Every finding on record at Concord Post Acute

Based on observation, interview and record review, the facility failed to ensure residents' personal and medical information was communicated in a way that protects personal privacy and confidential information for one sampled resident (Resident 1), when Resident 1's first name and medical information were communicated via a group messaging system involving nursing staff's personal smart phone (a mobile phone that performs many functions of a computer, typically having a touch screen and access). This failure resulted in violation of resident's right to secure and confidential personal and medical information.During a facility tour and concurrent interview on 7/8/26, at 10:20 a.m., with Infection Control Nurse (ICN), ICN stated he was using his smart phone to communicate with the housekeeping supervisor. ICN stated according to the facility policy, personal cell phones are prohibited unless their use is deemed necessary. ICN stated that it was not essential to utilize his personal device for this communication with the housekeeping supervisor.During a concurrent observation and interview on 7/8/26, at 10:50 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated he was using his personal cell phone to communicate with the wound care nurse via text message. LVN 1 stated the wound care team utilizes a group text to share patient names and relevant care information. LVN 1 stated the group text included wound care nurses, a nurse practitioner, and three (3) Licensed Vocational nurses. A message observed on LVN 1's personal smart phone referenced Resident's 1 medical information and first name.During an interview with the Director of Nursing (DON) on 7/8/26, at 11:19 a.m., the DON stated cell phone usage in patient care areas is discouraged and prohibited. DON stated the facility used WhatsApp (an instant messaging system which allows users to send text and voice messages and share media such as photos, videos and documents) for simple communication purposes. The DON stated the group chat that is used by the wound care team, and different facility departments communicate to each other what is happening with the resident. The DON stated the process of ensuring the resident's personal privacy and confidentiality maintained during the chat is by not using patient names or identifying information. DON stated she is not sure if WhatsApp is secure.During a concurrent observation and interview with the Facility Manager (FM) on 7/8/26, at 11:40 a.m., FM stated the Management group used WhatsApp to communicate maintenance issues, Notice of Medicare Non-Coverage (NOMNC) issues and interdisciplinary team ( IDT) group information related to residents. The WhatsApp on FM's personal cellular device indicated control for group permission and listed nine (9) staff members in the group. FM stated he believed the communication sending system was secure and they only use resident room numbers. FM stated the Wound care team was not part of the Management team on WhatsApp.During a record review of Resident 1's admission record dated 7/9/26, Resident 1 was admitted to the facility on [DATE] with a diagnosis of cerebral palsy, idiopathic aseptic necrosis of toes, peripheral vascular disease and chronic venous hypertension with ulcer of right lower extremity.During a review of Resident 1's Minimum Data Set (MDS-an assessment tool used to guide care), the Brief Interview for Mental Status (BIMS- an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident), dated 5/30/26, indicated Resident 1's BIMS summary score was 15/15. A score of 15/15 indicated Resident 1 was cognitively intact, with no memory or cognitive issues. Resident 1's MDS Section GG Functional Abilities section indicated functional limitation of upper and lower extremities, resident uses a wheelchair and walker. Resident requires set up or clean up, to partial/moderate assistance, with specific activities. Section M - skin conditions indicated the resident had one venous and arterial ulcer. During a review of Resident 1's order summary dated 7/6/26, the order summary indicated a Registered Nurse (RN) received an order for a vascular appointment for Resident 1. The order was created by a registered nurse on 7/6/26 and signed by physician on 7/8/26 by using a password on a cell phone.During a review of the facility policy and procedure (P&P) titled, Employee use of telephones and Phone Access, date unknown, the P&P indicated cellular phones may be used for personal calls and text messaging only when the employee is on an authorized meal break period. Employee cell phones will remain off and/or silent during all other work hours. Non-emergency messages will be placed at a designated location.During a review of the facility P&P titled, Residents Rights, dated February 2021, the P&P indicated, the unauthorized release, or disclosure of resident information is prohibited. Any release, or disclosure of resident information must be in accordance with current laws governing privacy of information.During an interview and record review with the DON on 7/9/26, at 1:00 pm, the DON stated the information in the Telephone and Phone Accessories , Employee use of policy indicated, failure to comply with cellular phone polices may result in disciplinary action and applies to the above mention policy. The DON stated the facility does not have a specific policy on personal cellular phone usage for communication with other departments relating to patient care.During an interview with the facility Administrator on 7/9/26, at 2:30 p.m., the Administrator stated the facility had no policy on personal cellar device usage to communicate resident care issues and the facility did not have a policy or procedure on the use of WhatsApp.

Based on observation, interview and record review, the facility failed to ensure it kept accurate records of controlled medications (medication with a potential for abuse) as evidenced by:1. The facility failed to ensure, for Residents 1-17, the scheduled (controlled medication, narcotic) medication system was complete (all documents readily available) and accurate (information matched). The record system included Shipping Manifests (pharmacy delivery receipt), Controlled Substance Accountability Sheets (CDR, Controlled Drug Record), Medication Administration Records (MAR, record of medication administration) and destruction logs. The facility records were incomplete. The facility records were inaccurate. These failures had the potential to result in undetected loss and diversion of scheduled medications. In addition, these failures had the potential to result in preventable medication errors (medication not given as ordered). 2. The facility failed to ensure, between 9/23-3/24, the Consultant Pharmacist identified the scheduled (controlled medication, narcotic) medication system was incomplete (all documents available) and inaccurate (information matched). The record system included Shipping Manifests (pharmacy delivery receipt), Controlled Substance Accountability Sheets (CDR, Controlled Drug Record), Medication Administration Records (MAR, record of medication administration) and destruction logs. The facility records were incomplete. The facility records were inaccurate. These failures had the potential to result in undetected loss and diversion of scheduled medications. In addition, these failures had the potential to result in preventable medication errors (medication not given as ordered). Findings: 1. During an interview, on 3/11/26 at 10 a.m., Medical Record Director (MRD) was asked to describe the pharmacy documentation (Shipping Manifests, CDR) system. His description included that all pharmacy documents were retained by the facility. During an interview, on 3/11/26 at 10:45 10 a.m., Director of Nursing (DON) was asked to describe the scheduled medication record system. DON's description included that scheduled medications were delivered by the pharmacy with a corresponding Shipping Manifest and CDR. DON further stated that all scheduled medication records were in her office. DON was asked to provide the scheduled medication Shipping Manifests and CDRs from 9/1/23 through 3/31/24. During a concurrent tour and interview, on 3/11/26 at 11:28 a.m., at Station 2, Licensed Vocational Nurse (LVN 1) identified a medication cart. LVN 1 was requested to describe the scheduled medication documentation process. Her description included scheduled medications were delivered with a Shipping Manifest and a corresponding CDR. The Shipping Manifest was sent for retention. The medication was locked in the medication cart. The CDR was filed at the medication cart. The CDR was used to document removal of patient medications. Administration of the medication was documented on the MAR. Completed CDRs were sent for retention. If there were scheduled medications remaining upon discontinuation, the remaining medication and the CDR were sent to the DON. During a concurrent interview and medical record review, on 3/12/26 at 10:20 a.m., DON identified the following CDRs that the facility did not have a corresponding Shipping Manifest.Resident 1 Rx 4818577.02 Oxycodone (narcotic pain reliever) 10 mg (milligram) tablet #60Resident 2 Rx 4923263 Oxycodone 5 mg tablet #10Resident 3 Rx 4872560 Hydrocodone (narcotic pain reliever)-Acetamin (acetaminophen, pain reliever) 5-325 tablet #28Resident 3 Rx 4940244 Oxycodone 5 mg tablet #8Resident 4 Rx 4925237 Hydrocodone-Acetamin 5-325 tablet #60Resident 5 Rx 4872291 Hydrocodone-Acetamin 5-325 tablet #30Resident 6 Rx 4925236 Oxycodone 5 mg tablet #60Resident 6 Rx 4857714 Oxycodone 5 mg tablet #25Resident 7 Rx 4857833 Hydrocodone-Acetamin 10-325 tablet #26Resident 8 Rx 4855609 Morphine Sulf (narcotic pain reliever) 15 mg tablet #44Resident 9 Rx 4925971 Hydrocodone-Acetamin 5-325 tablet #28Resident 9 Rx 4935099 Hydrocodone-Acetamin 5-325 tablet #56Resident 9 Rx 4864670 Hydrocodone-Acetamin 5-325 tablet #28Resident 10 Rx 4859997 Oxycodone 5 mg tablet #28Resident 11 Rx 4913753 Oxycodone-Acetaminophen 10-325 tablet #28Resident 12 Rx 4933419 Hydrocodone-Acetamin 5-325 tablet #28Resident 13 Rx 4844638 Hydrocodone-Acetamin 5-325 tablet #60 During a concurrent interview and record review, on 3/12/26 at 10:30 a.m., DON identified Resident 14's MAR. DON compared the 4807224 Oxycodone 10 mg tablet #60 date 11/27/23 CDR against the MAR. DON acknowledged the CDR removals did not have a corresponding MAR administration on the dates and times listed below.12/4/23 1600, 210012/12/23 000012/20/24 1750 During a concurrent interview and record review, on 3/12/26 at 10:30 a.m., DON identified Resident 15's MAR. DON compared the 4823063 Hydrocodone-Acetamin 5-325 mg tablet #42 date 12/12/23 CDR against the MAR. DON acknowledged the CDR removals did not have a corresponding MAR administration on the dates and times listed below.12/22/23 both doses12/31/23 0010 During a concurrent interview and record review, on 3/12/26 at 10:30 a.m., DON identified Resident 16's MAR. DON compared the 4752178 Oxycodone 5 mg tablet #28 date 10/9/23 CDR against the MAR. DON acknowledged the CDR removal did not have a corresponding MAR administration on the date and time listed below.10/21/23 500 During a concurrent interview and record review, on 3/12/26 at 10:30 a.m., DON identified Resident 17's MAR. She compared the 4686477 Hydrocodone-Acetamin 5-325 mg tablet #60 date 10/11/23 CDR against the MAR. DON acknowledged the CDR removals did not have a corresponding MAR administration on the dates and times listed below.12/2/23 illegible2/5/23 12002/7/23 12002/8/23 1600 During a concurrent interview and record review, on 3/12/26 at 10:30 a.m., DON identified Resident 11's MAR. She compared the 4840387 Hydrocodone-Acetamin 10-325 mg tablet #26 date 12/30/23 CDR against the MAR. DON acknowledged the CDR removal did not have a corresponding MAR administration on the date and time listed below.1/15/24 856 During a concurrent interview and record review, on 3/12/26 at 12:30 p.m., DON identified the Policy for Controlled Substances (Revision Date November 2022). DON reviewed the policy and acknowledged it required the documentation (Shipping Manifests, CDRs and MARs) to be accurate (monitored and reconciled). An administrative record review, of the Policy for Controlled Substances (Revision Date November 2022) showed, Dispensing and Reconciling Controlled Substances, 1. Controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow-up.2. The system of reconciling the receipt, dispensing and disposition of controlled substances includes the following: a. Records of personnel access and usage; b. Medication administration records; c. Declining inventory records. 2. During an interview, on 3/11/26 at 10 a.m., Medical Record Director (MRD) was asked to describe the pharmacy documentation (Shipping Manifests, CDR) system. MRD's description included that all pharmacy documents were retained by the facility. During an interview, on 3/11/26 at 10:45 a.m., Director of Nursing (DON) was asked to describe the scheduled medication record system. DON's description included that scheduled medications were delivered by the pharmacy with a corresponding Shipping Manifest and CDR. DON further stated that all scheduled medication records were in her office. DON was asked to provide the scheduled medication Shipping Manifests and CDRs from 9/1/23 through 3/31/24. During a concurrent tour and interview, on 3/11/26 at 11:28 a.m., at Station 2, Licensed Vocational Nurse (LVN 1) identified a medication cart. LVN 1 was requested to describe the scheduled medication documentation process. LVN 1's description included scheduled medications were delivered with a Shipping Manifest and a corresponding CDR. The Shipping Manifest was sent for retention. The medication was locked in the medication cart. The CDR was filed at the medication cart. The CDR was used to document removal of patient medications. Administration of the medication was documented on the MAR. Completed CDRs were sent for retention. If there were scheduled medications remaining upon discontinuation, the remaining medication and the CDR were sent to the DON. During a concurrent interview and medical record review, on 3/12/26 at 10:20 a.m., DON identified the following CDRs that the facility did not have a corresponding Shipping Manifest.Resident 1 Rx 4818577.02 Oxycodone (narcotic pain reliever) 10 mg (milligram) tablet #60Resident 2 Rx 4923263 Oxycodone 5 mg tablet #10Resident 3 Rx 4872560 Hydrocodone (narcotic pain reliever)-Acetamin (acetaminophen, pain reliever) 5-325 tablet #28Resident 3 Rx 4940244 Oxycodone 5 mg tablet #8Resident 4 Rx 4925237 Hydrocodone-Acetamin 5-325 tablet #60Resident 5 Rx 4872291 Hydrocodone-Acetamin 5-325 tablet #30Resident 6 Rx 4925236 Oxycodone 5 mg tablet #60Resident 6 Rx 4857714 Oxycodone 5 mg tablet #25Resident 7 Rx 4857833 Hydrocodone-Acetamin 10-325 tablet #26Resident 8 Rx 4855609 Morphine Sulf (narcotic pain reliever) 15 mg tablet #44Resident 9 Rx 4925971 Hydrocodone-Acetamin 5-325 tablet #28Resident 9 Rx 4935099 Hydrocodone-Acetamin 5-325 tablet #56Resident 9 Rx 4864670 Hydrocodone-Acetamin 5-325 tablet #28Resident 10 Rx 4859997 Oxycodone 5 mg tablet #28Resident 11 Rx 4913753 Oxycodone-Acetaminophen 10-325 tablet #28Resident 12 Rx 4933419 Hydrocodone-Acetamin 5-325 tablet #28Resident 13 Rx 4844638 Hydrocodone-Acetamin 5-325 tablet #60 During a concurrent interview and record review, on 3/12/26 at 10:30 a.m., DON identified Resident 14's MAR. DON compared the 4807224 Oxycodone 10 mg tablet #60 date 11/27/23 CDR against the MAR. DON acknowledged the CDR removals did not have a corresponding MAR administration on the dates and times listed below.12/4/23 1600, 210012/12/23 000012/20/24 1750 During a concurrent interview and record review, on 3/12/26 at 10:30 a.m., DON identified Resident 15's MAR. DON compared the 4823063 Hydrocodone-Acetamin 5-325 mg tablet #42 date 12/12/23 CDR against the MAR. DON acknowledged the CDR removals did not have a corresponding MAR administration on the dates and times listed below.12/22/23 both doses12/31/23 0010 During a concurrent interview and record review, on 3/12/26 at 10:30 a.m., DON identified Resident 16's MAR. DON compared the 4752178 Oxycodone 5 mg tablet #28 date 10/9/23 CDR against the MAR. DON acknowledged the CDR removal did not have a corresponding MAR administration on the date and time listed below.10/21/23 500 During a concurrent interview and record review, on 3/12/26 at 10:30 a.m., DON identified Resident 17's MAR. She compared the 4686477 Hydrocodone-Acetamin 5-325 mg tablet #60 date 10/11/23 CDR against the MAR. DON acknowledged the CDR removals did not have a corresponding MAR administration on the dates and times listed below.12/2/23 illegible2/5/23 12002/7/23 12002/8/23 1600 During a concurrent interview and record review, on 3/12/26 at 10:30 a.m., DON identified Resident 11's MAR. She compared the 4840387 Hydrocodone-Acetamin 10-325 mg tablet #26 date 12/30/23 CDR against the MAR. DON acknowledged the CDR removal did not have a corresponding MAR administration on the date and time listed below.1/15/24 856 During a concurrent interview and record review, on 3/12/26 at 12:30 p.m., DON identified the Policy for Controlled Substances (Revision Date November 2022). She reviewed the policy and acknowledged it required the documentation (Shipping Manifests, CDRs and MARs) to be accurate (monitored and reconciled). An administrative record review, of the Policy for Controlled Substances (Revision Date November 2022) showed, Dispensing and Reconciling Controlled Substances, 1. Controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow-up.2. The system of reconciling the receipt, dispensing and disposition of controlled substances includes the following: a. Records of personnel access and usage; b. Medication administration records; c. Declining inventory records. During a concurrent interview and record review, on 3/12/26 at 10:48a.m., DON identified Consultant Pharmacist reports from 9/23 through 3/24. DON inspected the reports and stated that the reports did not document scheduled medication issues with Shipping Manifest, CDR and MAR. During a concurrent interview and record review, on 3/12/26 at 12:30 p.m., DON identified the Policy for Pharmacy Services-Role of the Consultant Pharmacist (Revision Date April 2019). DON stated that it was the facility's expectation that issues with scheduled medications would have been identified. An administrative record review, of the Policy for Pharmacy Services-Role of the Consultant Pharmacist (Revision Date April 2019) showed, Polic Interpretation and Implementation, 3. The consultant pharmacist shall provide consultation on all aspects of pharmacy services in the facility, and collaborate with the facility and medical director to:, a. develop, implement, evaluate, and revise (as necessary) the procedures for the provision of all aspects of pharmacy services.

Based on observation, interview, and record review, the facility failed to ensure for one out of four sampled residents (Resident 1), was protected from sexual abuse (non-consensual sexual contact of any type with a resident) when Certified Nurse Assistant (CNA) 1 was witnessed with his face on Resident 1's exposed right breast.This failure resulted in Resident 1 experiencing sexual abuse.This failure had the potential to cause emotional distress, feelings of shame, embarrassment, and an unsafe living environment due to Resident 1 experiencing sexual abuse from CNA 1.Findings:During a record review of the facility's Report of Suspected Dependent Adult/Elder Abuse form SOC 341 sent to the State Agency, the form indicated that on 4/30/26 at 3:14 p.m., CNA 1 was reported to have sexually abused Resident 1.During a review of facility's admission Record (AR) printed on 5/14/26, the AR indicated Resident 1 was admitted on [DATE], with diagnoses that included Alzheimer's Disease With Late Onset and Other Specified Anxiety Disorder.During a review of Resident 1's Minimum Data Set (MDS - standardized resident assessment tool) dated 4/2/26, a Cognitive Patterns with Staff Assessment for Mental Status indicated Resident 1 had short-term and long-term memory problem. MDS Functional Abilities under Mobility indicated, Resident 1 was Independent with the following activities: The ability to roll left to right side of the bed, move from sitting on side of the bed to lying flat on the bed, the ability to move from lying on the back to sitting on the side of the bed with no back support, the ability to come to a standing position from sitting in a chair, wheelchair, or side of the bed, and the ability to transfer to and from a bed to a chair. Furthermore, Resident 1 could independently Walk 150 feet once standing and eat independently once the meal was placed before the resident.During a record review of Resident 1's Progress Notes (PN), dated 4/30/26, the PN indicated, Approx 1514 [Approximately 3:14 p.m.] CNA [2] approach this writer [Licensed Vocational Nurse (LVN) 1] and reported witnessing CNA [1] engaging in inappropriate contact with resident [1]. Resident [1]'s shirt was pulled up with right breast exposed. CNA [2] witnessed CNA [1] with his mouth on the resident [1]'s right breast. This writer [LVN 1] immediately proceeded to check the resident [1]. Resident [1] was observed lying in bed in room [Resident 1's room]. When asked about the incident, resident [1] was unable to provided a clear account of what occurred. A skin check was performed with resident consent, however the resident was noted to guard her chest area with her hand during the examination. Writer noted slightly redness to the right areola.During a concurrent observation and interview on 5/14/26 at 11:17 a.m., near the nursing station 4 with Resident 1, with the presence of CNA 4, CNA 4 asked Resident 1 to go to her room. Resident 1 walked to her room, and she sat on the side of the bed. Resident 1 could identify herself only. CNA 4 stated that Resident 1 could speak English and English. During an observation on 5/15/26 at 2:48 p.m., in Resident 1's room, Resident 1 walked around her room. Resident 1 had a roommate in bed B. Resident 1 sat on the edge of the right side of the bed, and then removed her slipped-on shoes, and Resident 1 laid down into her bed. While Resident 1 was lying in bed, she moved herself to the middle of the bed without assistance. Then Resident 1 got up to sit on the edge of the bed and put on her shoes. Further, Resident 1 walked around the room.During an interview on 5/15/26 at 3:32 p.m., with CNA 3, CNA 3 stated that she regularly cared for Resident 1 during daytime. CNA 3 stated Resident 1 could get in and out of bed independently and that Resident 1 could put on and take off her shoes independently. Further, CNA 3 stated Resident 1 was mostly friendly and pleasant.During a concurrent interview and record review on 5/14/26 at 10:34 a.m., with Scheduling Coordinator (SC), SC reviewed facility's Nursing Staffing Assignment And Sign-In Sheet dated 04/30/2026 PM Shift for Station 4. SC stated that CNA 1 was assigned to Station 4 Run#2, which included from room numbers . [room numbers redacted]. CNA 1's room assignment did not include Resident 1's room. Resident 1's room was assigned to Station 4 Run#5, which included room numbers [room numbers redacted] . CNA 2 was assigned to care for Resident 1.During an interview on 5/15/26 at 12:29 p.m., with CNA 1, CNA 1 stated that on 4/30/26, he walked into Station 4 after a staff meeting. CNA 1 stated he saw Resident 1 holding hands and walking with another resident. CNA 1 stated the other resident was a high risk for fall, and that CNA 1 could not identify the other resident. CNA 1 stated he assisted Resident 1 to go to her room. CNA 1 stated the other resident was fine by herself, and was just wandering. CNA 1 stated he walked with Resident 1 to her room. CNA 1 stated he assisted Resident 1 to sit on the edge of the bed, and then he sat next to Resident 1 on the left side of the bed. Further, CNA 1 stated that he knelt to help Resident 1 remove her shoes. CNA 1 then lifted Resident 1's legs and assisted her to lay down in bed. CNA 1 stated he helped Resident 1's alignment in the middle of the bed when CNA 2 walked in the room at the time.During a concurrent observation and interview on 5/15/26 at 2:58 p.m., with CNA 2, in Resident 1'and Resident 2's shared room, the room had two beds. Resident 1's bed was by the door (bed A), and Resident 2's bed was by the window (bed B). There were curtains being used in the room for privacy. There was a curtain that hung that would cover the foot of the bed, and the other curtain that would cover the area in between the residents. CNA 2 stated on 4/30/26, her regular room assignment included Resident 1 and Resident 2's room. CNA 2 stated on 04/30/2026 at around 3:14 p.m., she walked into Residents 1 and Resident 2's shared room, because she saw Resident 2 was in bed, and her bed elevated. CNA 2 stated she wanted to lower Resident 2's bed. CNA 2 stated as she walked into the room, Resident 1's curtain by the foot of the bed was pulled closed, and the other curtain in between Resident 1 and Resident 2 was halfway closed. CNA 2 stated she as she was passing by Resident 1's foot of the bed on the right side corner, CNA 2 peeked into Resident 1's bed, and she saw Resident 1 was lying flat in bed, with CNA 1 was sitting on the left side of the bed. Furthermore, CNA 2 stated that CNA 1's face was on Resident 1's exposed right breast. CNA 1 stated she was shocked, but she confronted CNA 1. CNA 2 stated she asked CNA 1 What are you doing? CNA 2 stated CNA 1 immediately stood up and pulled down Resident 1's shirts to cover Resident 1's breast. Then, CNA 1 pulled up his face mask to cover his mouth. CNA 2 stated that CNA 1 replied to her that he was assisting Resident 1 to get into her bed. CNA 2 stated that CNA 1 stepped outside of the curtain and he stood in front of her. CNA 2 stated that she looked at CNA 1, and she told him that it was not what she saw. CNA 2 stated that CNA 1 stepped towards her and raised his arms. Then, CNA 2 stated that CNA 1 walked out of the room. CNA 1 stated she called LVN 1 and to report the event. CNA 2 stated she was regularly assigned to Resident 1, and Resident 1 does not like to have her room curtains closed. CNA 2 stated that if Resident 1's curtains were closed, and the resident was in bed, the resident would get up to open the curtains.During an interview on 5/15/26 at 3:53 p.m., with LVN 1, LVN 1 stated that on 4/30/26, she finished getting the report from the morning shift nurse. LVN 1 stated that CNA 2 approached her and reported that she had witnessed CNA 1 sitting on the left side of Resident 1's bed and that CNA 1's face was on Resident 1's exposed right breast. LVN 1 stated that she immediately went to Resident 1's bedside with CNA 2. LVN 1 stated that Resident 1 could not recall the incident, but Resident 1 allowed her to check her chest area. LVN 1 stated that Resident 1 was guarding herself with her arms across her chest. LVN 1 stated that she assessed Resident 1's breast area, and she noted some circular shaped redness above the areola about 1 1/2 inches in size. LVN 1 stated that she reported the event to her supervisor. Furthermore, LVN 1 stated that Resident 1 did not allow other nurses to assess her during her shift.During an interview on 5/26/26 at 12:21 p.m., with Resident 1's Responsible Party (RP), RP stated that if Resident 1 did not have Alzheimer's Disease, she would not tolerate sexual abuse to happen. RP stated that Resident 1 was a strong and religious woman, and Resident 1 would stand her ground. RP stated that he visited Resident 1 after the incident, and RP noted Resident 1 had some hesitation during their hug, and that Resident 1 was somber and more reserved during the visit. Furthermore, RP added that as a close family member, he noticed something was different with Resident 1.During a review of the facility's policy and procedure (P&P) titled, Abuse, Neglect, Exploitation or Misappropriation Prevention Program, with revision date of 4/2021, the P&P indicated, Policy Statement Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but not limited to freedom from corporal punishment [physical punishment, used as a means to correct or control behavior], involuntary seclusion, verbal, mental, sexual or physical abuse, physical or chemical restraint not required to treat the resident's symptoms. Policy Interpretation and Implementation. The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: 1. Protect the residents for abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to: a. facility staff.

Based on observation, interview and record review the facility failed to protect four of six sampled residents (Resident 2, Resident 3, Resident 4, and Resident 5) from physical abuse when following was noted:1. Resident 2 and Resident 3 got into a physical altercation with each other resulting in Resident 2 sustaining a one-inch scratch (shallow cut in the skin caused by trauma), to the left neck; and Resident 3 sustaining redness to the right forehead.2. Resident 4 and Resident 5 got into a physical altercation with each other resulting in Resident 4 sustaining a skin tear, (traumatic wound occurring when the top layer of skin separates from the underlying layer), to the front of the left arm, top of head, hand and forearm and a scratch to the right cheek and Resident 5 sustaining a scratch to the left upper lip. 1. During a review of admission Record for Resident 2 printed on 1/28/26, the record indicated Resident 2 was admitted to the facility in March 2025 with a diagnosis of dementia (a loss of brain function that occurs with certain diagnoses, affecting on or more brain functions such as memory, thinking, language, judgement or behavior), with behavioral disturbance, (a persistent pattern of disruptive or dysfunctional behavior). During a review of Resident 2's Minimum Data Set, (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan) dated 12/23/25, the assessment indicated Resident 2 was able to make himself understood and able to understand others. During a review of admission Record for Resident 3, printed on 1/28/26, the record indicated Resident 3 was admitted to the facility in November 2023. During a review of Resident 3's MDS assessment dated [DATE], the assessment indicated Resident 3 had a Brief Interview for Mental Status score, (BIMS is a scoring system used to determine the resident's cognitive status regarding attention, orientation and ability to register and recall information), of three (3) out of 15 indicating severe cognitive impairment. During a concurrent observation and interview on 1/28/26 at 1:30 p.m. with Resident 2 in the facility patio area, Resident 2 stated he did not remember the incident of 4/23/25 and has never had a disagreement or altercation with any resident. Resident 3 was not available during the investigation. During a telephone interview on 1/29/26 at 3:34 p.m. with Licensed Vocational Nurse (LVN 2), LVN2 stated she was assigned to Station 4 on the evening shift on 4/23/25. LVN 2 stated at approximately 4:30 p.m. LVN2 was preparing medication for a resident when LVN 2 heard screaming coming from the direction of Station 3. LVN2 stated she rushed toward the noise and saw Resident 3 in his wheelchair in the hallway connecting Stations 3 and 4 yelling at Resident 2. LVN2 stated while she was redirecting Resident 3 back to the room, Resident 2 hit Resident 3 in the head with his fist and Resident 3 scratched Resident 2 on the left side of the neck with his fingernails. LVN2 stated she assessed Resident 3 and found a reddened area to the right side of the forehead. LVN2 stated Resident 3 denied pain when asked. During a telephone interview on 1/29/26 at 4:45 p.m. with LVN 3, LVN3 stated on 4/23/26 at approximately 4:45p.m. he heard someone yelling back up in the hallway between Stations 3 and 4. LVN 3 stated upon LVN 3's arrival the residents, (Resident 2 and Resident 3), had been separated and were being taken back to their rooms. LVN 3 stated he assessed Resident 2 and noted an approximately one (1)-inch scratch on the left side of Resident 2's neck with minimal bleeding. LVN 3 assessed Resident 2 and noted Resident 2 had a scratch to the left neck and no complaint of pain. LVN3 stated the wound was cleaned with saline, (mixture of salt and water and patted dry. During a review of Resident 2's progress notes dated 4/23/25, LVN 3 documented, LVN3 was notified by a staff that Resident 2 and Resident 3 had gotten into an altercation. The record indicated [Resident 3] was yelling at [Resident 2] .[Resident 2] hit [Resident 3] in the face and [Resident 3] scratched Resident 2 on the left neck. The record indicated both residents were redirected to their rooms. 2. During a review of admission Record for Resident 4 printed on 1/28/26, the record indicated Resident 4 was admitted to the facility in December 2025 with diagnoses of Alzheimer's Disease, (a progressive brain disorder that destroys memory, thinking skills and the ability to perform simple tasks), with agitation, (state of extreme mental and physical arousal characterized by restlessness, irritability and purposeless motions like pacing). During review of Resident 4's MDS assessment dated [DATE], the assessment indicated Resident 4 usually understands others and usually able to make himself understood. During a review of admission Record for Resident 5 printed on 1/28/26, the record indicated Resident 5 was admitted to the facility in March 2025, with diagnosis of dementia with agitation, depression, (persistent low mood, loss if interest in activities, feeling of emptiness), anxiety, (feeling of dread fear and uneasiness). During a review of Resident 5's MDS assessment dated [DATE], the record indicated Resident 5 usually understands others and usually able to make himself understood. During a concurrent observation and interview on 1/28/26 at 1:00 p.m. with Resident 4 in the resident's room in the facility locked unit, Resident 4 was sitting on the bed with arms crossed and fidgeting, (small movements especially in the hands and feet caused by nervousness or impatience). Resident 4 stated he did not recall the incident of 12/10/25 and turned to face the wall. During a concurrent observation and interview on 1/28/16 at 1:10 p.m. at Resident 5's room with a Spanish speaking interpreter on the phone, Resident 5 stated through the interpreter he did not want to be interviewed. During a telephone interview on 2/1/26 at 7:30 a.m. with CNA 2, CNA 2 stated she was assigned to Resident 4 and Resident 5 on 12/10/25. CNA2 stated at approximately 5:30 a.m. CNA 2 was delivering care behind closed doors to residents across the hallway from Residents 4 and 5 when she heard yelling outside the room where CNA2 was working. CNA2 stated she went to investigate, and by the time she reached the Resident's room Resident 4 was at the nursing station with LVN1. CNA2 stated she observed Resident 5 pacing around the room as if angry. CNA 2 noted there was a wound on the left side of Resident 5's face. During an interview on 1/28/26 at 4:00 p.m. with LVN1, LVN1 stated on 12/10/25 at 5:30 a.m. LVN1 was preparing to do morning blood sugar testing on Station 1 when Resident 4 approached LVN1. LVN1 stated Resident 4 was visibly upset and told her his roommate (Resident 5) hit him while he was sleeping. LVN1 stated she observed a superficial cut on the top of Resident 4's head, a small scratch on the right cheek, and scratches to Resident 4's right hand and forearm. LVN1 stated she observed slight bleeding from all the wounds. LVN1 stated she seated Resident 4 in the hallway at Station 1 and went to the room shared by Resident 4 and Resident 5 to assess Resident 5. LVN1 stated she observed Resident 5 out of bed and pacing around the room. LVN1 stated she approached the doorway and used hand gestures to ask if Resident 5 was alright. LVN1 stated Resident 5 approached the doorway in an aggressive manner, (acting in a forceful way that threatens others), gestured for LVN1 to leave, and slammed the door closed not allowing an assessment. LVN1 stated she observed a scratch to Resident 5's left upper lip. LVN1 stated she cleansed Resident 4's wounds, applied dressings and medicated Resident 4 for pain per Resident 4's request. During a review of Resident 4's progress notes dated 12/10/25, LVN 1 documented Resident 4 was visibly bleeding upon initial assessment . [Resident 4] had skin tears, on the crown of the head, the right cheek, (1x1 centimeter), back of the right hand, and the front of the left forearm .wounds were cleansed with normal saline and patted dry .[Resident 4] was medicated for pain and placed in a different room. During a review of Resident 5's Nurses Notes dated 12/10/25, LVN1 documented LVN1 entered Resident 5's room after being informed of a physical altercation with the roommate. Upon assessment LVN1 was able to observe a scratch on Resident 5's upper lip. During a concurrent interview and record review on 2/5/26 at 2:15p.m. with the Director of Nurses, (DON), the DON stated CNAs are updated on resident care plans during shift change huddles and facility is supposed to have individualized, person-centered care plans for all residents. The DON stated residents with dementia often experience agitation and aggression and to prevent abuse, the facility must have good training, communication, documentation and monitoring. During a review of Care Plan Reports for Residents 2, 3, 4, and 5 with varying dates, the DON stated Resident 2 did not have a care plan for dementia. The DON stated the altercation between Resident 2 and Resident 3 could have been avoided if Resident 2 had a care plan for dementia in effect. During a review of the facility's policy and procedure titled, Resident Rights, dated 2/2001, indicated.Residents have the right to be free from abuse, neglect, misappropriation of property and exploitation.

Based on interview and record review the facility failed to implement a comprehensive care plan for one of five sampled residents (Resident 1). The facility did not provide supervision to Resident 1 when she was in facility's patio.This failure resulted in Resident 1 falling on the ground sustaining a cut and bump to the back of the head and transfer to the acute care hospital for further care and evaluation.During a review of Resident 1's admission Record printed on 1/28/26, the record indicated Resident 1 was admitted to the facility in January 2017. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan), dated 5/7/25, indicated Resident 1's Brief Interview for Mental Status (BIMS, is a scoring system used to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information), score was zero (0) out of 15, indicating severe cognitive (mental status) impairment. The record indicated Resident 1 had a diagnosis of Alzheimer's Disease, (a progressive, irreversible brain disorder resulting in a loss of brain function affecting memory, thinking, language, judgment, or behavior). Resident 1 was unavailable for interview during the investigation. During a review of Resident 1's Fall Risk Assessment, (an evaluation used to identify a resident's likelihood of falling and suffering injury), dated 5/1/25, the assessment indicated Resident 1 was identified as high risk for fall and injury related to unsteady gait with use of a front wheel walker, greater than [AGE] years old, dependent and incontinent, easily distracted, periods of altered perception of surroundings, episodes of disorganized speech, periods of restlessness, lethargy, varying mental function, wandering, abusive and resists care. The record indicated Resident 1 has had 1-2 falls within the 90 days prior to the assessment. During a review of Resident 1's Fall Care Plan reviewed on 2/7/25, the care plan indicated Resident 1 was at high risk for falls related to confusion, gait/balance problems, incontinence and unaware of safety needs. The record indicated an intervention stating, Staff will monitor and assist resident while ambulating in the patio. During an interview with the (Director of Nursing) DON on 2/5/26 at 11:45 a.m. the DON stated Resident 1's fall could have been avoided if a member of the staff was on the patio with Resident 1 (as mentioned in Resident 1's care plan). During a review of the facility's policy and procedure titled, Care Plans, Comprehensive Person-Centered, dated 11/2019, 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 observation, interview and record review the facility failed to provide adequate supervision to one of three sampled residents (Resident 1), when Resident 1 with a history of wandering (traveling aimlessly form place to place), sustained an unwitnessed fall while ambulating on her own in the facility's patio area.This failure resulted in Resident 1 falling on the ground, sustaining a cut and bump to the back of the head, transfer to the acute care hospital for further care and evaluation. During a review of Resident 1's admission Record printed on 1/28/26, the record indicated Resident 1 was admitted to the facility in January 2017. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan), dated 5/7/25, indicated Resident 1's Brief Interview for Mental Status (BIMS, is a scoring system used to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information), score was zero (0) out of 15, indicating severe cognitive (mental status) impairment. The record indicated Resident 1 had a diagnosis of Alzheimer's Disease, (a progressive, irreversible brain disorder resulting in a loss of brain function affecting memory, thinking, language, judgment, or behavior). During a review of Resident 1's Fall Risk Assessment, (an evaluation used to identify a resident's likelihood of falling and suffering injury), dated 5/1/25, the assessment indicated Resident 1 was identified as high risk for fall and injury related to unsteady gait with use of a front wheel walker, greater than [AGE] years old, dependent and incontinent, easily distracted, periods of altered perception of surroundings, episodes of disorganized speech, periods of restlessness, lethargy, varying mental function, wandering, abusive and resists care. The record indicated Resident 1 has had 1-2 falls within the 90 days prior to the assessment. During a review of Resident 1's Elopement and Wandering Risk Assessment, (a clinical, standardized checklist used to identify, monitor and prevent residents with cognitive decline from leaving supervised areas unattended), dated 5/1/25, the assessment indicated Resident 1 had a score of eighteen. The assessment specified a score greater than ten indicates a resident would be considered at risk for wandering or elopement. During a review of Resident 1's Fall Care Plan reviewed on 2/7/25, the care plan indicated Resident 1 was at high risk for falls related to confusion, gate/balance problems, incontinence and unaware of safety needs. The record indicated an intervention stating, Staff will monitor and assist resident while ambulating in the patio. During an observation on 2/5/26 at 11:15 a.m. in the facility patio, where Resident 1 was found on 5/22/25, at the entrance to the patio area alongside the building and to the left of the door has a patio made of concrete slabs placed next to each other extending the length of the back of the building. The area is approximately three (3) feet wide. Alongside the patio is a grassy area extending to the fence and along the fence are garden containers. During a telephone interview on 2/3/26 at 10:30 a.m. with Certified Nursing Assistant (CNA 3), CNA 3 stated he was the assigned direct care staff for Resident 1 on 5/22/25. CNA 3 stated he provided incontinent care (changing of briefs) to Resident 1 around 6:25 p.m. in her room on that day and did not see her after that until he learnt about Resident 1's fall around 7:00 pm. CNA 3 stated Resident 1 was awake, alert and ambulatory. During a telephone interview on 2/3/26 at 2:00 p.m. with CNA 4, CNA 4 stated she was the hallway monitor (staff assigned to monitor the facility hallways for resident's safety) for Station 3 from 6:30 p.m. until 7:00 p.m. on 5/22/25. CNA 4 stated she observed Resident 1 when CNA 4 came out to the hallway from another resident's room. CNA 4 stated Resident 1 was walking towards Station 4, she called out to Resident 1, Resident 1 turned to look at CNA 4, then Resident 1 turned back and continued to walk. CNA 4 stated she did not pursue Resident 1 because Resident 1used to become agitated when her walking was interrupted. During an interview on 1/29/26 at 5:30 p.m. with CNA 1, CNA 1 stated on 5/22/25 at approximately 7:00 p.m. she observed Resident 1 lying on the pavement alone in the Station 4 patio area holding the back of her head, crawling on the ground. CNA 1 stated she called for help and waited with Resident 1 for the nurse to come. During an interview on 1/29/26 at 3:34 p.m. with Licensed Vocational Nurse (LVN 2), LVN 2 stated on 5/22/25 at approximately 7:00 p.m. she responded to a distress call from CNA1 stating there was a resident on the ground in the patio. LVN 2 stated when she arrived Resident 1 was awake, alert and lying on the grass. Resident 1 was slightly bleeding at the back of her head. LVN 2 stated she noticed that Resident 1's front wheel walker was tipped over on the grass near Resident 1. During an interview on 1/29/25 at 4:45p.m with LVN 3, LVN 3 stated she was the assigned nurse for Resident 1 on 5/22/25. LVN 3 stated she used saline to cleanse Resident 1's back of the head where it was bleeding and applied a dressing to the area. LVN 3 stated the door to patio area was supposed to be an alarmed door, however the alarm did not work for a very long time. LVN 3 also stated the alarm to patio door was not fixed until after Resident 1's fall. During a review of Resident 1's Change in Condition progress notes dated 5/22/25, LVN 3 documented [Resident 1] was observed to be on the ground in the patio resident kept trying to get up unassisted during the nursing assessment was assisted to a wheelchair .noted bump on the back of the head with slight bleeding . resident was taken to the acute hospital by ambulance on 5/22/25 at 8:40 p.m. During an interview on 1/29/26 at 3:00 p.m., the Director of Nurses, (DON), stated LVN3 informed him about Resident 1's fall. The DON stated the primary safeguards in place for resident safety and accidents prevention were staff monitoring the hallways, and coded/alarmed doors between each unit. The DON then stated however facility kept the door to the patio area open during the day to allow residents access to the patio. The DON stated the door lock for the door from Station 4 to the patio was not activated until 8:00 p.m. every day, allowing Resident 1 to go into the patio unsupervised on her own resulting in an unwitnessed fall. During an interview with the DON on 2/5/26 at 11:45 a.m. the DON stated Resident 1's fall could have been avoided if a member of the staff was on the patio with Resident 1 (as mentioned in Resident 1's care plan). During review of the facility's policy and procedure titled, Falls and Fall Risk, Managing dated 3/2018, indicated Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and try to minimize compilations from falling.

Based on interviews and record reviews, the facility failed to ensure compliance with required employment and licensure verification procedures when a previous staff member, who falsely represented themselves as a Registered Nurse (RN), used another person's RN license, and had a revoked Licensed Vocational Nurse (LVN) license in 2020 was hired and employed by the facility.These failures had the potential to place residents at risk for harm including medication errors, delays in necessary nursing interventions, and improper clinical decision-making by unlicensed nursing personnel.During a record review of Unlicensed Nurse (UN) 1's employee file, a printed copy of the RN nursing license dated 8/28/23, reflected a missing middle name and different spelling of the first name than that of UN 1. The RN nursing license copy further indicated it was generated and printed approximately five months prior to UN 1's application for RN position at the facility.During a record review of UN 1's Offer Letter, dated 1/31/24 from the facility, the Offer Letter showed UN 1 was offered a full-time RN position for the PM shift (3:00 p.m. to 11:30 p.m.) The Offer Letter further indicated UN 1 signed and accepted the offer on 1/31/24.During a record review of UN 1's record, titled, Background Report (BR), dated 2/6/24, the Professional License verification reflected that UN 1's identity did not match the name listed on the nursing license. The Professional License report showed the license belonged to a different RN with a similar name; however, the first name was spelled differently, and the individual had a different middle name.During a record review of UN 1's record, titled, Job Description: RN, dated 1/31/24, UN 1 signed the RN job description that specified, Must possess, as a minimum, a Nursing Degree an accredited college or university.Must possess a current, unencumbered, active license to practice as an RN in this state.Must remain in good standing with the Sate Board of Nursing at all times.During a record review of the facility's untitled document, dated 1/30/25, the record showed UN 1 was employed at the facility from 1/31/24 to 2/11/24.During a record review of UN 1's publicly available nursing license verification record, dated 12/12/25, the record indicated UN 1's LVN license had been revoked on 6/10/20, and UN 1's right to practice nursing was removed.During a record review and interview on 12/3/25 at 11:54 a.m. with the facility's Human Resources representative (HR) 1, UN 1's BR dated 2/6/24 was reviewed. HR 1 stated, as part of the background check and verification process, two forms of valid identification were required from UN 1. HR 1 further stated she was unable to explain why UN 1's license verification reflected a name different from the two forms of identification provided by UN 1. HR 1 stated the discrepancy was missed during the review process, and as a result, UN 1 was hired by the facility without a verified active nursing license. HR 1 stated employing an individual without a verified nursing license posed a risk to resident care and represented a significant liability to the facility. HR 1 further stated maintaining an active nursing license was essential to ensure nurses could provide appropriate care and support to residents.During a record review and interview on 12/2/25 at 2:39 p.m. with the Administrator (ADM), UN 1's BR dated 2/6/24 was reviewed. ADM stated HR and DSD were responsible for double-checking information received from the background check company. ADM further stated he would have investigated had discrepancies been identified between UN 1's name on the provided identification and the nursing license.During a record review and interview on 12/8/25 at 12:30 p.m. with Director of Staff Development (DSD), UN 1's employee file, including the application dated 1/22/24, was reviewed. DSD stated the facility was unable to verify that employment and personal reference checks were completed prior to hiring UN 1 due to the absence of documentation. DSD further stated reference check should have been conducted to verify UN 1's prior work history and to assess work performance and behavior.During a record review and interview on 12/11/25 at 9:33 a.m. with the Director of Nursing (DON), UN 1's employee file, including Application for Employment dated 1/22/24, BR dated 2/6/25, and UN 1's printed copy of nursing license dated 8/28/23, were reviewed. The DON stated prior to hiring a nursing personnel, the facility was responsible for ensuring the individual held an active nursing license and cleared of all the required background checks before working in the facility. The DON stated this was her first time becoming aware of the discrepancies with UN 1's identity and the nursing license UN 1 provided. The DON stated the facility should have verified the nursing license online and matched the identification provided to confirm the license belonged to UN 1. The DON further emphasized that conducting reference checks for all employees was essential to determine whether an applicant was reliable, trustworthy, and had demonstrated satisfactory performance in previous employment.During a follow up interview on 12/11/25 at 9:49 a.m. with DSD, DSD stated she was responsible for verifying nursing licenses online as part of the hiring process but was unable to recall if she had checked UN 1's nursing license prior to hiring. DSD stated HR 1 was responsible for ensuring that an applicant was cleared to work at the facility following completion of the background check, which included license verification. DSD further stated once HR 1 confirmed an applicant was cleared, she would proceed with finalizing the hire without conducting any additional verification herself. During a follow up interview on 12/11/25 at 10:03 a.m. with the DON, the DON stated hiring unlicensed nursing personnel posed several risks due to the individual's potential inability to perform required nursing duties and negatively impact resident care. The DON further stated if a nursing license was revoked, it indicated prior misconduct, and hiring such individual created a risk of similar issues occurring within the facility. During a record review of the facility's policy and procedures (P&P), titled, Credentialing of Nursing Service Personnel, dated May 2019, the P&P indicated, Nursing service personnel who require a license or certification to provide resident care or treatment without direction or supervision within the scope of the individual's license or certification must present verification of such license or certification prior to or upon employment.Upon obtaining the applicant's informed to conducting a license/certification/background investigation, the DON services, or designee, will.a. contact the appropriate state licensing board(s) to obtain a letter of verification/computer printout of such license/certification.c. contact previous employers to obtain written/oral verification of previous work experience and qualifications.5. Should the investigation reveal inconsistencies in information obtained and information provided by the applicant that would prevent the applicant's further employment.6. Should the investigation reveal the applicant does not hold a valid license or certification, appropriate state licensing boards and authorities will be notified of the applicant's attempt to practice without a license/certification.

Based on interview, record review, and facility policy review, the facility failed to develop and implement a person-centered care plan to address the use of antidepressant medication, antipsychotic medication, and address a diagnosis of post-traumatic stress disorder (PTSD) for 1 (Resident #162) of 5 sampled residents reviewed for unnecessary medications. Findings included: A facility policy titled, Care Plans, Comprehensive Person-Centered, with a copyright date of 2001, revealed, A comprehensive, person-centered care plan should include measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs. The policy revealed, 2. The Comprehensive person-centered care plan should be developed within the seven (7) days of the completion of the required MDS [Minimum Data Set] assessment. (Admission, Annual, or significant change in status), and should be completed within 21 days of admission. The policy revealed, 3. The care plan interventions should be derived from information obtained from the resident and his/her family/responsible party, with possible discretionary modifications resulting from the comprehensive assessment. An admission MDS, with an Assessment Reference Date (ARD) of 02/28/2025, revealed the facility admitted Resident #162 on 02/21/2025. The MDS revealed Resident #162 had a Brief Interview for Mental Status (BIMS) score of 6, which indicated the resident had severe cognitive impairment. The MDS indicated the resident had active diagnoses that included dementia, depression, and PTSD. Per the MDS, the resident received antidepressant and antipsychotic medication during the assessment timeframe. The MDS revealed the resident received antipsychotic medication on a routine basis. Resident #162's Psychiatric Progress Notes, dated 02/16/2025, revealed Resident #162 had diagnoses of PTSD and major neurocognitive disorder with behavioral disturbance related to superimposed delirium. The Psychiatric Progress Notes revealed the resident was a war veteran and recently had aggressive outbursts with staff. The record revealed the Assessment/Plan indicated the resident was receiving sertraline (a selective serotonin reuptake inhibitor [SSRI]) 25 milligram (mg) daily and olanzapine (an antipsychotic) 3.75 mg every night. Resident #162's Hospitalist Progress Note, dated 02/17/2025, revealed the resident had a diagnosis of PTSD on 08/31/2024. The Hospitalist Progress Note listed the chief complaint as confusion and abnormal behavior. The Case Management Progress Note revealed the resident's spouse no longer slept next to the resident as the resident often had dreams that they was in the country in war and had given their spouse a concussion. Resident #162's IDT [Interdisciplinary Team] Conference Notes, dated 02/25/2025, indicated Resident #162 ambulated with problems, had decreased safety awareness, and received antidepressant medications. The IDT Conference Notes revealed no evidence that the IDT reviewed the resident's diagnosis of PTSD or potential triggers. Resident #162's Social History Assessment, dated 02/27/2025 and completed by Social Services Director (SSD) #8, indicated that combat or exposure to a warzone (in the military or as a civilian) or any other stressful event or experience did not apply to the resident. The Social History Assessment indicated Resident #162 received psychotropic medications including olanzapine and sertraline, initiated on 02/21/2025. The Social History Assessment indicated Resident #162 was a veteran and indicated the resident was in the facility for long term and would eventually transition into the behavioral health unit. Resident #162's Order Summary Report, with active orders as of 04/16/2025, revealed an order for olanzapine 7.5 mg, one-half tablet at bedtime for dementia with behavioral disturbance for 30 days, with a start date of 03/23/2025 and end date of 04/22/2025. The Order Summary Report indicated the targeted behavior for olanzapine was agitation, with an order date of 02/23/2025. The Order Summary Report revealed an order to observe the resident for side effects of antipsychotic medication use of olanzapine, with an order date of 02/23/2025. The Order Summary Report revealed an order for sertraline hydrochloride (HCl), one tablet once a day for depression related to PTSD, with a start date of 02/22/2025. The Order Summary Report also revealed the targeted behavior for sertraline was verbalization of sadness/crying, with an order date of 02/23/2025. The Order Summary Report included an order to observe the resident for side effects of antidepressant medication use of sertraline. Resident #162's Care Plan Report, initiated 02/21/2025, revealed the resident had a diagnosis of PTSD but there was no focus statement or interventions for the diagnosis of PTSD or triggers associated with this diagnosis. The Care Plan Report revealed it did not include a focus statement or interventions regarding the use of antidepressant medication or antipsychotic medication. During an interview on 04/14/2025 at 10:44 AM, Resident #162 stated they had PTSD. Resident #162 stated they could use some psychological care. Resident #162 stated the PTSD symptoms came and went. Resident #162 stated they were a war veteran. During an interview on 04/16/2025 at 9:27 AM, the MDS Registered Nurse (RN) stated the normal process for a resident who had PTSD was to make sure all active diagnoses were being care planned. In review of the current care plan for Resident #162, the MDS RN stated that based on the care plan in the electronic medical record, the diagnosis was PTSD was not addressed. He stated nursing staff determined what the PTSD triggers were. He stated if the resident received psychotropic medications and exhibited behaviors, then they triggered for assessment. He stated Resident #162's psychotropic medication started on 02/21/2025. He stated the resident was on olanzapine for dementia with behavioral disturbance and had a psychiatric consultation scheduled that month. He stated that there was nothing in the care plan that addressed the resident's diagnosis of PTSD other than indicating that the resident had the diagnosis. During an interview on 04/16/2025 at 10:28 AM, the MDS RN stated they reviewed a resident's social history assessment for PTSD, and Resident #162 did not show triggers on admission. He stated that they looked at olanzapine use, which was why the resident was going to have a psychiatric evaluation. The MDS RN stated he thought they missed a focus area for PTSD on the care plan and they would add it. During an interview on 04/16/2025 at 12:07 PM, SSD #8 stated that Resident #162's spouse told her that Resident #162 had PTSD, and that the resident had been in a war. She stated that when Resident #162 was admitted to the facility, the resident was hard to assess. She stated Resident #162 answered no to all the assessment questions. SSD #8 stated they did not identify the PTSD triggers for Resident #162. She stated that she did not see that the resident had PTSD, and the resident did not verbalize any triggers. SSD #8 stated PTSD did not trigger on the social history assessment for Resident #162 based on the questions about trauma. She stated that the resident's spouse was not able to tell her anything other than the resident was a pilot. She stated the resident tried to go home with the spouse and was aggressive with the spouse. SSD #8 stated if there was a diagnosis, then a care plan focus should have been in place. During an interview on 04/17/2025 at 9:03 AM, SSD #32 reviewed Resident #162's care plan and stated focus areas were added on 04/16/2025 on the care plan for antidepressant and antipsychotic use. During an interview on 04/17/2025 at 12:53 PM, RN #12 stated nurses input the medications, physician orders, and care plans, to include the diagnosis of PTSD. She stated they also got help from management staff. She stated she was aware that Resident #162 had PTSD but was not aware of the resident's triggers. She stated the use of antidepressant and antipsychotic medications, and the diagnosis of PTSD should have been on the care plan. During a telephone interview on 04/17/2025 at 3:35 PM, Licensed Vocational Nurse (LVN) #13 stated she was the admitting nurse for Resident #162. She stated she might have missed entering the care plan for the use of antidepressant medication and antipsychotic medication. She stated that when admitting a resident, she assessed the resident, and she went by the paper the resident came with. She stated she did not look at Resident #162's hospital discharge records. She stated that she was not aware of the resident's PTSD diagnosis. She stated she was not aware of the triggers related to the resident's PTSD diagnosis. During an interview on 04/17/2025 at 10:45 AM, the Assistant Director of Nursing (ADON) stated if a resident was admitted with medications, the admitting nurse was the one who put in the care plan the medication and the diagnosis of PTSD. The ADON stated the Director of Nursing (DON), MDS staff, the Director of Staff Development, the Infection Preventionist, and himself reviewed the care plan the following day. He stated if they saw that something needed to be updated, they did it during that review. The ADON stated the use of antipsychotic and antidepressant medications and the diagnosis and triggers for PTSD might have been overlooked for Resident #162. During an interview on 04/17/2025 at 12:26 PM, the ADON stated the diagnosis of PTSD should be in the care plan. During an interview on 04/17/2025 at 1:03 PM, the Administrator stated his expectation was that the care plan be accurate based on the current assessment.

Based on interview, record review, and facility policy review, the facility failed to ensure a Level I preadmission screening and resident review (PASARR) was timely resubmitted after a resident remained in the facility longer than 30 days for 1 (Resident #145) of 4 sampled residents reviewed for PASARR. Findings included: A facility policy titled Pre-admission Screening and Resident Review, with a copyright date of 2001, revealed, All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review process. An admission Record revealed the facility admitted Resident #145 on 12/02/2024. According to the admission Record, the resident had a medical history that included diagnoses of depression and bipolar disorder. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/09/2024, revealed Resident #145 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. According to the MDS, Resident #145 had active diagnoses to include depression and bipolar disorder. Resident #145's Care Plan Report included a focus area initiated 12/12/2024, that indicated the resident was at risk for nutritional risk related to bipolar disorder, depression, and the use of psychotropic medications. A letter from the California Department of Health Care Services dated 03/11/2025, indicated If the individual remains in the NF [nursing facility] longer than 30 days, the facility must resubmit a new Level I Screening as a Resident Review on the 31st day, Resident #145's medical record revealed a Preadmission Screening and Resident Review Level I Screening with a start date of 04/15/2025. During an interview on 04/16/2025 at 3:13 PM, the MDS Registered Nurse (RN) stated he was responsible for ensuring the PASARRs were complete. The MDS RN stated if a resident remained in the facility after 30 days, a new PASARR was required. The MDS RN acknowledged another Level I PASARR was resubmitted for Resident #145 on 04/15/2025. During an interview on 04/16/2025 at 3:40 PM, the MDS Assistant stated Resident #145's Level I PASARR was due on 04/11/2025; however, it was not resubmitted until 04/15/2025. The MDS Assistant stated it was on his list to do on 04/11/2025, but he forgot to get it done. During an interview on 04/17/2025 at 12:50 PM, the Administrator stated he expected the PASARRs to be completed timely.

Based on interview, record review, and facility policy review, the facility failed to ensure the accuracy of the Minimum Data Set (MDS) for 2 (Resident #7 and Resident #108) of 35 sampled residents. Findings included: A facility policy titled, Resident Assessments with a copyright date of 2001, revealed, 10. Assessments are completed by staff members who have the skills and qualifications to assess relevant care areas and who are knowledgeable about the resident's strengths and areas of decline. 11. All persons who have completed any portion of the MDS resident assessment form must sign the document attesting to the accuracy of such information. 12. Information in the MDS assessments will consistently reflect information in the progress notes, plans of care and resident observation/interviews. 1. An admission Record revealed the facility admitted Resident #108 on 07/10/2024. According to the admission Record, the resident had a medical history that included diagnoses of obstructive uropathy and non-pressure chronic ulcer of the lower leg. Resident #108's Care Plan Report included a focus area initiated 09/12/2022, that indicated the resident had non-compliance with nursing care interventions. Resident #108's Progress Notes, dated 12/17/2024 at 2:54 PM, revealed, the resident refused treatment three times. A quarterly MDS, with an Assessment Reference Date (ARD) of 12/19/2024, revealed Resident #108 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident did not reject care. Resident #108's Progress Notes, dated 03/17/2025 at 3:21 PM, revealed, the resident was on charting related to refusal of care. According to the Progress Notes, the resident refused wound care three times. A quarterly MDS, with an ARD of 03/21/2025, revealed Resident #108 had a BIMS score of 10, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident did not reject care. During an interview on 04/15/2025 at 2:09 PM, Licensed Vocational Nurse (LVN) #4 stated Resident #108 refused all wound care. During an interview on 04/16/2025 at 10:31 AM, LVN #5 stated Resident #108 refused nearly all care, to include showers, incontinence brief changes, and wound care. Per LVN #5, Resident #108 had refused care for several years. During an interview on 04/16/2025 at 10:36 AM, Certified Nursing Assistant (CNA) #6 confirmed she was assigned to Resident #108. CNA #6 stated Resident #108 refused showers and care in general. CNA #6 stated the resident would rarely consent to care, but she would offer. During an interview on 04/16/2025 at 2:47 PM, the MDS Registered Nurse (RN) stated accuracy of the MDS was delegated to the person who completed the MDS. Per the MD RN, Social Services Director (SSD) #8 completed the behavior section of Resident #108's MDSs. The MDS RN stated there was a seven-day look back period for the completion of the behavior section related to rejection of care. Per the MDS RN, if a resident refused care within seven days of the assessment (look back) period, the MDS should indicate the resident rejected care. The MDS RN confirmed Resident #108's MDSs with an ARD of 12/19/2024 and 03/21/2025 were inaccurate because the resident refused care during those times. During an interview on 04/16/2025 at 3:39 PM, SSD #8 confirmed she was responsible for the behavior section of the MDS assessment. SSD #8 stated she talked with the resident and knew the resident did not reject care, as the resident always asked for their incontinence brief to be changed. SSD #8 stated she did not review the resident's progress notes or other parts of the clinical record when she completed the behavior section of the MDS assessment. During an interview on 04/17/2025 at 11:25 AM, the Assistant Director of Nursing (ADON) stated the process for the MDS was to collect and enter data based on documentation within a resident's clinical record. The ADON stated he was familiar with Resident #108 and was aware the resident refused care intermittently since admission to the facility, to include wound care, showers, and incontinence brief changes. The ADON stated it was his expectation that the MDS accurately reflected resident care. During an interview on 04/17/2025 at 12:49 PM, the Administrator stated it was his expectation that the MDS was accurate and reflected actual resident care activities. The Administrator stated he was aware of Resident #108 but was not aware the resident refused care as frequently. The Administrator stated if a resident refused care, his expectation would be the refusal was accurately reflected on the MDS. 2. An admission Record revealed the facility admitted Resident #7 on 09/23/2022. According to the admission Record, the resident had a medical history that included a diagnosis of dementia. Resident #7's Care Plan Report included a focus area initiated 10/17/2024, that indicated the resident had a hearing impairment as evidenced by decreased hearing acuity in both ears. Interventions directed staff to apply the resident's hearing aid to both ears (initiated 10/17/2024). An annual MDS, with an Assessment Reference Date (ARD) of 12/20/2024, revealed Resident #7 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. The MDS indicated Resident #7's hearing was adequate, and no hearing aid or other hearing appliance was used. A quarterly MDS, with an ARD of 03/22/2025, revealed Resident #7 had a BIMS score of 3, which indicated the resident had severe cognitive impairment. The MDS indicated Resident #7's hearing was adequate, and no hearing aid or other hearing appliance was used. During an interview on 04/14/2025 at 11:04 AM, Resident #7 was hard of hearing and acknowledged they wore hearing aids. During an interview on 04/15/2025 at 1:40 PM, Certified Nursing Assistant #10 stated Resident #7 had hearing aids. During an observation on 04/15/2025 at 1:44 PM, Resident #7 was in bed and hearing aids were noted in both of the resident's ears. During an interview on 04/16/2025 at 9:25 AM, the MDS Registered Nurse stated social services completed the hearing section of a resident's MDS. During an interview on 04/16/2025 at 11:51 AM, Social Services Director (SSD) #32 stated she and SSD #8 completed the hearing section of the MDS. SSD #32 stated she was aware Resident #7 had hearing aids. Per SSD #32, SSD #8 completed the hearing section of Resident #7's MDS with an ARD of 12/20/2024 and 03/22/2025. SSD #32 stated Resident 7's MDS with an ARD of 12/20/2024 and 03/22/2025 were not accurate as the resident wore hearing aids and had difficulty hearing. During an interview on 04/16/2025 at 12:01 PM, SSD #8 stated that when she did the MDS for Resident #7, she did not think the resident had hearing aids in. SSD #8 confirmed the resident used a hearing aid and both MDSs were inaccurate. During an interview on 04/17/2025 at 11:39 AM, the Assistant Director of Nursing (ADON) stated his expectation was the data in the MDS assessments should be accurate. The ADON acknowledged Resident #7's MDS with an ARD of 12/20/2024 and 03/22/2025 were inaccurate. During an interview on 04/17/2025 at 1:03 PM, the Administrator stated his expectation was that the MDS assessment were accurate.

Based on interview, record review, facility document review, and facility policy review, the facility failed to report an allegation of abuse to the state survey agency within two hours that involved 1 (Resident #18) of 1 sampled resident reviewed for abuse. Findings included: A facility policy titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, with a copyright date of 2001, 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. Findings of all investigations are documented and reported. Policy Interpretation and Implementation Reporting Allegations to the Administrator and Authorities 1. 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. 2. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies, which included a. The state licensing/certification agency responsible for surveying/licensing the facility. The policy revealed, 3. 'Immediately' is defined as, including a. within two hours of an allegation involving abuse or result in serious bodily injury. An admission Record revealed the facility admitted Resident #18 on 02/14/2009. According to the admission Record, the resident had a medical history that included diagnoses of unspecified dementia, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/19/2025, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. An untitled, undated typed facility document indicated that on 03/27/2025 at 9:30 AM, a resident stated that their bed bath water was cold. The document indicated that a certified nursing assistant (CNA) told the resident to shut up or they would pour water on the resident. Per the document, the resident stated, I will be quiet, please don't hurt me. The document indicated that the resident removed a bed sheet, and the CNA hit the resident on the knee and shoulder with an open hand with medium strength. A Facsimile Transmittal Cover Sheet, dated 03/27/2025, indicated the facility reported Alleged Staff to resident abuse to the state survey agency. The document had a handwritten note, initialed by the Assistant Director of Nursing (ADON), that indicated the report was submitted on 03/27/2025 at 5:00 PM. During an interview on 04/17/2025 at 11:25 AM, the ADON stated he was notified about 10 minutes after the incident allegedly occurred around 9:30 AM. He stated he reported the allegation to the state via telephone at 1:05 PM. During an interview on 04/17/2025 at 1:05 PM, the Administrator stated he was notified on 03/27/2025, and he did not know the exact time he was notified. He stated the initial report was sent to the state survey agency at 5:00 PM on 03/27/2025.

Based on record reviews, document review, and interviews, the facility failed to ensure timely completion of comprehensive Minimum Data Set (MDS) assessments for 2 (Resident #142 and Resident #113) of 7 sampled residents reviewed for resident assessments. Findings included: Review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated October 2023, revealed The Admission assessment is a comprehensive assessment for a new resident and, under some circumstances, a returning resident that must be completed by the end of day 14. The document indicated, The ARD must be set no later than day 14, counting the date of admission as day 1. The document revealed, The Annual assessment is a comprehensive assessment for a resident that must be completed on an annual basis unless an SCSA [significant change in status assessment] or an SCPA [significant correction to prior comprehensive assessment] has been completed since the most recent comprehensive assessment was completed. A review of Resident #142's Admission Record revealed the facility admitted the resident #142 on 07/01/2022. A review of Resident #142's annual MDS, with an Assessment Reference Date (ARD) of 07/09/2023, revealed the MDS was signed as being completed on 08/15/2023 by the MDS Registered Nurse (RN). A review of the facility's MDS 3.0 Final Validation Report, with a submission date of 08/18/2023, revealed Resident #142's annual MDS was signed as being completed more than 14 days after the ARD. A review of Resident #113's Admission Record revealed the facility admitted the resident on 07/01/2023. A review of Resident #113's admission MDS, with an ARD of 07/08/2023, revealed the MDS was signed as being completed on 07/25/2023 by the MDS RN. A review of the facility's MDS 3.0 Final Validation Report, with a submission date of 07/27/2023, revealed Resident #113's admission MDS was signed as being completed more than 14 days after the resident admitted . During an interview on 11/16/2023 at 11:28 AM, the MDS RN stated a MDS assessment should be signed as being completed 14 days after the admitted or the ARD. The MDS RN stated he was responsible to sign the MDS assessment as being accurate and complete. The MDS RN stated he did not recall any reason why the MDS assessments were late. During an interview on 11/16/2023 at 2:46 PM, the Director of Nursing (DON) stated she was not sure about the timing of MDS assessments but thought they had to be completed 14 days from the ARD. The DON stated she was not aware there were late MDS assessments. During an interview on 11/16/2023 at 3:25 PM, the Administrator stated MDS assessments should be completed within 14 days of the ARD. The Administrator stated he was not aware MDS assessments in July 2023 were late.

Based on observation, record review, interviews, and policy review, the facility failed to ensure staff followed professional standards of practice by not leaving medications at the bedside of 1 (Resident #128) of 8 residents observed for medication administration. Findings included: A review of Resident #128's Admission Record revealed the facility admitted the resident on 08/26/2021, with diagnoses that included chronic obstructive pulmonary disease (COPD), diabetes mellitus, fibromyalgia (nerve pain), hypertension (high blood pressure), malignant neoplasm (cancer) of the right breast, and chronic kidney disease. A review of Resident #128's annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/04/2023, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. A review of Resident #128's care plan initiated on 10/11/2021, revealed the resident had an alteration in neurological mental status related to disease process. Interventions directed staff to give medications as ordered. During medication administration observation on 11/15/2023 at 8:27 AM, Licensed Vocational Nurse (LVN) #12 prepared medications for Resident #128. The surveyor noted as LVN #12 placed six tablets in a medication cup for the resident. LVN #12 placed the medication cup, along with a cup of water on the resident's over-bed table. After LVN #12 talked with the resident about their upcoming appointments, LVN #12 walked out of the resident's room and left the six tablets in the medication cup on the resident's over-bed table. During an interview on 11/15/2023 at 12:51 PM, LVN #12 stated medications should not be left at the bedside unless the resident had been assessed to self-administer. She stated Resident #128 would be capable of administering their own medications but had not been assessed. LVN #12 stated she got busy talking about the appointments and forgot about the medications. During an interview on 11/16/2023 at 2:46 PM, the Director of Nursing stated medications should not be left at the bedside. During an interview on 11/16/2023 at 3:25 PM, the Administrator stated medications should not be left at the bedside and he expected medications to be administered as ordered by the physician according to professional standards.

Based on observations, interviews, record review, and policy review, the facility failed to ensure respiratory equipment was sanitized and properly stored for 1 (Resident #134) of 4 sampled residents reviewed for respiratory care. Findings included: Review of a facility policy titled, CPAP [continuous positive airway pressure]/BiPAP [Bi-level positive airway pressure] Support, revised in March 2015, revealed 8. Headgear (strap): Wash with warm water and mild detergent as needed. Allow to air dry. A review of Resident #134's Admission Record revealed the facility admitted the resident on 09/30/2023 with diagnoses that included asthma and encephalopathy. A review of Resident #134's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/07/2023, revealed Resident #134 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident used a non-invasive mechanical ventilator. A review of Resident #134's care plan, initiated on 10/01/2023, revealed the resident was at risk for complications with their respiratory system due to their diagnosis of asthma. Review of Resident #134's Order Summary Report with active orders as of 11/15/2023, revealed an order dated 10/06/2023, to replace the resident's CPAP mask, tubing, and accessories one time a day every Saturday. Review of Resident #134's Medication Administration Record and Treatment Administration Record for the time frame of 11/01/2023 through 11/30/2023, revealed no evidence of documentation staff documented the replacement of the resident's CPAP mask, tubing, and accessories weekly as ordered. On 11/13/2023 at 1:57 PM and 11/15/2023 at 2:32 PM, the surveyor observed as Resident #134's CPAP mask laid on top of the resident's dresser. The mask was dirty with a dried crusty white substance present. On 11/16/2023 at 9:26 AM, the surveyor observed Resident #134's CPAP mask was dirty with a dried crusty white substance present. During an interview on 11/15/2023 at 3:44 PM, Licensed Vocational Nurse #10 stated the CPAP machines were cleaned on Saturdays. During an interview on 11/15/2023 at 3:55 PM, Registered Nurse #11 stated that Resident #134's CPAP mask was cleaned on Saturdays and the masks and tubing were supposed to be stored in a bag. During an interview on 11/16/2023 at 2:28 PM, the Director of Nursing stated that the CPAP equipment should be cleaned every seven days. She said she expected the nurses to clean the mask with soap and water and air dry before placement in a plastic bag. She stated she expected the nurse to also monitor the mask and CPAP machine in the morning before they bagged it and expected the next shift to also check the equipment and make sure it was clean before placement on the resident. She expected the staff to clean and store the CPAP machines according to the manufacturer guidelines. During an interview on 11/16/2023 at 3:30 PM, the Administrator stated he expected the staff to follow the manufacturer guidelines to keep the equipment clean and sanitized.

Based on facility policy review, record reviews, interviews, and facility document review, the facility failed to ensure a resident's wheelchair was operable for 1 (Resident #7) of 1 sampled resident reviewed for accommodation of needs. Findings included: Review of a facility policy tilted, Maintenance Service, revised in December 2009, revealed 3. The Maintenance Director is responsible for developing and maintaining a schedule of maintenance service to assure that the buildings, grounds, and equipment are maintained in a safe and operable manner. A review of Resident #7's Admission Record revealed the facility readmitted the resident on 09/23/2022, with diagnoses that included morbid obesity, retention of urine, and chronic obstructive pulmonary disease. A review of Resident #7's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/21/2023, revealed Resident #7 had a Brief Interview for Mental Status (BIMS) score of 6, which indicated the resident had severe cognitive impairment. The MDS revealed Resident #7 was totally dependent on staff for transfers and toilet use. The MDS revealed the resident required extensive staff assistance with locomotion on and off their unit. The MDS revealed Resident #7 had impairments on their left and right lower extremities. The MDS revealed the resident used a wheelchair. Review of Resident #7's care plan initiated on 12/22/2017, revealed the resident had limited physical mobility and used a wheelchair that they could only propel themselves a few feet. The care plan revealed interventions that included instructions for staff to provide assistance with mobility as needed. During an interview on 11/14/2023 at 9:29 AM, Resident #7 said the left wheel on their wheelchair was broken and was not operable. The resident said they were forced to stay in bed. The resident said they needed to get out of bed. During an interview on 11/14/2023 at 9:21 AM, Licensed Vocational Nurse (LVN) #7 revealed Resident #7 needed a new wheel on the left side of their wheelchair. LVN #7 stated Resident #7 had not had an operable wheelchair in over a month. LVN #7 said the maintenance staff was aware the wheelchair needed repaired. LVN #7 said the resident was lying in bed because their wheelchair was inoperable but said even when the resident's chair was operable, the resident would not get out of bed. Review of the Maintenance Log, for the unit where Resident #7 resided, dated06/23/2023 to 11/03/2023, revealed no evidence Resident #7's wheelchair had been reported for repair. During an interview on 11/14/2023 at 3:34 PM, the Maintenance Director stated each month the residents' wheelchairs were washed, and any repairs were made. He said requests for repairs for residents' equipment should be placed on the Maintenance Log. The Maintenance Director said a request had not been made to repair Resident #7's wheelchair and he was not aware of the wheelchair did not work until 11/14/2023. During an interview on 11/15/2023 at 10:47 AM, Certified Nurse Assistant (CNA) #5 stated she had not placed Resident #7 in their wheelchair because the wheelchair was broken. She said when Resident #7's family member visited, Resident #7 requested to be placed in their wheelchair. She said LVN #7 informed the resident the wheelchair was still broken. CNA #5 said she did not know how long the wheelchair had been broken. CNA #5 said she assumed a nurse, or an assistant reported the broken wheelchair on the maintenance log. During an interview on 11/26/2023 at 10:21 AM, Maintenance Assistant (MA) #17 indicated he repaired the resident's wheelchair in October 2023 but was unaware of a current issue with the wheelchair. He said facility staff had been educated to report equipment issues on the Maintenance Log and said sometimes staff reported issues to him directly. During an interview on 11/16/2023 at 2:24 PM, the Director of Nursing indicated she expected the CNAs' involvement in ensuring residents' wheelchairs were operable. She stated if a wheelchair did not work, facility staff should complete a form in the Maintenance Log, then the maintenance staff should check the log and address the issue. During an interview on 11/16/2023 at 3:23 PM, the Administrator indicated he expected nursing staff to inform the maintenance staff of a residents' wheelchair that required a repair. The Administrator said they always had other wheelchairs available, and a broken wheelchair should not dictate the care being provided.

Based on interviews, record review, and facility policy review, the facility failed to implement their abuse prohibition policy when staff failed to identify an allegation as abuse. This failure to identify an allegation of abuse resulted in the allegation not being reported to the state, investigated, and the accused staff not being removed from resident contact, as directed by the facility's abuse prohibition policy for 1 (Resident #327) of 2 sampled residents reviewed for abuse. Findings included: Review of a facility policy titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, revised in September 2022, revealed All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, and theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Policy Interpretation and Implementation Reporting Allegations to the Administrator and Authorities 1. 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 other officials according to state law. 2. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility. The policy revealed '3. 'Immediately' is defined as: a. within two hours of an allegation involving abuse or result in serious bodily injury; or b. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. The policy revealed 6. Upon receiving any allegations 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 the protection of residents. The section of the policy titled, Investigating Allegations, revealed 5. The administrator ensures that the resident and the person(s) reporting the suspected violation are protected from retaliation or reprisal by the alleged perpetrator, or by anyone associated with the facility.6. Any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete. A review of Resident #327's Admission Record revealed the facility admitted the resident on 10/25/2023 with diagnoses that included depression, anxiety disorder, insomnia, essential hypertension, and acute and chronic respiratory failure with hypoxia. A review Resident #327's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/01/2023, revealed Resident #327 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. During an interview on 11/13/2023 at 12:17 PM, Resident #327 said a certified nurse assistant (CNA) made them feel intimidated and thought the CNA would retaliate against them due to report the resident made to a night shift nurse. The resident said the CNA would sit in the hallway on her phone and eat loudly. The resident said they asked a nurse to ask the CNA to be quieter, then the CNA came back into their room and told the resident that they were the worst resident and said the resident could close their door because she was not going to lower her voice. Resident #327 stated nobody had come to speak to them after the incident was reported to the nurse. The resident said they did not know the CNA's name or the nurse they reported the incident to. A review of Resident #327's Progress Notes revealed a late entry note, dated 10/29/2023 at 7:34 AM, which revealed during the night shift the resident reported to a nurse they felt unsafe in the facility due to a CNA. The Progress Note revealed, the resident reported they had pressed their call light due to not being able to sleep related to the CNA's loud voice. Per the Progress Note, Resident #327 reported the CNA answered their call light and told the resident they could close their door but did not agree to lower their voice. The Progress Note revealed, Resident #327 reported they felt threatened by the CNA's response and could no longer sleep due to fear of t the CNA. According to the Progress Note, Resident #327 reported the CNA's tone was aggressive and rude and the resident considered calling 911. The Progress Note indicated the CNA was asked to keep their voice down and to avoid the resident's room. The Progress Note revealed, the Facility Manager (FM) was notified of the incident. During an interview on 11/14/2023 at 9:39 AM Administrator indicated he had no reportable incidents since August 2023. During an interview on 11/14/2023 at 9:48 AM, the Facility Manager (FM) stated he did not remember the incident. The FM stated if an incident was reported to him, he would have gotten the social worker to start an abuse investigation. In a follow-up interview on 11/14/2023 at 2:10 PM, Resident #327 said the Administrator had not interviewed them about the incident. Resident #327 reported the CNA was rude and intimidating. During a telephone interview on 11/14/2023 at 4:43 PM, CNA #3 stated she did not remember any incident with any resident who complained about her. Per CNA #3, no nurse or facility staff had spoken to her about her tone of voice or about being quieter when the residents slept. She said she did not remember being told not to go into certain residents' rooms. During a telephone interview on 11/14/2023 at 4:55 PM, Registered Nurse (RN) #1 said she did remember the night Resident #327 reported to her they felt fearful and did not feel comfortable around CNA #3. Per RN #1, Resident #327 did seem fearful. According to RN #1, Resident #327 reported that CNA #3 was in the hallway eating loudly and had a phone conversation on speaker and was very loud. She said the resident could not sleep and knew it was bothering other residents too. RN #1 stated she did speak to CNA #3 about lowering her voice, that the residents were trying to sleep and to not go back into Resident #327's room. RN #1 stated she would answer the call lights for the resident. She stated Resident #327 told her that they did not feel comfortable and felt threatened so she stayed with the resident and ensured the resident they were safe, and that CNA #3 would no longer take care of them. RN #1 stated the way Resident #327 acted and told them about what happened, she considered the incident potentially to be abuse so she reported it to the FM. RN #1 stated she had not heard anything more about this incident and was never asked to write a statement. In a follow-up interview on 11/15/2023 at 10:28 AM, the FM acknowledged he did receive a telephone call from RN #1 related to the incident and he did not feel like it was an abuse allegation because it was about a loud voice. He said the incident occurred on 10/28/2023.He stated when he was notified of the incident the word abuse was not used. He said he was told the resident felt unsafe and thought about calling 911, but he thought that since he had the nurse speak with the CNA and remove her from caring for Resident #327, the incident was resolved. He said that he did not remove the CNA from resident contact. He stated the facility staff did not do an investigation because he did not consider it to be abuse. He stated no other staff or residents were interviewed. During an interview on 11/15/2023 at 12:24 PM, the Director of Staff Develeopment stated she was told a resident had voiced concerns about CNA #3 being too loud. She stated the nurse on the shift had in-serviced the CNA and told her not to go back into the resident's room who had voiced the concern. She stated she had not read the progress note related to the incident until 11/14/2023 and she was shocked that it was not investigated. She stated that if she had read it before, she would agree that it could be abuse and needed to be investigated. She stated the facility staff failed to investigate the incident. During an interview on 11/16/2023 at 2:28 PM, the Director of Nursing stated that she expected her staff to report any incident that could be abuse to the Administrator or herself. She stated that if it were staff-to-resident abuse, then the staff would be suspended (removed from resident contact), and they would start an investigation. She said if she had read the progress notes about this incident, she would have started an investigation. During an interview on 11/16/2023 at 3:30 PM, the Administrator stated he did not think the incident which involved Resident #327 and CNA #3 needed to be reported or investigated as it was not an abuse allegation. He said the words in the progress note were unclear and needed clarified. He said he read the progress notes, and he thought the wording was inaccurate after speaking to the resident, nurse, and CNA. He said he would always report any abuse as required.

Based on record reviews, document review, and interviews, the facility failed to ensure timely completion of quarterly Minimum Data Set (MDS) assessments for 3 (Residents #98, #85, and #110) of 7 sampled residents reviewed for resident assessments. Findings included: Review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated October 2023, revealed The Quarterly assessment is an OBRA non-comprehensive assessment for a resident that must be completed at least every 92 days following the previous OBRA [Omnibus Budget Reconciliation Act] assessment of any type. It is used to track a resident's status between comprehensive assessment to ensure critical indicators of gradual change in a resident's status are monitored. The document indicated, The MDS completion date must be no later than 14 days after the ARD. A review of Resident #98's Admission Record revealed the facility admitted the resident on 10/15/2020. A review of Resident #98's quarterly MDS, with an Assessment Reference Date (ARD) of 07/07/2023, revealed the MDS assessment was signed as being completed on 07/26/2023 by the MDS Registered Nurse (RN). A review of Resident #85's Admission Record revealed the facility admitted the resident on 12/22/2017. A review Resident #85's quarterly MDS, with an ARD of 07/07/2023, revealed the MDS assessment was signed as being completed on 07/26/2023 by the MDS RN. A review of Resident #110's Admission Record revealed the facility admitted the resident on 12/27/2019. A review of Resident #110's quarterly MDS, with an ARD of 07/07/2023, revealed the MDS assessment was signed as being completed on 07/26/2023 by the MDS RN. A review of the facility's MDS 3.0 Final Validation Report, with a submission date of 07/27/2023, revealed Residents #85, #98, and #110's quarterly MDS assessments were signed as being completed more than 14 days after the ARD. During an interview on 11/16/2023 at 11:28 AM, the MDS RN stated a MDS assessment should be signed as being completed 14 days after the admitted or the ARD. The MDS RN stated he was responsible to sign the MDS assessment as being accurate and complete. The MDS RN stated he did not recall any reason why the MDS assessments were late. During an interview on 11/16/2023 at 2:46 PM, the Director of Nursing (DON) stated she was not sure about the timing of MDS assessments but thought they had to be completed 14 days from the ARD. The DON stated she was not aware there were late MDS assessments. During an interview on 11/16/2023 at 3:25 PM, the Administrator stated MDS assessments should be completed within 14 days of the ARD. The Administrator stated he was not aware MDS assessments in July 2023 were late.

Based on record review and interviews, the facility failed to ensure the discharge Minimum Data Set (MDS) assessment was accurate for 1 (Resident #176) of 3 sampled residents reviewed for closed record review. Findings included: A review of Resident #176's Admission Record revealed the facility admitted Resident #176 on 07/04/2023. Per the Admission Record, the resident discharged home on 08/31/2023. A review of Resident #176's discharge MDS, with an Assessment Reference Date (ARD) of 08/31/2023, revealed the resident discharged to an acute hospital on 08/31/2023. A review of Resident #176's discharge summary Progress Notes, dated 08/31/2023, revealed the resident discharged home on 08/31/2023 at 11:20 AM. During an interview on 11/16/2023 at 11:28 AM, the MDS Registered Nurse (RN) stated he was responsible for ensuring the accuracy and completeness of the MDS assessments. The MDS RN stated that according to the Progress Notes, Resident #176 discharged home, and he verified the MDS assessment was coded incorrectly to indicate the resident discharged to the hospital. During an interview on 11/16/2023 at 2:46 PM, the Director of Nursing stated the MDS RN was responsible for the accuracy and completion of the MDS assessments. During an interview on 11/16/2023 at 3:25 PM, the Administrator stated he expected the MDS assessments to be accurate.

Based on record reviews, interviews, and policy review, the facility failed to refer a resident with a newly evident serious mental disorder for a Level II Preadmission Screening and Resident Review (PASARR) for 2 (Resident #48 and Resident #130) of 5 sampled residents reviewed for PASARR requirements. Findings included: A review of the facility policy titled, Admission Criteria, revised in March 2023, revealed b. If the level I screen indicates that the individual may meet the criteria for a MD [mental disorder], ID [intellectual disorder], or RD [related disorder], he or she is referred to the state PASARR representative for the Level II (evaluation and determination) screening process. 1. Review of Resident #48's Admission Record revealed the facility admitted the resident on 01/25/2022 with diagnoses that included bipolar disorder and unspecified psychosis. A review of Resident #48's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/15/2023, revealed the resident had active diagnoses that included bipolar disorder and psychotic disorder. Review of Resident #48's Preadmission Screening and Resident Review Level I Screening, dated 10/14/2022, revealed the resident had diagnoses of psychosis and bipolar disorder. Review of a document from the State of California-Health and Human [NAME] Agency Department of Health Care Services addressed to the resident, carbon copied to the facility, and dated 10/14/2022, revealed a Level II Mental Health Evaluation Referral was required for Resident #48. During an interview on 11/14/2023 at 2:38 PM, the MDS Registered Nurse (RN) stated Resident #48's result of the Level I PASARR was positive and that a Level II PASARR should have been completed. The MDS RN acknowledged he failed to contact the Department of Health Care Services to have the Level II completed. During an interview on 11/16/2023 at 2:10 PM, the Director of Nursing (DON) stated the facility was responsible for ensuring the Level II evaluation was completed. During an interview on 11/16/2023 at 3:16 PM, the Administrator stated the MDS staff, and the DON were responsible for ensuring Level II evaluations were completed. 47914 2. A review of Resident #130's Admission Record revealed the facility admitted the resident on 08/04/2022. Per the Admission Record, Resident #130 received a diagnosis of anxiety disorder on 08/25/2022 and diagnoses of depression and mood disorder on 10/14/2022. A review of Resident #130's annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/12/2023, revealed Resident #130 had active diagnoses to include anxiety disorder, depression, and psychotic disorder. A review of Resident #130's Preadmission Screening and Resident Review Level I Screening, dated 08/05/2022, revealed the resident did not have a diagnosed mental disorder such as depression, anxiety, panic, schizophrenia/schizoaffective disorder, psychotic, delusional, and/or mood disorder. The was not able to provide evidence a new Level I PASARR screening was completed after the resident received new mental disorder diagnoses. During an interview on 11/14/2023 at 3:05 PM, the MDS Registered Nurse (RN) indicated the facility would only do another Level I if the resident displayed a behavior that warranted a review. During an interview on 11/16/2023 at 1:05 PM, the Director of Nursing (DON) confirmed the facility did not submit a new Level I when Resident #130 was diagnosed with anxiety disorder. In a follow-up interview on 11/16/2023 at 2:14 PM, the DON confirmed a new Level I should have been submitted for Resident #130 for the new mental disorder diagnoses of depression and mood disorder. During an interview on 11/16/2023 at 3:18 PM, the Administrator indicated he was not a clinician, so he would rely heavily on the judgement of the DON and the MDS RN to determine when the PASARR screenings should be done.

Based on observations, record review, interviews, and facility policy review, the facility failed to ensure bed rails were used properly per assessment for 1 (Resident #152) of 5 sampled residents reviewed for accidents. Findings included: A review of the facility policy titled, Bed Safety and Bed Rails, revised in August 2022, revealed, 3. The use of bed rails or side rails (including temporarily raising the side rails for episodic use during care) is prohibited unless the criteria for use of bed rails have been met, including attempts to use alternatives, interdisciplinary evaluation, resident assessment, and informed consent. A review of Resident #152's Admission Record revealed the facility admitted the resident on 07/08/2023 with diagnoses that included traumatic subdural hemorrhage (brain bleed) with loss of consciousness, encephalopathy (brain disorder), and cerebral edema (swelling of the brain). Review of Resident #152's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/29/2023, revealed Resident #152 had a Brief Interview for Mental Status (BIMS) score of 0, which indicated the resident had severe cognitive impairment. The MDS indicated the resident required extensive assistance with bed mobility and transfers and had impairment on both sides in their lower extremities. A review of Resident #152's care plan initiated on 07/08/2023, revealed the resident had an activities of daily living self-care performance deficit and limited mobility. A review of Resident #152's Bed Rail Observation/assessment dated [DATE], revealed bed rails were not recommended for the resident. A review of Resident #152's Bed Rail Observation/assessment dated [DATE], revealed bed rails were not in use for the resident. On 11/13/2023 at 11:30 AM, the surveyor observed as Resident #152 laid in their bed, with half bed rails raised on both sides of the upper bed. On 11/14/2023 at 12:17 PM and 11/15/2023 at 3:08 PM, the surveyor observed as Resident #152 laid in their bed, with the bed rail by the wall raised and the outside rail lowered. During an interview on 11/15/2023 at 1:13 PM, Licensed Vocational Nurse (LVN) #15 said she was not sure if Resident #152 used the bed rails or not but since the resident was at risk for falls, she thought they might be on the resident's bed for safety. LVN #15 stated a resident would need to be assessed before they used bed rails. After review of Resident #152's medical record, LVN #15 confirmed the last bed rail assessment for the resident indicated bed rails were not in use. During an interview on 11/15/2023 at 3:42 PM, Certified Nurse Assistant #16 stated Resident #152 should not have bed rails. During an interview on 11/16/2023 at 2:46 PM, the Director of Nursing (DON) stated when a resident admitted to the facility, the staff checked with the resident to see if they wanted bed rails, and if so, an assessment was completed to determine if the rail was used as an enabler or as a restraint. Per the DON, if the rails were to be used for safety, it would need to be an interdisciplinary team decision and the resident would have to use alternatives before the use of the bed rails. The DON stated if a resident had not been assessed for the use of bed rail, the bed rails should not be used.

Based on observation, interview and record review, for two (Resident 15 and Resident 18) of 27 sampled residents, the facility failed to ensure safety from accident hazards. 1. On 3/4/15, Certified Nurse Assistant (CNA) 7 and CNA 8 improperly transferred Resident 15 from her wheelchair to bed. This failure resulted in Resident 15 to sustain a left lower leg fracture with pain and limited range of motion. 2. On 3/17/15 Resident 15 was not supervised in her wheelchair and sustained a fall. There was a potential for Resident 15 to sustain an injury. 3. There were two sharp metal brackets attached to the wall which were easily accessible by the residents in the dementia unit. This failure resulted in the potential for resident injury. 4. There was a 12 by 5 by 2 inch rectangular depression in the concrete walkway where the path met the artificial grass which posed a trip hazard to the residents in the dementia unit. This failure resulted in the potential for resident injury. 5. There was a torn screen in the window of room 422 in a manor where a resident would be able to climb out of the window and fall. This failure resulted in the potential for resident injury. Findings: 1. Review of the clinical record, showed Resident 15 was admitted on [DATE] with a [DIAGNOSES REDACTED]. In an initial tour observation on 3/16/15 at 9:48 a.m., Resident 15 was lying in bed with a bandage on her left lower leg. In an interview on 3/16/15 at 11:07 a.m., Certified Nurse Assistant (CNA 9) stated Resident 15 needed two persons and a mechanical lift (assistive device used for transferring from one surface to another) to get her in and out of bed. In an interview on 3/16/15 at 11:25 a.m., Licensed Vocational Nurse (LVN 5) stated Resident 15 was unable to verbalize her needs. LVN 5 stated Resident 15 needed a lift for transfer. LVN 5 stated the CNAs involved with the inappropriate transfer did not use the mechanical lift when it was required for Resident 15. In an interview on 3/19/15 at 10:20 a.m., the Director of Nursing (DON) stated from their investigation Resident 15 sustained the left lower leg fracture due to an improper transfer by CNAs 7 and 8. The DON stated Resident 15 needed two staff to transfer with a mechanical lift. CNAs 7 and 8 provided a (stand) pivot transfer (an assist in transfer from one place to another without the use of an assistive device) instead of the use of the mechanical lift. The DON stated CNAs 7 and 8 did not report to their supervising nurse that they did a pivot transfer instead of using the mechanical lift. The DON stated CNA 8 should have told CNA 7 to stop and get the mechanical lift before they transferred Resident 15 to the bed from her wheelchair. In a telephone interview on 3/19/15 at 10:35 a.m., CNA 7 confirmed she and CNA 8 provided a pivot transfer for Resident 15 and they were not supposed to do that type of transfer as Resident 15 needed a mechanical lift for transfer and that she should have followed the rules. In a telephone interview on 3/19/15 at 10:45 a.m., CNA 8 stated Resident 15 was agitated and started to slide down from her wheelchair. CNA 8 stated CNA 7 said, "Hurry up, hurry up," because Resident 15 was about to fall. CNA 8 stated she had done what she was asked to do by CNA 7. CNA 8 stated Resident 15 was supposed to be transferred with a mechanical lift. When asked if Resident 15 could have been assisted back into her wheelchair when she started to slide down instead of providing a (stand) pivot transfer, CNA 8 stated yes. Record review on 3/16/15 of the Resident Chart notes dated 3/5/15, showed, "CNA reported that resident's left foot is swollen. Assessed resident right away, left foot is swollen with bruising noted, painful when moved as resident exhibited facial grimacing and guarding behavior, limited range of motion." Record review of the Emergency Department Encounter, dated 3/5/15, showed an x-ray confirmed a [DIAGNOSES REDACTED]. Record review on 3/16/15 of the Care Plan, dated 9/14/11, showed, "I (the resident) require staff assistance for all ADL's (activities of daily living). I (the resident) use a Vander lift (a mechanical lift used to assist in transfers of residents) for all transfer." Record review on 3/16/15 of the Care Plan Conference Summary, dated 9/25/13 and 9/11/14, showed Resident 15 required, "Mechanical Lift for transfers." Record review on 3/20/15 of the facility's policy and procedure, titled "Safe Lifting and Movement of Residents," revised October 2009, showed, "Manual lifting of residents shall be eliminated when feasible. Mechanical lifting devices shall be used for heavy lifting, including lifting and moving residents when necessary. " Record review on 3/20/15 of the facility's policy and procedure, titled "Safety and Supervision of Residents," revised on December 2007, showed, "Implementing interventions to reduce accident risks and hazards shall include the following: ensuring that interventions are implemented. Due to their complexity and scope, certain resident risk factors and environmental hazards are addressed in dedicated policies and procedures. These risk factors and environmental hazards include: safe lifting and movement of residents." 2. Review of the clinical record on 3/17/15 showed Resident 18 was re-admitted on [DATE] with an [DIAGNOSES REDACTED]. In an observation on 3/17/15 at 1:00 p.m., Resident 33 was in the hallway and yelled out (Resident 18) was "going down, there she goes." Resident 18 was found on the floor in front of her wheelchair in her room. LVN 5, LVN 9 and CNA 9 all entered the room and assisted Resident 18 back to her wheelchair. LVN 9 proceeded to wheel Resident 18 to the nurse supervisor office located near Station 1. In the presence of LVN 9, Resident 18 attempted to get out of wheelchair again. In an interview on 3/18/15 at 12:39 p.m., CNA 9 stated Resident 18 would try to get out of her wheelchair and bed all the time. CNA 9 stated Resident 18 was always monitored and supervised either during activities or at the nurse's station. CNA 9 further said Resident 18 could not be left alone while in her wheelchair because she would attempt to get out of it several times a day. In an interview on 3/18/15 at 1:08 p.m., LVN 5 stated Resident 18 was to be kept around "common areas", such as the nurse's station so that staff could see and monitor her while she was in her wheelchair. LVN 5 stated Resident 18 was brought back to her room from activities for lunch. LVN 5 stated CNA 14 left Resident 18 in her room by herself to help other CNAs assist other residents with eating. LVN 5 stated CNA 14 should have brought Resident 18 out to the nurse's station, so she could be supervised. LVN 5 stated there was one CNA to assist residents to eat and one CNA to answer call lights during lunch time in Station 1 while half of the CNA staff was at the Midway dining area to assist residents to eat. In a telephone interview on 3/18/15 at 2:05 p.m., CNA 14 stated she was with Resident 18 in Resident 18's room and had started Resident 18's feeding while she was in her wheelchair. CNA 14 stated she (CNA 14) had left Resident 18 in her room to assist residents in the Midway dining room. CNA 14 stated Resident 18 was usually supervised and monitored by the nurse at the nursing station while in her wheelchair. Record review of the CNA feeding assignment sheet for 3/17/15, showed CNA 14 was assigned to assist Resident 18 for lunch. In an interview on 3/19/15 at 9:55 a.m., the Director of Staff Development (DSD 1) stated Resident 18 should not have been left alone in her room while in her wheelchair and she should be in the common areas for her to be monitored and supervised by staff members. In an interview on 3/19/15 at 10:50 a.m., Resident 33 stated he saw Resident 18 try to stand and straighten up off her wheelchair, and fell to the floor. Resident 33 stated there was no staff members present in the room with Resident 18 at the time of the fall. In an interview on 3/19/15 at 2:50 p.m., LVN 6 stated Resident 18 was not to be left alone when in wheelchair. LVN 6 stated Resident 18 would always be next to him at the medication cart or at the nurse's station when she is in her wheelchair. Record review on 3/18/15 of Resident 18's "Fall Risk Evaluation" dated 11/16/14, showed a total score of 16 and "The resident should be considered at High Risk for potential falls. A prevention protocol should be initiated immediately and documented on the care plan." Record review on 3/18/15 of the Care Plan, dated 3/21/14, showed Resident 18 was at, "Risk for falls, (+) unsteady gait," but there was no intervention to address supervision or monitoring if Resident 18 attempted to get out of the wheelchair, nor that Resident 18 should be in a common area when in wheelchair. Record review on 3/20/15 of the facility's policy and procedure titled, "Managing fall, and fall risk," revised on December 2007, showed that, "Frail elderly individuals are often at greater risk for serious adverse consequences of falls." The following observations were made during facility tours: 5. On 3/16/2015 at 10 a.m., two metal brackets were observed partially attached to the wall in a recreation area used by residents. Upon closer inspection the brackets were just being held to the wall by one fastener. This was pointed out to the Maintenance Supervisor (MS) during the environmental tour on 3/18/2015 at 3:35 p.m. The MS was able to reach out and pull one bracket out of the wall with ease. He stated that they had been there for a few months, ever since the downspouts were removed. The MS stated that the brackets, such as they were, could easily cause a hand injury. 6. On 3/16/2015 at 10 a.m., a gap between the concrete pathway was noted. Upon closer inspection the gap was created by a space between where the artificial turf was just short of meeting the pathway and measured twelve inches long by five inches wide by two inches deep. During the environmental tour with the MS on 3/18/2015 at 3:35 p.m., the MS agreed that it was a trip hazard and stated that he could see how a resident could fall there. 7. During the initial tour on 3/16/2015 at 10 a.m., a broken window screen was noted in room 422's window which was part of the locked unit. The window was open and was wide enough to let someone climb out into the courtyard. During the environmental tour with the MS on 3/18/2015 at 3:35 p.m., the MS stated that room 422 had a standard window that opened to 22 inches to let people climb out in case of a fire. He agreed that that the lack of a screen could encourage a confused patient to climb out as the window no longer looked like a barrier.

Based on interview, and record review, for one of two residents (Resident 1), the facility failed to provide constant supervision and observe safety measures in preventing accidents when she was left in her wheelchair without making sure that wheels were locked. This failure had resulted in Resident 1's fall, sustained a left hip fracture that required an avoidable hospitalization . Findings: On 9/30/14, review of the clinical record and the Minimum Data Set Assessment (MDS, an assessment tool used to direct resident care) dated 5/23/14, showed that Resident 1 had a BIMS (Brief Interview for Mental Status) score of 4 which meant that Resident 1's cognition was severely impaired. The facility readmitted Resident 1 from the hospital, on 7/23/14, with multiple [DIAGNOSES REDACTED]. The fall risk assessment dated [DATE] showed that Resident 1 had a score of 15 which meant that Resident 1 was at high risk for potential falls. Review of the fall care plan dated 7/23/14 showed that Resident 1 was to be assisted to walk and should be placed near the nurses' station. Review of the nurse's notes and the care plan showed the following: -On 7/23/14, Resident 1 was readmitted to the facility and was on an antibiotic for a urine infection. -On 7/24/14, Resident 1 was found on the floor, lying on her right side, near the nurses' station. Resident 1 sustained a skin tear to her right eyebrow. The fall incident was unwitnessed. Physical therapy (PT) notes, dated 7/24/14, regarding functional status, showed that Resident 1 needed moderate staff assistance when moving to or from distant areas within the facility while in her wheelchair. The functional notes also showed that PT notified Nursing and the Certified Nurse Aide (CNA) staff that Resident 1 required constant supervision (supervision, the action or process of watching and directing what someone does or how something is done; constant, at all times.)(Reference: merriam-webster dictionary). A Patient Care Plan entry, dated 7/24/14, showed care approaches for a fall that included closer observation, proper use of the wheelchair, redirecting Resident 1 as needed, continue physical therapy and to place Resident 1 near the nurses' station. The care plan did not address a need for Resident 1 to have constant supervision According to nurses' notes, dated 7/27/14 at 6:20 a.m., facility staff found Resident 1 on the pavement in the patio, lying on her left side. Resident 1 had sustained a skin tear to the forehead and left hand, and abrasions to both knees. The fall incident was unwitnessed. The Patient Care Plan, dated 7/27/14, showed entries for interventions that included keeping Resident 1 near the nurses' station and, "keep me in site when awake." According to nurses' notes, dated on 7/29/14 at 5:20 p.m., Resident 1 fell when she stood up from her wheelchair, lost balance, and slowly slid from her wheelchair. Resident 1 landed on her buttocks. There was no injury. The Patient Care Plan, dated 7/29/14, recorded approaches for falls as continuation of physical and occupational therapy and, "monitor for 72 hours." Nurses' notes, dated 7/30/14 at 8:04 a.m., recorded that Resident 1 had fallen three times in one week. Continued nurses' notes, dated 7/30/14 at 12:39 p.m., showed that Resident 1 could not participate in PT. Resident 1 was noted to have swelling, slight redness and decreased range of motion of her left hip and right knee. An x-ray performed at the facility showed a left hip fracture and the facility sent Resident 1 to the hospital. In an interview, and concurrent record review on 11/19/14 at 8:40 a.m., Director of Nursing (DON) said that a resident's care plan should be revised and updated if there was a new incident of fall. The Patient Care Plan, that DON referred to as the short term care plans, that were dated 7/24/14 through 7/29/14, did not list any new intervention that would prevent falls. DON also stated that since Resident 1's fall, the facility has developed a new fall protocol because DON said "we're missing something." DON said that if a resident falls, the Interdisciplinary Team (IDT, a group of facility staff composed of different department heads) and the supervisor should gather around the resident to determine what had caused the fall and then proceed to explore possible interventions to avoid another fall. DON stated the only other IDT note found in Resident 1's clinical record was dated 7/17/14; done after Resident 1's unobserved fall in the dining area. There were no IDT notes done after Resident 1's fall incident on 7/24/14 and 7/27/14. The fall care plan, dated 7/23/14 did not show that it was updated or revised with new approaches or interventions after Resident 1's multiple falls. Review of the facility's policy and procedure titled "Care Plans-Comprehensive" last revised October 2010 showed that resident assessments are ongoing and care plans are revised as information about the resident and the resident's condition change. It also showed that the Interdisciplinary Team (IDT, a group of facility staff composed of different department heads) is responsible for reviewing and updating care plans when there is a significant change in resident's condition and when the desired outcome is not met. In an interview, and concurrent record review, on 9/30/14 at 2:07 p.m., Registered Nurse Supervisor (RNS) stated, a post fall investigation was done and confirmed that the wheelchair rolled back behind Resident 1. The Interdisciplinary (IDT) Progress Notes dated 7/29/14 showed Resident 1 attempted to get up from her wheelchair, the wheelchair slid back and Resident 1 dropped to a sitting position on the floor. The IDT notes showed "It is suspected that the brakes (wheelchair locks) were not applied." During an interview on 9/30/14 at 3 p.m., Director of Staff Development (DSD) stated, for resident's safety, wheelchair brakes need to be applied when leaving residents in their wheelchairs especially those who are at high risk for falls. In a subsequent interview, on 9/30/14 at 4:30 p.m., DSD stated he would call the facility's corporate office to make clarification about facility practice regarding wheelchair locks. During separate interviews, the following responses from different facility staff members were obtained regarding locking or not locking wheelchairs: -On 9/30/14 at 2:35 p.m., Licensed Vocational Nurse (LVN) 1 said that locking wheelchairs is a form of restraint, also said that Resident 1 was not able to propel herself while in her wheelchair and "she just wants to stand up and has had falls because of that." LVN 1 said she was not sure if Resident 1's wheelchair locks needed to be applied. -On 9/30/14 at 3:20 p.m., LVN 2 stated that wheelchairs are not supposed to be locked when residents are in the dining room or hallways, "Aren't they restraints?" she said. -On 9/30/14 at 3 p.m., DSD said that wheelchairs needed to be locked when leaving residents in the hallways especially those that are high risk for falls. -On 11/18/14 at 8:33 a.m., LVN 3 stated that Resident 1 was one who did not stay in her wheelchair, and who was not able to follow instructions like locking wheelchair brakes. LVN 3 stated she did not remember Resident 1 being able to wheel herself to any area in the facility and "just gets up and tries to walk all the time, gait unsteady". Resident 1 had prior falls because of this behavior , LVN 3 had instructed staff to watch Resident 1 so they could assist right away when Resident 1 attempts to stand up and walk. LVN 3 also said that she instructed CNAs to lock the wheelchair brakes so that when Resident 1 attempts to get up and walk, the wheelchair stays steady and Resident 1 doesn't fall. -On 11/18/14 at 9:12 a.m., Certified Nursing Assistant (CNA) 1 said that the facility staff do not lock wheelchairs because of dignity issues, CNA 1 stated all residents that included those that are high risk of falling should be able to go wherever they want to go, "we just have to watch them closely." -On 11/17/14 at 10:42 a.m., DSD clarified that for resident safety, wheelchairs are locked for residents who are not able to propel themselves around the facility. DSD also added that for residents who are able to move around, and able to propel themselves independently while in their wheelchairs, the wheelchairs should not be locked because it would be a restraint. DSD said that the facility did not have a written policy that said when wheelchairs should be locked. Review of the Look-Back Report dated 7/27/14 on Resident 1's functional abilities showed that Resident 1 was wheeled to activities with moderate assist from staff. Review of the MDS dated [DATE] showed that Resident 1 was not able to move to or from distant areas within the facility such as the dining or activities rooms without help from staff. In an interview on 11/19/14 at 9:40 a.m., Occupational Therapist (OT) stated that for safety of residents who are cognitively impaired and are not able to lock their wheelchairs, "it's automatic. I have to lock the wheelchairs even if I leave them near the nurses' station, for safety reasons." OT said that these residents who are on wheelchairs don't have adequate muscle strength, so that when they try to stand up and the wheelchair is not locked, wheelchair might slide backwards and they fall. Review of the Occupational Therapy Notes (OT) and Physical therapy (PT) notes dated 7/24/14 showed that Resident 1 needed moderate staff assistance with wheelchair mobility (the ability to move around the environment using a wheelchair). -PT notes dated 7/25/14 showed that Resident 1 was impulsive and attempted to stand and walk away when not monitored. -OT notes dated 7/27/14 showed that Resident 1 was not safe when in wheelchair and required constant supervision as Resident 1 frequently attempts to stand and ambulate without assistance. -PT notes dated 7/28/14 showed that Resident 1 was anxious and made multiple attempts to stand without assistance. In an interview and concurrent record review, on 11/19/14 at 10:01 a.m., the Patient Care Plan, dated 7/24/14, showed interventions that included "proper use of wheelchair". DON said "I don't know why someone would say that because resident does not follow directions anyway, so somebody has to do it for her." Review of the hospital Emergency Department (ED) notes, dated 7/30/14, showed [DIAGNOSES REDACTED]. Surgery was done on Resident 1's left hip on 7/30/14 that required nail placement to her left femur (thigh bone). Resident 1's hospital stay was 29 days and she was discharged back to the facility.

Based on observation, interview and record review, for one (Resident 1), of two residents the facility failed to ensure that Resident 1 received adequate supervision when she was allowed to sleep in a bedside chair that had not been evaluated by the facility as being safe for sleeping. This failure led to Resident 1's unwitnessed fall when she fell asleep and slipped out of the bedside chair. Resident 1 sustained a fracture of the thigh bone that required an avoidable hospital stay and surgery. Findings: The facility reported that on 9/13/14 at about 9:10 p.m. Resident 1 fell from a bedside chair, sustaining a hip fracture. Review of the clinical record on 9/19/14, showed Resident 1 was a frail, elderly resident, admitted with [DIAGNOSES REDACTED]. In an interview on 9/19/14 at 10:30 a.m., the Director of Nursing (DON) stated Resident 1 preferred to sleep in her bedside chair frequently. DON added that the facility could not impose on Resident 1 to sleep in her bed. It was added to the care plan that Resident 1 preferred to sleep in her bedside chair. DON said Resident 1 was offered assistance with her activities of daily living if she needed assistance; otherwise, Resident 1 was encouraged to be as independent as she could be. (Independent, no help or staff oversight at any time) (Reference: MDS 3.0 RAI Manual Version 1.11.2 Effective 10/01/2013). Review of the activities of daily living functioning care plan, dated 5/9/14, showed Resident 1 was to have limited assistance for mobility (staff provides guided maneuvering of limbs or other non-weight bearing assistance). The fall risk care plan dated 5/9/14, showed Resident 1 preferred to sleep in her bedside chair. To avoid any serious injuries from falls, one of the approaches the facility planned was to keep the call light within Resident 1's reach to call for help when she was in bedside chair, however Resident 1's memory loss would probably prevent her from remembering to use the call light. The care plan did not show any intervention that assured Resident's 1's safety in using the bedside chair to sleep in. During an interview and concurrent record review on 9/19/14 at 10:45 a.m., Licensed Vocational Nurse (LVN) 1 stated Resident 1 was a non-compliant resident and one who would forget instructions like calling for help. The Physician's Progress Notes dated 8/14/14 showed that Resident 1 was confused. In an interview and concurrent record review on 9/19/14 at 11:40 a.m., DON confirmed Resident 1 had a prior fall on 6/12/14 at 3:45 p.m.. The Alas Fall Risk Evaluation (an assessment tool used to measure a resident's risk of falling), dated 8/16/14, showed Resident 1 had a score of nine which meant that she was not considered high risk for Falls. In that same evaluation form, under the item, "History of falls (past 3 months)," Resident 1 was given a score of zero, which meant that she did not have any fall in the past three months. DON confirmed the fall risk assessment was incorrect because the fall incident on 6/12/14 (two months prior to the assessment) should have been considered. DON said that would have made the score "11, a high risk for falls. The Alas Fall Risk Evaluation showed, "If the total score is 10 or greater, the resident should be considered at HIGH RISK for potential falls. A prevention protocol should be initiated immediately and documented on the care plan." DON said if Resident 1 was considered a HIGH RISK for falls, the care plan would have been changed to add few more interventions for fall precautions. During an interview on 9/23/14 at 4:06 p.m., Registered Nurse (RN) 1 stated fall risk evaluations were done by licensed nurses every three months. RN 1 also said if the fall risk assessment found Resident 1 to be at high risk for falls, the level of assistance reflected on the care plan would change from independent assist (no help or staff oversight at any time) to supervision (oversight, encouragement or cueing from staff). RN 1 said at the time of the fall, when he responded to LVN 1's call for assistance, he saw Resident 1 on the floor in front of the bedside chair, which was slightly tilted forward. RN 1 also said he was not sure if the chair was appropriate for her size and Resident 1 probably needed a chair that was, "More suitable for her." RN 1 stated he was not sure if the Interdisciplinary Team (IDT-a team of facility staff composed of different department heads) had a discussion concerning safety of the bedside chair that Resident 1 preferred to sleep in. In an interview on 9/19/14 at 11:12 a.m., Certified Nursing Assistant (CNA) 1 stated on the night of 9/13/14 around 8 p.m., he went into Resident 1's room and found Resident 1 in the toilet and he helped her back to the bedside chair because she refused to sleep in her bed. CNA 1 said after he assisted Resident 1 to her bedside chair, he left the room to take care of another resident. When he went back into Resident 1's room to provide care for Resident 1's roommate around 9 p.m., he saw Resident 1 on the floor, in a sitting position with her back against the bedside chair and her head resting on the chair seat. CNA 1 stated he asked Resident 1 what happened, and Resident 1 answered that she slipped out of the chair. In another interview on 9/19/14 at 10:45 a.m., LVN 1 stated Resident 1 refused to sleep in her bed, and wanted to sleep in her bedside chair instead. LVN 1 also said when she went into Resident 1's room after she was told of the fall incident, Resident 1 had told her she fell asleep and slipped out of the chair. In an observation and concurrent interview on 9/26/14 at 3:49 p.m., the bedside chair located to the left side of Resident 1's bed was a regular upright wooden non-reclining chair that had a thin cushion and wooden arm rests. DON confirmed it was the bedside chair that Resident 1 fell from. During a follow up interview on 9/30/14 at 11:50 a.m., DON confirmed there was no documentation to show Resident 1's use of the bedside chair to sleep in was ever assessed by the IDT team. There was nothing in the record regarding the reason Resident 1 refused to sleep in her bed. On 9/30/14 at 1:30 p.m., Occupational Therapist (OT) 1 stated the rehabilitation department did not see Resident 1 until after the fall incident. OT 1 also said the nursing department did not involve the rehab to determine safety of Resident 1 when using the bedside chair. OT 1 added if she had been asked to get involved in the assessment, she would have assessed possible reasons why Resident 1 did not want to sleep in her bed. In an interview on 10/1/14 at 9:05 a.m., CNA 3 stated she saw Resident 1 sleep in the bedside chair a number of times even before the fall. CNA 3 also said Resident 1 did not like to sleep in her bed because she was not comfortable and that Resident 1 once told her she "doesn't feel good" in the bed. On 9/13/14 an x-ray was done after Resident 1 complained of pain on her right hip. The x-ray report showed Resident 1 had a fracture of her thigh bone. She was sent to the hospital for further evaluation on 9/14/14 at 2:00 a.m. A review of the Emergency Department (ED) Provider Notes signed on 9/15/14 at 8:50 p.m. showed Resident 1 had pain that was described as 10 out of 10 (the worst possible pain) with associated vomiting, nausea, and shortness of breath. The ED notes confirmed fracture of the right femur (thigh bone) was confirmed by x-ray. The assessment dated [DATE] showed Resident 1 underwent surgery to repair it. ______________________________________________________________________Class "B" Citation No. 02-2687- 6-F The facility violated the aforementioned regulation when they failed to:1. Ensure Resident 1 received adequate supervision and safety precautions when she was allowed to sleep in a bedside chair;2. Evaluate a bedside chair as being safe for sleeping; 3. Prevent Resident 1 from slipping out of the bedside chair, sustaining a fracture of the thigh bone, resulting in an avoidable hospital stay and surgery.Resident 1 was a frail resident, admitted on [DATE] with [DIAGNOSES REDACTED]. The facility reported that on 9/13/14 at about 9:10 p.m. Resident 1 fell from a bedside chair, sustaining a hip fracture.In an interview on 9/19/14 at 10:30 a.m., the Director of Nursing (DON) stated Resident 1 preferred to sleep in her bedside chair frequently. DON added that the facility could not impose on Resident 1 to sleep in her bed. It was added to the care plan that Resident 1 preferred to sleep in her bedside chair. DON said Resident 1 was offered assistance with her activities of daily living if she needed assistance; otherwise, Resident 1 was encouraged to be as independent as she could be. (Independent, no help or staff oversight at any time) (Reference: MDS 3.0 RAI Manual Version 1.11.2 Effective 10/01/2013).Review of the activities of daily living functioning care plan, dated 5/9/14, showed Resident 1 was to have limited assistance for mobility (staff provides guided maneuvering of limbs or other non-weight bearing assistance). The fall risk care plan dated 5/9/14, showed Resident 1 preferred to sleep in her bedside chair. To avoid any serious injuries from falls, one of the approaches the facility planned was to keep the call light within Resident 1's reach to call for help when she was in bedside chair, however Resident 1's memory loss would probably prevent her from remembering to use the call light. The care plan did not show any other interventions that assured Resident's 1's safety in using the bedside chair to sleep in. During an interview and concurrent record review on 9/19/14 at 10:45 a.m., Licensed Vocational Nurse (LVN) 1 stated Resident 1 was a non-compliant resident and one who would forget instructions like calling for help.The Physician's Progress Notes dated 8/14/14 showed that Resident 1 was confused.In an interview and concurrent record review on 9/19/14 at 11:40 a.m., DON confirmed Resident 1 had a prior fall on 6/12/14 at 3:45 p.m. The Alas Fall Risk Evaluation (an assessment tool used to measure a resident's risk of falling), dated 8/16/14, showed Resident 1 had a score of nine which meant that she was not considered high risk for Falls. In that same evaluation form, under the item, "History of falls (past 3 months)," Resident 1 was given a score of zero, which meant that she did not have any fall in the past three months. DON confirmed the fall risk assessment was incorrect, because the fall incident on 6/12/14 (two months prior to the assessment) should have been included. DON said that would have made the score, "11," a high risk for falls. The Alas Fall Risk Evaluation showed, "If the total score is 10 or greater, the resident should be considered at HIGH RISK for potential falls. A prevention protocol should be initiated immediately and documented on the care plan." DON said if Resident 1 was considered a HIGH RISK for falls, the care plan would have been changed to add few more interventions for fall precautions.During an interview on 9/23/14 at 4:06 p.m., Registered Nurse (RN) 1 stated fall risk evaluations were done by licensed nurses every three months. RN 1 also said if the fall risk assessment found Resident 1 to be at high risk for falls, the level of assistance reflected on the care plan would change from independent assist (no help or staff oversight at any time) to supervision (oversight, encouragement or cueing from staff). RN 1 said at the time of the fall, when he responded to LVN 1's call for assistance, he saw Resident 1 on the floor in front of the bedside chair, which was slightly tilted forward. RN 1 also said he was not sure if the chair was appropriate for her size and Resident 1 probably needed a chair that was, "More suitable for her." RN 1 stated he was not sure if the Interdisciplinary Team (IDT-a team of facility staff composed of different department heads) had a discussion concerning safety of the bedside chair that Resident 1 preferred to sleep in.In an interview on 9/19/14 at 11:12 a.m., Certified Nursing Assistant (CNA) 1 stated on the night of 9/13/14 around 8:00 p.m., he went into Resident 1's room and found Resident 1 in the toilet and he helped her back to the bedside chair because she refused to sleep in her bed. CNA 1 said after he assisted Resident 1 to her bedside chair, he left the room to take care of another resident. When he went back into Resident 1's room to provide care for Resident 1's roommate around 9:00 p.m., he saw Resident 1 on the floor, in a sitting position with her back against the bedside chair and her head resting on the chair seat. CNA 1 stated he asked Resident 1 what happened, and Resident 1 answered that she slipped out of the chair. In another interview on 9/19/14 at 10:45 a.m., LVN 1 stated Resident 1 refused to sleep in her bed, and wanted to sleep in her bedside chair instead. LVN 1 also said when she went into Resident 1's room after she was told of the fall incident, Resident 1 had told her she fell asleep and slipped out of the chair. In an observation and concurrent interview on 9/26/14 at 3:49 p.m., the bedside chair located to the left side of Resident 1's bed was a regular upright wooden non-reclining chair that had a thin cushion and wooden arm rests. DON confirmed it was the bedside chair that Resident 1 fell from.During a follow up interview on 9/30/14 at 11:50 a.m., DON confirmed there was no documentation to show Resident 1's use of the bedside chair to sleep in was ever assessed by the IDT (Interdisciplinary) team. There was nothing in the record regarding the reason Resident 1 refused to sleep in her bed. On 9/30/14 at 1:30 p.m., Occupational Therapist (OT) 1 stated the rehabilitation department did not see Resident 1 until after the fall incident. OT 1 also said the nursing department did not involve the rehab to determine safety of Resident 1 when using the bedside chair. OT 1 added if she had been asked to get involved in the assessment, she would have assessed possible reasons why Resident 1 did not want to sleep in her bed. In an interview on 10/1/14 at 9:05 a.m., CNA 3 stated she saw Resident 1 sleep in the bedside chair a number of times even before the fall. CNA 3 also said Resident 1 did not like to sleep in her bed because she was not comfortable and that Resident 1 once told her she, "doesn't feel good" in the bed.On 9/13/14 an x-ray was done after Resident 1 complained of pain on her right hip. The x-ray report showed Resident 1 had a fracture of her thigh bone. She was sent to the hospital for further evaluation on 9/14/14 at 2:00 a.m.A review of the Emergency Department (ED) Provider Notes signed on 9/15/14 at 8:50 p.m. showed Resident 1 had pain that was described as 10 out of 10 (the worst possible pain) with associated vomiting, nausea, and shortness of breath. The ED notes confirmed fracture of the right femur (thigh bone) was confirmed by x-ray. The assessment dated [DATE] showed Resident 1 underwent surgery to repair it.Therefore the facility violated the aforementioned regulation when they failed to:1. Ensure Resident 1 received adequate supervision and safety precautions when she was allowed to sleep in a bedside chair;2. Evaluate a bedside chair as being safe for sleeping; 3. Prevent Resident 1 from slipping out of the bedside chair, sustaining a fracture of the thigh bone requiring an avoidable hospital stay and surgery.

Based on interviews and record review, the facility failed to supervise and protect one (Resident 1) of three sampled residents from the harmful effects of the sun. Resident 1 wheeled herself out to the patio on a day when temperatures were over 100 degrees. She was discovered unresponsive and was sent to the hospital emergency room where she was diagnosed with [REDACTED]. Findings: On 7/30/14, record review showed that Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The complete resident assessment, dated 5/14/14, showed that Resident 1 was moderately impaired in decision making, has short and long term memory problems, required supervision and cueing (direction) in activities of daily living, required the extensive assistance of two staff for bed mobility and transfers. Review of a care plan dated 11/12/13, showed, "Difficulty with decision making, difficulty communicating needs." Review of nurses' notes, dated 7/14/14 at 3:18 p.m., showed, "Change in resident condition: Temperature- 106 degrees, heart rate- 66, respirations- 20; Skin intact- hot; Resident was reported to have fainted, She was found at the outside patio slumped in her wheelchair by CNA 1 (certified nursing assistant) at 1:45 p.m. Supervisor attempted to arouse resident but resident was unresponsive. Resident was brought to her room. Emergency services were notified. Resident was stripped of her clothes. Skin was red and hot to touch. Cold compresses applied to her forehead, underneath her arms, on her back and down her legs in order to bring her temperature down..." Review of the hospital emergency room records, dated 7/14/14, showed, "The patient presents with acute (sudden) alteration in mental status. She was febrile (feverish) in the Emergency department. She was also having large amounts of diarrhea and cloudy urine. I suspect her primary trigger is acute heat stroke...given antibiotics and intravenous fluids. The patient did improve very significantly throughout her Emergency Department stay. Impression: 1. Acute febrile illness. Heat stroke versus sepsis (a toxic condition due to spread of bacteria or their toxic products in the body); 2. Urinary tract infection; 3. Second degree burns to trunk and extremities; 4. Acute lactic acidosis (disruption of blood's acid/ base balance) with severe sepsis syndrome." Review of the hospital physician's history and physical, dated 7/14/14, showed, "[AGE] year old female...who has significant baseline dementia who is cared for by a conservator (a court- appointed decision- maker). Patient apparently has been in her usual state of health until today when she was last seen at 12:50 p.m. on a 100 + degree day. She was seen outside at 1:45 p.m. and was noted to be altered and temperature of 104 degrees. Patient started developing blistering on her back and cold compresses and clothing changed and she was brought here. Patient with risk of hypotension (low blood pressure), seizure risk, watch for liver injury, DIC (a lack of blood clotting syndrome), renal (kidney) injury, and arrhythmia (heart dysfunction)." During interview on 7/30/14 at 9:00 a.m., the Director of Nurses (DON) stated, "A CNA was taking another resident out to the patio and saw Resident 1 slumped over and tried to arouse her. He yelled for help and staff came to assess her. Her temperature was high so they took her clothes off and put wet towels all over her body. They called 911 and sent her out. After a few days in the hospital, she was transferred to another skilled nursing facility." During interview on 7/30/14 at 10:15 a.m., CNA 1 stated, "I found Resident 1 and I know her. She was slumped and drooling. I tried to arouse her and she didn't respond so I called for help. She wasn't in the shade. She likes being in the sun." During interview on 7/30/14 at 11:15 a.m., registered nurse 1 (RN) stated, "Elderly are easily dehydrated. Heat stroke comes on fast. I was not aware she was out there until they brought her in. It was really hot that day." During an interview and concurrent record review on 7/30/14 at 11:45 a.m., the Director of Staff Development (DSD) stated, "I train the staff to make sure residents are hydrated. No one can go out unsupervised. If a staff takes a resident out to the patio, they have to monitor at least once every hour. DSD showed her attendance list and lesson plan for her training dated 6/22/14, addressing the elderly and hot weather. During phone interview on 8/5/14 at 3:30 p.m., Resident 1's conservator stated, "When I asked the facility staff what she was wearing that day, they told me she chose to wear a long sleeved shirt and long pants." __________________________________________________________ Class "B" Citation #02-2352- 38-F The facility violated the aforementioned regulation when it failed to supervise Resident 1on 7/14/14, when she 1 wheeled herself out to the patio, when temperatures were over 100 degrees. She was discovered unresponsive, sent to the emergency room , diagnosed with [REDACTED].On 7/30/14, record review showed that Resident 1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The complete resident assessment, dated 5/14/14, showed that Resident 1 was moderately impaired in decision making, had short and long term memory problems, required supervision and cueing (direction) in activities of daily living, and required the extensive assistance of two staff for bed mobility and transfers.The care plan, dated 11/12/13, showed, "Difficulty with decision making, difficulty communicating needs."Review of nurses' notes, dated 7/14/14 at 3:18 p.m., showed, "Change in resident condition: Temperature-106 degrees, heart rate-66, respirations-20; Skin intact- hot; Resident was reported to have fainted, She was found at the outside patio slumped in her wheelchair by CNA 1 (certified nursing assistant) at 1:45 p.m. Supervisor attempted to arouse resident but resident was unresponsive. Resident was brought to her room. Emergency services were notified. Resident was stripped of her clothes. Skin was red and hot to touch. Cold compresses applied to her forehead, underneath her arms, on her back and down her legs in order to bring her temperature down..."Review of the hospital emergency room records, dated 7/14/14, showed, "The patient presents with acute (sudden) alteration in mental status. She was febrile (feverish) in the Emergency department. She was also having large amounts of diarrhea and cloudy urine. I suspect her primary trigger is acute heat stroke...given antibiotics and intravenous fluids. The patient did improve very significantly throughout her Emergency Department stay. Impression:1. Acute febrile illness. Heat stroke versus sepsis (a toxic condition due to spread of bacteria or their toxic products in the body); 2. Urinary tract infection; 3. Second degree burns to trunk and extremities; 4. Acute lactic acidosis (disruption of blood's acid/ base balance) with severe sepsis syndrome."The hospital physician's history and physical, dated 7/14/14, showed, "[AGE] year old female...who has significant baseline dementia who is cared for by a conservator (a court- appointed decision- maker). Patient apparently has been in her usual state of health until today when she was last seen at 12:50 p.m. on a 100 + degree day. She was seen outside at 1:45 p.m. and was noted to be altered and temperature of 104 degrees. Patient started developing blistering on her back and cold compresses and clothing changed and she was brought here. Patient with risk of hypotension (low blood pressure), seizure risk, watch for liver injury, DIC (a lack of blood clotting syndrome), renal (kidney) injury, and arrhythmia (heart dysfunction)."During interview on 7/30/14 at 9:00 a.m., the Director of Nurses (DON) stated, "A CNA was taking another resident out to the patio and saw Resident 1 slumped over and tried to arouse her. He yelled for help and staff came to assess her. Her temperature was high so they took her clothes off and put wet towels all over her body. They called 911 and sent her out. After a few days in the hospital, she was transferred to another skilled nursing facility." During interview on 7/30/14 at 10:15 a.m., CNA 1 stated, "I found Resident 1 and I know her. She was slumped and drooling. I tried to arouse her and she didn't respond so I called for help. She wasn't in the shade. She likes being in the sun."During an interview on 7/30/14 at 11:15 a.m., Registered Nurse 1 (RN) stated, "Elderly are easily dehydrated. Heat stroke comes on fast. I was not aware she was out there until they brought her in. It was really hot that day."During an interview and concurrent record review on 7/30/14 at 11:45 a.m., the Director of Staff Development (DSD) stated, "I train the staff to make sure residents are hydrated. No one can go out unsupervised. If a staff takes a resident out to the patio, they have to monitor at least once every hour. DSD showed her attendance list and lesson plan for her training dated 6/22/14, addressing the elderly and hot weather.During phone interview on 8/5/14 at 3:30 p.m., Resident 1's conservator stated, "When I asked the facility staff what she was wearing that day, they told me she chose to wear a long sleeved shirt and long pants."Therefore, the facility failed to supervise Resident 1 to protect her from the harmful effects of the sun, resulting in hospitalization , heat stroke, and second degree burns.

Based on observation, interview and record review, the facility failed to ensure that for two of four sampled residents, (Residents 1 & 2), their environment was free from possible accident hazards and that Residents 1 & 2 received adequate supervision in order to prevent avoidable accidents from occurring. For Resident 1, his bed was against a wall and an unpadded upper side rail was in use despite the facility's knowledge of Resident 1 hitting his hands consistently and frequently against the wall and side rail. For Resident 2, who had multiple falls with injury, interventions were not modified nor implemented in order to reduce her risk of falls and serious injury. These failures had the potential to cause Residents 1 and 2 serious injury and harm with possible death as a final outcome. Findings: 1. During a tour of the facility on 4/30/14 at 10:50 a.m., Resident 2 was observed sitting in a chair in the Dining & Activity Room. Resident 2 had a bluish-purple discoloration on her right upper cheek below her eye, a lighter blue-purple discoloration along her right temple and another yellowish-green discoloration on the upper right side of her forehead. In an interview on 4/30/14 at 11 a.m. with Resident 2 regarding the appearance of bruising on her face, Resident 2 stated, "I'm always falling". In a concurrent observation and interview on 4/30/14 at 11:10 a.m. Resident 2 walked to her room in a moderately slow, unsteady pace to show where she fell . The Certified Nursing Assistant (CNA 1) in the dining room stated, "She's a little unsteady, but she usually walks without assistance." Resident 2 wore non-skid socks on her feet without shoes. Resident 2's room was located at the furthest end of the hallway from the nursing station and she did not have a room mate. During an interview and observation of Resident 2's room on 4/30/14 at 11:12 a.m., Resident 2's bed was in a semi-low position. Resident 2's bed had brakes on it, however the brakes were not in use and Resident 2's bed moved easily when pushed against. Resident 2's wooden three drawer night stand table was immediately next to Resident 2's bed with the edges of the night stand table noted to be round. Across from Resident 2's bed was a night light fixture which was uncovered, inoperable and had wiring exposed. The floor was tiled and there was no cushioned mat to break a fall, nor did the bed have an alarm on it (to signal staff that Resident 2 had gotten out of bed). Resident 2 was asked to locate her shoes. Resident 2 went to her closet, her shoes weren't there. In an interview on 4/30/14 at 11:30 a.m., CNA 1 stated, "She had that bruise ever since I started working this unit at the beginning of April. I help her to the bathroom when she needs to go. Her shoes are in here, (indicated the bottom dresser drawer) because she just wears the non-skid socks." Review of the medical record on 4/30/14 showed Resident 2 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]." Further review of physician's orders [REDACTED]. The "Fall Risk Evaluation," dated 7/1/13, showed Resident 2 was at high risk for falls. Resident 2 had falls on the following dates: 10/13/13, 10/21/13, 12/22/13, 1/23/14, and 3/20/14. The nursing care plan, dated 7/1/13, showed, "Staff would monitor for changes that would warrant increased supervision and assistance and notify the physician, and would supervise all ambulation." A care plan and post fall assessment, dated 10/13/13, showed after Resident 2 fell , she vomited six times (vomiting can be a sign of a concussion). Interventions included, "Neurology checks for changes in level of consciousness (assessment for signs of a head injury: pupil size and reaction to light, nausea, change in level of consciousness), give fluids as tolerated, meds as ordered, give a clear liquid diet and notify the physician and responsible party." A nursing care plan dated on 10/21/13 entitled, "After fall with head injury/side of face", showed staff would, "Apply ice to face swelling, pain meds, safety checks and neuro checks." A nursing care plan dated on 12/22/13 entitled, "Witnessed fall", showed staff would, "Monitor for pain, monitor for further injury, have Resident 2 wear comfortable shoes with laces properly tied." A "Post Fall Assessment," dated 12/22/13, showed Resident 2 tripped on her, "Untied shoe laces" at 3:00 p.m. The nursing care plan, dated 1/23/14, entitled, "Unwitnessed fall", showed staff would, "Notify the physician and responsible party, monitor Resident 2's walk, do neuro checks for three days, and monitor for pain." Review of the Post Fall assessment dated on 1/24/14 showed that Resident 2 had a "Witnessed fall", at 10:45 p.m., in her bedroom and that she was, "Found sitting on the floor next to her bed facing in the direction of the window", and there were, "No apparent injuries and neuro checks were initiated for 72 hours." A nursing care plan dated on 1/25/14 entitled, "Nausea and vomiting" showed staff would notify the physician, responsible party, and staff, monitor vital signs every shift, and monitor for episodes of vomiting." The nursing care plan dated on 3/20/14 entitled, "Unwitnessed fall and head injury", showed staff would do neuro checks for 72 hours, monitor for signs of pain, assist with ambulation, apply ice to bump on right forehead and treat as ordered." A Post Fall assessment dated [DATE] showed that Resident 2 fell at 3:30 a.m. in her bedroom and sustained a cut to the right side of her forehead from the handle on her bedside dresser as evidenced by the bottom handle of her dresser being bent. A "Care Plan Conference Summaries," dated 1/9/14 and 4/3/14 showed no mention of Resident 2's fall patterns. In an interview on 4/30/14 at 2:00 p.m., Licensed Vocational Nurse (LVN) 1 stated, "She told you that she always falls? That's true. She falls just about every night during the night shift. She gets out of bed, getting up on her own, mostly between 2 a.m. and 4 a.m.. The last time that she fell she was found on the floor with the night stand turned over onto the floor along with her. She hit the corner of the night stand and she needed to have a wound closed on her forehead." In an interview on 4/30/14 at 4:00 p.m., the Director of Nursing (DON), stated the facility's fall program consisted of "Hallway Monitors at Station 3 and 4 who are designated each day, who are walking up and down the hall and wear orange and red vests for identification proposes." "The Hallway Monitors are to be in constant motion during the Day and Evening shifts until 11 p.m. and if a Resident fell during these shifts, then they are to leave the Resident on the floor, call for help from the nursing staff for a head-to-toe assessment." "There has also been an attempt to stop more falls by having residents wear non-skid socks instead of shoes, and mats are for residents who fall frequently. Also a night light is provided in the rooms with low level illumination for someone that tries to get up." In an interview on 7/1/14 at 10:40 a.m., the DON reiterated that the facility's fall precaution program for Station 3 & Station 4 consisted of "Hall Monitors walking up and down the hall constantly in motion looking and hopefully preventing a fall from occurring. If something more should be done, it will depend on the needs of the resident and we discuss this in morning rounds, I am also contacted at home if there is a more serious injury during the night." We also have Physical Therapy help us determine about whether a fall mat should be put in place, it all depends on what the individual needs. We have even tried moving furniture around in an effort to have an effect on falling behavior." In an interview on 7/21/14 at 3:20 p.m., Licensed Vocational Nurse 2 (LVN 2), stated he worked the night shift as the charge nurse since January 2014. LVN 2 stated Resident 2 usually wandered between Stations 3 & 4 during the night shift, however she could be redirected. LVN 2 stated there was no particular reason for Resident 2's room being at the end of the hallway and, "Resident 2 falls sometimes because she won't have her non skid socks on and she'll get out of her bed or turns around too, quickly." LVN 2 also stated that regarding fall precautions, "The facility makes sure that the bed is in the low position, that there are no environmental issues, no clutter in the room, and that a night shift CNA will monitor the hallway assisting residents to the bathroom as needed". LVN 2 stated that the facility, "Hasn't used any fall mats on Station 3 and he was not sure when or if any have ever been used there." The facility's undated policy and procedure entitled, "Falls and Fall Risk, Managing" showed the, "Facility staff along with the input of the Attending Physician, will identify appropriate interventions to reduce the risk of falls, initiate approaches that might include rearrangement of room furniture, will implement additional or different interventions, or indicate why the current approaches remain relevant, or if underlying causes cannot be readily identified or corrected staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped." 2. During an observation on 4/30/14 at 2:45 p.m., Resident 1 was lying flat in bed asleep. Resident 1's bed was in the lowest position and was pushed directly against the wall next to him. Resident 1's bed had the upper left half side rail raised, with a comforter partially thrown over it. Upon further observation, the top of Resident 1's hands had deep, dark bluish-purple discolorations covering three fourths of both his hands. In an interview on 4/30/14 at 2:47 p.m. regarding the discolorations on Resident 1's hands, LVN 1 stated, "He always hits and bangs both of them against the wall and the side rail to get our attention." Review of the medical record on 4/30/14 showed that Resident 1 was admitted to the facility on [DATE] and that Resident 1 had [DIAGNOSES REDACTED]. A physician's orders [REDACTED].(prolongs clotting time to avoid unwanted clotting) The Minimum Data Set, (assessment) dated 1/30/14 reflected Resident 1's ability to make himself understood was limited to concrete requests and that his decisions were poor and he needed staff prompts and supervision daily. A fax cover sheet was sent on 3/9/14 to Resident 1's physician with the following information, "Skin discoloration to left posterior hand; purple with no open areas or tender to touch. Approximately 3 by 3 centimeters, irregular in shape. Able to move with full range of motion to hand and fingers, no complaints of pain." Unknown causes, no falls or incidents seen will continue to monitor for three days". The physician's orders [REDACTED]. A Nursing Care plan for Resident 1 originally dated 11/6/12 with no update showed that Resident 1, "Hits the bed rail and wall when agitated," The goal was he, "Would have no episodes of hitting the wall or bed rail." A second Nursing Care plan dated on 4/30/14 showed that Resident 1 had multiple discolorations on both his left and right hands and that staff would, "Prevent Resident 1 from hitting and banging walls" and that Resident 1 would, "Wear long sleeves."

Based on observation, interview and record review, the facility failed to ensure that one (Resident B) of three sampled residents was safely transferred from bed to chair. On 3/30/12, CNA A transferred Resident B ,who could not stand, using Lift B resulting in the resident slipping and sustaining a large hook shaped laceration to left lower leg/shin measuring 18.5 cm (8.2 inches) in length and requiring sutures. Two types of mechanical lift devices were in use in the facility: Lift A- lifted the resident in a sling that cradled the resident from head to legs. Lift B-resident must be able to bear most of their weight on their feet and to have the strength to hold onto the padded hand grips on the lift arm. Findings: Record review on 4/6/12 showed that Resident B was admitted [DATE] with [DIAGNOSES REDACTED]. On 3/30/12 at about 4:00 p.m. CNA A transferred Resident B out of bed using Lift B. After the transfer, Resident B was noted to have a hook-shaped laceration requiring transfer to the acute hospital emergency room (ER) for suturing. LVN A documented on the nursing assessment: "resident sustained [REDACTED]. 8 cm (centimeter) ( approx 3.2 inches) x (by) 3 cm. (1.2 inches) ( L shaped. sent to ER (emergency room ) per MD (medical doctor) order for evaluation and TX (treatment) M/d and R/P (responsible party-family) notified." The ER report indicated the laceration was much longer. According to the ER physician's note, dated 3/30/12 at 4:41 p.m.: Large hook shaped laceration to left lower leg/shin. Bleeding was controlled PTA (prior to admission). Laceration length: 18.5 cm (8.2 inches). On 4/18/12 at 4:20 p.m. during an interview, CNA C stated that when she entered Resident B's room on 3/30/12 after the incident, she saw, "Blood all over the floor." On 4/18/12 at 4:20 p.m. during an interview, LVN 2 stated that when she went into the room, "There was a pool of blood on the floor. (Resident B) was not showing pain, but I knew it was painful, because of how it looked. There was a lot of blood on the floor. We got an order and sent her out, it clearly needed sutures." We wrapped the leg in gauze to stop the bleeding. According to the Minimum Data Set Assessment (MDS) reviewed on 4/6/12, Resident B needed extensive assistance (totally dependent) on staff for transfers when she was moved from bed to chair and back again. The MDS indicated that Resident B had impairment of both legs due to contractures (permanent tightening and shortening of muscle and tendon). According to the care plan for Activities of daily living, Resident B was identified at risk for deteroiration in ADL funcitioning on 10/18/2007. The care plan was updated 9/9/10 and idenitified that Resident B needed: "Level of Transfer: 2 Persons, Mechanical Lift , (name of Lift A was specified)." On 4/6/12 at 10:45 a.m., observation showed that the laceration on Resident B's leg still had some crusted blood at the bottom end of the U-shaped injury. Concurrently, two CNAs (CNA D and CNA E) were observed transferring Resident B from bed to chair using Lift A. Resident B's knees were bent and the resident was not able to assist or follow any directions. On 4/18/12 at 3:45 p.m., during an interview, RN 1, who was on duty on 3/30/12 at the time Resident B was transferred, was asked which mechanical lift was used on 3/30/12 to transfer Resident B. RN 1 stated that, "It was the standing lift" (Lift B). When asked if she thought Resident B was able to stand, RN 1 said, "She cannot stand up." and "There should be two people there (to assist)." RN 1 said, that CNA A told her that when she was using the lift, (Resident B's) leg caught, referring to the laceration The standing lift (Lift B) was inspected on 4/18/12. There was a hard foam type of knee pad shelf that according to manufacturer's instruction was meant to be about one or two inches from the knees. There was also a platform for the resident's feet. Resident B's laceration could have been caused by either projection as she slipped down. According to the ER physician's note on 3/3/12 at 4:41 p.m. "The mechanism of injury was: trauma. Per medics patient being moved from bed in hoyer lift when lower leg caught on something. Sustained large hook shaped laceration to left lower leg/shin." On 4/23/12 at 11:10 a.m. during an interview, CNA A stated that she used the standing lift (Lift B) on 3/30/12 in transferring Resident B and that she knew there were supposed to be two people for the transfer. CNA A said, "I waited for help, it never came." CNA A stated that she had seen other staff use the standing lift for Resident B at other times. The Staff Development Coordinator (SDC) was interviewed on 4/18/12 to determine what instruction had been given to CNA A during orientation. The SDC presented a check list that included Transfers with a Mechanical lift and a Safety pamphlet, both of which were included in the orientation class and demonstration and CNA A was listed. The facility Employee Safety Orientation pamphlet stated, on the front page, "IT IS OUR POSITION THAT AT ANYTIME WHEN LIFTS ARE UTILIZED, IT REQUIRES TWO PERSONS AND SOMETIMES MORE FOR DIFFICULT TRANSFERS AND/OR LIFTS. (LIFTS) MUST BE USED AT ALL TIMES WITH 2 PERSONS FOR THE SAFETY OF RESIDENTS AND STAFF."

Based on staff interview, resident interview and record review, the facility failed to ensure that staff did not abuse one of one sampled residents (1) by using physical force to give Resident 1 an injection of [MEDICATION NAME] against her wishes. On 6/28/11, Resident 1 refused an injection of [MEDICATION NAME] (psychtropic medication used to treat [MEDICAL CONDITION] and used to control vocal utterances and dementia behavior in non-psychotic patients per Lexi-Comps Drug Reference Handbook, Geriatric Dosage Handbook, 12th edition) and the facilty staff forced her to have it, by covering her with a blanket and having male staff physically hold her against her wishes during the injection of [MEDICATION NAME]. The forced administration of [MEDICATION NAME] resulted in the resident crying, screaming, cursing, and spitting at staff during and after the injection was given. Resident 1 continued to be upset, crying for a long time after the incident. Findings: During an interview on 10/4/11 Visitor 1, a friend of Resident 1, stated he received a call from Resident 1 on 6/28/11 who was very upset because staff forceably gave her an injection of [MEDICATION NAME]. Visitor 1 stated that Resident 1 told him that they threw a blanket over her head and physically held her during the injection. Resident 1 told him that she cried and yelled at the staff during the injection and continued to cry for several hours after that. On 10/11/11, a review of the clinical record showed that Resident 1 was admitted to the facility on [DATE] from an acute care hospital with current [DIAGNOSES REDACTED]. The record contained a report from the acute hospital psychiatrist who documented that the resident was refusing anti-psychotic medications. On 4/5/11, [MEDICATION NAME] 1 mg (milligram) was ordered to be given intramuscularly (IM) every 12 hours for paranoid [MEDICAL CONDITION] with violence, severe yelling/agitation. On 5/25/11 at 2:40 p.m., the physician changed the order to [MEDICATION NAME] 25 mg IM. to be given once every month. for paranoid [MEDICAL CONDITION], fears of being held captive, verbal abuse of others. According Lexi-Comp's Drug Review 12th edition, [MEDICATION NAME] is a longer acting drug which can last up to 4 weeks. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Record review showed that LVN 2 (Licensed Vocational Nurse) wrote the following on nurses notes dated 6/28/11 at 2:30 p.m. : "Resident had combative episodes while getting her monthly injection. Continously curse and yell at the staff. Able to redirect back to her room. Was crying." There was no documentation that Resident 1 had outbursts or cursing or crying prior to the administration of [MEDICATION NAME]. There was no documentation that Resident 1 was physically held. A second nurse's note dated 6/28/11 at 9:00 p.m. written by LVN 3 indicated that Resident 1 had two episodes of angry outburst, continued yelling at staff saying, "You are piece of yuck." "Continued yelling for a while, tried to talk to her but would not listen. Continued to monitor resident. Needs attended to by staff ". On 12/711 at 11:58 a.m. during a telephone interview LVN 2 said she did not witness the injection of [MEDICATION NAME] on 6/18/11 but worked the floor that evening. She said she was Resident 1's nurse that evening. When asked how the resident was that evening. She said "She was pretty mad that evening. She said that someone put a blanket over her face and gave her a shot. LVN 2 said that the resident was mad for a couple of days after the incident. " I suggested that if it happened that she should talk to the social worker. " When asked if Resident 1 was violent. She said, "In my assessment she wasn't violent she just didn't like certain people. She'd curse and yell at them. I'd get them out of the room and she'd calm down." Review of the record showed that when the nursing staff attempted the monthly injection of [MEDICATION NAME] in July 2011, the resident refused again. Resident 1 had a change of physician and when Staff informed the new physician of the resident's refusal, the physician discontinued the [MEDICATION NAME] on 7/29/11. When Resident 1 also refused [MEDICATION NAME] (used for residents with Alzheimer's type dementia) the physician disconitnued all antipsychotic and anti-anxiety medications. During an interview on 11/16/11 at 8:23 a.m. LVN 2 stated she was the charge nurse on 6/28/11. LN 2 said, " Yes, I was the nurse charge on 6/28/11. Because I was pregnant I didn't give the shot. She has a tendency to spit and be combative swinging her arm out and saying no. The shot was scheduled for 9 a.m. I checked on her at breakfast and nothing was unusual I could see she was just eating. At 9:15 or 9:30 a.m., I told her (Resident 1), "You are due for your shot." Resident 1 said "I'm not taking that, waving her hand." When asked if Resident 1 took other medications in the past the nurse replied, "Yes. She took her oral meds (medications)." When asked if the resident was her usual self or more agitated than normal, the charge nurse replied, " She was normal I think she already knows its coming. She usually likes me". During an interview on 10/31/11 at 11:45 a.m,. the Director of Nursing (DON) stated that Resident 1 was given an injection of [MEDICATION NAME] because she was striking out at staff and spitting at staff. The DON was informed that the charge nurse on 6/28/11 stated that the resident was acting normal that day and not agitated until they tried to force her to take an injection she did not want. When asked why she gave the shot, the DON replied, "They (charge nurses) were concerned that if they were not successful in giving the shot the resident would continue to refuse all medications. First I tried talking to her (in English) then I directed staff to get a blanket. One was on the side and one was in the front I think it was most important to prevent her from striking out so they wrapped her in the blanket and secured it at the elbow using the tail end of the blanket to prevent her from spitting. I gave it I believe in the right arm." During a telephone interview on 12/6/11 at 3:35 p.m., CNA 1, who witnessed the incident on 6/28/11 and frequently cared for the resident, said Resident 1 always refused the medications. CNA 1 said that on 6/28/11, the DON told the male aides ( CNA 2 and CNA 3) to go get the blanket. The male Aides grabbed it (blanket) and started towards Resident 1. CNA 1 stated that Resident 1 was shouting "NO. NO. Don't. Don't. I don't want it. Please. Please. Don't do. Don't do. I don't want it." CNA 1 stated that after the shot she stayed with Resident 1 and said "She (Resident 1) cried and cried for a couple of days. " On 10/31/11 at 9:40 a.m. CNA 2 stated,"The DON was trying to give a shot. She asked us to get a blanket because Resident 1 was spitting at staff. She always does that. The DON asked (CNA 3) to bring a blanket and cover the face. He showed, holding up his hands, that blanket was parallel to the face. Blanket was not touching her. The blanket wasn't touching her body anywhere just her lap. It (blanket) was too long." He then said, the resident looked like she didn't want the shot. CNA 2. said "She (Resident 1) doesn't like any guys." During an interview on 10/31/11 at 9:48 a.m., CNA 3 said "DON asked us to wrap a shower blanket around her ( Resident 1) because she (Resident 1) was violent. We were behind her holding her from behind. She (Resident 1) said "help, these guys are trying to hurt me. She was resisting, didn't want the shot. She was trying to throw stuff at us after the shot. The DON gave the shot in the upper arm. On 10/12/11 at 10 a.m. during an interview, the medical records staff stated that she was a witness to Resident 1 being given an injection of [MEDICATION NAME] on 6/28/11. She said "I went to the doorway. They (staff) explained (to Resident 1) that the doctor ordered the medication to help with her mood and agitation so she wasn't so upset with people all the time. She (resident 1) was saying no. She started crying and screaming. They just talked to her explaining. The (male aides) wrapped her in blanket around her torso not over her head. It was round her chair not touching her body. She started spitting and they raised the edge of the blanket so they didn't t get spit on them. On 12/6/11 at 11 a.m. during an interview Resident 2 said, "I was passing by the room and I saw her (Resident 1) wrestling with them trying to keep blankets off her head and putting her arms up at her face. I tried to help by grabbing the blanket to get the blanket off her. It was none of my business but it didn't seem right what they were doing to her. She was yelling trying to get out of the blanket, yelling No and using her arms. They stopped pulling the blanket over her head. They were trying to hold her down touching her at her shoulders not at her neck. The two men, one on each side, were trying to hold her. They asked me to leave." When asked what Resident 1 looked like when he left; was she upset? He said, "Yes she was still upset. She looked scared really scared."

Based on interview and record review, the facility failed to provide supervision and use of an assistive device (lap belt) for one of one sampled residents (Resident 1) to ensure safety and avoid an accident. Resident 1 was known to be at risk for falls and required a lap belt to maintain posture in a chair. The resident was left alone without the lap belt in place and fell resulting in a head injury and suffered a bleed into her brain. Findings: Record review on 10/10/11 showed that Resident 1, a [AGE] year old female, was admitted to the facility on [DATE]. According to the face sheet, Resident 1 had [DIAGNOSES REDACTED]. Review of the facility's care plan, dated 9/16/11, titled "Falls, Potential," showed that the facility had identified problems that required interventions to ensure that Resident 1 did not fall. It listed a Fall Risk Score of 18 (where a score of above 10 is a high risk) and approaches that included "Monitor for steadiness, balance and pain; monitor for side effects from medications, labs and appetite as cause of falls." One day after admission, "Nurse's Notes", dated 9/17/11 at 7:45 p.m., showed "CNA stated found resident on the floor in her room." The next note, dated 9/17/11 at 7:48 p.m., showed the resident stated that she "...was in her wheelchair and slid out." A "Nurse's Note", dated 9/17/11 at 10:08 p.m., showed that the physician was notified and an order was received for a lap belt when seated in a chair. Another order, dated 9/20/11, instructed: "Monitor for episodes of restlessness" and on 9/21/11 and 9/22/11 were repeated physician's orders [REDACTED]." The care plan titled "Risk for Falls" showed additional approaches to prevent falls, added on 9/17/11: "Lap Belt and PT (physical therapy) evaluation." On further record review, there was a physical therapy evaluation and care plan, dated 9/21/11, (after the first fall) that showed "Patient referred due to new onset of decreased strength, decrease in transfers, reduced ability to safely ambulate and cognitive deficits placing patient at risk for falls, further decline in function and immobility. Underlying impairments: balance deficits, cognition, decreased safety awareness and dynamic balance." The physical therapist's care plan, dated 9/21/11 showed goals: "Increase ambulation ability using front wheel walker and stand-by assist to 350 feet; Increase transfer ability to stand-by assist. Good rehabilitation potential." The 9/17/11 physician's orders [REDACTED]. According to the "Nurse's Notes", dated 9/26/11 at 3 p.m., "Resident laying on floor on right side. Assessed resident and noted a cut above right eyebrow and a lump. Assisted to bed. Called MD and transported resident via 911." Resident 1 was sent to the emergency room and returned with a [DIAGNOSES REDACTED]. There was a physician's orders [REDACTED]. Resident 1 was observed in her room on 10/10/11 at 11:35 a.m. A family member was in the room sitting next to the resident. Resident had a red, purple and green bruise from the temple and cheek of her right face over her right neck and shoulder. Her right eye was swollen shut. The resident's family member said, "She never fell at home." During interview on 10/10/11 at 9:25 a.m., CNA 1 (certified nursing assistant) was asked why she did not apply the lap belt when she assisted Resident 1 from the bed to the chair on 9/26/11 before she fell . She said, "I didn't know this resident and saw her trying to get out of bed and yelling 'Help' so I assisted her into the wheelchair and left." CNA 1 had a walkie talkie attached to her uniform. When asked what could have been done differently, CNA 1 said that she could have asked other staff for information about the resident by using the walkie talkie. During interview on 10/17/11 at 9:50 a.m., the PT who wrote the above assessment and plan on 9/21/11, said, "She was able to scoot forward in the chair. If she tried to stand, she would probably fall." During interview on 10/17/11 at 10:45 a.m., RN 2, the MDS coordinator, (minimum data set which is a complete resident assessment) said, "I assess the functional ability by watching staff give the ADL (activities of daily living) care or by doing my own assessments. I questioned staff about Resident 1 on admission and they told me she was capable of getting out of the wheelchair with hand-held limited assistance which is only guidance and no weight bearing for the staff. After the fall on 9/26/11, her functional ability was "extensive assist" which means the staff bears the patient's weight by lifting the patient. During interview with the DSD (director of staff development) on 10/17/11, at 11:10 a.m., she was asked for the policy and procedure for one person transfers. She replied that gait belts were required for all CNA's but there was no written policy and procedure about transfers. During interview with the DON (director of nurses) on 11/2/11, at 1:00 p.m., she was asked for a policy and procedure for the use of the walkie talkies and the protocol for communicating information about resident needs between staff. She replied that there was no policy for the reporting system or for walkie talkie communication and said, "The walkie talkies are used to communicate about anything like going on a break or needing assistance. Everyone is supposed to listen to report from the licensed nurses at shift change regarding resident care needs." On 11/2/11 at 1:20 p.m., LVN 2 was asked about the expectation of the CNA who does not know the residents. She replied "Even if they don't know them, they should see what they need. If a resident needs transfer, the CNA should stay with the resident and ask for assistance of anyone at the station using the walkie talkie." During interview with the DON on 11/2/11 at 2:30 p.m., she said, "Everyone is supposed to listen to report from the licensed nurses." During further interview with CNA 1 on 11/2/11 at 1:30 p.m., she was asked about details of the event when Resident 1 fell and hit her head. She said that she helped her into the chair, did not see the lap belt and did not know the resident had dementia. "She was non-stop yelling 'Help'. I didn't tell anyone she was still yelling or ask for help when I left the room. She was a new resident. It was about two minutes later that I was called back because she fell ." When asked about receiving report on this resident, she replied, "I only pay attention to my own residents."