATE] at 12:51 PM, RN 3 stated that abnormal lab results were considered a change in a resident's condition. RN 3 further explained that there were two missed opportunities for RN 5 to initiate a CIC/SBAR and conduct an assessment of Resident 1: 1. When RN 5 received NP 1's orders of labs, chest-x-ray and new respiratory treatments for Resident 1's chest congestion and cough 2. When RN 5 received Resident 1's results indicating elevated WBCs of 16.85 x10*3/ul and chest x-ray with left lung opacities, RN 3 stated Resident 1 should have been assessed for shortness of breath or difficulty breathing so that staff can properly intervene if the resident was in respiratory distress. By not doing so, Resident 1 could die from respiratory complications. During an interview with the Director of Nursing (DON) on [DATE] at 11:41 AM, the DON further stated that nurses were expected to perform a full head-to-toe assessment when residents experience a change in condition. The DON stated this was important to fully understand the resident's clinical status and what interventions needed to be done. The DON stated that, by failing to properly assess Resident 1 and initiate a CIC/SBAR for continued assessment and monitoring of Resident 1's respiratory status, the resident was at risk for further decline. During an interview with MD 2 on [DATE] at 3:45 PM, MD 2 stated if the facility's staff could not get ahold of a resident's primary MD regarding abnormal lab/diagnostic results or change in condition, they were directed to call the medical director. During a concurrent interview and record review with the Director of Nursing (DON) on [DATE] at 5:57 PM, Resident 1's MAR for September to [DATE] was reviewed. The DON stated she could not find documented evidence that the Acetylcysteine, Budenoside, and Ipratropium-Albuterol respiratory medications were administered Resident 1. The DON further stated that by not receiving the respiratory medications as ordered, Resident 1 was placed at risk of COPD exacerbation (a sudden worsening of breathing symptoms, such as increased shortness of breath, cough, or sputum), which could lead to hospitalization or death. During another interview with MD 1 on [DATE] at 2:30 PM, MD 1 stated that NP 1 ordered CPT with Acetylcysteine to help with Resident 1's worsening chest congestion while waiting for the lab and chest x-ray results. MD 1 further stated that if she was made aware of Resident 1's abnormal chest x-ray with left lung opacity and elevated WBC of 16.85 x10*3/ul, she would have ordered antibiotics for Resident 1. MD 1 stated that Resident 1 could have become septic if the infection was left untreated. During the same interview with MD 1, MD 1 stated that Acetylcystiene, Budenoside, and Ipratropium-Albuterol respiratory medications were ordered specifically to help with Resident 1's COPD and missing several doses, especially consecutively, could trigger Resident 1 to experience a COPD exacerbation, further explaining that this could have led to Resident 1 experiencing a medical emergency from COPD exacerbation. During a review of the facility's P&P titled Change in a Resident's Condition or Status, revised February 20121, the P&P indicated the following: 1. The nurse will notify the resident's attending physician or physician on call when there has been a significant change in the resident's physical/emotional/mental condition. 2. A significant change of condition is a major decline or improvement in the resident's status that will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions 3. Except in medical emergencies, notification will be made within 24 hours of a change occurring in the resident's medical/mental condition or status. 4. Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR Communication Form. 5. The nurse will record in the resident' s medical record information relative to changes in the resident's medical/mental condition or status. During a review of the facility's P&P titled Resident Examination and Assessment, the P&P indicated the purpose of this procedure is to examine and assess the resident for any abnormalities in health status, which provides a basis for the care plan. The P&P further indicated how to perform a full head-to-toe assessment and indicated to notify the physician of any abnormalities such as labored breathing; breath sounds that are not clear; or cough, productive or nonproductive. During a review of the facility policy and procedure (P&P) titled Administering Medications dated [DATE], the P&P indicated, Medications are administered in accordance with prescriber orders, including any required timeframe.

Based on observation, interview, and record review, the facility failed to protect the resident's rights to be free from physical abuse for two of three sampled residents (Resident 2 and 3) by failing to protect Residents 2 and 3 from physical abuse. On 11/24/25, Resident 1 was observed by facility staff to be agitated, pacing back and forth in the room and swinging two metal wheelchair footrests in the air. Facility staff (Certified Nurse Assistant 1) failed to redirect and remove Resident 1 from the room leaving two other residents (Residents 2 and 3) in the room with Resident 1. As a result, Resident 1 hit Resident 2 several times in the head with the metal wheelchair footrests while Resident 2 was in bed. Resident 2 sustained severe, multiple lacerations (a jagged or irregular tear in the skin, often with edges that do not line up, caused by blunt force or tearing), bruising and severe pain to the face. Resident 3 verbalized fear and frightened for her life as she witnessed Resident 1 attempt to strike her with the metal footrests. The facility called 9-1-1 emergency services on 11/24/2025 at 12:08 AM, and Resident 2 was transferred to General Acute Care Hospital (GACH) 3. In GACH 3, Resident 2 was found to have sustained forehead soft tissue hematoma (collection of blood outside the blood vessel that forms a swollen area under the skin after an injury) as well as a right periorbital (around the eye socket) laceration. Resident 2's Computerized Tomography scan (CT scan - imaging using x-ray [a photographic or digital image of the internal composition of a part of the body] technique to create detailed images of the body) indicated there was partial mild irregularity of the right nasal (internal part of the nose) bone and a questionable right anterior (front) nasal bone fracture (broken bone). Resident 2 was readmitted back to the facility on [DATE] at 8:15 AM with derma bond (surgical glue) and steri-strips (sterile, adhesive, porous strips used to close small cuts, lacerations, and surgical incisions) applied to Resident 2's facial injuries. Findings: During a review of Resident 1's General Acute Care Hospital Records (GACH) 1 dated 5/21/2025, prior to admission to the facility, the GACH 1 record indicated Resident 1 was previously admitted to the GACH 1 Emergency Department (ED) due to an altercation with Family Member (FM) 1, threatening FM 1 with a knife. The GACH 1 ED record indicated Resident 1 was placed on a 5150 hold (involuntary psychiatric detention) at the GACH 1 for danger to others During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted the resident to the facility on 5/22/2025, with diagnoses including dementia (a general term for a decline in thinking, memory, and reasoning skills severe enough to interfere with daily life) with behavioral disturbance (loss of memory and thinking ability with agitation and physical aggression), psychosis ( loses of touch with reality, experiencing symptoms like hallucinations (seeing/hearing things not there) and delusions (false beliefs), along with confused thinking and speech. During a review of Resident 1's care plan initiated on 5/23/2025 indicated Resident [1] has a behavioral symptom manifested by delusions as evidenced by resident saying the resident hears God's voices all the time, the care plan indicated the care plan goals for the resident's behavior is to not result in harm or injury to self or others. The care plan interventions included for facility staff to provide behavioral management or modification as needed, such as providing redirection when exhibiting inappropriate behavior. During a review of Resident 1's History and Physical (H&P) dated 5/24/2025, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. The H&P indicated Resident 1 came from GACH 1 for altered mentation (confusion, not acting right, altered behavior), metabolic encephalopathy (brain dysfunction caused by illness) and dementia. During a review of a care plan developed for Resident 1 and initiated on 6/14/2025, the care plan indicated the resident has a behavioral problem of being physically aggressive related to pushing staff and throwing trash when entering her room. The care plan indicated that staff must intervene to protect the rights and safety of others, divert attention and remove Resident 1 from the situation and/or take to an alternate location. During a review of Resident 1's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 8/26/2025, the MDS indicated the resident had severe cognitive impairment (problems with a person's ability to think, learn, remember, use judgement, and make decisions). The MDS indicated Resident 1 was assessed requiring partial/moderate assistance for activities of daily living (basic self-care tasks). The MDS further indicated Resident 1 was assessed walking with partial/moderate staff assistance. The MDS further indicated Resident 1 manifested wandering behavior (a disturbance of motor activity that involves directionless, disoriented movement) and behavioral symptoms not directed towards (MDS examples indicated physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes or verbal/vocal symptoms like screaming, disruptive sounds). During a review of Resident 1's previous Change of Condition (COC) form dated 9/10/2025, authored by Registered Nurse (RN) 2, the COC indicated Resident 1's previous history of agitation observed by staff with escalating agitation. The COC further indicated that at 5:09 PM Resident 1 was yelling profanities (offensive language) at staff when staff enters her room. The COC indicated that Resident 1 throws water at the CNA and other staff passing her doorway. The COC indicated that Resident 1 was medicated with Haldol (a medication used to treat aggressive behavior) 5 milligrams (mg - unit of measure) intramuscularly (IM - injection under the muscle) and Benadryl (medication used to cause drowsiness) 25 mg IM one time. During a review of Resident 1's Nursing Progress Notes dated 11/13/2025 timed at 4:31 PM, the Note indicated another previous episode of agitation that indicated how Resident 1 was in an agitated state, had thrown water at staff and attempted to elope (a patient leaving a facility or designated safe area without authorization, often due to confusion). The Note indicated that the staff left her alone pacing up and down the hallway as to not trigger her anger. During a review of Resident 1's psychology (the scientific study of the human mind and its functions, especially those affecting behavior) note titled Behavioral Health documented on 11/24/2025 at 5:31 PM, the note indicated that Resident 1 reported to the psychologist that the resident was experiencing anxiety, frustration, and negative thinking patterns. The Note did not provide details regarding the specific situations or triggers that contributed to these symptoms. In addition, the Note did not include any recommendations or modifications to the treatment plan to address these concerns.The psychology note documented the following statements: Were there any treatment modifications needed in today's session due to cognitive impairment? No cognitive impairment noted. Medical Necessity for Ongoing Treatment: Symptoms Require More Attention, Risk of Significant Decline. During a review of Resident 1's Progress Notes dated 11/24/2025 documented at 10:40 PM, the Note indicated an incident happened around 10:30 PM when the [CNA 1] informed [Registered Nurse (RN) 1] that Resident 1 was playing with a wheelchair's metal footrests. The Notes indicated [CNA 1] tried to calm [Resident 1] down and get the wheelchair footrests from [Resident 1], but the resident was swinging it [at] CNA 1. The Note indicated CNA 1 went to ask help from RN 1 but while walking back to Resident 1's room, a scream was heard from the roommate, [Resident 2]. The Note indicated that Resident 1's physician (MD 1) was notified and ordered to administer Haldol 5 mg and Benadryl 25 mg IM to [Resident 1]. The Note indicated that RN 1 entered [Resident 1's] room and the roommate, [Resident 2] was observed with multiple lacerations to her face. The Note indicated the Police Department was notified and a police report was filed with the local police department. During a review of Resident 1's physician's telephone order dated 11/25/2025 the order indicated to transfer Resident 1 to GACH 2 to rule out (r/t) agitation. During a review of Resident 1's Nursing Progress Note dated 11/25/2025 documented at 2:35 AM, the Note indicated that Resident 1 was taken to GACH 2 on 11/25/2025 at 12:52 AM for further behavioral evaluations related to agitation. During a review of Resident 1's Change of Condition (COC) dated 11/25/2025, the COC indicated that an incident occurred around 10:30 PM when [CNA 1] informed [RN 1] that Resident 1 was playing [with] the footrest of the wheelchair. She [CNA 1] tried to calm her (Resident 1) down but get the footrests from her, but she was swinging it [at] her. The Note indicated CNA 1 left the room and went to ask for help from RN 1, but while walking back to Resident 1's room, a scream was heard from the roommate, Resident 1. 2. During a review of Resident 2's AR, the AR indicated the facility admitted the resident on 9/15/2023, with a diagnosis of dementia with behavioral disturbance and anxiety disorder (experiencing excessive worry and fear). During a review of Resident 2's H&P dated 11/27/2025, the H&P indicated Resident 2 did not have the capacity to understand and make decisions. During a review of Resident 2's MDS dated [DATE], the MDS indicated that Resident 2 had severe cognitive impairment. The MDS indicated that Resident 2 required partial/moderate assistance for activities of daily living. The MDS further indicated that Resident 2 required partial/moderate assistance to move from sitting on her side of the bed to lying flat on the bed, to come to a standing position from sitting in a chair, wheelchair or on the side of the bed, and the ability to transfer to and from the bed to a chair. During a review of Resident 2's Nursing Progress Notes Type: Situation Background Assessment Recommendations [SBAR] dated 11/24/2025 timed at 11:14 PM, the Note indicated an incident occurred around 10:30 PM when [CNA 1] informed [RN 1] that Resident 1 was playing the footrest of the wheelchair. The Note indicated [CNA 1] tried to calm her (Resident 1) down and get the footrests from her, but [Resident 1] was swinging it [at] [CNA 1]. The Note indicated CNA 1 went to ask help from RN 1 but while walking back to Resident 1's room, a scream was heard from the roommate, [Resident 1]. The Note indicated that [Resident 2] was found with lacerations on her face and treatment was applied. During a review of Resident 2's Nursing Progress Notes dated 11/24/2025 timed at 11:14 PM, the Note indicated that Resident 2 was medicated with Acetaminophen (pain medication) 325 mg two tablets for 7 out of 10 (a severe level of pain on the standard 0 to 10 pain rating scale used by medical professionals to quantify subjective pain experiences) facial pain. During a review of Resident 1's Police Report dated 11/24/2025, documented by Police Officer (PO) 1 on 11/24/20925 at 11:58 PM, the report indicated that at approximately 11:57 PM, PO 1 responded to a call at the facility regarding a resident who struck another resident with a wheelchair footrest. The report indicated that Resident 1 was the individual who struck Resident 2. RN 1 stated that the incident occurred at approximately 10:40 PM, when CNA 1 was in Resident 1's shared bedroom and observed Resident 1 swinging wheelchair footrests she had removed from her wheelchair, attempting to strike CNA 1. PO 1 further indicated in the report that CNA 1 left the room to seek assistance, and shortly afterward, nursing staff heard screams coming from the shared bedroom. Staff entered the room and observed Resident 2 with severe laceration on her forehead. According to the report, LVN 1 called 911, and Resident 2 was transported to GACH 3 for treatment. During a review of Resident 2's COC Evaluation dated 11/25/2025, the COC indicated Resident 2 manifested acute pain (pain that comes on suddenly and is caused by something specific) to the face. The Pain Status Evaluation indicated Resident 2 was unable to rate the pain but noted with facial grimacing (distorted facial expression) with body language noted as rigid, fists clenched, knees pulled up. During a review of Resident 2's Nursing Progress Notes at the facility dated 11/25/2025, the Note indicated Resident 2 was transferred to GACH 3 on 11/25/2025 at 12:08 AM via ambulance assisted by two emergency medical technicians (EMT) for further evaluation of facial lacerations. During a review of Resident 2's GACH 3 records titled 'emergency room (ER) Documentation dated 11/25/2025 timed at 12:35 AM, the GACH 3 record indicated Resident 2 was admitted to the ER for facial injuries. The GACH 3 record indicated that Resident 2 presented to the ER with altered mental status and had a number of lacerations on the face. The GACH 3 record indicated Resident 2 was assaulted by another resident [Resident 1] and she [Resident 2] was hit several times to the head, bleeding was controlled with steri-strips. The Record indicated that it was unknown if Resident 2 had lost consciousness after the assault. During a review of Resident 2's GACH 3 record titled Computerized Tomography of the head for moderate-severe head trauma, dated 11/25/2025 timed at 1:33 AM, the CT scan indicated Resident 2's forehead had a soft tissue hematoma (a medical condition characterized by the presence of localized bleeding and blood clot formation in the soft tissues of the bod), and there was no acute intracranial (within the skull) hemorrhage (bleeding) or fluid collection. During a review of Resident 2's GACH 3 records titled CT of the maxillofacial (jawbone and face) for facial trauma dated 11/25/2025 timed at 1:34 AM, the CT indicated Resident 2 had a forehead soft tissue hematoma as well as a right periorbital (around the eye socket) laceration. The CT indicated there was partial mild irregularity of the right nasal bone and there was a questionable right anterior nasal bone fracture. During a review of Resident's 2 Nursing Progress Note dated 11/25/2025 timed at 7:40 AM, the Note indicated the facility received a report from GACH 3 that Resident 2 had no intracranial injury noted and derma bond (surgical glue) was applied to the facial lacerations. The Note indicated Resident 2 was cleared by GACH 3 to return back to the facility. During a review of Resident 2's Nursing Progress Note dated 11/25/2025 at 8:15 AM, the progress note indicated that Resident 2 was readmitted back to the facility from GACH 3. During a review of Resident 2's MD Progress Note dated 11/26/25, the progress note indicated Resident 2 was attacked by another resident [Resident 1] without provocation on 11/24/2025 with the footrest of a wheelchair. The progress note indicated that Resident 2 did not remember what happened to her face and is full of cuts and bruises. During a concurrent observation and interview on 12/9/2025 at 10:25 AM with Resident 2 in her room, Resident 2 was noted to have visible facial injuries, including swelling, laceration and bruising to the center of the forehead, two scabbed lacerations above the right eyebrow, a scabbed laceration on the right cheek, and another scabbed laceration beneath the right nostril. Resident 2 was able to respond verbally to her name, however, Resident 2 could not state or recall how the facial injuries occurred. During an interview on 12/9/2025 at 11 AM with the Director of Nursing (DON), the DON stated that on 11/24/2025, Resident 1 was in an agitated state and was swinging two metal wheelchair footrests inside their (Residents 1, 2, and 3) room. According to the DON, CNA 1 witnessed Resident 1 swinging the dangerous metal object but was unable to remove the wheelchair footrests from Resident 1's hands. CNA 1 left the room to go to Nursing Station 1 to seek assistance. The DON stated that RN 1 and Licensed Vocational Nurse (LVN) 1 were on their way to Resident 1's room when they heard residents screaming. The DON stated while other staff (CNAs 2 and 3) tried to get Resident 1 under control, and when Resident 1 eventually calmed down, RN 1 entered the room and observed that Resident 2 had sustained facial injuries after being struck by the metal wheelchair footrests that Resident 1 had been swinging in the air inside their shared room. During an interview on 12/9/2025 at 11:34 AM with RN 1, RN 1 stated that on 11/24/2025 at approximately 10:30 PM, she was at Nursing Station 1 when CNA 1 approached after leaving Resident 1's room. CNA 1 reported that Resident 1 was inside her room swinging two metal wheelchair footrests in an aggressive manner. CNA 1 stated she attempted to calm Resident 1 and remove the footrests but was unsuccessful. Feeling frightened, CNA 1 left the room to seek assistance, leaving Resident 1 unattended with her roommates, Residents 2 and 3. During the same interview on 12/9/2025 at 11:34 AM with RN 1, RN 1 stated that RN 1, Licensed Vocational Nurse (LVN) 1, and CNA 1 left the Nursing Station to respond to Resident 1's room and heard a loud scream. Upon arrival, RN 1 observed Resident 1 actively swinging the metal wheelchair footrests in front of her bed in an agitated state, preventing staff from safely entering the room to assess Resident 2. RN 1 stated that CNA 2 and CNA 3 removed Resident 1 from the room and restrained her against the hallway wall using a linen cart. RN 1 instructed LVN 1 to call the attending physician, who ordered Haldol 5 mg IM and Benadryl 25 mg IM for agitation. RN 1 stated that it took approximately 30 to 40 minutes for Resident 1 to calm down. During that time, Resident 1 remained agitated, pinned against the wall, and eventually slid to the floor. Once seated, Resident 1 released both metal wheelchair footrests. During another interview on 12/9/2025 at 12 PM with RN 1, RN 1 stated that when she was finally able to enter Resident 1's room at approximately 11:10 to 11:20 PM on 11/24/2025, Resident 2 was observed lying in bed with her face covered in blood. RN 1 stated that Resident 2 sustained a deep, open laceration to the center of the forehead, two open lacerations above the right eyebrow, an injury to the right cheek, and a small laceration beneath the right nostril. RN 1 stated she cleaned the wounds and applied steri-strips to the lacerations on the forehead, above the right eyebrow, the right cheek, and under the right nostril. RN 1 stated she applied a cold compress to the right side of Resident 2's face due to redness and swelling, administered Tylenol for severe pain, and initiated neurological checks (a quick, systematic way nurses assess a patient's brain function after a head injury). RN 1 stated Resident 1 was placed on one-to-one observation (assigning a dedicated staff member to continuously monitor a patient for safety ensuring they are constantly within sight) at Nursing Station 1. During the same interview on 12/9/2025 at 12:00 PM with RN 1, RN 1 further stated that CNA 1 should have remained in Resident 1's room, utilized diversion techniques (a non-pharmacological method used to temporarily shift a patient's focus away from pain, anxiety, or discomfort by engaging them in other activities), and called out for assistance rather than leaving Resident 1 unattended with her roommates, Residents 2 and 3, still inside the shared room. RN 1 stated that CNA 1 leaving the room while Resident 1 was agitated and holding two metal footrests, with Residents 2 and 3 still present, resulted in Resident 2 being struck by the metal wheelchair footrests and sustaining multiple facial lacerations. During an interview on 12/9/2025 at 12:48 PM, CNA 4 stated she had been previously assigned to care for Residents 1, 2 and 3. CNA 4 stated that Resident 1 was ambulatory (able to walk), while Residents 2 and 3 were bedbound (unable to leave their beds to walk independently). CNA 4 stated that Resident 2 had severe dementia and limited ability to verbally communicate needs, whereas Resident 3 was alert and oriented and able to verbally communicate needs, but required moderate assistance with activities of daily living. CNA 4 reported frequently observing Resident 1 sitting up in bed talking to herself. CNA 4 further stated that Resident 3 reported witnessing Resident 1 strike Resident 2 with the metal wheelchair footrests on 11/24/2025, prompting Resident 3 to scream for help. During an interview on 12/9/2025 at 1:30 PM with Resident 3, Resident 3 stated that on the night of 11/24/2025, Resident 1 was in an agitated state and threw a cup of water from her bedside table. Resident 3 reported witnessing Resident 1 grab two metal wheelchair footrests, wave them around the room, and pace (walk at a steady and consistent speed, especially back and forth and as an expression of one's anxiety) back and forth from the doorway to the back of the room. Resident 3 stated that CNA 1 entered the room and attempted to remove the metal footrests from Resident 1's hands but was unsuccessful and then left the room. Resident 3 stated that after CNA 1 left the room, Resident 1 turned and approached Resident 3, who was lying in bed, and came within approximately four feet, and attempted to strike her (Resident 3) with the metal footrests. Resident 3 stated she was able to yell at Resident 1 to leave her alone. Resident 3 stated that Resident 1 then turned toward Resident 2's bed, who was also in bed. Resident 3 stated she heard the sound of the metal footrests as Resident 1 struck Resident 2 and screamed for help. Although a privacy curtain obstructed her view of Resident 2's upper body, Resident 3 observed Resident 1's body movements consistent with striking Resident 2 and heard the impact. Resident 3 stated she was frightened and feared for her life. Resident 3 stated that Resident 2 was unable to defend herself due to being bedbound. Resident 3 stated that after the physical assault against Resident 1, a nurse (RN 1) arrived and assisted Resident 2 with her injuries. During an interview on 12/9/2025 at 2:22 PM with CNA 1, CNA 1 stated that at the start of her shift on 11/24/2025 at approximately 3:30 PM, Resident 1 was observed sitting up in bed and talking to herself. CNA 1 stated that at approximately 10:30 PM, she observed Resident 1 standing at the entrance of her shared room, swinging two metal wheelchair footrests-one in each hand-in a crosswise back-and-forth motion. CNA 1 stated she approached Resident 1 and attempted verbal redirection, however, Resident 1 was not redirectable and swung the footrests toward CNA 1, nearly striking her. CNA 1 stated Resident 1 appeared highly agitated and had an intense facial expression. CNA 1 stated she left Resident 1's room and walked to Nursing Station 1, located down the hallway and notified RN 1 and LVN 1. CNA 1 stated that other CNAs (CNA 2 and CNA 3) responded and were able to remove Resident 1 from the room and restrain her against the hallway wall until Resident 1 slid to a seated position on the floor and released the wheelchair footrests from her hands. During the same interview on 12/9/2025 at 2:22 PM with CNA 1, CNA 1 stated that she entered Resident 1's room with RN 1 at approximately 11:30 PM (after Resident 1 calmed down) and observed Resident 2 lying in bed with her face covered in blood. CNA 1 stated that Resident 1 was then taken to Nursing Station 1 for observation. CNA 1 acknowledged that she should have remained in the room, called out for assistance, and maintained oversight of Resident 1. CNA 1 stated she left Resident 1 in the room due to fear of being struck by the metal wheelchair footrests. CNA 1 further stated that when she left the room, Residents 2 and 3 were left alone at-risk form harm due to Resident 1's agitated state and possession of a dangerous object. CNA 1 stated that she should have remained in the room and yelled for help instead. CNA 1 also stated that licensed nursing staff typically overhead page for assistance when incidents like these (agitated resident in possession of a dangerous object) happens, which did not occur in this situation. During an interview on 12/9/2025 at 3:15 PM with the Director of Staff Development (DSD), the DSD stated that staff had received education regarding abuse, including physical abuse and resident-to-resident altercations. During a concurrent review of the facility's Abuse Policy with the DSD, the DSD stated that the policy required staff to understand resident behaviors and symptoms that increase the risk for abuse and how to respond. However, the DSD stated that the facility's Abuse Policy did not provide specific guidance on how staff should respond to an agitated resident in possession of a dangerous object or how to prevent harm to residents and staff. The DSD stated that the facility did not have a designated code alert for an agitated resident with a dangerous object, although staff could use overhead paging to request assistance. The DSD stated that CNA 1 should have remained with Resident 1, who was agitated and holding two metal wheelchair footrests, and that by leaving the room to obtain assistance, CNA 1 left Residents 2 and 3 unattended. During a phone interview on 12/12/2025 at 2 PM with PO 1, PO 1 stated he arrived at the facility at approximately 11:57 PM on 11/24/2025. PO 1 stated upon arrival into the facility, RN 1 informed him that Resident 1 had struck Resident 2 in the head and described the incident as an alleged accident. PO 1 further stated that [CNA 1] left Resident 1's room to seek assistance, and shortly afterward, nursing staff heard screams coming from Resident 1, 2, and 3's shared bedroom. PO 1 stated that when the staff [RN 1] entered the room, the staff observed Resident 2 with severe laceration on her forehead. During a review of the facility's policy and procedure (P&P) titled Abuse Prevention/Prohibition revised on 11/2018, the P&P indicated the facility does not condone any form of resident abuse, neglect . and develops facility policies, procedures, training programs, and systems in order to promote an environment free from abuse and mistreatment. During a review of the facility P&P titled Resident to Resident Altercation revised on 9/2022, the P&P indicated that behaviors that may provoke a reaction by residents or others included verbally aggressive behavior, such as screaming, cursing, bossing around/demanding, insulting to race or ethnic group, intimidating, physically aggressive behavior, such as hitting, kicking, grabbing, scratching, pushing/shoving, biting, spitting, threatening gestures, throwing objects. During a review of the facility P&P titled Resident Safety revised on 7/2017, the P&P indicated that resident safety and supervision and assistance to prevent accidents are facility-wide priorities. The P&P indicated that implementing interventions to reduce accident risks and hazards shall include the following: communicating specific interventions to all relevant staff, assigning responsibility for carrying out interventions, providing training, as necessary, ensuring that interventions are implemented. The P&P indicated that monitoring the effectiveness of interventions shall include the following: ensuring that interventions are implemented correctly and consistently, evaluating the effectiveness of interventions, modifying or replacing interventions as needed and evaluating the effectiveness of new or revised interventions.

Based on observation, interview, and record review, the facility failed to maintain a system-wide method of accountability for controlled medications (medication with a high risk of abuse or theft) and maintain a system to ensure accountability of controlled medications to track compliance with its policy on Controlled Substances. The Controlled Drug-Count Records (the title of the document the facility uses for the controlled medication reconciliation [a process of counting all the controlled medication in the medication cart between the nurse leaving and the nurse coming on duty to determine if there are any discrepancies]) were not signed by two nurses during shift change between 6/3/23 and 8/2/23 totaling 102 times, in accordance with the facility's policy and practice to have licensed nurses sign the Controlled-Drug-Count Records as a documentation that controlled medication reconciliation had been performed between two nurses during shift change, for three of three sampled medication carts (Medication Carts 1, 2, and 3). In addition, the facility licensed nurses failed to follow proper procedures in accordance with the facility's practice and policy to ensure that controlled medications are counted at the end of each shift, between the licensed nurses coming on duty and the licensed nurses going off duty, on 8/1/23 and 8/2/23 while working on their respective nursing shifts. The Director of Nurses (DON) failed to maintain adequate oversight of Resident 1's Norco 5/325 mg Record of Controlled Substances (a log containing the date, time, and nurse's signature for all administered doses of a specific supply of a controlled medication) corresponding to the facility's pharmacy delivered supplies of Resident 1's Norco 5/325 mg dated 7/16/23 during the licensed nurses daily controlled medication reconciliation between 7/16/23 to 8/2/23. As a result, the facility was unable to account for 28 doses of Norco (a controlled medication used to treat pain) 5/325 milligrams (mg - a unit of measure for mass) for one of three sampled residents (Resident 1). These deficient practices increases the risk of diversion (the illegal distribution or abuse of prescription drugs or their use for purposes not intended by the prescriber) of controlled medications, staff working in an impaired state, increases the risk that medications are not available to residents when needed, and potential for accidental exposure to controlled substances for 94 of 94 total residents (facility census on 8/4/23) possibly resulting in respiratory depression (the inability to breathe) leading to hospitalization or death. On 8/4/23 at 3:34 PM, the Department of Public Health (Department) called an Immediate Jeopardy (IJ) situation (a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) in the presence of the Administrator (ADM), Director of Nursing (DON), and Assistant Administrator (AADM). On 8/5/23 at 1:13 PM, the facility provided the Department with an IJ Removal Plan that included the following summarized actions: 1. On 8/4/23, the AADM visited and assessed Resident 1 in her room. Resident had no complaints of pain. Per Resident 1, pain medication is effective. No signs and symptoms of adverse effects noted. 2. On 8/4/23, the DON conducted an immediate in-service (used to describe training done during time at work) to Licensed Nurses regarding the facility's policies and procedures titled Controlled Medication Storage and Medication Administration - General Guidelines. All narcotic (a controlled medication or other substance that affects mood or behavior) medication will be kept in the medication cart narcotic drawers for each respective nursing station and are double-locked. The DON emphasized the failure of maintaining accountability of controlled substances and potential impact to residents. The DON further stressed that when as needed medications are administered, the licensed nurse shall sign the electronic Medication Administration Record (eMAR - an electronic record of all medications a resident receives). The DON will continue until all licensed nurses have received in-services with an expected completion date of 8/14/23. 3. On 8/4/23, the DON initiated an in-service to licensed nurses regarding timeliness in arriving to the facility for duty and proper endorsement between licensed nurses coming off duty and licensed nurses coming on duty. Licensed nursing coming off duty are not to leave the facility until the relieving licensed nurse coming on duty is present to receive endorsement. In the event of an emergency, and the licensed nurse coming off duty or the licensed nurse coming on duty are unable to endorse to each other, the Licensed Nurse supervisor coming on duty will receive endorsement from the licensed nurse coming off duty. When the Licensed Nurse coming on duty arrived, he/she will receive endorsement from the licensed nurse supervisor, the DON, or another designated licensed nurse shall be present during the accountability of narcotic medications. These nurses shall sign off on the Controlled Drugs - Count Record. The DON will continue until all licensed nurses have received in-services with an expected completion date of 8/14/23. 4. On 8/5/23, the Pharmacy Consultant (PC) will also provide additional mandatory in-service to licensed nurses regarding the facility's policies and procedures titled Controlled Medication Storage and Medication Administration - General Guidelines and conduct medication pass observation. The PC will also check narcotic medication for all nursing station for accurate reconciliation and account for all controlled medications. 5. On 8/4/23, the DON initialed skills competency evaluation for all licensed nurses, focusing on medication administration which includes accountability of controlled substances and documentation of PRN medication administration. 6. On 8/4/23, Situation Background Assessment Recommendation (SBAR - a nursing communication tool used to monitor for a resident's possible change in health status) and care plan were initiated for Resident 1 to monitor for signs and symptoms of pain and decline in the ability to perform Activities of Daily Living (ADL). 7. On 8/4/23, SBAR and care plans were initiated by licensed nurses for all current residents to monitor for respiratory depression (a breathing disorder characterized by slow and ineffective breathing) related to possible exposure of narcotic consumption, which will be continued every shift for 72 hours through 8/7/2023. 8. During change of shift, two licensed nurses, which include the nurse coming on duty and the nurse going off duty for each station, will count the narcotic medications in the medication cart narcotic drawer in the presence of the Licensed Nurse Supervisor coming on duty. The two licensed nurses and the licensed nurse supervisor coming on duty will sign the Controlled Drug-Count Record revised on 8/5/2023 to acknowledge that the licensed nurse coming on duty and the licensed nurse coming off duty have counted the controlled drug on hand and have found that the quantity of each medication counted is in agreement (matched) with the quantity stated on the Controlled Drug-Count Record. The revised Controlled Drug - Count Record shall include the written names and signatures of the licensed nurse coming on duty, the licensed nurse coming off duty, and the Licensed Nurse Supervisor coming on duty. The licensed nurse coming off duty will endorse the medication cart keys which included the narcotic drawer key to the licensed nurse coming on duty under the supervision of the Licensed Nurse Supervisor. 9. Licensed nurses will provide a copy of any new physician's orders for controlled substances, a copy of the pharmacy receipt for those controlled substances, and a copy of the controlled substance count sheets (a log containing the date, time, and nurse's signature for all administered doses of a specific supply of a controlled medication) to the DON which will be kept in a designated binder in the DON's office for accurate reconciliation and accounting for all controlled medications. 10. A triple check (means to check again with extra caution/attention) will be conducted monthly by two (2) facility-designated licensed nurses and licensed pharmacy nurse for each medication cart, including narcotic/controlled substances to ensure accurate reconciliation and accounting for all controlled medications by validating medications through each residents' physician orders, medication administration record, and the actual medication on hand. An audit of the Controlled Drug-Count Record will be conducted Monday through Friday for 7 am to 3 pm shift and 3 pm to 11 pm shift by the Medical Records Director/Designee utilizing the Audit Tool Controlled/Medication to the Medication Administration Record (MAR) Form. The Licensed Nurse Supervisor will audit the Controlled Drug-Count Record Monday through Friday 11 pm - 7 am shift and Saturday and Sunday 7 am to 3 pm shift, 3 pm to 11 pm shift, and 11 pm to 7 am shift utilizing the Audit Tool Controlled/Medication, Pro Re Nata (PRN - refers as needed medications) medication to MAR form to acknowledge that the incoming licensed nurse and outgoing licensed nurse have counted the controlled drug on hand and have found that the quantity of each medication counted is in agreement with the quantity stated on the Controlled Drug-Count Record. Additionally, the Medical Record Director/Designee will conduct an audit of the Controlled Drug-Count Record form Monday through Friday to ensure that the correct licensed nurses are signing the form by checking the signatures against the licensed nurses' floor schedule as written on Nursing Staffing Assignment and Sign-In Sheet. Findings will be reported and discussed by the Medical Records Director/Designee. 11. Any deficient practices will be immediately reported to the DON/Designee who will investigate and make every reasonable effort to reconcile (resolve) all reported discrepancies. Discrepancies which cannot be immediately resolved shall be documented by the DON/Designee in a report to the Administrator. If a major discrepancy or pattern of discrepancies occurs or if there is apparent criminal activity, the DON/Designee shall notify the ADM and PC immediately. A determination shall be made by the ADM, the PC, and the DON/Designee concerning possible notification of police or other enforcement agencies and any other actions to be taken. 12. The DON/Designee will discuss and review findings of accountability of controlled substances to the monthly Quality Assurance Performance Improvement (a structured approach in to evaluating the performance of systems in an organization) meetings to ensure corrective actions are sustained. On 8/5/23 at 3:24 PM, while onsite and after confirming the facility's implementation of the IJ Removal Plan by observation, interview, and record review, the Department accepted the IJ removal plan and removed the Immediate Jeopardy, in the presence of the ADM, AADM, DON, and Senior [NAME] President (SVP). Cross-referenced with F760 Findings: A review of Resident 1's Face Sheet, dated 8/3/23, indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including essential hypertension (high blood pressure) and muscle weakness. A review of Resident 1's Minimum Data Set (MDS - a comprehensive resident assessment tool) section C (Cognitive Patterns) indicated Resident 1 had a Brief Interview for Mental Status (BIMS - a interview tool used to determine cognitive impairment) score of 12 (moderately impaired.) A review of Resident 1's History and Physical note (H&P - the formal document that physicians produce through the interview with the patient, the physical exam, and the summary of the testing either obtained or pending) dated 6/3/23, indicated Resident 1 had the capacity to understand and make decisions. A review of Resident 1's physician order dated 6/9/23 indicated the physician prescribed Norco 5/325 mg to take one tablet by mouth every six hours as needed for moderate pain (pain score 4 to 6). A review of Resident 1's eMAR, for the month of August 2023 and printed 8/3/23, indicated one dose of Norco 5/325 mg was given to Resident 1 on 8/1/23 at 10:58 PM and no additional doses were given on 8/2/23. A review of Resident 1's Care Plan, dated 6/1/23, indicated Resident 1 was at risk for chronic pain due to neuropathy (nerve pain), arthritis (inflammation of the joint) in her left knee and bursitis (inflammation of tissue that cushions bones, tendons, and muscles near joints) in her left knee with targeted interventions to monitor for pain every shift and administer Norco 5/325 mg every 6 hours as needed. A review of a pharmacy delivery receipt, dated 7/16/23, indicated a recent previous delivery was made to the facility for 60 tablets of Norco 5/325 mg on 7/16/23 timed at 1:23 AM for Resident 1. A review of the pharmacy delivery receipt dated 8/2/23, indicated 30 tablets of Norco 5/325 mg (replacement supply) was delivered to the facility on [DATE] timed at 10:30 PM for Resident 1. On 8/3/23 at 3:29 PM, during an interview, the DON stated LVN 1 was the nurse assigned on the morning shift (7 AM to 3 PM) on 8/2/23 and LVN 2 was the nurse assigned on the preceding night shift of 8/1/23 (11 PM to 7 AM) to Station 2, Medication Cart 2. The DON stated that at the start of LVN 1's morning shift on 8/2/23 (7 AM to 3 PM shift) around 9 AM, LVN 1 notified her that there were 14 tablets of Norco 5/325 mg missing from Resident 1's controlled medications supply. The DON stated that she looked for Resident 1's Norco 5/325 mg medications in Medication Cart 2, all other medication carts, and medication storage rooms in the facility but could not locate the medications. The DON stated she contacted the pharmacy to provide a replacement supply of Norco 5/325 mg, on 8/2/23. The DON stated the facility's pharmacy authorized one dose of Norco 5/325 mg from the controlled medication emergency kit (e-kit) and advised that the facility pharmacy would provide a replacement supply of Resident 1's Norco 5/325 mg. The DON stated the newly ordered replacement supply of Norco 5/325 mg was delivered to the facility on [DATE] at around 11 PM. During the same interview, on 8/3/23 at 3:29 PM, the DON stated that the facility's pharmacy had delivered Norco 5/325 mg supplies with pharmacy delivery receipt dated 7/16/23. The DON stated Resident 1's Record of Controlled Substances (a log containing the date, time, and nurse's signature for all administered doses of a specific supply of a controlled medication) that corresponds to the missing supply of Resident 1's Norco 5/325 mg delivered on 7/16/23 was also missing. During the same interview, on 8/3/23 at 3:29 PM, the DON stated LVN 1 (7 AM to 3 PM shift) and LVN 2 stated they signed the Controlled Drugs - Count Record but did not perform the controlled medication reconciliation for Medication Cart 2 together, as indicated in the facility's policy, during LVN 1 and 2's shift change (8/2/23 at 7 AM). During the same interview, on 8/3/23 at 3:29 PM, the DON stated LVN 3 administered the last known dose of Norco 5/325 mg from the missing supply (pharmacy delivery dated 7/16/23) on 8/1/23 at around 9 PM. The DON stated LVN 3 worked on 8/1/23 during the 3 PM to 11 PM shift and was also assigned to Medication Cart 2. The DON stated on 8/1/23 at around 11 PM, when LVN 3 was ready to leave the facility, LVN 2 who was scheduled to work the 11 PM to 7 AM shift, had not yet arrived at the facility. The DON stated LVN 3 performed a controlled medication reconciliation with another licensed nurse scheduled during the same 3 PM to 11 PM shift, Registered Nurse (RN) 1, on 8/1/23 at around 11 PM. The DON stated RN 1 later (unknown time) performed a controlled medication reconciliation for Medication Cart 2 with LVN 4 who was assigned as a charge nurse team leader during the 11 PM to 7 AM shift on 8/1/23. The DON stated LVN 4 (11 PM to 7 AM shift) and LVN 2 (11 PM to 7 AM shift) performed a controlled medication reconciliation for Medication Cart 2 at some point prior to leaving the facility at approximately 7 AM on 8/2/23. On 8/3/23 at 4:20 PM, during an interview, LVN 3 stated she was assigned to Medication Cart 2 on 8/1/23 for the 3 PM to 11 PM shift. LVN 3 stated that on 8/1/23, LVN 3 performed a controlled medication reconciliation with RN 1 around 10:50 PM because her shift was nearing its end, and LVN 2 (11 PM to 7 AM shift LVN) had not yet arrived at the facility. LVN 3 stated she provided one dose of Norco 5/325 mg to Resident 1 around 10:45 PM on 8/1/23. LVN 3 stated, after arriving on her shift (3 PM to 11 PM) the next day, on 8/2/23 around 3:20 PM, LVN 3 performed a controlled medication reconciliation with the DON because Resident 1's Norco 5/325 mg had been reported missing earlier that day. LVN 3 stated there was no Norco 5/325 mg available for Resident 1 during her shift that day, on 8/2/23. LVN 3 stated she assessed Resident 1 for pain during her shift around 4 PM or 5 PM and Resident 1 indicated her pain level was 4 to 5/10 (pain score on a scale from 0 to 10 where 0 is no pain and 10 is the worst possible pain). On 8/4/23 at 10:08 AM, during another interview with the DON, the DON stated interviewing LVN 1 again regarding what happened with Resident 1's Norco 5/325 mg when it was discovered missing on 8/2/23. The DON stated LVN 1 informed her that she assessed Resident 1's pain the morning of 8/2/23 and LVN 1 indicated it was 2/10 pain. The DON stated LVN 1 determined Tylenol (over the counter medication for mild pain) was sufficient at that time but tried to locate the Norco 5/325 mg in case the Tylenol was not effective later. The DON stated LVN 1 was unable to find Resident 1's Norco 5/325 mg available on 8/2/23. The DON stated LVN 1 informed her LVN 1 failed to make a progress note log entry regarding Resident 1's missing Norco 5/325 mg-controlled medications supply. On 8/4/23 at 10:39 AM, during a telephone interview with the Pharmacy Manager (RXM), RXM stated LVN 1 called the facility pharmacy at around 9 AM on 8/2/23 and stated Resident 1's Norco 5/325 mg was missing. RXM stated the pharmacy processed a refill of the Norco 5/325 mg which was delivered later that evening and provided the access code to the controlled medication e-kit for immediate use. RXM stated he was unaware whether the facility utilized any Norco 5/325 mg from the e-kit. On 8/4/23 at 10:52 AM, during a telephone interview, LVN 1 stated she worked on 8/2/23 during the 7 AM to 3 PM shift, but did not arrive until right before 8 AM. LVN 1 stated LVN 2 (previous shift [11 PM to 7 AM]) had already left by the time she arrived at the facility, so LVN 1 did not count the controlled medications with any other nurse as indicated in the facility policy. LVN 1 stated she counted the controlled medications of other residents using the Record of Controlled Substances when she arrived at the facility by herself and did not find discrepancies (inconsistencies). LVN 1 stated she would not have known at that time if Resident 1's controlled medication supply of Norco 5/325 mg for Resident 1 was missing because the corresponding Record of Controlled Substances document was also missing. LVN 1 stated she assessed Resident 1's pain around 9 AM and determined Resident 1 had 2/10 pain. LVN 1 stated she administered Tylenol, as the pain rating was not sufficient to administer Norco at that time. LVN 1 stated she then searched Medication Cart 2 to determine whether the Norco 5/325 mg was available in case the Tylenol was ineffective. LVN 1 stated she could not find Resident 1's Norco medications. LVN 1 stated she immediately informed the DON that Resident 1's Norco 5/325 mg controlled medications were missing. LVN 1 stated the DON proceeded to search her Medication Cart and all other facility carts and medication storage rooms but was unable to locate the medication. LVN 1 stated she contacted the pharmacy for a replacement supply . LVN 1 stated she failed to document that Resident 1's Norco 5/325 mg was missing in Resident 1's progress note. LVN 1 stated she performed a controlled medication reconciliation with LVN 3 before leaving from her shift around 3 PM on 8/2/23. LVN 1 stated she failed to follow facility policy of performing controlled medication reconciliation with LVN 2 when she started her shift in the morning, on 8/2/23. LVN 1 stated it was important to ensure controlled medication counts are correct to ensure the availability of the medications for the residents. LVN 1 stated if controlled medications are missing, there is a chance residents could experience medical complications like increased pain or accidental exposure which could cause decreased quality of life. On 8/4/23 at 12 PM, during a concurrent observation and interview in Resident 1's room, Resident 1 was observed sitting up on her bed. Resident 1 stated that on 8/2/23 she requested Norco 5/325 mg for severe pain at 4:45 PM and 11 PM. Resident 1 stated she was told by the licensed nurses (could not recall which licensed nurse) at both times the facility was out of the Norco. Resident 1 stated she did not remember which specific licensed nurse attended to her at those times. Resident 1 stated her pain was worsened because she did not receive her pain medication at those times, and she was supposed to be able to get the Norco every six hours. Resident 1 stated she would describe her pain at that time as severe. Resident 1 stated she never asks the licensed nurses for only Tylenol. Resident 1 stated sometimes licensed nurses tell her they will have to come back with her Norco because we keep them in a different place. A review of Medicare Skilled Daily Note (a daily nursing progress note), dated 8/2/23, authored by LVN 1, included no entry concerning missing Norco 5/325 mg, pain score ratings, attempts to follow up with the pharmacy regarding the missing Norco 5/325 mg, e-kit usage. A review of the facility's Controlled Drug - Count Record for Medication Cart 1 indicated the document was not signed according to facility policy a total of 28 times between 6/1/23 to 8/2/23. A review of Resident 1's eMARs (printed 8/3/23) dated July and August 2023, indicated the following information: 1. A review of Resident 1's July 2023 MAR indicated Resident 1 received a total of 31 doses of Norco 5/325 mg between 7/16/23 (the date the most recent previous supply of Norco 5/325 mg was received from the pharmacy) to 7/31/23. 2. A review of Resident 1's August 2023 MAR indicated Resident 1 received a total of 1 dose of Norco 5/325 mg on 8/1/23 to 8/2/23 (the date the Norco 5/325 mg goes missing). 3. A review of Resident 1's July and August 2023 MARs indicated that between 7/16/23 (the date the most recent previous supply of Norco 5/325 mg was received from the pharmacy) to 8/2/23 (the date the Norco 5/325 mg goes missing) indicated a total of 28 doses out of the 60 doses of Norco 5/325 mg supply of Resident 1's Norco 5/325 mg were unaccounted for. A review of the facility's Controlled Drug - Count Record for Medication Cart 2 indicated the document was not signed according to facility policy a total of 13 times between 6/1/23 to 8/2/23. A review of the Controlled Drug - Count Record for Medication Cart 3 indicated the document was not signed according to facility policy a total of 61 times between 6/1/23 to 8/2/23. A review of the Controlled Drug - Count Record for Medication Carts 1, 2, and 3 indicated the documents were not signed according to facility policy a total of 102 times, facility-wide between 6/1/23 to 8/2/23. On 8/4/23 at 12:48 PM, during a telephone interview, LVN 2 stated her assignment was a charge nurse on Station 2, Medication Cart 2 on the night shift, of 8/1/23 during the 11 PM to 7 AM shift. LVN 2 stated that she arrived at the facility for her shift around 12:10 AM and did not count the controlled medications with anyone at that time. LVN 2 stated LVN 3 who was assigned to Medication Cart 2 for the previous shift (3 PM to 11 PM) had already left the facility. LVN 2 stated she counted everything that was in her lockbox inside Medication Cart 2 by herself but did not count any of Resident 1's Norco. LVN 2 stated all of Resident 1's supplies of Norco in Medication Cart 2 had been removed from Medication Cart 2 and relocated inside Medication room [ROOM NUMBER] and put into a lock box there. LVN 2 stated this change occurred about a month ago at the direction of the DON. LVN 2 stated she was unclear on why the Norco supplies for residents in Medication Cart 2 was moved in a lockbox inside Medication room [ROOM NUMBER]. LVN 2 stated she was unclear if there was a different controlled medication reconciliation process for the Norco controlled medications that had been relocated to Medication room [ROOM NUMBER]. LVN 2 stated she had not been reconciling the medication counts for any of the Norco since the Norco supplies were relocated from Medication Cart 2 to a lockbox in Medication room [ROOM NUMBER]. During the same interview, on 8/4/23 at 12:48 PM, LVN 2 stated that in the morning of 8/2/23, at around 7 AM before leaving the facility, she counted all the controlled medications in Medication Cart 2 with LVN 4. LVN 2 stated LVN 4 (11 PM to 7 AM) was also leaving from night shift at that time and was not the nurse taking over accountability of the controlled medications in Medication Cart 2 for oncoming shift (7 AM to 3 PM) on 8/2/23. LVN 2 stated LVN 1 was scheduled to relieve her for the next shift, on 8/2/23 at 7 AM but had not yet arrived at the facility, by the end of her shift. On 8/4/23 at 1:20 PM, during a telephone interview, RN 1 stated she was scheduled to work on 8/1/23 for 3 PM to 11 PM shift. RN 1 stated that on 8/1/23, LVN 3 left around 11 PM and was unable to perform a controlled medication reconciliation with LVN 2 because LVN 2 had not yet arrived at the facility. RN 1 stated she counted the controlled medications with LVN 3 so LVN 3 could go home. RN 1 stated LVN 2 arrived around 12:10 AM, but RN 1 did not count the controlled medications with LVN 2 when she took over Medication Cart 2. RN 1 stated she also did not count the controlled medications with LVN 4 at any time prior to leaving the facility, on 8/1/23. RN 1 stated all the Norco supplies from Medication Cart 2 had been removed from Medication Cart 2 and placed in a lockbox inside Medication room [ROOM NUMBER]. RN 1 stated the keys to the lockbox were kept hanging on the side of the lockbox inside Medication room [ROOM NUMBER]. RN 1 stated anyone with keys to Medication room [ROOM NUMBER] could have accessed the Norco in the lockbox that was supposed to be in Medication Cart 2. RN 1 stated she was unsure why the DON made the decision to move the Norco to Medication room [ROOM NUMBER]. RN 1 stated if controlled medications are in two different places and people other than the responsible licensed staff have access to the controlled medications, the risk for diversion or accidental exposure to residents are increased. On 8/4/23 at 1:34 PM, during a concurrent interview and record review of Resident 1's MAR and pharmacy delivery receipts, the DON stated and acknowledged that it was a total of 28 doses of Norco 5/325 mg missing instead of 14 tablets mentioned previously. During the same interview, on 8/4/23 at 1:34 PM, the DON stated about a month ago she decided to move all the Norco from Medication Cart 2 into a lockbox in Medication room [ROOM NUMBER]. The DON stated she made this decision because in the past, Resident 1 and licensed staff disagreed on whether Resident 1 received her Norco. The DON stated her intent for doing this was to ensure at least two licensed nurses would need to be involved in administering Resident 1's Norco for verification that the medication administration occurred. The DON stated she failed to consider that by removing the Norco from Medication Cart 2, there would be no way to ensure the accountability of the controlled substances from shift to shift between licensed nurses when performing controlled medication reconciliation. The DON stated she failed to address the potential with which the Controlled Drugs - Count Record would not be signed for the Norco supplies according to facility policy by the oncoming and outgoing nurse between 6/1/23 to 8/2/23 if the controlled medications were on a separate location. The DON stated if one nurse is late, the nurse who was scheduled to leave should not leave before the next nurse arrives. During the same interview, on 8/4/23 at 1:34 PM, the DON stated the facility did not have a policy to address what licensed nurses needed to do to endorse over the accountability of controlled medications in the case that two licensed nurses' shifts on duty do not overlap. The DON stated if both the incoming and outgoing nurses do not sign off on the Controlled Drugs - Count Record then there would be a break in the chain of accountability for the controlled medications. The DON stated if a licensed nurse counts the medications themselves or if two nurses who are both leaving from the same shift, count the controlled medications together it does not serve the purpose of continuous accountability. The DON stated because the facility failed to maintain adequate oversight on the controlled medication reconciliation process and because controlled medications are now missing, the facility's residents are at risk of accidental exposure possibly leading to hospitalization or death, increased pain, ADL decline, and quality of life decline. The DON stated that failure to maintain oversight of the controlled medications such as leaving the key hanging by the lockbox inside Medication room [ROOM NUMBER] and the licensed nurses controlled medication reconciliation process further increased the risk of medication diversion, misappropriation of resident property, or staff providing resident care in an impaired state. A review of the facility's policy Controlled Substances, revised April 2019, indicated The facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled substances . Access to controlled medications remains locked at all times and access is recorded . Controlled substances are reconciled upon receipt, administration, disposition, and at the end of each shift ., Controlled medications are counted at the end of each shift. The nurse coming on duty and the nurse going off duty determine the count together . A review of the facility's policy Administering Medication, revised April 2019, indicated Medications are administered in a safe and timely manner, and as prescribed . Medications are administered in accordance with prescriber orders, including any required time frame . The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones .

Based on observation, interview and record review, the facility failed to ensure nine out of nine (Residents 79, 40, 292, 14, 42, 342, 87, 76, and 86) justice involved residents (residents currently in custody and held involuntarily through operation of law enforcement authorities in an institution, which is the responsibility of a governmental unit or over which a governmental unit exercises administrative control) residing in the facility were treated with respect and dignity and were able to exercise the same basic rights as all other residents in the facility in accordance to the facility's policy and procedure on Resident's Rights. This failure resulted in the facility imposing conditions (practices) which included restricting indoor and outdoor visitations, receiving telephone calls, receiving mails, participating in activities of their choice, moving around within the facility, communicating with outside agencies which included the State Long-term care Ombudsman (OMB; an individual who advocates for long-term care facility residents, defends their rights, and ensures they are protected from verbal abuse, neglect, and assault) and Department of Public Health (DPH) State Surveyors, which violated the resident's rights of Residents 79, 40, 292, 14, 42, 342, 87, 76, and 86. All decisions were made by the Federal Law Enforcement and Private Security Officers who were present with each justice involved resident. These deficient practices had the potential to affect Residents 79, 40, 292, 14, 42, 342, 87, 76, and 86's dignity and self-worth that could lead to severe negative psychosocial outcome such as fear, depression, agitation, isolation, suicidal ideation, and suicide. On 10/19/22 at 12:25 PM, during the facility's annual recertification survey, the Department of Public Health (DPH) called an Immediate Jeopardy (IJ-a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident), in the presence of the Administrator (ADM) and Director of Nurses (DON), in regard to the nine justice involved residents residing in the facility that were unable to exercise the same basic rights as all other residents in the facility. The facility was found to imposed conditions on the nine justice involved residents which resulted in restricting and violating the rights of the nine justice involved residents that included communicating with and access to persons inside and outside the facility, that includes visitation, without interference, discrimination, and fear of reprisal. On 10/20/22 at 6:10 PM, the DPH removed the IJ while onsite after the surveyor verified the facility implemented the IJ Removal Plan (a detailed plan to address the IJ findings) given by the ADM which included: 1. On 10/19/22, the DON and Social Services Director (SSD) interviewed the nine justice involved residents regarding their care, how staff treats them, and if they have experienced any adverse psychosocial effect as a result. 2. On 10/19/22, the DON notified the attending physician of all nine justice involved residents and the attending physician ordered for all nine justice involved residents to be transferred to the acute hospital because the facility cannot meet the residents' needs. The DON and Marketing Director (MKD) notified all justice involved residents regarding the attending physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 3. All nine justice involved residents signed the Notice of Proposed Transfer and Discharge. The attending physician from the acute hospital, which the nine residents were transferred to, coordinated with the DON and MKD regarding the transfer. The MKD will coordinate with all nine justice involved residents' responsible parties to ensure proper placement. 4. On 10/20/22, the DON followed up with the nine Justice Involved Resident's attending physician at the acute hospital and physician informed that all nine Justice involved Residents are stable and doing well. All nine justice involved residents are still in the acute hospital. The responsible party of all nine justice involved residents are still working on proper placement with facilities that they work with. 5. On 10/19/22, the ADM was provided in-service education and training from the [NAME] President of Operations (VPO) regarding the facility's policy and procedure regarding, but not limited to, Resident's Rights. Findings: A review of a formal referral letter from the long-term care ombudsman dated 10/14/22, indicated the OMB was at the facility on 10/11/22. The letter indicated the OMB was not allowed to see or interview the nine justice involved residents in their rooms. The letter indicated that the DON stated the facility had been instructed to follow a different set of rules and were told that the justice involved residents did not have the same rights as all other residents in the facility. The letter indicated that on 10/12/22, the OMB spoke to the Federal Law Enforcement (Justice Department agency charged with carrying out all law enforcement activities relating to the federal justice system) Supervisor and explained to the OMB that the justice involved residents were supervised by the Federal Law Enforcement while in the facility. The letter indicated that the Federal Law Enforcement Supervisor informed the OMB that the justice involved residents residing in the facility have all the rights to keep them alive. The letter indicated the justice involved residents were not allowed to have phone calls, outside snacks, were not allowed to walk around the facility and have visitors without the Federal Law Enforcement Supervisor permission. The letter indicated that on 10/12/22, the facility's administrator shared with the OMB that the facility was following a separate protocol (policy) for the justice involved residents according to the facility's corporate guidance and the Federal Law Enforcement Agency. A review of a Memorandum (a short note designating something to be remembered, especially something to be done or acted upon in the future) addressed to the facility and MKD, titled Policy and Procedures for Inmates in Nursing Home Facilities, dated 8/20/2021, signed by the Federal Law Enforcement Deputy and written in the Federal Law Enforcement letterhead indicated the following information: - Clients (Inmates [residents of the facility]) who are residing in a nursing home facility are not allowed any outside food, clothing or any other item that is not medically necessary unless it is pre-approved by (Federal Law Enforcement Agency). - Every client (inmate) that resides in a nursing home facility will be always accompanied by security staff (24 hours). - Clients (inmates) are allowed phone calls only when pre-approved by (Federal Law Enforcement Agency). Calls will be initiated and monitored by security staff onsite. - Clients (inmates) are not allowed to have family visitations or phone calls. If unannounced visitor arrives, notify (Federal Law Enforcement Agency) immediately. - For a client (inmate) to participate in an extra activity, it must be pre-approved by the (Federal Law Enforcement Agency). Clients will not be able to participate in any activity which involved non-custodial (a person found guilty of a crime or offense and punishment does not involve going to prison) members of the Skilled Nursing Facility. On 10/18/22 at 8:32 AM, during the initial tour of the facility, concurrent interview and review of the facility's residents census dated 10/17/22 with the DON, the DON stated the facility had 92 residents residing in the facility. The DON stated Residents 79, 40, 292, 14, 42, 342, 87, 76, and 86 were under a fictitious (not real or true) name to protect the resident's identity and for confidentiality. The DON stated Residents 79, 40, 292, 14, 42, 342, 87, 76, and 86 admitted in the facility were all justice involved residents. On 10/18/2022 at 9:26 AM, Private Security Officer (PSO) 2 stated that two PSOs were assigned to supervise each of the nine justice involved residents in the facility. PSO 2 stated there were three working shifts per day, 8 hours per shift. PSO 2 stated Justice Involved Residents needs 24-hour supervision, to keep an eye on Justice Involved Residents daily activities. PSO 2 stated the justice involved residents were not allowed to receive any visitors and mails, no telephone calls, and they were not allowed to eat in the facility's dining room. PSO 2 stated the justice involved residents can only eat inside their own rooms. During an interview on 10/18/22 at 9:35 AM, Licensed Vocational Nurse (LVN) 1 stated the Department of Public Health (DPH) surveyors were not allowed to go inside all justice involved residents' rooms due to Federal Law Enforcement policy. LVN 1 stated the DPH surveyors were not also allowed to check the justice involved resident electronic chart including the justice involved resident's name. LVN 1 stated all justice involved residents were on physical restraints, eat inside their rooms, not allowed to have visitors, receive mails and telephone calls. LVN 1 stated charge nurses give Justice Involved Residents medication but anything else, Justice Involved Residents need to talk and/or ask US Marshals On 10/18/2022 at 12:16 PM, the DON stated the DPH state surveyors were not allowed to access all justice involved residents' paper resident's records and physical charts without the Federal Law Enforcement Agency Supervisor's approval. During an interview on 10/18/22 at 2:42 PM, the Business Office Manager (BOM) stated all justice involved residents were not allowed to receive mails. BOM stated if she would receive the resident's mails, the BOM would notify the DON and ADM first, then give the mails to the PSOs. The BOM stated she does not go inside the justice involved residents' rooms, and when these residents need anything, they must talk to the PSOs. During an interview on 10/18/22 at 2:47 PM, the DON stated the DPH surveyors and ombudsman, including the justice involved resident's attorneys were not allowed to go inside the justice involved residents' room without Federal Law Enforcement Supervisor's permission. During the same interview, the DON stated the justice involved residents were not allowed to receive mails from the facility staff. The DON stated if the facility receives mails, the DON will give it to the Federal law Enforcement Supervisor who comes once a week (Thursdays). The DON stated if the facility receives the mail other than Thursday, the justice involved residents would need to wait until the next Thursday. The DON stated that PSOs were private security personnel, contracted by Federal Law Enforcement Agency. The DON stated the justice involved residents were not allowed to go to the facility's common areas and join other residents for safety reasons. The DON stated justice involved residents were only allowed to eat inside their rooms using only disposable spoons and containers. 1. A review of Resident 86's Face Sheet indicated an admission to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Face Sheet did not indicate a responsible party for Resident 86. A review of Resident 86's H&P dated 9/20/22 indicated the resident had the capacity to understand and make decisions. A review of Resident 86's MDS dated [DATE] indicated Resident 86 required limited assistance with transfers, toilet use and required total dependence (full staff performance every time during entire 7-day period) with dressing, required limited assistance with transfer and toilet use. The MDS indicated Resident 86 required supervision with bed mobility, eating and personal hygiene. A review of Resident 86's Resident Transfer Record dated 10/19/22 indicated Resident 86 as the Responsible Party ([RP]decision maker). During an observation outside Resident 86's room and interview with PSO 1 on 10/18/22 at 9:20 AM, PSO 1 stated the DPH surveyors were not allowed to go inside Resident 86's room without permission coming from Federal Law Enforcement Supervisor. PSO 1 stated justice involved residents were federal inmates and under the custody and property of the Federal Law Enforcement Agency. PSO 1 stated they were working as a private security contracted with Federal Law Enforcement Agency and need to stay with the justice involved residents at all times. 2. A review of Resident 87's Face Sheet indicated an admission to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Face Sheet did not indicate a responsible party for Resident 87. A review of Resident 87's undated H&P indicated the resident had the capacity to understand and make decisions. A review of Resident 87's MDS dated [DATE] indicated Resident 87 required limited assistance (resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight bearing assistance) with bed mobility, transfer, toilet use, personal hygiene and required supervision with dressing and eating. A review of Resident 87's Resident Transfer Record dated 10/19/22 indicated Resident 87 as the RP. On 10/18/22 at 9:26 AM, during an observation inside Resident 87's room and interview with PSO 2 in the presence of PSO 3 and Resident 87, PSO 2 stated that Resident 87's contact with the public was very limited. PSO 2 stated Resident 87 does everything inside Resident 87's room. PSO 2 stated Resident 87 was only allowed to go outside Resident 87's room during rehabilitation therapy. PSO 2 stated Resident 87 was handcuffed and shackled with steel iron chain connected to Resident 87's bed and the only time PSOs would disconnect the chain is when Resident 87 go to the bathroom, shower and during therapy. During an interview on 10/18/22 at 9:29 AM, Resident 87 stated he was not allowed to receive any visitors and mails. Resident 87 stated that telephone calls were not allowed. Resident 87 stated he was not allowed to go outside except during therapy and shower. 3. A review of Resident 79's Face Sheet (admission record) the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Face Sheet did not indicate a responsible party for Resident 79. A review of Resident 79's History and Physical (H&P) dated 6/15/22 indicated the resident had the capacity to understand and make decisions. A review of Resident 79's Minimum Data Set (MDS- a care area screening and assessment tool) dated 9/16/22 indicated Resident 79 required supervision (oversight, encouragement or cueing) during bed mobility, transfer, dressing, eating, toilet use and personal hygiene. A review of Resident 79's care plan for psychosocial dated 6/14/22 indicated Resident 79 had alterations in psychosocial functions as manifested by changes in roles/status/relocation and feeling of isolation from family and community friends with an intervention to encourage loved ones to visit/telephone/write if possible and to encourage to participate, attend activities of choice There was no documented evidence from the resident's records that from 6/14/22 to 10/19/22 indicating interventions were implemented in accordance with Resident 79's care plan such as encouraging loved ones to visit/telephone/write and encouraging Resident 79 to participate, attend activities of choice. A review of Resident 79's Resident Transfer Record dated 10/19/22 indicated Resident 79 as the RP. 4. A review of Resident 40's Face Sheet indicated the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Face Sheet did not indicate a responsible party for Resident 40. A review of Resident 40's H&P dated 8/31/22 indicated the resident had the capacity to understand and make decisions. A review of Resident 40's MDS dated [DATE] indicated Resident 40 required limited assistance (resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight bearing assistance) with bed mobility, transfer, dressing, toilet use, personal hygiene and required supervision during eating. A review of Resident 40's care plan for Activities of Daily Living (ADL) dated 8/1/22 indicated Resident 40 had self-care deficits related to unsteady gait and weakness with an intervention to maintain Resident 40's privacy and respect their rights. A review of Resident 40's Resident Transfer Record dated 10/19/22 indicated Resident 40 as the RP. 5. A review of Resident 292's Face Sheet indicated the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Face Sheet did not indicate a responsible party for Resident 292. A review of Resident 292's H&P dated 10/13/22 indicated the resident had the capacity to understand and make decisions. 6. A review of Resident 14's Face Sheet indicated an admission to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Face Sheet did not indicate a responsible party for Resident 14. A review of Resident 14's H&P dated 8/31/22 indicated the resident has the capacity to understand and make decisions. A review of Resident 14's MDS dated [DATE] indicated Resident 14 required extensive assistance (resident involved in activity, staff provide weight-bearing support) with bed mobility, transfer, dressing, toilet use, personal hygiene and required supervision during eating. A review of Resident 14's care plan for depression dated 8/20/22 indicated Resident 14 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 14's care plan for psychosocial dated 8/20/22 indicated Resident 14 had alterations in psychosocial functions as manifested by changes in roles/status/relocation and feeling of isolation from family and community friends. The care plan interventions indicated to provide emotional support/encourage expression of feelings, redirect behavior, utilize active listening techniques, encourage to verbalize feelings and concerns. From 8/20/22 to 10/19/22 there were no documented evidence indicating interventions were implemented in accordance with the resident's care plan that indicated Resident 14's family/friends were encouraged to visit, activities of choice were offered to avoid decline in psychosocial functions. A review of Resident 14's Resident Transfer Record dated 10/19/22 indicated Resident 292 as the RP. 7. A review of Resident 42's Face Sheet indicated the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Face Sheet did not indicate a responsible party for Resident 42. A review of Resident 42's H&P dated 5/10/22 indicated the resident had the capacity to understand and make decisions. A review of Resident 42's MDS dated [DATE] indicated Resident 42 required supervision with bed mobility, transfer, dressing, eating, toilet use and personal hygiene. A review of Resident 42's care plan for psychosocial dated 8/22/22 indicated Resident 42 had alterations in psychosocial functions as manifested by changes in roles/status/relocation and feeling of isolation from family and community friends. There was no care plan developed specific for the resident's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] A review of Resident 42's Resident Transfer Record dated 10/19/22 indicated Resident 42 as the RP. 8. A review of Resident 342's Face Sheet indicated an initial admission to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Face Sheet did not indicate a responsible party for Resident 342. A review of Resident 342's H&P dated 10/13/22 indicated the resident had the capacity to understand and make decisions. A review of Resident 342's care plan for [CONDITION(S)] medication dated 10/14/22 indicated Resident 342 required the use of psychoactive medication with an intervention to encourage family visits. There was no documentation from 10/14/22 to 10/19/22 indicating interventions were implemented in accordance with Resident 342's care plan such as respecting 342's rights and encouraging family visits. A review of Resident 342's Resident Transfer Record dated 10/19/22 indicated Resident 342 as the RP. 9. A review of Resident 76's Face Sheet indicated an initial admission to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Face Sheet did not indicate a responsible party for Resident 76. A review of Resident 76's H&P dated 10/13/22, indicated the resident had the capacity to understand and make decisions. A review of Resident 76's MDS dated [DATE] indicated Resident 76 required supervision with bed mobility, transfer, dressing, toilet use, and personal hygiene. A review of Resident 76's Resident Transfer Record dated 10/19/22 indicated Resident 76 as the RP. During an interview on 10/18/22 at 9 AM, PSO 6 stated that DPH state surveyors cannot enter the justice involved resident's rooms and would not answer any more questions about the justice involved residents. During an interview with PSO 1, on 10/18/22 at 9:20 AM, PSO 1 stated for all the other needs of the justice involved residents, the facility staff need to go through the Federal Law Enforcement Agency approval which included visitations, receiving mails, activities, and other special requests. A review of facility's Resident Council Minutes from the month of June 2022 to October 2022 indicated there were no justice involved residents' attendees during the facility's Resident Council Meetings. During an interview on 10/18/22 at 2:51 PM, Activities Director (AD) stated all justice involved residents were not allowed to go to the facility's Dining and Activity Room. The AD stated justice involved residents were not allowed to have visitors, receive mails and phone calls. The AD stated in the past (not able to remember when and who the resident was), one of the justice involved residents received a telephone call but the PSOs denied their right to take the phone call. The AD stated justice involved residents were not offered and allowed to join the facility's Resident Council Meeting. The AD stated she asked the Federal Law Enforcement agent what the justice involved residents can do aside from watching TV inside their rooms, and the response AD received was nothing (no other activities). The AD stated activity staff would need to obtain approval from the PSOs if the Justice Involved resident asks for basic items such as toothpaste. During an observation on 10/18/22 between the hours of 8:23 AM to 5 PM, all justice involved residents were observed inside their rooms with their doors closed with two security personnel (Federal Law Enforcement agent or PSOs) watching and monitoring each resident. The nine justice involved residents were not observed coming outside their rooms or going inside the facility's Dining and Activity Rooms. During an interview on 10/19/22 at 7:02 AM, Certified Nurse Assistant (CNA) 1 stated all justice involved residents were not allowed to have visitors except their attorneys. CNA 1 stated all justice involved residents eat inside their rooms and only allowed to use disposable utensils and dishware. CNA 1 stated all justice involved residents were not allowed to smoke. CNA 1 stated justice involved residents cannot have razors and clippers thus, staff need to ask permission from the PSOs before grooming the resident. CNA 1 further stated that facility staff cannot give personal items directly to the justice involved residents. On 10/19/22 at 9:43 AM, during a concurrent interview of the ADM and review of the memorandum provided by the Federal Law Enforcement Agency to the facility titled, Policy and procedures for inmates in nursing home facilities dated 8/20/21 the ADM stated the memo from Deputy of the Federal Law Enforcement served as a resource for the facility staff. The ADM stated the facility has their own justice involved residents' policy, and whenever they develop policies, the facility needed resources. The ADM stated justice involved residents can exercise rights, but restricted and required an approval from the Deputy Representative of the Federal Law Enforcement Agency. A review the facility's policy and procedure titled Residents Involved with the Criminal Justice System (no date), indicated the following: - Clients (Inmates [residents of the facility]) who are residing in a nursing home facility are not allowed any outside food, clothing or any other item that is not medically necessary unless it is pre-approved by (Federal Law Enforcement Agency). - Every client (inmate) that resides in a nursing home facility will be always accompanied by security staff (24 hours). - Clients (inmates) are allowed phone calls only when pre-approved by (Federal Law Enforcement Agency). Calls will be initiated and monitored by security staff onsite. - Clients (inmates) are not allowed to have family visitations or phone calls. If unannounced visitor arrives, notify (Federal Law Enforcement Agency) immediately. - For a client (inmate) to participate in an extra activity, it must be pre-approved by the (Federal Law Enforcement Agency). Clients will not be able to participate in any activity which involved non-custodial (a person found guilty of a crime or offense and punishment does not involve going to prison) members of the Skilled Nursing Facility. During an interview on 10/19/22 at 9:43 AM and concurrent interview of the facility's undated facility's policy and procedure titled Residents Involved with the Criminal Justice System, the ADM stated the undated policy was developed by the facility around September 2022 and used the Federal Law Enforcement Agency Memorandum provided by the Federal Law Enforcement Supervisor titled, Policy and procedures for inmates in nursing home facilities dated 8/20/21 as the facility's policy reference. During an interview on 10/19/22 at 3:39 PM, the DON stated that DPH state surveyors were still not allowed to interview and review all the medical records of the nine justice involved residents per the Federal Law Enforcement Agency Supervisor's instruction. During a conference meeting via TEAMS (allows users to communicate via text, chat, voice or video call from home or office) on 10/20/22 at 10:10 AM, attended by Los Angeles County Department of Public Health (LAC-DPH) Health Facilities Investigation Division (HFID) supervision team, the facility's ADM, DON, VPO, Quality Assurance Consultant (QA Consultant) and MKD. The VPO stated the DPH state surveyors were not allowed to access the justice involved resident's medical records since the residents were discharged from the facility on 10/19/22 and will not be coming back. The VPO stated the facility was trying to discuss with the Federal Law Enforcement Supervisor to allow the DPH state surveyors to continue to review and release the medical records of the nine justice involved residents with the Federal Law Enforcement Agency Supervisor. A review of another policy and procedure for justice involved residents provided by the facility titled Residents Involved with the Criminal Justice System, revised in March 2019 indicated, Residents involved in the justice system are entitled to the same rights as all other residents in the facility. The facility does not impose any restrictions on justice-involved residents that violate their resident rights. The P&P also indicated the following: a. All residents, including justice-involved residents, have the right to a dignified existence, self-determination, communication and access to persons and services inside and outside the facility. b. Justice involved residents include residents under the care of (taken into custody by) law enforcement c. Law enforcement jurisdiction is not integrated with facility operations. This facility maintains control over the conditions under which the resident receives care. A review of the facility's policy and procedure titled Residents Rights revised in December 2016, indicated Federal and state laws guarantee certain basic rights to all residents of this facility. These rights included the resident's right to: a. Be treated with respect and existence. b. Be free from corporal punishment or involuntary seclusion, and physical or chemical restraints not required to treat the resident's symptoms. c. Communication with and access to people and services, both inside and outside the facility. d. Exercise his or her rights as a resident of the facility and as a resident or citizen of the United States. e. Be supported by the facility in exercising his or her rights. f. Exercise his or her rights without interference, coercion, discrimination or reprisal from the facility. g. Communicates with outside

Based on observation, interview and record review, the facility failed to ensure that nine out of nine (Residents 79, 40, 292, 14, 42, 342, 87, 76, and 86) justice involved residents (residents currently in custody and held involuntarily through operation of law enforcement authorities in an institution, which is the responsibility of a governmental unit or over which a governmental unit exercises administrative control) residing in the facility were free from physical restraints with a locking device (any device attached or adjacent to the body that cannot be easily removed and restricts freedom of movement) for the purpose of discipline and not required to treat the resident's medical condition. There was no physician's order, medical justification, and reevaluation for continued use of the physical restraints used on all nine residents. These deficient practices resulted in Residents 79, 40, 292, 14, 42, 342, 87, 76, and 86's rights being violated, held against each resident's will, and had the potential to result in serious physical injury, and psychosocial harm that may lead to hospitalization and/or death. On 10/19/22 at 12:38 PM, during the facility's annual health recertification survey, the Department of Public Health (DPH) called an Immediate Jeopardy (IJ-a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident), in regard to nine (9) justice involved residents residing in the facility that were physically restrained with a locking device as directed by a Federal Law Enforcement Agency, in the presence of the Administrator (ADM) and Director of Nursing (DON). On 10/20/22 at 6:10 PM, the Department of Public Health removed the IJ while onsite after the surveyor verified the facility implemented the facility's IJ Removal Plan (a detailed plan to address the IJ findings) given by the ADM which included: 1. On 10/19/22, the nine Justice involved Residents were interviewed by the Director of Nursing (DON), Activity Staff, and Social Services Director (SSD) regarding their care, how staff treats them, and if they have experienced any adverse psychosocial effect as a result. Per interview with the nine residents, none were identified to be affected. 2. On 10/19/22, treatment nurses conducted body/skin assessments on all nine residents and no skin breakdown/impairment had results from the use of locking device. 3. On 10/19/22, the Administrator (ADM) was provided in-service education and training from the [NAME] President of Operations (VPO) regarding facility's policy and procedure regarding, but not limited to, Restraints. 4.On 10/19/22, all nine justice involved residents were transferred to acute hospital because the facility cannot meet the residents' needs, particularly being free from physical restraints with a locking device. 5.On 10/20/22, the DON followed up with the nine justice involved residents' attending physician at the acute hospital and physician informed that all nine residents are stable and doing well. All nine residents are still in the acute hospital. The Responsible Party (RP) of all nine residents are still working on proper placement with facilities that they work with. Cross referenced to F550. Findings: A review of a formal referral letter from the long-term care ombudsman dated 10/14/22, indicated the OMB (OMB; an individual who advocates for long-term care facility residents, defends their rights, and ensures they are protected from verbal abuse, neglect, and assault) was at the facility on 10/11/22. The letter indicated the OMB was not allowed to see or interview the nine justice involved residents in their rooms. The letter indicated that the DON stated the facility had been instructed to follow a different set of rules and were told that the justice involved residents did not have the same rights as all other residents in the facility. The letter indicated that on 10/12/22, the OMB spoke to the Federal Law Enforcement Supervisor and explained to the OMB that the justice involved residents were supervised by the Federal Law Enforcement while in the facility. The letter indicated that the Federal Law Enforcement Supervisor informed the OMB that the justice involved residents residing in the facility have all the rights to keep them alive. The letter indicated the justice involved residents were not allowed to have phone calls, outside snacks, were not allowed to walk around the facility and have visitors without the Federal Law Enforcement Supervisor permission. The letter indicated that on 10/12/22, the facility's administrator shared with the OMB that the facility was following a separate protocol (policy) for the justice involved residents according to the facility's corporate guidance and the Federal Law Enforcement Agency. A review of a Memorandum (a short note designating something to be remembered, especially something to be done or acted upon in the future) addressed to the facility and the facility's Marketing Director (MKD), titled Policy and Procedures for Inmates in Nursing Home Facilities, dated 8/20/2021, signed by the Federal Law Enforcement Deputy and written in the Federal Law Enforcement letterhead indicated, Every client (inmate) that resides in a nursing home facility will be always accompanied by security staff (24 hours). During the facility's initial tour and observation at the facility's hallway on 10/18/22 at 8:05 AM, and a concurrent interview with Private Security Officer (PSO) 4, stated that all justice involved residents were always chained to the bed, with either handcuffs or [NAME] (something that confines the legs or arms; one of a pair of metal rings connected by a chain and fastened to a person's wrists or the bottoms of the legs to prevent the person from escaping), except when these residents are going for physical therapy (PT-evaluate and treat abnormal physical function related to an injury, disability, or other health condition to improve residents' range of movement, quality of life and prevent further injury or disability) or to the bathroom. During an interview on 10/18/22 at 8:10 AM, PSO 5 stated all justice involved residents were physically restrained to their beds. On 10/18/22 at 8:32 AM, during the initial tour of the facility, concurrent interview and review of the facility's residents census dated 10/17/22 with the DON, the DON stated the facility had 92 residents residing in the facility. The DON stated Residents 79, 40, 292, 14, 42, 342, 87, 76, and 86 were under a fictitious (not real or true) name to protect the resident's identity and for confidentiality. The DON stated Residents 79, 40, 292, 14, 42, 342, 87, 76, and 86 admitted in the facility were all justice involved residents. On 10/18/2022 at 9:26 AM, PSO 2 stated that two PSOs were assigned to supervise each of the nine justice involved residents in the facility. PSO 2 stated there were three working shifts per day, 8 hours per shift. PSO 2 stated justice involved residents needs 24-hour supervision, to keep an eye on justice involved residents' daily activities. PSO 2 stated all nine justice involved residents were restrained to the bed. On 10/18/2022 at 12:16 PM, the DON stated the DPH state surveyors were not allowed to access all justice involved residents' paper resident's records and physical charts without the Federal Law Enforcement Agency Supervisor's approval. 1. During an observation on 10/18/22 at 8:35 AM, Resident 86's room door was open, and Resident 86 was visible from outside the residents' room. Resident 86 was observed with a right-handcuff restraint attached to the bed. During an interview on 10/18/22 at 9:20 AM, while outside Resident 86's room, PSO 1 stated all justice involved residents walk around in the facility accompanied by two PSOs when they go to physical therapy. PSO 1 stated all justice involved residents were restrained to their bed with hand cuffs two metal rings, joined by a short chain, that are locked around wrist(s) to prevent free movement. PSO 1 stated every justice involved residents were different when it comes to the number of hand cuffs is applied. PSO 1 stated he was not allowed to tell the DPH state surveyors on how many handcuffs Resident 86 had. A review of Resident 86's Face Sheet (admission record) indicated the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 86's History and Physical (H&P) dated 9/20/22 indicated the resident had the capacity to understand and make decisions. A review of Resident 86's Minimum Data Set (MDS- a care area screening and assessment tool) dated 9/21/22 indicated Resident 86 required limited assistance with transfers, toilet use and required total dependence (full staff performance every time during entire 7-day period) with dressing, required limited assistance with transfer and toilet use. The MDS indicated Resident 86 required supervision with bed mobility, eating and personal hygiene. A review of Resident 86's Physician's Orders for the month of October 2022, indicated there were no physician orders for the use of physical restraints while in the facility. A review of Resident 86's care plan for restraints dated 10/14/22 indicated Resident 86 was at risk for injury and needs physical restraint due to the [Federal Law Enforcement Agency] policy with the following interventions: 1. Apply restraint per [Federal Law Enforcement Agency] policy, 2. [NAME] per [Federal Law Enforcement Agency] policy and 3. Hand cuffs per [Federal Law Enforcement Agency] policy. On 10/18/22 at 12:33 PM, during a concurrent interview and record review of Resident 86's medical records (nurses notes, care plans, progress notes, medication administration records), the DON stated there were no documented evidence of ongoing monitoring and reevaluation for the continued use of restraints for Resident 86. 2. A review of Resident 79's Face Sheet indicated the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 79's History and Physical (H&P) dated 6/15/22 indicated the resident had the capacity to understand and make decisions. A review of Resident 79's MDS dated [DATE] indicated Resident 79 required supervision (oversight, encouragement, or cueing) during bed mobility, transfer, dressing, eating, toilet use and personal hygiene. A review of Resident 79's Physician's Orders for the month of October 2022, indicated there were no physician orders for the use of physical restraints while in the facility. A review of Resident 79's care plan for restraints dated 10/14/22 indicated Resident 79 was at risk for injury and needs physical restraint due to [Federal Law Enforcement Agency] policy with the following interventions: 1. Apply restraint per [Federal Law Enforcement Agency] policy, 2. [NAME] per [Federal Law Enforcement Agency] policy and 3. Hand cuffs per [Federal Law Enforcement Agency] policy. On 10/18/22 at 12:33 PM, during a concurrent interview and record review of Resident 79's medical records (nurses notes, care plans, progress notes, medication administration records), the DON stated there were no documented evidence of ongoing monitoring and reevaluation for the continued use of restraints for Resident 79. 3. A review of Resident 87's Face Sheet indicated an admission to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A review of Resident 87's undated H&P indicated the resident had the capacity to understand and make decisions. A review of Resident 87's MDS dated [DATE] indicated Resident 42 required limited assistance (resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight bearing assistance) with bed mobility, transfer, toilet use, personal hygiene and required supervision with dressing and eating. A review of Resident 87's MDS dated [DATE] indicated Resident 42 required limited assistance (resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight bearing assistance) with bed mobility, transfer, toilet use, personal hygiene and required supervision with dressing and eating. A review of Resident 87's Physician's Orders for the month of October 2022, indicated there were no physician orders for the use of physical restraints while in the facility. A review of Resident 87's care plan for restraints dated 10/14/22 indicated Resident 87 was at risk for injury and needs physical restraint due to [Federal Law Enforcement Agency] policy with the following interventions: 1. Apply restraint per [Federal Law Enforcement Agency] policy, 2. [NAME] per [Federal Law Enforcement Agency] policy and 3. Hand cuffs per [Federal Law Enforcement Agency] policy. On 10/18/22 at 9:26 AM, during a concurrent observation and interview with PSO 2, in the presence of PSO 3, Resident 87 was lying on his bed with a metal locking leg cuffs applied to both legs and secured to the foot part of the bed. PSO 2 stated Resident 87 was restrained on both legs with steel iron chain that is secured to the bed. PSO 2 stated justice involved residents wears handcuffs but since Resident 87 was very fragile, they do not apply it to Resident 87 all the time. PSO 2 stated they would remove both physical restraints to both legs during Resident 87's shower, toileting, and physical therapy. On 10/18/22 at 12:33 PM, during a concurrent interview and record review of Resident 87's medical records (nurses notes, care plans, progress notes, medication administration records), the DON stated there were no documented evidence of ongoing monitoring and reevaluation for the continued use of restraints for Resident 87. 4. A review of Resident 40's Face Sheet indicated an admission to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 40's H&P dated 8/31/22 indicated the resident had the capacity to understand and make decisions. A review of Resident 40's MDS dated [DATE] indicated Resident 40 required limited assistance with bed mobility, transfer, dressing, toilet use, personal hygiene and required supervision during eating. A review of Resident 40's Physician's Orders for the month of October 2022, indicated there were no physician orders for the use of physical restraints while in the facility. A review of Resident 40's care plan for physical device dated 8/1/22 indicated Resident 40 has handcuffs when in bed and out of bed with an intervention to review need for device. restraint possible discontinuation, reduction, less restrictive measures, or continuation of use regularly. A review of Resident 40's care plan for restraints dated 10/14/22 indicated Resident 40 was at risk for injury and needs physical restraint due to [Federal Law Enforcement Agency] policy with the following interventions: 1. Apply restraint per [Federal Law Enforcement Agency] policy, 2. [NAME] per [Federal Law Enforcement Agency] and 3. Hand cuffs per [Federal Law Enforcement Agency] policy. On 10/18/22 at 12:33 PM, during a concurrent interview and record review of Resident 40's medical records (nurses notes, care plans, progress notes, medication administration records), the DON stated there were no documented evidence of ongoing monitoring and reevaluation for the continued use of restraints for Resident 40. 5. A review of Resident 292's Face Sheet indicated an admission to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 292's H&P dated 10/13/22 indicated the resident had the capacity to understand and make decisions A review of Resident 292's Physician's Orders for the month of October 2022, indicated there were no physician orders for the use of physical restraints while in the facility. A review of Resident 292's care plan for restraints dated 10/14/22 indicated Resident 292 was at risk for injury and needs physical restraint due to [Federal Law Enforcement Agency] policy with the following interventions: 1. Apply restraint per [Federal Law Enforcement Agency] policy, 2. [NAME] per [Federal Law Enforcement Agency] policy and 3. Hand cuffs per [Federal Law Enforcement Agency] policy. On 10/18/22 at 12:33 PM, during a concurrent interview and record review of Resident 292's medical records (nurses notes, care plans, progress notes, medication administration records), the DON stated there were no documented evidence of ongoing monitoring and reevaluation for the continued use of restraints for Resident 292. 6. A review of Resident 14's Face Sheet indicated an admission to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .) A review of Resident 14's H&P dated 8/31/22 indicated the resident has the capacity to understand and make decisions. A review of Resident 14's MDS dated [DATE] indicated Resident 40 required extensive assistance (resident involved in activity, staff provide weight-bearing support) with bed mobility, transfer, dressing, toilet use, personal hygiene and required supervision during eating. A review of Resident 14's Physician's Orders for the month of October 2022, indicated there were no physician orders for the use of physical restraints while in the facility. A review of Resident 14's care plan for restraints dated 10/14/22 indicated Resident 14 was at risk for injury and needs physical restraint due to [Federal Law Enforcement Agency] policy with the following interventions: 1. Apply restraint per [Federal Law Enforcement Agency] policy, 2. [NAME] per [Federal Law Enforcement Agency] policy and 3. Hand cuffs per [Federal Law Enforcement Agency] policy. On 10/18/22 at 12:33 PM, during a concurrent interview and record review of Resident 14's medical records (nurses notes, care plans, progress notes, medication administration records), the DON stated there were no documented evidence of ongoing monitoring and reevaluation for the continued use of restraints for Resident 14. 7. A review of Resident 42's Face Sheet indicated an initial admission to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 42's H&P dated 5/10/22 indicated the resident had the capacity to understand and make decisions. A review of Resident 42's MDS dated [DATE] indicated Resident 42 required supervision with bed mobility, transfer, dressing, eating, toilet use and personal hygiene. A review of Resident 42's Physician's Orders for the month of October 2022, indicated there were no physician orders for the use of physical restraints while in the facility. A review of Resident 42's care plan for restraints dated 10/14/22 indicated Resident 42 was at risk for injury and needs physical restraint due to [Federal Law Enforcement Agency] policy with the following interventions: 1. Apply restraint per [Federal Law Enforcement Agency] policy, 2. [NAME] per [Federal Law Enforcement Agency] policy and 3. Hand cuffs per [Federal Law Enforcement Agency] policy. During an interview on 10/18/22 at 8 AM in the presence of three (3) PSOs, Resident 42 stated that his attending physician (AP) 1 ordered for Resident 42 to be chained to the bed. Resident 42 stated the reason why he was not chained to the bed that time was because he was going to an outside appointment. Resident 42 stated he was always chained on bed and the PSOs will remove it during physical therapy and bathroom breaks. On 10/18/22 at 12:33 PM, during a concurrent interview and record review of Resident 42's medical records (nurses notes, care plans, progress notes, medication administration records), the DON stated there were no documented evidence of ongoing monitoring and reevaluation for the continued use of restraints for Resident 42. 8. A review of Resident 342's Face Sheet indicated an initial admission to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 342's H&P dated 10/13/22 indicated the resident had the capacity to understand and make decisions. A review of Resident 342's Physician's Orders for the month of October 2022, indicated there were no physician orders for the use of physical restraints while in the facility. A review of Resident 342's care plan for restraints dated 10/14/22 indicated Resident 342 was at risk for injury and needs physical restraint due to [Federal Law Enforcement Agency] policy with the following interventions: 1. Apply restraint per [Federal Law Enforcement Agency] policy, 2. [NAME] per [Federal Law Enforcement Agency] policy and 3. Hand cuffs per [Federal Law Enforcement Agency] policy. A review of Resident 342's care plan for [CONDITION(S)] medication dated 10/14/22 indicated Resident 342 requires the use of psychoactive medication with an intervention to encourage family visits. On 10/18/22 at 12:33 PM, during a concurrent interview and record review of Resident 342's medical records (nurses notes, care plans, progress notes, medication administration records), the DON stated there were no documented evidence of ongoing monitoring and reevaluation for the continued use of restraints for Resident 342. 9. A review of Resident 76's Face Sheet indicated an initial admission to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 76's H&P dated 10/13/22, indicated the resident had the capacity to understand and make decisions. A review of Resident 76's MDS dated [DATE] indicated Resident 76 required supervision with bed mobility, transfer, dressing, toilet use, and personal hygiene. A review of Resident 76's Physician's Orders for the month of October 2022, indicated there were no physician orders for the use of physical restraints while in the facility. A review of Resident 76's care plan for restraints dated 10/14/22 indicated Resident 76 was at risk for injury and needs physical restraint due to [Federal Law Enforcement Agency] policy with the following interventions: 1. Apply restraint per [Federal Law Enforcement Agency] policy, 2. [NAME] per [Federal Law Enforcement Agency] policy and 3. Hand cuffs per [Federal Law Enforcement Agency] policy. On 10/18/22 at 12:33 PM, during a concurrent interview and record review of Resident 76's medical records (nurses notes, care plans, progress notes, medication administration records), the DON stated there were no documented evidence of ongoing monitoring and reevaluation for the continued use of restraints for Resident 76. During an interview on 10/18/22 at 9:35 AM, Licensed Vocational Nurse (LVN) 1 stated the DPH surveyors were not allowed to go inside all justice involved residents' rooms due to Federal Law Enforcement policy. LVN 1 stated all justice involved residents were on physical restraints, eat inside their rooms, not allowed to have visitors . During an interview on 10/18/22 at 9:35 AM, LVN 2 stated justice involved residents were all restrained with physical restraints. LVN 2 stated all justice involved residents need to be always restrained for the safety of other residents and facility staff. LVN 2 stated there were no clinical indication for the use of the physical restraints on the nine justice involved residents. On 10/18/22 at 12:16 PM, during a concurrent interview with the DON and record review of all justice involved residents' electronic medical records, the DON stated handcuffs, leg cuffs, and shackles were considered as physical restraints. The DON stated that application of physical restraints to all residents needs a physician's order. The DON stated she could not find physician orders for physical restraints use for all the nine justice involved residents' electronic medical records. During the same interview on 10/18/22 at 12:16 PM, the DON stated that physical restraints were applied to all justice involved residents, some in the arms, some in the legs. The DON stated the PSOs would rotate the sites of the physical restraints. The DON stated the physical restraints were chains, approximately two feet long attached to the resident's bed. The DON stated the restraints would be removed when justice involved residents would go to the bathroom. The DON stated that PSOs who were under contract with the Federal Law Enforcement Agency were the only persons that had access to remove the resident's physical restraints. The DON stated no one from the facility staff had access/and or keys to all the justice involved residents locked physical restraints. The DON stated all justice involved residents need physical restraints because They are inmates, they might run and do something, they are criminals. The DON stated upon review of the resident's records, there were no clinical indication for the use of physical restraints to all the justice involved residents. During a concurrent interview with the DON and record review of all nine-justice involved resident's physician orders, care plans, and MDS on 10/18/22 at 12:33 PM, the DON stated that physician orders, care plans and the MDS coding for physical restraints were only initiated and documented on 10/14/22 in the resident's paper medical records, which were a few days before the DPH state surveyors arrived in the facility on 10/18/22. During the same interview on 10/18/22 at 12:33 PM, the DON stated the facility did not consider the handcuffs, leg cuffs, and shackles as physical restraints upon admission of the justice involved residents in the facility. The DON stated the facility recently discussed that the facility would consider the handcuffs, leg cuffs, and shackles as physical restraints moving forward. The DON stated the physician's orders for physical restraints should be indicated and reflect in the electronic medical records of all the justice involved residents. During an interview on 10/19/22 at 7:02 AM, Certified Nurse Assistant (CNA) 1 stated facility staff do not have access or keys to all justice involved resident's locked physical restraints. CNA 1 stated the handcuffs' chain were long and all the justice involved residents can move around their beds, CNA 1 stated the PSOs removes the physical restraints during showers. During an interview on 10/19/22 at 7:11 AM, CNA 2 stated all justice involved residents have metal handcuffs and leg cuffs applied to them and attached to their beds. CNA 2 stated those physical devices were not considered as physical restraints since the residents could still move. CNA 2 stated the facility staff does not have keys to the locked physical restraints. CNA 2 stated justice involved residents wears the hand cuffs even when they are eating. During an interview on 10/19/22 at 7:22 AM, Treatment Nurse (TXN) 1 stated facility staff do not have keys to all justice involved residents including treatment and/or wound nurses. TXN 1 stated Resident 86 was handcuffed and shackled. TXN 1 stated Resident 87 was handcuffed. TXN 1 stated she does not see all justice involved residents regularly if there are no wound/skin issues. TXN 1 stated We do not do such thing and most justice involved residents were alert and able to verbally report to the staff if they have skin problems and issues caused by physical restraints. TXN 1 stated there were no order for regular skin monitoring or evaluation of skin breakdown for use of physical restraints. TXN 1 stated she could not find documented evidence of skin monitoring for physical restraints use in the Treatment Administration Records (TAR) for the nine justice involved residents. A review of an undated policy and procedure titled Residents Involved with the Criminal Justice System that was provided by the ADM, indicated All residents, including justice-involved residents, have the right to dignified existence, self-determination, and will be provided provisions that are clinically necessary. The policy indicated that Law enforcement jurisdiction and facility operations maintain control over the conditions under which the resident receives care. The policy indicated that If a justice-involved individual is admitted , the following measures are taken: a.Reviewing the medical records and other pertinent documentation from correctional providers. b.Conducting a comprehensive assessment and resident centered care plan by the interdisciplinary team. c.Ensuring that the safety, rights, and quality of care are maintained for all residents and staff. The policy did not indicate the use of physical restraints such as handcuffs and shackles. On 10/19/22 at 9:43 AM, during a concurrent interview and record review of the facility's undated policy and procedure titled Residents Involved with the Criminal Justice System the ADM stated physical restraints were not mentioned in the facility's policy and procedure. A review of facility's policy and procedure titled Use of Restraints revised in April 2017, indicated Restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. Restraints should only be used to treat the resident's medical symptoms(s) and never for discipline or staff convenience, or for the prevention of falls. When the use of restraints is indicated, the least[TRUNCATED]

Based on observation, interview and record review, the facility failed to immediately implement measures and appropriate corrective actions of a resident's allegation of abuse to Certified Nursing Assistant (CNA) 1 for one of three sampled residents (Resident 1) by failing to: 1. Initiate an investigation when Resident 1 informed Licensed Vocational Nurse (LVN) 1 and CNA 2 of an alleged sexual abuse to the facility's administrator and other officials from 6/2/22 to 6/3/22 when Resident 1 alleged CNA 1 touched the resident's breast/chest area and when CNA 1 asked Resident 1 to suck his dick (penis). 2. Complete a thorough investigation of the allegation when LVN 1 informed Resident 1 that the resident's sexual abuse allegation was a misunderstanding. 3. Protect Resident 1 from further potential abuse when CNA 1 was reassigned back to Resident 1, on 6/4/22, after Resident 1 made the first sexual abuse allegation to CNA 1 between 6/2/22 and 6/3/22. The facility reported the allegation of sexual abuse to the Department of Public Health on 6/7/22 (4 to 5 days after Resident 1 reported the allegations to LVN 1 and CNA 2 between 6/2/22 to 6/3/22) This deficient practice resulted in psychological distress for Resident 1 by being fearful of CNA 1, thinking that the alleged incident may happen again. Findings: A review of Resident 1's Face sheet (Admission Record) indicated the facility initially admitted Resident 1 to the facility on [DATE] and readmitted to the facility on [DATE]. Resident 1's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's History and Physical dated 9/9/21, indicated Resident 1 had fluctuating capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS, a standardized resident assessment and care-planning tool)), a standardized care screening and assessment tool, dated 3/24/22, indicated Resident 1's cognition (thought process) as moderately impaired. The MDS indicated Resident 1 did not exhibit any physical behavioral symptoms directed towards others (e.g, hitting, kicking, pushing, scratching, grabbing, abusing others sexually) or verbal behavioral symptoms directed towards others (e.g, threatening others, screaming at other, cursing at others). The MDS did not indicate any mood problems for Resident 1. The MDS indicated Resident 1 required one-person extensive((means that the individual would not be able to perform or complete the activity of daily living (ADL) without another person to aid in performing the complete task, by providing weight-bearing assistance) physical assistance for bed mobility, transfers, locomotion, dressing, toilet use, and personal hygiene. The MDS indicated Resident 1 could not walk. A review of the Nursing Staffing Assignment and Sign-in Sheet dated 6/2/22, indicated CNA 1 was assigned in Resident 1's room, to provide care for Resident 1's roommate, on 6/2/22 during the 11 P.M. to 7 A.M. shift. A review of Nursing Staffing Assignment and Sign-in Sheet dated 6/4/22 indicated CNA 1 was assigned back to Resident 1's room, provide care for Resident 1, on 6/4/22 during the 11 P.M. to 7 A.M. shift. A review of a Fax transmittal report submitted to the department submitted to the department on 6/7/22 indicated the facility reported an incident of alleged sexual abuse by Certified Nursing Assistant (CNA 1) towards Resident 1. A review of Resident 1's Departmental Notes dated 6/7/22, indicated the Social Services Director (SSD) received a phone call from the Resident 1's family member (Family 1). Family 1 asked about the incident that happened to Resident 1. The Note indicated the SSD went to Resident 1's room on 6/7/22 at around 10:30 A.M. and Resident 1 informed the SSD that CNA 1 touched and asked Resident 1 to do inappropriate things. The Note indicated the SSD informed the Administrator (ADM) and the Director of Nursing (DON). The Note indicated the Police Department arrived at the facility and interviewed Resident 1. A review of Resident 1's Interdisciplinary Team (IDT; a group of health care professionals with various areas of expertise who work together toward the goals of their patients) conference record dated 6/7/22, indicated that on 6/7/22, the SSD received a phone call from Family 1 stating Family 1 spoke with Resident 1 and there was an incident that happened but did not know the details. The IDT note indicated Family 1 asked the SSD to speak with Resident 1 to find out the details about the incident and SSD went to Resident 1's room at around 10:30 A.M. The IDT note indicated Resident 1 stated that the CNA who was assigned to Resident 1 touched Resident 1 and asked Resident 1 to do inappropriate things. The IDT note indicated that SSD informed the administrator and the DON. The IDT note indicated the IDT members called Family 1 at 3:15 P.M. and informed Family 1 the details of the initial findings. A review of the facility document titled Witness statement/Interview, dated 6/7/22, indicated the Director of Staffing and Development (DSD) spoke to CNA 1 on 6/7/22 and asked the CNA if there was any incident that occurred with Resident 1. The document indicated CNA 1 responded that he was not aware of any incident that happened with Resident 1. A review of Resident 1's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The Progress Note indicated, I was asked to see the patient, he complained of sexual harassment by a CNA. Patient was well groomed and alert and oriented times 4 (someone who is alert and oriented to person, place, time and event). Resident 1 reported that a certain CNA touched his breast over the clothing and asked Resident 1 to suck his penis but did not took his penis out, but patient reported, he can't see it hard from under the CNA uniform (sic). Patient reported that he yelled at the CNA and it stopped. Patient reports that this happened last week but it also happened several times before, not sure how many . During an interview with the DON on 6/8/22 at 10:45 A.M., the DON stated Resident 1 reported Resident 1's allegation of sexual abuse on 6/7/22 at around 10:30 A.M. to the facility's SSD. The DON stated during the initial interview, Resident 1 described CNA 1 as the alleged staff that showed his private part and touched Resident 1's chest and breast area. During an observation and interview on 6/8/22 at 11:15 A.M., inside Resident 1's room, Resident 1 was observed awake and sitting in bed. Resident 1's left arm was observed to be weaker than his right arm. Resident 1's room was observed to have three beds and Resident 1's bed was situated at the end of the room next to the window with the privacy curtain drawn around his bed. Resident 1 stated CNA 1 came into the resident's room a week ago (unable to recall the exact date) during the night to change Resident 1's incontinence brief. Resident 1 stated CNA 1 then proceeded to touch his breast/chest area. Resident 1 stated CNA 1 pointed to his private area and told Resident 1 to suck his dick (penis). Resident 1 stated he told CNA 1 Don't do that to me, Resident 1 stated he told CNA 1 again No, and then CNA 1 left the room. Resident 1 stated he reported the incident to LVN 1 that same night (unable to recall the date). Resident 1 stated that when he told LVN 1 about the incident with CNA 1, LVN 1 told him Maybe you misunderstood him (CNA 1), there is no need to make a big deal about this. Let's understand each other. Resident 1 stated he told LVN 1 that what CNA 1 did was sexual harassment and inappropriate. Resident 1 stated he informed LVN 1 that he did not want CNA 1 assigned and providing care to him anymore. During a follow up interview on 6/8/22 at 1:38 P.M., Resident 1 stated the incident with CNA 1 made him feel scared that the sexual abuse might happen again. During a telephone interview with LVN 1 on 6/8/22 at 2:24 P.M., LVN 1 stated she was not sure of the exact date when Resident 1 reported the sexual abuse allegation to her. LVN 1 stated the sexual abuse allegation was reported by Resident 1 either on a Thursday (6/2/22) or a Sunday (6/5/22) during the night shift. LVN 1 stated Resident 1 reported that CNA 1 had touched his breast area. LVN 1 stated that during the night shift when Resident 1 first reported the incident, LVN 1 had talked to CNA 1 in front of Resident 1, inside the resident's room. LVN 1 stated that during that time, CNA 1 denied the sexual allegation in front of Resident 1. LVN 1 stated Resident 1 had asked him that he did not want CNA 1 assigned to him again. LVN 1 stated she did not report Resident 1's allegation to the administrator because LVN 1 did not think Resident 1's allegation was an abuse allegation. LVN 1 stated that thinking about the allegation now, LVN 1 stated that she should have reported Resident's 1 allegations to the Administrator or DON. During a telephone interview on 6/9/22 at 12:10 P.M., CNA 1 stated he could not recall the date but during the night shift LVN 1 told him Resident 1 had accused him of touching his chest area. CNA 1 stated that he told LVN 1 Why would I do that? CNA 1 stated CNA 1 would not touch Resident 1 unless he needed to change his incontinence briefs. CNA 1 stated he became aware that Resident 1 had made sexual abuse allegations about him from another CNA (CNA 2) on 6/3/22 during the change of shift, the next morning. CNA 1 stated that CNA 2 informed him that Resident 1 had made sexual abuse allegations against CNA 1. During a telephone interview on 6/15/22 at 4:15 P.M. with CNA 2, CNA 2 stated that a week ago (unable to recall exact date) while he gave Resident 1's morning breakfast tray, Resident 1 informed him that he had been sexually abused by CNA 1. CNA 2 stated that he did not respond to Resident 1 during that time, when Resident 1 reported his allegations to CNA 1. CNA 2 stated he was not interested in what Resident 1 had to say. CNA 2 stated he told Resident 1 he was busy and left Resident's 1 room. CNA 2 stated he told CNA 1 during the change of shift that day, to be careful with Resident 1 because Resident 1 informed him (CNA 2) that CNA 1 tried to sexually abuse him (Resident 1). CNA 2 stated he did not report Resident 1's allegation to anyone else other than CNA 1. On 7/13/22 at 3:38 P.M., during a telephone interview and concurrent record reviews of Resident 1's care plans and progress notes from 2/2022 to 7/2022 with DON 1, DON 1 stated she could not find documented evidence that Resident 1 had manifested inappropriate behaviors or making up stories in the facility's progress notes or care plans. During a telephone interview on 7/13/22 at 3:45 P.M., with the Administrator (ADM), the ADM stated he is the facility's abuse coordinator. The ADM stated if there was an allegation of abuse reported by a resident to any staff member it should be reported immediately and In my absence to the DON or the next highest authority, so that the facility can investigate. The ADM stated the facility follow the mandated reporting process and report all allegations of abuse within two hours. The ADM stated all facility staff should report all alleged violations of abuse, neglect, or mistreatment immediately. A review of the facility's policy and procedure titled, Abuse-Reporting and Investigations revised in November 2018, indicated The facility will report all allegations of abuse as required by law and regulations to the appropriate agencies within 2 hours. The facility promptly and thoroughly investigates reports of resident abuse, mistreatment, neglect, exploitation, misappropriation of resident property, or injuries of an unknown source when appropriate.

Based on observation, interview and record review the facility failed to ensure that one of three sampled residents (Resident 1) was free from significant medication error by failing to administer [MEDICATION(S)] (is a drug used to treat seizures [is a sudden, uncontrolled electrical disturbance in the brain, that can cause changes in behavior, movements and loss of consciousness (is a state of being awake and aware of one's surroundings]) 500 milligrams (mg) twice a day as indicated in the discharge medication instructions of the (General Acute Care Hospital [GACH] 1) upon admission to the skilled nursing facility starting 5/4/21, for three days (5/4/21 to 5/6/21). This deficient practice resulted in Resident 1 having a [CONDITION(S)] while in the facility, on 5/7/21 then transferred to the General Acute Care Hospital (GACH) for further evaluation and treatment. Findings: A review of the admission record indicated Resident 1 was admitted to the facility on [DATE] at 5:01 PM, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's General Acute Care Hospital (GACH) Emergency Department Discharge Summary Report dated 5/4/21 at 3:45 PM, indicated on the list of medication, Resident 1 was taking [MEDICATION(S)] 500 milligrams (mg, unit of measurement) 1 tablet by mouth twice a day. The GACH report indicated, to continue listed medications and no changes. A review of Resident 1's GACH Emergency Department Discharge Instruction dated 5/4/21 at 1:10 PM, indicated a hand off report was given to the charge nurse at the facility. A review of Resident 1's Nursing Notes, dated 5/4/21 at 5:12 PM, indicated that Resident 1 was admitted to the facility on [DATE] at 4:09 PM from the GACH. The note indicated that orders (not specified) were verified by the physician. A review of Resident 1's Care Plan for [CONDITION(S)] Disorder/[CONDITION(S)] dated 5/4/21, the care plan indicated one of the approach was to give medication as ordered, [MEDICATION(S)] (is a drug used to treat seizures by decreasing abnormal excitement in the brain) 500 milligram (mg, unit of measurement) tablet by mouth at bedtime. A review of the History and Physical Exam dated 5/6/21, indicated Resident had the capacity to understand and make decisions. A review of Resident 1's admission nursing assessment dated [DATE] at 6:20 PM, indicated Resident 1 arrived at the facility at 4:09 PM with the transfer records from the GACH. The Admission Nursing Assessment further indicated Resident 1 was able to verbalize needs and answer question appropriately. It indicated Resident 1 needs extensive assistance (resident involve in the activity, but staff provides weight- bearing support) from one person for bed mobility and dressing. A review of Resident 1's Physician's Telephone Orders dated 5/6/21 at 4:00 PM, indicated a medication order for [MEDICATION(S)] 500 mg one tablet by mouth daily at bedtime. A review of Resident 1's Nursing Notes dated 5/7/21 at 9:49 PM, indicated at 6:30 PM charge nurse observed Resident 1 having a [CONDITION(S)] that lasted for one (1) minute. The Nursing Note indicated, Resident 1 was in a side-lying position and Resident 1's head was being protected from hard surfaces and objects. The note indicated MD was notified with orders to transfer Resident 1 to the GACH and Resident 1 was transferred to GACH at 9:50 PM. A review of Resident 1's Situation, Background, Assessment and Recommendation (SBAR, is a tool is provided below to aid strengthening communication between nurses) Communication Form dated 5/7/21, indicated Resident 1 was being evaluated for [CONDITION(S)] that occurred at 6:40 PM and the MD was notified at 7:00 PM with orders to transfer Resident 1 to the GACH. A review of Resident 1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Nurse's notes dated 5/4/2021 to 5/6/2021, it did not indicate any reason why the [MEDICATION(S)] was not given. The Nurse's notes did not indicate a follow up or call has been made to Resident 1's attending physician the [MEDICATION(S)] was not given. During an observation and interview of Resident 1 in his room on 11/9/21 at 2:10 PM, Resident was currently resting, able to open eyes, noted a delayed response with a blank stare. Resident 1 was able to answer simple questions such as his own name and location. During the interview, Resident 1's speech was slow and garbled. During a telephone interview with the Director of Nursing (DON) on 12/21/21 at 1:33 PM, the DON stated when there was a new admission from the acute hospital, the admitting nurse would review the medication that the resident was taking from home or from the acute hospital. If the resident was discharged from the GACH, the admitting nurse from the facility would review the GACH discharge instructions and resident's medications list and inform the attending physician. The DON stated this way the facility would know what medications to order and what medication to change and continue in the facility. The DON stated, it was important to reconcile the medications with the facility's attending physician for Resident 1 so the resident can continue with his medications especially the important medications such as for his [CONDITION(S)]. During a telephone interview with the DON on 12/21/21 at 1:40 PM and review of Residents 1 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . DON was not able to answer why it was not given. The DON stated if an anti-[CONDITION(S)] medication has not been given for 3 days or more it was the reason why Resident 1 had [CONDITION(S)]. During a telephone interview with the Pharmacist (PH) on 12/24/21 at 11:36 AM, PH stated that the admitted orders were faxed and received from the facility only on 5/6/21 and none for 5/4/2021. The PH stated when they received orders from the facility they make sure to deliver it within 2 to 4 hours even if it's was received after office hours. During a telephone interview with the Registered Nurse (RN 1) on 12/24/21 at 1:19 PM, RN 1 stated new admission to the facility from the GACH have discharge instructions and a medication list. RN 1 stated after reviewing the medication list, they call their attending physician to clarify which medications to continue, to change or discontinue while in the facility. RN 1 stated after getting the orders from the attending physician, they send the order for the medications to the facility and they usually get it within two (2) to four (4) hours, if not they follow it up with the pharmacy to make sure we start the medication as ordered. During a telephone interview with RN 1 on 12/24/21 at 1:25 PM, RN1 stated it was the facility' process that if there was no medication list from resident's GACH discharge records to call the GACH to confirm the medications the resident was currently taking. RN 1 stated, if the medication was not given especially [CONDITION(S)] medications, the attending physician should have been notified. RN 1 stated, it was important for Resident 1 to continue and receive his routine medications (regularly taken to manage certain diseases) especially for [CONDITION(S)] to manage his condition and avoid complications. During a telephone interview with the DON on 12/28/21 at 8:59 AM, DON stated there was a discharge paper works received from GACH for Resident 1 but did not see the medication list. DON stated it was their policy if there was an admission to make sure to have accurate information especially with resident's medications. DON stated, admitting nurse could have called GACH to verify missing information such as medication list or verify with the resident. During a telephone interview with the DON on 12/28/21 at 9:10 AM, DON stated, she did not know why the admitting nurse did not call GACH to verify resident's medication list or they could have asked the resident knowing Resident 1 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . DON stated, it was not acceptable that the medication was not given from 5/4/2021 to 5/6/2021. DON stated, she did not find any documentation what the licensed nurses did like to follow up with GACH nor called the attending physician about [MEDICATION(S)] medication not given since admission. During a telephone interview with the DON on 12/28/21 at 1:57 PM and review of medication delivery receipt from Pharmacy (PY) dated 5/7/2021, the medication delivery receipt indicated Resident 1's [MEDICATION(S)] was delivered to the facility on [DATE] at 12:40 AM. The DON stated, Resident 1's [MEDICATION(S)] was delivered to the facility on [DATE] at 12:40 AM but it was not given to the resident right away. During a concurrent telephone interview with the DON on 12/28/21 at 2:05 PM and review of Resident 1's MAR for the month of 5/2021, the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated, it was not signed meaning it was not given on those dates. The DON stated, the licensed nurses should have informed the doctor to get an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . During a telephone interview with PH on 12/28/291 at 2:24 PM and review of the list of medications ordered sent via fax by the facility to the pharmacy on 5/6/2021, the fax date and time stamp in the order for [MEDICATION(S)] indicated 5/6/2921 at 9:47 PM. The PH stated, the date and time stamp in the fax order they received meant it was the date and time they have received the order from the facility. During a telephone interview with PH on 12/28/291 at 2:30 PM and review of medication delivery receipt from the Pharmacy (PY) dated 5/7/2021, the medication delivery receipt indicated Resident 1's [MEDICATION(S)] was delivered to the facility on [DATE] at 12:40 AM. A review of the facility's undated policy and procedure, titled Admission Policy reviewed 1/28/2021, indicated residents for admission are screened by admission coordinator based on faxed information from transferring facility or acute hospital. Licensed nurse obtain report from transferring facility or acute hospital through telephone and from documents sent. Licensed nurse will verify all order to the attending physician.

Based on interview and record review, the facility failed to provide pain management (the process of alleviating pain) for one of two sampled residents (Resident 1), including: 1. Failure to assess Resident 1's non-verbal scale of pain according to the facility's Pain Assessment form to provide an accurate pain assessment and appropriate interventions, on 8/4/2021 during the evening shift (3 PM to 11 PM), night shift (11 PM to 7 AM), and on 8/5/2021 during the morning shift (7 AM to 3 PM). Resident 1 sustained severe facial contusion (a trauma and bruise that appears on the face after an injury) after a fall from the bed to the floor, on 8/4/2021 at 10 PM when Certified Nurse Assistants (CNA) 1 and 2 turned and repositioned Resident 1 in bed, while the resident's bed sheet was being changed. 2. Failure to develop and implement an individualized pain care plan after the fall incident on 8/4/2021, to address and manage Resident 1's pain to the left side of the body and left leg from 8/4/2021 to 8/5/2021. 3. Failure to implement the facility's policy and procedure on Pain Assessment and Management, revised on March 2020, by not recognizing the presence of Resident 1's unrelieved pain, addressing the underlying causes of pain; monitoring for the effectiveness of the pain medication given, and modifying approaches as necessary. Resident 1 received pain medication on 8/4/2021 during the night shift, and on 8/5/2021 during the morning shift. Licensed Vocational Nurse (LVN) 2 did not recognize and notify Resident 1's attending physician (MD 1) of Resident 1's unrelieved pain and new onset of pain to the left side of the body after the last pain medication was administered on 8/4/2021 at 11:30 PM. No pain intervention was provided to Resident 1 from 11:31 PM to 8:29 AM (9 hours). Registered Nurse Supervisor (RNS) 1 did not recognize and notify MD 1 of Resident 1's unrelieved pain after the pain medication was administered on 8/5/2021 at 8:30 AM to 2:26 PM prior to Resident 1's transfer to the general acute care hospital (GACH) for evaluation after the fall, bump on the left eye, and pain on the left leg. This deficient practice resulted to Resident 1 moaning and complaining of pain during diaper changes and turning in bed on the night shift (8/4/2021) and dayshift (8/5/2021). As a result, Resident 1 was transferred to the General Acute Care Hospital (GACH) on 8/5/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 1 had an open reduction and internal fixation (ORIF- a type of surgery that is used to repair broken bones that need to be put back together) of the left hip on 8/10/2021. Cross reference with F580 and F689. Findings: A review of Resident 1's Face Sheet (admission record) indicated the resident was admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Risk for Pain Care Plan dated 12/18/2020 and reevaluated on 3/2021 and 6/2021, indicated Resident 1 was at risk for pain related to diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Risk for Pain care plan indicated staff interventions such as monitor for pain as needed, monitor for non-verbal signs and symptoms of pain such as facial grimacing, moaning, crying, restlessness, shortness of breath and grunting, administer medications as ordered. A review of Resident 1's Minimum Data Set (MDS, a standardized resident assessment and care screening tool), dated 6/18/2021, indicated the resident had moderately impaired cognition (thought process). The MDS indicated Resident 1 required extensive (resident involved in activity with staff providing weight-bearing support [taking the person's weight by holding]) one-person assistance during bed mobility, transfers, toilet use, dressing, and personal hygiene. A review of Resident 1's Situation, Background, Assessment, and Recommendation (SBAR; a technique used to facilitate prompt and appropriate communication) Communication Form (SBAR) written by LVN 1 on 8/4/2021 (no time), indicated Resident 1 fell on the floor while the CNAs were giving care to the resident on 8/4/2021. The SBAR form under Pain Evaluation indicated a check was marked indicating Resident 1 was in pain and a handwritten note indicated Aching pain. The Pain Evaluation in the SBAR form, indicated the specific areas that licensed nurses needed to specify to evaluate the pain such as the location, intensity, and non-verbal signs of pain [for residents with dementia] were left blank. The SBAR form indicated MD 1 was notified on 8/4/2021 at 10:17 PM. The Nursing Notes section in the SBAR form indicated LVN 1 assessed Resident 1 and noted Resident 1's left orbital (bony structure around the eye) redness. A review of Resident 1's Care Plan dated 8/4/2021, indicated Resident 1's concerns and problems of Actual incident of fall. The Resident Care Plan indicated Resident 1 Slipped off the bed to floor in her room and had a bump on the left eyebrow. The approach plan section indicated the approach plan included assessing Resident 1 after falling, check and assess Resident 1's joint mobility, presence of pain, level of comfort, and sustained injury. A review of Resident 1's recapped Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The Nurses Medication Notes in the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The Nurses Medication Notes indicated RNS 1 administered two tablets of acetaminophen 325 mg on 8/5/2021 at 8:30 AM. A review of Resident 1's Pain Assessment for August 2021, indicated the specific areas for licensed nurses to complete when assessing a resident's pain included verbal scale (no pain, mild pain, moderate pain, severe pain, and worst pain), non-verbal scale (no pain, least pain [stressed and tense expression], mild pain [guarded movement, grimacing], moderate pain [moaning, restless], and excruciating pain [increased intensity of above behavior]), site of pain, frequency of pain (none, occasional, intermittent, frequent, constant), relief after pain medication (no relief, minimal, moderate, and total relief), and sedation level. Resident 1's Pain Assessment after the fall indicated the following information: a. On 8/4/2021, during the evening shift (3 PM to 11 PM) (no specific time), indicated no pain under verbal scale. b. On 8/4/2021 to 8/5/2021, during the night shift (11 PM to 7 AM) (no specific time), indicated no pain under the verbal scale. c. On 8/5/2021, during the morning shift (7 AM to 3 PM) (no specific time), indicated mild pain under the verbal scale, site of pain indicated other, frequency of pain indicated occasional, relief after treatment indicated no relief. A review of Resident 1's Physician Telephone Order form dated 8/5/2021 timed at 10 AM, indicated MD 1's order to transfer Resident 1 to the GACH for medical treatment and further evaluation due to the fall, bump on the left eye, and pain on the left leg. A review of Resident 1's Patient Report for the left x-ray examination of the femur electronically signed by the interpreting physician on 8/5/2021 timed at 12:38 PM, indicated an acute intertrochanteric (between the trochanters [(bony prominences of the thighbone]) left hip fracture with proximal (situated close) migration (moved from another place) of the distal fracture (a medical term indicating a shortening of the overall bone length) fragment and apex varus angulation (a medical term used to denote to the inward angulation of the distal segment of a bone or a joint). A review of Resident 1's Progress Note dated 8/5/2021 timed at 2:26 PM, indicated Resident 1 was transferred to the GACH due to a fall. A review of the GACH's Emergency Department Medical (EDMD) General dated 8/5/2021 timed at 6:11 PM, indicated Resident 1 arrived from the facility after a fall the other day (8/4/2021) and complained of left hip pain since the fall. The EDMD General note indicated Resident 1's left eye was severely bruised and swollen shut. The EDMD tentative diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the GACH's Orthopedic (relating to the branch of medicine dealing with the correction of deformities of bones or muscles) Surgical Consultation dated 8/5/2021 timed at 9:02 PM, indicated a painful swelling and limit of motion involving Resident 1's left hip, and slight shortening of the left lower extremity along with external rotation (a hip external rotation is when the leg rotates outward, away from the rest of the body). The Orthopedic Surgical Consultation indicated under the Diagnostic Impression that Resident 1 sustained an intertrochanteric fracture of the left hip, comminuted (when bone is broken into more than two pieces) and displaced (a type of fracture when the bone fragments on each side of the break are not aligned). A review of the GACH's Computerized Tomography (CT [a diagnostic imaging test] maxillofacial (referred to the face and jaw) scan, dated 8/5/2021, indicated a marked left periorbital swelling and probable hematoma. A review of Resident 1's GACH CT scan of the head dated 8/6/2021, indicated 2.2 centimeters left periorbital and supraorbital hematoma. A review of the GACH's Orthopedic Surgical Consultation note dated 8/10/2021 indicated Resident 1 had an ORIF surgery of the intertrochanteric and subtrochanteric (defined as within 5 centimeters distal [away from the body] to the upper part of the femur) fractures of the left hip on 8/10/2021. A review of GACH 1's Discharge Instructions indicated Resident 1 was discharged from the GACH on 8/12/2021 to another Skilled Nursing Facility. During an interview on 8/12/2021 at 2 PM, Director of Nursing (DON) 1 stated that on 8/4/2021, CNA 1 and 2 were cleaning Resident 1 and both were standing at the foot of the resident's bed and was trying to change the fitted sheet when Resident 1 fell . DON 1 stated after the incident they assessed the resident and noted redness discoloration on the eye/orbit area. DON 1 stated the following morning, on 8/5/2021, Resident 1 complained of severe pain in the left thigh. DON 1 stated after the x-ray was done and results were reported to MD 1, Resident 1 was transferred to the GACH on 8/5/2021. During a telephone interview on 9/23/2021 at 9:38 AM, LVN 1 stated that he was assigned to Resident 1 on 8/4/2021, during the 3 PM to 11 PM shift. LVN 1 stated that on 8/4/2021 he was notified by CNA 1 and 2 that they were cleaning Resident 1 and resident moved and fell out of the bed. LVN 1 stated that Resident 1 had redness on her forehead and complained of pain in the forehead. During a telephone interview with CNA 1, on 9/23/2021 at 1:13 PM, CNA 1 stated after the fall incident on 8/4/2021 at around 10 PM, Resident 1 was awake but verbalized her head was hurting. CNA 1 stated she noted redness on the Resident 1's head. CNA 1 stated she notified LVN 1 and RNS 2 and applied ice pack to Resident 1's head. During a telephone interview on 9/23/2021 at 2:22 PM, RNS 2 (assigned on 8/4/2021 during the evening shift) stated Resident 1 was confused. RNS 2 stated he did not note any injuries on Resident 1 after the fall incident. RNS 2 stated Resident 1 was not complaining of pain status post [MEDICAL RECORD OR PHYSICIAN ORDER] During a telephone interview, on 9/24/2021 at 11:34 AM, DON 1 stated there was no other progress notes documented by the licensed nurses in Resident 1's medical records from 8/4/2021 to 8/5/2021, aside from the Progress Note documented by RNS 1 on 8/5/2021 at 2:26 PM indicating Resident 1's transfer to the GACH. During another interview with RNS 1 in the facility, on 9/28/2021 at 2:35 PM, RNS 1 stated that she was working the morning shift on 8/5/2021 when Resident 1 verbalized pain and was pointing to her legs. RNS 1 stated she gave Resident 1 pain medication. RNS 1 stated Resident 1 did not move much. RNS 1 stated Resident 1's left eye had a bump with black discoloration. RNS 1 stated Resident 1's pain level was more than 5 (indicated moderate pain in the numeric pain scale). RNS 1 stated she notified MD 1 and MD 1 ordered x-ray of the left hip. RNS 1 stated that MD 1 ordered Resident 1's transfer to the GACH. During a telephone interview on 10/1/2021 at 2:28 PM, LVN 2 stated he was assigned to Resident 1 on 8/4/2021 during the night shift from 11 PM to 7 AM. LVN 2 stated during his rounds, LVN 2 saw the Resident 1's face was too swollen. LVN 2 stated he applied cooling measures immediately. LVN 2 stated during his pain assessment, Resident 1 was moaning. LVN 2 stated that throughout the night he was nervous because Resident was not talking and was just in bed with eyes closed. LVN 2 stated he asked Resident 1 of her pain level, but Resident 1 was just moaning and unable to verbalize pain. LVN 2 stated Resident 1 would moan every time CNA 4 would move Resident 1's left arm or leg during diaper change. LVN 2 stated Resident 1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . LVN 2 stated he did not call MD 1 to notify of Resident 1's status (moaning and face being too swollen) during the 11 PM to 7 AM shift. LVN 2 stated he endorsed for the morning shift (RNS 1) to notify MD 1 to order a left side x-ray. During a telephone interview on 10/5/2021 at 12:41 PM, CNA 4 stated he was assigned to Resident 1 on 8/4/2021 during the night shift from 11 PM to 7 AM. CNA 4 stated at the start of his shift, he saw Resident 1 had a big bruise on her eye. CNA 4 stated every time she would turn Resident 1 to the left side during diaper change, Resident 1 would complain of pain to the left side of her body. CNA 4 stated that during his night shift, the first time he changed Resident 1's diaper was at 11:09 PM, second diaper change was around 2 AM, and the last diaper change was at 4:30 AM. CNA 4 stated Resident 1 speaks Tagalog and told CNA 4 that she was in pain. CNA 4 stated Resident 1 was not able to tell the location of her pain but every time he would turn her, Resident 1 would say Ouch. CNA 4 stated he notified LVN 2 of Resident 1's pain at around 4:30 AM. CNA 4 stated LVN 2 stated Resident 1's pain was due to the fall on the floor during the evening shift. CNA 4 stated Resident 1 did not sleep during the night shift and was verbalizing about demons. During another telephone interview with LVN 2, on 10/5/2021 at 2:41 PM, LVN 2 stated Resident 1 was not able to verbalize pain and was moaning on 8/4/2021 at around 7 AM. LVN 2 stated when the morning shift licensed nurse arrived to the facility (RNS 1), they assessed Resident 1 and observed that Resident 1 was moaning and was having pain on the left shoulder, that was the time when x-ray technician (a technician who specialized taking and processing x-rays) came around 7 AM. LVN 2 stated CNA 4 reported the moaning at the end of the shift around 7 AM. LVN 2 stated he did not provide Resident 1 pain medication during the night shift. LVN 2 stated he did not call MD 1 during the night shift. During a telephone interview on 10/5/2021 at 9:12 PM, MD 1 stated after Resident 1's fall on 8/4/2021, Resident 1 had a Very bad black eye with large hematoma at the periorbital area. MD 1 stated that Resident 1 is very demented, but she could be redirected. MD 1 stated the following day on 8/5/2021, MD 1 followed up with the facility and decided to transfer Resident 1 out to the GACH because the resident's injury was not evident on the first time, he was informed of Resident 1's injury, on 8/4/2021. MD 1 stated the following day (8/5/2021) Resident 1 had a really bad swelling and bruising and he decided to send the resident out to the GACH. MD 1 stated he was not informed of Resident 1's pain on the left side, in the evening of 8/4/2021. MD 1 stated the facility notified him of the resident's left hip pain, the following day, on 8/5/2021. During a concurrent telephone interview and record review of Resident 1's Risk for Pain care plan dated 12/18/2020 and Actual incident of fall care plan dated 8/4/2021, on 10/7/2021 at 10:35 AM, DON 2 stated she could not find documented evidence that a new care plan was developed or revised for Resident 1's actual pain to the left side or left leg and swollen left eye injury on 8/4/2021, aside from the previously developed Risk for Pain care plan and the Actual Incident of Fall care plan, to address Resident 1's unrelieved pain as evidenced by moaning and complaints of pain when turned to the left side during the night shift (8/4/2021) and morning shift (8/5/2021). During a concurrent telephone interview and record review of Resident 1's Pain assessment dated [DATE] to 8/5/2021, on 10/7/2021 at 12:20 PM, DON 2 stated the licensed nurses for the evening (LVN 1), night shift (LVN 2), and morning shift (RNS 1) should have conducted accurate pain assessments to Resident 1 after the fall incident to address Resident 1's worsening pain. DON 2 stated LVN 2 should have notified MD 1 during the night shift when Resident 1 was observed moaning in pain to address Resident 1's pain. DON 2 stated RNS 1 should have notified MD 1 after pain medication was administered on 8/5/2021 at 8:30 AM, when Resident 1 was assessed having no relief from the pain medication as indicated in Resident 1's documented Pain Assessment on 8/4/2021 during the morning shift. DON 2 stated the licensed nurses should have utilized the non-verbal pain scale or face pain scale indicated in Resident 1's Pain Assessment form to provide appropriate pain management according to Resident 1's non-verbal cues of pain. DON 2 stated LVN 2 (night shift) should have indicated Resident 1's accurate Pain Assessment and notified MD 1, since Resident 1 was moaning in pain during the night shift during turning and every diaper change. DON 2 stated that CNA 4 should have notified LVN 2 every time Resident 1 would moan and complain of pain when being turned during diaper changes, to address Resident 1's pain. A review of the facility's policy and procedure, revised on March 2020 and titled Pain Assessment and Management indicated the purpose of this procedure is to help staff to identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that addresses the underlying causes of pain. The policy indicated the facility's pain management program was based on a facility-wide commitment to appropriate assessment and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The policy indicated that pain management is a multidisciplinary care process that included: a. Assessing the potential for pain, b. Recognizing the presence of pain, c. Identifying the characteristics of pain, d. Addressing the underlying causes of pain, e. Developing and implementing approaches to pain management, f. Identifying and using specific strategies for different levels and sources of pain, g. Monitoring for the effectiveness of interventions, and h. Modifying approaches as necessary. The Pain Assessment and Management policy indicated comprehensive pain assessments are conducted . whenever there is a significant change in condition, and when there is onset of new pain or worsening of existing pain. The Pain Assessment and Management policy's Steps in the Procedure, Recognizing Pain section indicate observation of the resident (during rest and movement) for physiologic and behavioral (non-verbal) signs of pain such as verbal expressions of groaning, crying, screaming, changes in the skin color and vital signs, and [CONDITION(S)] (difficulty sleeping). The policy indicated to report to the physician or practitioner significant changes in the level of the resident's pain, and prolonged and unrelieved pain despite care plan interventions.

Based on interview and record review, the facility failed to ensure adequate supervision was provided for a resident who was assessed as high risk for falls and requiring extensive assistance (resident involved in activity with staff providing weight-bearing support [taking the person's weight by holding]) with two-persons during bed mobility when changing the bed sheets for one of two sampled residents, (Resident 1). Resident 1, who had [CONDITION(S)] (a brain damage caused by multiple strokes), with moderately impaired cognition (moderate decline in cognitive abilities included memory and thinking skills), and [CONDITION(S)] (a paralysis of one side of the body) was not provided weight bearing support by Certified Nurse Assistants (CNA) 1 and 2 when the resident was turned and repositioned in bed during the changing of Resident 1's bed sheets. This deficient practice resulted in Resident 1 falling from the bed to the floor on 8/4/2021 at 10 PM. As a result, Resident 1 was moaning in pain, sustained severe facial contusion (a trauma and bruise that appears on the face after an injury) and fracture of the left hip (a break in the upper portion of the femur [thighbone or upper bone of the leg]). Resident 1 was transferred to a General Acute Care Hospital (GACH) on 8/5/2021 with diagnoses of fractured left hip and facial contusion with 2.2 centimeters (cm; unit of measurement) periorbital (bone located around the eyes) and supraorbital (an area lies directly under the eyebrow) hematoma (a condition when blood vessels under the skin damaged and leak, the blood pools and results in a bruise). Resident 1 had an open reduction and internal fixation (ORIF- a type of surgery that is used to repair broken bones that need to be put back together) of the left hip on 8/10/2021. Findings: A review of Resident 1's Face Sheet (admission record) indicated the resident was admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses of cerebral infarction (a stroke: a damage to tissues in the brain due to a loss of oxygen to the area), other intervertebral disc degeneration (a condition characterized by the breakdown of one or more of the discs that separate the bones of the spine causing back and neck pain) of the [MEDICATION(S)] region (the area of the spine extending from the base of the neck to the abdomen), [CONDITION(S)], and [CONDITION(S)] without behavioral disturbance. A review of Resident 1's Fall Risk assessment dated [DATE] indicated a score of 10. The Fall Risk Assessment indicated if the total score is 10 or greater, the resident should be considered at high risk for potential falls. The Fall Risk Assessment indicated, a prevention protocol should be initiated immediately and documented in the resident's care plan. A review of Resident 1's Care Plan: Fall Risk, dated 12/18/2020 and reevaluated on 3/2021, 6/2021, and 9/2021, indicated Resident 1 was at risk for falls related to diagnoses including [CONDITION(S)] (CVA; stroke), balance problems, memory problems, vision problems, and poor safety awareness. The Fall Risk care plan indicated staff interventions such as mattress on the floor as needed, assisting resident with activities of daily living (ADLs) as needed, maintaining a safe environment, keeping 1/4 (quarter) bed side rails up when in bed for ADL changes, mobility, repositioning and as an enabler. The care plan goals included facilitating turning/repositioning and promoting safety. A review of Resident 1's Minimum Data Set (MDS, a standardized resident assessment and care screening tool), dated 6/18/2021, indicated the resident had moderately impaired cognition. The MDS indicated Resident 1 required extensive one-person assistance during bed mobility, transfers, toilet use, dressing, and personal hygiene. A review of Resident 1's Situation, Background, Assessment, and Recommendation (SBAR; a technique used to facilitate prompt and appropriate communication) Communication Form (SBAR), dated 8/4/2021 timed at 11 PM, indicated Resident 1 fell on the floor while the CNAs were giving care to the resident on 8/4/2021. The SBAR form indicated Medical Doctor (MD 1) was notified on 8/4/2021 at 10:17 PM. The nursing notes section in the SBAR form indicated Licensed Vocational Nurse (LVN) 1 assessed Resident 1 and indicated Resident 1 had redness to the left orbital (bony structure around the eye) area. The SBAR form indicated a check marked indicating the resident was in pain and a handwritten note indicated Aching pain. The SBAR form indicated Tylenol (acetaminophen) was provided to Resident 1 (no time of administration indicated). A review of Resident 1's Medication Administration Record (MAR) for August 2021 indicated Resident 1 had a physician order dated 9/10/2020 for two tablets of acetaminophen 325 milligrams (mg) by mouth as needed for mild pain (pain level of 1 to 3). The MAR for acetaminophen 325 mg was blank for August 2021. A review of a facility document titled Witness Statement Report written and signed by CNA 1 dated 8/4/2021 (no time), indicated that on 8/4/2021 at around 10 PM when CNA 1 and 2 provided care and assisted Resident 1 in bed. The Witness Statement Report indicated after cleaning Resident 1, CNA 1 placed the fitted sheet (the sheet with the elastic edge that fits over the mattress) on the foot of the bed. The Witness Statement Report indicated CNA 2 grabbed the fitted sheet so that CNA 2 can put the other end of the fitted sheet, but the resident fell when CNA 2 was fixing the fitted sheet. A review of another facility document titled Witness Statement Report written and signed by both CNA 1 and 2 dated 8/4/2021 (no time), indicated that on 8/4/2021 around 10 PM, CNA 1 and 2 were cleaning Resident 1. CNA 1 stated she was cleaning Resident 1 while CNA 2 was holding the resident on the other side but during the time that CNA 1 and 2 were putting the fitted sheet, Resident 1 fell on the floor. The Witness Statement Report indicated CNA 1 and 2 immediately reported the fall incident to the RN Supervisor (RNS) 1 and the charge nurse LVN 1. A review of Resident 1's Physician Orders for August 2021, with an order date of 9/10/2020, indicated 1/4 (quarter) side rails as enabler (aiding in turning and repositioning within the bed) for bed mobility. A review of Resident 1's Physician Telephone Order form dated 8/5/2021 timed at 7 AM (9 hours from fall incident), indicated MD 1's order for an x-ray (an imaging test used to take images of the X in the body and in particular bones by using radio waves) of the skull (skeleton of the head), left femur, left tibia (a shin: inner and larger inside bone located in the lower leg), and fibula (a smaller outside bone located in the lower leg) to rule out fracture (broken bone). A review of Resident 1's Physician Telephone Order form dated 8/5/2021 timed at 10 AM, indicated MD 1's order to transfer Resident 1 to GACH 1 for medical treatment and further evaluation due to a fall, bump on the left eye and pain on the left leg. A review of Resident 1's Patient Report for the left x-ray examination of the femur electronically signed by the interpreting physician on 8/5/2021 at 1:21 PM, indicated an acute intertrochanteric (between the trochanters [(bony prominences of the thighbone]) left hip fracture with proximal migration of the distal fracture (a medical term indicating a shortening of the overall bone length) fragment and apex varus angulation (a medical term used to denote to the inward angulation of the distal segment of a bone or a joint). A review of Resident 1's Progress Note dated 8/5/2021 timed at 2:26 PM, indicated Resident 1 was transferred to GACH 1 due to a fall. A review of GACH 1's Emergency Department (ED) Triage note dated 8/5/2021 timed at 2:59 PM, indicated Resident 1 arrived at the GACH 1 ED. The ED note indicated that according to the Emergency Medical Technician (EMT; trained emergency personnel that transports patients to medical facilities), Resident 1 was being changed and fell from the bed to the floor. A review of GACH 1's Emergency Department Medical (EDMD) General dated 8/5/2021 timed at 6:11 PM, indicated Resident 1 arrived from the facility after a fall on 8/4/2021 and had complained of left hip pain since the fall. The EDMD General note indicated Resident 1's left eye was severely bruised and swollen shut. A review of GACH 1's Orthopedic (relating to the branch of medicine dealing with the correction of deformities of bones or muscles) Surgical Consultation dated 8/5/2021 timed at 9:02 PM, indicated the physical examination performed by the orthopedic surgeon (MD 2) indicated painful swelling and limit of motion involving Resident 1's left hip, and slight shortening of the left lower extremity along with external rotation (a hip external rotation is when the leg rotates outward, away from the rest of the body). The Orthopedic Surgical Consultation indicated under the Diagnostic Impression that Resident 1 sustained an intertrochanteric fracture of the left hip, comminuted (when bone is broken into more than two pieces) and displaced (a type of fracture when the bone fragments on each side of the break are not aligned). A review of GACH 1's Computerized Tomography scan (CT [a diagnostic imaging test] maxillofacial (referred to the face and jaw) dated 8/5/2021 indicated marked left periorbital swelling and probable hematoma. A review of GACH's CT head dated 8/6/2021 indicated 2.2 centimeters left periorbital and supraorbital hematoma. A review of GACH 1's Orthopedic Surgical Consultation note dated 8/10/2021 indicated Resident 1 had an open reduction and internal fixation (a type of surgery used to stabilize and heal a broken bone) of the intertrochanteric and subtrochanteric (defined as within 5 centimeters distal [away from the body] to the upper part of the femur) fractures of the left hip (ORIF of the left hip fracture) on 8/10/2021. A review of GACH 1's Discharge Instructions indicated Resident 1 was discharged from GACH 1 on 8/12/2021 to another Skilled Nursing Facility. During an interview on 8/12/2021 at 2 PM, Director of Nursing (DON 1) stated that on 8/4/2021, CNA 1 and 2 were cleaning Resident 1 and both were standing at the foot of the resident's bed. DON 1 stated when CNA 1 and 2 were trying to change Resident 1's fitted sheet, CNA 1 and 2 pulled the fitted sheet and Resident 1 fell from the bed. DON 1 stated MD 1 was notified on 8/4/2021 and ordered for skull x-ray. DON 1 stated the following morning (8/5/2021), Resident 1 complained of severe pain on the left thigh. During an interview on 8/13/2021 at 10:06 AM, Director of Staff Development (DSD) stated CNA 1 and 2 stated decided to clean and change the Resident 1's bed together on 8/4/2021 at around 10 PM. DSD stated CNA 1 and 2 were both standing at the foot of the bed, and both CNAs were changing Resident 1's fitted sheet. During a telephone interview on 9/1/2021 at 2:42 PM, CNA 2 stated that on 8/4/2021 at around 10 PM, Resident 1 had an incontinent (inability to control urine or bowel movement) episode of bowel movement. CNA 2 stated Resident 1's fitted sheet needed to be changed. CNA 2 stated when they (CNA 1 and 2) were putting the fitted sheet, they pulled the fitted sheet and resident slide from the bed. CNA 2 stated they were standing at the foot of the bed. Resident 2 was on the right side of the bed in a side lying position and was facing the right side toward CNA 2. CNA 2 stated she tried to pull the fitted sheet from the bed and Resident 1 slide down from the bed. CNA 2 stated she was standing at the right side of the bed where Resident 1 fell . CNA 2 stated that Resident 1 did not have the side rails up. CNA 2 stated that if they had placed Resident 1 back on the supine (lying face up) position when pulling the fitted sheet, they could have prevented Resident 1's fall. During a telephone interview on 9/23/2021 at 9:38 AM, LVN 1 stated that he was assigned to the Resident 1 on 8/4/2021, during the 3 PM to 11 PM shift. LVN 1 stated that he was passing medication at that time and he was not in the room during Resident 1's fall incident. LVN 1 stated that Resident 1 was confused but not combative or restless. LVN 1 stated that on 8/4/2021 he was notified by CNA 1 and 2 that they were cleaning Resident 1 and resident moved and fell out of the bed. LVN 1 stated that Resident 1 had redness on her forehead and complained of pain in the forehead. During a telephone interview on 9/23/2021 at 1:13 PM, CNA 1 stated she was assigned to Resident 1 on 8/4/2021. CNA 1 stated that it was about 10 PM when CNA 1 assisted Resident 1 with incontinence care, with the help of CNA 2. CNA 1 stated Resident 1's fitted sheet needed to be replaced because it was soiled with feces. CNA 1 stated that CNA 1 was standing on the left side of the bed while CNA 2 was standing at the right side of the bed. CNA 2 turned Resident 1 on her right-side facing CNA 2. CNA 1 stated that both CNA 1 and 2 was standing at the foot of the bed while placing the fitted sheet underneath the resident. CNA 1 stated when CNA 2 grab the fitted sheet underneath Resident 1 while the resident was still on a side-lying position, Resident 1 fell from the right side of the bed, face down. CNA 1 stated she was not able to hold on to Resident 1. CNA 1 stated that CNA 2 was not holding on to Resident 1 from the right side of the bed, because CNA 2 was grabbing on to the fitted sheet to apply to the right corner at the foot of the mattress. CNA 1 stated that Resident 1 did not have the 1/4 side rails up prior to the fall and did not have the strength to hold herself during turning and repositioning in bed. CNA 1 stated Resident 1 did not have a fall mattress on the floor. During the same telephone interview with CNA 1, on 9/23/2021 at 1:13 PM, CNA 1 stated that she observed redness on Resident 1's head. CNA 1 stated they should have communicated with each other how they were going to clean and change the fitted sheet of the mattress while Resident 1 was still in bed. CNA 1 stated, I should not trust anyone. CNA 1 stated that she thought CNA 2 was holding on to Resident 1 and would not leave Resident 1 on a side-lying position. CNA 1 stated that they should have placed Resident 1 to the center of the bed. CNA 1 stated they did not do that. During a telephone interview with RNS 2, on 9/23/2021 at 2:22 PM, RNS 2 stated that he was working on 8/4/2021 when Resident 1 had the fall incident on 8/4/2021. RNS 2 stated when he entered Resident 1's room after the fall incident, Resident 1 was on the floor and was facing up and lying on her back. RNS 2 stated that after the incident they assisted Resident 1 back to the bed and performed head to toe assessment. RNS 2 stated, Resident 1 had left sided weakness and was unable to lift on her own. RNS 2 stated Resident 1 required maximum assistance and total care with her ADLs. RNS 2 stated that the fall happened because CNA 1 and 2 were not focused on Resident 1 while doing the care. RNS 2 stated Resident 1's fall incident of slipping from the bed was something he would not expect to happen, in the presence of two CNAs' close supervision in bed. During a telephone interview, on 9/24/2021 at 11:34 AM, DON 1 stated there was no other progress notes documented by the licensed nurses (such as other interventions and continuous assessments provided) in Resident 1's Progress Notes for August 2021 (from 8/4/2021 to 8/5/2021) aside from the Progress Note documented by RNS 1 on 8/5/2021 at 2:26 PM indicating Resident 1's transfer to GACH 1. During another interview on 9/28/2021 at 2:35 PM, RNS 1 stated that she was working the morning shift on 8/5/2021. RNS 1 stated that on 8/5/2021, during the morning shift, Resident 1 complained of pain on the left hip and stated Pain. RNS 1 stated Resident 1 was pointing to her legs and not moving much. RNS 1 stated Resident 1's left eye had a bump with black discoloration. RNS 1 stated she notified MD 1 and MD 1 ordered x-ray of the left hip. RNS 1 stated that MD 1 ordered Resident 1's transfer to the acute hospital after the notification of the x-ray result. RNS 1 stated Resident 1 required maximum assistance with her ADLs which means resident was dependent on a caregiver or CNA. RNS 1 stated Resident 1 required two-person assistance with her ADLs and transfers. During an interview on 9/28/2021 at 2:56 PM, CNA 3 stated that if the resident is paralyzed in one side, they need two-person assist during turning. CNA 3 stated that most of the facility's beds did not have side rails, so someone had to hold the resident during bed mobility. CNA 3 stated that when CNAs change the fitted sheet, resident should be turned in a side lying position and one staff should protect the resident to prevent fall/injury. CNA 3 stated that it is important to place the resident in the safest position at the center of the bed. During an interview and record review on 9/28/2021 at 3:11 PM, Occupational Therapist (OT) 1 stated when the staff is changing the fitted sheet for dependent residents, staff must make sure that while one staff is working with the resident, another staff should stabilize the resident to prevent falls. OT 1 stated there should be proper communication and teamwork between staff members during turning and repositioning of residents in bed. OT 1 stated Resident 1 required one or two-person assistance with her transfers. During an interview on 9/28/2021 at 3:30 PM, DON 1 stated that Resident 1 required total two-person assistance with transfers and during bed mobility when changing the bed sheets for safety. DON 1 stated when repositioning Resident 1 in bed, one staff should supervise and hold the resident while the other staff member should be doing the actual care such as cleaning the resident or changing the bed sheets. DON 1 stated that during changing Resident 1's bed sheet while the resident was occupying the bed, the resident's body should be properly supported by the staff member and both staff members should communicate to each other, including the resident, for the step-by-step procedure to ensure safety. DON 1 stated Resident 1's fall could have been prevented if the staff was more cautious and guarded the resident more during repositioning in bed to ensure safety. During a telephone interview on 10/1/2021 at 12:25 PM, Physical Therapist (PT) 1 stated Resident 1 required extensive assistance with ADLs. PT 1 stated, extensive assistance means Resident 1 could do 25 percent of the activities while 75 percent would be provided by the staff. PT 1 stated that Resident 1 could not walk and had left sided weakness. PT 1 stated during bed change while the resident was occupying the bed, the resident should be placed on the side-lying position. PT 1 stated that while one staff member would be rolling the bed sheet, the other staff member should block the resident. PT 1 stated that when the bed sheet was replaced, Resident 1 should have been placed back at the center of the bed, from side-lying position. PT 1 stated that these steps need to be communicated by each staff member while providing the care. During a telephone interview on 10/1/2021 at 2:28 PM, LVN 2 stated he was assigned to Resident 1 on 8/4/2021 during the night shift from 11 PM to 7 AM. LVN 2 stated during his rounds, LVN 2 saw the Resident 1's face was too swollen. LVN 2 stated he applied cooling measures immediately. LVN 2 stated during pain assessment, Resident 1 was moaning. During a concurrent telephone interview and record review of Resident 1's SBAR for 8/4/2021 and 8/5/2021, on 10/6/2021 at 10:13 AM, DON 2 stated Resident 1 received two tablets of acetaminophen 325 mg on 8/4/2021 at 11 PM for pain. During a concurrent telephone interview and record review of Resident 1's Fall Risk care plan dated 12/18/2020, on 10/7/2021 at 10:45 AM, DON 2 stated she could not find documented evidence that Resident 1's Fall Risk care plan was revised to indicate that Resident 1 required two-person assistance with transfers and during bed mobility when changing the bed sheets for safety, as stated by DON 1 during her interview on 9/28/2021 at 3:20 PM. A review of the Certified Nursing Assistant (undated) Job Description indicated the primary purpose of the job position is to provide each of the assigned residents with routine daily nursing care and services in accordance with the resident's assessment and care plan, and as may be directed by the supervisor. The General Job Function Safety section indicated, CNA should promote a safe environment for residents and employ proper techniques of body mechanics to ensure resident/staff safety at all times. A review of the facility's policy and procedure, revised on February 2018 and titled Bed, making an Occupied, indicated the steps in the procedure for occupied bed making, included raising the bedside rail and positioning the resident on the opposite side of the bed where the staff would be working, if the resident could not turn by himself/herself, assist as needed. When replacing linens, the resident should be asked to turn over to his/her side and assist as needed. The policy and procedure indicated the resident should be repositioned back by asking or rolling the resident over on his back to the center of the bed and assist as necessary. A review of the facility's policy and procedure, revised on March 2018 and titled, Falls and Fall Risk Managing, indicated based on previous evaluations, the staff would 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 identify accident risks and implement interventions to prevent accidents and a hazardous environment for 89 of 89 (Residents 1 to 89) residents living in the facility, 22 staff working in the facility and an undetermined number of visitors by failing to ensure: 1. The facility had a functioning fire alarm system since 4/8/2021. The facility's Administrator 1 did not report the fire alarm system was out of service since 4/8/2021 (for more than 4 hours in a 24-hour period), to the Department of Public Health, as required in the National Fire Protection Association (NFPA) 101, Life Safety Code Requirements. 2. The facility expedited replacement one of one fire alarm control panel (a fire alarm control unit that acts as a [NAME] between life-saving appliances [such as fire sprinkler systems [devices that discharges water when the effects of a fire have been detected or a predetermined temperature has been exceeded], smoke detectors [a fire-protection device that automatically detects and gives a warning of the presence of smoke], or transmitting a signal used to alert first responders/fire department] that watch for hazards tasked with alerting people to danger or problems with fire protections systems in a building) as indicated in the facility's signed Sales Agreement proposal dated 4/28/2021 to replace (upgrade) the emergency fire alarm panel initiated on 2/20/2020 and proposal revised on 4/13/2021 (14 months from initial proposal). 3. The facility established an effective Fire Watch (a procedure that consisted of qualified personnel conducting continuous patrol of the entire premises for the purposes of detecting fire and transmitting an immediate alert to the building occupants and to the fire department) program by failing to ensure: a. The facility had an updated Fire Watch policy. The facility provided two outdated Fire Watch policies to the Department that was not reviewed annually. b. The facility followed its Fire Watch Policy to for fire watch personnel consist of personnel solely dedicated to performing the fire watch with no other facility-related activities for 20 days during the 11 pm to 7 am shift from 4/10/2021 to 4/30/2021. c. The facility's fire watch personnel follow the facility fire watch policy by performing the fire watch procedure every half hour for two days from 4/10/2021 to 4/12/2021 as indicated in the facility policy. d. The facility's fire watch log sheets from 4/15/2021 to 4/28/2021 (14 days) were documented accurately. The first set of fire watch log sheets received from the facility indicated the fire watch procedure was performed every half hour, while a second set of fire watch log sheets for the same dates (4/15/2021 to 4/28/2021) indicated the fire watch procedure was performed every hour reflecting a discrepancy in documentation and validation of proper fire watch procedure being performed by facility personnel. 4. The facility obtained an emergency approval permit requiring inspections from Office of Statewide Health Planning and Development (OSHPD) State agency that reviews and approves plans for construction, repairs, renovations, and remodeling made to buildings to comply with State codes]) prior to repairing and replacing the facility's fire alarm panel, smoke detectors, and pull stations. These deficient practices had the potential to result in a serious adverse outcome such as delayed fire evacuation that may result to residents, staff or visitor [CONDITION(S)] and deaths in the event of a fire or emergency in the facility. On 4/12/2021, at 5:05 pm, a facility self- reported incident (FRI) investigation was conducted regarding the facility's malfunctioning fire alarm system. The FRI was reported on 4/10/2021 (over the weekend) at 10:35 am via e-mail. During the tour of the facility, Surveyor 1 observed the fire panel located in Nursing Station 1 was not on (indicator light was off). The Director of Nursing (DON) stated a continuous fire watch was started by the facility on 4/10/2021. On 6/1/2021 and 6/7/2021, two anonymous complaints were received by the Department of Public Health regarding the facility's continued malfunctioning fire alarm system and the facility not reporting the repair and replacement of the fire alarm control panel. On 6/8/2021 at 8:45 am, during an interview, the maintenance supervisor (MS 1) when the fire alarm system kept going on and off, the facility decided to replace the fire alarm panel (unable to recall exact date). MS 1 stated the facility's fire alarm technicians started replacing the fire alarm panel and a few of the smoke detectors and a couple of the pull stations (devices to manually set off the fire alarm, in case of fire). During this interview, the OSHPD paperwork was requested for review. MS 1 stated the facility did not request OSHPD permits or approval prior to repairing and replacing of the facility's fire alarm panel, smoke detectors and pull stations. On 6/8/2021 at 4:21 pm, an Immediate Jeopardy (IJ-a situation in which the provider's non-compliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death of a resident or residents) was declared and the facility's vice president of operations (Administrator 2) was notified of the situation and concerns regarding identifying accident risks and implementing interventions to prevent accidents and a hazardous environment due to the facility's malfunctioning fire alarm system, failure to establish an effective fire watch program and not obtaining an emergency approval permit for the fire alarm replacement that required inspections from OSHPD. On 6/10/2021, at 3:47 pm, the IJ was removed in the presence of Administrator 2 and the director of nursing (DON) after the implementation of the acceptable plan of action (POA, interventions to correct the deficient practice) was verified and confirmed on an onsite visit through observation, interview and record review. The acceptable POA included the following actions: 1. The facility's Vice President of Operations (Administrator 2) contacted the facility's fire alarm company working on repairing the facility fire panel and confirmed that the facility's current fire panel had been in communication with the alarm company and City Fire Department. Confirmed with the fire alarm company that the Fire Panel will be fully operational by 06/10/2021. 2. OSHPD compliance officer was notified in person on 06/08/2021 by the facility's vice president of operations (Administrator 2) and maintenance supervisor (MS) of the facility's fire panel being repaired during OSHPD officer's onsite visit. 3. On 06/09/2021 Vice President of Program Development informed OSHPD of the facility's Fire Panel project. 4. Staff members, Nursing Aides, Certified Nurse Assistants (CNA), and Maintenance Assistant, have been assigned to continue the facility's fire watch until facility no longer required to be on a fire watch. 5. Department Managers were in-serviced by the Vice President of Operations (Administrator 2) on 06/8/2021 regarding facility fire panel being repaired and facility is currently performing a fire watch. 6. Facility Clinical Resource Consultant and Director of Staff Development (DSD) Consultant will continue with the ongoing education regarding facility fire panel being repaired facility being on fire watch. Ongoing education of staff will continue by DSD Consultant and/or Clinical Resource Consultant until all staff have been in-serviced. 7. The facility's most recent fire drill was held on 5/12/2021. The facility monthly fire drills (a practice of the emergency procedures to be used in case of fire) frequency will increase to once a week until the facility is no longer required to be on fire watch. 8. An Addendum had been added to the facility's Emergency Procedure-Fire Watch protocol on 6/9/21 to include notifying the local Fire Department and CDPH when facility fire alarm system and/or sprinkler system is out of service for more than four hours. 9. Department Managers visited all residents in-house on 06/08/2021 to ensure all residents are aware and feel safe and comfortable. For residents with cognitive impairment, resident's responsible party was contacted via telephone by department manager. 10. Maintenance Supervisor and/or Designee will perform facility rounds daily between 9 am to 9:30 am to ensure facility fire panel is working properly as evidence by no warning indicators being activated. Findings of rounds will be reported to Administrator and/or designee for corrective actions. 11. VP of Program Development will stay in continues conversation with OSHPD and will notify Administrator and/or Designee. VP of Program Development will represent facility as point of contact with OSHPD and will communicate via email on a weekly basis till completion of project and OSHPD Compliance Officer will be the facility point of contact from OSHPD until instructed otherwise. 12. Regional Compliance Officer provided VP of Program Development with an Emergency Authorization to Proceed project number on 6/10/2021. 13. The Vice President of Operations (Administrator 2) will be in contact with CDPH Licensing and Certification on a weekly basis via email regarding status of the project till its completion. 14. Director of Plant Operations will be in contact with the facility's fire alarm company (vendor repairing facility fire panel) daily and will ensure proper function of facility fire panel by testing the panel after completion of the installation of the fire panel. 15. Vice President of Operations (Administrator 2) and VP of Program Director reviewed report received from OSHPD on 06/10/20, and VP of Program Director initiated a new project to correct items identified on the OSHPD report. Findings: On 4/12/2021, at 5:05 pm, an unannounced visit was conducted by the Department regarding a facility self- reported incident reported by Administrator 1 over the weekend dated 4/10/2021 at 10:53 am about the facility's malfunctioning fire alarm system. Administrator 1 was not in the facility. On 4/12/2021 at 5:10 pm, during an observation and concurrent interview, the DON stated that on 4/10/2021, the facility's fire alarm system was going off by itself, sending false alarm signals (false alarms when there is no actual emergency) to the local fire department. The DON stated the local fire department kept coming to the facility when the fire alarm goes off. During the tour of the facility with the DON, Surveyor 1 observed the fire panel located in Nursing Station 1 to be shut off (no indicator light was on). The DON stated a continuous fire watch was started by the facility on 4/10/2021. On 4/12/2021 at 6:15 pm during a concurrent interview and record review of the facility's Fire Watch Log with the DON, the requested logs dated 4/10/2021 to 4/12/2021 indicated the facility started the facility's fire watch on 4/10/2021 at 1 am and were performed every hour. The DON stated the facility notified the facility's fire alarm company regarding the fire alarm false triggers and the fire alarm company would come to the facility sometime the same week to fix it. A review of the facility administrator's email (ADM 1) to the Department of Public Health district office supervisor, dated 4/12/2021 timed at 12:35 pm, indicated the facility had cleaned all the fire alarms and have ordered new fire alarms from the facility's vendor. The e-mail indicated the fire alarm replacements should be coming in around the same week. On 6/1/2021 at 8 am, an anonymous complaint was received by the Department of Public Health indicating the facility's fire alarm was constantly going off and had not been resolved. An unannounced priority visit was conducted by the Department to the facility on [DATE] at 10:10 am. On 6/1/2021 between 10:20 am to 11:24 am, during an observation of the facility grounds and concurrent interview with the maintenance supervisor (MS 1), there were technicians observed working on the facility's fire alarm control panel. MS 1 stated the facility's fire alarm control panel stopped working last month (unable to recall exact date). MS 1 stated the facility continued to perform Fire Watch procedures because replacing the fire alarm control panel was a long process. On 6/1/2021 at 11:41 am, during an interview, the director of staff development (DSD 1) stated that on 4/11/2021 the facility's fire alarm had falsely triggered (false alarms when there is no actual emergency), and the local fire department was dispatched (send to a destination with a purpose) to the facility. The facility's Fire Alarm Company came, and the facility management was notified that the facility's fire alarm control panel was broken (unable to recall when). On 6/1/2021 at 12:40 pm, during an interview with Administrator 2 stated the facility's Fire Alarm Company came to the facility on [DATE] and notified the facility that the fire alarm control panel was broken. Administrator 2 stated the facility signed a contract with the facility's Fire Alarm Company to repair/replace the fire alarm control panel on 4/28/2021. A review of a Work Order with job number 8 dated 4/21/2021, indicated the facility's fire alarm company came to the facility to check the malfunctioning fire alarm. The work order indicated the fire control panel's main signal light was broken. The work order indicated that none of the annunciator (electrically controlled signal board or indicator) lights were lit. The work order indicated the internal contact of the fire alarm might be failing. The work order indicated the facility's fire alarm control panel system consisted of smoke detectors, fire alarm pull stations (a button, lever, or other device in a building used to set off the fire alarm when manually pulled), and water flow detector all tied to the same single zone (each zone typically consist of some or all of the initiating devices in an area or floor of a building). The work order indicated that the facility's current fire control panel system was not supported by the fire control panel manufacturer anymore. The work order indicated the facility's fire alarm control panel system must be upgraded. A review of a document titled Sales Agreement signed by the facility's corporate management indicated the proposal of the fire alarm company to replace the facility's fire control panel was originally initiated by the fire alarm company on 2/20/2020 and revised on 4/13/2021. The facility signed the sales agreement on 4/28/2021. The sales agreement indicated The seller (fire alarm company) is hereby authorized to engineer (build), furnish materials, and perform installation of new fire alarm control panel . During an interview conducted through an e-mail communication with Administrator 2, on 6/21/2021 at 2:27 pm, Administrator 2 stated he was not aware of an original proposal from the facility's fire alarm company/vendor on 2/20/2020 because he was not employed by the facility during that time. On 6/7/2021 at 8:30 am, an anonymous complaint was received by the Department indicating Administrator 2's slow response to the facility's continued faulty fire alarm system. The complaint indicated that Administrator 2 did not involve and obtain an approval permit from the OSHPD when the facility repaired and replaced its fire alarm control panel. A review of the facility Fire Watch Log Sheets for April 2021 (4/10/2021 to 4/30/2021) with the initials of the facility's designated fire watch personnel indicated from 4/10/2021 at 1 am to 4/12/2021 at 5 pm, the facility performed the fire watch procedure every hour. The log indicated from 4/12/2021 timed at 6:30 pm up to 4/30/2021 the facility performed the facility's fire watch procedure every half hour. The log indicated that the fire alarm went off ten times for the month of April 2021. A review of another set of Fire Watch Log Sheets found and received from the facility with dates, 4/15/2021 at 3 pm up to 4/28/2021 at 11 am with the initials of the facility's designated fire watch personnel, indicated the facility performed the fire watch procedure every hour. The facility's Fire Watch Log Sheets indicated a discrepancy in documentation of the fire watch monitoring times from 4/15/2021 to 4/28/2021 (14 days) where the log sheets indicated on another set of fire watch log sheets that the facility's fire watch was performed every half hour on the mentioned dates (4/15/2021 to 4/28/2021), reflecting validation of proper fire watch procedure being performed by facility personnel. A review of the facility's Fire Watch Log Sheets for May 2021 (5/1/2021 to 5/31/2021) and June 2021 (6/1/2021 to 6/7/2021) with the initials of the facility's designated fire watchers indicated the facility performed the facility's fire watch procedure every half hour. A review of the facility's Fire Watch Policy (undated) provided by the facility to Surveyor 2 on 6/8/2021, indicated the facility would establish a fire watch immediately and continuously upon recognition that the fire alarm system is inoperative. The policy indicated the fire watch personnel shall have the responsibility for the continuous patrol of the entire premises for the purpose of detecting fire and transmitting an immediate alarm to the facility occupants and to the Fire Department. The policy indicated the fire watch personnel was responsible in make written records of patrol rounds and shall be recorded in a logbook. The policy indicated the designated fire watch personnel should patrol their designated area at least once each half hour (30 minutes) and be able to immediately relay emergency information. The policy indicated that fire watch personnel should remain on duty until properly relieved. During a telephone interview, on 6/21/2021 with DSD 1 at 1:45 pm, in the presence of MS 1, DSD 1 stated that she was responsible in assigning the designated and dedicated fire watch personnel for each shift for the entire 24-hour period since 4/10/2021. DSD 1 stated that there should be a dedicated fire watch personnel each shift with no other responsibilities. DSD 1 stated that after she completes the staffing assignments that included the pre-assigned fire watch personnel for each shift. DSD 1 further stated that for the month of April 2021 (4/10/2021 to 4/30/2021), there was no dedicated fire watch personnel assigned for the night (11 pm to 7 am) shift. DSD 1 stated it was the charge nurse or the RN supervisor who was assigned to perform the fire watch aside from their charge nurse and RN responsibilities. During the same telephone interview, on 6/21/2021 at 1:45 pm, when DSD 1 was asked about the discrepancy in documentation of the Fire Watch Log Sheets from 4/15/2021 to 4/28/2021 (14 days). DSD 1 stated she was not aware of the Fire Watch log sheets conducted every hour from 4/15/2021 to 4/28/2021. DSD 1 stated the Fire Watch log sheets conducted every hour must have been a mistake because the facility had switched to every half hour fire watch starting 4/12/2021. DSD 1 stated she did not ensure that the facility's Fire Watch program was implemented according to the facility's policy and validate the discrepancy in the Fire Watch documentation when the fire watch was started in the facility for the month of April. On 6/8/2021 at 8:35 am, an unannounced visit was conducted by the Department to the facility. At 8:45 am, during an interview, MS 1 stated that back in mid-April (unable to recall date), the fire alarm technician came to the facility and fixed the fire alarm. MS 1 stated, after the fire alarm technician fixed the fire alarm, it would go off again, after a few hours. MS 1 stated when the fire alarm system kept going on and off, the facility decided to replace the fire alarm panel (unable to recall exact date). MS 1 stated that the previous week (6/1/2021), the fire alarm technicians came to the facility and started replacing the fire alarm panel, a few of the smoke detectors and a couple of the pull stations. During a concurrent observation, at Nursing Station 1 (where the fire panel was located), there was no OSHPD permit posted near the location of the fire alarm control to indicate OSHPD had approved a fire alarm control panel to be repaired and replaced. When asked, MS 1 stated he did not have the OSHPD paperwork to approve or permit the fire alarm control panel that had been replaced by the facility. On 6/8/2021 between 9 am and 9:50 am, during the facility tour and interview with a maintenance staff (MS 2). MS 2 was assigned to do the fire watch of the facility for the day. During this observation, there were two smoke detectors missing and two of the pull stations were disconnected or missing. On 6/8/2021 at 10:40 am, during an interview, Administrator 2 informed Surveyor 1 that he did not have any paperwork from OSHPD. Administrator 2 stated the OSHPD was not notified of the facility's fire alarm replacement project that is why there was no OSHPD permit posted near the area of the facility's project. On 6/8/2021 at 2:17 pm, during an observation, the OSHPD compliance officer (OSHPD Officer 1) came to the facility. During OSHPD Officer 1's facility inspection, he validated the facility's non-functioning fire alarm system. On 6/8/2021 between 2:30 pm to 2:45 pm, during Surveyor 2's interview with Residents 1, 2, 3, 4, and 5 stated the facility's fire alarm would go off randomly day and night for the past couple of months (4/2021 and 5/2021). The residents stated they were notified it was a false alarm. A review of OSHPD Officer 1's written report titled Construction Advisory Report - Investigation dated 6/8/2021, indicated an investigation was initiated by the OSHPD pursuant to California Administrative Code (CAC) Section 7-128 due to unauthorized replacements, modifications, and installations. The report indicated the following information: a. Active construction appeared to include the replacement of a fire alarm panel. b. The installing contractor had commenced replacement (of the fire alarm panel) recently but had been unable to complete the replacement due to an emergency. c. Only 2 of a reported 15 smoke detectors were currently tied into the fire alarm panel. d. The facility is requested to apply for a project, submit plans, and commence the (Fire panel replacement project) plan review, approval, and building permit process, in accordance with Title 24, CAC 7-113. A review of another fire watch policy and procedure titled Emergency Procedure- Fire Watch revised on August 2018 was provided by the facility to Surveyor 1 on 6/9/2021, indicated the facility would notify the fire department and the State Regulatory/Licensing Agency when the facility's fire alarm system is not working correctly. The policy did not indicate the timeframe when to notify the fire department and the State Regulatory/Licensing agency. The policy indicated that the fire watch tours occurs at one half hour intervals and the fire watch staff consists of personnel solely dedicated to the fire watch with no other facility-related activities. On 6/9/2021 at 12:10 pm, during an interview, Administrator 2 acknowledged that the facility's Fire Watch policies were outdated and did not indicate the necessary information and requirements to conduct an effective Fire Watch program. On 6/9/2021 at 12:55 pm, during a concurrent interview and record review of the facility document titled Event History dated 3/1/2021 to 6/6/2021 (Activity report/history is a documented record of the fire alarm system and shows when it is activated) with Administrator 2, showed that on 4/8/2021 at 10:58 pm, Administrator 1 notified the monitoring station (a company that monitors the fire alarm systems at a different location and dispatches the fire department when there is an emergency) that the fire alarm system was going off and was sending false alarms to the fire department. A review of the National Fire Protection Association (NFPA) 101, 2012 Edition, Life Safety Code Handbook, 9.6.1.6 indicated Where a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction [State Regulatory/Licensing agency] shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service. On 6/9/2021 at 12:55 pm, during an interview, Administrator 2 could not state why the facility's Fire Watch policy did not indicate a timeframe when to notify the State Regulatory/Licensing agency when the fire alarm system goes out of service for more than 4 hours in a 24-hour period. Administrator 2 stated he did not know why Administrator 1 waited to notify the Department about the malfunctioning fire alarm system (36 hours after the initial e-mail report to the Department). Administrator 2 stated he did not know if the facility's fire alarm system would be back online by the end of the day (6/9/2021), as projected. On 6/10/2021 at 1:25 pm, during an observation of facility grounds, and interview with Administrator 2, Administrator 2 stated the facility's fire alarm control panel remained non-functional. There were two technicians working on the fire alarm panel. On 6/10/2021 at 2 pm, during an interview, Certified Nursing Assistant (CNA) 1 stated he was assigned to do the fire watch during this shift. CNA 1 stated the facility's fire alarm system had been broken for two months. CNA 1 stated that one specific staff was assigned to do the fire watch rounds each shift for the whole facility every half hour. On 6/10/2021 at 3:15 pm, during an interview, Administrator 2 acknowledged that whenever there were alterations to the facility's building structure, the facility is required to notify the Department (and OSHPD) of any changes or repairs, when it affects the safety of residents, staff and the public. Administrator 2 acknowledged that the facility should have notified the Department when the fire alarm system was out of service for more than 4 hours in a 24-hour period. A review of the facility's policy titled Fire Alarm System revised on January 2019, indicated the facility would maintain an operable fire alarm system at all times. The policy indicated that A fire zone panel (fire alarm control panel) is located at each nurses' station. If a fire is detected by one of the alarm systems, or if the system is manually activated, an indicator light on the fire zone panel will identify the area in which the fire is located.

Based on interview and record review, the facility failed to provide wound care services for one of two sampled residents (Resident 1) by failing to: 1. Ensure Resident 1 received appropriate pressure injuries (injuries to skin and underlying tissue resulting from prolonged pressure on the skin) treatment. 2. Ensure Resident 1 received wound evaluation from a wound specialist/consultant (a health care professional who focuses on evaluating and treating non-healing wounds). These deficient practices resulted in Resident 1's pressure injuries became worse Resident 1 developed 12 new pressure injuries, and was admitted to a general acute care hospital (GACH) with [DIAGNOSES REDACTED]. Findings: A review of Resident 1's Record of Admission indicated the resident was admitted to the facility on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's History and Physical, dated 8/29/17, indicated the resident had fluctuating capacity to understand and make decisions. A review of the Resident 1's Skin Condition on Admission, dated 8/29/17, indicated upon admission the resident had the following pressure injuries: 1. Sacral coccyx (tailbone) pressure injury, Stage 3, measuring 10.0 by 9.0 by 0.2 centimeters (cm). 2. Right ischial tuberosity (lower part of the buttocks) pressure injury, Stage 3, measuring 1.0 by 3.0 by 0.2 cm. 3. Right greater trochanter (upper part of the thighbone) pressure injury, Stage 3, measuring 2.0 by 2.0 by 0.3 cm. A review of Resident 1's Care Plan, dated 12/8/17, indicated the resident was at risk for slow wound healing due to contributing factors that included [MEDICAL CONDITION] (paralysis of the legs and lower body), history of pressure sores/ulcers, weight loss, dependent on transfers, and unable to change position independently. The nursing approached intervention were to observe for signs and symptoms of infection, and refer the resident to a wound consultant. A review of Resident 1's Minimum Data Set ((MDS), a resident assessment and care-screening tool), dated 9/8/17, indicated the resident's cognitive (ability to process thoughts) was intact. The MDS indicated Resident 1 required limited assistance for bed mobility (how the resident moves, turns, and positions body while in bed), and totally dependent on staff for transfers. A review of Resident 1's Physician order [REDACTED]. 1. Order dated as 12/8/17-Cleanse Sacral coccyx pressure injury with normal saline solution (NSS, normal salt solution), pat dry, apply [MEDICATION NAME] cream (medication cream used on the skin for second [MEDICAL CONDITION](a serious burn in which the skin develops blisters) or third [MEDICAL CONDITION](severe burn characterized by destruction of the skin)), cover the wound with dry dressing daily, and as needed (PRN) for thirty days. 2. Order dated as 12/12/17-Cleanse right greater trochanter pressure injury with NSS, pat dry, apply hydrogel (a gel in which the liquid component is water), cover the wound with dry dressing daily, and PRN for thirty days. 3. Order dated as 12/20/17-Cleanse mid back (middle of the resident's back) pressure injury with NSS, pat dry, apply [MEDICATION NAME] cream, cover the wound with dry dressing daily, and PRN for thirty days. 4. Order dated as 12/20/17-Cleanse left ischial tuberosity pressure injury with NSS, pat dry, apply [MEDICATION NAME] cream, cover the wound with dry dressing daily, and PRN for thirty days. 5. Order dated as 12/20/17-Cleanse right ischial tuberosity pressure injury with NSS, pat dry, apply [MEDICATION NAME], cover the wound with dry dressing daily, and PRN for thirty days. 6. Order dated as 1/2/18-Cleanse left lateral (from the side) back pressure injury with NSS, pat dry, apply [MEDICATION NAME] cream, cover the wound with dry dressing daily, and PRN for fourteen days. 7. Order dated as 1/2/18-Cleanse left lateral foot blister with NSS, pat dry, cover the wound with transparent film dressing every three days, or PRN for twenty-one days. 8. Order dated as 1/2/18-Cleanse right lateral foot blister with NSS, pat dry, cover the wound with transparent film dressing every three days, or PRN for twenty-one days. A review of Resident 1's Change of Condition (C[NAME]), dated 12/17/17, and timed at 10 a.m., indicated that Resident 1 was noted with a fluid blister on her left lateral foot, measuring 4.5 by 4 centimeter (cm). A review of Resident 1's Change of Condition, dated 12/20/17, and timed at 10 a.m., indicated that Resident 1 was noted with reopened pressure injury, Stage 3, on mid back, on the right ischial tuberosity, and Stage 3 on the left ischial tuberosity. The C[NAME] indicated that Resident 1's pressure injuries had malodorous smell (smelling very unpleasant) with small amount of serosanguineous (blood and the liquid part of blood/serum) drainage. A review of Resident 1's Change of Condition, dated 12/27/17, and timed at 4 p.m., indicated the Hospice Nurse (a nurse who gives supportive care to people in the final phase of a terminal illness) was informed regarding the resident's wounds were worsening with purulent drainage (pus/green thick liquid that shows sign of infection), and odor. The C[NAME] indicated Resident 1 received a new order for Bactrim DS (medication used to treat or prevent certain kinds of bacterial infections), 800-160 milligram (mg), one tablet, by mouth, twice a day for seven days. A review of Resident 1's Change of Condition, dated 1/2/18, and timed at 10:45 a.m., indicated Resident 1 was noted with a 101.1 Fahrenheit temperature (fever-high temperature), a pulse rate of 173 (fast heart rate (normal for adult 60-100)). A review of Resident 1's Transfer Summary Form, dated 1/3/18, and timed 11:10 a.m., indicated the resident was transferred to a GACH for [MEDICAL CONDITION]. The Transfer Summary Form indicated that the resident had pressure injuries and wounds to mid back, sacral coccyx, left lateral back, right greater trochanter, right ischial tuberosity, left ischial tuberosity, left groin, left lateral foot, and right lateral foot (there was no staging for each wound provided on the form). During an interview on 1/25/18, at 11:53 a.m., the facility's Director of Nursing (DON) stated that it was the facility's responsibility to ensure that Resident 1 received pressure injuries treatment, and wound evaluation from the wound specialist. During an interview on 1/25/18, at 1:19 p.m., Licensed Vocational Nurse 1 (LVN 1/Treatment Nurse) stated that Resident 1's pressure injuries became worse, and Resident 1 developed other pressure injuries while the resident was at the facility. LVN 1 stated the wound specialist did not evaluated Resident 1's pressure injuries due to the resident's insurance issues. LVN 1 stated Resident 1 was supposed to have a consultation with a wound specialist so that the wound specialist could determine what type of treatment the resident needed. On 1/25/18 at 1:44 p.m., two attempts were made to interview the facility's medical director with no success. A review of Resident 1's GACH History and Physical, dated 1/3/18, and timed at 11:29 p.m., indicated the resident was hypotensive ((72/43) low blood pressure) in the emergency room due to septic shock. A review of Resident 1's GACH Discharge Summary, dated 1/21/18, and timed at 2:53 p.m., indicated Resident 1 was admitted to an Intensive Care Unit ((ICU) a unit that provides care to patients with severe and life-threatening illnesses and injuries) with fever (high temperature), rapid (fast) heart rate, and severe septic shock. The GACH Discharge Summary indicated Resident 1 required intravenous (IV, directly into the vein) antibiotics (medication that inhibits the growth of or destroy microorganisms/bacteria) secondary to osteo[DIAGNOSES REDACTED] of the left hip and osteo[DIAGNOSES REDACTED] of the sacrum and Pseudomonas (gram-negative bacteria) infection from Resident 1's 23 wounds (including 15 pressure injures (three preexist, 12 new) and eight other wounds). The GACH Discharge /summary indicated Resident 1 had [DIAGNOSES REDACTED]. A review of Resident 1's GACH Initial Impaired Skin Integrity Form, dated 1/3/17, indicated upon admission, the resident had 15 pressures injuries as follow: 1. Resident 1's Sacrum/coccyx had a Stage 4 pressure injury (full thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone, or supporting structures such as tendon, joint capsules). This was a wound progression from Stage 3 to Stage 4, which developed osteo[DIAGNOSES REDACTED]. 2. Resident 1's right ischial had an unstageable pressure injury ((depth unknown)-full-thickness skin and tissue (consists of groups of cells with a similar structure working together for a specific function) loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, green or brown) and/or eschar (tan, brown, or black) in the wound bed). This was a wound progression from Stage 3 to unstageable pressure injury. 3. Resident 1's right hip had a Stage 4 pressure injury. This was a wound progression from Stage 3 to Stage 4. 4. Resident 1's left hip had an unstageable pressure injury. This wound was a progression to osteo[DIAGNOSES REDACTED]. 5. Resident 1's mid back had a Stage 3 pressure ulcer. 6. Resident 1's left lateral back had an unstageable pressure injury. 7. Resident 1's right medial foot had Deep Tissue Injury ((DTI)-persistent non-blanchable (an [DIAGNOSES REDACTED]tous lesion that loses all redness when pressed is termed) deep red, maroon or purple discoloration due to damage of underlying soft tissue) with partial thickness and wound in clusters. This was a new skin condition for the resident. 8. Resident 1's right lateral foot had DTI with partial thickness loss. 9. Resident 1's left heel had DTI. This was a new skin condition for the resident. 10. Resident 1's left medial lower leg had DTI with partial thickness tissue loss. This was a new skin condition for the resident. 11. Resident 1's left lateral foot had DTI with partial thickness 12. Resident 1's right first toe had DTI. This was a new skin condition for the resident. 13. Resident 1's right fifth toe had DTI. This was a new skin condition for the resident. 14. Resident 1's left fifth toe had DTI with partial thickness with discoloration on the other toes. This was a new skin condition for the resident. 15. Resident 1's right heel had DTI. This was a new skin condition for the resident. During a telephone interview on 4/6/18, at 1:53 p.m., Certified Nursing Assistant 1 (CNA 1) stated that Resident 1's skin smelled liked rotten meat, like a dead rat. CNA 1 stated that Resident 1's pressure injuries got bigger. During a review of Resident 1's medical record, and a concurrent telephone interview with LVN 1 on 4/5/18, at 4:23 p.m., LVN 1 stated that the Physicians (Physicians from Hospice care and Physicians from the facility) did not see Resident 1's pressure injuries and or skin conditions while resident resided at the facility. LVN 1 stated the Hospice Physician ordered to use [MEDICATION NAME] cream for Resident 1's pressure injuries. LVN 1 stated that [MEDICATION NAME] cream was used to treat residents [MEDICAL CONDITION] that Resident 1 did not have burns. LVN 1 sated that Resident 1 was supposed to see a Physician so that the Physician could order the necessary wound treatment. LVN 1 stated that if pressure injuries were not treated appropriately, the pressure injuries could become worse, and the resident could get an infection. On 4/9/18 at 7:35 a.m., an attempt was made to interview the facility's wound consultant with no success. A review of the facility's undated policy and procedure titled Pressure Sores, indicated all available measures would be taken to prevent skin breakdown and pressures sores, and that if these conditions occurred, treatment would be initiated immediately and preventive measures taken to prevent further deterioration of the skin. A review of the facility's policy and procedure titled Change of Condition, dated as 5/2016, indicated that resident safety was the priority and that all change of condition would be handled promptly. According to http://www.npuap.org/wp-content/uploads/2014/08/Quick-Reference-Guide-DIGITAL-NPUAP-EPUAP-PPPIA-Jan2016.pdf, indicated that in the presence of clinical signs of infection ([DIAGNOSES REDACTED] (redness), enderness, [MEDICAL CONDITION] (swelling), purulence (discharging pus), and malodor (very unpleasant smell)), required assessment by a medical practitioner vascular surgeon, and possible urgent surgical debridement (the medical removal of dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue), and to provide laboratory services as needed.

Based on interview and record review, the facility failed to ensure the abuse policy was implemented for one sampled resident (Resident 1). The facility staff did not report incidents of alleged staff to resident abuse to the administrator in a timely manner, per facility policy. Staff witnessed Certified Nurse Aide 1 (CNA 1) slap Resident 1's face and verbally refer to the resident as Baldy in the past and did not report the incidents to the administrator. As a result, Resident 1 was subject to further physical and mental abuse. Findings: A review of the admission face sheet indicated Resident 1 was admitted to the facility, on 5/23/14, with [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS, an assessment and care planning tool), dated 6/3/16, indicated Resident 1 was usually able to make herself understood and usually understood others, she had severely impaired cognitive skills for daily decision-making, and the resident was totally dependent on staff assistance for all her activities of daily living. A review of the SOC 341 (a State form used to report suspected elder abuse), dated 6/22/16, indicated two staff members (CNA 2 and CNA 3) had knowledge of abuse which occurred at the facility. An interview with Resident 1 was attempted, on 7/7/16, at 2:15 p.m., however the resident was unable to answer questions due to confusion. During interviews with the staff members, on 7/12/16, at 12:15 p.m., CNA 3 stated some time in April 2016, CNA 1 called him to help her transfer Resident 1 from the shower chair to the wheelchair. After the transfer was completed, CNA 3 stated he observed CNA 1 slap Resident 1's face several times and he told her to stop. He stated CNA 1 struck the resident on both sides of her face with both hands and the resident put her hands up to cover her face. She looked scared and frightened. CNA 3 stated when he cared for Resident 1 now, she sometimes seems scared. CNA 3 stated he did not report the incident at that time because he was very busy. He stated, on 6/20/16, he talked to a co-worker and reported the incident the following day, though it had actually occurred in April. At 3:15 p.m., CNA 2 stated she observed CNA 1 slap Resident 1 in the face .around a year ago. CNA 2 stated she could not remember exactly when the incident occurred. She stated CNA 1 had asked for her assistance in providing bedside care for Resident 1, and while doing so, CNA 2 stated she observed CNA 1 slap the resident's face with an open hand. CNA 2 stated she was shocked and told CNA 1 not to hit the resident. She stated CNA 1 ignored her comment and continued fixing the resident's bed. CNA 2 stated she failed to report the incident at the time because she was scared. During an interview with the Director of Nurses (DON), on 7/7/16, at 3:45 p.m., she stated CNA 3 told her he had witnessed an incident when CNA 1 slapped Resident 1 in the face several times and called her bald in Tagalog. A review of a care plan, initiated 3/10/16, indicated Resident 1 was at risk for body image disturbance due to [DIAGNOSES REDACTED] (hair loss) related to history [MEDICAL CONDITION]. The care plan interventions included to refer for counseling if needed, allow resident to verbalize feelings regarding change in body image, and observe for changes in mental status. According to the facility investigation, there was a third staff member (Staff 3) who also witnessed CNA 1 abusing Resident 1. In addition, a review of the social service progress notes, dated 6/21/16, indicated Resident 1 was interviewed regarding the abuse incident and stated she had been hurt several times by CNA 1. During an interview with the Administrator, on 7/12/16, at 12:45 p.m., he stated he did not understand why the staff members failed to report the incidents. The Administrator stated they all attended the facility's abuse training. A review of the facility's policy and procedure titled, Patient Abuse, updated 4/30/13, indicated the facility Administrator and/or designee shall ensure the prevention, monitoring, and identification of unusual occurrences and events that may constitute abuse. Any incidences or occurrences that may constitute abuse shall be recorded on the Incident Report form and reported to the Director of Nurses, facility Administrator/Abuse Coordinator immediately after and/or no later than 24 hours after the identification of the unusual occurrence or events constituting abuse or probable abuse. The policy indicated CNAs were most likely to notice something was wrong. Professionally and legally nursing home staff was required to report. Possible abuse must be reported immediately to the nursing home administrator. The time period for reporting events that cause reasonable suspicion of abuse, but do not result in serious bodily injury to a resident was immediately, not later than 24 hours after forming the suspicion.

Based on interview and record review, the facility failed to ensure residents were free of physical and mental abuse for one sampled resident (Resident 1), per facility policy. Staff reported having observed Certified Nurse Aide 1 (CNA 1) slap Resident 1's face and verbally refer to the resident as Baldy in the past. Staff failed to report the two incidents of abuse in a timely manner. These deficient practices resulted in a reasonable person experiencing pain, mental anguish, and emotional distress. Findings: A review of the admission face sheet indicated Resident 1 was admitted to the facility, on 5/23/14, with [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS, an assessment and care planning tool), dated 6/3/16, indicated Resident 1 was usually able to make herself understood and usually understood others, she had severely impaired cognitive skills for daily decision-making, and the resident was totally dependent on staff assistance for all her activities of daily living. A review of the SOC 341 (a State form used to report suspected elder abuse), dated 6/22/16, indicated two staff members (CNA 2 and CNA 3) had knowledge of abuse which occurred at the facility. An interview with Resident 1 was attempted, on 7/7/16, at 2:15 p.m., however the resident was unable to answer questions due to confusion. During interviews with the staff members, on 7/12/16, at 12:15 p.m., CNA 3 stated some time in April 2016, CNA 1 called him to help her transfer Resident 1 from the shower chair to the wheelchair. After the transfer was completed, CNA 3 stated he observed CNA 1 slap Resident 1's face several times and he told her to stop. He stated CNA 1 struck the resident on both sides of her face with both hands and the resident put her hands up to cover her face. She looked scared and frightened. CNA 3 stated when he cared for Resident 1 now, she sometimes seems scared. CNA 3 stated he did not report the incident at that time because he was very busy. He stated, on 6/20/16, he talked to a co-worker and reported the incident the following day, though it had actually occurred in April. At 3:15 p.m., CNA 2 stated she observed CNA 1 slap Resident 1 in the face .around a year ago. CNA 2 stated she could not remember exactly when the incident occurred. She stated CNA 1 had asked for her assistance in providing bedside care for Resident 1, and while doing so, CNA 2 stated she observed CNA 1 slap the resident's face with an open hand. CNA 2 stated she was shocked and told CNA 1 not to hit the resident. She stated CNA 1 ignored her comment and continued fixing the resident's bed. CNA 2 stated she failed to report the incident at the time because she was scared. During an interview with the Director of Nurses (DON), on 7/7/16, at 3:45 p.m., she stated CNA 3 told her he had witnessed an incident when CNA 1 slapped Resident 1 in the face several times and called her bald in Tagalog. A review of a care plan, initiated 3/10/16, indicated Resident 1 was at risk for body image disturbance due to [DIAGNOSES REDACTED] (hair loss) related to history [MEDICAL CONDITION]. The care plan interventions included to refer for counseling if needed, allow resident to verbalize feelings regarding change in body image, and observe for changes in mental status. According to the facility investigation, there was a third staff member (housekeeper) who also witnessed CNA 1 abusing Resident 1. In addition, a review of the social service progress notes, dated 6/21/16, indicated Resident 1 was interviewed regarding the abuse incident and stated she had been hurt several times by CNA 1. During an interview with the Administrator, on 7/12/16, at 12:45 p.m., he stated he did not understand why the staff members failed to report the incidents. The Administrator stated they all attended the facility's abuse training. A review of the facility's policy and procedure titled, Patient Abuse, updated 4/30/13, indicated the facility Administrator and/or designee shall ensure the prevention, monitoring, and identification of unusual occurrences and events that may constitute abuse. Any incidences or occurrences that may constitute abuse shall be recorded on the Incident Report form and reported to the Director of Nurses, facility Administrator/Abuse Coordinator immediately after and/or no later than 24 hours after the identification of the unusual occurrence or events constituting abuse or probable abuse. The policy indicated CNAs were most likely to notice something was wrong. Professionally and legally nursing home staff was required to report. Possible abuse must be reported immediately to the nursing home administrator. The time period for reporting events that cause reasonable suspicion of abuse, but do not result in serious bodily injury to a resident was immediately, not later than 24 hours after forming the suspicion.