Every finding on record at Cottonwood Canyon Healthcare Center

Based on interview and record review, the facility failed to provide medication as ordered by the physician for one of two residents reviewed for medication administration (Resident 1). As a result, Resident 1 did not receive a pain medication prescribed for fibromyalgia (a long-term condition that causes body pain and fatigue). Findings:A complaint was received by the California Department of Public Health (CDPH) indicating Resident 1 had not received pregabalin (a pain medication) during a three-day admission to the facility. Resident 1 was admitted to the facility on [DATE] with diagnoses to include fibromyalgia, per the undated Face Sheet. According to Resident 1's physician's orders, dated 8/13/26, Resident 1 was to receive pregabalin three times each day, starting on 8/14/26 at 9 A.M. According to Resident 1's Medication Administration Record (MAR), Resident 1 did not receive the pregabalin on 8/14/26 or 8/15/26 as the medication was not available or was on hold. Resident 1 transferred back to the hospital on 8/15/26. An interview was conducted with Licensed Nurse (LN) 1 on 8/26/26 at 12:15 P.M. LN 1 stated when a new admission arrived, all medications needed to be ordered by the physician. LN 1 stated that any controlled medications (any drug which is tightly controlled by the government due to the risk of misuse or dependence) required additional authorization by the physician. LN 1 stated when Resident 1 was admitted , the nurse did not inform the physician of the need to provide the authorization to the pharmacy. Per LN 1, if the admission nurse had obtained the authorization, Resident 1 would have received the first dose of medication on time. LN 1 stated each nurse that identified that the pregabalin was not available should have called the pharmacy and informed the charge nurse, but none of the nurses had done so. An interview was conducted on 8/26/26 at 1 P.M. with the Assistant Director of Nursing (ADON). Per the ADON, controlled medications such as pregabalin required the physician's authorization for the pharmacy to provide it to the facility. The ADON stated the charge nurse had not followed the facility process to obtain the pregabalin. The ADON stated each nurse who was assigned to Resident 1 should have informed the pharmacy to obtain the medication. Per the ADON, the charge nurse could have also informed the pharmacist to obtain the medication. The ADON further stated, this failure to follow the correct process could have caused Resident 1's pain to be unmanaged and could have caused additional medical complications. The ADON stated Resident 1 had not received any doses of pregabalin while she was admitted to the facility.Per a facility policy, revised 10/2018 and titled Ordering and Receiving Medications from Pharmacy, .All new drug orders.should be available the day ordered by the physician.For C-111-V orders, the MD can write a fax Rx and fax it to the pharmacist (security or non-security) at the time of the order. Pharmacy can pick up Rx at the MD office.The MD can submit electronically through DEA approved method.Facility nurse (FN) must inform the MD that until this is done there can be no delivery.

Based on observation, interview, and record review, the facility failed to ensure safe use of mechanical lift equipment (Hoyer lift) for resident transfers for one resident (Resident 1). This deficient practice had the potential to affect all residents requiring mechanical lift transfers. Findings:A review of Resident 1's admission record indicated, he was admitted on [DATE] with a diagnosis that included Osteitis Deformans (a chronic disorder that disrupts the normal recycling process of bone tissue) and Hemiplegia and Hemiparesis (hemiplegia indicated by partial or total paralysis and hemiparesis indicated by weakness on one side of the body). A review of Resident 1's care plan dated, 2/10/26 indicated, use Hoyer lift with appropriate sling for all transfers, lock brakes, position patient safely, and monitor during transfers. On 4/15/26 at 10:40 A.M., an observation and interview was conducted with Resident 1. Resident 1 stated an incident occurred on 12/15/25 when he landed on the floor during a transfer from the Hoyer lift to a wheelchair. Resident 1 stated he was strapped in the Hoyer lift when certified nursing assistant (CNA) 1 attempted to move him over the wheelchair arm rest; the Hoyer lift tilted over, hitting CNA 1 on the head and shoulder, causing Resident 1 to land on the floor. Resident 1 stated he complained of back pain. Resident 1 stated staff came to assist and 911 was called. Resident 1 further stated the 911 Paramedics placed a neck collar on him, and he was taken to the general acute care (GACH) for evaluation. On 4/15/26 at 12:25 P.M., a telephone interview was conducted with certified nurse assistant (CNA 1). CNA 1 stated she attempted to transfer Resident 1 from shower chair to a wheelchair, but the Hoyer lift tilted forward. CNA 1 stated she attempted to hold Resident 1 while CNA 2 used remote to lower the resident to the floor. CNA 1 stated the base of the Hoyer lift should have been opened wide but could not recall if the base of the Hoyer lift was opened. CNA 1 stated she should have done a safety check before moving the patient. On 4/15/26 at 12:20 P.M., a telephone interview was conducted with CNA 2. CNA 2 stated when she walked into the room she observed Resident 1 was already in the Hoyer lift and strapped in. CNA 2 stated she used the remoted to start the transfer when the Hoyer lift tilted forward. CNA 2 stated CNA 1 attempted to hold Resident 1 so he wouldn't hit the floor and used the remote to lower him to the floor. CNA 2 stated she could not recall if the base of the Hoyer was opened wide. On 4/15/26 at 3:05 P.M., an interview and record review was conducted with Maintenance Supervisor (MS). MS stated the Hoyer lift was removed from the floor after the incident. MS stated he inspected the Hoyer lift after the incident and did not find any defects. MS stated he cleaned the Hoyer lift and it was put back in service. MS stated that if the base of the Hoyer lift was not opened or opened wide enough, it could have caused the Hoyer lift to tilt forward. On 4/15/26 at 4:40 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated her expectation was for her staff to follow policy when using the Hoyer lift for the safety of the residents and staff. A review of the facilities policy titled Lifting Machine, Using a Mechanical, dated 2001, indicated .7. Make sure the lift is stable and locked.13. Lift the resident 2 inches from the surface to check the stability of the attachments, the fit of the sling and the weight distribution.A review of the manufacturer's guidance titled Battery Operated Patient Lift, revised 8/10/16, indicated .while lifting or lowering a patient maintain the base unit legs spread to the widest position and ensure that the casters are unlocked.keep the patient centered over the base and facing the operator/caregiver.

Based on interview and record review, the facility left Resident 1 alone with a meal tray and did not provide feeding assistance or supervision to Resident 1 who had been assessed and identified as requiring feeding assistance and supervision (according to the facility's nutritional care plan). The facility also failed to provide adequate (one on one supervision) for Resident 1 who was assessed as a high risk for a fall and did not implement appropriate fall-prevention interventions (based on assessment of Resident 1's individual needs), for one of three sampled residents (Resident 1).As a result, Resident 1 required emergency services, was hospitalized , sustained a head injury, sustained a spinal L4 compression fracture, (break in the fourth lumbar vertebra lower back, the part of your spine with five strong bones that support your upper body's weight) was intubated, (a plastic tube is inserted into a person's windpipe/trachea to open and to deliver oxygen, via a breathing machine called a ventilator) transferred to the ICU, (intensive care unit-a higher level of care within the hospital) experienced seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness) and required placement of a feeding tube (FT-feeding tube-medical device used to provide nutrition when oral intake is altered or unsafe).Cross-Reference F842, F726, F656 and F678Findings:Resident 1's skilled nursing facility record was reviewed. Per the admission record Resident 1 was admitted to the skilled nursing facility on [DATE] with diagnoses which included difficulty in walking, muscle weakness and a fall history. Resident 1 was also diagnosed with an Intellectual Developmental Disability (IDD-is a condition that limits intelligence and disrupts abilities necessary for living independently) and dysphagia (difficulty swallowing).Resident 1's recent transfer documents from the hospital to the skilled nursing facility included a document titled Inpatient Physical Therapy Evaluation dated [DATE] at 1:30 P.M., which indicated, .Safety Judgment: Decreased awareness of need for safety, Decreased awareness of need for assistance. Resident 1's Minimum Data Set (MDS-nursing facility assessment tool) dated [DATE] indicated that Resident 1 was rarely or never understood with severe cognitive deficits (a decrease in the mental processes that take place in the brain, including thinking, attention, language, learning, memory, and perception) to understand and make decisions. According to the MDS section J: Resident 1 was assessed as a fall risk and had experienced falls prior to admission to the skilled nursing facility. On [DATE] at 1:40 P.M., an interview was conducted with CNA 1. CNA 1 stated that upon starting her shift on [DATE], she observed Resident 1 independently wheeling himself (using a wheelchair for ambulation -the act of walking or moving place to place) in the hallway. CNA 1 stated she provided Resident 1 with a meal tray, and watched Resident 1 eat independently. CNA 1 reported that Resident 1 remained seated in his wheelchair unsupervised in the hallway until approximately 8 P.M., on [DATE]. CNA 1 stated that after returning from a bathroom break, she observed nursing staff (LN 2) with Resident 1 who was lying face down on the floor with a bleeding head wound. CNA 1 stated oxygen was applied to Resident 1 who was minimally responsive, moving only his hand, at the time he was found on the floor. CNA 1 stated she was not informed that Resident 1 was a fall risk. Record review of Resident 1's nutritional care plan with date initiated as [DATE] interventions indicated, .1:1 (one staff to one Resident) Feeding Assistance. Resident 1's Speech evaluation dated [DATE] indicated, .Previous treatment 1:1 feeder.Swallowing Abilities=Severe.Risk Factors: Aspiration [choking]. The facility's document labeled Feeding list undated included Resident 1's name.On [DATE] at 1:51 P.M., an interview and record review were conducted with LN 1. LN 1 stated he was the nursing supervisor on duty when Resident 1 fell ([DATE]). LN 1 stated he had directed the CNA's (assigned to hallway 100 where Resident 1's room was) to closely monitor Resident 1 because Resident 1 had repeatedly attempted to get out of his wheelchair and was seen wheeling himself throughout the hallway. LN 1 stated Resident 1 was a high fall-risk and required close supervision at all times and should be on a one to one [1:1] supervision (one staff supervising one resident) for safety. LN 1 further stated Resident 1 did not have orders for a 1:1 supervision and Resident 1 was not care-planned (plan created by nursing based on an assessment) for 1:1 supervision but should have been because he was a safety risk. LN 1 stated Resident 1's assigned CNA (CNA 1) used the restroom and that CNA 1 had told a registry (temporary or contracted staff) CNA, (CNA 3) to watch [Resident Name]. CNA 3 ignored CNA 1's instructions to supervise Resident 1. LN 1 stated Resident 1 had not been supervised and fell. LN 1 stated Resident 1's baseline was alert but not oriented (confused) x [times]3 [person, place, time] and was non-verbal (did not speak). LN 1 further stated after the fall Resident 1 was having agonal breathing (an abnormal, reflex-driven pattern of slow, gasping, or snoring-like breaths that occurs in severe emergencies), but had a pulse. LN 1 further stated the only intervention that we did was oxygenation (the process of supplying, treating, or enriching blood with oxygen), he [Resident 1] still had a pulse we just gave oxygen via non re-breather mask (non-invasive medical device that delivers high concentration of oxygen) used for acute respiratory distress (life-threatening, a very serious condition and may cause rapid, severe shortness of breath, low oxygen levels, and stiff lungs, often occurring in critically ill patients due to sepsis, pneumonia, or injury). On [DATE] at 2:03 P.M., an interview was conducted with CNA 1. CNA 1 stated she did not ask another nursing staff to supervise Resident 1 because she was unaware Resident 1 was a fall risk. CNA 1 stated LN 1 did not endorse or communicate to her that Resident 1 required close monitoring or supervision. CNA 1 stated Resident 1 had confusion and was unable to fully verbalize his needs, communicating primarily through gestures. CNA 1 further stated if she had been informed Resident 1 was a fall risk, she would have immediately notified another nursing staff member to supervise Resident 1 to prevent the fall.On [DATE] at 2:11 P.M., an interview was conducted with CNA 2. CNA 2 stated Resident 1 was not assigned to her on [DATE]; however, Resident 1 was located on the same unit throughout her shift. CNA 2 stated she observed Resident 1 sitting alone in his wheelchair and noted Resident 1 appeared confused and not fully oriented, which she believed to be Resident 1's baseline. CNA 2 stated she was not informed that Resident 1 was a fall risk and therefore did not recognize the need for close supervision. CNA 2 stated she later observed nursing staff next to Resident 1 who was found on the floor. CNA 2 stated she observed Resident 1 to have had irregular breathing, which prompted LN 2 to administer oxygen via a non-rebreather mask. CNA 2 further stated Resident 1 had been observed earlier seated in his wheelchair with a walker positioned in front of him and that no staff member instructed her to monitor or supervise Resident 1 at any time during her shift, including when the assigned CNA 1 left the area to use the restroom.On [DATE] at 3:40 P.M., an interview was conducted with CNA 4. CNA 4 stated Resident 1 required maximum assistance (the staff performs approximately 75% or more of the physical work, while the patient contributes 25% or less) for sit-to-stand movements and transfers due to being wobbly and unstable. CNA 4 stated Resident 1 used a walker and had ambulated with a walker during therapy sessions. CNA 4 stated Resident 1 was confused and appeared unable to consistently understand how to use the call light for safety, despite staff encouragement. CNA 4 further stated that due to Resident 1's confusion, and inability to fully verbalize his needs, staff would need to respond promptly to prevent unsafe attempts to stand if Resident 1 needed assistance.On [DATE] at 3:47 P.M., an interview was conducted with CNA 5. CNA 5 stated that when Resident 1 was first admitted to the skilled nursing facility she noticed Resident 1 frequently sat on the edge of the bed without assistance and had difficulty understanding how to safely use the call light. CNA 5 stated Resident 1 often laughed or giggled when attempting to use the call light and continued not to use it, indicating limited comprehension and developmental delay. CNA 5 stated Resident 1 was a known fall risk, as he (Resident 1) could sit up unassisted in bed and attempted to stand or ambulate without assistance. CNA 5 stated she had reported to the LN's that Resident 1 repeatedly sat at the edge of the bed and required ongoing supervision to reduce the risk of a fall. CNA 5 further stated that despite reminders, Resident 1 continued unsafe behaviors and required supervision to prevent falls.Resident 1's skilled nursing facility record was reviewed. Resident 1's History and Physical (H&P) examination by the facility Medical Doctor (MD) dated [DATE], indicated, .This resident.does NOT have the capacity to understand and make decisions. Resident 1's admission fall risk assessment titled, .FALL RISK OBSERVATION/ASSESSMENT. dated [DATE] at 20:37 (8:37 P.M.) indicated, Resident 1's fall risk score was a 20 that identified Resident 1 was a .HIGH RISK. Resident 1's fall risk care plan initiated [DATE], indicated, .Educate/remind resident to call for assistance .Keep call light within reach.Keep within supervised view as much as possible. Resident 1's skilled nursing facility Electronic Health Record (EHR) progress noted by Licensed Nurse (LN) 1 titled Nurse's Note dated,[DATE] at 20:00 (8:00 P.M.), indicated, .Resident spotted one time trying to get out of his wheelchair.Medication nurse for 100 hall instructed all of the CNAs [Certified Nursing Assistant] in the hallway to do visual inspections every 30 minutes and switch with other CNA as needed to keep resident under continuous supervision. Nurse on duty had also instructed CNAs that if resident was to be alone inside of room, to be in the same room with the resident.A record review of Resident 1's progress noted by LN 1 was reviewed. The note titled Nurse's Note dated [DATE] at 20:55 (8:55 P.M.) late entry, indicated, .Heard medication nurse shouting across the hallway to the front nurse's station. Medication nurse requested crash cart (a set of trays/drawers/shelves on wheels used in hospitals for transportation and dispensing of emergency medication/equipment at site of medical/surgical emergency for life support protocols); crash cart taken to her. Walked into the room to find resident lying face down and having agonal (a critical, abnormal reflex characterized by gasping, snorting, or labored, infrequent breaths that occur when the brain is severely deprived of oxygen) respirations. Resident also had a bleeding laceration (a ragged, jagged tear in the skin), on top left of the forehead. Oxygen tank and non-rebreather (a, high-concentration oxygen therapy device featuring a reservoir bag, one-way valves, and a face mask). used C-spine[Cervical-spine refers to neck] to stabilize cervical neck [sic], used a 3 person assist to turn resident to the supine [lying flat on your back with your face, chest, and stomach facing upward] position. Resident breathing had slowed down to the point where he was fully unconscious [a person is not reacting to sound, touch, or pain] by this time. Writer ran out, grabbed treatment cart to control bleeding to the forehead using gauze and bandages.A record review of Resident 1's EHR progress note was conducted. Nurse's Note dated [DATE] at 21:00 (9 P.M.) late entry by LN 2, indicated, .Found the resident lying on the floor .Some abrasion to bilateral UE [upper extremity-arms and hands]. The residentwas[sic] unresponsive [unconscious] at this time. The chest compression (manual technique, life-saving used during CPR to pump blood to a person's heart and brain) initiated [sic] and oxygen with a non re-breather [sic] mask was given. 9-11 was called. arrived at 21:10. Resident is transportation to [Hospital Name] for further eval.Resident 1's hospital record was reviewed. Resident 1's hospital emergency notes titled, H&P(History and Physical) dated [DATE] 9:38 P.M, indicated, .General Appearance: Awake and non-responsive, uncomfortable appearing, hematoma (clotted blood that pools outside of blood vessels, usually after an injury), to forehead.Review of Resident 1's Trauma notes titled, Trauma Tertiary [third in order] Note dated, [DATE] 12:32 P.M., indicated .presented to [Hospital Name] after being found down. Patient was found to have the following injuries: L4 compression fracture with 30% height loss.Patient is intubated someone who has had a hollow breathing tube (inserted through their mouth or nose into their windpipe (trachea) to maintain an open airway, deliver oxygen, provide anesthesia, or assist breathing with a ventilator, used when patient can not breathe adequately on their own) (.Seizure activity noted overnight.Neurology consulted given seizure activity.Resident 1's hospital discharge notes were reviewed. The document titled, Discharge Summary dated [DATE] 3:05 P.M., indicated, .Diagnosis on discharge Seizure disorder Dysphagia [difficulty swallowing].It was presumed that the patient suffered arrest from acute respiratory failure, in the setting of recurrent aspiration [choking]. Apparently, patient was witnessed to have two generalized TC [tonic clonic- sudden loss of consciousness, body stiffening which is a tonic phase, and rhythmic jerking-clonic phase] seizures after admission. MRI [a magnetic resonance image of the brain] 12/26, which revealed findings concordant [consistent or align with one another] with recent seizure activity.Patient's brother has elected to maintain FC [feeding connection]/FT [feeding tube].Record review of Resident 1's skilled nursing facility and hospital records indicated Resident 1 had no documented history of seizure activity or dependence on a feeding tube prior to the facility-to-hospital transfer on [DATE].On [DATE] at 11:48 A.M., an interview was conducted with CNA 3. CNA 3 stated she was a registry CNA who had worked the night Resident 1 fell. CNA 3 stated she was not the primary CNA assigned to Resident 1 but had observed Resident 1 earlier in the hallway sitting on his (Resident 1) wheelchair making random sounds, not fully verbal, and attempting to stand up from the wheelchair. CNA 3 stated she was informed by the LNs (LN 1 and LN 2) at the start of the shift that Resident 1 was a fall risk. CNA 3 stated she was not instructed by CNA 1 to monitor or supervise Resident 1 prior to CNA 1 using the restroom. CNA 3 stated she heard a nurse call out for help then entered Resident 1's room, where she observed Resident 1 lying on the floor with a bleeding forehead, non-responsive and breathing irregularly. CNA 3 stated after the fall, LN 2 had applied oxygen via a mask, and she observed no rescue breaths or chest compressions had been provided. CNA 3 further stated Resident 1 did not regain consciousness not waking up, and his (Resident 1) body was twitching while on the floor.On [DATE] at 12 P.M., an interview and record review were conducted with LN 2. LN 2 stated she did not witness Resident 1's fall that happened in his room because she (LN2) was at the nursing station charting. LN 2 stated she heard somebody called out and his [Resident 1] roommate said somebody fell. LN 2 stated she entered Resident 1's room and observed Resident 1 lying face down on the floor, unresponsive, with visible bleeding around the head. LN 2 stated Resident 1 had poor safety awareness and had episodes of ambulating without assistance to use the bathroom in his room despite, reminders to use the call light and did not reliably call staff for help. LN 2 stated she was not aware Resident 1 was identified as a fall risk prior to the incident but acknowledged that, given Resident 1's IDD, confusion and communication deficits (difficulty with memory, thinking and controlled impulses) that Resident 1 should have been considered a safety and fall risk. LN 2 stated if she had known Resident 1 was a fall risk, then Resident 1's care plan should have been updated with interventions for Resident 1 to be placed on a 1:1 supervision and not left unattended to prevent the fall. On [DATE] at 3 P.M., an interview was conducted with the Director of Staff Development (DSD). The DSD stated staff were required to communicate resident-specific risks and care needs, including cognitive (related to thinking, learning, and understanding) impairment, fall risk and feeding assistance, through shift handoff reports and nurse-led huddles prior to providing care. The DSD stated staff must know this information before assuming resident care (all facility residents) to ensure safe and competent services. The DSD further stated failure to communicate these risks could result in preventable injuries, including falls and choking, due to staff being unaware of Resident 1's supervision and assistance needs.On [DATE] at 3:44 P.M., an interview and record review was conducted with the Director of Staff Development (DSD). The DSD stated Resident 1's fall risk care plan initiated [DATE], indicated, .Educate/remind resident to call for assistance .Keep call light within reach.Keep within supervised view as much as possible. was not individualized and specific to Resident 1's cognitive (relating to the mental processes of knowing, learning, thinking, and understanding things) and safety needs. The DSD further stated that if Resident 1 was unable to comprehend or appropriately use the call light for safety, use call light on the care plan does not effectively lessen Resident 1's fall risk because Resident 1 had decreased safety awareness with limited understanding of the purpose of a call light, and dependent on that nursing intervention alone is insufficient. The DSD stated the care plan should instead include direct supervision and staff-initiated monitoring to ensure Resident 1's safety. The DSD stated that 1:1 supervision allows staff to immediately intervene and redirect unsafe movement, which helps prevent falls and injury. The DSD stated Resident 1's fall risk should have been clearly communicated to all licensed nurses and CNAs. The DSD further stated that when a high fall-risk resident is left unsupervised, even briefly, a resident may fall and sustain serious injury caused by delayed staff response for impulsive residents.On [DATE] at 12:45 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated her expectations was that the LNs (LN 1 and LN 2) involved with Resident 1's care should have completed a comprehensive safety assessment for Resident 1 to update and personalize Resident 1's safety needs based on Resident 1's cognitive impairment and decreased safety awareness and should have implemented structured monitoring every 30 minutes with clearly assigned staff responsibility. The DON stated staff should have used a sensitive or alternative call-light system, as Resident 1 did not comprehend the purpose or safe use of a standard call light. The DON stated that a 1:1 supervision should have been implemented when Resident 1 was observed attempting to stand on the day of the incident. The DON stated 1:1 supervision was critical due to Resident 1's cognitive limitations, impulse behaviors, and fall risk assessment, explaining that Resident 1 was unable to consistently recognize danger or follow safety instructions. The DON stated that 1:1 supervision ensures continuous observation and immediate staff intervention, allowing staff to redirect unsafe movement, attend to Resident 1's needs and prevent accidents before they occur. The DON stated her expectation was that all nursing staff and CNAs are informed of fall risk and supervision needs, particularly for new admissions, and that residents (all facility residents) are closely monitored during the first 72 hours to determine whether enhanced supervision is required. The DON further stated that delayed staff response for impulsive residents (such as Resident 1) or residents (all fall risk facility residents) unable to recognize danger significantly increases the risk for injury, including fall-related harm and further health decline. The DON acknowledged that failure to clearly communicate a fall risk and lack of supervision placed Resident 1 at risk because the nursing staff were unaware of the level of monitoring required, resulting in inadequate supervision and hospitalization.On [DATE] at 1:30 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated staff were expected to competently assess residents with cognitive impairment and impulsive behaviors, anticipate risks, and implement appropriate interventions to prevent injury. The DON stated Resident 1's assigned staff were required to provide direct assistance to Resident 1 during feeding due to choking risk and not to leave Resident 1 unattended. The DON further stated failure of staff to understand Resident 1's specific risks and care needs placed Resident 1 at risk for injury, further health decline and death.A review of the facility's policy and procedure titled, Care Plans, Comprehensive Person-Centered dated [DATE], indicated .describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.A record review of the facility's policy and procedure titled, Falls and Fall Risk, Managing dated [DATE], indicated .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, or until the reason for the continuation of the falling is identified as unavoidable .

Based on interview and record review the facility failed to maintain accurate, complete and reliable medical records that reflected the actual care provided during an emergency event, for one of three residents (Resident 1).This deficient practice placed (Resident 1) at risk for delayed or inappropriate medical treatment, misinformed clinical decision-making and compromised continuity of care.Cross reference F689Findings:A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses which included history of Intellectual Developmental Disability (IDD-is a condition that limits intelligence and disrupts abilities necessary for living independently).A record review of Resident 1's Minimum Data Set (MDS-nursing facility assessment tool) dated [DATE] indicated that Resident 1 was rarely or never understood with severe cognitive (the mental processes that take place in the brain, including thinking, attention, language, learning, memory and perception) deficits to understand and make decisions.On [DATE] at 1:40 P.M., an interview was conducted with CNA 1. CNA 1 stated that upon starting her shift on [DATE], she observed Resident 1 independently wheeling himself (using a wheelchair for ambulation -the act of walking or moving place to place) in the hallway. CNA 1 stated she provided Resident 1 with a meal tray, and watched Resident 1 eat independently. CNA 1 stated she was not informed that Resident 1 was a fall risk. CNA 1 reported that Resident 1 remained seated in his wheelchair unsupervised in the hallway until approximately 8 P.M., on [DATE]. CNA 1 stated that after returning from a bathroom break, she observed nursing staff (LN 2) with Resident 1 who was lying face down on the floor with a bleeding head wound. CNA 1 stated oxygen was applied to Resident 1 who was minimally responsive, moving only his hand, at the time he was found on the floor. On [DATE] at 1:51 P.M., an interview and record review was conducted with LN 1. LN 1 stated Resident 1's baseline was alert but not oriented x [times]3 [person, place, time] and was non-verbal. LN 1 further stated Resident 1 was having agonal breathing but had a pulse. LN 1 further stated the only intervention that we did was oxygenation not chest compressions he [Resident 1]still had a pulse we just gave oxygen via non re-breather (a mask that delivers a high concentration of oxygen) and what was documented on his [Resident 1] medical record was not true we did not do chest compressions cause [sic] he still had a pulse. I don't know why the med nurse [LN 2] charted that. On [DATE] at 2:11 P.M., an interview was conducted with CNA 2. CNA 2 stated she later observed nursing staff already present with Resident 1 after Resident 1 was found on the floor. CNA 2 stated she assisted with placing Resident 1 in a safe position and observed Resident 1 had irregular breathing, prompting LN 2 to administer oxygen via a non-rebreather mask. CNA 2 stated Resident 1 was non-verbal, moving his fingers and confirmed that Cardiopulmonary resuscitation (CPR- an emergency lifesaving procedure performed when the heart stops beating) or chest compressions were not initiated because the resident had a pulse.On [DATE] at 11:48 A.M., an interview was conducted with CNA 3. CNA 3 stated she was a registry CNA that worked the night Resident 1 fell. CNA 3 stated she was not the primary CNA assigned to Resident 1 but had observed Resident 1 earlier in the hallway sitting on his (Resident 1) wheelchair making random sounds, not fully verbal and attempting to stand up from the wheelchair. CNA 3 stated she was informed by the LNs (LN 1 and LN 2) at the start of the shift that Resident 1 was a fall risk. CNA 3 stated she was not instructed and/or endorsed by CNA 1 to monitor or supervise Resident 1 prior to CNA 1 using the restroom. CNA 3 stated she heard a nurse call out for help then entered Resident 1's room, where she observed Resident 1 lying on the floor with a bleeding forehead, non-responsive and breathing irregularly. CNA 3 stated Resident 1 was placed in the hallway because Resident 1 was impulsive, repeatedly attempted to move toward other residents' rooms and was resistant to redirection when his (Resident 1) primary CNA (CNA 1) attempted to return him to bed. CNA 3 stated after the fall, LN 2 had applied oxygen via a mask and she observed no rescue breaths or chest compressions were provided. CNA 3 further stated Resident 1 did not regain consciousness not waking up and his (Resident 1) body was twitching while on the floor.On [DATE] at 12 P.M., an interview and record review was conducted with LN 2. LN 2 stated she did not witness Resident 1's fall that happened in his room because she was at the nursing station charting. LN 2 stated she heard somebody called out and his [Resident 1] roommate said somebody fell. LN 2 stated she entered Resident 1's room and observed Resident 1 lying face down on the floor, unresponsive, with visible bleeding around the head. LN 2 stated she attempted to reposition Resident 1 and placed Resident 1 on her knee. LN 2 stated she instructed staff to obtain the crash cart and oxygen. LN 2 stated she performed chest rubs [a technique where a person's chest bone is rubbed hard with knuckles to see if an unconscious person reacts to pain] for stimulation, not chest compressions and confirmed Resident 1 had a pulse. LN 2 stated she initially applied portable oxygen and then placed Resident 1 on a non-rebreather mask. LN 2 acknowledged that documentation indicating chest compressions were performed was inaccurate and stated it should have reflected chest rubs only, explaining the medical record must accurately describe care provided for continuity of care during hospital transfer. LN 2 stated Resident 1 had poor safety awareness and had episodes of ambulating without assistance to use the bathroom in his room despite, reminders to use the call light and did not reliably call staff for help.Resident 1's record review was conducted on [DATE]. Resident 1's Electronic Health Record (EHR) .Resident 1's (EHR) progress noted by Licensed Nurse (LN) 1 titled Nurse's Note dated,[DATE] at 20:00 (8:00 P.M.), indicated, .Resident spotted one time trying to get out of his wheelchair.Medication nurse for 100 hall instructed all of the CNAs[Certified Nursing Assistant] in the hallway to do visual inspections every 30 minutes and switch with other CNA as needed to keep resident under continuous supervision. Nurse on duty had also instructed CNAs that if resident was to be alone inside of room, to be in the same room with the resident.Resident 1's record was reviewed on [DATE]. Resident 1's EHR progress noted by LN 1 titled Nurse's Note dated [DATE] at 20:55 (8:55 P.M.) late entry, indicated, .Heard medication nurse shouting across the hallway to the front nurses station. Medication nurse requested crash cart, crash cart taken to her. Walked in to the room to find resident lying face down and having agonal [an abnormal, reflexive pattern of gasping and labored breaths that occurs when the brain is deprived of oxygen] respirations. Resident also had a bleeding laceration on top left of the forehead. Oxygen tank and nonrebreather[an oxygen mask that delivers high concentrations of oxygen] brought and setup , infiated [sic] and fixed to face at 10-15 liters per minute. Used C-spine[Cervical-spine refers to neck] to stabilize cervical neck [sic], used a 3 person assist to turn resident to the supine [lying flat on your back with your face, chest and stomach facing upward] position. Resident breathing had slowed down to the point where he was fully unconscious [a person is not reacting to sound, touch, or pain] by this time. Writer ran out, grabbed treatment cart in order to control bleeding to the forehead using gauze and bandages. As per medication nurse [LN 2], she checked for carotid [the rhythmic throbbing felt in the carotid arteries on either side of the neck, reflecting blood flow from the heart to the brain] pulse, pulse was too faint to be identifiable. Compressions [use your hands to push down hard and fast in a specific way on the person's chest] were briefly initiated by on duty medication nurse as she initially thought resident had no pulse. After 5 minutes with the nonrebreather mask, resident breathing briefly stabilized and chest rise and fall was noted, compressions at this time were stopped and carotid pulse was noted to be present.Resident 1's record review was conducted on [DATE]. Resident 1's EHR progress noted by LN 2 titled Nurse's Note dated [DATE] at 21:00 (9 P.M.) late entry, indicated, .Found the resident lying on the floor in his room next to the bed with half of his body on the landing mate [sic], and left side on a semi prone [lying flat on your stomach, with your face and chest facing downward] to the floor. Noted his left side of the head of head [sic] with some bleeding, Some abrasion to bilateral UE [upper extremity-arms and hands]. The residentwas [sic] unresponsive [unconscious] at this time. The chest compression initiated [sic] and oxygen with a non re-breather [sic] mask was given. 9-11 was called. arrived at 21:10. Resident is transportation [sic] to [Hospital Name] for further eval.Resident 1's record review was conducted on [DATE]. Resident 1's EHR Interdisciplinary (IDT) note titled IDT Fall dated [DATE] 14:46 (2:46 P.M.) .The resident was unresponsive at this time. The chest compression initiated and oxygen with a non re-breather mask was given.On [DATE] at 3:27 P.M., an interview and record review was conducted with the Director of Staff Development (DSD). The DSD stated that nursing documentation must be accurate, complete and reflect exactly what care was provided, particularly during emergency events. The DSD stated staff are expected to document the actual interventions performed follow established emergency protocols and avoid documenting interventions that did not occur, such as recording chest compressions when only chest rubs were performed. The DSD stated that documenting care inaccurately is not acceptable, emphasizing that the medical record is a legal document and must truthfully reflect the resident's (Resident 1) condition and the care delivered. The DSD stated the IDT Fall dated [DATE] was inaccurate. The DSD further stated the IDT was responsible for reviewing and validating documentation, not merely reading nursing notes at face value, because inaccurate documentation can misrepresent the Resident 1 clinical status and the underlying cause of the event and negatively impact continuity of care during hospital transfer.On [DATE] at 1:02 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated that nursing documentation must be timely, accurate, complete and objective, particularly during emergency events. The DON stated staff are expected to document only what they directly observed and the care that was actually provided and documentation must truthfully reflect what occurred. The DON stated staff should not document interventions that were not performed, specifically noting that chest compressions should not have been documented on Resident 1's health record when compressions were not performed. The DON further stated that inaccurate documentation placed all residents at risk, explaining that incorrect information in the medical record can mislead medical providers, delay appropriate treatment and monitoring and negatively Impact continuity of care during hospital transfer. The DON stated that inaccurate documentation may result in delayed or inappropriate medical decision-making, placing Resident 1 at risk for further health decline.A review of the facility's policy and procedure titled, Charting and Documentation dated [DATE], indicated .Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate .

Based on interview and record review the facility failed to develop, revise and implement an individualized, person-centered care plan to address supervision, prevent falls and feeding assistance needs for one of three sampled residents (Resident 1). This deficient practice placed Resident 1 at risk for falls, choking, serious injury and delayed emergency response due to the lack of an individualized and implemented care plan that aligned with Resident 1's needs when:1. Resident 1, who was a high fall-risk resident, was left unsupervised, despite requiring close monitoring the comprehensive care plan lacked personalization specific to Resident 1's needs that are clear, specific, and measurable interventions to ensure continuous one on one (1:1) supervision.2. Staff failed to provide feeding assistance to Resident 1 according to the nutritional care plan, even though the resident was identified as requiring 1:1 feeding assistance that required assistance with meals.Cross-Reference F689 and F7261. Fall risk-unsupervisedA review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses which included history of Intellectual Developmental Disability (IDD-is a condition that limits intelligence and disrupts abilities necessary for living independently).A record review of Resident 1's Minimum Data Set (MDS-nursing facility assessment tool) dated 12/25/25 indicated that Resident 1 was rarely or never understood with severe cognitive (the mental processes that take place in the brain, including thinking, attention, language, learning, memory, and perception) deficits to understand and make decisions.On 1/14/26 at 1:40 P.M., an interview was conducted with CNA 1. CNA 1 stated that upon starting her shift on 12/25/25, she observed Resident 1 independently wheeling himself (using a wheelchair for ambulation -the act of walking or moving place to place) in the hallway. CNA 1 stated she provided Resident 1 with a meal tray, and watched Resident 1 eat independently. CNA 1 stated she was not informed that Resident 1 was a fall risk. CNA 1 reported that Resident 1 remained seated in his wheelchair unsupervised in the hallway until approximately 8 P.M., on 12/25/25. CNA 1 stated that after returning from a bathroom break, she observed nursing staff (LN 2) with Resident 1 who was lying face down on the floor with a bleeding head wound. CNA 1 stated oxygen was applied to Resident 1 who was minimally responsive, moving only his hand, at the time he was found on the floor. On 1/14/26 at 1:51 P.M., an interview and record review were conducted with LN 1. LN 1 stated he was the nursing supervisor on duty when Resident 1 fell (12/25/25). LN 1 stated he had directed the CNA's (assigned to hallway 100 where Resident 1's room was) to closely monitor Resident 1 because Resident 1 had repeatedly attempted to get out of his wheelchair and was seen wheeling himself throughout the hallway. LN 1 stated Resident 1 was a high fall-risk and required close supervision at all times and should be on a one to one [1:1] supervision (one staff supervising one resident) for safety. LN 1 further stated Resident 1 did not have orders for a 1:1 supervision and Resident 1 was not care-planned (plan created by nursing based on an assessment) for 1:1 supervision but should have been because he was a safety risk. LN 1 stated Resident 1's assigned CNA (CNA 1) used the restroom and that CNA 1 had told a registry (temporary or contracted staff) (CNA 3) to watch [Resident Name]. CNA 3 ignored CNA 1's instructions to supervise Resident 1. LN 1 stated Resident 1 had not been supervised and fell. LN 1 stated Resident 1's baseline was alert but not oriented (confused) x [times]3 [person, place, time] and was non-verbal (did not speak). On 1/14/26 2:03 P.M., an interview was conducted with CNA 1. CNA 1 stated she did not ask another nursing staff to supervise Resident 1 because she was unaware Resident 1 was a fall risk. CNA 1 stated LN 1 did not endorse or communicate to her that Resident 1 required close monitoring or supervision. CNA 1 further stated that had she been informed Resident 1 was a fall risk, she would have immediately notified another nursing staff member to supervise Resident 1 to prevent the fall.On 1/14/26 at 2:11 P.M., an interview was conducted with CNA 2. CNA 2 stated Resident 1 was not assigned to her on 12/25/25; however, Resident 1 was located on the same unit throughout her shift. CNA 2 stated she observed Resident 1 sitting alone in his wheelchair and noted Resident 1 appeared confused and not fully oriented, which she believed to be Resident 1's baseline. CNA 2 stated she was not informed that Resident 1 was a fall risk and therefore did not recognize the need for close supervision. CNA 2 stated she later observed nursing staff next to Resident 1 who was found on the floor. CNA 2 stated she observed Resident 1 to have had irregular breathing, which prompted LN 2 to administer oxygen via a non-rebreather mask (medical emergency device used to deliver high concentrations of oxygen). CNA 2 further stated Resident 1 had been observed earlier seated in his wheelchair with a walker positioned in front of him and that no staff member instructed her to monitor or supervise Resident 1 at any time during her shift, including when the assigned CNA 1 left the area to use the restroom.On 1/14/26 at 3:40 P.M., an interview was conducted with CNA 4. CNA 4 stated Resident 1 required maximum assistance (the staff performs approximately 75% or more of the physical work, while the patient contributes 25% or less) for sit-to-stand movements and transfers due to being wobbly and unstable. CNA 4 stated Resident 1 used a walker and had ambulated with a walker during therapy sessions. CNA 4 stated Resident 1 was confused and appeared unable to consistently understand how to use the call light for safety, despite staff encouragement. CNA 4 further stated that due to Resident 1's confusion, and inability to fully verbalize his needs, staff would need to respond promptly to prevent unsafe attempts to stand if Resident 1 needed assistance.On 1/14/26 at 3:47 P.M., CNA 5 was interviewed. CNA 5 stated that when Resident 1 was first admitted to the skilled nursing facility she noticed Resident 1 frequently sat on the edge of the bed without assistance and had difficulty understanding how to safely use the call light. CNA 5 stated Resident 1 often laughed or giggled when attempting to use the call light and continued not to use it, indicating limited comprehension and developmental delay. CNA 5 stated Resident 1 was a known fall risk, as he (Resident 1) could sit up unassisted in bed and attempted to stand or ambulate without assistance. CNA 5 stated she had reported to the LN's that Resident 1 repeatedly sat at the edge of the bed and required ongoing supervision to reduce the risk of a fall. CNA 5 further stated that despite reminders, Resident 1 continued unsafe behaviors and required supervision to prevent falls.On 1/27/26 at 11:48 A.M., CNA 3 was interviewed. CNA 3 stated she was a registry CNA who had worked the night Resident 1 fell. CNA 3 stated she was not the primary CNA assigned to Resident 1 but had observed Resident 1 earlier in the hallway sitting on his (Resident 1) wheelchair making random sounds, not fully verbal, and attempting to stand up from the wheelchair. CNA 3 stated she was informed by the LNs (LN 1 and LN 2) at the start of the shift that Resident 1 was a fall risk. CNA 3 stated she was not instructed by CNA 1 to monitor or supervise Resident 1 prior to CNA 1 using the restroom. CNA 3 stated she heard a nurse call out for help then entered Resident 1's room, where she observed Resident 1 lying on the floor with a bleeding forehead, non-responsive and breathing irregularly. CNA 3 stated after the fall, LN 2 had applied oxygen via a mask, and she observed no rescue breaths or chest compressions had been provided. CNA 3 further stated Resident 1 did not regain consciousness not waking up, and his (Resident 1) body was twitching while on the floor.On 1/27/26 at 12 P.M., an interview and record review were conducted with LN 2. LN 2 stated she did not witness Resident 1's fall that happened in his room because she (LN2) was at the nursing station charting. LN 2 stated she heard somebody called out and his [Resident 1] roommate said somebody fell. LN 2 stated she entered Resident 1's room and observed Resident 1 lying face down on the floor, unresponsive, with visible bleeding around the head. LN 2 stated Resident 1 had poor safety awareness and had episodes of ambulating without assistance to use the bathroom in his room despite, reminders to use the call light and did not reliably call staff for help. LN 2 stated she was not aware Resident 1 was identified as a fall risk prior to the incident but acknowledged that, given Resident 1's IDD, confusion and communication deficits (difficulty with memory, thinking and controlled impulses) that Resident 1 should have been considered a safety and fall risk. LN 2 stated if she had known Resident 1 was a fall risk, then Resident 1's care plan should have been updated with interventions for Resident 1 to be placed on a 1:1 supervision and not left unattended to prevent the fall. Resident 1's recent transfer documents from the hospital to the skilled nursing facility included a document titled Inpatient Physical Therapy Evaluation dated 12/19/25 at 1:30 P.M., which indicated, .Safety Judgment: Decreased awareness of need for safety, Decreased awareness of need for assistance. Resident 1's Minimum Data Set (MDS-nursing facility assessment tool) dated 12/25/25 indicated that Resident 1 was rarely or never understood with severe cognitive deficits (a decrease in the mental processes that take place in the brain, including thinking, attention, language, learning, memory, and perception) to understand and make decisions. According to the MDS section J: Resident 1 was assessed as a fall risk and had experienced falls prior to admission to the skilled nursing facility. On 1/28/26 at 3:44 P.M., an interview and record review were conducted with the Director of Staff Development (DSD). The DSD stated Resident 1's fall risk care plan initiated 12/22/25, indicated, .Educate/remind resident to call for assistance .Keep call light within reach.Keep within supervised view as much as possible. was not individualized and specific to Resident 1's cognitive (relating to the mental processes of knowing, learning, thinking, and understanding things) and safety needs. The DSD further stated that if Resident 1 was unable to comprehend or appropriately use the call light for safety, use call light on the care plan does not effectively lessen Resident 1's fall risk because Resident 1 had decreased safety awareness with limited understanding of the purpose of a call light, and dependent on that nursing intervention alone is insufficient. The DSD stated the care plan should instead include direct supervision and staff-initiated monitoring to ensure Resident 1's safety. The DSD stated that 1:1 supervision allows staff to immediately intervene and redirect unsafe movement, which helps prevent falls and injury. The DSD stated Resident 1's fall risk should have been clearly communicated to all licensed nurses and CNAs. The DSD further stated that when a high fall-risk resident is left unsupervised, even briefly, a resident may fall and sustain serious injury caused by delayed staff response for impulsive residents.On 1/29/26 at 12:45 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated her expectations was that the LNs (LN 1 and LN 2) involved with Resident 1's care should have completed a comprehensive safety assessment for Resident 1 to update and personalize Resident 1's safety needs based on Resident 1's cognitive impairment and decreased safety awareness and should have implemented structured monitoring every 30 minutes with clearly assigned staff responsibility. The DON stated staff should have used a sensitive or alternative call-light system, as Resident 1 did not comprehend the purpose or safe use of a standard call light. The DON stated that a 1:1 supervision should have been implemented when Resident 1 was observed attempting to stand on the day of the incident. The DON stated 1:1 supervision was critical due to Resident 1's cognitive limitations, impulse behaviors, and fall risk assessment, explaining that Resident 1 was unable to consistently recognize danger or follow safety instructions. The DON stated that 1:1 supervision ensures continuous observation and immediate staff intervention, allowing staff to redirect unsafe movement, attend to Resident 1's needs and prevent accidents before they occur. The DON stated her expectation was that all nursing staff and CNAs are informed of fall risk and supervision needs, particularly for new admissions, and that residents (all facility residents) are closely monitored during the first 72 hours to determine whether enhanced supervision is required. The DON further stated that delayed staff response for impulsive residents (such as Resident 1) or residents (all fall risk facility residents) unable to recognize danger significantly increases the risk for injury, including fall-related harm and further health decline. The DON acknowledged that failure to clearly communicate a fall risk and lack of supervision placed Resident 1 at risk because the nursing staff were unaware of the level of monitoring required, resulting in inadequate supervision and hospitalization.A review of the facility's policy and procedure titled, Care Plans, Comprehensive Person-Centered dated March 2022, indicated .Assessments of residents are ongoing and care plans are revised as information about the residents and the resident's condition change.2. Feeding AssistanceA review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses which included history of Intellectual Developmental Disability (IDD-is a condition that limits intelligence and disrupts abilities necessary for living independently). Resident 1's Minimum Data Set (MDS-nursing facility assessment tool) dated 12/25/25 indicated that Resident 1 was rarely or never understood with severe cognitive (the mental processes that take place in the brain, including thinking, attention, language, learning, memory, and perception) deficits to understand and make decisions.On 1/14/26 at 1:40 P.M., an interview was conducted with CNA 1. CNA 1 stated that upon starting her shift on 12/25/25, she observed Resident 1 independently wheeling himself (using a wheelchair for ambulation -the act of walking or moving place to place) in the hallway. CNA 1 stated she provided Resident 1 with a meal tray, and watched Resident 1 eat independently. CNA 1 stated she was not informed that Resident 1 was a fall risk. CNA 1 reported that Resident 1 remained seated in his wheelchair unsupervised in the hallway until approximately 8 P.M., on 12/25/25. CNA 1 stated that after returning from a bathroom break, she observed nursing staff (LN 2) with Resident 1 who was lying face down on the floor with a bleeding head wound. CNA 1 stated oxygen was applied to Resident 1 who was minimally responsive, moving only his hand, at the time he was found on the floor. On 1/14/26 at 3:47 P.M., an interview was conducted with CNA 5. CNA 5 stated Resident 1 was able to feed self but was on her feeder's list due to difficulty with swallowing and to prevent choking hazards.Resident 1's nutritional care plan with date initiated as 12/22/25 interventions indicated, .1:1 Feeding Assistance. Resident 1's Speech evaluation dated 12/22/25 indicated, .Previous treatment 1:1 feeder.Swallowing Abilities=Severe.Risk Factors: Aspiration [choking].The facility's document labeled Feeding list undated included Resident 1's name.On 1/28/26 at 3 P.M., an interview was conducted with the Director of Staff Development (DSD). The DSD stated staff were required to communicate resident-specific risks and care needs, including cognitive (related to thinking, learning, and understanding) impairment, fall risk and feeding assistance, through shift handoff reports and nurse-led huddles prior to providing care. The DSD stated staff must know this information before assuming resident care (all facility residents) to ensure safe and competent services. The DSD further stated failure to communicate these risks could result in preventable injuries, including falls and choking, due to staff being unaware of Resident 1's supervision and assistance needs.On 1/29/26 at 1:30 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated staff were expected to competently assess residents with cognitive impairment and impulsive behaviors, anticipate risks, and implement appropriate interventions to prevent injury. The DON stated Resident 1's assigned staff were required to provide direct assistance to Resident 1 during feeding due to choking risk and not to leave Resident 1 unattended. The DON further stated failure of staff to understand Resident 1's specific risks and care needs placed Resident 1 at risk for injury, further health decline and death.A review of the facility's policy and procedure titled, Care Plans, Comprehensive Person-Centered dated March 2022, indicated .describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

Based on interview and record review the facility failed to ensure appropriate emergency respiratory interventions, including providing rescue breaths or assisted ventilation (movement of air in and out of the lungs), for one of three sampled residents (Resident 1).This deficient practice placed Resident 1 at risk for hypoxia (low oxygen levels), and respiratory arrest.Cross-Reference F726 and F689Findings:A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses which included history of Intellectual Developmental Disability (IDD-is a condition that limits intelligence and disrupts abilities necessary for living independently).A record review of Resident 1's Minimum Data Set (MDS-nursing facility assessment tool) dated [DATE] indicated that Resident 1 was rarely or never understood with severe cognitive (the mental processes that take place in the brain, including thinking, attention, language, learning, memory, and perception) deficits to understand and make decisions.On [DATE] at 1:40 P.M., an interview was conducted with CNA 1. CNA 1 stated that upon starting her shift on [DATE], she observed Resident 1 independently wheeling himself (using a wheelchair for ambulation -the act of walking or moving place to place) in the hallway. CNA 1 stated she provided Resident 1 with a meal tray, and watched Resident 1 eat independently. CNA 1 stated she was not informed that Resident 1 was a fall risk. CNA 1 reported that Resident 1 remained seated in his wheelchair unsupervised in the hallway until approximately 8 P.M., on [DATE]. CNA 1 stated that after returning from a bathroom break, she observed nursing staff (LN 2) with Resident 1 who was lying face down on the floor with a bleeding head wound. CNA 1 stated oxygen was applied to Resident 1 who was minimally responsive, moving only his hand, at the time he was found on the floor. On [DATE] at 1:51 P.M., an interview and record review was conducted with LN 1. LN 1 stated Resident 1's baseline was alert but not oriented (confused) x [times]3 [person, place, time] and was non-verbal (did not speak). LN 1 further stated after the fall Resident 1 was having agonal breathing (an abnormal, reflex-driven pattern of slow, gasping, or snoring-like breaths that occurs in severe emergencies), but had a pulse. LN 1 further stated the only intervention that we did was oxygenation (the process of supplying, treating, or enriching blood with oxygen), he [Resident 1] still had a pulse we just gave oxygen via non re-breather mask (non-invasive device that delivers high concentration of oxygen) used for acute respiratory distress (life-threatening, a very serious condition and may cause rapid, severe shortness of breath, low oxygen levels, and stiff lungs, often occurring in critically ill patients due to sepsis, pneumonia, or injury). On [DATE] at 2:11 P.M., an interview was conducted with CNA 2. CNA 2 stated she later observed nursing staff next to Resident 1 who was found on the floor. CNA 2 stated she observed Resident 1 to have had irregular breathing, which prompted LN 2 to administer oxygen via a non-rebreather mask. CNA 2 further stated Resident 1 had been observed earlier seated in his wheelchair with a walker positioned in front of him and that no staff member instructed her to monitor or supervise Resident 1 at any time during her shift, including when the assigned CNA 1 left the area to use the restroom.On [DATE] at 11:48 A.M., an interview was conducted with CNA 3. CNA 3 stated earlier on [DATE] she had seen Resident 1 in the hallway sitting on his (Resident 1) wheelchair making random sounds, not fully verbal, and attempting to stand up from the wheelchair. CNA 3 stated she was informed by the LNs (LN 1 and LN 2) at the start of the shift that Resident 1 was a fall risk. CNA 3 stated she was not instructed by CNA 1 to monitor or supervise Resident 1 prior to CNA 1 using the restroom. CNA 3 stated she heard a nurse call out for help then entered Resident 1's room, where she observed Resident 1 lying on the floor with a bleeding forehead, non-responsive and breathing irregularly. CNA 3 stated after the fall, LN 2 had applied oxygen via a mask, (medical emergency device used to deliver high concentrations of oxygen) and she observed no rescue breaths or chest compressions had been provided. CNA 3 further stated Resident 1 did not regain consciousness not waking up, and his (Resident 1) body was twitching while on the floor.On [DATE] at 8:40 A.M., an interview was conducted with LN 2. LN 2 stated Resident 1's oxygen levels was not registering on the oxygen pulse oximetry (device that measures blood oxygen saturation/levels). LN 2 stated she did not check Resident 1's chest for rise and fall to determine effective breathing and did not provide rescue breaths, despite uncertainty regarding Resident 1's respiratory status. LN 2 stated she provided chest rubs and oxygen via mask, confirmed Resident 1 had a pulse, and acknowledged that chest compressions were documented inaccurately, as they were not performed. LN 2 stated she understood rescue breaths are required when a resident is not breathing adequately to ensure airway patency and oxygen delivery to the brain and acknowledged that delayed or missed rescue breathing can result in serious harm, including brain injury. On [DATE] at 3 P.M., an interview was conducted with the Director of Staff Development (DSD). The DSD stated staff are expected to follow the American Heart Association (AHA) Basic Life Support (BLS) guidelines during emergencies or changes in condition. The DSD stated when a resident (all facility residents) are unresponsive with a pulse and abnormal or ineffective breathing, staff must initiate rescue breathing at a rate of one breath every six seconds (10 breaths per minute) and assess chest rise and fall to confirm airway patency. The DSD stated that supplemental oxygen does not replace rescue breaths, as oxygen alone does not provide ventilation (movement of air in and out of the lungs) or ensure air movement into the lungs. The DSD further stated failure to provide rescue breaths could result in delayed oxygen delivery to the brain, brain injury, respiratory failure and compromised continuity of care during hospital transfer.On [DATE] at 2 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated staff were required to immediately recognize and respond when Resident 1 was unresponsive or exhibited irregular or ineffective breathing, as failure to do so placed Resident 1's life at risk. The DON stated supplemental oxygen did not replace rescue breaths, because rescue breathing was necessary to assess airway patency, confirm chest rise, and provide effective ventilation. The DON further stated failure to provide rescue breaths could result in inadequate oxygen delivery to the brain and vital organs, leading to coma or death if not promptly addressed.According to the American Heart Association at https:// https://cpr.heart.org/en/resuscitation-science/cpr-and-ecc-guidelines/adult-basic-life-support .For adult patients who are not breathing normally but have a pulse, it is reasonable for rescuers to provide 1 breath every 6 seconds (10 breaths per minute). rescuers can monitor for adequate ventilation by observing chest rise. Ventilation is essential for oxygen delivery and carbon dioxide elimination for a person with a pulse who is not breathing or not breathing effectively. passive oxygen delivery does not ensure sufficient ventilation.A review of the facility's policy and procedure titled, Emergency Procedure - Cardiopulmonary Resuscitation and Basic Life Support dated [DATE], indicated .Staff are trained to follow current AHA Guidelines and recommendations for the sequence of resuscitation, including: a. Recognition of cardiac arrest; b. Initiation of resuscitation; c. Opening the airway.

Based on interview and record review the facility failed to ensure staff assigned to high fall-risk residents were competent, informed, and trained to meet the residents' safety and care needs, for one of three residents sampled (Resident 1) when:1. Cardiopulmonary resuscitation (CPR) rescue breaths was not provided and only oxygen via a non-rebreather mask was administered when Resident 1 was found unresponsive with irregular breathing, and oxygen saturation was not registering on pulse oximetry (device that measures blood oxygen saturation/levels) .2. Resident 1, who was a high fall-risk resident, was left unsupervised, despite requiring close monitoring.3. Staff failed to provide feeding assistance to Resident 1, even though the resident was identified as requiring feeding assistance on a feeding assist list and required assistance with meals.As a result, this placed Resident 1 at risk for harm, including inadequate emergency response, respiratory compromise, falls with injury, choking or aspiration, and unmet care needs due to staff not being competent or informed of Resident 1's required level of care.Cross-reference F689, and F678Findings:1. CPRA review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses which included history of Intellectual Developmental Disability (IDD-is a condition that limits intelligence and disrupts abilities necessary for living independently).A record review of Resident 1's Minimum Data Set (MDS-nursing facility assessment tool) dated [DATE] indicated that Resident 1 was rarely or never understood with severe cognitive (the mental processes that take place in the brain, including thinking, attention, language, learning, memory, and perception) deficits to understand and make decisions.On [DATE] at 1:40 P.M., an interview was conducted with CNA 1. CNA 1 reported that Resident 1 remained seated in his wheelchair unsupervised in the hallway until approximately 8 P.M., on [DATE]. CNA 1 stated that after returning from a bathroom break, she observed nursing staff (LN 2) with Resident 1 who was lying face down on the floor with a bleeding head wound. CNA 1 stated oxygen was applied to Resident 1 who was minimally responsive, moving only his hand, at the time he was found on the floor. On [DATE] at 1:51 P.M., an interview and record review was conducted with LN 1. LN 1 further stated after the fall Resident 1 was having agonal breathing (an abnormal, reflex-driven pattern of slow, gasping, or snoring-like breaths that occurs in severe emergencies), but had a pulse. LN 1 further stated the only intervention that we did was oxygenation (the process of supplying, treating, or enriching blood with oxygen), he [Resident 1] still had a pulse we just gave oxygen via non re-breather mask (non-invasive device that delivers high concentration of oxygen) used for acute respiratory distress (life-threatening, a very serious condition and may cause rapid, severe shortness of breath, low oxygen levels, and stiff lungs, often occurring in critically ill patients due to sepsis, pneumonia, or injury). On [DATE] at 2:11 P.M., an interview was conducted with CNA 2. CNA 2 stated she later observed nursing staff already present with Resident 1 after Resident 1 was found on the floor in his room. CNA 2 stated she assisted with placing Resident 1 in a safe position and observed Resident 1 had irregular breathing, prompting LN 2 to administer oxygen via a non-rebreather mask. CNA 2 stated Resident 1 was non-verbal, moving his fingers, and confirmed that Cardiopulmonary resuscitation (CPR- an emergency lifesaving procedure performed when the heart stops beating) or chest compressions were not initiated because the resident had a pulse.On [DATE] at 11:48 A.M., an interview was conducted with CNA 3. CNA 3 stated she heard a nurse call out for help then entered Resident 1's room, where she observed Resident 1 lying on the floor with a bleeding forehead, non-responsive and breathing irregularly. CNA 3 stated after the fall, LN 2 had applied oxygen via a mask, and she observed no rescue breaths or chest compressions had been provided. CNA 3 further stated Resident 1 did not regain consciousness not waking up, and his (Resident 1) body was twitching while on the floor.On [DATE] at 8:40 A.M., an interview was conducted with LN 2. LN 2 stated Resident 1's oxygen levels was not registering on the oxygen pulse oximetry. LN 2 stated she did not check Resident 1's chest for rise and fall to determine effective breathing and did not provide rescue breaths, despite uncertainty regarding Resident 1's respiratory status. LN 2 stated she provided chest rubs and oxygen via mask, confirmed Resident 1 had a pulse, and acknowledged that chest compressions were documented inaccurately, as they were not performed. LN 2 stated she understood rescue breaths are required when a resident is not breathing adequately to ensure airway patency and oxygen delivery to the brain and acknowledged that delayed or missed rescue breathing can result in serious harm, including brain injury. On [DATE] at 3 P.M., an interview was conducted with the Director of Staff Development (DSD). The DSD stated staff are expected to follow the American Heart Association (AHA) Basic Life Support (BLS) guidelines during emergencies or changes in condition. The DSD stated when a resident (all facility residents) are unresponsive with a pulse and abnormal or ineffective breathing, staff must initiate rescue breathing at a rate of one breath every six seconds (10 breaths per minute) and assess chest rise and fall to confirm airway patency. The DSD stated that supplemental oxygen does not replace rescue breaths, as oxygen alone does not provide ventilation (movement of air in and out of the lungs) or ensure air movement into the lungs. The DSD further stated failure to provide rescue breaths could result in delayed oxygen delivery to the brain, brain injury, respiratory failure and compromised continuity of care during hospital transfer.On [DATE] at 2 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated staff were required to immediately recognize and respond when Resident 1 was unresponsive or exhibited irregular or ineffective breathing, as failure to do so placed Resident 1's life at risk. The DON stated supplemental oxygen did not replace rescue breaths, because rescue breathing was necessary to assess airway patency, confirm chest rise, and provide effective ventilation. The DON further stated failure to provide rescue breaths could result in inadequate oxygen delivery to the brain and vital organs, leading to coma or death if not promptly addressed.According to the American Heart Association at https:// https://cpr.heart.org/en/resuscitation-science/cpr-and-ecc-guidelines/adult-basic-life-support .For adult patients who are not breathing normally but have a pulse, it is reasonable for rescuers to provide 1 breath every 6 seconds (10 breaths per minute). rescuers can monitor for adequate ventilation by observing chest rise. Ventilation is essential for oxygen delivery and carbon dioxide elimination for a person with a pulse who is not breathing or not breathing effectively. passive oxygen delivery does not ensure sufficient ventilation.A review of the facility's policy and procedure titled, Staffing, Sufficient and Competent Nursing dated [DATE], indicated .Licensed staff must demonstrate the skills and techniques necessary to care for resident needs including (but not limited to) the following areas.Identifying and responding to changes in condition.2. Fall risk-unsupervisedA review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses which included history of Intellectual Developmental Disability (IDD-is a condition that limits intelligence and disrupts abilities necessary for living independently).A record review of Resident 1's Minimum Data Set (MDS-nursing facility assessment tool) dated [DATE] indicated that Resident 1 was rarely or never understood with severe cognitive (the mental processes that take place in the brain, including thinking, attention, language, learning, memory, and perception) deficits to understand and make decisions.On [DATE] at 1:40 P.M., an interview was conducted with CNA 1. CNA 1 stated Resident 1 fed himself and further stated she was not aware Resident 1 required one on one (1:1) feeding assistance and was not informed that Resident 1 was a fall risk. CNA 1 reported that Resident 1 remained seated in his wheelchair unsupervised and repeatedly refused to return to his room for dinner despite staff encouragement. CNA 1 stated that around 8 P.M., after returning from a bathroom break, she observed nursing staff (LN 2) was with Resident 1 in his room lying face down on the floor with a bleeding head wound. CNA 1 further stated Resident 1 was minimally responsive, moving his hand, at the time he was found on the floor.On [DATE] at 1:51 P.M., an interview and record review was conducted with LN 1. LN 1 stated he was the nursing supervisor on duty. LN 1 stated he had directed the CNA's (assigned to hallway 100 where Resident 1's room was) to closely monitor Resident 1 because Resident 1 had repeatedly attempted to get out of his wheelchair and was seen wheeling himself throughout the hallway. LN 1 stated Resident 1 was a high fall-risk and required close supervision at all times and should be on a one to one [1:1] supervision for safety. LN 1 stated Resident 1 did not have orders for a 1:1 supervision and was not care-planned as a 1:1 supervision but should have because he was a safety risk. LN 1 stated Resident 1's assigned CNA (CNA 1) used the restroom and that CNA 1 had told a registry CNA (CNA 3) to watch [Resident Name] but instead ignored CNA 1's instructions to supervise Resident 1as the reason why Resident 1 was not supervised and fell. LN 1 stated Resident 1's baseline was alert but not oriented x [times]3 [person, place, time] and was non-verbal. On [DATE] 2:03 P.M., an interview was conducted with CNA 1. CNA 1 stated she did not ask another nursing staff to supervise Resident 1 because she was unaware Resident 1 was a fall risk. CNA 1 stated LN 1 did not endorse or communicate to her that Resident 1 required close monitoring or supervision. CNA 1 further stated that had she been informed Resident 1 was a fall risk, she would have immediately notified another nursing staff member to supervise Resident 1 to prevent the fall.On [DATE] at 2:11 P.M., an interview was conducted with CNA 2. CNA 2 stated Resident 1 was not assigned to her; however, Resident 1 was located on the same unit throughout her shift. CNA 2 stated she observed Resident 1 sitting alone in his wheelchair and noted Resident 1 appeared confused and not fully oriented, which she believed to be Resident 1's baseline. CNA 2 stated she was not informed that Resident 1 was a fall risk and therefore did not recognize the need for close supervision. CNA 2 stated she later observed nursing staff already present with Resident 1 after Resident 1 was found on the floor. CNA 2 further stated Resident 1 had been observed earlier seated in his wheelchair with a walker positioned in front of him and that no staff member instructed her to monitor or supervise Resident 1 at any time during her shift, including when the assigned CNA1 left the area to use the restroom.On [DATE] at 3:40 P.M., an interview was conducted with CNA 4. CNA 4 stated Resident 1 required maximum assistance for sit-to-stand movements and transfers due to being wobbly and unstable. CNA 4 stated Resident 1 used a walker and had ambulated with a walker during therapy sessions. CNA 4 stated Resident 1 was confused and appeared unable to consistently understand how to use the call light for safety, despite staff encouragement. CNA 4 further stated that due to Resident 1's confusion and inability to fully verbalize his needs, staff would need to respond promptly to prevent unsafe attempts to stand if Resident 1 needed assistance.On [DATE] at 3:47 P.M., an interview was conducted with CNA 5. CNA 5 stated that when Resident 1 was first admitted she noticed Resident 1 frequently sat on the edge of the bed without assistance and had difficulty understanding how to safely use the call light. CNA 5 stated Resident 1 often laughed or giggled when attempting to use the call light and continued not to use it, indicating limited comprehension and developmental delay. CNA 5 stated Resident 1 was a known fall risk, as he (Resident 1) could sit up unassisted in bed and attempted to stand or ambulate without assistance. CNA 5 stated she had reported to the LN's that Resident 1 repeatedly sat at the edge of the bed and required ongoing supervision to reduce fall risks. CNA 5 further stated that despite reminders, Resident 1 continued unsafe behaviors and required supervision to prevent falls.On [DATE] at 11:48 A.M., an interview was conducted with CNA 3. CNA 3 stated she was a registry CNA that worked the night Resident 1 fell. CNA 3 stated she was not instructed and/or endorsed by CNA 1 to monitor or supervise Resident 1 prior to CNA 1 using the restroom. CNA 3 stated she heard a nurse call out for help then entered Resident 1's room, where she observed Resident 1 lying on the floor with a bleeding forehead, non-responsive and breathing irregularly. CNA 3 stated Resident 1 was placed in the hallway because Resident 1 was impulsive, repeatedly attempted to move toward other residents' rooms and was resistant to redirection when his (Resident 1) primary CNA (CNA 1) attempted to return him to bed. CNA 3 further stated Resident 1 did not regain consciousness not waking up and his (Resident 1) body was twitching while on the floor.On [DATE] at 12 P.M., an interview and record review was conducted with LN 2. LN 2 stated she did not witness Resident 1's fall that happened in his room because she was at the nursing station charting. LN 2 stated she heard somebody called out and his [Resident 1] roommate said somebody fell. LN 2 stated she entered Resident 1's room and observed Resident 1 lying face down on the floor, unresponsive, with visible bleeding around the head. LN 2 stated Resident 1 had poor safety awareness and had episodes of ambulating without assistance to use the bathroom in his room despite, reminders to use the call light and did not reliably call staff for help. LN 2 stated that had she known Resident 1 was a fall risk, that Resident 1's care plan should have been updated with interventions for Resident 1 to be placed on a 1:1 supervision and not left unattended to prevent the fall. Resident 1's record was reviewed. Resident 1's safety evaluation per acute hospital health records titled Inpatient Physical Therapy Evaluation dated [DATE] at 1:30 P.M., indicated, .Safety Judgment: Decreased awareness of need for safety, Decreased awareness of need for assistance. Resident 1's History and Physical (H&P) examination by the facility Medical Doctor (MD) dated [DATE], indicated, .This resident.does NOT have the capacity to understand and make decisions. Resident 1's admission fall risk assessment titled, .FALL RISK OBSERVATION/ASSESSMENT. dated [DATE] at 20:37 (8:37 P.M.) indicated, Resident 1's fall risk score was a 20 that identified Resident 1 was a .HIGH RISK. Resident 1's fall risk care plan initiated [DATE], indicated, .Educate/remind resident to call for assistance .Keep call light within reach.Keep within supervised view as much as possible. Resident 1's Electronic Health Record (EHR) progress noted by Licensed Nurse (LN) 1 titled Nurse's Note dated,[DATE] at 20:00 (8P.M.), indicated, .Resident spotted one time trying to get out of his wheelchair.Medication nurse for 100 hall instructed all of the CNAs [Certified Nursing Assistant] in the hallway to do visual inspections every 30 minutes and switch with other CNA as needed to keep resident under continuous supervision. Nurse on duty had also instructed CNAs that if resident was to be alone inside of room, to be in the same room with the resident. Resident 1's EHR progress noted by LN 2 titled Nurse's Note dated [DATE] at 21:00 (9 P.M.) late entry, indicated, .Found the resident lying on the floor in his room next to the bed with half of his body on the landing mate [sic], and left side on a semi prone [lying flat on your stomach, with your face and chest facing downward] to the floor. Noted his left side of the head of head [sic] with some bleeding, Some abrasion to bilateral UE [upper extremity-arms and hands]. The residentwas [sic] unresponsive [unconscious] at this time.On [DATE] at 3:44 P.M., an interview and record review was conducted with the Director of Staff Development (DSD). The DSD stated Resident 1's fall risk care plan initiated [DATE], indicated, .Educate/remind resident to call for assistance .Keep call light within reach.Keep within supervised view as much as possible. was not individualized and specific to Resident 1's cognitive (relating to the mental processes of knowing, learning, thinking and understanding things) and safety needs. The DSD further stated that if Resident 1 was unable to comprehend or appropriately use the call light for safety, use call light on the care plan does not effectively lessen Resident 1's fall risk because Resident 1 had decreased safety awareness with limited understanding of the purpose of a call light and reliance on that intervention alone is insufficient. The DSD stated the care plan should instead include direct supervision and staff-initiated monitoring to ensure Resident 1's safety. The DSD stated that 1:1 supervision allows staff to immediately intervene and redirect unsafe movement, which helps prevent falls and injury. The DSD stated Resident 1's fall risk should be clearly communicated to all licensed nurses and CNAs. The DSD further stated that when a high fall-risk resident is left unsupervised, even briefly, the resident (all fall risk facility residents) may fall and sustain serious injury caused by delayed staff response for impulsive residents (all fall risk facility residents) or residents (all fall risk facility residents)unable to recognize danger results in missed redirection opportunities and increased risk for falls and harm.On [DATE] at 12:45 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated her expectations was that the LNs (LN 1 and LN 2) involved with Resident 1's care should have completed a comprehensive safety assessment for Resident 1 to update and personalize Resident 1's safety needs based on Resident 1's cognitive impairment and decreased safety awareness and should have implemented structed monitoring every 30 minutes with clearly assigned staff responsibility. The DON stated staff should have used a sensitive or alternative call-light system, as Resident 1 did not comprehend the purpose or safe use of a standard call light. The DON stated that a 1:1 supervision should have been implemented when Resident 1 was observed attempting to stand on the day of the incident. The DON stated 1:1 supervision was critical due to Resident 1's cognitive limitations, impulse behaviors and fall risk assessment, explaining that Resident 1 was unable to reliably recognize danger or follow safety instructions. The DON stated that 1:1 supervision ensures continuous observation and immediate staff intervention, allowing staff to redirect unsafe movement, attend to Resident 1's needs and prevent accidents before they occur. The DON stated her expectation was that all nursing staff and CNAs are informed of fall risk and supervision needs, particularly for new admissions and that residents (all facility residents) are closely monitored during the first 72 hours to determine whether enhanced supervision is required. The DON further stated that delayed staff response for impulsive residents (such as Resident 1) or residents (all fall risk facility residents) unable to recognize danger significantly increases the risk for injury, including fall-related harm and further health decline. The DON acknowledged that failure to clearly communicate fall risk and supervision needs placed Resident 1 at risk because the nursing staff were unaware of the level of monitoring required, resulting in inadequate supervision and hospitalization.A review of the facility's policy and procedure titled, Staffing, Sufficient and Competent Nursing dated [DATE], indicated .Licensed nurses and certified nursing assistants are available 24 hours a day, seven(7) days a week to provide co competent resident care services including: a. assuring resident safety. 3. Feeding AssistanceA review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses which included history of Intellectual Developmental Disability (IDD-is a condition that limits intelligence and disrupts abilities necessary for living independently).A record review of Resident 1's Minimum Data Set (MDS-nursing facility assessment tool) dated [DATE] indicated that Resident 1 was rarely or never understood with severe cognitive (the mental processes that take place in the brain, including thinking, attention, language, learning, memory, and perception) deficits to understand and make decisions.On [DATE] at 1:40 P.M., an interview was conducted with CNA 1. CNA 1 stated she provided Resident 1 with a meal tray, which she placed on a bedside table for Resident 1 while Resident 1 sat on his wheelchair in the hallway to eat independently. CNA 1 stated Resident 1 fed himself and further stated she was not aware that Resident 1 required one on one (1:1) feeding assistance and was not informed that Resident 1 was a fall risk.On [DATE] at 3:47 P.M., an interview was conducted with CNA 5. CNA 5 stated Resident 1 was able to feed self but was on her feeder's list due to difficulty with swallowing and to prevent choking hazards.Resident 1's record review was conducted on [DATE]. Resident 1's nutritional care plan date initiated [DATE] interventions indicated, .1:1 Feeding Assistance. Resident 1's Speech evaluation dated [DATE] indicated, .Previous treatment 1:1 feeder.Swallowing Abilities=Severe.Risk Factors: Aspiration [choking]. The facility's document titled: Feeding list undated included Resident 1's name.On [DATE] at 3 P.M., an interview was conducted with the Director of Staff Development (DSD). The DSD stated staff were required to communicate resident-specific risks and care needs, including cognitive (related to thinking, learning, and understanding) impairment, fall risk and feeding assistance, through shift handoff reports and nurse-led huddles prior to providing care. The DSD stated staff must know this information before assuming resident care (all facility residents) to ensure safe and competent services. The DSD further stated failure to communicate these risks could result in preventable injuries, including falls and choking, due to staff being unaware of Resident 1's supervision and assistance needs.On [DATE] at 1:30 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated staff were expected to competently assess residents with cognitive impairment and impulsive behaviors, anticipate risks, and implement appropriate interventions to prevent injury. The DON stated Resident 1's assigned staff were required to provide direct assistance to Resident 1 during feeding due to choking risk and not to leave Resident 1 unattended. The DON further stated failure of staff to understand Resident 1's specific risks and care needs placed Resident 1 at risk for injury, further health decline and death. A review of the facility's policy and procedure titled, Staffing, Sufficient and Competent Nursing dated [DATE], indicated .Licensed nurses and certified nursing assistants are available 24 hours a day, seven(7) days a week to provide co competent resident care services including: a. assuring resident safety.

Based on interview and record review the facility failed to accurately code the Minimum Data Set (MDS) to reflect the resident's true injury status following a fall, for one of three sampled residents (Resident 1).As a result, this placed Resident 1 at risk for inaccurate care planning, inappropriate monitoring and follow up, and the transmission of incorrect health information to Centers for Medicare & Medicaid Services (CMS).Cross-reference F689Findings:A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses which included history of Intellectual Developmental Disability (IDD-is a condition that limits intelligence and disrupts abilities necessary for living independently).A record review of Resident 1's Minimum Data Set (MDS-nursing facility assessment tool) dated 12/25/25 indicated that Resident 1 was rarely or never understood with severe cognitive (the mental processes that take place in the brain, including thinking, attention, language, learning, memory, and perception) deficits to understand and make decisions.Resident 1's EHR (Electronic Health Record) progress noted by LN 1 titled Nurse's Note dated 12/25/25 at 20:55 (8:55 P.M.) late entry, indicated, .Walked in to [sic] the room to find resident lying face down and having agonal [an abnormal, reflexive pattern of gasping and labored breaths that occurs when the brain is deprived of oxygen] respirations. Resident also had a bleeding laceration (a jagged cut) on top left of the forehead. Resident breathing had slowed down to the point where he was fully unconscious [a person is not reacting to sound, touch, or pain] by this time. Resident 1's EHR progress noted by LN 2 titled Nurse's Note dated 12/25/25 at 21:00 (9 P.M.) late entry, indicated, .Noted his left side of the head of head [sic] with some bleeding, Some abrasion to bilateral UE [upper extremity-arms and hands]. The residentwas [sic] unresponsive [unconscious] at this time.On 1/27/26 at 12:54 P.M., an interview and record review were conducted with the Minimum Data Set Coordinator (MDSC). The MDSC stated Resident 1's MDS dated [DATE] was coded inaccurately, as Section J1900C .Major injury-bone fractures, joint dislocations, closed head injury with altered consciousness. was not coded to reflect a major injury. The MDSC stated record review showed Resident 1 required cervical [neck bones] precautions, had slowed respirations, bleeding to the head and was fully unconscious, which met criteria for a major injury and should have been coded accordingly. The MDSC stated accurate MDS coding is required to ensure reportable falls are correctly captured, appropriate interventions and care planning are implemented, and Centers for Medicare Services (CMS) quality measures accurately reflect the care provided. The MDSC stated the MDS required correction and resubmission to accurately reflect Resident 1's condition.On 1/29/26 at 1:47 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated that accurate MDS coding is essential to correctly reflect a resident's clinical status and to guide care planning and clinical decision making. The DON stated that serious events, including major injuries, must accurately be captured on the MDS because the information is submitted to the CMS federal database and is used to determine quality measures, regulatory reporting, and appropriate resident care.A review of Centers for Medicare and Medicaid Services (CMS, a federal agency) RAI Manual 3.0 October 2025, (Page J-37) Section J1900: Number of Falls Since Admission/Entry or Reentry or Prior Assessment .Major Injury Includes, but is not limited to, traumatic bone fractures, joint dislocations/ subluxations, internal organ injuries, amputations, spinal cord injuries, head injuries, and crush injuries .A review of the facility's policy and procedure titled, Resident Assessments dated October 2023, indicated .Information in the MDS assessments will consistently reflect information in the progress notes, plans of care, and resident observations/interviews .

Based on interviews and record review, the facility failed to develop and implement an effective discharge planning process for 1 of 3 sampled residents (Resident 5), who had severe cognitive impairment due to dementia and no family or surrogate decision-maker, when the facility did not document evidence of interdisciplinary team (IDT) meetings or third-party involvement (like conservator or ombudsman) to advocate for Resident 5's needs before her discharge to an assisted living facility on 2/27/25. This failure had the potential to result in an inappropriate placement, compromising Resident 5's safety and well-being.Findings:Resident 5 was admitted to the facility on [DATE] with diagnoses that included dementia (memory problem), per the admission Record. Per the same document, under Contacts, Resident 5 had a bioethics IDT (a group of people that discuss moral, social, and legal issues that may arise).A review of Resident 5's medical record was conducted.Per the Minimum Data Set (MDS - a standardized assessment tool used to evaluate residents' health status and care needs), dated 2/19/25, Resident 5's Brief Interview for Mental Status (BIMS - a measure to track a resident's mental decline or improvements in a long-term care facility) score 2, which indicated Resident 5 had severe cognitive impairment.Per the Progress Notes, dated 1/15/25, the Social Service Director (SSD) documented that a public resident representative (third-party agency) met with SSD and discussed the criteria for a public representative. Resident 5 was under bioethics IDT and cannot make a medical decision. There was no documented evidence that a plan for Resident 5 to have a conservatorship (a court-appointed person, or conservator, for residents who can no longer make decisions).A further review of Resident 5's medical record was conducted. There was no documented evidence that IDTs were conducted to address Resident 5's discharge needs, goals, or the appropriateness of the assisted living facility, or the status of conservatorship.On 2/27/25 at 9:08 A.M., the SSD documented that Resident 5 will be discharged to [address provided]. No evidence was provided on how the decision was made, who authorized it, or whether the facility was equipped to meet Resident 5's dementia care needs.Per the Discharge summary, dated [DATE] at 2 P.M., Resident 5 was discharged to an assisted living facility.On 8/11/25 at 4:10 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated the IDT meeting should have been done before discharge and documented in the medical record. Resident 5 should have a conservatorship assigned to assist in making decisions on their behalf to ensure the resident's needs and safety are met.On 8/14/25 at 4 P.M., an interview was conducted with the SSD. The SSD stated Resident 5 used to live in an independent living facility with a family member's oversight, the family member passed away, and Resident 5 had no other family member who could decide for her.Resident 5 was diagnosed with dementia and was walking around and asking to go home. The SSD further stated that she requested the assistance of the placement provider to locate Resident 5's location for transfer, and they found the assisted living facility. The SSD further stated that there was no IDT meeting or a third-party agency decision made for Resident 5 that occurred before discharge.Per the facility's policy and procedure, dated 3/2025, titled Discharge Summary and Plan, .2. The purpose of the discharge plan is to ensure a safe transition from the facility to the post-discharge setting. 3. The discharge plan is developed by the care planning/interdisciplinary team with the assistance of the resident and the representative .

Based on interview and record review, the facility failed to attempt to reschedule a resident's shower schedule or find a suitable time for a shower for one of three sampled residents (Resident 4).This failure resulted in Resident 4 not showering for 11 days, which could lead to discomfort and compromised hygiene.Findings:Resident 4 was admitted to the facility on [DATE] with diagnoses that included a fracture (broken) of the left ilium (pelvic bone), per the admission Record.On July 7, 2025, at 2:52 P.M., a complainant reported that Resident 4 had not received a shower at the facility for over ten days. Resident 4 preferred morning showersA review of the Activity of Daily Living (ADL- a set of self-care tasks) Report dated 6/23/25 through 7/7/25, under bathing, Resident 4 indicated that the staff had not assisted Resident 4 with showering from 6/23/25 until 7/4/25. Resident 4 did not receive a shower for 11 days.Per the Shower Schedule, Resident 4's scheduled shower was during the PM shift (a work period that falls in the late afternoon or second shift).On 7/8/25 at 1:15 P.M., Resident 4 was not available for an interview.On 7/8/25 at 2:30 P.M., a joint interview and record review was conducted with the Assistant Director of Nursing (ADON). The ADON stated Resident 4 was admitted on [DATE], and had a scheduled shower every Wednesday and Saturday. Resident 4 had refused showers three times. The ADON further said that not showering for 11 days was a long time, and should have involved the family and the physician.The ADON stated there was no documented evidence that the physician or family member was made aware of this or offered Resident 4 alternatives, which the staff should have done. The ADON further stated it was important for a resident to shower to maintain personal hygiene [cleanliness]. Licensed Nurses assigned to Resident 4 were not available for interview.Per the facility's policy and procedure, dated 2/2018, titled Bath, Shower/Tub, The purpose of this procedure are to promote cleanliness, provide comfort to the resident and observe the condition of the resident's skin .

Based on interview and record review, the facility failed to develop and implement an effective discharge planning process to identify and address goals for three of three sampled residents (Resident 4, Resident 5, and Resident 6). This failure resulted in rushed discharges without adequate coordination of post-discharge care, placing residents at risk for rehospitalization and inadequate support. (Cross-reference: F-656, Comprehensive Care Plans) Findings: 1. Resident 4 was admitted to the facility on [DATE] with diagnoses that included heart failure (heart muscle cannot pump enough blood to the body), Schizoaffective Disorder, Bipolar Type (mental illness), per the admission Record. On 4/24/25, a review of Resident 4's medical record was conducted. Resident 4 was discharged from the facility on 4/4/25. There was no evidence that a Discharge Care Plan was developed. Per the Progress Notes, the following event happened: On 4/1/25 at 1:59 P.M., the Social Service Director (SSD) documented that Resident 4 would like to be discharged to Texas with family. On 4/2/25 at 12:01 P.M., the Case Manager (CM) documented that Resident 4's last coverage day (LCD- the date insurance coverage ended) was 4/3/25. Resident 4 tried calling the insurance company. On 4/4/25 at 12:26 P.M., the SSD documented Resident 4 agreed to be discharged to a homeless shelter. The SSD further noted that the transportation would pick up Resident 4 at 3:30 P.M., and the home health agency (HHA) would call Resident 4. On 4/4/25 at 3:42 P.M., the SSD documented that Resident 4 was picked up at 3:35 P.M., and [name of] HHA was assigned. Resident 4's discharge plan was documented at 12:26 P.M., and the discharge was executed by 3:35 P.M. on the same day, allowing less than four hours for coordination. On 4/24/25 at 2:19 P.M., an interview was conducted with Licensed Nurse (LN) 3. LN 3 stated Resident 4 wanted to move to Texas with family, and the SSD was responsible for anything about discharge. LN 3 further stated that the SSD did a discharge plan on 4/4/25 [at 12:26 PM], and LN 3 helped gather Resident 4's medications to take. LN 3 further stated that Resident 4 left the facility at 3:55 P.M. The discharge planning may not have been sufficient time for Resident 4 to adjust to the community. On 4/24/25 at 2:35 P.M., an interview was conducted with the SSD. The SSD stated she and her assistant were responsible for developing a discharge care plan for Resident 4 on admission, which was missed. The SSD further stated the care plan should have been created to ensure the resident was discharged according to the plan. The SSD further stated Resident 4 wanted to move back to Texas with family, and the plan was changed when an LCD was issued. Resident 4 agreed to move to the homeless shelter, and she started calling the different homeless shelters and arranging transportation. The SSD stated Resident 4 was discharged to the homeless shelter three hours after the discharge planning, and it may not be enough time for planning. 2. Resident 5 was admitted to the facility on [DATE] with diagnoses that included encephalopathy (abnormal fluid build-up in the brain), per the admission Record. On 2/24/25, a review of Resident 5's medical records was conducted. Per the Care Plan Report, Resident 5 wanted to be discharged home in San [NAME]. Per the Progress Notes, the following event happened: On 3/21/24 at 11:51 A.M., the SSD documented that Resident 5 had not returned to a prior level of function but would be able to maintain some independence with support at the assisted living facility, and home health will follow up. The SSD further documented that Resident 5 told the SSD that the family member was handling Resident 5's finances, and that the SSD should reach the family member. On 3/26/26 at 2:23 P.M., the SSD documented that Resident 5 agreed to be discharged since the insurance would no longer cover the skilled nursing services and would be moving to address #1 in San Diego 92139 an independent/assisted living facility (ALF). The SSD further documented that Resident 5 was hospice (seriously ill with six months or less to live if their illness follows its natural course) appropriate, and an order was in place. Hospice #1 was assigned to provide services. The SSD also noted that a message was left to the family member. There was no documented evidence that the Interdisciplinary Team (IDT group of individuals from various disciplines collaborated to achieve a resident's shared goal) and the family members were involved in the discharge plan. There was no documented evidence that Hospice #1 or Hospice #2 was evaluated and accepted by Resident 5. On 3/27/25 at 3:45 P.M., Licensed Nurse (LN) 2 documented that the facility van dropped Resident 5 at address #2 in San Diego 92114, and Hospice # 2 will follow up. On 4/18/25, The California Department of Public Health received a report that Resident 5 was sent to the hospital by an unknown person on 4/17/25. On 4/24/25 at 1:40 P.M., an interview was conducted with LN 2. LN 2 stated she was not involved with Resident 5's discharge planning, but she was the LN who discharged Resident 5 to address #2. LN 2 stated that she followed what the SSD told her. On 4/24/25 at 2:35 P.M., an interview was conducted with the SSD. The SSD stated Resident 5 would like to be discharged , and the ALF staff told her that Resident 5 would qualify for hospice service. The SSD stated she should have involved the IDT to ensure Resident 5's needs were identified before discharge. 3. Resident 6 was admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy (problem with brain functions) per the admission Record. On 4/24/25, a review of Resident 6's medical record was conducted. Per the Care Plan Report, Resident 6 preferred to return to their previous living situation with Resident 6's significant other (RSO). Per the MDS (Minimum Data Set- standardized assessment tool that measures health status) dated 2/11/25, Resident 6 had severely impaired cognition. Per the Progress Notes, the following event happened: On 2/20/25 at 5:45 P.M., the LN documented that Resident 6 was seen by the physician and ordered for hospice evaluation. There was no documented evidence that this order involved the RSO or discharge planning. On 3/8/25 at 11:43 A.M., the LN documented that Resident 6 had a change of condition for possible urinary tract infection. On 3/9/25 at 9:14 A.M., the LN documented that Resident 6 had an order from the physician for Resident 6 to start with antibiotic treatment. On 3/10/25 at 12:30 P.M., the SSD documented that Resident 6 indicating preference to dc [discharge] back to home, and Resident 6 was adamantly stated that RSO would provide the transportation. The SSD further documented going with Hospice #3 at home. On 3/10/25 at 3:53 P.M., the SSD documented that Resident 6 will have Hospice # 4. Due to Resident 6's location, Hospice #3 could not provide service for Resident 6. On 3/11/25 at 12:12 A.M., the LN documented that Resident 6's indwelling catheter was removed and monitored Resident 6 for urinary retention every six hours. On 3/11/25 at 9 A.M., LN 2 documented that Resident 6 was discharged with RSO. On 3/11/25 at 12:51 P.M., the SSD documented that Hospice #5 could not provide service for Resident 6. The SSD did not note what happened to Hospice #4. The SSD further documented that she reached out to a home health agency (HHA) requesting possible admission to hospice services. On 4/15/25, The California Department of Public Health received a complaint reporting that on 3/28/25, Adult Protective Services was called to check on Resident 6's health and living conditions. On 4/24/25 at 1:40 P.M., an interview was conducted with LN 2. LN 2 stated she was not involved with Resident 6's discharge planning but was present on the day of Resident 6's discharge. LN 2 further stated that Resident 6 required daily help with activities, and LN 2 was unsure if the RSO could handle the care. LN 2 further stated she was unsure if the RSO would know what to do if Resident 6 experienced urinary retention. On 4/24/25 at 2:35 P.M., an interview was conducted with the SSD. The SSD stated Resident 6 kept saying she wanted to go home, and the RSO agreed to the discharge. The SSD stated she did not assess if the RSO can care for Resident 6 alone at home. On 4/30/25 at 2:55 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated that the SSD handled all the discharge and discharge planning. Moving forward, she will be more involved with the discharge planning and ensure all the residents' needs for safe discharge are in place and documented. Per the facility's policy and procedure, dated 3/25, titled Discharge Summary and Plan, .Every resident has an individualized discharge plan at admission and is part of the comprehensive care plan .A member of the IDT reviews the final discharge plan with the resident and family at least twenty-four (24) hours before the discharge is to take place .If the resident indicates an interest in returning to the community, the facility determines if appropriate and adequate support is in place. This may include the capacity of the resident's caregiver at home .

Based on the interview and record review, the facility failed to ensure the care plan for discharge (leaving the facility) was developed for one of three sampled residents (Resident 4). This failure increased the risk for Resident 4 to have an unsafe discharge from the facility back to the community. Findings: Resident 4 was admitted to the facility on [DATE] with diagnoses that included heart failure (the heart muscle can not pump enough blood to the body), per the Admission Record. On 4/24/25, a review of Resident 4's medical record was conducted. Resident 4 was discharged from the facility on 4/4/25. There was no evidence that a Discharge Care Plan was developed for Resident 4. On 4/24/25 at 2:35 P.M., an interview was conducted with the Social Service Director (SSD). The SSD stated she and her assistant were responsible for developing a discharge care plan for Resident 4 on admission, which was missed. The SSD further stated that the care plan should have been created to ensure the resident was discharged according to the plan. On 4/30/25 at 2:55 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated that the discharge care plan should have been developed to meet residents' needs. Per the facility's policy and procedure, dated 3/25, titled Discharge Summary and Plan, .Every resident has an individualized discharge plan, which begins at admission and is part of the comprehensive care plan . Per the facility's policy and procedure, dated 3/22, titled Care Plans, Comprehensive Person-Centered, .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 the interview, and record review, the facility failed to ensure comprehensive resident-centered care plans were implemented for one of two sampled residents (1) when Resident 1 had no bowel movements for three days, and the physician's order was not followed. This deficient practice had the potential to affect resident's health and safety. Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses which included malignant neoplasm (abnormal tissue growth) of ill-defined sites within the digestive (a group of organs that work together to digest and absorb nutrients from the food that was eaten) system, per the Admission Record. A review of Resident 1's medical record was conducted. Per the Plan of Care, dated 11/21/24, Resident 1 was At risk for complications with bowel regimen due to risk for constipation due to decreased physical mobility, weakness, used of medications, under Interventions/Tasks, the LN was to Administer medications per physician order. Per the Order Summary Report, dated 11/21/24, Resident 1 had the following physician's order:Magnesium Hydroxide Suspension (medication to treat occasional constipation) every 24 hours as needed;Bisacodyl Suppository (medication to treat constipation) every 24 hours as needed if Magnesium Hydroxide was ineffective;Fleet enema every 72 hours as needed if Bisacodyl was ineffective. Per the Bowel Movement Report, dated 11/25/24 at 1:32 P.M., through 11/29/24 at 4:38 A.M., Resident 1 had no bowel movement for three days. Per the Medication and Treatment Administration Record, dated 11/26/24 through 11/28/24, there was no documented evidence that Resident 1 was offered or given medications ordered by the physician. On 12/17/24 at 4:30 P.M., an interview and record review was conducted with the Director of Nursing (DON). The DON stated the LN should have given Resident 1 medication to help with constipation, but they did not. Per the facility's policy and procedure, dated 3/22, titled Care Plans, Comprehensive Person-Centered, .Services provided for or arranged by the facility and outlined in the comprehensive care plan are: a. provided by qualified persons .

Based on interview and record review, the facility failed to ensure the discharge medication list order from the hospital matched the facility's admission medication list for one of two sampled residents (1) when one tablet of Sennoside (a medication used to treat constipation) was omitted from the order. As a result, Resident 1 did not receive the desired dose of medicine to be effective. Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses which included malignant neoplasm (abnormal tissue growth) of ill-defined sites within the digestive (a group of organs that work together to digest and absorb nutrients from the food that was eaten) system, per the Admission Record. A review of Resident 1's medical record was conducted. Per the Hospital Discharge Order List, dated 11/21/24, the physician ordered for Sennosides 17.2 milligrams. Per the facility's Order Summary, dated 11/21/24, Resident 1 was to receive Sennosides 8.6 milligrams, take one tablet orally at bedtime for constipation [Instead of two tablets]. Further review of Resident 1's medical record was conducted. No evidence of order change from the physician was noted. Licensed Nurse (LN) 1 was not available for an interview. On 12/17/24 at 4:30 P.M., a joint interview and record review was conducted with the Director of Nursing (DON). The DON stated LN 1 should ensure the orders from the hospital matched their admission order, and any changes would be documented in the medical record. The DON stated that LN 1 did not transcribe the order correctly. Per the facility's policy and procedure, dated 7/17, titled Reconciliation of Medications on Admission, The purpose of this procedure is to ensure medication safety by accurately accounting for the resident's medications, routes and dosage upon admission or readmission to the facility .

Based on interview and record review, the facility failed to ensure a resident's medical record was complete for one of two sampled residents (1) when the licensed nurse (LN) had incomplete documentation after receiving an order, and the inventory sheet (record of resident's belongings) was not signed. As a result, the facility could not verify a physician's order and Resident 1's inventory sheet when discharged was not completed. Findings Resident 1 was admitted to the facility on [DATE] with diagnoses which included malignant neoplasm (abnormal tissue growth) of ill-defined sites within the digestive (a group of organs that work together to digest and absorb nutrients from the food that was eaten) system, per the Admission Record. A review of Resident 1's medical record was conducted. Per the Progress Notes, dated; 11/28/24, LN 1 documented that Resident 1 insisted on going home because the Butalbital/Acetaminophen/Caffeine (a combination of medications to treat tension headaches) was not routine. LN 1 further documented the nurse practitioner was called and changed the order from as needed to routine, and on 11/30/24, LN 2 documented, Received new order for Butalbital/Acetaminophen / Caffeine to be changed from three times a day routinely to as needed. LN 2 did not document who changed the order and how LN 2 received the order. In addition, a review of the Resident Inventory of Personal Effects, under Certification of Receipt on Discharge, the signature to indicate that belongings left with Resident 1 was blank. On 12/19/24 at 4:22 P.M., an interview was conducted with LN2. LN 2 stated she could not remember how she received the order, whether by telephone or in person, and whom she spoke to. LN 2 further stated she could not remember if she talked to Resident 1 about the order change. LN 2 stated she should have documented the event thoroughly, as she could no longer recall it. LN 2 further stated Resident 1 was very upset on 12/6/24 because Resident 1 was not getting the medication routinely and wanted to leave against medical advice. LN 2 stated Resident 1's inventory was not signed before discharge from the facility and should have been. LN 2 further stated she could not verify that Resident 1's belongings were taken home or were missing. On 12/23/24 at 9:09 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated that licensed nurses should document the resident's medical record completely and thoroughly. The DON further stated the LNs should have documented the name of the physician or the nurse practition changing the order back to as needed. In addition, the DON stated the resident's belongings should have been reviewed before leaving the facility and the resident should have signed the inventory sheet to acknowledge that the resident took all belongings home. The DON further stated Resident 1's inventory sheet was blank. The facility could not provide a policy and procedure for accountability of resident's belongings. Per the facility's policy and procedure titled Medication and Treatment Orders, .7. Verbal orders must be recorded immediately in the resident's chart by the person receiving the order and must include the prescriber's last name, credentials, the date and the time of the order .

Based on observation, interview and record review, the facility failed to offer written and follow-up initiation of the advance directives for seven of 20 sampled residents (Residents 10, 29, 77, 36, 237, 61 and 62). This failure resulted in staff not knowing residents' directives regarding care and the residents' legal health care agent. Findings: 1. Resident 10 was admitted to the facility on [DATE] with diagnoses which included paranoid schizophrenia (a severe mental disorder that may interfere with a resident's ability to think, manage emotions, make decisions, and relate to others) per the Admission Record. Per the same document, Resident 10 was responsible for herself and had five emergency contacts. A review of Resident 10's medical record was conducted. Per the Physician Orders for Life-Sustaining Treatment (POLST), dated 7/29/24, under Section D, there was no information about the advance directive. Per the history and physical, dated 8/1/24, Resident 10 can make needs known but can not make medical decisions because Resident 10 has diagnosis of schizophrenia, which was not consistent with the facility's Admission Record. Upon further review of Resident 10's medical record, there was no evidence that the facility offered or had follow-up about Resident 10's advance directives. 2. Resident 29 was admitted to the facility on [DATE] with diagnoses which included cerebral infarction (blood flow to the brain was blocked) per the Admission Record. Per the same document, Resident 29 had two agents (DPOA- durable power of attorney) to manage Resident 29's care. A review of Resident 29's medical record was conducted. Per the Physician Orders for Life-Sustaining Treatment (POLST), dated 8/7/24, under Section D, there was no information about the advance directive. Upon further review of Resident 29's medical record, there was no evidence that the facility offered or had follow-up about Resident 29's advance directives. 3. Resident 77 was admitted to the facility on [DATE] with diagnoses which included protein malnutrition (not enough nutrients in the body) per the Admission Record. Per the same document, Resident 77 was responsible for himself. A review of Resident 77's medical record was conducted. Per the Physician Orders for Life-Sustaining Treatment (POLST), dated 11/14/24, under Section D, there was no information about the advance directive. Upon further review of Resident 77's medical record, there was no evidence that the facility offered advance directives to Resident 77. On 12/12/24 at 2:45 P.M., an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated Resident 10, Resident 29, and Resident 77's medical records had no evidence that the advance directive was offered, followed up, or filed. The ADON further stated it was important to have the advance directive to ensure a resident's wishes were honored when a resident can no longer make decisions. Per the facility's policy and procedure, dated 9/22, titled Advance Directives, .the facility staff will offer assistance in establishing advance directives .the Nursing staff will document in the medical record the offer . 46235 4. Resident 36 was admitted to the facility on [DATE] with diagnoses including chronic osteomyelitis (bone infection) according to the facility's Admission Record. During an observation on 12/9/24 at 9:23 A.M., Resident 36's room door was closed with a sign on the wall which indicated enhanced barrier precaution (an approach when healthcare workers wore gowns and gloves during high contact with residents to reduce transmission of organisms). Resident 36 was sitting on a motorized wheelchair in his room and stated he was admitted to the facility with a wound. During a review of Resident 36's medical records, there was a Physician Order for Life-Sustaining Treatment (POLST- written order which outlines a resident's treatment preferences) dated, 8/26/24 but no advance directive. Section D of the POLST which pertained to advance directive was left blank. 5. Resident 237 was admitted to the facility on [DATE] with diagnoses including chronic pulmonary edema (fluid buildup in the lungs making it difficult to breathe) according to the facility's Admission Record. During an observation on 12/9/24 at 10:08 A.M., Resident 237 was in bed in his room with oxygen on via nasal cannula (small, flexible tube with two prongs that sit inside the nostrils to deliver oxygen). Resident 237 stated he still felt short of breath with the use of oxygen. Resident 237's medical records were reviewed. A POLST for Resident 237 dated 11/20/24 did not have information in section D regarding advance directive. There was no advance directive in Resident 237's medical records. An interview and joint record review was conducted on 12/11/24 at 9:36 A.M. with the ADON. The ADON stated Resident 237's POLST was left blank regarding advance directives. 6. Resident 62 was admitted to the facility on [DATE] with diagnoses including acute respiratory failure with hypoxia (a condition where the lungs fail to adequately exchange oxygen, leading to low oxygen in the blood) according to the facility's Admission Record. On 12/9/24 at 3:55 P.M. Resident 62 was observed yelling out, Ahh repeatedly while in bed in his room. Resident 62 was asked if he needed help, Resident 62 stated he wanted his doctor but did not state the reason. During a review of Resident 62's medical records, a POLST form dated 2/23/24 did not indicate if resident 62 had an advance directive. There was no advance directive found in resident 62's medical record or documentation that it was discussed with the resident or the resident's representative. An interview and joint record review was conducted on 12/11/24 at 9:36 A.M. with the ADON. The ADON stated Resident 62 had a durable power of attorney (legal decision maker) and the POLST was left blank regarding advance directives. 7. Resident 61 was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction (paralysis and weakness affecting one side of the body due to a stroke) according to the facility's Admission Record. Resident 61 was observed in bed in his room on 12/10/24 at 3:37 P.M. Resident 61 had a one-to-one certified nurse assistant (CNA) sitting at bedside. When Resident 61 was asked how he was doing, Resident 61 stated he was doing okay. A review of Resident 61's medical record was conducted. A POLST form dated 2/21/23 did not have boxes checked regarding advance directive. There was no advance directive in Resident 61's medical record or documentation that it was discussed with the resident or the resident's representative. During an interview on 12/10/24 at 8:10 A.M. with the Social Service Director (SSD), the SSD stated the POLST, and advance directives were followed up by the medical records staff. During an interview on 12/11/24 at 9:36 A.M. with the ADON, the ADON stated the charge nurse checked upon residents' admission for advance directives. The ADON stated medical records staff uploaded advance directives in the resident's medical records. The ADON further stated section D of resident's POLST should be completed for staff to know who can medically decide for the residents' care. An interview was conducted on 12/12/24 at 2:24 P.M. with the Director of Nursing (DON). The DON stated it was her expectation for nursing staff to check resident's hospital records for an advance directive or check with the resident's family. The DON stated social services was responsible for verifying the advance directive and then medical records staff will upload the forms in the resident's medical record. The DON further stated it was important to find out if a resident had an advance directive to provide proper care for the resident in the event of an emergency. A review of the facility's policy and procedure (P&P) titled, Advance Directives, dated September 2022 was reviewed. The P&P indicated, .Prior to or upon admission of a resident, the social services director or designee inquires of the resident, his/her family members and/or his her legal representative, about the existence of any written advance directives .The resident or representative is provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so .

Based on observation, interview, and record review, the facility failed to ensure opened dressings were labeled with an open date, and expired food was removed from the walk-in refrigerator in the kitchen. These failures placed residents at risk of acquiring foodborne illness. Findings: On [DATE] at 7:54 A.M., a joint observation and interview were conducted with the Director of Dietary Services (DDS). Inside the walk-in refrigerator were opened, undated gallons of mayonnaise and Asian artisan dressings, and an opened tub of cottage cheese with a USED BY (the last date recommended for the use while at peak quality) date of [DATE]. The DDS stated the kitchen staff should have written the date when the food was opened and should have used the food before the used-by date or should have discarded the food item. The DDS further stated it was important to have foods labeled, dated, and discarded to ensure that the food served in the kitchen was safe and palatable for the residents. Per the facility's undated policy and procedure titled Food Receiving and Store, .7. Refrigerated foods are labeled, dated and monitored so they are used by their use-by date, frozen, or discarded .

Based on observation, interview and record review, the facility failed to ensure four of 20 residents reviewed had accurate and complete medical records when: 1. Resident 66's treatment record was incomplete, 2. Resident 23's post dialysis note was incomplete and did not indicate reassessment after dialysis site bleeding, 3. Resident' 36 and Resident 63's Diabetic Administration Record was incomplete. This failure did not provide an accurate representation of the care provided to the residents and had the potential for residents to not receive the appropriate care. Findings: 1. Resident 66 was admitted to the facility on [DATE] with diagnoses which included End Stage Renal Disease (ESRD- kidney failure) per the Admission Record. A review of Resident 66's medical record was conducted. Per the Order Summary Report, dated 12/1/24, the staff was to monitor Resident 10's dialysis site for bleeding and infection every shift. Per the December 2024 Treatment Administration Record (TAR), the monitoring for the dialysis site was blank on 12/2/24, 12/3/24, 12/9/24, and 12/10/24. On 12/12/24 at 11:54 A.M., a joint interview and record review was conducted with the Director of Nursing (DON). The DON stated dialysis site should have been monitored per the physician's order, and the licensed nurses should initial the TAR to indicate the site was monitored. The DON further stated if it was not signed, it was not done. The facility could not provide policy and procedure for Treatment Administration Records. Per the facility's policy and procedure, dated 11/2022, titled Documentation of Medication Administration Record, .Documentation of medication administration includes .initials, signature and title . 39449 2. Resident 23 was admitted to the facility on [DATE] with diagnoses to include end stage kidney disease per the facility Admission Record. A review of Resident 23's Brief Interview of Mental Status dated 9/30/24 (BIMS, an assessment tool) indicated 13 out of a possible 15 for intact mental cognition. A review of Resident 23's physician History and Physical Examination dated 9/12/24 indicated Resident 23 had the capacity to understand and make decisions. On 12/9/24 at 11:34 A.M., an observation and interview and conducted with Resident 23. Resident 23 was observed in bed with a raised/bulging arterio-venous (AV-connection of blood vessels used for dialysis [process to filter waste from blood]) shunt on his left upper arm. Resident 23 stated his dialysis schedule was Tuesdays, Thursdays and Saturdays. Resident 23 stated last Saturday, 12/7/24 around 1:30 P.M., he came from dialysis and when he bent his arm to eat his AV started to bleed. Resident 23 stated he pressed the call light and waited for a long time for a staff to respond. Resident 23 stated the male employee pressed his arm and went out. Resident 23 stated his AV shunt was still bleeding and he had to clamp the AV shunt himself and was used to clamping his AV shunt. Resident 23 stated the male nurse did not return for one hour. A review of Resident 23's physician order dated 6/26/24 indicated the following: Hemodialysis (a machine which filters wastes, salts and fluid when kidneys were no longer healthy to this work adequately) on Tuesday, Thursday and Saturday. Hemodialysis- remove dressing on left upper arm after four hours from dialysis treatment on Tuesday, Thursday and Saturday. Assess and document site for signs of bleeding, swelling, redness, drainage or pain at site. If active bleeding, utilize the dialysis emergency kit at bedside. A review of the facility's document titled, Nursing Hemodialysis Communication Observation and Assessment-Facility Post -Dialysis indicated on 12/7/24 at 1:54 P.M., Resident 23 returned to the facility. Resident 23 was noted to have bleeding to dialysis site, pressure applied, arm elevated, dressing intact. No bleeding noted after pressure applied. At four-hour post removal noted at 5:54 P.M. and no bleeding noted. On 12/11/24 at 5: 57 P.M., an interview was conducted with LN 12. LN 12 stated last Saturday, Resident 23 came back from dialysis and a CNA informed me Resident 23 had bleeding on his left upper arm (LUA) AV shunt. LN 12 stated he applied pressure, elevate his arm and came back 20 minutes later to check Resident 23's LUA AV shunt. LN 12 stated Resident 23 had no more bleeding, and no clamps was applied to Resident 23's LUA AV shunt. On 12/12/24 at 10:20 A.M., a concurrent interview and record review was conducted with LN 12. LN 12 stated he returned 20 minutes after he applied pressure to Resident 23's LUA AV shunt. LN 12 stated he returned three times to Resident 23 to check Resident 23's LUA AV shunt was still bleeding. LN 12 stated he checked Resident 23's LUA AV shunt at around 1:54 P.M., after 20 minutes and at 5:54 P.M. LN 12 stated he did not document the second time he checked Resident 23's LUA AV shunt. On 12/12/24 at 11:05 A.M., a concurrent interview and record review was conducted with the DSD. The DSD stated LN 12 should have reassessed Resident 23 and documented in a timely manner. On 12/12/24 at 12:05 P.M., a concurrent interview and record review was conducted with the ADON. The ADON stated every time Resident 23 came back from dialysis, LNs should assess, document in progress notes and communicate with the team. The ADON stated if you did not document it, you did not do it. Per the facility policy entitled Hemodialysis Catheters- Access and Care of, dated February 2023, indicated .Documentation .The nurse should document in the resident's medical record every shift as follows: .5. Observations post-dialysis . 46235 3a. Resident 36 was admitted to the facility on [DATE] with diagnoses including chronic osteomyelitis (bone infection) and diabetes (too much sugar circulating in the blood) according to the facility's Admission Record. During an observation on 12/9/24 at 9:23 A.M., Resident 36's room door was closed with a sign on the wall which indicated enhanced barrier precaution (EBP-an approach when healthcare workers wore gowns and gloves during high contact with residents to reduce transmission of organisms). Resident 36 was sitting on a motorized wheelchair in his room and stated he was admitted to the facility with a wound. Resident stated he took insulin for his diabetes. A review of Resident 36's physician's orders for December 2024 was conducted. The physician's orders indicated an order date on 8/26/24 for Insulin Lispro .Inject as per sliding scale .subcutaneously (under the skin) before meals and at bedtime . The physician's order did not indicate when to check Resident 36's blood sugar. An interview and joint record review of Resident 36's Diabetic Administration Record (DAR) with licensed nurse (LN) 11 was conducted on 12/12/24 at 9:51 A.M. LN 11 stated Resident's 36's DAR for December 2024 had no blood sugar result for 12/4/24 at 11 A.M. and on 12/5/24 at 11 A.M. LN 11 also checked Resident 36's DAR for November 2024 and stated there were no blood sugar results for 11/1/24 at 8 P.M., 11/5/24 at 11 A.M., 11/7/24 at 11 A.M., 11/9/24 at 11 A.M., 11/28/24 at 11 A.M. and 11/29/24 at 11 A.M. LN 11 stated the DAR was not clicked during medication pass which was a problem because staff and the physician will not know if the resident's blood sugar was high or low, and if the resident needed insulin coverage. LN 11 further stated the resident's medical records should have accurate and complete information for the physician to decide when to discontinue the resident's blood sugar finger sticks or adjust insulin doses. 3b. Resident 63 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus with diabetic neuropathy (type of nerve damage) according to the facility's Admission Record. A review of Resident 63's physician's orders for December 2024 was conducted. The physician's orders indicated an order date on 10/7/24 for Insulin Lispro .Inject as per sliding scale .subcutaneously (under the skin) before meals and at bedtime . The physician's order did not indicate when to check Resident 63's blood sugar. An interview and joint record review of Resident 63's DAR with LN 11 was conducted on 12/12/24 at 9:51 A.M. LN 11 reviewed Resident 63's DAR for December 2024. LN 11 stated there was no documentation on Resident 63's DAR for 12/4/24 at 6:30 A.M. and 11:30 A.M., 12/5/24 at 11:30 A.M. and on 12/10/24 at 8 P.M. LN 11 reviewed Resident 63's DAR for November 2024 and stated there was no documentation for 11/2/24 at 6:30 A.M., 11/3/24 at 6:30 A.M., 11/7/24 at 11:30 A.M., 11/9/24 AT 11:30 A.M., 11/28/24 at 11:30 A.M. and on 11/29/24 at 11:30 A.M. LN 11 stated the DAR was not clicked during medication pass which was a problem because staff and the physician will not know if the resident's blood sugar was high or low, and if the resident needed insulin coverage. LN 11 further stated the resident's medical records should have accurate and complete information for the physician to decide when to discontinue the resident's blood sugar finger sticks or adjust insulin doses. An interview was conducted with the Director of Nursing (DON) on 12/12/24 at 2:24 PM. The DON stated she expected resident's diabetic administration records to be complete and accurate. The DON stated medication administration should also be followed according to physician's orders. The DON stated if it was not documented, it was not done. The DON stated it was important to document resident's blood sugar results and insulin administration to prevent glycemic (change in blood sugar in the blood) reactions. The DON further stated if the blood sugar was not documented, the physician would not see trends and monitor the effectiveness of the medication which may need an adjustment. A review of the facility's policy and procedure (P&P) titled, Obtaining a Fingerstick Glucose Level, dated December 2024 was conducted. The P&P indicated, .The purpose of this procedure is to obtain a blood sample to determine the resident's blood glucose level .The person performing this procedure should record the following information in the resident's medical record .The date and time the procedure was performed .The name and title of the individual(s) who performed the procedure . During a review of the facility's P&P titled, Documentation of Medication Administration, dated November 2022 the P&P indicated .A nurse documents .all medications administered to each resident . Administration of medication is documented immediately after it is given . Documentation of medication administration includes, as a minimum . initials, signature and title of the person administering the medication .

Based on observation, interview, and record review, the facility failed to ensure infection control practices were followed when an expired disinfectant (kills or inactivates germs) wipes were removed from the cart, and a resident with a wound infection was not placed on Enhanced Barrier Precaution (EBP-infection control measure to prevent spread of infection) timely. These deficient practices could potentially spread infectious diseases in the facility. Findings: 1. On [DATE] at 9:46 A.M., an observation and interview was conducted with the Treatment Nurse (TN). Before the wound care observation, the TN stated she sanitized all her equipment with the wipes and placed the wipes back in the cart. After the wound care treatment, the TN rolled the used table and scissors out of the resident's room to the treatment cart in the hallway. The TN then got the wipes inside the treatment cart and showed that the expiration date was [DATE]. The TN stated she should not use the wipes since they were expired. The TN walked to the next medication cart and grabbed another wipes container. The TN then showed that the expiration date of the wipes was unreadable. The TN stated she could not use the wipes because she could not read the year the wipes expired. The TN stated she should not use expired wipes to ensure the equipment was sanitized. On [DATE] at 8:44 A.M., an interview was conducted with the Infection Preventionist (IP). The IP stated expired wipes should have been taken off use to ensure the efficacy of the wipes and prevent the spread of germs. Per the facility's policy and procedure, dated ,d+[DATE], titled Cleaning and Disinfection of Environmental Surfaces, .Manufactures' instructions will be followed for proper use of disinfecting (or detergent) products including: manufacture expiration date . 47466 2. A review of the facility's Admission Record indicated Resident 62 was admitted to the facility originally on [DATE] but was readmitted on [DATE] with diagnoses that included muscle weakness and Acute respiratory failure with hypoxia (low oxygen level). An observation on [DATE] on Resident 62's room was conducted. Resident 62 had Enhanced Barrier Precaution(EBP-infection control measure to prevent spread of infection) signage and PPEs (personal protective equipment) in a clear plastic cubicle outside his room by the door. An interview on [DATE] at 9 A.M., with licensed Nurse (LN) LN 11 was conducted. LN 11 stated Resident 62 was on EBP due to a wound on his foot and was being treated daily by the treatment nurse. A record review of Resident 62's Physician's order summary dated [DATE] indicated Resident 62 had treatment to his left lateral foot wound and was on low air loss mattress to maintain skin integrity. An interview on [DATE] at 2 P.M., with the IP (Infection Preventionist Nurse) was conducted. The IP stated we did not place Resident 62 on EBP until [DATE] and did not notify Resident 62's physician. The IP stated it was important to have Resident 62 on EBP to protect Resident 62 from the spread of infection and could have affected his health condition and or decline. An interview on [DATE] at 2:46 P.M., with the Assistant Director of Nursing (ADON) was conducted. The ADON stated it was important to have Resident 62 on EBP to prevent the spread of infection and avoid worsening of the wound that could affect Resident 62's health condition. A review of the facility's policy titled Enhanced Barrier Precautions dated [DATE], indicated .Policy Interpretations and Implementations . #5. EBPs are indicated ( when contact precautions do not otherwise apply) for residents with wounds .

Based on interview and record review, the facility failed to ensure call lights were answered in a timely manner for a confidential group. This failure resulted in resident's suffering a lack of dignity when the confidential group voiced anger and frustration over call light incidences with the facility staff. The facility census was 86. Cross reference F851 Findings: On 12/10/24 at 10 A.M., a confidential group meeting was conducted. Three out of seven in attendance indicated complaints regarding the facility call light response time. According to the confidential group, the facility call light response depended on the shift, when staff were busy and there were times, staff took break all at the same time. The confidential group stated there were times they waited an hour for staff to answer call lights any time of the day. According to the confidential group the facility was understaffed and there were times, residents waited for an hour to get medications including pain medications. On 12/10/24, a record review of Resident Council Minutes on call light from September to November 2024 was conducted and indicated the following: 9/19/24 - call lights - ongoing concern 10/17/24 - call lights - on going concerns 11/29/24 - call lights are taking too long On 12/11/24 at 10:08 A.M., and interview was conducted with the Activity Director (AD). The AD stated when resident council have concerns, they go to department leaders. The AD stated call light response concerns were given to the Director of Staff Development (DSD). The AD stated the resident council stated call light response was a concern on all shifts. The AD stated the call light response concerns were ongoing. The AD stated there was no improvement on call light response. On 12/12/24 at 11:18 A.M., a concurrent interview and record review was conducted with the DSD. The DSD stated she received call light response concerns a few weeks ago. The DSD stated residents complained call light response took 30 minutes or more. The DSD stated she conducted in-services and follow up with residents and employees but call light response concerns were still ongoing. The DSD stated call light response was everyone's responsibility to make sure call light was answered timely. On 12/12/24 at 12:20 P.M., an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated the acceptable call light response time should be between less than five (5) minutes and longest call light response time should be 30 minutes. The ADON stated employees should respond to call light in a timely manner because residents would be upset. The ADON stated when residents wait for their pain medications, residents would yell and become agitated. The ADON stated when residents would wait for incontinent care (providing assistance in cleaning and changing residents when soiled), residents would be prone to infection and would be emotional and not feel comfortable. Per the undated facility policy titled, Answering the Call Light indicated, .the purpose of this procedure is to ensure timely responses to the resident's requests and needs .1. Answer the resident call system immediately .

Based on observation, interview, and record review, the facility failed to ensure that 1 of 2 sampled resident's, reviewed for abuse, were free from physical abuse when (Resident 1) was physically assaulted by another resident (Resident 2). This failure resulted in the following: 1.Resident 1 had pain, bleeding, and a laceration on top of his right eyebrow, bruising of the face and a small cut on top of his nose. 2. Resident 1 was transferred to a general acute care hospital due to right eye pain and was diagnosed with a nasal fracture (break in bone) with overlying soft tissue swelling (bruising) and periorbital (tissues lining the eye socket) hematoma (area of blood that collects outside the vessels). 3. Resident 1 underwent suturing (to close the wound) of two-centimeter (cm) lacerations over the right eyebrow and a one cm laceration of the right lower lid. 4.Resident 1 received a tetanus vaccine (an injection to prevent infection caused by bacteria called Clostridium tetani. When these bacteria enter the body, they produce a toxin that causes painful muscle contractions) and oral antibiotics (medication to fight against infection). 5.Resident 1 manifested symptoms of anxiety, panic (onset of intense fear or discomfort) disorder and depression. Findings: On 6/27/23 at 1:03 P.M., an unannounced onsite visit at the facility was conducted related to a reported resident to resident altercation.Resident 1 was admitted to the facility on [DATE], with diagnoses which included hemiplegia (total or partial paralysis of one side of the body) of his right side, per the facility's Admission Record. A review of Resident 1's History and Physical (H & P) dated 4/20/23, indicated Resident 1 could make his needs known but could not make medical decisions. A review of Resident 1's minimum data set (MDS, an assessment tool), dated 4/19/23, indicated Resident 1 had a Brief Interview for Mental Status (BIMS, ability to recall) score of 15 which meant Resident 1 had an intact cognition. Resident 1's functional status on activities of daily living (ADLs, such as eating, bed mobility, transfer, grooming .) indicated he required an extensive assistance with one-person physical assist. On 6/27/23 at 2:36 P.M., an observation and an interview were conducted with Resident 1. Resident 1 was lying in bed, had hard time expressing himself and had a fading hematoma around his right eye. Resident 1 stated Resident 2 came up to his bed and hit him (Resident 1) in the face. Resident 1 was teary eyed, stated he did not feel safe and wanted to leave the facility. On 6/28/23, a review of Resident 1's change in condition (CIC) dated 6/18/23 at 12 A.M., completed by Licensed Nurse (LN) 1 indicated, Resident 1 was a victim of resident abuse, was found by staff with bleeding and laceration on top of his right eyebrow, bruising of the face, small cut on top of the nose and complained of pain. On 6/28/23, a review of the hospital emergency department (ED) notes, dated 6/18/23, completed by Medical Doctor (MD 1) indicated Resident 1 complained of right eye pain after an assault from his roommate (Resident 2). The ED notes indicated Resident 2 hit Resident 1 with a closed fist multiple times on the face. The physical exam completed by MD 1 indicated Resident 1 had a hematoma in his right superior orbit (eye socket), and a small laceration to the lower lid and right eyelid. The ED notes indicated the results of Resident 1's cat scan (CT, computerized tomography, a procedure that uses a computer linked to an x-ray machine to make a series of detailed pictures of areas inside the body) showed right periorbital soft tissue swelling and hematoma, right nasal bone fractures with soft tissue swelling. The ED notes indicated Resident 1 underwent suturing of a two-centimeter (cm) laceration over the right eyebrow and a one cm laceration of the right lower lid. The ED notes indicated Resident 1 received a tetanus injection. The discharge notes from the ED indicated Resident 1 was to received oral antibiotics two times a day for 10 days. On 6/28/23, a review of Resident 1's nurses progress notes dated 6/19/23 at 1:45 A.M., completed by LN 3 indicated, Resident 1 came back from the hospital on 6/19/23 at 1:30 A.M. Per the LN's note, Resident 1 complained of 7/10 (level of severity, 10 being the most painful) pain on his right eye and was given pain meds. Per the LN's note, Resident 1 had two stitches above his right eyebrow with dark purplish bruising around his eyes with swelling. Per the LN's note, Resident 1 was reported to have right sided nasal fracture, and right orbital swelling. Per the LN's note, Resident 1 was referred to an eye care specialist and Ears, Nose Throat (ENT) doctor. On 6/28/23, a review of Resident 1's physician progress noted dated 6/19/23 at 3:30 P.M., indicated, the physician gave a new order for antianxiety medication to Resident 1. On 6/28/23, a review of Resident 1's nurses progress notes dated 6/20/23 at 12:56 P.M., completed by the Director of Nursing (DON) indicated, Resident 1 did not feel safe at the facility and requested to transfer. On 6/28/23, a review of Resident 1's nurses progress notes dated 6/20/23 at 2:31 P.M., completed by LN 4 indicated, Resident 1 refused breakfast and lunch, felt depressed and did not feel safe at the facility. On 6/28/23, a review of Resident 1's social services (SS) notes dated 6/20/23 at 4:20 P.M., completed by SS indicated, Resident 1 was in pain, was depressed and verbalized to SS that he did not want to live at the facility. On 6/28/23, a review of Resident 1's nurses progress notes dated 6/21/23 at 8:51 A.M., completed by LN 5 indicated, Resident 1 refused to eat unless was sent out of the facility. On 6/28/23, a review of Resident 1's CIC dated 6/21/23 at 9:01 A.M., indicated, .Behavioral Status Evaluation: Depression (e.g., crying, hopelessness, not eating, multiple somatic complaints) .Neurological Status Evaluation: Nursing observations, evaluation, and recommendations are: since he came back from ED [sic] reported not eating, claiming continues to do till placement done out of here . On 6/28/23, a review of Resident 1's social services notes dated 6/21/23 at 1:56 P.M., completed by SS indicated, Resident 1 verbalized to SS that he (Resident 1) was depressed and angry that he could not defend himself. On 6/28/23, a review of Resident 1's social services notes dated 6/22/23 at 4:01 P.M., completed by SS indicated, Resident 1 verbalized to SS that he wanted a discharge plan. Per SS notes, Resident 1 was noted with Post- Traumatic Stress Disorder (PTSD, a mental and behavioral disorder that can develop because of exposure to a traumatic event) due to physical abuse - flashback, fear, severe anxiety, and/ or mistrust, loss of interest in activities (meals), guilt, and/ or loneliness . On 6/28/23, a review of Resident 1's mental health physician progress notes dated 6/22/23 at 9 P.M., indicated Resident 1 demonstrated symptoms of severe anxiety and moderate intensity of depression. Per the physician progress notes, Resident 1 symptoms of anxiety observed included Persistent and exaggerated negative beliefs of expectations about self and others which cause significant anxiety, intrusive thoughts, frequently shifting concerns, uncomfortable with uncertainty, anticipatory anxiety such as fearing continued negative events and worry is experienced as difficult to control and distressing. The pt. manifests the diagnostic features of panic disorder .Pt was recently attacked by a resident at the facility and reported he does not feel safe since the attack and wants to be moved to another facility .Regarding symptoms of anxiety: Patient presents as nervous. Symptoms of depression include feeling alone in the world even when others are around. Regarding depressive symptoms: Patient presents as troubled with cares . Resident 2 was admitted to the facility on [DATE], with diagnoses which included Huntington's disease (genetic disease that attacks the brain, causing unsteady and uncontrollable movements, cognition [perception, awareness, thinking, judgement] and mental health), per the facility's Admission Record. A review of Resident 2's minimum data set (MDS, an assessment tool), dated 4/26/23, indicated Resident 2 had a BIMS score of 6 which meant Resident 2 had a severely impaired cognition. Resident 2's functional status on transfer indicated the activity occurred once or twice with one-person physical assist. On 6/27/23 at 2:10 P.M., an observation and an interview were conducted with Resident 2. Resident 2 was lying in bed, watching television. During the interview, Resident 2 was asked about the altercation with Resident 1. Furthermore, during the interview, Resident 2 got agitated, yelled, made a fist, and swung his fisted hands up in the air. Resident 2 stated Resident 1 called him names and the staff did not do anything about it. On 6/27/23 at 3:09 P.M., an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated on 6/18/23, Resident 1 was agitated, and was yelling. CNA 1 stated before the time of the physical altercation occurred, she (CNA 1) answered Resident 1 and 2's call light. CNA 1 stated she checked on Resident 1 while Resident 2 yelled at them (CNA 1 and Resident 1). CNA 1 stated while she was asking questions to understand what happened, Resident 2 swung opened the privacy curtain between him and Resident 1. CNA 1 stated I thought it (curtain) got ripped off. CNA 1 stated Resident 2 kept on yelling, bent to his knees, and grabbed Resident 1's bed. CNA 1 stated From the few words I got, (name of Resident 2) was threatening to hit (name of Resident 1). CNA 1 stated Resident 1 was Very scared, and Resident 2 was Aggressive. CNA 1 stated she asked Resident 2 to get off Resident 1's bed, for him to sit down, and it took her several times to say it before Resident 2 complied. CNA 1 stated once Resident 2 laid back to his bed, she (CNA 1) stepped out from the residents' room to inform the licensed nurse (LN) 1. CNA 1 stated LN 1 directed her to inform LN 2. CNA 1 stated a few minutes after stepping out, the assigned CNA (2) came back and checked Residents 1 and 2 and found Resident 1 was injured and bleeding in his right eyebrow. CNA 1 stated I realized the issue and did a mistake by leaving them alone in the room. CNA 1 stated she panicked and should have not left the two residents. On 6/28/23, a review of Resident 2's nurses' progress notes dated 5/28/23 at 10:43 A.M., completed by LN 6, indicated Resident 2 had an increased agitation, refusing care and became physical with a staff. Per the nurses' notes, Resident 2 was sent to the hospital. On 6/28/23, a review of Resident 2's hospital records dated 5/28/23, completed by MD 2, indicated Resident was aggressive and was combative with the staff at the skilled nursing facility (SNF). Per MD notes, Resident 2 was extremely agitated and combative at the emergency department (ED) and required chemical restraints by the ED physician. On 6/28/23, a review of Resident 2's nurses' progress notes dated 6/3/23 at 1:26 P.M., completed by LN 6, indicated Resident 2 came back from the hospital. Per the nurses' notes, Resident has history of aggressive and combative behavior and noncompliance with medication requiring chemical restraints and a sitter. His Seroquel (antipsychotic medication) was increased and will be referred for psyche consult while in the facility. Will be monitored for adherence to medications and changes in mood or behavior . On 6/28/23, a review of Resident 2's H & P dated 6/6/23, indicated Resident 2 could make needs known but could not make medical decisions. A physician's progress notes dated 6/6/23, indicated Resident 2 had increased agitation, his behaviors were not controlled in the facility and was sent to hospital. Per MD notes, the plan was to monitor Resident 2 and he seemed okay as far as agitation was concerned. On 6/28/23 at 3:57 P.M., a telephone interview was conducted with LN 2. LN 2 stated the physical altercation could have been prevented if CNA 1 stayed with the residents and did not leave the residents' room. On 6/28/23 at 3:59 P.M., a telephone interview was conducted with the DON. The DON stated CNA 1 should have called for help and should not have left the residents' room to prevent the physical altercation. On 6/28/23, a review of the facility's policy titled, Abuse Prevention Program, revised December 2016, indicated, Our residents have the right to be free from abuse .This includes but is not limited to .physical abuse .1. Protect our residents from abuse by anyone including, but not necessarily limited to .other residents . On 6/28/23, a review of the facility's policy titled, Resident to Resident Altercation, revised December 2016, indicated, .1. Facility staff will monitor residents for aggressive/inappropriate behavior towards other residents, family members, visitors, or to the staff .