Every finding on record at Colonial Gardens Nursing Home

Based on interview and record review, the facility failed to report an allegation of staff-to-resident abuse to the State Agency (SA) involving one of two sampled residents (Resident 2). This deficient practice created the potential for unidentified abuse and delayed investigation by the SA.Findings: During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE]. Resident 2's diagnoses included encephalopathy (any disorder or disease that affects the function or structure of the brain), drug-induced tremor (an involuntary, rhythmic shaking movement in one or more parts of the body), schizoaffective disorder bipolar type (a mental illness that can affect thoughts, mood, and behavior), and psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality). During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool), dated 7/7/2026, the MDS indicated Resident 2 had severe cognitive skills for daily decision making (a major loss of intellectual and mental capacity). The MDS indicated Resident 2 did not exhibit hallucinations (false perceptions of objects or events involving the senses) or delusions (having false or unrealistic beliefs). The MDS indicated Resident 2 required partial to moderate assistance from staff for toileting and personal hygiene, showering/bathing herself, and for transfers into and out of the shower. During a review of Resident 2's Daily Skilled Medicare Charting assessment, dated 8/5/2026, the assessment indicated Resident 2 was alert, easily understood by others, and could understand others. The assessment indicated Resident 2 did not exhibit disorganized thinking, hallucinations, or delusions. During a review of Resident 2's Change of Condition (COC) assessment, dated 8/6/2026 by Licensed Vocational Nurse (LVN) 1, the assessment indicated Resident 2 was alleging that staff were inappropriately touching her during showers. The assessment indicated LVN 1 documented Resident 2 was having false accusations towards staff. During a review of Resident 2's Daily Skilled Medicare Charting assessment, dated 8/6/2026, the assessment indicated the facility conducted the assessment after the COC assessment on 8/6/2026. The assessment indicated Resident 2 remained alert, easily understood by others, and could understand others. The assessment indicated Resident 2 continued to remain free of disorganized thinking, hallucinations, or delusions. During a review of Resident 2's progress notes dated 8/7/2026 at 1:22 a.m. and 2:28 p.m., 8/8/2026 at 5:41 a.m., 12:50 p.m., and 10:23 p.m., and 8/9/2026 at 12:55 a.m., the progress notes indicated Resident 2 was being monitored for making false accusations towards staff. During a review of Resident 2's Electronic Medical Record (EMR), the EMR did not indicate there was any investigation into Resident 2's allegations of being touched inappropriately by staff. During a concurrent observation and attempted interview on 8/21/2026 at 12:39 p.m., with Resident 2 in the hallway. Resident 2 was observed visually scanning the hallway. Resident 2 was asked if she felt safe in the facility. Resident 2 did not respond. Resident 2 was fidgeting and walked away after not wanting to speak further. During an interview on 8/21/2026 at 12:50 p.m., with LVN 1, LVN 1 stated that on 8/6/2026, Resident 2 and Certified Nursing Assistant (CNA) 1 were behind the shower curtain when she overheard Resident 2 become agitated and raise her voice. LVN 1 stated CNA 1 came out from behind the shower curtain and Resident 2 calmed down. LVN 1 stated she did not observe Resident 2's entire shower that day, or CNA 1 directly assisting Resident 2. LVN 1 stated that after Resident 2 returned to her room, CNA 1 approached her and informed her that Resident 2 was falsely accusing her of poking Resident 2 in her vaginal area. LVN 1 stated she concluded the allegation was false because she briefly observed Resident 2 with her shirt and pants on in the shower. LVN 1 stated Resident 2 had a known behavior of showering with her clothes on due to being uncomfortable being nude in the shower. LVN 1 stated it was possible for staff to touch a resident inappropriately, even if she did not observe it herself. LVN 1 stated an allegation of unwanted touching should be reported. LVN 1 stated it was important to report for resident safety. During an interview on 8/21/2026 at 1:13 p.m., with Registered Nurse (RN) 2, RN 2 stated it was the facility's policy to report the allegation to the Abuse Coordinator (facility's Administrator [ADM]), regardless of whether it happened. During an interview on 8/21/2026 at 3:31 p.m., with the Assistant Director of Nursing (ADON), the ADON stated she was not aware of this COC assessment until 8/21/2026 when LVN 1 told her about it. The ADON stated LVN 1 should have reported the allegation to the ADM. The ADON stated it was not appropriate for facility staff to immediately conclude Resident 2's allegation was false. The ADON stated this prevented an investigation of the allegation, and the ability to prevent abuse from reoccurring. The ADON stated it could also lead staff to discredit any future allegations of staff-to-resident abuse made by Resident 2 because staff would believe those were false as well. During a review of the facility's policy and procedure (P&P) titled Abuse Investigation and Reporting, dated 7/2017, the P&P indicated all reports of resident abuse were to be promptly reported to local, state and federal agencies and thoroughly investigated by facility management.

Based on interview and record review, the facility failed to ensure the admission Record ( face sheet, front page of the chart that contains a summary of basic information about the resident) for one of two sampled residents (Resident 2) clearly and accurately indicated the individual responsible for making Resident 2's medical decisions and providing informed consent. This deficient practice created the potential for Resident 2 to be permitted to make medical decisions or provide informed consents for treatment, despite lacking the capacity to make such decisions.Findings: During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE]. Resident 2's diagnoses included encephalopathy (any disorder or disease that affects the function or structure of the brain), drug-induced tremor (an involuntary, rhythmic shaking movement in one or more parts of the body), schizoaffective disorder bipolar type (a mental illness that can affect thoughts, mood, and behavior), and psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality). The admission Record indicated Resident 2 was self-responsible. During a review of Resident 2's History and Physical (H&P), dated 7/3/2026, the H&P indicated Resident 2 did not have memory loss, but lacked the capacity to make medical decisions. During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool), dated 7/7/2026, the MDS indicated Resident 2 had severe cognitive impairment (a major loss of intellectual and mental capacity). The MDS indicated Resident 2 required partial to moderate assistance from staff for toileting and personal hygiene, showering/bathing herself, and for transfers into and out of the shower. During an interview on 8/21/2026 at 3:26 p.m., with the Assistant Director of Nursing (ADON), the ADON stated that if the resident's H&P indicated the resident lacked capacity to make medical decisions, this meant the resident could make medical decisions for themselves, include providing informed consent for anything that required consent to be obtained. The ADON stated a resident who lacked medical decision-making capacity could not be considered self-responsible. The ADON stated it was important for facility staff to know the resident's decision-making capacity to ensure that their rights were honored, and that the appropriate person was being contacted for care decisions. During a review of the facility's policy and procedure (P&P) titled Resident Rights, dated 2001, the P&P indicated residents had the right to be supported by the facility in exercising their rights, including being informed of and participating in their care planning and treatment.

Based on interview and record review, the facility failed to ensure a comprehensive care plan was revised for one of four sampled residents (Resident 3), following a second episode of aggression.This deficient practice had the potential to place Resident 3 at risk for further episodes of physical and verbal aggression toward staff and residents. Findings:a. During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 3's diagnoses included bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), and hypertension (high blood pressure).During a review of Resident 3's Minimum Data Set ([MDS], a resident assessment tool), dated 3/6/2026, the MDS indicated Resident 3's cognitive skills (ability to think and reason) for daily decision making were intact. The MDS indicated Resident 3 required moderate assistance (helper does less than half the effort) for toileting, showering, and dressing.During a review of Resident 3's situation, background, assessment, recommendation (SBAR- a communication tool used by healthcare workers when there is a change of condition among the residents), dated 3/10/2026, the SBAR indicated Resident 3 was verbally aggressive towards staff.During a review of Resident 3's SBAR dated 3/17/2026, the SBAR indicated Resident 3 was verbally aggressive towards staff, and threw furniture and his food tray.During a review of Resident 3's SBAR Note, dated 3/23/2026, the note indicated staff witnessed Resident 3 hit another resident (Resident 4) in the face.b. During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 4's diagnoses included schizoaffective disorder, diabetes (poor blood sugar control), and depression (an overwhelming feeling of sadness).During a review of Resident 4's MDS, dated [DATE], the MDS indicated Resident 4's cognitive skills for daily decision making were moderately impaired. The MDS indicated Resident 4 required supervision for oral hygiene, toileting, and showering.During a concurrent interview and record review on 4/2/2026 at 12:46 p.m. with Registered Nurse (RN) 1, Resident 3's SBARs, dated 3/10/2026, 3/17/2026, and 3/23/2026, and Resident 3's care plans and Interdisciplinary Team (IDT, group of different disciplines working together towards a common goal of a resident) Meeting Notes, dated 3/2026, were reviewed. The care plans did not indicate revisions were made after Resident 3 was verbally aggressive on 3/10/2026. There were no IDT Meetings documented from 2/27/2026 through 3/17/2026 to evaluate or revise the resident's care and behavioral interventions. RN 1 stated the facility's practice was to conduct IDT Meetings to formally evaluate or reevaluate the resident's care and medication regimen in collaboration with the psychiatrist. RN 1 stated an IDT meeting should have been conducted to reevaluate the care for Resident 3 prior to the resident's altercation on 3/23/2026 due to prior documented aggressive behaviors. RN 1 stated this would have allowed for a timely revision of Resident 3's aggression care plan. RN 1 stated Resident 3's care plan should have been revised on 3/10/2026 following continued aggressive behavior to allow for implementation of additional interventions to prevent further episodes. RN 1 stated without alternative interventions, Resident 3 was at risk for continued aggression toward staff and escalation to altercations with other residents.During an interview on 4/2/2026 at 4:03 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she authored Resident 3's SBAR dated 3/10/2026. LVN 1 stated she did not revise Resident 3's care plan. LVN 1 stated the care plan should be revised after continued episodes of aggressive behavior for appropriate interventions to prevent reoccurrence or escalation.During a review of the facility's Policy and Procedure (P&P) titled, Comprehensive, Person-Centered Safety and Supervision of Residents, revised 3/2022, the P&P indicated the facility was to ensure assessments of residents were ongoing and care plans are revised as information about the residents and the residents' conditions change. The P&P indicated the interdisciplinary team reviewed and updated the care plan when there was a significant change in the resident's condition and when the desired outcome was not met.

Based on interview and record review, the facility failed to ensure accurate and complete documentation of monitoring of a resident's aggressive behaviors following readmission from a 5150 hold (a 72-hour hold for a resident experiencing a mental health crisis and evaluated to be a danger to others, themselves, or gravely disabled) at the general acute care hospital (GACH) and a physical altercation for one out of five sampled residents (Resident 1).This deficient practice had the potential to place Resident 1 and other residents at risk for physical harm caused by Resident 1.Findings:a. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included major depressive disorder (overwhelming feeling of sadness), hypertension (high blood pressure), and abnormalities of gait and mobility.During a review of Resident 1's Minimum Data Set ([MDS], a resident assessment tool), dated 3/14/2026, the MDS indicated Resident 1's cognitive skills (ability to think and reason) for daily decision making were moderately impaired. The MDS indicated Resident 1 required moderate assistance (helper does less than half the effort) for toileting, showering and dressing.During a review of Resident 1's situation, background, assessment, recommendation (SBAR- a communication tool used by healthcare workers when there is a change of condition among the residents), dated 3/2/2026, the SBAR indicated on 3/2/2026, Resident 1 punched another resident in the face, resulting in a transfer to the general acute care hospital (GACH).During a review of Resident 1's care plan titled, Psychotropic Medications (medications that manage mental health conditions), initiated on 1/21/2026, and revised on 3/16/2026, the care plan indicated to monitor and record the occurrence of target behaviors, including aggression towards others, and document per facility protocol.During a review of Resident 1's SBAR, dated 3/19/2026, the SBAR indicated on 3/19/2026, staff witnessed Resident 1 strike Resident 2's face, resulting in a transfer to the GACH.b. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was initially admitted to the facility on [DATE]. Resident 2's diagnoses included diabetes, anxiety (an overwhelming feeling of uneasiness), and hypertension. During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2's cognitive skills for daily decision making were moderately impaired. The MDS indicated Resident 2 required moderate assistance for toileting, showering and dressing.During a concurrent interview and record review on 4/2/2026 at 12:16 p.m. with Registered Nurse (RN) 1, Resident 1's Nursing Progress Notes, dated 3/10/2026 through 3/18/2026, and Resident 1's Medication Administration and Monitoring Record, dated 3/2026, were reviewed. The progress notes indicated Resident 1 was readmitted on [DATE] following hospitalizations under a 5150 hold (a 72-hour psychiatric hold for a resident experiencing a mental health crisis and evaluated to be a danger to others, themselves, or gravely disabled) for a prior altercation with a resident. The Medication Administration and Monitoring Record did not indicate Resident 1's aggressive behaviors were monitored from 3/13/2026 to 3/18/2026, prior to his altercation with Resident 2. RN 1 stated that it was important to monitor and document Resident 1's aggressive behaviors to ensure the safety of the resident and others.During an interview on 4/2/2026 at 3:34 p.m. with the Director of Nursing (DON), the DON stated the expectation of the licensed nurses was to document Resident 1's condition every shift. The DON stated Resident 1's recent readmission to the facility and physical altercation, placed Resident 1 at increased risk for further aggressive behavior, requiring ongoing supervision and monitoring for changes in behavior. The DON stated the lack of monitoring and documentation increased the risk for Resident 1 to engage in another physical altercation. During a review of the facility's Policy and Procedure (P&P) titled, Safety and Supervision of Residents, revised 2/2021, the P&P indicated the facility was to ensure individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents. The P&P indicated the facility was to implement interventions to reduce accident risks and hazards which included the following ensuring interventions were implemented and documented.

Based on interview and record review, the facility failed to report an injury of unknown origin to the California Department of Public Health (CDPH) for one of three sampled residents (Resident 3).This deficient practice resulted in delayed investigation by CDPH and had the potential to place residents safety at risk.Findings:During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE]. Resident 3's diagnoses included dementia (a progressive state of decline in mental abilities), hypertension (HTN- high blood pressure), and hyperlipidemia (high levels of fats in the blood).During a review of Resident 3's History and Physical (H&P) dated 11/1/2025, the H&P indicated Resident 3 did not have the capacity to understand or make medical decisions.During a review of Resident 3's Minimum Data Set (MDS- a resident assessment tool), dated 2/2/2026, the MDS indicated Resident 3 had moderate cognitive (ability to think and understand) impairment. The MDS indicated Resident 3 required set up or clean-up assistance from staff for eating, toileting and personal hygiene.During a review of Resident 3's Situation Background Assessment Recommendation Communication (SBAR- communication form used to share resident change in condition information with provider) dated 3/6/2026, the SBAR indicated on 3/6/2026, Resident 3 was noted with weakness while walking in the dining hall for lunch, and required assistance with getting back to her room. Resident 3's SBAR form indicated Resident 3 complained of eight out of ten left hip and left leg pain. The SBAR indicated Resident 3's physician was notified and ordered a X-Ray (imaging test that uses radiation to take pictures of the inside of the body) of the hip.During a review of Resident 3's SBAR Communication form dated 3/6/2026, the SBAR indicated Resident 3 complained of left hip pain but was unable to give a complete description of what happened to cause pain. Resident 3's SBAR indicated while Resident 3's X-Ray was being completed, Resident 3 stated she had a fall but was unable to give a detailed description of how the fall occurred.During a review of Resident 3's Interdisciplinary Team (IDT, group of different disciplines working together towards a common goal of a resident) Progress Note dated 3/9/2026, the IDT Progress Note indicated X-Ray findings of the left hip indicated acute complete femoral neck fracture with partial displacement (a break in the uppermost part of the femur, just below the ball of the hip joint). Resident 3's IDT Progress Note indicated Resident 3's physician was made aware and ordered to send Resident 3 to the General Acute Care Hospital (GACH) for further evaluation and treatment.During an interview on 3/16/2026 at 11:04 a.m. with Registered Nurse (RN) 1, RN 1 stated on 3/6/2026, Resident 3 was alert and oriented to name only and was unable to explain how her fall occurred. RN 1 stated the details of Resident 3's fall, such as when or where fall occurred, were unknown.During a concurrent interview and record review on 3/16/2026 at 2:42 p.m. with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating dated 9/2022 was reviewed. The P&P indicated, if resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. The P&P indicated, the administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies, the state licensing/certification agency responsible for surveying/licensing the facility. The DON stated Resident 3's fall was unwitnessed and the details were unknown. The DON stated Resident 3 was unable to explain details surrounding her fall. The DON stated reporting injuries of unknown origin was important to ensure a thorough investigation of the incident takes place and appropriate interventions were implemented to prevent recurrence. The DON stated failure to report an injury of unknown origin delayed investigation by CDPH and placed residents safety at risk.

Based on interview and record review, the facility failed to ensure fall risk assessments accurately reflected residents' status and was updated following a fall for one of three sampled residents (Resident 3).These deficient practices had the potential to place Resident 3 at an increased risk for a fall.Findings:During a review of Resident 3's admission Record, the admission record indicated Resident 3 was admitted to the facility on [DATE]. Resident 3's diagnoses included dementia (a progressive state of decline in mental abilities), hypertension (HTN- high blood pressure) and hyperlipidemia (high levels of fats in the blood).During a review of Resident 3's History and Physical (H&P) dated 11/1/2025, the H&P indicated Resident 3 did not have the capacity to understand or make medical decisions.During a review of Resident 3's Minimum Data Set (MDS- a resident assessment tool), dated 2/2/2026, the MDS indicated Resident 3 had moderate cognitive (ability to think and understand) impairment. The MDS indicated Resident 3 required set up or clean-up assistance from staff for eating, toileting and personal hygiene.a. During a concurrent interview and record review on 3/16/2026 at 11:04 a.m. with Registered Nurse (RN) 1, Resident 3's Fall Risk Assessment dated 2/2/2026 was reviewed. The Fall Risk Assessment indicated Resident 3's mental status was alert and oriented times (x) 3 (medical term confirming resident is awake, knows their identity, location and time). RN 1 stated Resident 3 was alert and oriented to her name only and had periods of confusion. RN 1 stated the mental status section of Resident 3's Fall Risk Assessment should have indicated intermittent confusion instead of alert and oriented x3. RN 1 stated accurate Fall Risk Assessment's were important to ensure staff knew the appropriate interventions and preventative measures to implement for fall prevention. RN 1 stated inaccurate Fall Risk Assessment's placed residents at an increased risk for falls.During a concurrent interview and record review on 3/16/2026 at 2:42 p.m. with the Director of Nursing (DON), Resident 3's Fall Risk Assessment dated 2/2/2026 was reviewed. The Fall Risk Assessment indicated Resident 3's mental status was alert and oriented x3. Resident 3's Physician Progress notes dated 2/15/2026, indicated Resident 3 had periods of confusion. The DON stated the Fall Risk Assessment should reflect residents mental status, and should have indicated Resident 3 had intermittent confusion. The DON stated Fall Risk Assessment accuracy was important because it not only indicated the level of risk, but determined which interventions nursing staff were to implement.During a review of the facility's policy and procedure (P&P) titled, Fall Risk Assessment dated 2001, the P&P indicated the staff, with the support of the attending physician, will evaluate functional and psychological factors that may increase fall risk, including ambulation, mobility, gait, balance, excessive motor activity, activities of daily living capabilities, activity tolerance, continence and cognition.b. During a concurrent interview and record review on 3/16/2026 at 11:04 a.m. with Registered Nurse (RN) 1, Resident 3's Situation Background Assessment Recommendation Communication (SBAR- communication form used to share resident change in condition information with provider) dated 3/6/2026 was reviewed. The SBAR Communication form indicated on 3/6/2026, Resident 3 had a fall and was unable to give a detailed description of how the fall occurred. RN 1 stated nurses were responsible for completing an updated fall risk assessment after a fall. RN 1 stated an updated Fall Risk Assessment was not completed after Resident 3 fell. RN 1 stated updated Fall Risk Assessment's were important because nursing staff needed to reassess the resident to determine what preventative measures needed to be implemented to ensure safe ambulation (walking). RN 1 stated failure to update Resident 3's Fall Risk Assessment's placed the resident at an increased risk for falls.During a concurrent interview and record review on 3/16/2026 at 2:42 p.m. with the Director of Nursing (DON), Resident 3's Fall Risk Assessment's dated 2/2/2026 were reviewed. The Fall Risk Assessment was not updated after Resident 3's fall on 3/6/2026. The DON stated nursing staff should have updated Resident 3's Fall Risk Assessment to ensure appropriate interventions were being implemented for fall prevention and resident safety. The DON stated the facility did not have a specific policy for required documentation for residents after a fall.

Based on interview and record review, the facility failed to follow the care plan and monitor for paranoid delusions (fixed, irrational beliefs that others are plotting against or trying to harm you, without evidence) for one of three sampled residents (Resident 1).This deficient practice had the potential to result in unmonitored paranoid delusions and unaddressed aggressive behaviors. Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 3's diagnoses included major depressive disorder (mental health condition characterized by intense sadness and loss of interest in activities), hypertension (HTN-high blood pressure), and chronic kidney disease (CKD- kidney damage resulting in loss of ability to filter waste and fluid from blood).During a review of Resident 1's History and Physical (H&P) dated 1/20/2026, the H&P indicated Resident 1 had the capacity to understand and make decisions.During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 1/25/2026, the MDS indicated Resident 1 had moderate cognitive (ability to think and understand) impairment. The MDS indicated Resident 1 required moderate assistance from staff for toileting and supervision from staff for eating and personal hygiene.During an interview on 3/16/2026 at 10:05 a.m. with Resident 1, Resident 1 stated on 3/2/2026, while eating dinner in the dining hall, he read Resident 2's lips and saw Resident 2 was talking about him while on the phone. Resident 1 stated he walked up to Resident 2 and punched him in the face.During a concurrent interview and record review on 3/16/2026 at 11:04 a.m. with Registered Nurse (RN) 1, Resident 1's medical records and care plan dated 3/12/2026 were reviewed. The medical records did not indicate there was a physician order for the behavior monitoring of Resident 1's paranoid delusions. The care plan indicated Resident 1 had episodes of paranoid behavior as evidenced by the resident claiming the mafia was trying to kill him. RN 1 stated the care plan included an intervention to monitor Resident 1's episodes of paranoid delusions every shift. RN 1 stated staff documented monitoring behaviors in the task section of the Medication Administration Record (MAR). RN 1 stated behavior monitoring tasks were created when an order was made to monitor for specific behaviors. RN 1 stated monitoring Resident 1's paranoid delusions was important to ensure effectiveness of medication regimen and to determine the need of physician reassessment. RN 1 stated not following care plan interventions placed Resident 1 at risk of unmonitored paranoid delusions and unaddressed behaviors.During an interview on 3/16/2026 at 2:42 p.m. with the Director of Nursing (DON), the DON stated following the care plan was important to prevent unaddressed aggressive behaviors and to keep residents and staff safe. The DON stated monitoring Resident 1's paranoid delusions allowed the care team to evaluate the effectiveness of the residents current plan of care, as well as the need for physician reassessment or medication adjustment.During a review of the facility's policy and procedure (P&P) titled Care Plans, Comprehensive Person-Centered dated 2/2022, the P&P indicated, The comprehensive, person-centered care plan: . describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The P&P indicated, Services provided for or arranged by the facility and outlined in the comprehensive care plan are: provided by qualified persons.

Based on interview and record review, the facility failed to ensure one of five residents (Resident 1), received treatment and care in accordance with professional standards of practice. The facility failed to: 1). Ensure Resident 1's Medical Doctor (MD) was notified of the resident's refusal to eat breakfast and lunch, during the resident's change of condition (COC) on 12/18/2025.2). Carry out (follow) MD's urinalysis ([UA] a common diagnostic test that examines the urine to detect disorders) order on 12/18/2025.3). Monitor Resident 1 for dehydration (having lost a large amount of water from the body [dizziness on sitting/standing, change in mental status, decreased urine output, concentrated urine, poor skin turgor, dry, cracked lips, dry mucous membranes, sunken eyes, constipation, fever, infection, electrolyte imbalance]) as indicated in the resident's care plan titled, Resident has decreased or unable to eat/drink adequate amounts of food or fluid intake related to (r/t) resident refusing breakfast and lunch. Resident allowing food to fall out of mouth.4). Notify Resident 1's MD when there was a delay in transferring to a General Acute Care Hospital (GACH) on 12/22/2025. These failures had the potential to affect the care and services Resident 1 needs and the potential to delay care, resulting in complications and hospitalization.Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and was readmitted on [DATE]. Resident 1's diagnoses included Metabolic Encephalopathy (a change in how the brain works due to an underlying condition) and dysphagia (difficulty swallowing), oropharyngeal phase (the second stage of swallowing, where food or liquid is moved from the back of the mouth, through the throat, and into the esophagus [a muscular tube in the chest that connects the throat to the stomach] while closing off the airway to prevent choking). During a review of Resident 1's Minimum Data Set ([MDS], a resident assessment tool) dated 12/23/2025, the MDS indicated Resident 1 had severe (extreme) cognitive impairment (problems with the ability to think, remember, and solve problems). The MDS indicated Resident 1 was dependent (helper does all the effort) with Activities of Daily Living (ADLs) such as toileting and personal hygiene. The MDS indicated Resident 1 was dependent with staff in rolling from a lying on back position to her left and right side, from sitting to lying position, lying to sitting on side of bed and sitting to standing position. During a review of Resident 1's clinical records, the following were identified: 1). On 12/18/2025, Resident 1 had a Change of Condition (COC), indicating Resident 1 was not eating breakfast and lunch, and was allowing food to fall out of mouth. The COC indicated, a family member (FM 1) stated, This was a pattern when Resident 1 gets urinary tract infection, and requested a UA to be done. The COC indicated Resident 1's urine was yellow and had no foul odor. Resident 1's MD ordered UA. The COC did not indicate that MD was informed of Resident 1's refusal to eat breakfast and lunch and food falling out of the resident's mouth. During a review of Resident 1's Progress Notes dated 12/18/2025, the progress notes did not indicate Resident 1's MD was informed of Resident 1's refusal to eat breakfast and lunch and food falling out of the resident's mouth. 2). On 12/18/2025, Resident 1's care plan titled, Resident has decreased or unable to eat/drink adequate amounts of food or liquid intake r/t Resident refusing breakfast and lunch. Resident allowing food to fall out of mouth, was created. One of the interventions indicated to assess the resident for dehydration.During a review of Resident 1's clinical records from 12/18/2025, the clinical records had no indication Resident 1 was monitored for dehydration. 3). During a review of Resident 1's progress notes dated 12/19/2025 at 1:48 p.m., the progress notes indicated a urine specimen was collected from Resident 1.During a review of Resident 1's lab reports, dated 12/22/2025, the lab report did not indicate a UA result. 4). On 12/22/2025 at 1:45 p.m., Resident 1 had a COC indicating Resident 1 had poor meal intake and was pocketing food and had abnormal lab results (unspecified). Resident 1's MD ordered to transfer Resident 1 to GACH for evaluation. During a review of Resident 1's progress notes, dated 12/22/2025 at 2:07 p.m., the progress notes indicated GACH had no available bed. At 6:08 p.m., the progress notes indicated the GACH emergency department (ED) notified the facility that GACH could not take (admit) Resident 1 due to saturated admissions (high number of admissions). The progress notes did not indicate Resident 1's MD was notified that Resident 1 was still waiting bed availability to be transferred to GACH. During a review of Resident 1's progress notes dated 12/23/2025 at 4:08 a.m., the progress notes indicated Resident 1 was still waiting to be transferred to hospital. The progress notes did not indicate resident's MD was notified of the delayed transfer to GACH. During a concurrent interview and record review on 2/18/2026 at 12:22 p.m., with Licensed Vocational Nurse (LVN) 1, the following were reviewed:Resident 1's COC, dated 12/18/2025Progress notes, dated 12/19/2025, 12/22/2025, and 12/23/2025Resident 1's COC, dated 12/21/2025.LVN 1 stated the COC indicated Resident 1 was not eating much, which could cause Resident 1 to deteriorate, become weak/ lack of energy, and dehydrated. LVN 1 stated there was no documented evidence that the license staff informed Resident 1's MD about the COC on 12/18/2025 (resident refusing breakfast and lunch and allowing food to fall out of mouth). LVN 1 stated Resident 1's MD should have been informed when the GACH was full and was unable to take (admit) the resident in ED for evaluation. LVN stated the staff should have obtained other orders from MD to ensure Resident 1's needs were met. LVN 1 stated Resident 1's condition could have gotten worse due to the delayed transfer. During an interview on 2/18/2026 at 1:40 p.m., with LVN 1, LVN 1 stated they were not sure if they have documents to indicate staff were assessing Resident 1 for dehydration. During a concurrent interview and record review on 2/18/2026 at 2:08 p.m. with the Director of Nursing (DON), the following were reviewed:Resident 1's COC, dated 12/18/2025Resident 1's labs, dated 12/22/2025Resident 1's care plan titled, Resident has decreased or unable to eat/drink adequate amounts of food or liquid intake related to (r/t) Resident refusing breakfast and lunch. Resident allowing food to fall out of mouth, dated 12/18/2025,Resident 1's progress notes dated from 12/18/2025 to 12/22/2025.The DON stated Resident 1's COC dated 12/18/2025 indicated an order for UA, however, there was no result found in Resident 1's clinical record. The DON stated there was a possibility the specimen was not collected. The DON stated Resident 1's progress notes had no indication Resident 1 was assessed for dehydration on 12/18/2025 as indicated in Resident 1's care plan titled, Resident has decreased or unable to eat/drink adequate amounts of food or liquid intake r/t Resident refusing breakfast and lunch. Resident allowing food to fall out of mouth, which indicated an intervention to assess for dehydration. The DON stated when Resident 1's transfer to GACH was delayed on 12/22/2025, the staff should have informed Resident 1's MD and obtained new orders or recommendation. If residents were not transferred timely, there could be a delay in and cause other problems to occur. During an interview on 2/20/2026 at 11:27 a.m. with the DON, the DON stated the facility-contracted laboratory told the DON stated there was no urine specimen collected on 12/18/2025. During a review of facility's policy and procedure (P&P) titled, Physician Orders, dated 2/2014, the P&P indicated, the receiving nurse should carry out the order. During a review of facility's P&P titled, Change in a Resident's Condition or Status, dated 2/2021, the P&P indicated the facility should promptly notify the resident's attending physician of changes in the resident's medical condition and/or status) and need to transfer the resident to the hospital/treatment center. During a review of facility's P&P titled, Care Plans, Comprehensive Person-Centered, dated 3/2022, the P&P indicated, the comprehensive, person-centered care plan describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The P&P indicated, a comprehensive, person-centered care plan is developed and should be implemented for each resident.

Based on observation, interview, and record review, the facility failed to develop and implement a care plan addressing a resident's diagnosis of sleep apnea (blocked airways) and use of a Bilevel Positive Airway Pressure ([BiPAP] a breathing therapy used to help a person with breathing difficulties) for one out of three sampled residents (Resident 2). These deficient practices had the potential to place Resident 2 at risk for device related injury, respiratory distress, and not receiving the necessary care and services. Findings: During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE]. Resident 2's diagnoses included diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), and hypertension (HTN- high blood pressure). During a review of Resident 2's Minimum Data Set (MDS- a resident assessment tool), dated 11/7/2025, the MDS indicated Resident 2's cognition (ability to think and process information) was intact. The MDS indicated Resident 2 required moderate (helper does less than half the effort) assistance from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 2's Order Summary Report, dated 12/30/2025, the order summary report indicated on 11/21/2025, Resident 2's attending physician prescribed the use of a BiPAP machine at bedtime for treatment of sleep apnea. During a concurrent observation and interview on 12/30/2025 at 8:00 a.m., in Resident 2's room, observed Resident 2's BiPAP machine on the nightstand next to the resident's bed. Resident 2 stated he used the BiPAP machine every night for sleep apnea. During a concurrent interview and record review on 12/30/2025 at 11:15 a.m., with the Assistant Director of Nursing (ADON), Resident 2's clinical health records including the document titled Psychiatric Evaluation and Mental Status Examination, dated 11/21/2025, Order Summary Report dated 12/30/2025, and the resident's active care plans, were reviewed. Resident 2's psychiatric evaluation included a diagnosis of sleep apnea. The order summary report indicated an active physician order dated 11/21/2025, for the use of the BiPAP machine nightly at bedtime to treat the resident's sleep apnea. Upon review of Resident 2's care plans, the ADON stated there was no care plan created or initiated to address Resident 2's sleep apnea. The ADON stated there was no care plan initiated for Resident 2's use of BiPAP. The ADON stated care planning serves as a communication tool among staff to ensure consistent implementation of goals and interventions, including monitoring of BiPAP use, resident education, and evaluation of tolerance. The ADON stated that without a care plan the staff would not know how to provide necessary care and services. The ADON stated this had the potential to place Resident 2 at risk for inconsistent use of the BiPAP machine and related complications, such as respiratory distress or injuries. During a review of the facility's policy and procedures (P&P) titled Care Plans, Comprehensive Person-Centered, revised 3/2022, the P&P indicated the facility would develop and implement a comprehensive person-centered care plan which includes measurable objectives and timelines to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

Based on observation, interview, and record review, the facility failed to ensure the safe storage of medications for one of three sampled residents (Resident 2). This deficient practice had the potential to place Resident 2 at risk for unsafe medication administration, misuse of medications and overdose. Findings: During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE]. Resident 2's diagnoses included diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), and hypertension (HTN- high blood pressure). During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool), dated 11/7/2025, the MDS indicated Resident 2's cognition (ability to think and process information) was intact. The MDS indicated Resident 2 required moderate (helper does less than half the effort) assistance from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a concurrent observation and interview on 12/30/2025 at 8:00 a.m., in Resident 2's room, with Resident 2, observed four prescription medications inside the nightstand next to Resident 2's bed, within reach and not secured. The medication bottles were not labeled for self-administration and were not stored in a locked medication card or secured drawer. Resident 2 stated, I take the medications every day whenever I want. The medication bottles included the following:a. Atorvastatin (medication used to lower high cholesterol) 40 milligrams (mg- metric unit of measurement, used for medication dosage and/or amount), one tablet daily.b. Torsemide (medication used to treat fluid retention) 20 mg, two tablets daily c. Fenofibrate (medication used to treat high cholesterol)160 mg, 1 tablet daily.d. Lisinopril (medication used to treat high blood pressure) 2.5 mg, one tablet daily. During interview on 12/30/2025 at 1:20 p.m., with the Assistant Director of Nursing (ADON), the ADON stated the facility did not permit residents to keep medications at their bedside. The ADON stated the facility did not allow self-administration of medications unless there was a completed self-administration assessment, and a documented physician order. The ADON stated Resident 2 was assessed for self-administration of medication and was determined as not appropriate to self-administer medications. The ADON stated residents were not supposed to have medications in their rooms or take them on their own. The ADON stated that was not part of the facility policy or standard practice. The ADON stated the presence of multiple medications at Resident 2's bedside, and the resident's unsupervised administration, was unacceptable, unsafe, and should have been addressed by the nursing staff. The ADON stated unsecured access to antihypertensive and diuretics, such as lisinopril, and torsemide, placed Resident 2's at risk for overdose, dangerous drops in blood pressure or dehydration, adverse medications interactions or complications. During a review of the facility's policy and procedure (P&P) titled Medication Labeling and Storage, revised 2023, the P&P indicated the facility would store all medications and biologicals in locked compartments. The P&P indicated only authorized personnel would have access to keys. During a review of the facility's P&P titled Administering Medications', revised 4/2019, the P&P indicated medications would be administered in a safe and timely manner. The P&P indicated only persons licensed or permitted by the state to prepare, administer and document the administering of medications.

Based on interview, and record review, the facility failed to ensure Certified Nurse Assistant (CNA 1) had the competencies and skill sets necessary to immediately provide Basic Life Support ([BLS] medical care for residents experiencing cardiac arrest [when the heart stops beating] or respiratory distress [difficulty in breathing]) for one of three sampled residents (Resident 3), who had a full code status (when a medical personnel does everything possible to save a person's life in a medical emergency), was observed unresponsive in bed. This deficient practice had the potential for delayed provision of BLS for Resident 3 and other residents at risk of not receiving timely life saving measures. Findings:During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was originally admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 3's diagnoses included hypertension (high blood pressure) and heart failure (heart cannot pump enough blood and oxygen to meet the body's needs).During a review of Resident 3's History and Physical (H&P) dated [DATE], H&P indicated Resident 3 had the capacity to make medical decisions and was a full code status (when medical personnel does everything possible to save a person's life in a medical emergency). During a review of Resident 3's Minimum Data Set ([MDS] a resident assessment tool) dated [DATE], the MDS indicated Resident 3 usually understood and was understood by others. The MDS indicated Resident 3 required supervision for eating, and upper dressing. The MDS indicated Resident 3 was dependent (helper does all the effort Resident does none of the effort to complete the activity or the assistance of 2 or more helpers is required for the resident to complete the activity) for eating, oral hygiene and toileting hygiene. During a review of Resident 3's Progress Note dated [DATE] at 4:40 a.m., the Note indicated CNA 1 was checking on Resident 3's diaper and found Resident 3 unresponsive. The Notes indicated CNA 1 called Registered Nurse (RN 1) and RN 1 immediately assessed Resident 3 who was unresponsive, not breathing and pulseless. The Notes indicated RN 1 initiated Cardiopulmonary Resuscitation ([CPR] - an emergency procedure to restart a person's heart a person's heart and breathing after one or both suddenly stop. The note indicated the paramedics arrived at the facility at 4:10 a.m., after 911 was called and Resident 3 expired at 4:39 a.m. During a phone interview on [DATE] at 11:37 a.m., with CNA 1, CNA 1 stated on [DATE] at around 4:00 a.m., he went to Resident 3's room and noticed Resident 3 was not moving and walked out of the room to inform RN 1. CNA 1 stated RN 1 ran to the room and started CPR on Resident 1, while a Licensed Vocational Nurse (LVN) called 911, because RN 1 was shouting [from the room] to call 911. CNA 1 stated he had BLS training two months prior and during his BLS training, he was taught to initiate CPR as soon as he found someone unresponsive. CNA 1 stated, he left Resident 1 and did not check for Resident 1's pulse and breathing nor start CPR because at the facility, he was supposed to call the licensed nurse first. CNA 1 was unable to verbalize the process prior to initiating CPR. During a phone interview on [DATE] at 11:53 a.m., with RN 1, RN 1 stated on [DATE] at around 4:00 a.m., CNA 1 walked to the nurses' station 1 to notify her that Resident 3 was not responsive. RN 1 stated, she ran to Resident 3's room with an RN in training to assess Resident 3. RN 1 stated she found Resident 3 unresponsive, not breathing and without a pulse. RN 1 stated she initiated CPR immediately and yelled to call 911 as the RN in training was assisting her. RN stated all patient care personnel such as CNAs, LVNs and RNs were trained to provide BLS, and should immediately check for alertness, breathing, pulse and initiate CPR. RN 1 stated CNA 1 should not have left Resident 1 and started CPR immediately. During a review of the facility's Policies and Procedures (P&P) titled, Emergency Procedure-Cardiopulmonary Resuscitation and Basic Life Support dated 2021, the P&P indicated personnel have completed training on the initiation of CPR and BLS, including defibrillation, for victims of sudden cardiac arrest. The P&P indicated if an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, staff members who are trained in CPR/BLS shall initiate CPR. The P&P indicated staff are trained to follow current America Heart Association (AHA) Guidelines and recommendations for the sequence of resuscitation, including, recognition of cardiac arrest, initiation of resuscitation and opening the airway.

Based on observation, interview and record review, the facility failed to provide a safe, home-like environment for one of three sampled residents (Resident 2) by failing to replace the broken window in Resident 2's room in a timely manner.This failure had the potential to result in Resident 2 feeling uncomfortable due to cold air coming inside the window and negatively affecting Resident 2's well-being. Findings:During an observation on 11/18/2025 at 8:40 a.m. in Resident 2's room, Resident 2's window was observed with a wooden panel and an opening or gap in the upper half of the window. Cold air was felt coming inside the room through the opening.During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 2's diagnoses included hemiplegia (total paralysis of the arm, leg, and trunk on the same size of the body) and hemiparesis (weakness of one entire side of the body), Atrial fibrillation (irregular and often very rapid heart rhythm) and schizoaffective disorder (a mental illness that can affect thoughts, mood and behavior).During a review of Resident 2's History and Physical (H&P) dated 10/25/2025, the H&P indicated Resident 2 had the capacity to express needs but was unable to make medical decisions.During a review of Residents 2's Minimum Data Set (MDS - a resident assessment tool) dated 10/29/2025, the MDS indicated Resident 2 had severe cognitive (ability to think and reason) impairment. The MDS indicated Resident 2 was dependent on staff with activities of daily living (ADLs) such as dressing, toilet use, personal hygiene, transfer and mobility.During an interview on 11/18/2025 at 8:57 a.m., with the Maintenance Supervisor (MS), the MS stated Maintenance rounds were done to the facility rooms every day to check for things that needed to be fixed. The MS stated the window in Resident 2's room was broken on 11/14/2025 (4 days prior). The MS stated that the Maintenance assistant (MA) removed the frame from the window and covered the window with a piece of wood. The MS stated the window frame was ready to be installed on 11/14/2025 and the MA should have put the window frame on 11/14/2025 or 11/15/2025. The MS stated he did not know why the window had not been installed. The MS stated it was the facility's responsibility to keep the facility in working order for residents' safety and provide a home-like environment. The MS also stated there was cold air coming inside Resident 2's room which placed the resident at risk of feeling cold.During an interview on 11/18/2025 at 9:45 a.m., with MA, the MA stated the window frame of Resident 2's room was ready on 11/14/2025 and he had a plan to install it on 11/17/2025 but was not done because he was busy with other tasks (unspecified). The MA also stated Maintenance staff were onsite at the facility on the weekends in emergency cases, and Resident 2's window could have been done on the weekend. The MA stated the facility was Resident 2's home and should be in working conditions for resident 2's safety. The MA stated the window should have been repaired as soon as it was ready to protect Resident 2 from getting cold. During an interview on 11/18/2025 at 12:54 p.m., with the Director of Nursing (DON), the DON stated the piece of wood on Resident 2's the window was for temporary protection until the Maintenance could install a new window for the resident. The DON stated changing the window frame as soon as it was received, was considered a priority, and it needed to be fixed right away for the Residents' safety. The DON also stated cold air could come inside Resident 2's room through the gap and could make the resident feel uncomfortable. The DON stated the MA should have replaced Resident 2's window as soon as it was ready, regardless of the weekend. The DON stated the facility was residents' homes and should be kept clean, safe and in working conditions for the residents. During a review of the facility's Policies and Procedures (P&P) titled, Maintenance Services dated 2001, the P&P indicated the maintenance department is responsible for always maintaining the building grounds and equipment in a safe and operable manner. The P&P indicated functions of maintenance personnel included maintaining the building is in good repair, free from hazards and establishing priorities in providing repair services. During a review of the facility's P&P titled, Homelike Environment dated 2001, the P&P indicated Residents are provided with a safe, clean, comfortable and homelike environment.

Based on interview and record review, the facility failed to inform Physician 1 and Conservator 1 of an abuse allegation for one of three sampled residents (Resident 5).This deficient practice resulted in a delay in potential medical and psychiatric evaluations and resulted in Conservator 1 being unaware of Resident 5's well-being.Findings:During a review of Resident 5's admission Record (Face Sheet), the Face Sheet indicated Resident 5 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included nontraumatic chronic subdural hemorrhage (a slow collection of blood on the surface of the brain that develops over time, without being caused by a severe head injury), schizophrenia (a mental illness that is characterized by disturbances in thought), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest).During a review of Resident 5's Minimum Data Set (a resident assessment tool), dated 9/14/2025, the MDS indicated Resident 5's cognitive skills (process of thinking) for daily decision making were moderately impaired. The MDS indicated Resident 5 required supervision with oral hygiene, toileting, bathing, dressing, and personal hygiene.During a review of Resident 5's History and Physical (H&P), dated 9/9/2025, the H&P indicated Resident 5 did not have the mental capacity to understand and make decisions.During a review of Resident 5's Progress Note, dated 9/9/2025 at 10:46 p.m., authored by LVN 11, indicated on 9/9/2025, Resident 5 falsely accused a certified nursing assistant of hitting him. The Progress Note indicated that LVN 11 assessed Resident 5's arm for any bruises, scratches, and discoloration, but found none.During an interview on 9/24/2025 at 1:03 p.m., with LVN 11, LVN 11 stated, on 9/9/2025, Resident 5 refused Certified Nursing Assistant (CNA) 11's request to change him and CNA 11 requested LVN 11 to speak to Resident 5. LVN 11 stated she approached Resident 5 in the dining room to ask him when it would be a good time for the staff to change him. LVN 11 stated Resident 5 replied, I do not want to go, they hit me when they do anything. LVN 11 stated Resident 5 did not specify who they were but also complained there were scratches and bruises on his arm. LVN 11 stated she assessed Resident 5's arms and did not find any scratches or bruises. LVN 11 stated Resident 5 did not have any injury to his arms, and she went to Resident 5's room and observed CNA 11 change Resident 5's underwear and nightgown without being hit by any people in the room. LVN 11 stated she did not believe Resident 5's allegation was true. LVN 11 stated she documented the incident in Resident 5's Progress Notes but did not notify Physician 1 and Conservator 1. LVN 11 stated she determined Resident 5's allegation was not considered a change in condition due to Resident 5's behavior of fabricating stories in the past and felt his allegation was not true.During an interview on 9/25/2025 at 8:12 a.m., with the Director of Nursing (DON), the DON stated once a licensed nurse was made aware of an abuse allegation, they were responsible for notifying the resident's physician and their responsible party. The DON stated Physician 1 should have been notified of Resident 5's abuse allegation, including the fact that Resident 5 thought there were scratches and bruises on his arm. The DON stated notifying Physician 1 would have allowed Physician 1 to order for any medical or psychiatric evaluations and/or medications. The DON stated if Resident 5 were confused, a medical diagnosis such as an infection could have explained the sudden onset. The DON stated, without notifying Physician 1, the necessary evaluation and treatment were delayed. The DON stated in addition to notifying Physician 1, Conservator 1should have been notified to ensure he was aware of what was going on with Resident 1. The DON stated Conservator 1 was responsible for making any medical decisions for Resident 1 and may advocate for other assessments and/or treatments.During a review of the facility's Policy and Procedure (P&P) titled, Change in a Resident's Condition or Status, revised 2/2021, the P&P indicated, Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status.During a review of the facility's Performance Improvement Plan- Abuse Investigation and Reporting, initiated 7/1/2025, the Improvement Plan indicated the goal was for staff to inform the Administrator and the DON promptly about any incidents and report any abuse allegations immediately to the three government agencies. The Improvement Plan indicated the licensed nurse would initiate the Situation, Background, Assessment, Recommendation (SBAR- a communication tool used by healthcare workers when there is a change of condition among the residents) and notify the primary physician and the resident and/or their responsible party.

Based on interview and record review, the facility failed to report an abuse allegation to the State Agency (California Department of Public Health [CDPH]), the ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities), and local law enforcement for one of three sampled residents (Resident 5).This deficient practice resulted in a delayed notification to CDPH, the ombudsman, and law enforcement and also resulted in a delay of an onsite inspection This deficient practice had the potential to result in potential abuse to all residents in the facility.Findings:During a review of Resident 5's admission Record (Face Sheet), the Face Sheet indicated Resident 5 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included nontraumatic chronic subdural hemorrhage (a slow collection of blood on the surface of the brain that develops over time, without being caused by a severe head injury), schizophrenia (a mental illness that is characterized by disturbances in thought), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest).During a review of Resident 5's Minimum Data Set (a resident assessment tool), dated 9/14/2025, the MDS indicated Resident 5's cognitive skills (process of thinking) for daily decision making were moderately impaired. The MDS indicated Resident 5 required supervision with oral hygiene, toileting, bathing, dressing, and personal hygiene.During a review of Resident 5's History and Physical (H&P), dated 9/9/2025, the H&P indicated Resident 5 did not have the mental capacity to understand and make decisions.During a review of Resident 5's Progress Note, dated 9/9/2025 at 10:46 p.m., authored by LVN 11, indicated on 9/9/2025, Resident 5 falsely accused a certified nursing assistant of hitting him. The Progress Note indicated that LVN 11 assessed Resident 5's arm for any bruises, scratches, and discoloration, but found none.During a review of the facility's In-Service Training titled, Abuse Reporting/Investigation/Prevent/Correct Alleged and Management of Residents with Behaviors, dated 8/16/2025, presented by the Quality Assurance (QA) Nurse, the In-Service indicated LVN 11 received training to report any abuse allegations immediately and up to two hours to the CDPH, the Ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities), and local law enforcement. During an interview on 9/24/2025 at 1:03 p.m., with LVN 11, LVN 11 stated, on 9/9/2025, Resident 5 refused Certified Nursing Assistant (CNA) 11's request to change him and CNA 11 requested LVN 11 to speak to Resident 5. LVN 11 stated she approached Resident 5 in the dining room to ask him when it would be a good time for the staff to change him. LVN 11 stated Resident 5 replied, I do not want to go, they hit me when they do anything. LVN 11 stated Resident 5 did not specify who they were but also complained there were scratches and bruises on his arm. LVN 11 stated she assessed Resident 5's arms and did not find any scratches or bruises. LVN 11 stated the facility's policy indicated any abuse allegations had to be reported to the Administrator (ADM), who was the abuse coordinator, State Agency, the ombudsman, and local law enforcement within two hours. LVN 11 stated she did not report Resident 5's abuse allegation because he did not have any injury to his arms. LVN 11 stated she went to Resident 5's room and observed CNA 11 change the resident's underwear and nightgown without being hit. LVN 11 stated she did not believe Resident 5's allegation was true.During an interview on 9/24/2025 at 2:46 p.m., with the Director of Staff Development (DSD), the DSD stated LVN 11 was in-serviced on reporting all abuse allegations to the ADM, CDPH, the ombudsman, and law enforcement to ensure a proper investigation was initiated. The DSD stated all abuse allegations had to be reported regardless of if the individual does not believe the allegation to be true.During an interview on 9/25/2025 at 8:05 a.m., with the Director of Nursing (DON), the DON stated she was unaware of Resident 5's abuse allegation on 9/9/2025. The DON stated per the facility's policy and recent in-services, LVN 11 should have reported the abuse allegation to the ADM who would then initiate an investigation. The DON stated Resident 5 did not specify who hit him, therefore, the alleged perpetrator could have been a staff member or another resident. The DON stated Resident 5's abuse allegation did not have many specifics and without the proper reporting and investigation, Resident 5 and other residents were at risk for further abuse.During an interview on 9/25/2025 at 8:58 a.m., with the ADM, the ADM stated he was the abuse coordinator in the facility, and he was responsible for investigating all abuse allegations brought to his attention. The ADM stated all staff members were responsible for notifying him of all abuse allegations and were instructed to notify CDPH, the ombudsman, and law enforcement to ensure all reports were completed within the two-hour window. The ADM stated once Resident 5 informed LVN 11 of being hit, LVN 11 had the responsibility of reporting, not only to him, but to the necessary agencies so an investigation could be initiated. The ADM stated ensuring proper reporting was essential to protecting the residents in the facility.During a review of the facility's Policy and Procedure (P&P) titled, Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating, revised 4/2024, the P&P indicated, All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management.During a review of the facility's Performance Improvement Plan- Abuse Investigation and Reporting, initiated 7/1/2025, the Improvement Plan indicated the root cause was communication when an incident happened. The Improvement Plan indicated the goal was for staff to inform the Administrator and the DON promptly about any incidents and report any abuse allegations immediately to the three government agencies. The Improvement Plan indicated to monitor this goal daily and monthly, and to track and trend the Change of Conditions for possible abuse allegations.

Based on interview and record review, the facility failed to develop a person-centered care plan for one of three sampled residents' (Resident 5) after Resident 5 informed Licensed Vocational Nurse (LVN) 11 of an abuse allegation.This deficient practice had the potential to negatively affect Resident 5's physical, mental, and psychosocial well-being, delay the delivery of necessary care and services.Findings:During a review of Resident 5's admission Record (Face Sheet), the Face Sheet indicated Resident 5 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included nontraumatic chronic subdural hemorrhage (a slow collection of blood on the surface of the brain that develops over time, without being caused by a severe head injury), schizophrenia (a mental illness that is characterized by disturbances in thought), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest).During a review of Resident 5's Minimum Data Set (a resident assessment tool), dated 9/14/2025, the MDS indicated Resident 5's cognitive skills (process of thinking) for daily decision making were moderately impaired. The MDS indicated Resident 5 required supervision with oral hygiene, toileting, bathing, dressing, and personal hygiene.During a review of Resident 5's History and Physical (H&P), dated 9/9/2025, the H&P indicated Resident 5 did not have the mental capacity to understand and make decisions.During a review of Resident 5's Progress Note, dated 9/9/2025 at 10:46 p.m., authored by LVN 11, indicated on 9/9/2025, Resident 5 falsely accused a certified nursing assistant of hitting him. The Progress Note indicated that LVN 11 assessed Resident 5's arm for any bruises, scratches, and discoloration, but found none.During a review of Resident 5's Care Plans, dated 4/17/2025 through 9/11/2025, the Care Plans did not indicated there was a Care Plan that addressed Resident 5's abuse allegation on 9/9/2025.During an interview on 9/24/2025 at 1:03 p.m., with LVN 11, LVN 11 stated, on 9/9/2025, Resident 5 refused Certified Nursing Assistant (CNA) 11's request to change him and CNA 11 requested LVN 11 to speak to Resident 5. LVN 11 stated she approached Resident 5 in the dining room to ask him when it would be a good time for the staff to change him. LVN 11 stated Resident 5 replied, I do not want to go, they hit me when they do anything. LVN 11 stated Resident 5 did not specify who they were but also complained there were scratches and bruises on his arm. LVN 11 stated she assessed Resident 5's arms and did not find any scratches or bruises. LVN 11 stated Resident 5 did not have any injury to his arms, and she went to Resident 5's room and observed CNA 11 change Resident 5's underwear and nightgown without being hit by any people in the room. LVN 11 stated she did not believe Resident 5's allegation was true. LVN 11 stated she documented the incident in Resident 5's Progress Notes. LVN 11 stated she did not develop or update Resident 5's care plan because she determined Resident 5's allegation was not considered a change in condition due to Resident 5's behavior of fabricating stories in the past and felt his allegation was not true.During an interview on 9/25/2025 at 8:29 a.m., with the Director of Nursing (DON), the DON stated care plans were used as a guideline on how to care for each individual resident and provided an appropriate approach to each problem. The DON stated care plans were used as a communication tool to inform all staff assigned to the residents of the problems, the goals, and the interventions to be done. The DON stated after an abuse allegation was made, the licensed nurse was responsible for developing a care plan that addressed the allegation and to include immediate interventions implemented and other pertinent interventions for the continuation of care. The DON stated Resident 5 did not have a care plan developed after informing LVN 11 of his abuse allegation on 9/9/2025. The DON stated there were no guidelines on how to approach Resident 5's situation. The DON without the necessary care plan addressing Resident 5's abuse allegation, Resident 5 was at risk for a delay in delivery of necessary care and services and was at risk for further potential abuse.During a review of the facility's Policy and Procedure (P&P) titled, Care Plans Comprehensive Person-Centered, revised 3/2022, 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.

Based on interview and record review, the facility failed to implement the Care Plan for one out of five sampled residents (Resident 2), who had a diagnosis of schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior) and exhibited increased in behaviors.This failure had the potential to result in Resident 2 having ongoing behaviors which could lead to altercations that endanger himself, other residents, and staff at the facility.During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 2's diagnoses included schizoaffective disorder.During a review of Resident 2's Minimum Data Set ([MDS] a resident assessment tool), dated 7/21/2025, the MDS indicated Resident 2 had severe cognitive impairment (problems with the ability to think and reason). Resident 2's MDS indicated Resident 2 required supervision or touching assistance (Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) for Activities of Daily Living (ADLs) such as toileting and personal hygiene.During a review of Resident 2's Care Plan with a focus of Resident 2's potential for behavior problem related to diagnoses of schizoaffective disorder, bipolar type (mental health condition that involves experiencing both symptoms of psychosis (hallucinations [a perception of having seen, heard or touched something that wasn't actual there] and delusions [when a person can't tell what's real from what's imagined]) and mood episodes (such as mania and depression) manifested by mood swings from pleasant to irritable, angry outburst, delusional statements , dated 2/11/2024, the care plan indicated staff interventions included to monitor behavior episodes, document behavior and potential causes. The Care Plan interventions also indicated to notify the physician if it interferes with functioning and to intervene as necessary to protect the rights and safety of others. During a review of Resident 2's Medication Administration Record (MAR), dated 8/2025, the MAR indicated Resident 2 had two episodes of angry outbursts on 8/8/2025, 8/9/2025 and 8/10/2025 during the day shifts. The MAR indicated Resident 2 had episodes of delusional statements on the following dates during the day shifts: 2 episodes on 8/8/2025, 4 episodes on 8/9/2025, 4 episodes on 8/10/2025, 4 episodes on 8/11/25 and 4 episodes on 8/12/2025. The MAR also indicated Resident 2 had episodes of mood swings (from pleasant to irritable) on the following dates during the day shifts:3 episodes on 8/8/2025, 2 episodes on 8/9/2025, 3 episodes on 8/10/2025, 2 episodes on 8/11/2025 and 1 episode on 8/12/2025. During a review of Resident 2's SBAR ([Situation, Background, Assessment, Recommendation] a communication tool used by healthcare workers when there is a change of condition among residents) dated 8/13/2025, the SBAR indicated Resident 2 hit another resident because the resident called him (Resident 2) names. During a concurrent interview and record review on 8/15/2025 at 1:32 p.m., with Licensed Vocational Nurse (LVN) 4, Resident 2's care plan, dated 2/11/2024, MAR dated 08/2025, and progress notes dated 8/8/2025 to 8/12/2025 were reviewed. LVN 4 stated Resident 2 had increased behaviors such as episodes mood swings from 8/8/2025 to 8/12/2025 and an increase of angry outbursts from 8/9/2025 and 8/10/2025. LVN 4 stated there was no documentation to indicate what incidents occurred and what interventions were implemented to address the episodes of behaviors on 8/8/2025-8/12/2025 (prior to the resident-to-resident alteration on 8/13/2025). LVN 4 stated in addition to the number of episodes of the behavior Resident 2 exhibited, staff should have also documented the location, the behavior Resident 2 was exhibiting, and the endorsement to the following shift in the progress notes. During a concurrent interview and record review on 8/15/2025 at 2:24 p.m., with Registered Nurse (RN) 1, Resident 2's Care Plan dated 2/11/2024, and progress notes from 8/8/2025 to 8/12/2025 were reviewed. RN 1 stated if a resident exhibited behaviors, licensed nurses should document non-pharmacological (actions to treat a problem without using medication) and pharmacological (using medicine) interventions used and whether those interventions were effective. RN 1 stated this was important to prevent an incident from occurring because of a resident's increased behavior. RN 1 stated Resident 2's progress notes did not indicate what interventions were done during Resident 2's episodes of increased behaviors from 8/8/2025 to 8/12/2025.During a concurrent interview and record review on 8/15/2025 at 4:34 p.m., with the Director of Nursing (DON), Resident 2's care plan dated 2/11/2024 and progress notes dated 8/8/2025 to 8/12/2025 were reviewed. DON stated, staff should monitor and document when a resident exhibited behaviors and notify the physician if there was an increase in those behaviors. The DON also stated if the specific behaviors or incident were not documented, staff would not be able to target and prevent behaviors from recurring. During a review of facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, dated 3/2022, 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 also indicated, When possible, interventions address the underlying source.During a review of facility's P&P titled, Behavioral Assessment, Intervention and Monitoring, dated 3/2019, the P&P indicated, If the resident is being treated for altered behavior or mood, the Interdisciplinary Team (IDT) will seek and document any improvements or worsening in the individual's behavior, mood, and function.

This is a Repeat Deficiency at F609 from 6/24/2025 investigation. Based on interview and record review, the facility failed to report abuse allegations to the State Agency (California Department of Public Health [CDPH]), the ombudsman (an advocate for residents of nursing homes), and local law enforcement for three of seven sampled residents (Residents 5, 6, and 7) when Certified Nursing Assistant (CNA) 5 allegedly was rough with Residents 5, 6 and 7. This repeat deficient practice of delayed notification to CDPH, the ombudsman, and law enforcement resulted in a delay of an onsite inspection and had the potential to result in abuse to all residents in the facility.During a review of the facility's Plan of Correction / In-Service Training titled, Reporting Alleged Violations, dated 6/25/2025 and 6/26/2025, presented by the Director of Staff Development (DSD), the In-Service indicated the Director of Nursing (DON), the Administrator (ADM), Certified Nursing Aide (CNA) 3, and CNA 4 were all educated to report any abuse allegations immediately and for up to two hours to the CDPH, the ombudsman, and law enforcement. Cross Reference F610Findings:a. During a review of Resident 7's admission Record (Face Sheet), the admission Record indicated Resident 7 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including encephalopathy (a medical condition where the brain does not function properly), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), and anxiety disorder (mental health condition characterized by excessive and persistent worry, fear, and nervousness about everyday situations). During a review of Resident 7's Minimum Data Set (MDS- a resident assessment tool), dated 7/25/2025, the MDS indicated Resident 7 had moderately impaired cognitive skills (problems with ability to remember, think, and use judgement) for daily decision making. The MDS indicated Resident 7 required supervision with eating, oral hygiene, and personal hygiene. During a review of the facility's Performance Improvement Plan - Abuse Investigation and Reporting dated 7/1/2025, the plan indicated the root cause was communication when an incident happened. The improvement plan indicated the goal was for staff to inform the Administrator and the DON promptly about any incidents, report any abuse allegations immediately to the three government agencies. The improvement plan indicated any grievances would be reported during the daily stand-up meeting for review and would be investigated and reported promptly. The improvement plan indicated to monitor this goal daily and monthly, to track and trend the grievances for possible abuse allegations, and to review the grievance reports. During a concurrent interview and record review on 8/6/2025 at 8:52 a.m., with the Director of Staff Development (DSD), Resident 7's Grievance / Complaint Report Form, dated 7/22/2025 was reviewed. The Grievance Form indicated that on 7/22/2025, Resident 7 reported to Social Services (SS) 1 that CNA 5 was slightly rough when trying to shave him. The DSD stated that on 7/22/2025, SS 1 notified him (SSD) of Resident 7's allegation against CNA 5 and the DSD immediately interviewed CNA 5 who stated, Resident 7 refused to be shaved because he wanted to go to the patio for a smoke break. The DSD stated he did not suspect abuse at the time and believed the incident to be a misunderstanding. The DSD stated shaving should not be an unpleasant experience and should be tailored to the residents' comfort. During an interview on 8/6/2025 at 9:09 a.m., SS 1 stated that on 7/22/2025, Resident 7 approached her in the hallway and informed her that CNA 5 was rough with him when CNA 5 shaved him. SS 1 stated she informed the DSD of the allegation but did not inform the Director of Nursing (DON) nor the Administrator (ADM). SS 1 stated any kind of roughness can be seen as a type of abuse due to shaving's physical nature of using a razor, using their hands to apply the shaving cream, and positioning the resident. SS 1 stated as a mandated reporter (an individual who is legally required to report suspected cases of abuse or neglect to the appropriate authorities), Resident 7's allegation should have been reported to the DON and the ADM and to CDPH, the ombudsman, and law enforcement. During an interview on 8/6/2025 at 10:40 a.m., the DSD stated even though he interviewed CNA 5, who stated the allegation was a misunderstanding, Resident 7's allegation should not have been discredited and should have been reported to the DON, the ADM, CDPH, the ombudsman, and law enforcement to allow investigations to be initiated. The DSD stated he did not implement his In-Service Lesson Plan into his own practice. The DSD stated an investigation was initiated and the allegation was found to be untrue. The DSD stated prior to an investigation, all abuse allegations should be reported to ensure a separate investigation from CDPH was done. During an interview on 8/6/2025 at 12:04 p.m., with the DON, the DON stated she was not made aware of Resident 7's allegation, on 7/22/2025, until 8/5/2025. The DON stated when SS 1 and DSD were made aware of Resident 7's allegation, the allegation should have been immediately reported to CDPH, the ombudsman, and law enforcement prior to the investigation taking place. b. During a review of Resident 5's admission Record, the admission Record indicated Resident 5 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including hepatic encephalopathy (a condition where the brain becomes impaired due to liver disease), schizophrenia (a mental illness that is characterized by disturbances in thought), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest).During a review of Resident 5's MDS, dated [DATE], the MDS indicated Resident 5's cognitive skills for daily decision making were moderately impaired and required supervision with oral hygiene, toileting, bathing, dressing, and personal hygiene.During a review of Resident 5's History and Physical (H&P), dated 7/8/2025, the H&P indicated Resident 5 did not have the mental capacity to understand and make decisions.During an interview on 8/5/2025 at 2:25 p.m. and 8/6/2025 at 9:14 a.m., CNA 3 stated that on an unknown date, she overhead Resident 5 telling an unknown staff member that CNA 5 was very rough while CNA 5 shaved him and roughly slapped shaving cream on his face. CNA 3 stated upon hearing the conversation, she immediately notified Licensed Vocational Nurse (LVN) 2. CNA 3 stated she did not report the abuse allegation to the DON nor the ADM, who were the abuse coordinators, because she was following the chain-of-command by reporting to the LVN and allow the LVN to report the abuse allegation to the abuse coordinators.During an interview on 8/5/2025 at 2:51 p.m., LVN 2 stated she was never made aware of Resident 5's abuse allegation against CNA 5.During an interview on 8/6/2025 at 11:59 a.m., the DON stated she and the ADM were not made aware of Resident 5's allegation against CNA 5 regarding rough handling during shaving. During an interview on 8/5/2025 at 2:29 p.m., CNA 4 stated Resident 5 approached him on an unknown date and Resident 5 stated to get him away from CNA 5 because CNA 5 was rough when he was shaved and was told CNA 5 was beating him. CNA 4 stated he reported the conversation to an unknown LVN who told him the allegation would be reported to the DON. During an interview on 8/6/2025 at 12:01 p.m., the DON stated she and the ADM were not made aware of Resident 5's allegation against CNA 5 regarding being beaten and handled roughly during shaving.c. During a review of Resident 6's admission Record, the admission Record indicated Resident 6 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included metabolic encephalopathy (a condition where the brain does not work properly due to chemical imbalances in the body), depression, and schizoaffective disorder.During a review of Resident 6's MDS, dated [DATE], the MDS indicated Resident 6's cognition was severely impaired and was dependent on staff's assistance with toileting, bathing, and lower body dressing. During a review of Resident 6's H&P, dated 3/25/2025, the H&P indicated Resident 6 was unable to make healthcare decisions.During an interview on 8/5/2025 at 2:35 p.m., CNA 4 stated Resident 6 complained he was being rough housed by CNA 5. CNA 4 stated Resident 6 was unable to provide details to his allegation. CNA 4 stated after being notified of Resident 6's allegation, he notified an unknown LVN and was told the allegation would be reported to the DON. During an interview on 8/6/2025 at 10:27 a.m., the DSD stated the expectation of the staff was to report anything suspicious they see or hear. The DSD stated all staff were in-serviced on the types of abuse and how to report any abuse allegations to CDPH, the ombudsman, and law enforcement. The DSD stated any staff member who had knowledge of an abuse allegation were expected to follow the process to the end to ensure the line of communication was not broken. The DSD stated the CNAs who notified the LVNs on duty should have informed the DON and ADM to ensure CDPH, the ombudsman, and law enforcement were notified of Resident 5 and 6's abuse allegations. The DSD stated the facility was responsible for reporting all abuse allegations to the three agencies within two hours and any staff with knowledge of an abuse allegation should not go up the chain-of-command and assume the allegations would be reported. During an interview on 8/6/2025 at 11:55 a.m., the DON stated all staff members in the facility were mandated reporters and were expected to report all allegations to the DON and the ADM to ensure CDPH, the ombudsman, and law enforcement were notified. The DON stated reporting abuse allegations was a collaborative effort and the staff members with knowledge should ensure all parties were aware to ensure the allegation was reported within two hours. During a review of the facility's policy and procedure (P&P) titled, Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating, revised 9/2022, the P&P indicated, All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. The P&P indicated if resident abuse, neglect, exploitation, misappropriation of resident property, or injury of unknown origin was suspected, the administrator or the individual making the allegation was to report immediately, but not later than two hours if the alleged violation involved abuse or resulted in serious bodily injury; or twenty-four hours if the alleged violation did not involve abuse and had not resulted in serious bodily injury.

This is a Repeat Deficiency at F610 from 6/24/2025 investigation. Based on interview and record review, the facility failed to thoroughly investigate an allegation of abuse for one of seven sampled residents (Resident 7), when Resident 7 informed Social Services (SS) 1, on 7/22/2025, that Certified Nursing Assistant (CNA) 5 was rough during facial shaving. This deficient practice resulted in CNA 5 not being suspended pending the investigation of the allegation and placed Resident 7 and all the residents in the facility at risk for further potential abuse.Cross Reference F609Findings:During a review of Resident 7's admission Record (Face Sheet), the admission Record indicated Resident 7 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including encephalopathy (a medical condition where the brain does not function properly), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), and anxiety disorder (mental health condition characterized by excessive and persistent worry, fear, and nervousness about everyday situations).During a review of Resident 7's Minimum Data Set (MDS- a resident assessment tool), dated 7/25/2025, the MDS indicated Resident 7 had moderately impaired cognitive skills (problems with ability to remember, think, and use judgement) for daily decision making. The MDS indicated Resident 7 required supervision with eating, oral hygiene, and personal hygiene. During a review of the facility's Performance Improvement Plan - Abuse Investigation and Reporting dated 7/1/2025, the plan indicated the root cause was communication when an incident happened. The improvement plan indicated the goal was for staff to inform the Administrator and the DON promptly about any incidents, report any abuse allegations immediately to the three government agencies. The improvement plan indicated any grievances would be reported during the daily stand-up meeting for review and would be investigated and reported promptly. The improvement plan indicated to monitor this goal daily and monthly, to track and trend the grievances for possible abuse allegations, and to review the grievance reports. During a concurrent interview and record review on 8/6/2025 at 8:52 a.m., with the Director of Staff Development (DSD), Resident 7's Grievance / Complaint Report Form, dated 7/22/2025 was reviewed. The Grievance Form indicated that on 7/22/2025, Resident 7 reported to SS 1 that CNA 5 was slightly rough when trying to shave him. The DSD stated that on 7/22/2025, SS 1 notified him (SSD) of Resident 7's allegation against CNA 5 and the DSD immediately interviewed CNA 5 who stated, Resident 7 refused to be shaved because he wanted to go to the patio for a smoke break. The DSD stated he did not suspect abuse at the time and believed the incident to be a misunderstanding. The DSD stated shaving should not be an unpleasant experience and should be tailored to the residents' comfort. During an interview on 8/6/2025 at 9:09 a.m., SS 1 stated, on 7/22/2025, Resident 7 approached her in the hallway and informed her that CNA 5 was rough with him when CNA 5 shaved him. SS 1 stated she informed the DSD of the allegation but did not inform the Director of Nursing (DON) nor the Administrator (ADM). SS 1 stated any kind of roughness can be seen as a type of abuse due to shaving's physical nature of using a razor, using their hands to apply the shaving cream, and positioning the resident. SS 1 stated as a mandated reporter (an individual who is legally required to report suspected cases of abuse or neglect to the appropriate authorities), Resident 7's allegation should have been reported to the DON and the ADM for a thorough investigation to occur.During an interview on 8/6/2025 at 10:40 a.m., the DSD stated even though he interviewed CNA 5, who stated the allegation was a misunderstanding, Resident 7's allegation should not have been discredited and should have been reported to the DON and the ADM to allow investigations to be initiated. The DSD stated an investigation was initiated but should have been more thorough where other staff members and residents were interviewed, to determine if others were potentially affected by CNA 5. The DSD stated he did not implement his In-Service Lesson Plan into his own practice. The DSD stated that on 7/22/2025, CNA 5 was in-serviced on the proper way of shaving but was not suspended pending an investigation of Resident 7's allegation. The DSD stated CNA 5 should have been suspended on 7/22/2025 to ensure Resident 7's and all the residents' safety. During an interview on 8/6/2025 at 12:04 p.m., the DON stated she was not made aware of Resident 7's allegation, on 7/22/2025, until 8/5/2025. The DON stated when SS 1 and DSD were made aware of Resident 7's allegation, the allegation should have been immediately reported to her and the ADM to initiate a thorough investigation. The DON stated on 7/22/2025, CNA 5 should have been suspended while the investigation was ongoing. The DON stated other residents should have been interviewed to determine if there were other allegations of rough shaving. The DON stated allowing CNA 5 to continue to work after Resident 7's allegation not only placed Resident 7 at risk for further potential abuse, it placed all residents in the facility at risk for potential abuse. The DON stated a thorough investigation was necessary to determine whether the allegation was true and if disciplinary action was needed. During a review of the facility's policy and procedure (P&P) titled, Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating, revised 9/2022, the P&P indicated, Upon receiving any allegation of abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source, the administrator is responsible for determining what actions (if any) are needed for protection of residents. The P&P indicated all allegations were thoroughly investigated by the administrator or designee. The P&P indicated, Any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete.

Based on observation, interview, and record review, the facility failed to ensure one of seven sampled resident (Resident 4's) care plan was reviewed and revised with updated interventions to address Resident 4's behavior of pocketing medications. This deficient practice resulted in Resident 4 having medication in his possession without staff knowledge and an increased risk for adverse medication reactions. Cross Reference F755.Findings:During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including paranoid schizophrenia (a subtype of schizophrenia with prominent delusions and hallucinations often involving false beliefs of being watched or targeted), and anxiety disorder (feeling of fear, dread and uneasiness that can be a normal reaction to stress). During a review of Resident 4's care plan titled, Behavior Problem, revised 6/13/2025, the care plan indicated Resident 4 had a behavior problem related to spitting medications and the interventions indicated to administer medications as ordered. Further review of the care plan indicated there were no specific interventions on how to properly administer Resident 4's medications. During a review of Resident 4's Minimum Data Set (MDS- a resident assessment tool), dated 6/30/2025, the MDS indicated Resident 4 had moderately impaired cognition (problems with memory, thinking, and using judgement), had hallucinations (perceptual experiences in the absence of real external sensory stimuli), and delusions (misconceptions or beliefs that are firmly held, contrary to reality). The MDS indicated Resident 4 required moderate assistance (helper does less than half the effort) with toileting, bathing, and dressing. The MDS indicated Resident 4 received antipsychotic medication (a class of medicines used to treat severe mental disorders and behaviors in which thought, and emotions are so impaired that contact is lost with external reality). During a review of the Physician's Order Summary Report dated 6/24/2025, the Summary Report indicated Resident 4 to receive Klonopin (medication used to treat anxiety) 0.5 milligrams (mg, a unit of measurement), once a day, for anxiety manifested by constant yelling and verbal aggression. The Order Summary Report indicated Resident 4 to receive Risperdal 4 mg, twice a day for paranoid schizophrenia manifested by delusions, disorganized or incoherent speaking, and unusual movement and pacing.During a review of Resident 4's Medication Administration Record (MAR) dated 8/5/2025, the MAR indicated Resident 4's Klonopin and Risperdal were administered at 8 a.m. During a concurrent observation and interview on 8/5/2025 at 2:40 p.m. with Resident 4 in the hallway, Resident 4 approached the State Surveyor and revealed a green pill pressed with zc78 and a yellow pill pressed with 0.5 in his hand. Resident 4 stated not to tell any of the nurses. Resident 4 stated that on an unknown date, the medications fell to the floor, and he kept them. During a concurrent observation and interview on 8/5/2025 at 3:24 p.m. with Licensed Vocational Nurse (LVN) 3 at LVN 3's medication cart, LVN 3 was approached by the State Surveyor and was handed the green pill pressed with zc78 and a yellow pill pressed with 0.5 received from Resident 4. LVN 3 compared the yellow pill to Resident 4's Klonopin bubble pack (a type of packaging where small items are held in a plastic bubble or dome, which is then sealed to a cardboard backing) and the green pill to Resident 4's Risperdal bubble pack. LVN 3 stated the medications matched Resident 4's prescribed Klonopin and Risperdal. LVN 3 stated Resident 4 had the tendency to pocket medication (placing medication between the cheek and gums of the mouth rather than swallowing) when administered medication. LVN 3 stated since Resident 4 had a dose of Klonopin and Risperdal in his pocket, Resident 4 did not receive the full dose of his medications. During an interview on 8/5/2025 at 3:41 p.m., when asked about Resident 4's Behavior Problem Care Plan, LVN 3 stated the care plan did not have specific interventions on how to properly administer Resident 4's medications. LVN 3 stated the interventions should have indicated to prepare all medications and supplies, observe Resident 4 take all medications into his mouth, drink water, have Resident 4 open his mouth to check underneath his tongue and cheeks, and check Resident 4's hands and pockets. LVN 3 stated care plans were a communication tool to all staff regarding Resident 4's behaviors and instruction on how to properly care for him. During an interview on 8/6/2025 at 11:53 a.m., the Director of Nursing (DON) stated Resident 4's care plans were a tool to communicate actual or potential problems and to refer to how to properly care for him. The DON stated Resident 4's care plan should have been revised to indicate personalized interventions such as observing Resident 4 swallow all his medications, to open his mouth to check for pocketing, and to check his hands and surrounding areas for any medications that could have been spit out. The DON stated by not including personalized interventions in Resident 4's care plan, the facility was not addressing his behavior of spitting out medications which could result in the continuation of the behavior. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, revised 3/2022, 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, When possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers. Assessments of residents are ongoing and care plans are revised as information about the residents' conditions change.

Based on observation, interview, and record review, the facility failed to ensure medications were administered to meet the needs of each resident and in accordance with professional standards of practice for one of seven sampled residents (Resident 4). Resident 4 was observed with two medications in hand, without staff knowledge. This deficient practice resulted in Resident 4 not receiving the correct dose of medication, and the potential for other residents to receive medications not prescribed to them.Cross Reference F657Findings:During a review of Resident 4's admission Record, the admission record indicated Resident 4 was readmitted to the facility on [DATE] with diagnoses including paranoid schizophrenia (a subtype of schizophrenia with prominent delusions and hallucinations often involving false beliefs of being watched or targeted) and anxiety disorder (feeling of fear, dread and uneasiness that can be a normal reaction to stress). During a review of Resident 4's Minimum Data Set (MDS- a resident assessment tool), dated 6/30/2025, the MDS indicated Resident 4 had moderately impaired cognition (problems with memory, thinking, and using judgement), had hallucinations (perceptual experiences in the absence of real external sensory stimuli), and delusions (misconceptions or beliefs that are firmly held, contrary to reality). The MDS indicated Resident 4 required moderate assistance (helper does less than half the effort) with toileting, bathing, and dressing. The MDS indicated Resident 4 received antipsychotic medication (a class of medicines used to treat severe mental disorders and behaviors in which thought, and emotions are so impaired that contact is lost with external reality).During a review of the Physician's Order Summary Report dated 6/24/2025, the Summary Report indicated Resident 4 to receive Klonopin (medication used to treat anxiety) 0.5 milligrams (mg, a unit of measurement), once a day, for anxiety manifested by constant yelling and verbal aggression. The Order Summary Report indicated Resident 4 to receive Risperdal 4 mg, twice a day for paranoid schizophrenia manifested by delusions, disorganized or incoherent speaking, and unusual movement and pacing.During a review of Resident 4's Medication Administration Record (MAR) dated 8/5/2025, the MAR indicated Resident 4's Klonopin and Risperdal were administered at 8 a.m. During a concurrent observation and interview on 8/5/2025 at 2:40 p.m. with Resident 4 in the hallway, Resident 4 approached the State Surveyor and revealed a green pill pressed with zc78 and a yellow pill pressed with 0.5 in his hand. Resident 4 stated not to tell any of the nurses. Resident 4 stated that on an unknown date, the medications fell to the floor, and he kept them. During a concurrent observation and interview on 8/5/2025 at 3:24 p.m. with Licensed Vocational Nurse (LVN) 3 at LVN 3's medication cart, LVN 3 was approached by the State Surveyor and was handed the green pill pressed with zc78 and a yellow pill pressed with 0.5 received from Resident 4. LVN 3 compared the yellow pill to Resident 4's Klonopin bubble pack (a type of packaging where small items are held in a plastic bubble or dome, which is then sealed to a cardboard backing) and the green pill to Resident 4's Risperdal bubble pack. LVN 3 stated the medications matched Resident 4's prescribed Klonopin and Risperdal. LVN 3 stated Resident 4 had the tendency to pocket medication (placing medication between the cheek and gums of the mouth rather than swallowing) when administered medication. LVN 3 stated since Resident 4 had a dose of Klonopin and Risperdal in his pocket, Resident 4 did not receive the full dose of his medications. During an interview on 8/6/2025 at 11:47 a.m., the Director of Nursing (DON) stated the licensed nurses administering medications were responsible for observing Resident 4 swallow each pill before moving on to the next resident. The DON stated ensuring Resident 4 swallowed his medications ensured Resident 4 took the ordered dose. The DON stated taking the full dose was essential to treat the specific behaviors Resident 4 exhibited. The DON stated because Resident 4 had a dose of Klonopin and Risperdal in his pocket, not only was Resident 4 at risk of taking an additional dose on another day, but other residents were also at risk. The DON stated Resident 4 could have given the Klonopin and Risperdal to another resident and they could be at risk of adverse reactions and interactions with their medications. During a review of the facility's policy and procedure (P&P) titled, Administering Medications, revised 4/2019, the P&P indicated Medications are administered in a safe and timely manner, and as prescribed.

Based on observation, interview, and record review, the facility failed to: 1. Assess the elopement (to leave unnoticed) risk for one of two sampled residents (Resident 1) who attempted to elope from the facility on 4/30/2024 and 5/23/2024 and was assessed on the Minimum Data Set (MDS, resident assessment and care-screening tool) as having wandering behaviors (when a person leaves a safe area or caregiver, which can be a risk to their safety, also called elopement), per the care plan. 2. Follow its policy and procedures (P&P) titled Interdisciplinary Team Conference (IDT, group of different disciplines working together towards a common goal for a resident) and Elopement Wandering Resident by not holding an IDT meeting to ensure resident ' s safety, after Resident 1 ' s elopement attempts on 4/30/2024 and 5/23/2024. As a result, Resident 1 eloped from the facility on 9/8/2024 and was still missing as of 9/12/2024. On 9/12/2024 at 3:33 p.m., an Immediate Jeopardy ([IJ] a situation in which the facility's noncompliance with one or more requirements of participation had cause, or was likely to cause serious injury, harm, impairment, or death to a resident) was called in the presence of the Administrator (ADM) and Director of Nursing (DON) due to the facility's failure assess Resident 1 as high risk for elopement and to conduct IDT meetings after each elopement to prevent Resident 1 ' s elopement from the facility. On 9/13/2024 at 10:44 a.m., the facility submitted an acceptable IJ Removal Plan (IJRP). After onsite verification of the IJRP implementation through observation, interview, and record review, the IJ was removed onsite on 9/13/2024 at 4:17 p.m., in the presence of the ADM and DON. The IJPR included the following immediate actions: 1. Staff faxed a missing persons flyer to 90 hospitals in the area on 9/11/2024 and 9/12/2024. Police Departments in the area were notified on 9/11/2024 and continued to help in locating the resident. Resident 1 ' s family member (FM 1), who was also the conservator (a person appointed by the court to manage the personal affairs and finances of an adult who is unable to do so themselves), was also notified. The facility continued to call local hospitals and communicate with police department in search of Resident 1 on a daily basis. 2. The facility was a locked facility (a secure area that prevents residents from leaving at will), and all current residents were affected by this deficient practice. The Elopement Risk Assessment and Elopement Care Plans for all current residents were completed by the IDT on 9/12/2024. Licensed nurses would complete an Elopement Risk Assessment and an Elopement Care Plan upon admission, quarterly, annually, or when any type of elopement episode occurred. Once the elopement assessments were completed, the IDT would meet to review and give recommendations and interventions. Residents that score 10 or higher on the Elopement Risk Assessment would be considered high-risk. A list of residents at high-risk for elopement would be provided to the certified nursing assistants (CNAs) and licensed nurses by the (MDS) Coordinator to be addressed at the daily team huddles. Team Huddles between the licensed nurses and the CNAs would be done at the beginning of each shift to communicate any new residents that have been triggered for high-risk elopement. Any resident that was considered a high-risk would be moved closer to the nurse ' s station, given a pink arm band, and a pink door name to identify them as high-risk for elopement. 3. Residents identified due to previous elopement attempts were stationed closer to the nurse ' s station for closer observation. Hall monitoring would be done every 30 minutes throughout the day. Yard monitoring would be done for any resident that goes outside. 4. Licensed nurses were in-serviced on the Elopement Risk Assessments and Elopement Care Plans and the P&P for Elopement on 9/12/2024 and 9/13/2024. Licensed nurses that were not in-serviced would be in-serviced by 9/23/2024. The IDT was in-serviced on 9/12/2024 regarding the Elopement Risk Assessment, the Elopement Care Plan, The Elopement, and IDT Conference P&P. The Elopement Wandering Resident P&P was updated on 9/12/2024 to reflect the new interventions that will be implemented. All staff will be in-serviced on how to identify and monitor any resident that has been identified as high-risk for potential elopement by 9/23/2024. 5. The Quality Assurance Performance Improvement (QAPI) for elopement was initiated on 9/12/2024. The QAPI lesson plan objective would be to understand the staff ' s role in prevention of elopement and be able to complete the required assessment documentation pre and post of an actual event. The objective of the QAPI would be for the staff member to detect, prevent as much as possible and correct any potential risk factors to ensure the safety of the residents. The facility will receive feedback from all staff if they feel there was a better means of monitoring the resident ' s safety and whereabouts. The QAPI will be reviewed throughout the next month for effectiveness. The QAPI will be presented at the next QA Meeting that was scheduled for 9/17/2024 for review and/or recommendations. Findings: During a review of Resident 1's Admission Record (face sheet), dated 6/10/2024, the face sheet indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1 ' s diagnoses included schizoaffective disorder (a mental health condition that was marked by symptoms, such as hallucinations (seeing, hearing, smelling, tasting, or feeling something that appears to be real but doesn't actually exist), delusions (when a person cannot tell what was real from what was imaginary), and mood disorder (a mental health condition that primarily affects the feelings and moods experienced by an individual) symptoms, bipolar type (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), hypertension (high blood pressure), major depressive disorder (a mental health condition that causes a persistently low or depressed mood and a loss of interest in activities that once brought joy), anxiety disorder (a condition in which a person has excessive worry and feelings of fear, dread, and uneasiness), dysphagia (difficulty swallowing), and chronic obstructive pulmonary disease (COPD - a common lung disease that makes it difficult to breathe and worsens over time). During a review of Resident 1 ' s History and Physical (H&P) dated 5/24/2024, the H&P indicated Resident 1 was guarded (cautious) and needed assistance with instrumental activities of daily living (IADLs, complex activities that allow an individual to live independently in a community such as managing medications, paying bills, and cooking meals) and was independent with activities of daily living (ADLs, self-care activities performed daily such as dressing, toileting hygiene, and bathing). During a review of Resident 1's Minimum Data Set ([MDS], a standardized assessment and care planning tool), dated 8/26/2024, the MDS indicated Resident 1 had the ability to understand and be understood by others. The MDS indicated Resident 1 ' s ability to make decisions regarding daily life was moderately impaired (decisions poor, cues/supervision required). The MDS indicated Resident 1 was independent with eating and required set-up and clean-up assistance for toileting and personal hygiene. The MDS indicated Resident 1 had behaviors of hallucinations, delusions and wandering that occurred one to three days per week. The MDS indicated Resident 1 did not use wander and/or elopement alarm (an alarm used to help prevent people from leaving a safe area or caregiver, worn on the wrist or ankle) or other alarms. During a review of Resident 1's care plan titled, Wandering, dated 4/18/2024, the care plan indicated Resident 1 was at risk for wandering and injury. The care plan indicated the goal was for Resident 1 to wander safely within appropriate areas and have no falls or injury for three months. The care plan indicated staff were to monitor Resident 1 ' s whereabouts, assess the resident ' s risk for elopement and maintain a safe and hazard free environment. During a review of Resident 1 ' s Situation, Background, Assessment, Recommendation (SBAR - a written communication tool that helps provide essential, concise information, usually during crucial situations), dated 4/30/2024 at 2:30 p.m., the SBAR indicated on 4/30/2024 Resident 1 had an attempted Absent without Leave (AWOL - a resident ' s absence from the facility without permission). The SBAR indicated Resident 1 was found walking on the street outside of the facility and transported back to the facility. During a review of Resident 1 ' s care plan titled, Wandering, revised 4/30/2024, the care plan indicated interventions to include increase Gabapentin (medication used to treat for seizures [sudden, uncontrolled burst of electrical activity in the brain], nerve pain, and can also be used to relieve anxiety) 300 milligrams (MG - a unit of measure), Ativan (medication used to treat anxiety) 1 MG every eight hours as needed for 14 days due to agitation (a condition in which a person was unable to relax and be still). The care plan did not indicate any non-pharmacological (a treatment or intervention that does not use medication) interventions to prevent Resident 1 ' s wandering behaviors. During a review of Resident 1 ' s care plan titled, Wandering dated 5/21/2024, the care plan indicated Resident 1 was at risk for wandering, actual wandering, a had a history of elopement and exit seeking behavior. The care plan indicated interventions such as monitoring Resident 1 ' s whereabouts, assess the resident ' s risk for elopement, ensure the resident had an identification band, monitor toileting needs, redirecting, cueing as appropriate and maintain a safe and hazard free environment. During a review of Resident 1 ' s SBAR, dated 5/23/2024 at 2 p.m., the SBAR indicated on 5/23/2024 Resident 1 had an attempted AWOL. The SBAR indicated Resident 1 attempted to leave over the fence of the outside patio and was brought back inside the facility by staff. During a review of Resident 1 ' s care plan titled, Wandering revised 5/23/2024, the care plan indicated interventions including a psychiatric consult as ordered, as needed and document effectiveness. During a review of Resident 1 ' s care plan titled, Inappropriate Behavior, dated 8/31/2024, the care plan indicated Resident 1 had acute wandering, related to increased agitation. The care plan indicated Resident 1 will not injure himself or others daily for three months. The care plan interventions included staff will provide a safe, calm quiet environment/approach, establish daily routine based on input of the resident, assist the resident for ability to control behavior and express needs, and refer to a mental health specialist and review medications monthly. During a review of Resident 1 ' s SBAR, dated 8/31/2024 at 3:30 p.m., the SBAR indicated Resident 1 was exhibiting increased agitation, was sexually inappropriate, delusional, pacing hallways, had exit seeking behaviors (wandering into unfamiliar places to find a way out) and increased risk for elopement. The SBAR indicated Resident 1 ' s family member (FM 1) and Physician and were notified and the Physician ordered for Resident 1 to be transferred to a general acute care hospital (GACH). During a review of Resident 1 ' s Physician and Telephone Orders dated 8/31/2024 at 3:30 p.m., the orders indicated to transfer Resident 1 to a GACH for psychiatry evaluation. During a review of Resident 1 ' s Licensed Personnel Progress Notes dated 9/6/2024 at 1:25 p.m., the progress note indicated Resident 1 was readmitted to the facility from the GACH. During a review of Resident 1 ' s care plan titled, AWOL, dated 9/6/2024, the care plan indicated Resident 1 would have no episodes of leaving the facility every day for 90 days. The care plan interventions indicated to alert all staff that resident was an AWOL risk, frequent visual checks at least every 2 hours, to assess the resident ' s safety and whereabouts, redirect resident when close to the fence, redirect away from the fence, and the yard monitor (staff assigned to observe and frequently check resident ' s whereabouts when outside) would closely watch Resident 1 when on the patio. During a review of Resident 1 ' s SBAR dated 9/8/2024 at 9:20 a.m., the SBAR indicated a Certified Nursing Assistant (CNA 3) reported he was unable to find Resident 1. The SBAR indicated Resident 1 left the facility AWOL. The SBAR indicated staff searched inside and the surrounding areas outside of the facility but was unable to locate Resident 1. The SBAR indicated FM 1 and the police were notified. During a review of Resident 1 ' s Social Services Progress Note, dated 9/9/2024, the progress noted indicated Resident 1 left the facility AWOL. The progress note indicated Resident 1 broke the window, climbed out and walked out of the back fence. During an observation on 9/10/2024 at 10:31 a.m., Resident 1 ' s room was observed at the far end of the hallway, away from the nursing station and next to a locked exit door leading to the smoking patio. There were no other residents observed residing in the room. During an interview on 9/10/2024 at 10:47 a.m., with the Infection Preventionist (IP) Nurse, the IP stated the staff needed to be in-serviced of AWOL risks for Resident 1. The IP stated frequent visual checks and hourly visual checks should have been done for Resident 1. The IP stated that someone must not have been following the protocol which led to Resident 1 ' s elopement. During an interview on 9/10/2024 at 11:52 a.m., with CNA 2, CNA 2 stated about three months ago he (CNA 2) observed Resident 1 outside in the yard, standing by a bush. CNA 2 stated Resident 1 suddenly ran and jumped over the fence. CNA 2 stated the gate of the fence was locked and he called the Director of Staffing Development (DSD) to assist. CNA 2 stated the DSD got in his vehicle to look for Resident 1. CNA 2 stated the DSD found Resident 1 in the surrounding neighborhood and brought the resident back to the facility. CNA 2 stated staff were expected to do frequent visual checks on Resident 1 and know the resident ' s whereabouts while in the yard. During an interview on 9/10/2024 at 12:55 p.m. with FM 1, FM 1 stated Resident 1 had been known to go AWOL. FM 1 stated Resident 1 was at another facility where he continuously tried to go AWOL, but the previous facility watched Resident 1 very well and he was not able to escape. FM 1 stated Resident 1 had a history of AWOL which was why he was placed in a locked facility. During an interview on 9/10/2024 at 2:24 p.m. with the DSD, the DSD stated Resident 1 ' s biggest risk was going AWOL. The DSD stated he could not recall the date, but he searched for Resident 1 after he eloped when he was first admitted to the facility. The DSD stated he found Resident 1 and bring him back to the facility in his (DSD) car. The DSD stated Resident 1 came to the facility with a history of exit seeking behaviors. The DSD stated Resident 1 attempted to leave the yard on several occasions and jumped the fence twice (unable to recall the dates). The DSD stated a yellow tape was placed across the area where Resident 1 jumped the fence to prevent him from going over the fence. The DSD stated on 9/8/2024 at approximately 9:20 a.m., Resident 1 broke the window in his room and went out of the window. The DSD stated nobody heard the window break. The DSD stated Resident 1 ' s window led to an area of the facility that was not used or monitored by staff. The DSD stated Resident 1 ' s room should have been in an area where the window faced the patio and staff could see when the resident attempted to leave through the window. The DSD stated the trouble with Resident 1 being out was alarming because he cut himself and the facility had not received a call from any of the hospitals indicated the resident was there. During a telephone interview on 9/10/2024 at 3:32 p.m., with CNA 3, CNA 3 stated he was assigned to Resident 1 on 9/8/2024. CNA 3 stated Resident 1 received his medications around 7:30 a.m., began walking around the facility. CNA 3 stated Resident 1 went on a smoke break out on the patio at 9 a.m. CNA 3 stated he (CNA 3) went on break, returned at 9:15 a.m. and went to Resident 1 ' s room. CNA 3 stated he got to Resident 1 ' s room about 9:18 a.m. and Resident 1 was not there. CNA 3 stated, CNA 5 reported that she had just seen Resident 1 at 9:20 a.m. walking down the hallway. CNA 3 stated Resident 2, who was in the room next to Resident 1 ' s room, came out of the room and told CNA 3 that he saw blood in the bathroom he shared with Resident 1, at about 9:21 a.m. CNA 3 stated he went to Resident 1 ' s room and observed small drops of blood on the bathroom floor, bathroom sink and on Resident 1 ' s bed. CNA 3 stated he ran out of the room to try and locate Resident 1. CNA 3 stated when he could not find Resident 1, he notified the charge nurse and went back to Resident 1 ' s room. CNA 3 stated when he noticed the broken window. CNA 3 stated he went to his car and searched throughout the neighborhood. CNA 3 stated Resident 1 was nowhere to be found so he returned to the facility. CNA 3 stated when he arrived back to the facility, the police department was there. During a concurrent interview and record review on 9/11/2024 at 9:38 a.m., with the Director of Nursing (DON), Resident 1 ' s care plans titled, Wandering dated 4/8/2024 and 5/21/2024, Inappropriate Behavior, dated 8/31/2024 and AWOL dated 9/6/2024 and the facility ' s Policy and Procedures (P&P) titled Interdisciplinary Team Conference (IDT), undated, and Elopement Wandering Resident undated, were reviewed. The DON stated if a resident eloped and was found, an SBAR or Change of Condition (COC) was supposed to be done on the resident. The DON stated an IDT meeting was only done for residents that eloped and were not found. The DON stated Resident 1 ' s care plan should have had better interventions to meet the resident ' s specific needs. The DON stated the facility was a locked facility, and all residents were considered high risk for elopement, but the elopement and wandering care plans for the Resident 1 did not reflect an individualized care plan for his elopement behaviors. The DON stated the facility did not put residents on 1:1 monitoring (close supervision, to keep the resident within sight at all times to reduce the risk and incidence of harm to the resident) unless they were high risk for elopement. The DON stated Resident 1 should have been considered a high-risk for elopement [JE1] since he had successfully eloped from the facility twice in the past. The DON stated she could not predict Resident 1 would break the window. The DON stated the IDT P&P indicated an IDT meeting will be held after an incident occurred to ensure resident ' s safety and the care plan reviewed and revised. The DON stated the importance of holding an IDT meeting after an incident was to collaborate as a team to formulate interventions and solve problems for the resident. The DON stated, the facility did not hold an IDT after Resident 1 eloped on 4/30/2024 and 5/23/2024. The DON stated Resident 1 ' s elopement care plan indicated an intervention to assess risk for elopement. The DON stated the facility did not do a risk assessment on their residents because all facility ' s residents were considered high risk. The DON stated the risk assessment should not have been checked as an intervention on Resident 1 ' s care plan. The DON stated she has never seen a risk assessment form and the facility has never used one in her [AGE] years of working in the facility. The DON stated if Resident 1 was not found, he can get hurt, he doesn ' t have food to eat, his wound can get infected from the injury, and he can suffer from dehydration, or heat stroke. b. During a concurrent observation and interview on 9/12/2024 at 12:01 p.m. with Resident 2, in Resident 2 ' s room, Resident 2 ' s room was observed next to Resident 1 ' s. Resident 2 pointed towards the bathroom he shared with Resident 1 and stated Resident 1 broke the window in his room and then came in the bathroom bleeding. Resident 2 did not recall the exact time or day of the incident. Resident 2 pointed to the areas in the bathroom where the blood was located. Resident 2 also pointed to the direction toward the window in Resident 1 ' s room, stating Resident 1 left the bathroom and walked towards the window. Resident 2 stated he did not hear or see Resident 1 break the window but saw the blood in the bathroom and Resident 1 walking towards his bed. Resident 2 stated he notified the nurse that there was blood in the bathroom. During a review of Resident 2's face sheet, dated 9/20/2024, the face sheet indicated Resident 2 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses which schizoaffective disorder, bipolar type, hypertension, dysphagia, and COPD. During a review of Resident 2 ' s History and Physical (H&P), dated 7/31/2024, the H&P indicated Resident 2 could make needs known but could not make medical decisions. During a review of Resident 2's Minimum Data Set (MDS - a standardized assessment and care planning tool), dated 7/31/2024 the MDS indicated Resident 2 had some difficulty communicating words or finishing thoughts but was able if prompted or given time. The MDS indicated Resident 2 could comprehend most conversation. During a review of the facility ' s undated P&P titled Elopement Wandering Resident, the P&P indicated the facility would modify the resident ' s care plan to indicate the resident was at high-risk for elopement. The P&P indicated an IDT conference would be held after an incident occurred to ensure resident ' s safety. During a review of the facility ' s P&P titled Interdisciplinary Team Conference (IDT), undated, the P&P indicated the facility would initiate an IDT Conference for each resident within 14 days of admission, quarterly, and during any change of condition to review, revise and accelerate the plan of care.

Based on interview and record review, the facility failed to provide the required supervision for one of three sampled residents (Resident 2) after two fall incidents. 1. Resident 2 fell on [DATE] (first fall), the facility failed to revise the resident's care plan, failed to reassess the resident's fall risk, ensure the resident's wheelchair alarm was functional, and failed to ensure an interdisciplinary team (IDT, group of different disciplines working together towards a common goal for a resident) meeting was held post fall. 2. Resident 2 fell on [DATE] (second fall), two days after being readmitted back to the facility from a general acute care hospital (GACH), after the resident's wheelchair alarm failed to activate. These deficient practices resulted in Resident 2's sustaining a contusion (bruise) and skin tear to the left side of the forehead from a fall incident on 2/1/2023 and the resident was transferred to the general acute care hospital (GACH). The resident received a computerized tomography scan (CT, combines a series of X-ray images taken from different angles around your body) and wound care. Resident 2 returned to the facility and sustained another subsequent avoidable fall on 2/7/2022 after the resident's wheelchair alarm failed to activate. Findings: During a review of Resident 2's Admission Records, the Admission Records indicated Resident 2 was admitted to the facility on [DATE] with diagnosis that included dementia (general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities), schizoaffective disorder (a mental health problem where the resident experience psychosis [people loose contact with reality] as well as mood [predominant emotion] symptoms), irritable bowel syndrome (common disorder affecting stomach and intestines causing pain in the belly, gas, diarrhea [loose stools], and constipation[difficult bowel movements]), and essential hypertension (high blood pressure). During a review of Resident 2's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 1/28/2023, the MDS indicated Resident 2's cognitive skills for daily decision making was severely impaired (the ability to understand or to be understood by others). The MDS indicated Resident 2 required limited assistance with dressing, eating, personal hygiene, and walking, and extensive assistance with bed mobility, transfer, and toilet use. The MDS indicated Resident 2 used a wheelchair for mobility and had a bed and wheelchair alarm. During a record review of Resident 2's Fall Risk Assessments (used to estimate a resident's fall risk) initiated on 12/12/2022, 12/23/2022, and 1/28/2023, the fall risk assessments indicated Resident 2 was a high fall risk with a score of 19 (high risk indicates a score of 10 or more) and had multiple risk factors that predisposed the resident to falls. The risk factors indicated Resident 2 had the following: a) Intermittent confusion, b) A history of 1 to 2 falls in the last 3 months, c) 1 to 2 medical diagnoses predisposing to falls, d) Chairbound and/or assist with elimination, e) Poor gait and balance (balance problem while standing, walking, change in gait when walking through doorway, unstable when making turns, and required assistive devices); and f) Takes 3 to 4 medications that increase risks for falls. The Fall Risk Assessments instructions indicated a prevention protocol should be initiated immediately and documented on Resident 2's care plan. During a record review of Resident 2's care plan titled, Safety compromised related to risk for fall, initiated 12/23/2022, the care plan goal indicated Resident 2 would be free of falls and injury for three months. The staff's interventions indicated all equipment (wheelchair alarm) would be free of damage and malfunction, monitor for falls, assess for injury, and notify the physician and family, least restrictive measures per protocol, and monitor for effectiveness of least restrictive measures. During a review of Resident 2's Physician's Order dated 2/1/2023 to 2/28/2023, the order indicated starting on 12/12/2022, the resident may have a wheelchair alarm to alert staff if resident was getting up unassisted. The order indicated the alarm does not limit freedom of movement and it was ordered due to poor safety awareness. The order indicated staff were to monitor episodes of attempting to get out of bed unassisted and tally by hashmark and if 10 or more episodes were noted to notify the physician. During a review of Resident 2's Licensed Progress Note dated 2/1/2023 at 7 p.m., the note indicated Resident 2 was found on the floor bleeding and had complaints of pain to the left forehead. During a review of Resident 2's Situation, Background, Assessment, and Recommendation ([SBAR] a communication tool used by licensed nurses when a resident has a change in condition) dated 2/1/2023 at 7 p.m., the SBAR indicated Resident 2 fell on [DATE], which resulted in a head contusion (bruise) and a skin tear on the left forehead. During a review of Resident 2's Licensed Progress Note, dated 2/2/2023 at 12:40 p.m., the note indicated on 2/2/2023 at 12:40 a.m., Resident 2 was transferred to a general acute care hospital (GACH) for further evaluation. During a review of Resident 2's GACH Physician History and Physical (H&P) dated 2/2/2023 at 11:02 p.m., the GACH H&P indicated Resident 2 was alert, oriented to self only, did not follow commands well, and had poor safety awareness. The GACH H&P indicated Resident 2 had a fall incident and was found on the floor at the facility with complaints of head pain. The GACH H&P indicated Resident 2 sustained a skin tear on the left side of the forehead and had a CT scan of the head. During a review of Resident 2's GACH Discharge Summary dated 3/2/2023 at 11:02 p.m., the GACH Discharge Summary indicated Resident 2 was admitted to the GACH on 2/2/2023 status post fall. The discharge summary indicated Resident 2 sustained a head contusion (bruise) and a skin tear on the left side of the forehead. The discharge summary indicated wound care done for the lacerated wound, suturing (stitch up) versus steri-strips (adhesive skin closure). The discharge summary indicated a urine culture (urine tested for infection) revealed the resident had a urinary tract infection (bladder infection) and was treated with intravenous ([IV] medication given directly to the bloodstream) hydration and IV Rocephin (medication that fight infections caused by bacteria [tiny organisms]). During a review of Resident 2's Licensed Progress Note dated 2/5/2023 at 7:40 p.m., the note indicated Resident 2 was readmitted back to the facility. During a record review of Resident 2's medical records, there was no documented evidence Resident 2's Safety care plan was revised with new/updated interventions, a post-fall risk assessment was completed, and an IDT meeting was held to address the resident's new fall prevention measures after the resident was readmitted to the facility on [DATE]. During a record review of Resident 2's Licensed Progress Note dated 2/7/2023 at 8 a.m., the note indicated a Certified Nurse Assistant (CNA 3) reported Resident 2 fell in the hallway (on 2/7/2023). The note indicated Resident 2, was observed by the CNA, trying to get up from the wheelchair several times prior to the fall incident but the CNA was with another resident when Resident 2 fell . The note indicated Resident 2's wheelchair alarm was not working properly at the time of the fall. During a record review of the facility's Interview Record of CNA 3 regarding Resident 2's fall dated 2/7/2023, the written statement indicated Resident 2's wheelchair alarm did not alarm when the resident was trying to get up. The written statement indicated Resident 2's wheelchair alarm activated after the resident was already on the floor. During a concurrent interview and record review on 3/2/2023 at 11:05 a.m., with LVN 1, Resident 2's Fall risk assessment dated [DATE] and care plan titled, Safety compromised related to risk for fall, initiated 12/23/2022, was reviewed. LVN 1 stated after Resident 2's fall incident on 2/1/2023, the resident's Fall risk assessment was not reassessed and new interventions for fall prevention were not found in the care plan. During a telephone interview with the Director of Nursing (DON) on 3/15/2023 at 9:58 a.m., the DON verified the licensed nurses' documentation indicated Resident 2's wheelchair alarm was not working when the resident fell . The DON stated Resident 2's care plan should have been revised after the resident was readmitted back to the facility on [DATE]. The DON stated the staff should have made sure Resident 2's wheelchair alarm was working. The DON stated there should be updated fall interventions to prevent future falls. During a record review of the facility's P&P titled, Resident Fall (undated), the P&P indicated the facility will promptly respond to all residents after a fall to provide necessary care and treatment to medically stabilize, and to initiate prompt interventions to prevent or reduce further falls with or without injury. The P&P indicated the facility will develop a care plan based upon the post fall report. The P&P indicated the interdisciplinary team (IDT, group of different disciplines working together towards a common goal of a resident) will discuss the fall during the stand-up meeting and revise the care plan and inform the direct care staff to prevent or minimize further falls.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program to address the rashes noted on seven of seven residents (Residents 1, 2, 3, 4, 5, 6, and 7). The facility failed to ensure all seven residents, who were exhibiting symptoms of suspected scabies (a contagious, intensely itchy skin condition caused by a tiny, burrowing mite), were provided with necessary care and treatment, and placed on contact precautions (intended to prevent transmission of infectious agents). On 1/25/2023, the facility identified an additional 36 of 88 residents with rashes. The facility failed to: a. Perform skin scrapings (a test to confirm or rule out scabies) for Resident 1 and 2 prior to being treated with Ivermectin (an antiparasitic drug, used to treat scabies) on 1/18/2023 and 1/19/2023 and Resident 1 and 2's roommates (Resident 3 and 4), who also had rashes, were not treated. b. Monitoring for effectiveness of treatment Residents 1, 2, 3, 4, 5, 6, and 7 when treated with tea tree oil (used to treat acne, athlete's foot, lice, nail fungus and insect bites) and A&D ointment (used as a moisturizer to treat or prevent dry, rough, scaly, itchy skin and minor skin irritations) in October, November, and December 2022. c. Obtain physician's order to treat Resident 7 with Permethrin. Resident 7, who was readmitted to the facility on [DATE] with small red dots all over the body, was treated with Elimite (Permethrin) 5 percent (%) cream (an insecticide, used to treat scabies) on 12/20/2022. d. Ensure the Infection Preventionist Nurse (IPN) followed the facility's policies and procedures titled, Scabies, when facility staff, Rehabilitation Staff (RS) 1, RS 2, Certified Nurse Assistant (CNA) 3 and CNA 4, reported having suspected scabies, and were treated with Permethrin ordered by the staff's private physicians. e. Ensure proper infection surveillance (close observation or monitoring) of all residents and staff with suspected scabies by completing a line listing (a table that contains key information about each case in an outbreak [a sudden increase in the incidence of a disease or medical condition in a particular place or population]). f. Report an outbreak of scabies to the local Health Department. g. Adhere to the facility's policy and procedure titled, Scabies, which stipulates to place all residents and staff suspected of scabies in contact precaution to prevent the spread of the infection. These deficient practices placed all residents, staff, vendors, and visitors at risk for scabies exposure. An additional 36 residents were identified with rashes. On 1/24/2023 at 5:30 p.m., the Department identified an Immediate Jeopardy ([IJ] a situation in which the facility's noncompliance with one or more requirements of participation has caused, or likely to cause, serious injury, harm, impairment, or death to a resident and the situation created a need for an immediate corrective action). The Administrator (ADM) and Infection Preventionist Nurse (IPN) were notified at this time of the immediate actions that needed to be taken and the seriousness of the residents' health and safety threatened due to the facility's failure to identify residents (Residents 1, 2, 3, 4, 5, 6, and 7) with suspected scabies, conduct skin scrapings, provide treatment as ordered by the physician, ensure the facility's policy and procedure for scabies was followed, and institute contact precautions and placed all residents, staff, vendors, and visitors at risk for scabies exposure. On 1/27/2023 at 5:33 p.m., the ADM provided an acceptable removal plan of action. The IJ removal plan included the following: 1. On 1/25/2023 at 1 p.m., the facility's Dermatologist (a medical doctor who specializes in conditions that affect the skin, hair, and nails) assessed all 43 residents identified with rashes. 2. On 1/26/2023 at 7 a.m., the Dermatologist performed skin scrapping of the 43 residents identified with rashes. The Dermatologist changed the treatment from Ivermectin to Elimite cream and gave specific recommendations for treatment and monitoring. The families and/or responsible parties have been notified. 3. All residents that did not have a rash but have been exposed to a resident with a rash, have been seen and evaluated by both the wound care nurse and the Dermatologist on 1/25/2023. On 1/26/2023, the Dermatologist gave recommendations of possible treatment. 4. The facility is currently evaluating all staff for rashes. If any staff has a rash, a physician's order will be given by the Dermatologist for Elimite cream from the facility's pharmacy so that treatment may begin. All staff will be evaluated by 2/3/2023. Weekly questionnaire for staff will be done every Tuesday for one month. Staff have been told to report any new rash on themselves to the IPN as soon as possible. Any new staff that is identified with a rash will be provided Elimite cream per the physician's orders. 5. Visitors that have visited with our residents within the past two weeks have been contacted on 1/25/2023 and were asked if they currently have a rash. 6. On 1/25/2023, staff was also notified via the facility's text alert system on inquiring if they currently have a rash, to please contact the facility immediately for appropriate treatment from the facility's pharmacy. Residents' families and/or responsible parties that are signed up to the facility's text alert system have been notified on 1/25/2023 via text message of rashes identified in the building. 7. Contact precautions have been initiated for all resident that have been identified with a rash. Residents are currently in hospital gowns as a precaution. All staff when treating a resident with a rash will use contact precautions and will use appropriate personal protective equipment (PPE, protective clothing or equipment worn to protect against infectious materials). 8. All 43 residents will remain on contact precautions until the skin scrapping were performed and confirmed. 9. A line list of both the residents and staff has been created to track the progress of each rash. 10. On 1/26/2023, certified nurse assistants (CNAs) were in-serviced on providing showers and bed baths to the residents identified with rashes. Staff will be in-serviced on rashes and how to properly report on the residents and themselves. 11. The resident rooms will be disinfected, and a deep cleaning will be done once the new treatment has begun. All rooms will be completely disinfected and deep cleaned by no later than 1/27/2023. All rooms will be completely disinfected and deep cleaned a second time by 2/3/2023. 12. The admitting nurse for all new or readmissions will do a complete body assessment to ensure that the resident does not have a rash. The CNA's will monitor the residents on their scheduled shower days and will report any resident with a rash to the charge nurse for further treatment. Facility will do weekly skin sweeps prior to dermatologist weekly visits to identify any new rash. 13. The wound care nurse and Physician Assistant (PA, type of mid-level health care provider with the ability to diagnose illness, develop and manage treatment plans, and prescribe medications) will come in every week and inquire if there are any residents that have new rashes that need to be addressed. If there are any new rashes, he/she will assess, and will forward their assessment to the Dermatologist. 14. The Dermatologist will visit weekly to assess any new rashes and to follow-up on existing rashes and provide orders as needed. The Dermatologist will visit weekly for two months for further treatments and evaluations of any resident with skin issues. 15. On 1/26/2023, the facility's Medical Director did rounds and read the Dermatologist's report. The Medical Director agrees with the course of treatment recommended. The Medical Director will come in weekly for one month to follow-up on the Dermatologist's reports and to ensure there are no new rashes. 16. The facility will follow the Dermatologist's recommendation sheet which lists all treatments he wants followed for residents with rashes, scabies, or exposure. The recommendation sheet also addresses time frames, initial treatments, follow-up treatments and how often he will continue to monitor the residents. 17. The Director of Nursing (DON) shall present any negative findings to the quarterly Quality Assurance (QA) committee for review and recommendations. On 1/27/2023 at 5:39 p.m., while onsite, after the IJ Removal Plan was verified as implemented through observation, interviews and record review, the ADM was notified the IJ was lifted. Findings: a. During a review of Resident 1's Admission Record (Face Sheet), the Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 1's diagnoses included diabetes mellitus (a group of diseases that result in too much sugar in the blood), bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), hyperlipidemia (a condition in which there are high levels of fat particles called lipids in the blood), hypertension (high blood pressure), and unspecified dermatitis (a group of conditions in which the skin becomes inflamed, forms blisters, and becomes crusty, thick, and scaly). During a review of Resident 1's Minimum Data Set (MDS), an assessment and care screening tool, dated 12/16/2022, the MDS indicated Resident 1 had severely impaired cognitive skills for daily decision making (ability to reason and think), and required limited assistance with transfers, dressing, toileting, personal hygiene, and bathing. The MDS indicated Resident 1 did not have any skin problems. During a review of Resident 1's Progress Note dated 12/9/2022, the note indicated Resident 1 had scattered scratches to the face and widespread red dots noted to the body. During a review of Resident 1's Physician's Order dated 12/9/2023, the order indicated to apply tea tree oil and A&D ointment from the neck to the feet twice a day for one month. The order was renewed on 1/10/2023 for unresolved unspecified dermatitis. During a review of Resident 1's Treatment Administration Record (TAR) for the months of November and December 2022, the TARs indicated Resident 1 was treated with tea tree oil and A&D ointment for unspecified dermatitis. There was no monitoring of effectiveness of the treatment noted. During a review of Resident 1's care plan titled, Unspecified Dermatitis, dated 12/9/2022, the care plan indicated the resident's goal was for the rash to resolve in one month. The staff's interventions indicated to keep Resident 1 clean and dry, apply treatment as ordered, notify the physician if treatment was ineffective, and keep nails trim and short. During a review of Residents 1's Physician's Telephone Order, on 1/18/2023, the order indicated to give Ivermectin 15 milligram (mg, unit of measurement) by mouth, one time dose for widespread dermatitis. The order was signed by the licensed nurse, however there was no physician signature noted. During a review of Resident 1's Medication Administration Record (MAR) for the month of January 2023, the MAR indicated on 1/18/2023, Resident 1 was given Ivermectin 15 mg by mouth. During a concurrent observation and interview on 1/19/2023 at 10 a.m. with Resident 1, in Resident 1's room, Resident 1 was observed lying on the bed scratching his neck with long fingernails. Resident 1 had three linear, deep scratch marks measuring approximately three inches long across his face. Resident 1 had multiple red skin rashes on his neck, trunk, arms, hands, and legs. Resident 1 stated he was very itchy at times. During an interview with Certified Nurse Assistant (CNA) 1 on 1/19/2023 at 10:10 a.m., CNA 1 stated Resident 1 always complained of itchiness all over the body. CNA 1 stated she had been applying A&D ointment after the resident's showers, but the ointment did not work because Resident 1 still had rashes. b. During a review of Resident 2's Admission Record (Face Sheet), the Face Sheet indicated Resident 2 was admitted to the facility on [DATE]. Resident 2's diagnoses included psychosis (a mental disorder characterized by a disconnection from reality), muscle wasting and atrophy (decrease in the size and wasting of muscle tissue), and epilepsy (disorder in which nerve cell activity in the brain is disturbed, causing seizures). During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 had moderately impaired cognition, and required supervision with transfers, dressing, toileting, and limited assistance with personal hygiene and bathing. The MDS indicated Resident 2 had identified skin problems. During a review of Resident 2's Non-pressure Sore Skin Problem report dated 11/30/2022, the report indicated Resident 2 had widespread dermatitis all over the body. During a review of Resident 2's Dermatologist Consultation Note, dated 11/30/2022, the note indicated the resident's skin was abnormal with rash and itching, with multiple discoloration and raised lesions. The note indicated the treatment plan indicated to start with tea tree oil and A&D ointment twice daily for one month. During a review of Resident 2's TARs for the months of November 2022 and December 2022, the TARs indicated Resident 2 was treated with tea tree oil and A&D ointment for unspecified dermatitis. There was no monitoring of effectiveness of the treatment noted. During a review of Resident 2's Physician's Order dated 12/9/2023, the order indicated to apply tea tree oil and A&D ointment from the neck to the feet twice a day for one month. The order was renewed on 1/10/2023 for unresolved unspecified dermatitis. During a review of Resident 2's care plan titled, Unspecified Dermatitis, dated 12/9/2022, the care plan indicated the goal was Resident 1's rash would resolve in one month. The staff's interventions indicated to keep Resident 2 clean and dry, apply treatment as ordered, notify the physician if treatment was ineffective, and keep nails trim and short. During a review of Residents 2's Physician's Telephone Order dated 1/19/2023, the order indicated to administer Ivermectin 15 mg by mouth, one dose for widespread dermatitis. The order was signed by LVN 1, however there was no physician's signature. During a review of Resident 2's MAR for the month of January 2023, the MAR indicated on 1/19/2023, the resident received Ivermectin 15 mg by mouth, one dose for widespread dermatitis. During a concurrent observation and interview on 1/19/2023 at 10:25 a.m. with Resident 2, in Resident 2's room, Resident 2 was observed lying on the bed with long fingernails scratching his left arm. Resident 2 was observed with multiple red rashes on his trunk, arms, hands, and legs. Resident 2 stated his rashes were always very itchy. During interview with CNA 2 on 1/19/2023 at 10:30 a.m., CNA 2 stated Resident 2 was always seen scratching. CNA 2 stated she applied A&D ointment to Resident 2's rashes. CNA 2 stated the A&D ointment seemed to not work because the rashes had been there for many months since 11/30/2022. CNA 2 stated Resident 2's fingernails should be trim and cut short to prevent skin infection due to scratching. CNA 2 stated she reported the resident's worsening rashes to LVN 1 the licensed nurses on duty at that time (unable to give a specific date). c. During a review of Resident 3's Admission Record (Face Sheet), the Face Sheet indicated Resident 3 was initially admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 3's diagnoses included bipolar disorder, anxiety disorder (a mental health disorder characterized by feelings of worry, or fear that are strong enough to interfere with one's daily activities), hyperlipidemia, hypertension, and muscle weakness. During a review of Resident 3's admission nursing assessment dated [DATE], the assessment indicated the resident's skin was clear. During a review of Resident 3's MDS dated [DATE], the MDS indicated Resident 3 had moderately impaired cognition, required supervision with transfers, dressing, toileting, and limited assistance for personal hygiene, and bathing. The MDS indicated Resident 3 did not have any skin problems. During a review of Resident 3's Treatment Administration Record (TAR) for December 2022, the TARs indicated Resident 3 was treated with tea tree oil and A&D ointment on left arm and chest for unspecified dermatitis, however there were no monitoring of effectiveness of treatment. During a review of Resident 3's Physician's Order dated 12/1/2022, the order indicated to apply tea tree oil and A&D ointment to the left arm and chest twice a day for two weeks. The order was renewed on 12/14/2022, 12/28/2022, and 1/18/2023 with an indication for unresolved unspecified dermatitis. During a review of Resident 3's Progress Note dated 12/1/2022, the note indicated small red dots were noted on Resident 3's left arm and chest area. The note indicated the PA (physician assistant) was notified and orders were received and carried out. During a review of Resident 3's care plan titled, Dermatitis to left arms and chest, dated 12/1/2022, the care plan indicated the goal was for the dermatitis to resolve in two weeks. The staff's interventions indicated to keep Resident 3 clean and dry, apply treatment as ordered, notify the physician if treatment was ineffective, monitor daily for response to treatment, and keep nails trim and short. During a concurrent observation and interview on 1/19/2023 at 11:20 a.m. with Resident 3, in Resident 3's room, Resident 3 was observed sitting at the edge of the bed scratching his right leg with long fingernails. Resident 3 was observed with multiple pin-point rashes and multiple scratches to both arms and both legs. Resident 3 stated the bed linen had feces on them that touched his skin and that was the reason he had rashes. Resident 3 stated he was given a tube of A&D ointment and was told to apply it to his rashes. Resident 3 stated his rashes were very itchy at night and the nurses gave him medicine (name unknown) to sleep, however the itchiness did not go away. During an interview with CNA 1 on 1/19/2023 at 10:20 a.m., CNA 1 stated Resident 3 always complained of itchiness all over the body. CNA 1 stated she had applied the ordered ointment to Resident 3's rashes after his showers but could not recall the name of the ointment. CNA 1 stated Resident 3 had a lot of rashes which worsened when the resident scratched them. d. During a review of Resident 4's Admission Record (Face Sheet), the Face Sheet indicated Resident 4 was initially admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 4's diagnoses included diabetes mellitus, anxiety disorder, chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe), hypertension, and muscle weakness. During a review of Resident 4's MDS dated [DATE], the MDS indicated Resident 4 had moderately impaired cognition, and required limited assistance with transfers, dressing, toileting, personal hygiene, and bathing. The MDS indicated Resident 4 did not have any skin problems. During a review of Resident 4's Progress Note dated 12/1/2022, the note indicated the resident had widespread dermatitis and denied itching at that time. During a review of Resident 4's Physician's Order dated 12/1/2022, the order indicated to apply tea tree oil and A&D ointment from the neck to the feet twice a day for one month. During a review of Resident 4's TAR for the month of December 2022, The TAR indicated the resident was treated with tea tree oil and A&D ointment from the neck to the feet for widespread dermatitis. There was no monitoring of effectiveness of the treatment. During a review of Resident 4's care plan titled, Dermatitis - widespread dermatitis, dated 12/1/2022, the care plan indicated the goal was for the resident's dermatitis to resolve in one month. The staff's interventions indicated to keep Resident 4 clean and dry, apply treatment as ordered, and notify the physician if treatment was ineffective. During a concurrent observation and interview on 1/19/2023 at 11:45 a.m. with Resident 4, in Resident 4's room, Resident 4 was observed lying on the bed scratching his right arm. Resident 4 stated he was sometimes itchy. During an interview with CNA 2 on 1/19/2023 at 10:20 a.m., CNA 2 stated Resident 4 very seldom complained of itchiness but has observed the resident scratching since December 2022 (did not specify date). e. During a review of Resident 5's Admission Record (Face Sheet), the Face Sheet indicated Resident 5 was initially admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 5's diagnoses included anxiety disorder, hyperlipidemia, hypertension, unspecified dermatitis, and muscle weakness. During a review of Resident 5's MDS dated [DATE], the MDS indicated Resident 5 had severely impaired cognition, and required supervision with transfers, dressing, toileting, personal hygiene, and bathing. The MDS indicated Resident 5 had identified skin problems. During an observation of Resident 5 on 1/19/2023 at 1:30 p.m., in Resident 5's room, the resident was observed lying on his bed with multiple red, dry rashes on his neck, arms, hands, and legs. During a review of Resident 5's admission nursing assessment dated [DATE], the assessment indicated Resident 5 was noted with scabies rashes. During a review of Resident 5's Progress Note dated 10/15/2022, the note indicated Resident 5's skin was intact with dermatitis noted to the body. During a review of Resident 5's Progress Note dated 10/18/2022, the note indicated Resident 5 was seen and examined by the Dermatologist for unspecified dermatitis. An order was received to apply tea tree oil and A&D ointment from the neck to the feet twice a day for one month. During a review of Resident 5's Non-pressure Sore Skin Problem report dated 10/19/2022, the report indicated Resident 5 had widespread dermatitis all over the body. During a review of Resident 5's Physician's Order dated 10/19/2022, the order indicated to apply tea tree oil and A&D ointment from the neck to the feet twice a day for one month. The order was renewed on 11/19/2022, 12/19/2022 and 1/19/2023. The orders were signed by licensed nurse, however there no physician's signature. During a review of Resident 5's care plan titled, Unspecified Dermatitis widespread, dated 10/19/2022 and revised on 1/19/2022, the care plan indicated the goal was Resident 5 would improve in one month. The staff's interventions indicated to keep Resident 5 clean and dry, apply treatment as ordered, notify the physician if treatment is ineffective, and monitor daily for response to treatment. During a review of Resident 5's TARs for the months of November and December 2022, the TARs indicated Resident 5 was treated with tea tree oil and A&D ointment for unspecified dermatitis. There was no monitoring of the effectiveness of treatment documented. f. During a review of Resident 6's Admission Record (Face Sheet), the Face Sheet indicated Resident 6 was initially admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 6's diagnoses included anxiety disorder, dementia (progressive memory loss and group of thinking and social symptoms that interferes with daily functioning), epilepsy and muscle weakness. During a review of Resident 6's MDS dated [DATE], the MDS indicated Resident 6 had severely impaired cognition, required supervision with transfers, dressing, toileting, and limited assistance for personal hygiene, and bathing. The MDS indicated Resident 6 did not have any skin problems. During an observation on 1/19/2023 at 1:39 p.m. in Resident 6's room, the resident was observed lying on the bed with multiple rashes on his neck, arms, hands, and legs. During a review of Resident 6's Progress Note dated 10/15/2022, the note indicated Resident 6's skin was intact with dermatitis noted. The note indicated Resident 6's physician was notified and orders were received and carried out. During a review of Resident 6's Non-pressure Sore Skin Problem report dated 10/19/2022, the report indicated Resident 6 had widespread dermatitis. During a review of Resident 6's Physician's Telephone Order dated 12/19/2022, the order indicated to apply tea tree oil and A&D ointment from the neck to the feet twice a day for one month. The order was renewed on 1/19/2022 for unspecified dermatitis. The order was signed by the licensed nurse, however there was no physician's signature. During a review of Resident 6's TARs for the months of December 2022 and January 2023, the TARs indicated Resident 6 was treated with tea tree oil and A&D ointment for widespread dermatitis, however there was no monitoring of the effectiveness of treatment noted. During a review of Resident 6's care plan titled, Widespread Dermatitis, dated 12/20/2022, the care plan indicated the goal was for Resident 6's dermatitis to resolve in one month. The staff's interventions indicated to apply treatment as ordered, notify the physician if treatment is ineffective, monitor daily for response to treatment, and keep nails trim and short. g. During a review of Resident 7's Admission Record (Face Sheet), the Face Sheet indicated Resident 7 was initially admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 7's diagnoses included anxiety disorder, epilepsy, hypertension, and unspecified dermatitis. During a review of Resident 7's MDS dated [DATE], the MDS indicated Resident 7 had severely impaired cognition, and required extensive assistance with transfers, dressing, toileting, personal hygiene, and bathing. The MDS indicated Resident 7 did not have any skin problems. During an observation on 1/19/2023 at 2:40 p.m., in Resident 7's room, Resident 7 was observed lying on the bed with multiple rashes to his neck, arms, and legs. During a review of Resident 7's admission nursing assessment dated [DATE], the assessment indicated the resident had dermatitis to the whole body. During a review of Resident 7's Non-pressure Sore Skin Problem report dated 12/14/2022, the report indicated Resident 7 had widespread dermatitis all over the body. During a review of Resident 7's Progress Note dated 12/16/2022, the note indicated small red dots noted all over Resident 7's body. During a review of Resident 7's Physician's Order dated 12/16/2022, the order indicated to apply tea tree oil and A&D ointment from the neck to the feet twice a day for one month for contact dermatitis. During a review of Resident 7's Physician's Order dated 12/16/2022, the order indicated to apply Permethrin 5% cream from the head to the toes on 12/17/2022 at bedtime (QHS) and shower the next morning on 12/18/2022 after 12 hours. The order indicated to change Resident 7's linen and clothes. During a review of Resident 7's TAR for the month of December 2022 and January 2023, facility unable to provide TAR for December 2022, and there was no documentation Permethrin 5% cream was applied to Resident 7 or that the order was carried out. During a review of Resident 7's MAR for the month of December 2022 and January 2023, there was no documentation Permethrin 5% cream was applied to Resident 7 or that the order was carried out. During a review of Resident 7's History and Physical (H&P) dated 12/20/2022, the H&P indicated the resident's physician ordered Permethrin 5% external cream, one application topically to the affected area one time to start on 12/20/2022. During a review of Resident 7's TAR for the month of December 2022, the TAR indicated Resident 7 was treated with tea tree oil and A&D ointment for widespread dermatitis, however there was no monitoring of the effectiveness of treatment. During a review of Resident 7's care plan titled Widespread Dermatitis, dated 12/20/2022, the care plan goals was that Resident 7's dermatitis would resolve in one month. The staff's interventions indicated to apply treatment as ordered, notify the physician if treatment is ineffective, monitor daily for response to treatment, and keep nails short. During a concurrent interview and record review of Residents 1, 2, 3, 4, 5, 6, and 7's MAR and TAR for the month of October, November, December 2022 and January 2023, on 1/19/2023 at 10:14 a.m., with Treatment Nurse (TN) 1, TN 1 stated Residents 1, 2, 3, 4, 5, 6, and 7 were treated with tea tree oil and A&D ointment every day, however there was no daily monitoring for treatment effectiveness. TN 1 stated the Wound Consultant Physician Assistant (WCPA) visited every week to check the residents. TN 1 stated the Dermatologist visited every month. TN 1 stated she used an N95 respirator mask and gloves during Residents 1, 2, 3, 4, 5, 6, and 7's wound treatment. TN 1 stated there were no residents placed on contact precautions in the facility. During an interview with Licensed Vocational Nurse (LVN) 1 on 1/19/2022 at 1:45 p.m., LVN 1 stated Residents 1, 2 ,3, 4, 5, 6, and 7 were being monitored by the WCPA because of suspicious rashes. LVN 1 stated the residents' physicians were aware of the rashes. LVN 1 stated TN 1 was responsible for treating and providing updates on the residents with skin conditions to WCPA and Dermatologist. During a telephone interview on 1/19/2023 at 1 p.m. with the WCPA, the WCPA stated she ordered Ivermectin due to unresolved rashes for two residents (Residents 1 and 2). The WCPA stated Resident 1 and 2's roommates (Residents 3 and 4) who also exhibited multiple rashes were not treated. The WCPA stated she did not order skin scrapings because it was not offered as one of their (the company in which she works) services. During an interview on 1/19/2023 at 2:55 p.m. with the IPN, the IPN stated Rehabilitation Staff (RS) 1 informed him, RS 1 went to urgent care on last week of December 2022 (did not specify exact date) and was diagnosed with scabies. The IPN stated the rash to RS 1's arms did not look like scabies to him. The IPN stated he did not consult with the facility's Medical Director regarding RS 1's diagnosis because he believed it did not look like scabies to him. The IPN stated the Dermatologist was visiting the facility every month and the WCPA was visiting on a weekly basis for all the residents with skin problems. The IPN stated the suspicious rashes were not reported to the local Public Health office nor the Department of Public Health. The IPN stated the facility had no confirmed cases of scabies and the IPN was not aware that a suspected case of scabies or rashes needed to be reported. During a concurrent observation and interview on 1/24/2023 at 10 a.m. with RS 1, in the Rehab room, RS 1 was observed with multiple brown pin-point scars to both arms. RS 1 stated she had multiple red pin-point rashes the last week of December 2022. RS 1 stated she consulted urgent care and was told she had scabies. RS 1 stated she was treated with Permethrin 5% cream. RS 1 stated she reported her diagnosis to the IPN however the IPN did not believe her. RS 1 stated she provided physical therapy treatment for Residents 1 and 7 during the month of December 2022 and up until January 2023. During a concurrent observation and interview on 1/24/2023 at 10:23 a.m. with CNA 3, CNA 3 stated she went to her primary physician on December 2022 (unable to recall exact date) and was told she had scabies. CNA 3 was observed with multiple brown spots on both arms. CNA 3 stated skin scraping was not done and was instructed by her primary physician to apply Permethrin 5% cream at home to her whole body for 24 hours, then shower after. CNA 3 stated she notified the IPN. During an interview on 1/24/2023 at 10:29 a.m. with LVN 2, LVN 2 stated the Dermatologist visited once a month. LVN 2 stated the last visit was[TRU

Based on observation, interview, and record review, the facility failed to ensure four (4) of 10 sampled residents (Residents 84, 36, 345, and 80) were free from physical restraints, by not ensuring: 1. Assessments were completed prior to applying the physical restraints. 2. Adequate monitoring and periodic release of the physical restraints to ensure adequate blood circulation and skin integrity. 3. Development and implementation of care plans addressing the use of physical restraints. 4. Least restrictive measures were used prior to the implementation of restraints, per the facility's policy. These deficient practices resulted in the use of unnecessary physical restraints, placing the residents at risk for psychosocial harm from not being treated with respect and dignity; and from physical harm by impeding the circulation of the resident's arms and legs, decline in activities of daily living (ADLs), impaired skin integrity, entrapment or death caused by physical restraints. Findings: a. During a review of Resident 84's Admission Record, the admission record indicated Resident 84 was admitted to the facility on [DATE]. Resident 84's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 84's Quarterly Minimum Data Set (MDS), a standardized assessment and screening tool, dated 3/16/22, the MDS indicated the resident had severe cognitive (ability to think and reason) impairment. The MDS indicated Resident 84 required total dependence on staff with bed mobility, transfer, dressing, toilet use, personal hygiene and bathing. During an observation on 4/4/2022 at 10:17 a.m., in the resident's room, Resident 84 was observed in bed awake, and verbal with slurred speech. Resident 84 was lying in a semi-fowlers position (positioned on the back with the head and trunk raised between a 15- and 45-degrees angle) with bilateral (having or relating to two sides) foam bolster wedges underneath his trunk area. Resident 84 was receiving oxygen therapy at two (2) liters per minute (l/m) via nasal cannula (flexible tubing with one end designed to deliver oxygen through the nostrils) and gastrostomy tube ([G-tube] surgically placed device used to give direct access to the stomach to deliver feedings, hydration, or medication) feeding. An abdominal binder (fitted elastic material that goes around your abdomen ) was wrapped around Resident 84 abdomen and bilateral hand mittens. During an interview with Certified Nurse Assistant (CNA) 5 on 4/4/2022 at 10:20 a.m., CNA 5 stated Resident 84's bilateral mittens were always applied to prevent Resident 84 from pulling out his G-tube. CNA 5 confirmed that there was no documentation indicating the on-going assessment and monitoring of Resident 84's bilateral mittens every 2 hours. CNA 5 stated it was very important to release the mittens every 2 hours to prevent skin breakdown. During a concurrent observation and interview with Licensed Vocational Nurse 6 (LVN 6) on 4/5/2022 at 10:48 a.m., Resident 84 was observed with a Stage I pressure ulcer (superficial reddening of the skin that when pressed does not turn white) on the left wrist measuring approximately one (1) centimeter ([cm] unit of measurement) by 3 cm. LVN 6 stated the mittens should have been released every 2 hours to prevent skin breakdown caused by the prolonged period of time the mittens were placed. During a review of Resident 84's Pressure Ulcer Risk assessment dated [DATE], the assessment indicated Resident 84 was at high risk for skin breakdown and prevention protocol should be initiated immediately. During a review of Resident 84's Fall Risk assessment dated [DATE], the assessment indicated Resident 84 was at high risk for falls and a prevention protocol should be initiated immediately and documented on the care plan. During a review of Resident 84's Bowel and Bladder assessment dated [DATE], the assessment indicated Resident 84 was a poor candidate for toileting schedule for retraining. During a review of Resident 84's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 84's Admission Progress Nursing Note dated 4/3/2022 at 8:16 p.m., the admission nursing note indicated an abdominal binder and bilateral mittens was in placed to prevent the resident from pulling out the G-tube. During a review of Resident 84's CNA notes from 4/3/2022 to 4/5/2022, the notes indicated the mittens were not included in monitoring from 7:00 a.m. to 3:00 p.m. (AM shift), from 3:00 p.m. to 11:00 p.m. (PM shift) and from 11:00 p.m. to 7:00 a.m. (Night Shift). During a review of Resident 84's Progress Nursing Notes from 4/3/2022 to 4/5/2022, the notes indicated that there was no documentation the resident's bilateral mittens had been released every 2 hours. There was no skin assessment and monitoring documented. During an interview with the Director of Rehabilitation (DOR) on 4/4/2022 at 11:00 a.m., DOR stated if residents did not move a lot the muscles tighten, so, staff want residents to move as much as possible. DOR stated Resident 84 was totally dependent on mobility per joint mobility assessment (JMA) done by Physical Therapy (PT) on 4/4/2022. During an interview with the DON on 4/6/2022 at 2:25 p.m., the DON stated all restraints were initiated because of the resident's change of condition. DON stated that prior to initiation of any restraints, an Interdisciplinary Team meeting ([IDT] group of different disciplines working together towards a common goal of a resident) should be conducted to discuss the resident's plan of care during the resident's stay in the facility. DON stated a valid consent for any restraint was required prior to use. DON confirmed Resident 84's IDT meeting was not done, and the resident did not have an informed consent for the use of the bilateral mittens. The DON stated Resident 84's abdominal binder was the least restrictive measure to prevent the resident pulling out the G-tube and did not need the bilateral mittens. The DON stated that all restraints should be care planned, assessed and monitored for skin breakdown. b. During a review of the Resident 36's Admission Record, the admission record indicated the resident was admitted to the facility on [DATE]. Resident 36's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 36's MDS, dated [DATE], the MDS indicated Resident 36 had clear speech, was able to make himself understood and was able to understand others. The MDS indicated Resident 36 required limited assistance with one person assist with activities of daily living ([ADLs] self-care activities performed daily) such as bed mobility, dressing, transfer, personal hygiene, walking in the room and corridor, locomotion on and off the unit (how residents move to and return off unit locations), toilet use, and required supervision with eating. During a review of Resident 36's Annual History and Physical (H/P) dated 2/27/2022, the H/P indicated Resident 36 was able to make needs known but could not make medical decisions. During a review of Resident 36's Physical restraints or prolonged use of a device pelvic restraint in wheelchair document, dated 1/18/2022, indicated consent obtained from the surrogate decision maker/conservator was signed by the resident's physician. During a review of Resident 36's care plan titled, Safety Compromised related to Falls manifested by poor safety awareness, behavior problems, medical problems, possible side effects to restraints, dated 11/26/2021 and revised 1/18/2022, the care plan indicated Resident 36 may have pelvic restraints in wheelchair due to poor safety awareness secondary to dementia. During a review of the Resident's 36's Care Conference note dated 2/15/2022, there was no mention of the use of physical restraints during the IDT meeting. During a review of Resident 36's Physical Therapy Treatment note dated 12/3/2022, the note indicated Resident 36 was able to ambulate (walk) 50 feet with two turns with partial or moderate assistance. The note indicated Resident 36 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 36's Joint Mobility assessment dated [DATE], the JMA indicated that Resident 36 could move his upper extremities and lower extremities within functional limit. During an observation on 4/4/2022 at 10:35 a.m., Resident 36 was observed wheeling himself in the hallway with a pelvic restraint double tied at the back of the resident's wheelchair. During a concurrent observation and interview on 4/6/2022 at 1:44 p.m., CNA 15 was observed demonstrating how to remove Resident 36's pelvic restraint. The restraint ties were observed to be inserted three times in the wheelchair bar. CNA 15 was observed having difficulty removing the restraint. CNA 15 stated she needed to make sure the ties were looped around the bar of the wheelchair because Resident 36 attempted to remove it and get up unassisted. CNA 15 stated that Resident 36 was continent (ability to control) of both bowel and bladder function and needed staff to release or remove the pelvic restraint when the resident needed to use the bathroom. During an interview with Resident 36 on 4/6/2022 at 1:55p.m., Resident 36 stated he could not independently go to the bathroom because of the restraint. Resident 36 stated the restraint was tied behind the wheelchair so he could not reach it. Resident 36 stated he could use the bathroom if he was not tied to the wheelchair. Resident 36 stated he feels humiliated going to the dining room with the restraint. During a review of Resident 36's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . c. During a review of the Resident 345's Admission Record, the admission record indicated the resident was admitted to the facility on [DATE]. Resident 345's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 345's Baseline Care Plan dated 3/29/2022, the care plan indicated Resident 345 was verbally confused with adequate vision and hearing. The care plan indicated Resident 345 had a lap buddy restraint. During an initial tour of the facility on 4/4/2022 at 8:35 a.m., Resident 345 was observed with a lap buddy restraint and was attempting to tell CNA 12 to remove the restraint. During an interview with CNA 12 on 4/4/2022 at 12:35 p.m., CNA 12 stated Resident 345 was continent of both bowel and bladder function and needed help removing the restraint. CNA 12 stated the restraint was applied for the resident's safety because Resident 345 tried to get up unassisted. CNA 12 stated the discoloration noted to Resident's 345's forehead was from a fall incident. CNA 12 stated Resident 345 was new to the facility and was not that familiar with Residents 345's behaviors. CNA 12 stated at the beginning of each shift, the charge nurse or supervisor would inform staff about new admissions. During a review of Resident 345's Consent for Chemical/Physical Restraint dated 4/1/2022, there was no physician signature indicating the consent was obtained from the resident's surrogate/decision maker. During a review of Resident 345's medical records, there was no physical restraint assessment, or documentation indicating a least restrictive device was offered, attempted and unsuccessful. During a review of Resident 345's Physician's Telephone Order dated 4/1/2022, the order indicated to apply a lap buddy due to poor safety awareness related to dementia. During a review of Resident 345's Joint Mobility assessment dated [DATE], the assessment indicated that Resident 345's upper and lower extremities were within functional limit per the occupational therapist (OT). The assessment indicated Resident 345 was functioning at high level of independence but utilizing a merry walker (considered a restraint if the resident was unable to open and close the front gate and caregiver assistance must be provided to release the resident form the device). During a review of Resident 345's Nursing Note dated 4/1/2022 at 9 p.m., the note indicated may have lap buddy due to poor safety awareness related to dementia, informed consent obtained by nurse from the responsible party. During a concurrent observation and interview with CNA 6 and Resident 345 on 4/5/2022 at 6:27 a.m., CNA 6 stated Resident 345 was unable to remove the lap buddy. CNA 6 stated she made sure the restraint was applied properly and correctly so Resident 345 could not easily remove it. Resident 345 was asked to demonstrate the removal of restraint and was observed unable to remove the restraint. Resident 345 verbalized the restraint was hard to remove. d. During a review of Resident 80's Admission Record, the admission record indicated the resident was admitted to the facility on [DATE]. Resident 80's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the admission record Resident 80's family member (FM 1 and FM 2) were indicated as the resident's emergency contacts. During a review of Resident 80's MDS, dated [DATE], the MDS indicated Resident 80 usually expressed ideas and wants and usually understood verbal content. The MDS indicated Resident 80 had severely impaired cognitive skills for daily decision making. The MDS indicated Resident 80 required extensive assistance with eating, bed mobility, walking, and was totally dependent with transfer, toilet use, personal hygiene, and dressing. During a review of Resident 80's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 80's undated H/P, the H/P indicated Resident 80 did not have the capacity to understand and make decisions. During a review of Resident 80s Verification of Resident Information Consent for Chemical and Physical Restraints or Prolonged Use of a Device form dated 2/15/2022, the form indicated informed consent was obtained from the IDT and not FM 1 or FM 2. During a review of Resident 80's IDT team notes dated 2/15/2021, there was no documented evidence of any attempt to contact the resident's family to obtain informed consent for restraint use prior to use of the pelvic restraint. During a review of Resident 80's medical records, the records indicated there was no documented evidence of the following: 1. Restraint assessment prior to use, 2. Care plans addressing use of pelvic restraints, 3. Monitoring of the resident's tolerance to the pelvic restraint, 4. Release every hour to allow freedom to move, and 5. Facility attempts to use the least restrictive devices prior to implementing the use of pelvic restraints. During an observation on 4/4/2022 at 12:23 p.m., in the dining room, Resident 80 was observed sitting on his wheelchair wearing a pelvic restraint with two (2) straps tied at the back of the wheelchair. During an observation on 4/5/2022 at 8:50 a.m., Resident 80 was observed asleep while seated on his wheelchair wearing a pelvic restraint with 2 straps tied at the back of the wheelchair. During a concurrent observation and interview with CNA 4 on 4/5/2022 at 1:33 p.m., in the patio, Resident 80 was seated on his wheelchair with a pelvic restraint with 2 straps tied at the back of the wheelchair. CNA 4 stated that Resident 80 was only released out of the pelvic restraint when he expressed the need to use the restroom or if he needed something that required him to get up out of the chair. CNA 4 stated Restorative Nurse Assistants (RNA's) or the Rehabilitation Therapy (RT) staff was in charge of ambulating with the residents. CNA 4 stated Resident 80 could not remove the restraints by himself. During an interview on 4/5/2022 at 1:55 p.m., CNA 3 stated Resident 80's pelvic restraint was only removed when the resident needed to go to the restroom or if the resident needed something requiring him to move. CNA 3 stated residents on restraints were not routinely released from the restraints and stayed in the same position for eight hours in the wheelchair. CNA 3 stated Resident 80 could not remove his own restraints. During a review of Resident 80's Pressure Ulcer Risk assessment dated [DATE], the assessment indicated Resident 80 was high risk for skin breakdown and prevention protocol should be initiated immediately. During a review of Resident 80's Nurse Assistant Notes from 2/16/2022 to 4/5/2022, the notes indicated Resident 80 was in the wheelchair for a total of 49 days during the AM shift (from 7:00 a.m. to 3:00 p.m.) and PM shift (from 3:00 p.m. to 11:00 p.m.) wearing a pelvic restraint. During a review of Resident 80's care plan titled, Impaired Physical Mobility, initiated 2/22/2022, the staff's interventions indicated to be turn and reposition Resident 80's every 2 hours unless contraindicated. During an interview with the MDS Coordinator (MDSC) on 4/5/2022 at 2:04 p.m., MDSC stated restraint use required a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During a concurrent interview with the DOR and a record review of Resident 80's Rehabilitation Notes on 4/6/2022 at 11:00 a.m., DOR stated if residents did not move a lot their muscles tighten and want the resident to move as much as possible. DOR stated Resident 80 ambulated 60 feet using a front wheel walker with supervision on 4/1/2022. DOR stated constant nursing supervision may alleviate the need of pelvic restraints but would definitely result in more work for the nursing staff. During a concurrent interview with the DON and record review of Resident 80's medical records on 4/6/2022 at 2:06 p.m., the DON confirmed there was no documented evidence that Resident 80 had any of the following: 1. Restraint assessment prior to implementing use of pelvic restraints, 2. Monitoring log documenting residents' tolerance, and behaviors with restraint use 3. Log documenting that he (Resident 80) was released from the restraints every 2 hours, 4. Restraint care plan addressing the proper use of restraint and what to watch for, 5. Informed consent obtained from FM 1 or 2 allowing the use of restraints, 6. Documentation that the least restrictive measures were attempted prior to pelvic restrain use. During a review of the facility's undated policy and procedure (P/P) titled, Physical Restraints, the P/P indicated that the use of restraints and postural supports are followed and the guidelines for the use of restraints. To ensure residents' right to be free from any physical restraint imposed for purposes of discipline or convenience and not required to treat the resident's medical symptoms. 1. Restraints shall only be used with a written order of a physician or other person lawfully authorized to prescribe care. The order must specify the circumstances under which the restraints are to be used. Orders must be specific to individual residents. There shall be no standing orders or PRN (as needed) orders for restraints. 2. Restraints will be utilized only when necessary to ensure the safety and protection of the resident as ordered by the physician and permitted by law. Restraints of any type shall not be used as punishment, as a substitute for more effective medical and nursing care, or for the convenience of staff. 3. Restraints shall be used in such a way as not to cause physical injury to the resident and to ensure the least possible discomfort to the resident. 4. Before initiating physical restraints, facility staff shall verify that the resident's medical record contains documentation that the resident has given consent to the proposed treatment or procedure. During a review of the facility's P/P titled, Restraints Assessments: Physical and Chemical, dated 12/2006, the P/P indicated: 1. Residents have the right to be free from any physical and chemical restraints imposed for purposes of discipline or staff convenience and not required to treat medical symptoms. 2. The facility shall verify that the attending physician of a resident has obtained informed consent for the purpose of prescribing and ordering the use of a physical or chemical restraint on resident. This shall be documented in the resident's health record. 3. The physician or through a designee shall make reasonable attempts to notify the resident's interested family member, as designated in the resident's health record within 48 hours of the prescription and order. 4. The facility shall use a physical or chemical restraint only after an assessment by the interdisciplinary team has been completed and a less restrictive measures attempted were unsuccessful. 5. On the written order of the physicians, physical restraint order is not required in an emergency. Notification of an interested family member is not required in an emergency. PRN orders for physical restraints are not allowed.

Based on observation, interview and record review, the facility failed to maintain an effective pest control program to prevent and eradicate (destroy) cockroach infestation (presence of an unusually large number of cockroaches [small insect that can carry and spread infectious diseases]) in the facility's kitchen where food was prepared for 92 of 92 residents. The deficient practice resulted in 92 of 92 residents in the facility to have the potential to experience food infection from ingesting food containing toxins from bacteria, and disease transmission from vector-borne (illness that results from infections transmitted to humans by insects such as cockroaches) that can lead to life threating complications and death. On 8/2/2021 at 7:23 p.m., an Immediate Jeopardy (IJ is 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 Administrator (ADM), Director of Nursing (DON), Maintenance Supervisor (MS) and Dietary Supervisor (DS) were notified of the cockroaches found in the facility. On 8/4/2020 at 2:18 p.m., the IJ was removed in the presence of the administrator after implementation of the acceptable plan of action (POA, interventions to correct the deficient practice) was verified and confirmed on an onsite visit via observation, interview, and record review. The acceptable POA included the following actions: 1. All Departments heads including the Dietitian and Medical Director were notified of the infestation. The Medical Director (MD) approved for residents to be off their therapeutic diets for 4 days, once the kitchen was opened, residents' diets would be resumed and monitored by the Dietary Department along with nursing to ensure the proper textured diets. 2. 48-hour menu was prepared under the guidance of the Registered Dietitian (RD) and approved on 8/2/2021. All meals were prepared in individual disposable containers from permitted facilities. 3. Food was served out of the facility's dining room to accommodate a disaster style service to ensure the kitchen was not being used until cleared. 4. The Kitchen was deep cleaned on 8/3/2021 and 8/4/2021 and all dishware (dish, glass, utensil and other equipment used in food preparation) were rewashed. 5. The pest control company inspected for signs and sources of roaches and provided treatment as needed on 8/3/ and 8/4/2021. The pest control company would spray and monitor the kitchen every week for three (3) months to ensure no pests, after three months, monthly pest control maintenance would resume. 6. Kitchen staff were in-service on 8/3/2021 and 8/4/2021 regarding cleaning sanitation and reporting any signs of pests. 7. All open food items will be discarded by 8/3/2021. 8. Maintenance supervisor (MS) will monitor for pest at least weekly 9. Rehabilitation and nursing staff will monitor meals during mealtimes. 10. Dietary Department will continue to monitor meals to ensure diet orders were followed 11. The administrator will submit findings to the Quality Assurance (QA) Committee and propose an action plan for identifying and monitoring pest control. 12. Water was being supplied from 5-gallon bottle water containers. Finding: During a review of the County of Los Angeles, Department of Public Health, Effective Management of Cockroach Infestation, retrieved 7/16/2020, indicated cockroaches may become pests in any structure that has food preparation or storage areas. They contaminate food and eating utensils, occasionally damage fabric and paper products, leave stains on surfaces, and produce unpleasant odors when present in high numbers. When cockroaches that live outdoors and came into contact with human excrement in sewers or with animal fecal matter, they had the potential to transmit bacteria that causes food poisoning if they enter the structures. publichealth.alcounty.gov/eh/docs/specializedvector_management) During a review of the Centers for Disease Control and Prevention, Guidelines for Environmental Infection Control in Health Care Facilities, updated 7/1/2019, indicated the guidelines were recommendations for the prevention and control of infectious diseases associated with healthcare environments. Pest Control included cockroaches from inside the health care facilities that can serve as agents for the mechanical transmission of microorganisms, or as active participants in the disease transmissions process by serving as a vector (a live carrier that transfers infectious pathogens from one living organism to other living organisms). https://www.cdc.gov/infectioncontrol/guidelines/environmental/index.html During a review of the routine inspection report dated, 8/2/2021 at 12:45 p.m., the report indicated multiple cockroaches were observed in the facility's kitchen including one live adult German cockroach (German cockroaches carry many viruses, bacteria, and parasites on their bodies and in their feces, which can cause diarrhea, dysentery, salmonella, and other serious health concerns) under the drainboard of the dish washing machine. Ten plus live adult German cockroaches were observed at the cove base and wall junction under the spray and rinse sink. There was fecal spotting (cockroach stool) observed at the cove base (lower wall space ) and wall junction under the spray rinse sink. One dead German cockroach observed near a refrigerator and fire extinguisher. Ten plus live German cockroaches under the ware -washing area. One live adult German cockroach was observed near the dietary office and fecal spotting was observed at the dishwasher electrical box. During a review of the Registered Environmental Health Official (REHO) inspection report, dated 8/2/2021, the report indicated at 1:45 p.m., the Los Angeles County Department of Public Health Environmental Health services closed the facility's kitchen due to the pest infestation. During a review of the facility's census report dated 8/2/2021, the census indicated there were 92 residents residing in the facility including: a) 40 of residents on regular diet. b) 18 of residents on puree (smooth, creamy substance made of liquidized or crushed fruit or vegetables) diet. c) 36 of residents on mechanical (foods that required less chewing than a regular diet) soft diet. During an observation of the facility's kitchen on 8/2/2021 at 5:07 p.m., a live cockroach was observed in the in the janitor's closet along with loose wall coving (curved strip of wood fitted as a feature of a wall) and 3 holes measuring approximal 1 by ½ inches. Two dead cockroaches were observed underneath the reach-in refrigerator. During a concurrent interview and review of the pest control report on 8/2/2021 at 6:15 p.m., the MS stated the facility had a pest control company, who treated the kitchen environment on the first week of every month. The MS stated the last pest control visit was conducted on 7/2/2021. The MS stated the pest control report indicated the facility was serviced for elimination of pest, but the report did not indicate if the facility had pest. During an interview on 8/3/2021 at 11:50 a.m., MS stated the pest control company went into the facility on [DATE] and on 8/3/2021, many dead cockroaches were seen. MS stated he had reminded the kitchen staff to use the log to communicate any pest problems. During a concurrent interview on 8/3/2021 at 12:10 p.m., with Cooks 1 and 2, Cook 1 stated he has seen cockroaches at nighttime by the stove. Cook 1 stated he did not document in the log the times he saw cockroaches. Cook 2 stated seen cockroaches in the mornings upon turning the kitchen's light on. Cook 2 stated he forgot to notify the supervisor because he was busy. During an interview on 8/3/2021 at 12:30 p.m., the DON stated cockroaches carried bacteria and could contaminate anything they (cockroaches) touch and get residents' sick. The DON stated it was the responsibility of the staff to notify the supervisor of the presence of cockroaches in the kitchen to avoid infestation. During a review of the facility's undated policy and procedures (P/P) titled, Pest Control, the P/P indicated if pest was seen, the food service manager or appropriate staff would arrange for a pest control company to complete preventative spray treatments at the pointed time to eliminate any reported pest situation. The P/P indicated a contractor would document the visit along with actions taken; any pest traps that were in the kitchen area would be monitored every shift and disposed of according to the contractor's specifications.

Based on interview and record review, the facility failed to provide supervision, as stipulated in a resident's plan of care for eating for one of two residents (Resident 1). Resident 1, who had 16 missing teeth and several loose and broken teeth, required supervision with cueing prompts to slow down while eating due to the resident's behavior of eating too fast. On [DATE], Resident 1 was not supervised and provided the needed prompts during dinner. Resident 1, who weighed 236 pounds (lbs.), was served a hot dog on a bun on [DATE], at approximately 4:30 p.m. Resident 1 was sitting in the wheelchair when the resident began to choke on the hot dog, could not speak, face turned blue (not getting oxygen), and the resident was grasping her throat with her hands. Another resident noticed the resident was choking and yelled out to get the staff's attention and a certified nursing assistance (CNA1) saw Resident 1 choking. CNA 1 stood behind Resident 1's wheelchair and attempted to perform an abdominal thrusts ((Heimlich maneuver ) an emergency technique for preventing suffocation when a person's airway (windpipe) becomes blocked with food or other object; a procedure when a rescuer encircle both hands around the victim's abdomen (stomach), make a fist with the dominate hand with the thumb side of the fist against the middle of the victim's abdomen just above the navel, wrap the other hand firmly around the fist, pull the hands inward and upward, pressing into the victim's abdomen with quick and forceful upward thrusts as if the rescuer was trying to lift the victim off his or her feet from the position). CNA 1's arms could not form a complete circle around the resident's abdomen for an effective abdominal thrust procedure. During the attempts to perform the Heimlich maneuver, that lasted about three minutes, Resident 1 went into respiratory failure (a syndrome in which the respiratory system fails in one or both of its gas exchange function: oxygenation and carbon dioxide elimination) and became unresponsive. Resident 1 was transferred to the hospital emergency roiagnom on [DATE] at 5:27 p.m., and was pronounced deceased at 5:40 p.m. Findings: A review of Resident 1's Admission Record indicated the resident was readmitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. A review of a Minimum Data Set (MDS), a standardized assessment and care screening tool, dated [DATE], indicated Resident 1 was usually able to make herself understood and also understood others. The resident required supervision (oversight, encouragement and/or cueing) with eating and limited assistance (resident highly involved in activity; staff provided guided maneuvering of limbs or other non-weight bearing assistance) of a one-person physical assist with bed mobility, transferring, dressing, and toilet use. According to the MDS, Resident 1, who weighed 236 lbs. and was 60 inches tall (five feet), used a wheelchair for locomotion around the facility. On [DATE] at 2:45 p.m., during a telephone interview, a certified nursing assistant (CNA 1), who was assigned to pass dinner trays and provide supervision during the resident's meals, stated on [DATE], at approximately 4:30 p.m., he and another CNA (CNA 2) were in the dining room passing out dinner trays and coffee. CNA 1 stated the dinner included a hot dog and the hot dog served to Resident 1 was not cut up into small pieces. CNA 1 stated Resident 1 had the tendency to eat fast. CNA 1 stated, At approximately 4:45 p.m., during the mealtime, while he was passing out coffee, CNA 2 called his name and stated Resident 1 was choking. CNA 1 stated as he turned around, he saw Resident 1 with both hands on the neck, the resident's face was blue and she could not speak. CNA 1 stated the resident was sitting in the wheelchair, so he went behind the wheelchair and put his arms around Resident 1 to perform abdominal thrusts. CNA 1 stated he asked Resident 1 to stand up, but the resident did not respond, and the resident was too heavy for CNAs 1 and 2 to lift. CNA 1 stated he performed abdominal thrusts while Resident 1 was sitting in the wheelchair for about three (3) minutes and then Resident 1 passed out. CNA 1 stated after Resident 1 passed out, the licensed vocational nurse (LVN 1) entered the dining room and instructed him to lay the resident on the floor to initiate cardiopulmonary resuscitation ((CPR) an emergency procedure used during cardiac and/or respiratory arrest, in which heart massaging and artificial breathing were used to maintain circulation of oxygen rich blood to the brain). On [DATE] at 3:15 p.m., during an interview, CNA 2 stated that Resident 1 had some missing teeth and did not have any dentures. CNA 2 stated on [DATE], between the hours of 4:30 to 5 p.m., she and CNA 1 were passing out dinner trays, which included hot dogs. CNA 2 stated Resident 1's hot dog was placed inside a bun and the hot dog was not cut up into small pieces. CNA 2 stated a male resident called out, The patient is choking!, CNA 2 stated CNA 1 stood behind the wheelchair then put his arms around Resident 1 with his arms under the resident's chest, in an attempt to do abdominal thrusts. CNA 2 stated CNA 1 kept attempting to perform the abdominal thrusts, but they were not effective, because CNA 1 could not completely put his arms around the resident's body due to Resident 1 being obese (grossly fat or overweight). CNA 2 stated when LVN 1 arrived in the dining room she helped them put Resident 1 on the floor. A review of the facility's undated policy and procedures titled, Heimlich Maneuver, indicated the following: 1. If a person was choking on food or a foreign body and unable to speak or make any sounds, act immediately. 2. Call out for help. 3. Stand behind the resident and wrap arms around the waist, make a fist, grab it with your other hand and place the thumb side of fist against resident's abdominal area above the navel and below xiphoid process (the lower part of the breastbone). Press inward and upward with quick thrust movements. The facility's policy also stipulated how to perform the Heimlich maneuver if a resident was lying down or unconscious. It indicated to roll the resident onto his/her back then kneel and straddle the resident's hips. Place one hand on top of the other then place both hands on the resident's abdomen above the navel and below xiphoid process. Press inward and upward with six to eight quick thrusts. Move the resident's head (to the side) and look in the mouth for objects, remove it. If unconscious, attempt to ventilate. If unable to ventilate, repeat (the process of abdominal thrust). On [DATE] at 3:30 p.m., during an interview, LVN 1 stated a staff member informed her that Resident 1 was choking. LVN 1 stated when she arrived in the dining room, she saw CNA 1 performing the Heimlich maneuver while Resident 1 was sitting in the wheelchair, but nothing was coming out of the resident's mouth. LVN 1 stated she assisted the CNAs to lay Resident 1 on the floor. LVN 1 stated CNA 1 positioned the resident's face to the right side in case any food came out of her mouth. LVN 1 stated CNA 1 then knelt beside Resident 1 to continue with abdominal thrusts. LVN 1 stated after a minute of abdominal thrusts, while Resident 1 was lying on the floor, a piece of un-chewed hot dog, about one (1) inch in length came out. LVN 1 stated she used her fingers to sweep the piece of hot dog out of the resident's mouth. LVN 1 stated after the piece of hot dog came out, Resident 1 took a deep breath and then the resident stopped breathing. LVN 1 stated the director of nursing (DON) entered the dining room and called 911. LVN 1 stated she and CNA 1 initiated CPR. LVN 1 stated the paramedics arrived within five minutes from the time the DON initiated the 911 call. LVN 1 stated Resident 1 choked on the hot dog because the resident was eating too fast. LVN 1 stated staff used to remind Resident 1 to slow down due to her fast eating habit. When asked why Resident 1's hot dog was not cut up when the resident had missing teeth and was known to have a fast eating habit, LVN 1 stated, I am not her nurse, so I don't know. On [DATE] at 4 p.m., during an interview, the DON stated on [DATE] between the hours of 4:30 to 4:45 p.m., a staff member told her Resident 1 was choking. The DON stated when she arrived in the dining room, she saw Resident 1 lying on the floor unconscious. The DON stated she called 911 and went and got an Ambu-bag (self-inflating bag, a hand-held device commonly used to provide positive pressure ventilation to patients who are not breathing or not breathing adequately to provide rescue breathing) to use on Resident 1, while CNA 1 was doing the chest compressions. The DON stated the paramedics arrived within five minutes after she called 911. On [DATE] at 5 p.m., during an interview, LVN 2 stated Resident 1 had a history of [REDACTED]. LVN 2 stated when the staff would prompt the resident to slow down during mealtime; Resident 1 would slow down for a couple of minutes and then would eat fast again. LVN 2 stated he was not sure if Resident 1's eating habit had been discussed during the interdisciplinary team ((IDT), a group meeting consisting of heads of various departments, who worked together to discuss a resident's care) meeting, because he (LVN 2) did not attend the meeting. LVN 2 stated he was not sure if the nursing care plan had been developed to address the resident's risk of choking due to the resident's fast eating habit. A review of Resident 1's dental care progress notes, dated [DATE], indicated the resident was partially edentulous (no teeth) because Resident 1 did not want to wear dentures. A review of a dental note, dated [DATE], indicated the resident had 16 missing teeth, plus three broken teeth. A review of Resident 1's IDT meeting notes, dated [DATE] and [DATE], indicated that there was no documented evidence the IDT team had discussed the resident's risk for choking due to being partially edentulous and had a habit of eating fast. On [DATE] at 5:10 p.m., the review of Resident 1's medical record with the DON indicated there was no risk assessment for choking or a care plan developed to address the resident's habit of eating fast and being partially edentulous, which put the resident at an increased risk of choking. On [DATE] at 11:50 a.m., during a telephone interview with the facility's registered dietitian (RD) regarding why Resident 1 was served a regular non-chopped diet in spite of having missing teeth. The RD stated according to her dietary assessment, Resident 1 had some missing front top and bottom teeth, but the molars (large, flat teeth at the back of the mouth, used primarily to grind food during chewing) were still present for chewing ((sic)incorrect). The RD stated she thought the resident had approximately four missing teeth, but she was not 100 percent (%) sure. The RD stated she was aware Resident 1 had a behavior of eating fast, but stated the behavior itself, would not necessitate changing the resident's form of diet. During a follow-up telephone interview with the RD, on [DATE] at 2:55 p.m., regarding Resident 1's dental status, the RD stated she was not aware the resident was missing that many teeth, including molars. On [DATE] at 12:40 p.m., during a telephone interview, the director of dentistry, stated according to Resident 1's dental notes, dated [DATE], the resident had 16 missing teeth, plus three root tips (broken teeth in which only the root of these teeth were present). The dentist stated each human has 32 teeth (16 on the upper and 16 on the lower jaw). The dentist stated Resident 1's Teeth Numbers 1, 3, 7, 8, 9, 12, 15, 16, 17, 18, 19, 24, 25, 26, 31, and 32 were missing and teeth Numbers 2, 12, and 29 had only the roots present. A review of Resident 1's physician's orders [REDACTED]. On [DATE] at 2:30 p.m., during a subsequent interview, the DON stated she was aware that Resident 1 had some missing teeth, but she did not know the exact count. The DON stated if she knew Resident 1 had that many missing teeth, she would have developed a nursing care plan for risk of choking with interventions, which would have included to observe and monitor the resident during mealtimes, prompt the resident to slow down during eating, make sure the resident was able to tolerate her diet, and discuss with the physician if there was any concern or a change in condition. When the DON was asked if Resident 1's physician was aware of the resident's dental status, the DON stated, I never told the doctor, but the record was available for all staff and the physician to review. On [DATE] at 3:05 p.m., during an interview, CNA 1 stated Resident 1 was eating too fast during the incident. CNA 1 stated it was so hard for him to observe every resident during the mealtime, because he had to pass the dinner trays and the coffee. CNA 1 stated when Resident 1 choked, he tried to perform the abdominal thrusts on the resident while the resident was sitting in the wheelchair, but CNA 1 stated it was too hard for him to perform the abdominal thrusts, because Resident 1 was large (obese). CNA 1 stated after LVN 1 and CNA 2 helped him transfer Resident 1 to the floor, he continued with the abdominal thrusts and was able to remove a piece of the hot dog from the resident's mouth. CNA 1 stated he was not able to remove the second piece of hot dog in the resident's airway. CNA 1 stated he inspected Resident 1's hot dog on her dinner tray and noted there were two pieces bitten off from the resident's hot dog. CNA 1 stated when the paramedics arrived; they used a machine (defibrillator, used to control heart fibrillation by application of an electric current to the chest wall to stimulate the heart) to shock Resident 1. On [DATE] at 4:30 p.m., during a telephone interview, Resident 1's physician stated he did not know the resident had 16 missing teeth and three broken teeth. The physician stated the nurses did not report to him any issue regarding Resident 1's eating issues. The physician stated if the nurse had informed him about the resident's dental status, he would have changed the resident's diet from a regular to a mechanical soft (food made easier to chew and swallow) with ground meat. A review of the Fire Department's Emergency Medical Services (EMS) Report, dated [DATE], indicated the emergency response unit was dispatched at 4:51 p.m.; the paramedics arrived at 4:56 p.m., and saw Resident 1 at 4:57 p.m. The report indicated Resident 1 was found lying on the floor unconscious and unresponsive. Two large pieces of food was removed from the resident's mouth by the paramedics with the McGill forceps (an angled forceps used for grasping and holding objects) with copious (large) amount of vomit. There was no change in Resident 1's status, after removal of the food items. Advanced Cardiac Life Support ((ACLS) included management of a patient's airway; IV access, administering life-saving drugs, and read and interpret heart rhythms) was started at 4:59 p.m. by the paramedics. The paramedics transferred Resident 1 to the hospital at 5:12 p.m. A review of the GACH's emergency room report, dated [DATE], indicated Resident 1 was unresponsive and in full arrest (cardiopulmonary arrest) upon arrival at the hospital. According to the report, the resident arrived at the hospital on [DATE] at 5:27 p.m., and passed away at 5:40 p.m. A review of Resident 1's death certificate indicated the resident's immediate cause of death was respiratory failure (not enough oxygen into the lungs).