Every finding on record at Delta Oaks Post Acute

Based on observation, interview, and record review, the facility failed to maintain a comfortable homelike environment for 6 of 29 sampled residents (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, and Resident 6) when, Resident 1 and Resident 2's room (Room A) and Resident 3 and Resident 4's room (Room B) remained warm through 8/24/26 after the facility was made aware of the warm room temperatures on 8/16/26, and Resident 5 and Resident 6's room (Room C) was also found to be warm on 8/24/26.This failure resulted in residents experiencing discomfort from the warm room temperatures and placed residents at risk for dehydration, weakness, and altered mental status (a serious change in a person's thinking, awareness, or ability to respond) from heat-related illness.Findings:During an observation on 8/24/26 at 2:44 PM in the subacute unit, cool air was coming from the air-conditioning vents in the hallway ceiling, and the hallway thermostat displayed 74 F (degrees Fahrenheit, a unit used to measure temperature). Portable air conditioners were present in some resident rooms. Room A, Room B, and Room C did not have portable air conditioners.During a concurrent observation and interview on 8/24/26 at 3:15 PM with Resident 2 in Room A, Resident 2 was lying in bed with a thin blanket covering him. Resident 2 was nonverbal (unable to communicate using spoken words) but responded to questions by nodding and shaking his head. Resident 2 shook his head no when asked if he was comfortable in the room, nodded yes when asked if the room was warm, and gestured toward the blanket indicating that he wanted it removed.During a concurrent observation and interview on 8/24/26 at 3:24 PM with Certified Nursing Assistant (CNA) 1 in Room A, CNA 1 stated that Room A was warm and uncomfortable. CNA 1 further stated that Room B and Room C were also warm and that Resident 3's Family Member (FM) had repeatedly expressed concerns to staff about the warm temperature in Resident 3's room (Room B).During a concurrent observation and interview on 8/24/26 at 3:36 PM with the Director of Maintenance (DM) in the subacute unit, the DM measured the room temperatures using a scan thermometer (a handheld device used to measure temperature). The DM measured Room A at 80 F, Room B at 81 F, and Room C at 80 F. The DM stated that no air was coming from the air-conditioning vent in Room B. The DM further stated that some resident rooms had portable air conditioners that helped cool the rooms and that Room A, Room B, and Room C could benefit from having portable air conditioners.During an interview on 8/24/26 at 4:01 PM with the Sub-Acute Director (SAD), the SAD stated that warm rooms such as Room A, Room B, and Room C placed residents at risk for dehydration, exhaustion (extreme tiredness and weakness), and altered mental status (a serious change in a person's thinking, awareness, or ability to respond).During an interview on 8/24/26 at 4:07 PM with the Administrator (Adm), the Adm stated that the facility should provide a comfortable environment for residents. The Adm acknowledged that warm room temperatures could cause resident discomfort. The Adm further stated that he was not aware that no air was coming from the air-conditioning vent in Room B.During an interview on 8/25/26 at 8:06 AM with Resident 3's Family Member (FM), the FM stated that for approximately one week, she had noticed that the air conditioning in Room B turned on and off causing the room to become warm. The FM stated that she had repeatedly reported the warm room to nursing staff and was told that a work order had been submitted, but the room remained warm. The FM stated that Room B was very uncomfortable and remained warm during her visit on the afternoon of 8/24/26. The FM further stated that the warm room should not be ignored because Resident 3 was unable to verbally express discomfort and that the facility needed to address the condition.During a concurrent interview and review of TELS (an electronic system used to submit and track maintenance work orders) on 8/25/26 at 12:16 PM with the DM, a work order dated 8/16/26 at 4:41 PM indicated that Room A and Room B were reported as warm and that the thermostat outside Room A and Room B had no lights and was not working. A second work order dated 8/23/26 at 4:18 PM indicated that the thermostat between Room A and Room B was not working and that the rooms were hot. The DM stated that when the hallway reached the set temperature, the hallway thermostat triggered the air-conditioning vents in the resident rooms to shut off, resulting in no air coming from the vents and causing the rooms to become warm. The DM clarified that the thermostat having no lights was not the cause of the warm rooms. The DM stated that portable air conditioners could help cool the rooms and acknowledged that Room A and Room B had been reported as warm and that a solution had not yet been provided to keep the residents comfortable.Review of the facility's policy and procedure (P&P), titled Maintenance of Building Temperatures / Provisions for Extreme Heat or Cold, indicated that complaints or concerns of resident discomfort related to building temperatures were to be forwarded to maintenance, nursing, and administration. The P&P further indicated, All reports of temperature problems must be reported to the Administrator or DON. In conjunction with maintenance staff, Administrator and nursing will assess and determine the extent and length of the problem and determine what types of action will need to be taken.All necessary repairs are to be made within forty-eight (48) hours.

Based on observation, interview, and record review, the facility failed to maintain a safe and sanitary environment and implement infection prevention and control practices (steps taken to prevent and stop the spread of infection) to minimize the potential for contamination and transmission of infectious agents (germs that can make a person sick) for a census of 104 when the facility failed to:1. Store clean linens in a manner that protected them from potential contamination when clean linens were placed directly on top of a trash receptacle in Resident 1's room;2. Properly contain and store biohazardous waste (medical waste that may contain germs and could spread infection) when two biohazard waste receptacles were filled beyond capacity, preventing the lids from fully closing, with red biohazard bags protruding outside the receptacles, and additional red biohazard bags were observed on the floor of the biohazard room; and3. Properly contain and store medical supplies/equipment when multiple drainage/collection bags and attached tubing were stored uncovered and overflowing from a container in the medication room, with portions of the tubing, connectors, and clamps hanging from the container, and in direct contact with the floor.These deficient practices had the potential to result in cross-contamination (the spread of germs from one place or thing to another), exposure to infectious materials (items or substances that may carry germs and spread infection), and the transmission of infectious agents, placing Resident 1 and the facility's remaining 103 residents at risk for infection. Findings:1. Review of Resident 1's admission RECORD, indicated Resident 1 was admitted to the facility with a diagnosis of, but not limited to acute respiratory failure with hypoxia (a sudden serious breathing problem that causes dangerously low oxygen in the body), dependence on respirator status (the person needs a breathing machine to help them breathe), diabetes mellitus (a condition where there is too much sugar in the blood), and presence of tracheostomy (an opening in the neck with a tube to help a person breathe) and gastrostomy (an opening into the stomach used to give food, fluids, or medicines through a feeding tube).During a concurrent observation and interview on 8/19/26 at 7:34 AM with the Central Supply (CS), in Resident 1's room, a stack of clean linens, including white towels, washcloths, and bed linens, was observed uncovered and placed directly on top of a trash receptacle. The trash receptacle was located on the left side of Resident 1's bed and to the right upon entering the resident's room. The clean linens were observed in direct contact with the top surface/lid of the trash receptacle. The CS observed the linens and confirmed that they were clean supplies intended for use by the Certified Nursing Assistants (CNAs) in providing care to Resident 1. The CS stated that clean linens should not be placed on top of a trash receptacle because doing so created an infection control concern and could potentially contaminate the clean linens. The CS further stated that this could affect Resident 1 and that the resident deserved clean linen supplies, particularly because the resident was already compromised.2. During a concurrent observation and interview on 8/19/26 at 8:01 AM with the CS, upon entering the facility's biohazard room, two gray biohazard waste receptacles were observed positioned next to each other against the wall. Both receptacles contained red biohazard waste bags that were filled beyond the capacity of the receptacles, preventing the lids from fully closing. The lids of both receptacles remained partially open, with the red biohazard waste bags protruding above and outside the receptacles. A red biohazard waste bag from the receptacle on the right extended over the front edge and outside of the receptacle. Additional red biohazard bags were observed lying directly on the floor in front of the receptacles. The CS observed the condition of the biohazard waste receptacles and confirmed that they were overflowing. The CS stated that the biohazard waste should have been appropriately contained and the receptacles should have remained covered rather than left open and exposed. The CS stated that nursing staff were responsible for ensuring that biohazard waste was appropriately addressed and that additional biohazard waste receptacles were available for use when the existing receptacles became full. The CS further stated that the overflowing and uncovered biohazard waste presented an infection control concern because the biohazard waste was left exposed. The CS also identified a safety concern for staff or other individuals entering the room due to the condition of the waste containers and materials in the area, which could contribute to an accident. The CS stated that odor from the exposed biohazard waste could be detected when the door to the room was opened and that the condition did not contribute to maintaining a clean, sanitary, and homelike environment within the facility.3. During a concurrent observation and interview on 8/19/26 at 8:11 AM with the CS, upon entering the facility's medication room, a large plastic container was observed positioned on a wooden platform against the wall. The container was filled beyond its top edge with multiple medical supplies, including intravenous (IV - meaning into a vein) bags, IV tubing, and other drainage/collection bags with attached tubing. Several bags and lengths of tubing extended over the sides of the container. Portions of the tubing, including connectors and clamps, were observed hanging from the container and lying directly on the medication room floor. The contents were uncovered and were not contained within a closed or covered receptacle. The CS observed the condition and confirmed that the items were used IV bags, IV tubing, and other related medical supplies that had been used during the provision of resident care in residents' rooms. The CS identified the items as biohazardous waste and stated that they should have been handled and disposed of properly. The CS stated that it was not acceptable for used resident-care supplies to be overflowing from an uncovered container inside the medication room. The CS stated that only nursing staff had keys and access to the medication room and that nursing staff were responsible for maintaining the organization and cleanliness of the medication room. The CS further stated that the medication room needed to be maintained in a clean and sanitary condition and identified the observed condition as both an infection control and safety concern. The CS stated that additional biohazard waste receptacles were available in the facility's back storage area and that nursing staff could request additional receptacles when needed. The CS confirmed that appropriate biohazard waste receptacles were available for use at the time of the observation.During an interview on 8/19/26 at 11:21 AM with the Infection Preventionist (IP), the IP stated that the facility had only one designated biohazard room for the entire facility. The IP stated that examples of biohazardous waste placed in red biohazard bags included sharps containers containing used razors and needles and used suction canisters. The IP stated that biohazard waste receptacles should not be allowed to overflow, should remain covered, and should not have red biohazard bags exposed or protruding from the receptacles. The IP stated that overflowing biohazard waste receptacles were not acceptable because, if a bag fell to the floor and opened, its contents could spill out, potentially exposing staff to biohazardous materials, compromising staff safety, and increasing the potential for the spread of infection. Regarding the medication room, the IP stated that every nurse was responsible for ensuring that the medication room was maintained in a clean and sanitary condition. The IP stated that the presence of overflowing used intravenous (IV) tubing and total parenteral nutrition (TPN - nutrition given directly into a person's bloodstream through an IV when they cannot get enough nutrition by eating or through the stomach) bags in an uncovered container inside the medication room, rather than being properly contained in a designated biohazard waste receptacle, was not acceptable. The IP stated that used resident-care supplies should be appropriately contained and disposed of and that leaving these items exposed and overflowing in the medication room created an infection control and safety concern and increased the risk for the spread of infection. Regarding the clean linens observed on top of the trash receptacle in Resident 1's room, the IP stated that an in-service training regarding the proper handling of clean linens had been conducted the previous Friday. The IP stated that clean linens should be placed inside a protective plastic bag when being transported into a resident's room to protect the linens from contamination. The IP stated that placing uncovered clean linens directly on top of a trash receptacle could contaminate the clean linens. The IP further stated that if contaminated linens were subsequently used to provide care to a resident, the resident would be placed at increased risk for infection and there was also the potential for the spread of infection through cross-contamination. The IP stated that it was important for staff to follow the facility's Infection Prevention and Control Program and established infection prevention practices to prevent cross-contamination, reduce the potential for the spread of infection, and ensure resident and staff safety.During an interview on 8/19/26 at 4:22 PM with the Director of Nursing (DON), the DON stated that it was her expectation that the facility's designated biohazard room be maintained in a clean and sanitary condition and that biohazard waste receptacles not be allowed to overflow. The DON stated that nursing staff were responsible for ensuring that biohazardous waste was properly contained and that the biohazard room was appropriately maintained. The DON stated that when biohazard waste required removal, nursing staff should contact Maintenance to arrange for pickup by the facility's contracted biohazard waste disposal company. The DON stated that it was important for biohazardous waste to remain properly contained and not overflow because improperly contained biohazardous waste created potential safety and infection control risks. The DON further stated that preventing cross-contamination was particularly important because the facility was experiencing a COVID-19 outbreak at the time. Regarding the biohazardous waste observed in the medication room, the DON stated that nursing staff were responsible for properly handling and disposing of used intravenous (IV) supplies and for maintaining the medication room in a clean and sanitary condition. The DON stated that it was her expectation that biohazard waste containers in the medication room should not be allowed to overflow. The DON stated that nurses had been provided education regarding the proper handling and disposal of used IV supplies. The DON explained, when the smaller biohazard waste containers became full, nursing staff were expected to remove them from the medication room, take them to the facility's designated biohazard room, and replace them with new containers. The DON stated that maintaining appropriate infection control practices was a team responsibility and was not limited to one individual. The DON identified the observed condition as an infection control concern that created a potential risk for cross-contamination. Regarding the clean linens observed on top of the trash receptacle in Resident 1's room, the DON stated that it was her expectation that clean linens and other clean supplies intended for resident use be placed and maintained in a clean area to protect them from potential contamination. The DON stated that protecting clean resident-care supplies from contamination was important to prevent exposing residents to factors that could increase their risk of contracting an infection. The DON stated that infection prevention and control was very important in maintaining a healthy and safe environment for everyone in the facility, including residents, family members, visitors, and staff.Review of the facility policy and procedure titled, Infection Prevention and Control, dated 5/6/26, the P&P indicated, Policy Statement - The facility adopted infection prevention and control policies and procedures are intended to help maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. Policy Interpretation and Implementation - 1. Infection prevention and control policies and procedures apply to all personnel, consultants, contractors, residents, visitors, and volunteers. 2. The objectives of the infection prevention and control policies and procedures are to: a. monitor, prevent, detect, investigate, and control infections in the facility; b. maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public; . 5. All personnel are trained on infection prevention and control policies and procedures .

Based on interview and record review the facility failed to implement effective interventions and supervision to ensure the safety of one resident (Resident 2), in a sample of six when Resident 1 (Resident 2's roommate), who had an extensive history of verbal aggression towards Resident 2, hit Resident 2 on his legs on 5/7/26. This failure resulted in Resident 2 having 3 out of 10 pain (A pain level of 3 on a standard 0 to 10 scale indicates mild, noticeable pain) and placed Resident 2 at risk of psychosocial harm including fear, anxiety, depression, withdrawal, and feelings of hopelessness.Findings:A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility with diagnoses which included blindness in one eye, muscle weakness, anxiety disorder (a group of treatable mental health conditions characterized by persistent, excessive, and disproportionate fear or worry in everyday situations), and cataract (a clouding of the eye's lens).A review of Resident 1's Minimum Data Set (MDS- a federally mandated resident assessment tool) Cognitive Patterns, dated 4/10/26, indicated Resident 1 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 13 out of 15 (Brief Interview for Mental Status score of 13 means cognition is generally intact and normal).A review of Resident 1's MDS (Minimum Data Set (MDS) is a standardized assessment tool that measures health status) section B titled, Hearing, Speech, and Vision, dated 4/10/26, indicated, Resident 1 had impaired vision (sees large print, but not regular print in newspapers/books).Review of Resident 1's Progress Notes, dated 7/7/25 at 11:08 p.m., indicated, .Type: Follow-up Documentation . [Resident 1] voiced multiple complaints regarding his roommate [Resident 2], stating that his roommate keeps the fan on and TV on too loud. [Resident 1] expressed frustration, stating that [Resident 2] gets to do whatever he wants and its unfair.Due to [Resident 1's] blindness, it is difficult for him to locate the call light independently: However [Resident 1] is able to call out [yell] when in need of assistance.Review of Resident 1's Progress Notes, dated 10/05/25 at 5:55 p.m., indicated, .Type: Nurses Progress Note. [Resident 1] tried to hit sitter, staff went to his room trying to calm him down, [Resident 1] started yelling at staff. [Resident 1] started hitting the TV tv fall off from the wall. staff put tv on the side. [Resident 1] trying to get into roommates personal space and shut down roommate's TV, staff stop him from getting into roommates' personal space. explained to resident that they both have to respect each others personal space and TV preference. volume was down and tv out of reach.Review of Resident 1's Progress Notes, dated 10/7/25 at 1:53 p.m., indicated, . [Resident 1] has been complaining of his roommate's TV. [Resident 1] was asking for ear plugs so he can keep the noise out. Writer attempted to find ear plugs but was unsuccessful. Writer spoke with roommate about using his headphones with the TV, roommate refused. [Resident 2] shook his head and waved his fingers no to writer, pointing to [Resident 1] and doing a crazy signal to [Resident 1]. Writer was able to get resident's roommate to turn TV down so that [Resident 1] can sleep but reinforcement of usage of headphones are needed due to the roommate [Resident 2] is refusing to put them in use. Writer educated both on compromising and getting along with one another, both acknowledged understanding but both were not happy. Writer will endorse to oncoming nurses regarding both residents on being mindful of the volumes of TV and keep encouraging roommate to utilize ear phones.A review of Resident 1's psychiatric follow up appointment document, dated 12/19/25, indicated, .[Resident 1] was seen for psychiatric follow- up related to history of Major Depressive Disorder and Anxiety Disorder.[Resident 1] reports little interest or pleasure in activities due to vision loss, depressed mood, and irritability or anger when others do not follow rules or when his room mate plays the television loudly.Symptom Triggers: Vision loss and functional limitations, Environmental stressors room mate noise, rule-related conflicts.NON-PHARM RECOMMENDATIONS.Provide Low-Stimulation Environment.Review of Resident 1's Progress Notes, dated 12/26/25 at 3:19 p.m., indicated, . Social Service Progress Note . SSD spoke with [Resident 1] regarding roommates [Resident 2's] increased TV volume. Residents agreed to keep volume at a certain level to allow each other to hear their televisions .A review of Resident 1's document titled, 1:1 Monitoring [dedicated safety or supervision intervention where one qualified staff member is assigned to continuously watch or assist a single individual] , dated 1/2/26 at 2 p.m., indicated, . [Resident 1] complaining of roommates loud TV agitated wants to beat [roommate] up .A review of Resident 1's document titled, 1:1 Monitoring, dated 1/8/26 at 5:30 a.m., indicated, . roommate turn the TV on so loud that made [Resident 1] upset .A review of Resident 1's document titled, 1:1 Monitoring, dated 1/9/26 at 5:30 a.m., indicated, . [Resident 1] yelling at CNA .A review of Resident 1's psychiatric follow up appointment document, dated 3/11/26, indicated, .[Resident 1] was seen for psychiatric follow- up related to history of Major Depressive Disorder and Anxiety Disorder.[Resident 1] reports diminished interest and pleasure in activities related to vision loss, along with depressed mood and episodic irritability particularly in response to environmental stressors such as rule noncompliance by others or excessive noise from his room mate.[Resident 1] has a history of prior psychiatric treatment and remains on psychotropic medications, which appear to be effective. A review of Resident 1's document titled, 1:1 Monitoring, dated 3/22/26 at 2:30 p.m., indicated, . [Resident 1 lying] in bed yelling at his roommate.Review of Resident 1's Progress Notes, dated 3/24/26 at 3:41 p.m., indicated, .Interdisciplinary Progress Note.Resident was wean off from 1:1 during evening shift as previously discussed with RP [resident representative]. [Resident 1] is stable, no c/o agitation or any behavioral symptoms noted. Resident stays calm and follow the direction. Staff was reminded to introduce themselves before going in resident room and explain the tasks, so [Resident 1] is aware about the surroundings.A review of Resident 1's SBAR Communication (a standardized, four-step framework used primarily in healthcare to share information clearly, concisely, and accurately. It stands for Situation, Background, Assessment, and Recommendation) Form, dated 5/7/26 at 5:56 a.m., the document indicated , .Resident to resident altercation.Physical aggression.Writer summoned by CNA that resident in [room number] were arguing about TV volume, and writer immediately went to check on residents and [Resident 1] was seen on [Resident 2's] bed side hitting [Resident 2] on right leg. Residents were separated right away.Per [Resident 1] he hit [Resident 2] with both hands. [Resident 1] was also heard saying [Resident 1] will send [Resident 2] to the hospital if [Resident 1] could.Review of Resident 1's Progress Notes, dated 5/7/26 at 9:41 a.m., indicated, .Social Service Progress Note . SSA [social services assistant] met with [Resident 1] at bedside following a physical altercation with [Resident 2]. [Resident 1] reported that his TV was on and that his roommate [Resident 2].was using the remote to turn the TV off. [Resident 1] stated he asked the roommate several times to stop. [Resident 1] explained that although he is blind and can't see, he is still able to perceive figures and forms of people. [Resident 1] further stated that he observed [Resident 2] making a middle-finger gesture toward him and laughing. [Resident 1] reported becoming upset and feeling disrespected, which led him to strike the roommate [Resident 2] in the head. [Resident 1] stated he has a history of PTSD [a mental health condition triggered by experiencing or witnessing a terrifying or life-threatening event] related to prior military service as an ex-Marine; however, he stated the altercation occurred because he felt disrespected and wanted to send him to the hospital.A review of Resident 1's trauma assessment titled, Trauma Questionnaire - V 2, dated 5/7/26, indicated, .Have you ever experienced this kind of event? Yes. [Resident 1] stated that they are an ex-marine. [Resident 1] claimed that they have PTSD due to being in the war.Review of Resident 1's Care Plan, initiated on 5/7/26, indicated, Focus. [Resident 1] had a resident to resident altercation, [Resident 1] hit room mate with both hands .Goal . Will have no further incidents of resident to resident altercation.Interventions. Evaluate resident for triggers and provide counseling.Review of Resident 1's Progress Notes, dated 5/7/26 at 1:26 p.m., indicated, .Interdisciplinary Care Conference - .[Resident 1] was involved in resident-to-resident altercation.[Resident 1] stated that [Resident 2] was not turning the TV volume down which made him mad. Root cause analysis: [Resident 1] has diagnose of anxiety and depression with visual impairment. [Resident 1] noted with be sensitive to loud noise. Recommendations: IDT recommendation: Residents will be immediately separate the resident to different rooms. [Resident 1] will be provided a calm and quite environment. A review of Resident 2's admission Record indicated Resident 2 was admitted to the facility with diagnoses which included hemiplegia and hemiparesis (no use/limited use of one side of the body), dysphagia (difficulty or discomfort in swallowing), muscle weakness and aphonia (the total loss or severe reduction of the human voice, leaving a person unable to speak).A review of Resident 2's Minimum Data Set (MDS- a federally mandated resident assessment tool) Cognitive Patterns, dated 5/10/26, indicated Resident 2 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 12 out of 15 (Brief Interview for Mental Status score of 12 means moderate cognitive impairment).A review of Resident 2's SBAR Communication Form, dated 5/7/26, indicated, .Resident to resident altercation.Pain: New.Intensity of Pain: 3. [Resident 1] was seen on [Resident 2's] bed side hitting [Resident 2] on right leg. Residents were separated right away. [Resident 2] pointed pain of 3/10 through communication forms to right [lower extremity] below his knee where he was hit.A review of Resident 2's PHQ-2 to 9 Evaluation (Patient Health Questionnaire PHQ-2 and PHQ-9 are standardized, validated screening and evaluation tools developed to detect and measure the severity of depression) dated 5/7/26, indicated, Resident 2 was feeling down, depressed, or hopeless for 7-11 days (out of the last 14 days).During an interview on 6/9/26 at 10:36 a.m., in Resident 1's room, Resident 1 stated his roommate Resident 2 used to control the TV volume for both Resident 1 and Resident 2's TV in Resident 1's room. Resident 1 stated he had told facility staff in the past that Resident 1 was going to beat Resident 2. Resident 1 stated on the day of the incident, Resident 1 got up from his bed and walked to Resident 2's bedside when Resident 2 was watching TV. Resident 1 stated he wanted to fracture Resident 2's head so that Resident 2 could be sent out to the hospital. Resident 1 stated because he could not see, he started punching Resident 2's legs while slowly trying to walk his way up to find Resident 2's head. Resident 1 stated while he was punching Resident 2, staff heard Resident 1 and took Resident 1 out of the room. Resident 1 stated if Resident 2 did not control the TV Resident 1 would not have gotten angry. Resident 1 stated he had seen a lot of fights, and he had a history of PTSD.During an interview on 6/9/26 at 11:37 a.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 2 could have been in pain and Resident 2 could have been scared from the physical altercation. CNA 1 stated in the past Resident 1 and Resident 2 shared a room together where both residents had their own TV. CNA 1 stated CNA 1 had operated Resident 1's TV in the past because Resident 1 could not see and Resident 2 operated his own TV. CNA 1 stated Resident 1 had stated in the past that Resident 1 would beat Resident 2 without a reason. CNA 1 stated facility staff were aware that Resident 1 did not like Resident 2. CNA 1 stated Resident 1 had stated in the past that Resident 1 was mad at Resident 2's loud TV volume and Resident 1 wanted to tear the TV from the wall. CNA 1 stated in the past at times Resident 2 had his TV volume high which made Resident 1 mad. CNA 1 stated Resident 1 was on 1:1 monitoring in the past because Resident 1 had a fall and his family had requested the 1:1 monitoring. CNA 1 stated Resident 1 got upset after he was taken off 1:1 monitoring. CNA 1 stated the physical altercation between Resident 1 and Resident 2 could have been prevented if Resident 1 and President 2 were separated before the incident. During an interview on 6/9/26 at 12:32 p.m., with Certified Nursing Assistant (CNA) 2, CNA 2 stated Resident 2 was nice, and Resident 2 did not have any behavioral issues in the past. CNA 2 stated Resident 1 got violent in the past where Resident 1 screamed and wanted to do whatever he wanted. CNA 2 stated Resident 1 could have physically hurt his roommate and facility staff members when Resident 1 got violent. CNA 2 stated there were times in the past when Resident 2's TV volume was low, and Resident 1 still got upset and stated that Resident 1 did not want to listen to Resident 2's TV. CNA 2 stated in the past Resident 1 was on 1:1 monitoring because Resident 1 couldn't see. CNA 2 stated Resident 1 was not happy when he was taken off from 1:1 monitoring.During an observation and interview on 6/9/26 at 1:01 p.m., in Resident 2's room, Resident 2 used a communication board for communication. Resident 2 pointed to his legs and stated Resident 1 hit Resident 2's legs when Resident 2 was watching TV in his room. Resident 2 was observed to be crying when pointing to his legs. Resident 2 stated he was in pain, and he felt sad when Resident 1 hit his legs. Resident 2 stated he was scared of Resident 1 when Resident 1 was hitting him and thought Resident 1 could hit him again. Resident 2 stated Resident 1 had yelled and threatened about hitting Resident 2 in the face multiple times before the incident. During an interview on 6/9/26 at 2:51 p.m., with Licensed Nurse (LN) 1, LN 1 stated Resident 2 never had any behavioral issues in the past. LN 1 stated Resident 1 had yelled at Residents and staff in the past. LN 1 stated in the past Resident 1 had gone to Resident 2's bedside and tried to find Resident 2's TV remote. LN 1 stated Resident 1 got upset, yelled and used derogatory words towards Resident 2 when Resident 1 couldn't find Resident 2's TV remote. LN 1 stated Resident 1 had behavioral issues towards Resident 2 for a long time before the incident. LN 1 stated the care plan intervention was for the staff to calm Resident 1 by redirecting Resident 1. LN 1 stated LN 1 had seen Resident 1 get frustrated, stood close to Resident 2's bedside trying to hurt Resident 2 in the past before the incident. LN 1 stated Resident 2 had pushed his call light and banged on his bedside table to call staff for help in the past when Resident 1 stood close Resident 2's bedside and yelled at Resident 2. LN 1 stated facility staff were aware Resident 1 had aggressive behavior towards Resident 2 in the past before the incident. LN 1 stated Resident 1's aggressive behavior led to Resident 1 physically hitting Resident 2. LN 1 stated Resident 2 could have felt sad, upset, hurt and probably unsafe when Resident 1 hit Resident 2.During a concurrent interview and record review on 6/9/26 at 4:30 p.m., with the Director of Nursing (DON), the DON stated Resident 1 had been on 1:1 monitoring to help Resident 1 with his care. The DON stated Resident 1 had a history of yelling at facility staff members in the past. The DON stated Resident 1 had been on psychiatric medications and facility staff had been monitoring Resident 1's behavior and redirecting Resident 1. The DON stated Resident 2 had a universal TV remote in the past which could control the TV volume of both Resident 1 and Resident 2's TV volume. The DON stated Resident 1 had his own TV remote which was not universal. The DON stated after the incident on 5/7/26 she found out that Resident 2 had a universal remote which also controlled the TV volume of Resident 1's TV. The DON stated the physical altercation between Resident 1 and Resident 2 could have been avoided if facility staff knew before that Resident 2 had a universal remote which he used to control the TV volume for both Resident 1 and Resident 2's TV. The DON stated Resident 1 could have been provided with a calm environment and redirected to avoid the altercation with Resident 2. During a phone interview on 6/17/26 at 11:57 a.m., with Responsible Party (RP) 2, RP 2 stated the facility staff had informed RP 2 that Resident 1 had punched Resident 2's legs because Resident 2's TV was loud. RP 2 stated Resident 2 had told RP 2 in the past that Resident 1 was weird. RP 2 stated after the incident RP 2 was worried about Resident 2's safety. RP 2 stated Resident 1 and Resident 2 should have been separated before the incident happened when facility staff were aware of the verbal threats from Resident 1 prior to the incident. During a review of a facility policy and procedure titled Abuse Prohibition Policy and Procedure, dated 2021, the document indicated, .HealthCare Centers prohibit abuse, mistreatment, neglect, misappropriation of resident property, and exploitation for all residents. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the patient's medical symptoms. Verbal Abuse is any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to patients or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to: threats of harm; saying things to frighten a patient. Physical Abuse includes hitting, slapping, pinching, kicking. Mental Abuse includes, but is not limited to humiliation, harassment, and threats of punishment or deprivation. Mental abuse may occur through either verbal or nonverbal conduct which causes or has the potential to cause the patient to experience humiliation, intimidation, fear.PURPOSE. To ensure that Center staff are doing all that is within their control to prevent occurrences of abuse. Actions to prevent abuse, neglect, exploitation, or mistreatment. Identifying, correcting, and intervening in situations in which abuse, neglect, and/or misappropriation of patient property is more likely to occur. If the suspected abuse is resident-to-resident, the resident who has in any way threatened or attacked another will be removed from the setting or situation and an investigation will be completed.

Based on observation, interview, and record review, the facility failed to develop a comprehensive care plan (written plan that guides staff on daily care, safety, and interventions based on the resident's needs) for 1 of 6 sampled residents (Resident 1) when, Resident 1's trauma assessment and progress notes section of Resident 1's electronic health record indicated Resident 1 had PTSD (Post-Traumatic Stress Disorder. It is a mental health condition triggered by experiencing or witnessing a terrifying, life-threatening, or deeply shocking event. While it is completely normal to feel afraid or stressed immediately after trauma, people with PTSD experience long-lasting symptoms that interfere with their daily lives).This failure resulted in facility staff not having a care plan for PTSD for Resident 1 which could have provided guidance to facility staff on how to care for Resident 1 including adverse behaviors and identifying PTSD triggering events.Findings: A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility with diagnoses which included blindness in one eye, muscle weakness, anxiety disorder (a group of treatable mental health conditions characterized by persistent, excessive, and disproportionate fear or worry in everyday situations), and unspecified cataract (a clouding of the eye's lens).A review of Resident 1's Minimum Data Set (MDS- a federally mandated resident assessment tool) Cognitive Patterns, dated 4/10/26, indicated Resident 1 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 13 out of 15 (Brief Interview for Mental Status score of 13 means cognition is generally intact and normal).Review of Resident 1's Progress Notes, dated 6/5/26 at 12:20 p.m., indicated, .Sertraline HCl Tablet [a prescription antidepressant] 25 MG Give 1 tablet by mouth one time a day for Depression and Anxiety disorder [manifested by] irritability, restlessness and verbal aggression.Review of Resident 1's Progress Notes, dated 5/7/26 at 9:41 a.m., indicated, .Social Service Progress Note. SSA [Social Services Assistant] met with [Resident 1] at bedside following a physical altercation with [Resident 2]. [Resident 1] reported that his TV was on and that his roommate [Resident 2].was using the remote to turn the TV off. [Resident 1] stated he asked the roommate several times to stop. [Resident 1] explained that although he is blind and can't see, he is still able to perceive figures and forms of people. [Resident 1] further stated that he observed [Resident 2] making a middle-finger gesture toward him and laughing. [Resident 1] reported becoming upset and feeling disrespected, which led him to strike the roommate [Resident 2] in the head. [Resident 1] stated he has a history of PTSD related to prior military service as an ex-Marine; however, he stated the altercation occurred because he felt disrespected and wanted to send [Resident 2] to the hospital.A review of Resident 1's trauma assessment titled, Trauma Questionnaire - V 2, dated 5/7/26, indicated, .Have you ever experienced this kind of event? Yes. [Resident 1] stated that they are an ex-marine. [Resident 1] claimed that they have PTSD due to being in the war.During an interview on 6/9/26 at 10:26 a.m., with the Nurse Practitioner (NP), the NP stated staff had informed NP that Resident 1 had outbursts in the past.During an interview on 6/9/26 at 10:36 a.m., in Resident 1's room, Resident 1 stated his roommate Resident 2 used to control the TV volume for both Resident 1 and Resident 2's TV in Resident 1's room. Resident 1 stated he had told facility staff in the past that he was going to beat Resident 2. Resident 1 stated on the day of the incident, Resident 1 got up from his bed and walked to Resident 2's bedside when Resident 2 was watching TV. Resident 1 stated he wanted to fracture Resident 2's head so that Resident 2 could be sent out to the hospital. Resident 1 stated he could not see so he started punching Resident 2's legs while slowly trying to walk his way up to find Resident 2's head. Resident 1 stated while he was punching Resident 2, staff heard him and took him out of the room. Resident 1 stated if Resident 2 did not control the TV Resident 1 would not have gotten angry. Resident 1 stated he had seen a lot of fights, and he had a history of PTSD.During an interview on 6/9/26 at 11:37 a.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 1 had gotten mad and yelled at staff in the past. CNA 1 stated Resident 1 had stated in the past that he would beat Resident 2 without a reason. CNA 1 stated facility staff were aware that Resident 1 did not like Resident 2. CNA 1 stated Resident 1 had stated in the past that he was mad at Resident 2's loud TV volume and Resident 1 wanted to tear the TV from the wall.During a concurrent interview and record review on 6/9/26 at 3:43 p.m., with LN 2, LN 2 stated social services progress note dated 5/7/26 at 9:41 a.m., indicated Resident 1 had a history of PTSD. LN 2 stated there was no documentation indicating Resident 1 had a care plan for PTSD to provide trauma care. LN 2 stated Resident 1 should have had a care plan initiated after trauma was identified by facility staff. LN 2 stated by having no care plan facility staff would not be able to provide the care needs for residents with PTSD.During a phone interview on 6/15/26 at 10:27 am, with the DON, the DON stated Resident 1 had claimed he had PTSD due to being in the war. The DON stated Resident 1 should have had a care plan for PTSD based on the trauma assessment dated [DATE]. The DON stated she could not find a PTSD care plan for Resident 1. The DON stated a care plan for PTSD could have provided guidance to facility staff on how to care for a resident with PTSD.During a review of a facility policy and procedure titled CARE PLAN COMPREHENSIVE, dated 2021, the document indicated, .An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, physical, mental and psychosocial needs shall be developed for each resident.Each resident's comprehensive care plan is designed to.Incorporate identified problem areas.Reflect the resident's expressed wishes regarding care and treatment goals.Care plan interventions are designed after careful consideration of the relation of the relationship between the resident's problems areas and their causes.The resident's comprehensive care plan is developed within seven [7] days of the completion of the resident's comprehensive assessment MDS.

Based on observation, interview, and record review, the facility failed to ensure interventions were implemented to maintain and prevent decline in psychological functional ability (represents an individual's capacity to perform essential daily tasks, work, and interact with their environment) for 1 of 6 sampled residents (Resident 2) when Resident 2 did not have a psychological or behavioral health consult as outlined in the comprehensive care planned interventions.This failure placed Resident 2 at risk for a decline in functional and psychosocial health (complications related to the dynamic interplay between psychological well-being -thoughts, emotions, identity- and social environment -relationships, cultural context, and societal influences).Findings: A review of Resident 2's admission Record indicated Resident 2 was admitted to the facility in 2024 with diagnoses which included hemiplegia and hemiparesis (hemiplegia and hemiparesis), dysphagia (difficulty or discomfort in swallowing food, liquids, or even saliva), muscle weakness and aphonia (the total loss or severe reduction of the human voice, leaving a person unable to speak).A review of Resident 2's Minimum Data Set (MDS- a federally mandated resident assessment tool) Cognitive Patterns, dated 5/10/26, indicated Resident 2 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 12 out of 15 (Brief Interview for Mental Status score of 12 means moderate cognitive impairment).Review of Resident 2's Progress Notes, dated 4/18/26 at 3:27 p.m., indicated, .Change in Condition Progress Note - Writer notified by CNA that resident was crying and expressing concern by using communication board r/t another CNA [on night shift] was insisting and yelling at resident to turn himself around a lot of times. Resident stated that CNA was standing next to him yelling, resident expressed by moving his hands and fingers back and forth no indicating he cant turn around on his own.Review of Resident 2's Care Plan, Initiated on 4/18/26 and Revised on 5/8/26, indicated, Focus.Resident with potential/risk to exhibit Psycho-Social distress related to alleged verbal abuse.Goal .[Resident 2] will indicate and/or staff will observe [Resident 2] to experience no psycho-social distress.Interventions.Initiated on 4/18/26 . Psychology/Behavioral Health Consult as indicated. Encourage [Resident 2] to verbalize feelings. Listen to [Resident 2] attentively.Review of Resident 2's Progress Notes, dated 4/20/26 at 1:20 p.m., indicated, .Interdisciplinary Care Conference - Concern/Issue: Writer notified by CNA that [Resident 2] was crying and expressing concern by using communication board r/t another CNA [on night shift] was insisting and yelling at resident to turn himself around a lot of times. Resident stated that CNA was standing next to him yelling, resident expressed by moving his hands and fingers back and forth no indicating he can't turn around on his own. Resident stated it's always the same way with her and she treats him this way.Recommendations.SSD to do psychosocial visit with resident to provide emotional support daily x72 hrs [hours] Monitor resident for any psychosocial disturbance every shift Care Plan updated Psych [psychiatric] Referral related to episodes of depression.Review of Resident 2's Progress Notes, dated 4/20/26 at 2:08 p.m., indicated, .Social Service Progress Note.SSA [Social Services Assistant) met with resident by bedside to check on psychosocial wellbeing regarding alleged verbal abuse. [Resident 2] stated that their CNA wanted to reposition them, but [Resident 2] stated they weren't able to; and stated that the CNA raised her voice at him. [Resident 2] expressed feeling sad at that moment. [Resident 2] stated they feel safe within the community. Will continue to monitor psychosocial wellbeing.A review of Resident 2's PHQ-2 to 9 Evaluation (Patient Health Questionnaire PHQ-2 and PHQ-9 are standardized, validated screening and evaluation tools developed to detect and measure the severity of depression) dated 5/7/26, indicated, Resident 2 was feeling down, depressed, or hopeless for 7-11 days (in the last 14 days).Review of Resident 2's Care Plan, initiated on 5/7/26, indicated, Focus.Resident to resident altercation [Resident 2] was hit in the right [lower extremity] by another resident [Resident 1] with his hands .Goal .Will have no further episodes of resident to resident altercation.Interventions.Monitor [Resident 2] for any [signs and symptoms] psychosocial and emotional distress every shift 72 hours.During an interview on 6/9/26 at 11:37 a.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 2 could not move on his own and he needed two people assist for his care. CNA 1 stated Resident 2 was able to use his left hand to point out letters and spell words using the communication board in his room. CNA 1 stated Resident 2 was nice, and Resident 2 had never had any behavioral issues in the past. CNA 1 stated Resident 2 could have been in pain and Resident 2 could have been scared from the physical altercation with Resident 1. During an observation and interview on 6/9/26 at 1:01 p.m., in Resident 2's room, Resident 2 used a communication board for communication. Resident 2 pointed to his legs and stated Resident 1 hit Resident 2's legs when Resident 2 was watching TV in his room. Resident 2 was observed to be crying when pointing to his legs. Resident 2 stated he was in pain, and Resident 2 felt sad when Resident 1 hit Resident 2's legs. Resident 2 stated he feared Resident 1 when Resident 1 hit him. Resident 2 stated after the incident Resident 2 feared Resident 1 and thought Resident 1 could hit Resident 2 again. Resident 2 stated Resident 1 had yelled and threatened about hitting Resident 2 in the face multiple times before the incident. During an interview on 6/9/26 at 2:51 p.m., with Licensed Nurse (LN) 1, LN 1 stated Resident 2 never had any behavioral issues in the past. LN 1 stated she had seen Resident 1 get frustrated, stood close to Resident 2's bedside trying to hurt Resident 2 in the past before the incident. LN 1 stated Resident 2 had pushed his call light and banged on his bedside table to call staff for help in the past when Resident 1 stood close to Resident 2's bedside and yelled at Resident 2. LN 1 stated Resident 2 could have felt sad, upset, hurt and probably unsafe when Resident 1 hit Resident 2.During a concurrent interview and record review on 6/9/26 at 3:43 p.m., with LN 2, LN 2 stated there is no documentation indicating Resident 2 had a psychiatric evaluation since 3/2026. During a concurrent interview and record review on 6/9/26 at 4:30 p.m., with the Director of Nursing (DON), the DON stated facility staff had monitored Resident 2 for psychosocial depression. The DON stated Resident 2 could have felt depressed and felt he was not safe after the incident on 5/7/26.During a concurrent phone interview and record review of Resident 2's care plans on 6/15/26 at 10:27 am, with the DON, the DON stated Resident 2's care plan interventions initiated on 4/18/26 indicated psychology behavioral health consult which meant Resident 1 was going to be seen by psychiatrist for any psychosocial disturbance or depression. The DON stated the social services director followed up on any psychiatric appointments and referrals for the residents.During a concurrent phone interview and record review of Resident 2 medical record on 6/16/26 at 4:01 p.m., with Social Services Director (SSD), the SSD stated the social services department staff would follow up and ask the resident or the resident's responsible party if a resident needed a psychiatric evaluation. The SSD stated she could not find documentation indicating a facility staff member had asked Resident 2 if he wanted a psychiatric evaluation.During a phone interview on 6/17/26 at 11:57 a.m., with Responsible Party (RP) 2, RP 2 stated the facility called RP 2 on 6/16/26 and asked RP 2 if the facility could refer Resident 2 for a psychiatric consultation. RP 2 stated the facility should have arranged for Resident 2 to be seen by a psychiatric consultant earlier when Resident 2 showed emotional distress by indicating Resident 2 felt hopelessness and depressed. RP 2 stated Resident 2 could have had loss of motivation, increased his hopelessness affecting his mental health by not having a psychiatric evaluation.During a review of a facility policy and procedure titled CARE PLAN COMPREHENSIVE, dated 2021, the document indicated, .An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, physical, mental and psychosocial needs shall be developed for each resident.Each resident's comprehensive care plan is designed to.Incorporate identified problem areas.Reflect the resident's expressed wishes regarding care and treatment goals.Aid in preventing or reducing declines in the resident's functional status.Care plan interventions are designed after careful consideration of the relation of the relationship between the resident's problems areas and their causes.The resident's comprehensive care plan is developed within seven [7] days of the completion of the resident's comprehensive assessment MDS.

Based on observation, interview, and record review, the facility failed to ensure services provided met professional standards of practice for 1 of 6 sampled residents (Resident 1) when the facility failed to follow up on a referral from 1/15/26 from the optometrist (an eye care professional who provides primary vision care) and make arrangements for an appointment/transportation for Resident 1 to be seen by an ophthalmologist (a medical doctor (MD) who specializes in eye and vision care. They are qualified to perform eye surgery, diagnose and treat complex eye diseases, and prescribe vision correction tools like glasses and contact lenses).This failure had the potential to place Resident 1 at risk for functional decline and complications from delayed treatment.Findings:A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility with diagnoses which included blindness in one eye, and unspecified cataract (a clouding of the eye's lens).A review of Resident 1's Minimum Data Set (MDS- a federally mandated resident assessment tool) Cognitive Patterns, dated 4/10/26, indicated Resident 1 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 13 out of 15 (Brief Interview for Mental Status score of 13 means cognition is generally intact and normal).A review of Resident 1's MDS section B titled, Hearing, Speech, and Vision, dated 4/10/26, indicated, Resident 1 had impaired vision (sees large print, but not regular print in newspapers/books).Review of Resident 1's Care Plan, initiated on 1/20/25, indicated, Focus. [Resident 1] has vision impairment related to BLINDNESS in both eyes .Goal . [Resident 1] will remain free from falls or injury or decreased socialization .Interventions.Consult with physician for vision evaluation.Assess [Resident 1's] response to visual loss.Review of Resident 1's Progress Notes, dated 7/7/25 at 11:08 p.m., indicated, .Due to [Resident 1's] blindness, it is difficult for him to locate the call light independently: However [Resident 1] is able to call out [yell] when in need of assistance.Review of Resident 1's Progress Notes, dated 8/28/25 at 9:11 a.m., indicated, .Type: Social Service Progress Note.[Resident 1] also said that he is able to see which [Resident 1] has lost sight in both eyes when asked what does he see he said you setting there SS [social services staff] asked do you see the color of my shirt and he replied yes its black SS is wearing a yellow shirt today.Review of Resident 1's Progress Notes, dated 10/20/25 at 5:59 p.m., indicated, . Type: Physician Progress Notes. HEENT : Abnormal vision rt. [right] eye , Awaiting Oph. [ophthalmology or an ophthalmologist] Consult. AGAIN ASKED NURSE TO SCHEDULE OPHTHALMOLOGY CONSULT.Review of Resident 1's Progress Notes, dated 11/3/25 at 6:39 p.m., indicated, . Physician Progress Notes. HEENT [Head, Eyes, Ears, Nose, and Throat]: Blurry vision Rt. Eye, Oph. is working on it.A review of Resident 1's psychiatric follow up appointment document, dated 12/19/25, indicated, .[Resident 1] was seen for psychiatric follow up.[Resident 1] is verbal and fully dependent on staff for daily living activities because of blindness.[Resident 1] reports little interest or pleasure in activities due to vision loss.Review of Resident 1's Progress Notes, dated 12/23/25 at 1:32 p.m., indicated, .Change in Condition Progress Note. Writer was notified by CNA (Certified Nursing Assistant) that [Resident 1] was leaning forward to readjust himself and hit his head on the medication cart. Upon assessment [Resident 1] stated he was trying to fix his pants and didn't see the cart. [Resident 1] has a small bump on his forehead and has aching pain 7/10 [severe pain] saying he has a head ache.A review of Resident 1's vision assessment, dated 1/15/26, the document indicated, Resident 1 had medical diagnosis of phthisis bulbi (an end-stage eye that has shrunk, collapsed, and permanently lost all function following severe injury or disease), and cataracts in left eye. Optometrist referred Resident 1 for a hypertension retinopathy ultrasound (eye damage caused by high blood pressure, which narrows and leaks retinal blood vessels. An ultrasound is used when cloudy conditions block standard views, allowing doctors to look behind the eye for signs of fluid or a detached retina caused by severe hypertension).Review of Resident 1's Progress Notes, dated 1/20/26 at 2:29 p.m., indicated, . Interdisciplinary Care Conference. [Resident 1] will be referred for the following ancillary services.vision.Review of Resident 1's Progress Notes, dated 5/20/26 at 5:29 p.m., indicated, .Social Service Progress Note - SSD (social services director spoke with resident regarding post unwitnessed fall- [Resident 1] stated he was attempting to get into his wheelchair and thought it was his wheelchair however he stated it was not and fell. [Resident 1] stated that this has not happened before getting into wheelchair. However he stated he has tripped on bedside table and landed on the floor and helped himself get up after he has laid there for a second and did not ask for help. [Resident 1] stated he fell 2 months ago on hip and did not ask for help or inform staff, that he helped himself up, as he does from time to time.A review of Resident 1's psychiatric follow up appointment document, dated 6/4/26, indicated, .Follow up psychiatric evaluation for [Resident 1] .primarily due to increased irritability, restlessness, and frustration following vision loss related to cataracts and adjustment. Symptom Triggers: Changes in routine, environmental stimulation noise activity.During an interview on 6/9/26 at 10:36 a.m., in Resident 1's room, Resident 1 stated he could move his hands and locate his call light which was on the right side of his bed. Resident 1 stated he could not see the TV (television) clearly. Resident 1 stated listening to the TV made him feel relaxed. Resident 1 stated he was blind and he wanted to see the eye doctor. Resident 1 stated the eye doctor could have helped him by providing treatment for his vision. Resident 1 stated in the past he had called staff for help but when no one came to help him, he got up on his own to use the restroom. Resident 1 stated he fell on the floor because he could not see. Resident 1 stated he had injured himself and he was in pain from his past fall at the facility.During an interview on 6/9/26 at 11:37 a.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated CNA 1 had operated Resident 1's TV in the past because Resident 1 could not see.During an interview on 6/9/26 at 12:32 p.m., with Certified Nursing Assistant (CNA) 2, CNA 2 stated in the past Resident 1 was on 1:1 monitoring (dedicated safety or supervision intervention where one qualified staff member is assigned to continuously watch or assist a single individual) because Resident 1 could not see. CNA 2 stated Resident 1 was not happy when he was taken off from 1:1 monitoring.During a concurrent interview and record review on 6/9/26 at 3:43 p.m., with LN 2, LN 2 stated Resident 1 was visually impaired and there was no documentation indicating Resident 1 was seen by an ophthalmologist. LN 2 confirmed a doctor's note dated 10/17/25 indicated Resident 1 needed to be seen by an ophthalmologist. LN 2 stated once identified by the doctor that a resident needed a vision appointment the social services director would enter the residents' name on the list to be seen by the in-house eye specialist. LN 2 stated the facility had ancillary services for residents in the facility where the in-house eye doctor would come to the facility and assess residents who required vision care services. LN 2 stated Resident 1 did not have clear vision and Resident 1 was not able to identify who was in front of him, where his bedside table was and where the bathroom was. LN 2 stated a visually impaired resident could fall when trying to get up on their own. LN 2 stated Resident 1 had multiple falls in the past at the facility. LN 2 stated Resident 1 was seen by an optometrist on 1/15/26. LN 2 stated the document from Resident 1's optometric visit on 1/15/26 indicated Resident 1 had to be referred for a hypertension retinopathy ultrasound with an ophthalmologist. LN 2 stated the facility staff should have followed up to get Resident 1's retinopathy ultrasound done. LN 2 stated the intervention for Resident 1's vision care was not followed which could have delayed Resident 1's care and could have put Resident 1 at risk for more falls.During a concurrent interview and record review on 6/9/26 at 4:30 p.m., with the Director of Nursing (DON), the DON stated Resident 1's family members had cancelled Resident 1's eye specialist appointments in the past. The DON stated she could not find a document indicating cancellation of Resident 1's eye specialist appointment.During a phone interview on 6/15/26 at 10:27 am, with the DON, the DON stated Resident 1 was seen by an optometrist on 1/15/26 and the optometrist order indicated Resident 1 to have an ophthalmology referral. The DON stated there was no documentation indicating Resident 1 was seen by an ophthalmologist. The DON stated the facility staff should have made an appointment for Resident 1 to be seen by an ophthalmologist. The DON stated Resident 1 could have gotten treatment done for his vision loss. The DON stated Resident 1 may have been more independent, able to move around on his own, which could have helped Resident 1 from having fall incidents.During a phone interview on 6/16/26 at 1:07 p.m., with Responsible Party (RP) 1, RP 1 stated Resident 1 was visually impaired, and the facility should have followed the eye doctors' orders to provide proper treatment for Resident 1's vision. RP 1 stated a delay in treatment could have possibly deteriorated Resident 1's vision more. RP 1 stated the facility did not inform [RP 1] about Resident 1's vision appointment.

Based on interview and record review, the facility failed to ensure the appropriate discharge process was followed for one of two sampled residents (Resident 1) when;1. The facility did not provide a copy of the 30-day Notice of Transfer/Discharge (a written document given to residents or their representative when a facility plans to move them to another location or end their stay) to Resident 1;2. The facility failed to provide a copy of Resident 1's discharge notice, dated 4/9/26, to a representative of the Office of the State Long-Term Care (LTC) Ombudsman (advocates for residents of nursing homes to protect resident rights);3. The contents of the discharge notice signed by Resident 1 on 4/9/26 did not include the discharge location; and 4. An updated discharge notice when a discharge location was identified on 4/20/26 was not given to Resident 1 until the day of discharge on [DATE].These failures had the potential to result in Resident 1 not being fully informed of her rights and not having adequate advocacy support during the discharge process. These failures did not allow for a reasonable period of at least 30 days between the time the notice was issued, and the date Resident 1 was discharged which has the potential to inhibit Resident 1 from participating and/or assisting in planning of the discharge or appealing the discharge. Findings:During a review of Resident 1's NOTICE OF TRANSFER / DISCHARGE, dated 4/9/26, the notice indicated the reason for transfer/discharge was for non-payment of the share of cost (a set monthly amount that a resident on Medi-Cal/Medicaid must pay toward their care in the facility, similar to a deductible or co-pay). The form was signed by the facility representative. The Copy to: State LTC Ombudsman Office line was left blank, and the Transfer/Discharge to field was also left blank. The effective date (date the discharge was to occur) was listed as 4/9/26, the same date the notice was given to Resident 1.During an interview on 4/20/26 at 1:46 PM with Resident 1, Resident 1 stated she was given a 30-day eviction notice on or about 4/10/26 when the Social Services Director (SSD) and another staff approached her. Resident 1 stated she signed the notice with her initials due to shaky hands. Resident 1 stated she was not given a copy of the 30-day notice.During a concurrent interview and record review on 4/21/26 at 12:30 PM, the SSD reported that she and the Business Office Manager (BOM) initiated the 30-day Notice-of-Transfer/Discharge for Resident 1 on 4/9/26 due to non-payment. The SSD stated that the notice had not yet been submitted to the Ombudsman. The SSD further stated that a room & board home (a place where you pay for a private room to sleep and live in, plus regular meals) placement had been found and they would send a copy of the 30-day notice to the Ombudsman when Resident 1 was discharged . The SSD also stated that Resident 1 did not ask for a copy of the notice, so a copy was not provided to her.During a concurrent interview and record review on 4/21/26 at 4:07 PM with the Administrator (ADM), the ADM confirmed that Resident 1's NOTICE OF TRANSFER / DISCHARGE, dated 4/9/26, was the facility's 30-day Notice of Transfer/Discharge for Resident 1. The ADM stated that they must give a copy by regulation to the resident. The ADM further stated that they should send a copy for all discharge and transfer notices within 24 hours to the Ombudsman.During a concurrent interview and record review on 4/21/26, at 3:19 PM, Resident 1's NOTICE OF TRANSFER / DISCHARGE, dated 4/9/26, was reviewed with the Director of Nursing (DON). The DON stated that a copy of Resident 1's transfer/discharge notice was not given to the Ombudsman because the facility would fax the notice to the Ombudsman on the day Resident 1 was discharged .During an interview on 4/21/26 at 5:24 PM, with the ADM, the ADM stated that the risk for not giving a copy of the discharge notice to Resident 1 was that the resident would not be properly informed about the discharge. The ADM stated the risk for not providing the form to the Ombudsman was that an Ombudsman was the resident's advocate and the Ombudsman would not be aware of the discharge if the notice was not sent to them.During an interview on 4/20/26, at 2:58 PM, with the Ombudsman (OMB), the OMB stated that their office should have received a copy of the 30-day notice of Transfer/Discharge at the same time the notice was given to the resident. During a follow-up interview on 4/22/26, at 2:13 PM, the OMB stated that up until the time of the interview, their office had not yet received the copy of the 30-day Notice of Transfer/Discharge for Resident 1. The OMB further stated that they need to receive the notice in order to provide advocacy for the resident and attend any appeal hearing (occurs when a resident disagrees with the notice and files an appeal). During a follow up phone interview on 4/30/26, at 9:06 AM, with the SSD, the SSD stated that Resident 1's original NOTICE OF TRANSFER / DISCHARGE, dated 4/9/26, had the transfer/discharge to field intentionally left blank because there was no destination address yet. The SSD further stated that the board and care placement was confirmed as the best fit for Resident 1 was on 4/20/26, and once that was known, Resident 1 signed an updated 30-day notice that included the discharge location. The SSD stated she was unsure of the exact date the final notice was sent to the Ombudsman. The SSD also stated that when a resident signs a notice without a destination address yet, the facility's normal practice was to have the resident sign a new/updated notice once the address is known, and that the updated notice is typically uploaded only on the actual discharge day.During a follow up phone interview on 4/30/26, at 9:22 AM, with the Medical Records Director (MRD), the MRD stated that Resident 1's updated NOTICE OF TRANSFER / DISCHARGE, dated 4/23/26, was faxed to the Ombudsman on 4/23/26 at 2:58 PM and that Resident 1 was discharged at approximately 3:55 PM on 4/23/25.During a follow up phone interview on 4/30/26, at 10:53 AM, with Resident 1, Resident 1 stated that the facility had her sign another paper as she was leaving the facility on 4/23/26.During a follow up phone interview on 4/30/26, at 11:17 AM, the SSD stated that she created and signed the updated notice on 4/20/26. The SSD further stated they were still waiting for the DME's (durable medical equipment such as wheelchairs and walkers) and therefore asked Resident 1 to sign the updated Transfer/Discharge Notice on the day she was leaving, 4/23/26.During a follow up phone interview on 4/30/26, at 2:55 PM, the ADM stated that Resident 1's original notice with the Transfer/Discharge to field left blank did not meet the facility's requirements. The ADM further stated that the updated notice signed by Resident 1 on 4/23/26 (the actual day of discharge) was not considered a new notice that reset the 30-day clock, because Resident 1 wanted to go. In addition, the ADM believes the Ombudsman office was notified before Resident 1 left the building around 3:55 PM on 4/23/26. The ADM added that he does not know if the Ombudsman was notified by phone, but he knows the Ombudsman was notified before the discharge. The ADM stated the facility's process when a discharge destination was not known at the time the initial discharge notice was signed, was that they let the residents know they will be discharged within 30 days to a safe location and then update them later.During a review of the facility's policy titled Transfer or Discharge Notices, revised 3/25, indicated, .The resident and representative are provided with a written notice of impending transfer or discharge at least 30 days prior to the transfer or discharge.notified in writing of the following information:.the specific location. to which the resident is being transferred or discharged . a copy of the notice is sent to the Office of the State Long-Term Care Ombudsman at the same time the notice of transfer or discharge is provided to the resident and representative.if the information in the notice changes, the facility will update the recipients of the notice as soon as practicable with the new information to ensure residents and their representatives are aware of and can respond appropriately.For significant changes, such as a change in the transfer or discharge destination, a new notice will be given that clearly describes the change(s) and resets the transfer or discharge date in order to provide 30-day advance notification and allow adequate time for discharge planning.

Based on interview and record review, the facility failed to review and revise the comprehensive person-centered care plan (a step-by-step guide for staff to make sure a person gets the right care in the right way) as necessary to reflect changes in one of two sampled residents (Resident 1) related to discharge planning.This failure had the potential to result in an uncoordinated discharge that did not adequately address Resident 1's discharge needs and preferences.Findings:A review of Resident 1's admission RECORD, indicated Resident 1 was admitted to the facility with diagnoses including Multiple Sclerosis (body's own immune system attacks the protective covering of the nerves).During a review of Resident 1's Care Plan Report, Resident 1's long term care plan, dated 12/4/25, the care plan identified Resident 1 as .Long Term placement on Skilled Nursing Unit. During a review of Resident 1's Progress Notes, dated 1/16/26, at 2:50 PM, the note indicated, .Discharge plan: Resident is requesting to leave the facility to Oakland bay area, closer to significant other. SS [social services] will assist with placement to facility. During a review of Resident 1's Progress Notes, dated 4/17/26, at 12:54 PM, the note indicated, .Discharge plan: Resident has plans to discharge to community. Resident is pending placement to [name of care home]. During a review of Resident 1's Progress Notes, dated 4/20/26, the note indicated that a Discharge Evaluation had been completed. During a review of Resident 1's DISCHARGE PLANNING COMMUNICATION FORM, completed on 4/20/26, the form indicated, Resident 1's discharge destination was a room & board home (a place where you pay for a private room to sleep and live in, plus regular meals) for long term care with an anticipated discharge date and time of 4/22/26 at 10:30AM.During a concurrent interview and record review on 4/21/26 at 12:30 PM with the Social Services Director (SSD) , the SSD reported that she and the Business Office Manager (BOM) initiated the 30-day Notice-of-Transfer/Discharge (a written document given to resident or their representative when a facility plans to move them to another location or end their stay) for Resident 1 on 4/9/26. The SSD also stated that Resident 1's care plan did not include a discharge plan.During a concurrent interview and record review on 4/21/26 at 3:19 PM with the Director of Nursing (DON), the DON reviewed Resident 1's care plan in the electronic health record system and confirmed that there was no discharge care plan documented in the system. The DON indicated that discharge planning was managed by social services.During a follow up telephone interview on 4/23/26 at 10:03 AM with the SSD, the SSD stated that she was primarily responsible for developing and summarizing discharge plans. The SSD acknowledged that the care plan dated 12/4/26, which classified Resident 1 as a long-term placement in the Skilled Nursing Unit, had not been updated. She indicated that, because Resident 1 was scheduled for discharge later that same day (4/23/26) at 1 PM, she was actively working on updating the relevant care plan at the time of interview. The SSD further stated that a discharge care plan was vital for safe resident discharge, requiring coordination between the interdisciplinary team (IDT, group of different professionals at a nursing home who work together to create and update a resident's care plan), and the resident. In addition, the SSD stated that failing to update the plan may result in unrecorded actions, risking the safety and coordination of the process. The SSD confirmed that Resident 1's care plan was not properly updated.During a review of the facility's Policy and Procedure (P&P) titled, CARE PLAN COMPREHENSIVE, effective 8/25/21, the P&P indicated that . the comprehensive care plan includes the following: .resident's preference and potential for future discharge.discharge plan, as applicable, that address the resident's discharge goal(s), the preparation of resident and/or resident representative to be an active partner and effectively transition them to post-discharge care. Assessments of resident are ongoing and the care plans are reviewed and revised as information about the resident and the resident's condition change.

Based on interview and record review, the facility failed to implement safety measures to prevent accidents for one of three sampled residents (Resident 1) when on 3/31/26 while Certified Nursing Assistant (CNA) 1 was providing care alone to Resident 1 on a low air loss mattress (LAL -low air loss mattress, a specialized therapeutic surface featuring air-filled bladders with tiny holes that release a constant, gentle flow of air), Resident 1 fell off of the bed onto the concrete ground.This failure resulted in Resident 1 falling from an elevated bed (approximately 3 feet) onto the concrete ground which resulted in Resident 1 being sent to the emergency department with injuries that included, a fracture to Resident 1's cervical spine neck (C1 -a traumatic break of a bone at the top of the spine), a laceration (a torn, jagged, or ragged tear in the skin or soft tissue) to Resident 1's chin requiring nine sutures (used to close a wound by sewing the edges of the cut together using a thread to help with wound healing), and multiple bruises and injuries to Resident 1's face and body.Findings:A review of Resident 1's admission RECORD, indicated, Resident 1 was admitted to the facility in late 2023 with diagnoses that included, chronic respiratory failure (a long term condition where the lungs cannot properly oxygenate the blood), and anoxic brain damage (a type of brain injury caused by lack of oxygen to the brain leading to brain cell death).A review of Resident 1's Minimum Data Set, (MDS - a resident assessment tool), Section C: Cognitive Patterns, (an assessment of the mental abilities and functions the brain uses to think, learn, remember, pay attention, process information and solve problems) dated 2/28/26, indicated, Resident 1's, .Cognitive Skills for Daily Decision Making.Severely impaired-never/rarely made decisions.A review of Resident 1's MDS, Section B: Hearing, Speech, and Vision, dated 2/28/26 indicated that Resident 1 could not speak, was rarely/never understood, and rarely/never understood others.A review of Resident 1's MDS, Section GG: Functional Limitation in Range of Motion (ROM -the measurement of the distance and direction a body part can move), dated 2/28/26, indicated, .Upper extremity (shoulder, elbow, wrist, hand) .2 - Impairment on both sides.Lower extremity (hip, knee, ankle, foot) .2 - Impairment on both sides.A review of Resident 1's MDS, Section GG: Self-Care assessment dated [DATE], indicated Resident 1 was coded on the assessment tool as, 01. Dependent - Helper [nursing assistant] does ALL of the effort. Resident does none of the effort to complete the activity.assistance of 2 or more helpers is required.to complete the activity. for all hygiene (self-care skills and hygiene involved in toileting and cleaning) including bathing, dressing, and all movement of the body including, rolling side to side, and transferring in and out of bed.A review of Resident 1's Progress Note, written by LN 1, dated 3/31/26, indicated, .At approximately 1430 [2:30 PM] the resident experienced a witness fall from the bed during patient care by [CNA 1]. [CNA 1] remained present in the room at the time of the fall. Upon immediate evaluation, resident noted with laceration under chin with bleeding observed.Dermatologist [a doctor who specializes in the skin], RN [registered nurse], LVN [licensed vocational nurse], and [CNA 1] were present during evaluation. Dermatologist evaluated laceration and indicated that it may require sutures.Emergency services were called and resident was sent out to [HOSPITAL NAME] for further evaluation. [Resident 1] remained in position of fall until ambulance arrived with neck brace and slide sheet [used to easily reposition, turn, or transfer residents] to safety transfer.During an interview on 4/15/26 at 9 AM, CNA 1 confirmed she was working on 3/31/26 around 2 PM and was in Resident 1's room changing Resident 1's clothing, bedding, and performing personal hygiene care on Resident 1 when Resident 1 fell from the bed. CNA 1 explained she raised the bed in the air approximately 3 or more feet because CNA 1 stated she was tall and needed the bed to be high, at a working level. CNA 1 further stated she was working alone and did not get assistance from another staff member to provide care for Resident 1. CNA 1 explained she believed she could handle Resident 1 without assistance since, she was not heavy. CNA 1 stated when she was ready to roll Resident 1 from her right side to her back, Resident 1 began to, wiggle her legs. CNA 1 further stated she was standing on the other side of the bed and Resident 1 was facing away from CNA 1. CNA 1 added when Resident 1 began to wiggle her legs, Resident 1's legs slipped off the mattress. CNA 1 explained she grabbed Resident 1's upper body with her hands but due to Resident 1 being heavier than CNA 1, CNA 1 could not hold on and Resident 1 slipped out of her hands out of the bed and onto the ground. CNA 1 explained she went to the other side of the bed to check on Resident 1 and saw Resident 1 had landed on her back between the bed and the window and was bleeding. CNA 1 further explained she went outside of Resident 1's room to call for help. CNA 1 further explained that Resident 1's Licensed Nurse (LN) 1 and a lot of other staff, came into Resident 1's room. CNA 1 confirmed Resident 1 was on a LAL mattress. CNA 1 stated she did not recall seeing Resident 1 hit her head but confirmed the small side rails were up near Resident 1's head during care. CNA 1 confirmed she was aware Resident 1 would sometimes move or wiggle during care. Additionally, CNA 1 confirmed Resident 1 did not have floor mats on the ground.During an interview on 4/15/26 at 9:58 AM, with LN 1, LN 1 confirmed on 3/31/26 she was the nurse for Resident 1 and was sitting at the nurses station around 2:30 PM when she saw CNA 1 come out of Resident 1's room and stated that Resident 1 fell out of bed and was bleeding. LN 1 stated she, LN 2 and a doctor went into the room to help. LN 1 stated she found Resident 1 naked on her back on the ground between the bed and the window. LN 1 further stated she observed Resident 1 bleeding from her chin with a 2-3-inch laceration. LN 1 explained LN 2 held Resident 1's head still on the ground and LN 1 called 9-1-1. LN 1 stated the consultant dermatologist (a doctor specializing in diagnosing and treating conditions of the skin) came in the room and stated the laceration under Resident 1's chin was large and deep and needed sutures to be repaired. LN 1 further explained when the paramedics came she told them the events of what CNA 1 stated occurred. LN 1 stated that CNA 1 explained she was providing care by herself to Resident 1 and somehow Resident 1 managed to fall out of bed. LN 1 further stated the sub-acute unit (a specialized unit providing around the clock respiratory care for medically stable residents) staff were supposed to work in pairs when providing clothing changes, hygiene care, and bedding changes, due to the residents having so many tubes like Resident 1. LN 1 explained that Resident 1 had a tracheostomy tube (a long tube inserted into a surgically created opening in the neck and windpipe to create an airway), a nasogastric tube (a thin tube through the nose down into the stomach commonly used for feeding and medication) and a foley catheter (a flexible indwelling tube inserted into the bladder to continuously drain urine into a collection bag). LN 1 further explained Resident 1 was total dependent care, was not alert or aware (state of reduced consciousness) of what was happening, could not control body movement, was known to slightly move her feet or hands during care, and was a fall risk. LN 1 confirmed Resident 1 also was on a LAL mattress which was also a fall risk due to the nature of the mattress.During an interview on 4/14/26 at 10:16 AM, LN 2 confirmed he was near the nurses' station on 3/31/26 at 2:30 PM, when CNA 1 came out of Resident 1's room and stated that Resident 1 had fallen out of bed. LN 2 stated he rushed to Resident 1's room with LN 1 and other staff. LN 2 stated he found Resident 1 on her back, naked, and on the ground between the bed and the window. LN 2 explained there was a lot of blood and went to Resident 1's head to stabilize the head and spine until the paramedics arrived. LN 2 confirmed he was familiar with Resident 1's care and explained Resident 1 was known to wiggle around and have unpredictable movement of her hands and feet when she was in pain, or something was wrong. LN 2 confirmed Resident 1 was a total dependent care and was on a LAL mattress. Additionally, LN 2 confirmed a LAL mattress could be slippery and residents could slide off of them easily which was why the facility always required at least two staff members when providing care.During a concurrent interview and record review on 4/15/26 12:42 PM, with the Director of Nursing (DON), Resident 1's electronic medical record (EHR - a digital version of a resident's chart used to document progress, medication, treatment plans and diagnoses) was reviewed. The DON reviewed the document titled, Lift Transfer Reposition, dated 2/13/26, and confirmed the document indicated that Resident 1 required two staff for repositioning (moving and changing of body position) in bed. Additionally, the DON reviewed the Interdisciplinary Care Conference (IDT -a structured meeting where healthcare professionals from various specialties meet with residents and resident families to develop, review, or update a personalized treatment plan) meeting dated 4/1/26, and confirmed from the interviews with staff (unnamed) and CNA 1 the bed was not in the low position on 3/31/26. The DON further confirmed Resident 1 was sent out to the emergency department on 3/31/26 and was diagnosed with a laceration to the chin requiring nine sutures and a neck fracture to Resident 1's C1. The DON stated the cause of the fall was determined to be due to CNA 1 providing care to Resident 1 alone and not the required two staff members for major care. The DON further stated the fall could have been prevented if CNA 1 had used two staff members and had turned/rolled Resident 1 towards CNA 1 instead of away from her. The DON confirmed CNA 1 turned Resident 1 away from her which placed Resident 1 on the side of the bed without a barrier to prevent Resident 1 from falling. The DON explained it was her expectation that staff providing major care which includes showering, personal hygiene care, bedding change and repositioning a resident should always be at least 2 staff members.A review of CNA 1's employee file document titled, Certified Nursing Assistant Skills Performance Evaluation, dated 12/13/25, indicated, .SKILLS.Repositioning resident in bed (2-person assist for residents using LAL mattress) . had a check mark in the box marked, yes, which indicated she was checked-off and understood the facility protocol.A review of Resident 1's activities of daily living (ADL- activities of daily living -routine self-care tasks that individuals perform daily to maintain independence and hygiene such as bathing, dressing, eating, and mobility) care plan, dated 11/20/23, indicated .[Resident 1] has an ADL Self Care Performance Deficit r/t [related to] ANOXIC BRAIN DAMAGE. [Resident 1] needs dependent assistance with ADLS. The care plan further indicated Resident 1 was totally dependent on staff for toilet use, bathing, grooming, bed mobility (changing positions in bed), personal hygiene, dressing and transferring.A review of Resident 1's skin care plan, dated 11/28/23, indicated, .Preventative: [Resident 1] has high risk/or at risk for pressure ulcer (localized injury to the skin or soft tissue usually over bony areas caused by prolonged pressure) or skin impairment.[Resident 1] needs LAL mattress for pressure redistribution.A review of Resident 1's [HOPITAL NAME] medical record document titled, Emergency Department Notes, dated 4/1/26, indicated, . [Resident 1] HISTORY OF PRESENT ILLNESS.Chief Complaint.ACCIDENT.presents to the Emergency Department following an accident. She fell at her facility and sustained a laceration to her chin as well as an acute [sudden onset medical condition] C1 fracture confirmed on MRI [MRI - Magnetic Resonance Imaging, a painless medical test that uses a powerful magnet, radio waves and a computer to produce detailed images of organs and soft tissues] .Laceration was repaired.[Resident 1].presenting to the ED [Emergency Department] after a fall with an acute C1 fracture. Neurosurgery (a physician who diagnoses and treats disorders of the brain, spine, and nerves) consulted after initial assessment and chart review.recommendations include Aspen [a ridged, two-piece cervical collar designed to restrict neck movement to promote healing after injury] collar for 3-4 months.A review of Resident 1's, Weekly Non-Pressure Report [skin assessment], dated 4/2/26, indicated, .Wound [number] 1.Location [NAME] -Surgical Site with 9 sutures.Comments/Observations. [Resident 1] returned to facility from acute care hospital noted with 9 dissolvable clear sutures. Periwound [around the wound] noted with purplish-yellow bruising.Wound [number] 2.Location R [right] Clavicle [a slender, S-shaped bone acting as a strut between the shoulder blade and chest bones] - Reddened/denuded skin [an area where the top layer of skin has been removed or damaged].[Resident 1] returned to facility from acute care hospital noted with reddened/denuded skin, 60 [percent] skin, 40 [percent] dermis [middle layer of skin].Wound [number] 4.Location Periorbital Eyes [surrounding both eyes] - Diffuse [spreading widely] bruising.A review of the facility's policy and procedure titled, Fall Management, dated 5/2021, indicated, .PURPOSE To reduce risk of falls and minimize the actual occurrence of falls. To address injury and provide care for a fall.Those determined to be at risk will receive appropriate interventions to reduce risk and minimize injury.1. Identify patient's fall risk by reviewing the Nursing Documentation. 2. Communicate patient's fall risk status to caregivers.

Based on observation, interview, and record review, the facility failed to practice appropriate infection prevention and control measures for a census of 116, when on 4/14/26: 1. Licensed Nurse (LN) 4 did not perform hand hygiene (the action of cleansing hands to remove germs, dirt, and microorganisms (bacteria/viruses) includes washing with soap and water or a alcohol-based hand sanitizer) between glove changes while providing tracheostomy (a surgical procedure that creates an opening in the neck and directly into the windpipe to create an alternative airway) inner cannula tube (a removable, hollow liner that fits inside the main body (outer cannula) of a tracheostomy tube) care and suctioning to Resident 1 (procedure that uses a vacuum-connected hollow tube to remove mucus, saliva, and secretions from a patient's breathing tube); and, 2. LN 5 did not wear the appropriate personal protective equipment (PPE - specialized clothing and equipment used by healthcare professionals to minimize exposure to infectious agents and hazardous material) when LN 5 accessed and administered medications to Resident 2 via gastrostomy tube (G-tube -a medical device inserted through the abdomen directly into the stomach to deliver nutrition, fluids and medications); and, 3. Certified Nursing Assistant (CNA) 3 and CNA 4 were observed removing a shower chair (a water resistant, non-slip 4 legged seat with wheels designed to transport a patient to and from a shower room) from a resident room that had a sign posted Contact Precautions, (infection control measure used in healthcare setting with patients known or suspected to have a serious illness that could easily be transmitted by direct or indirect contact with items in the patient's environment) without sanitizing it. These failures had the potential to spread infections to residents residing in the facility, negatively impacting their health and well-being.Findings:1. During an observation on 4/14/26 at 8:49 AM, with LN 4, in Resident 1's room, LN 4 was observed putting on sterile gloves (disposable, individually packaged medical gloves completely free from microorganisms) to change Resident 1's disposable inner cannula. LN 4 was observed removing the sterile gloves and replacing them with non-sterile gloves from a box in Resident 1's room and continued providing care to Resident 1. LN 4 did not perform hand hygiene between glove changes. LN 4 continued to suction Resident 1 with non-sterile gloves. LN 4 was observed removing her gloves a second time and replacing them with another pair of gloves. LN 4 did not perform hand hygiene a second time after removing gloves.During an interview on 4/14/26 at 8:59 AM, with LN 4, LN 4 confirmed she did not complete any form of hand hygiene after changing gloves twice and continued to suction Resident 1 using non-sterile gloves. LN 4 explained the expectation and policy in the facility was to perform hand hygiene before putting on gloves and after removing gloves. LN 4 further explained the risk to (Resident 1) for not completing hand hygiene properly was infection.2. During an observation on 4/14/26 at 9:26 AM, with LN 5, in Resident 2's room, LN 5 was observed preparing to administer Resident 2's medications by placing the medications on a side table, performing hand hygiene and putting on gloves. LN 5 was observed accessing Resident 2's G-Tube and checked for proper placement by pushing air into it with a large syringe and listened for the sound of the air in Resident 2's stomach. LN 5 stated she heard the air and grabbed a syringe and flushed the G-tube with 30mL (mL -milliliters unit of measure of fluids/liquid) of water. LN 5 was observed taking one crushed medication at a time and mixing it with 10mL of water and then pouring 2-3 medications separately into Resident 2's G-tube. LN 5 then realized she forgot to put on a protective gown that was required since Resident 2 was on Enhanced Barrier Precautions (EBP -an infection control strategy used in nursing homes that requires use of gowns and gloves during high-contact resident care activities to reduce the transmission of infections). LN 5 retrieved a gown from the door to Resident 2's room and placed it on.During an interview on 4/14/26 at 9:41 AM, LN 5 confirmed she forgot to put on the required PPE gown while she accessed and poured medications into Resident 2's G-tube. LN 5 explained that anytime a resident had an indwelling line (is a thin, flexible, hollow tube inserted into the body and left in place for an extended period to deliver fluids, medications, or to drain bodily fluids), like a G-tube staff were required to wear a gown and gloves to protect the themselves and the residents. LN 5 explained PPE was important to prevent the spread of germs.3. During an observation on 4/14/26 at 9:58 AM, in Resident 5's room, CNA 3 and CNA 4 were observed removing Resident 5 from a shower chair and into bed using a mechanical lift (a motorized or hydraulic machine used by caregivers to safely raise, lower, and transfer people with limited mobility between surfaces). CNA 3 and CNA 4 were observed removing the shower chair from Resident 2's room to the hallway in front of nurses station one. CNA 3 and CNA 4 did not sanitize (the process of using a clean wipe to reduce bacteria on surfaces to safe levels) the chair after Resident 5 was removed from it. CNA 3 and CNA 4 confirmed Resident 5 was on contact precautions and verified a Contact Precautions sign was on the door at the entry to Resident 5's room.During an observation and interview on 4/14/26 at 10:15 AM, CNA 2 was observed grabbing the unsanitized shower chair along the wall in front of nurses station one. CNA 2 confirmed with CNA 3 that she was finished with the chair, and CNA 2 began to take it. CNA 3 stopped CNA 2 from taking the shower chair and told her it was not sanitized. CNA 3 and CNA 4 stated they were supposed to sanitize the shower chair prior to taking it out of the room. CNA 4 stated it was important to sanitize the shower chair before removing from or directly after removing it from the residents room because another staff member could assume it was clean. CNA 3 stated it was important to sanitize any equipment after use but especially in a room where a resident was on contact precautions. CNA 4 stated the risk was the spread of infection and residents could get sick. CNA 2 confirmed she assumed the shower chair was cleaned since it was in the hallway along the wall, available for use.During an interview on 4/14/26 at 4:40 PM, with the Infection Preventionist (IP), the IP stated it was her expectation that staff performed hand hygiene before putting on clean gloves and after removing dirty gloves. The IP further stated it was her expectation that staff wore the proper PPE of a gown and gloves anytime they performed care that would involve bodily fluids like accessing a G-tube. The IP explained the proper PPE for EBP precautions was at least gown and gloves. The IP further explained that anytime equipment like a shower chair was used on a resident with or without contact precautions, the staff were required to sanitize the equipment before and after use. The IP stated the risk to the residents for improper infection control practices was the spread of infection in the facility.During an interview on 4/15/26 at 12:42 PM, with the Director of Nursing (DON), the DON stated she expected hand hygiene before and after glove use during any resident care. The DON further stated hand hygiene was important to make sure the hands were not contaminated with secretions or other bodily fluids to prevent the transfer of bacteria to the residents because these residents were at higher risk of infection. The DON explained she expected staff to wear proper PPE including gown and gloves when administering medications via G-tube. The DON further explained the risk to the resident was transferring infection to the G-tube port when the proper precautions were not maintained. The DON added that not cleaning equipment like a shower chair after use and putting it out along the hallway available for use did not meet her expectations. The DON stated the equipment should be cleaned and disinfected before and after each use. The DON added that the risk of leaving the equipment out without being sanitized was that another staff member could take and use the equipment and spread infection to other residents.A review of facility a policy and procedure (P&P) titled, Infection Prevention and Control Program, dated 9/18/2024, indicated, .An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.The program is based on accepted national infection prevention and control standards.Those with potential direct exposure to blood or body fluids are trained in and required to use appropriate precautions and personal protective equipment.A review of the Centers for Disease Control and Prevention (CDC) publication titled, Consideration for Use of Enhanced Barrier Precautions in Skilled Nursing Facilities, dated June 2021, indicated, .1. Multidrug-resistant organism (MDRO) transmission is common in skilled nursing facilities, contributing to significant morbidity and mortality for residents.2. Enhanced Barrier Precautions (EBP) is an approach of targeted gown and glove use during high contact resident care activities.3. EBP may be applied (when Contact Precautions do not otherwise apply) to residents with any of the following.Wounds or indwelling medical devices.https://www.cdc.gov/hicpac/workgroup/EnhancedBarrierPrecautions.htmlA review of the CDC publication titled, Clinical Safety: Hand Hygiene for Healthcare Workers, dated 2/27/24, indicated, .Hand hygiene protects both healthcare personnel and patients. Hand hygiene means cleaning your hands with: Handwashing with water and soap.Antiseptic hand rub (alcohol-based foam or gel hand sanitizer).Cleaning your hands reduces: The potential spread of deadly germs to patients. The spread of germs, including those resistant to antibiotics.Know when to clean your hands.Immediately before touching a patient. Before performing an aseptic task such as placing an indwelling device or handling invasive medical devices.Immediately after glove removal.Know when to wear (and change) gloves. Gloves are not a substitute for hand hygiene. If your task requires gloves, perform hand hygiene before donning gloves and touching the patient.Always clean your hands after removing gloves.https://www.cdc.gov/clean-hands/hcp/clinical-safety/index.htmlA review of the CDC publication titled, Transmission-Based Precautions, dated 4/3/24, indicated, .use disposable or dedicated patient-care equipment.If common use of equipment for multiple patients is unavoidable, clean and disinfect such equipment before use on another patient.https://www.cdc.gov/infection-control/hcp/basics/transmission-based-precautions.html

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 2) received medications as ordered by the physician and was free of significant medication errors (one which could jeopardize the residents health and safety) when on 4/1/26 Resident 2 was given two of Resident 4's medications in error.This failure may have contributed to Resident 2 being sent out to a hospital for vomiting blood on 4/6/26. In addition, this failure had the potential to interact with Resident 2's other medications causing additional harm to Resident 2's health and safety.Findings:A review of Resident 2's admission Record, indicated Resident 2 was admitted to the facility with diagnoses which included, acute respiratory failure (a sudden-onset where the lungs cannot get enough oxygen into the blood), encounter for tracheostomy (a long tube inserted into a surgically created opening in the next and windpipe to create an airway), dependance on respirator/ventilator (machine that assists the resident to breath) posthemorrhagic anemia (a rapid drop in red blood cells caused from blood loss) thrombocytopenia (low platelet count [tiny cell fragments that help blood clot] in the blood) chronic kidney disease stage 3B (moderate to severe kidney damage) and Atrial Fibrillation (a common heart rhythm disorder characterized by a rapid, irregular, or fluttering heartbeat).A review of Resident 2's Medication Administration Record (MAR -official legal document sued by healthcare professionals to track and record every medication administered to a patient) dated April 2026, indicated Resident 2 was on the following daily medications to prevent blood clots (a gel-like solid or semi-solid mass formed when blood platelets and proteins thicken), Aspirin 81 mg, (a common non-steroidal Anti-inflammatory drug used for pain, reduce fever and prevent blood clots/mg -milligram, a unit of measure) and Clopidogrel Bisulfate 75 mg, (a prescription antiplatelet medication used to prevent serious blood clots).During a concurrent interview and record review on 4/14/26 at 12:29 PM, with Licensed Nurse (LN) 3, LN 3 reviewed and confirmed he wrote a, Change In Condition, progress note (CIC/COC -a documented update in a patient's medical record that describes a significant shift in their physical, mental, or functional health), dated 4/1/26, which indicated, .[Resident 2] noted to have received medications intended for another resident [Resident 4], including Heparin [a high alert, anticoagulant commonly used as an injection under the skin for the prevention of blood clots] and Keppra [used to prevent seizures]. Resident assessed immediately.no signs of distress noted.no active bleeding observed. 10:35 [AM] Nurse Practitioner and director of subacute [provides specialized 24/7 respiratory care for medically stable patients] services notified. Orders received to hold [Resident 2s] scheduled medications and initiate bleeding precautions with close monitoring. LN 3 confirmed he gave Resident 2 a Heparin Injection Solution of 5000 units (5000 units - equivalent to 1 milliliter-a unit of measure) and injected the Heparin into Resident 2's upper left quadrant (location of his abdomen if divided in four quarters) and Levetiracetam (generic brand for Keppra) 750 mg (mg= milligram a unit of measure) via 7.5 mL (mL= milliliters, a unit of measure) placed into Resident 2's gastrostomy tube (G-tube -a medical device inserted through the abdomen directly into the stomach to deliver nutrition, fluids and medications). LN 3 stated after administration of these two medications he left the room to check Resident 2's orders in the MAR and realized he was looking at Resident 4's MAR and had given Resident 4's medications to Resident 2. LN 3 explained he made the mistake because he did not follow the medication rights of administration that included, right resident, right medication, right dose, right time, and right documentation. LN 3 stated usually there was a photograph of the resident in the MAR but Resident 4 did not have a photograph in his MAR. LN 3 further stated he did not verify Resident 2's identity by confirming his name or checking for a wrist band to confirm he had the right resident prior to giving the medication. LN 3 stated once he realized his mistake he notified the nurse practitioner (NP) who was in the facility. LN 3 explained he continued to monitor Resident 2 for the rest of the day for side effects of bleeding. LN 3 explained that Resident 2 was placed on monitoring every 30 minutes for four hours and continued monitoring for side effects of bleeding every shift for 72 hours (3 days).During an interview on 4/15/26 at 10:31 AM, in Resident 2's room, Resident 2 confirmed he was sent out to a hospital about one week ago for vomiting blood. Resident 2 could not speak due to his tracheostomy tube (a curved tube inserted into a surgically created opening in the windpipe to provide an airway) but was able to answer yes or no by shaking his head up and down for yes and side to side for no. Resident 2 held up two fingers when asked how many times he vomited blood. Resident 2 shook his head yes when asked if LN 3 explained to him he was given another residents medication by accident. When staff asked Resident 2 if someone had told him the reason he was vomiting blood, he shook his head no. When Resident 2 was asked if the doctors at the hospital determined the cause of vomiting blood, he shook his head no. When asked if Resident 2 had previously ever vomited blood, had blood in his urine or feces, had unexplained bruising or nose bleeds, Resident 2 shook his head no. When asked how many days Resident 2 was hospitalized for vomiting blood, Resident 2 held up 3 fingers.During an interview on 4/15/26 at 10:55 AM, with LN 2, LN 2 confirmed he sent Resident 2 out to the Emergency Department (ED) on 4/6/26, per Nurse Practitioner (NP) order. LN 2 explained he was the nurse taking care of Resident 2 on 4/6/26 when another staff member told him that Resident 2 was vomiting blood. LN 2 stated he went into Resident 2's room to check and he observed, coffee ground emesis (vomit containing old, oxidized blood from an upper gastrointestinal bleed (GI)). LN 2 further stated from his experience he knew it was most likely due to a GI bleed (gastrointestinal bleed -a symptom of an underlying disease involving blood loss anywhere within the digestive tract). LN 2 explained the NP was in the facility, so he called him to come and assess Resident 2 and confirm his findings. LN 2 stated the NP came to Resident 2's bedside and ordered Resident 2 to be sent out to a hospital to be further evaluated. LN 2 further explained that Resident 2 was given in error a Heparin injection five days previously and reported that information to the Emergency Medical Technician's when he transferred Resident 2 to their care.During an interview on 4/15/26 at 11:08 AM, with the NP, the NP confirmed he came to Resident 2's room on 4/6/26 and observed that Resident 2 had vomited blood. The NP stated he observed the bloody vomit and observed blood on the floor next to Resident 2's bed. The NP confirmed he gave the order for Resident 2 to be sent to the hospital for further evaluation. The NP stated he was aware of the previous medication error when Resident 2 received Heparin approximately five days prior. The NP stated he was not sure if Resident 2 vomiting blood was related to the medication error and sent Resident 2 to the hospital as a precaution.During an interview on 4/15/26 at 12:06 PM, with the Medical Director (MD), the MD stated he was not aware that Resident 2 received Heparin and Levetiracetam (Keppra) in error and confirmed the medication error should not have happened. The MD stated he did not believe the accidental Heparin was the cause the Resident 2's vomiting blood but could not be sure due to the combination of other blood thinning medications Resident 2 was on. The MD confirmed that Heparin was considered a high-alert medication (drugs with a heightened risk of causing significant patient harm, or death, when used in error). During a concurrent interview and record review on 4/15/26 at 12:42 PM, with the Director of Nursing, the Interdisciplinary Care Conference (IDT -a structured meeting where healthcare professionals from various specialties meet with residents and resident families to develop review or update a personalized treatment plan) note dated 4/2/26 was reviewed. The DON confirmed the medication error that occurred with Resident 2 was reviewed by the care conference team and determined the medication error could have been prevented by LN 3 if he used the safe medication administration practice and followed facility policy and procedures. The DON stated her expectation was that each nurse following the safe rights of medication administration, check the residents picture, and the name on the medication should match the name in the MAR.A review of Resident 2's, [HOSPITAL NAME] medical record document titled, Discharge Summary, dated 4/9/26 indicated, .Discharge diagnosis.Coffee ground emesis.A review of Resident 2's, [HOSPITAL NAME] medical record document titled, History and Physical, dated 4/6/26, indicated, .[Resident 2] presented to the hospital with coffee-ground emesis. Currently hemodynamically stable [stable blood flow]. Hemoglobin around 8 [normal range 13.5 to 17.5 grams per deciliter [g/dL -unit of measure].Monitor H/H [Hemoglobin and Hematocrit -key components of blood measuring tests. Hemoglobin - Hgb/Hb is the iron-rich protein that transports oxygen, Hematocrit Hct- is the percentage of total blood volume composed of red blood cells. They are primarily used to diagnose anemia and monitor blood loss].Transfuse [common medical procedure where donated blood or blood products are delivered into a patient's bloodstream] if hemoglobin less than 7.A review of Resident 2's, medical record, Care Plan Report, dated 3/24/26, indicated, .[Resident 2] is at risk for injury or complications related to the use of anticoagulation/antiplatelet therapy. Atrial Fibrillation, Medications: (Clopidogrel Bisulfate).Goal.[Resident 1] will not exhibit signs/symptoms of bleeding.Interventions/Tasks.Observe for active bleeding.A review of Resident 2's, medical record, Care Plan Report, dated 4/1/26, indicated, .[Resident 1] At risk for side effects r/t [related to] incorrect medication administration.Notify MD for any worsening s/sx [signs and symptoms].A review of Resident 4's, MAR dated, March 2026, indicated, .Heparin Sodium Porcine [pork derivative] Injection Solution 5000 UNIT/ML.Inject subcutaneously every 12 hours.LevETIRAcetam Oral Solution 500 MG/ML.Give 7.5 ml via G-Tube every 12 hours related to ENCEPHALOPAHTY [disease or damage of the brain that alters its function].EPILEPSY [chronic neurological disorder with recurring seizures caused by sudden electrical activity in the brain].A review of the facilities policy and procedure titled, Administering Medications, revised April 2019, indicated, .Medications are administered in a safe and timely manner, and as prescribed.9. The individual administering medications verifies the resident's identity before giving the resident his/her medications. Methods of identifying the resident include: a. Checking identification band; b. Checking photograph attached to medical record; and c. If necessary, verifying resident identification with other facility personnel.10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.26. Medications ordered for a particular resident may not be administered to another resident.

Based on observation, interview and record review the facility failed to ensure medications were stored safely and securely for a census of 116, when on 4/14/26 Licensed Nurse (LN) 5 left medications on top of a medication cart (a mobile cart containing medication used for administration of medication to residents) and left the medication cart unlocked when she walked away from it. These failures had the potential for medication diversion (medication taken by someone it was not intended for), and unsafe medication use in the facility.Findings: During an observation on 4/14/26 at 9:23 AM, with LN 5, LN 5 was observed preparing medications by removing them out of the medication cart, putting the medications into a medication cup and leaving them on top of the medication cart. LN 5 was observed walking away from the medication cart to retrieve something from another cart down the hall. LN 5 left approximately 7 medications on top of the medication cart unattended and left the medication cart unlocked. During an interview on 4/14/26 at 9:41 AM, LN 5 confirmed she left medications unattended on top of the medication cart and left the medication cart unlocked when she walked away from it. LN 5 explained she was supposed to remove the medications from the top of the cart and lock the cart prior to leaving it. LN 5 added that it was important to secure the cart and medications to prevent another resident or person from taking medications from the cart. During an interview on 4/15/26 at 12:42 PM, with the Director of Nursing (DON), the DON stated it was her expectation that medication never be left unattended on top of a medication cart. The DON further stated it was her expectation that the medication cart should never be left unlocked when unattended. The DON explained that it was important because some residents were confused and they could possibly take the medication from the medication cart, which could be harmful to the residents. A review of a facility policy and procedure (P&P) titled, Administering Medications, revised April 2019, indicated, .19. During administration of medications, the medication cart is kept closed and locked when out of the sight of the medication nurse.No medications are kept on top of the cart. A review of a facility P&P titled, Security of Medication Cart, revised April 2007, indicated, .The medication shall be secured during medication passes.The nurse must secure the medication cart during the medication pass to prevent unauthorized entry.The cart must be locked before the nurse enters the resident's room.Medication carts must be securely locked at all times when out of the nurse's view.

Based on interview, and record review, the facility failed to ensure resident Interdisciplinary Team Care Conferences (IDT, a care plan meeting with the resident and family members where interdisciplinary team members from different healthcare disciplines discuss, identify, address, implement and review plans to meet needs regarding the resident's care) were conducted quarterly for three of three sampled residents (Resident 1, Resident 2 and Resident 3) when IDT Care Conferences were not documented quarterly in 2025 for Resident 1, Resident 2, and Resident 3.These failures had the potential for unmet care needs for Resident 1, Resident 2 and Resident 3.Findings:a. A review of Resident 1's admission RECORD, indicated that Resident 1 was admitted to the facility in 2023 with diagnoses which included subarachnoid hemorrhage (SAH, A type of stroke characterized by bleeding in the space between the brain and the tissues that cover the brain), and hypertension (a condition in which the force of the blood pushing against the blood vessel walls is consistently too high. This causes the heart to work harder to pump blood).A review of Resident 1's IDT Care Conference Notes 2025, indicated that an IDT Care Conference with Resident 1's Responsible Party (RP, the person designated to direct the care of a loved one admitted into a nursing facility) was held on 1/17/25 regarding skin assessment findings, on 7/16/25 regarding possible discharge and supplies needed, on 8/14/25 regarding possible hospice, and on 11/25/25 regarding discharge planning.During an interview on 4/1/26, at 12:20 p.m., with Resident 1's RP in his room, the RP stated that Resident 1's primary physician at the facility had not discussed the plan of care with her. The RP further stated that she had not attended IDT Care Conference meetings to discuss Resident 1's care in about a year.During a concurrent interview and record review on 4/1/26, at 2:51 p.m., with the Director of Nursing (DON), the Social Services Director (SSD), and the Subacute Assistant Director of Nursing (ADON), Resident 1's electronic medical record (EMR) was reviewed. The DON stated the IDT Care Conference meetings were held initially upon admission, whenever there were concerns voiced by the residents and/or family, then quarterly. The DON further stated the resident and/or the resident's RP/Power of Attorney (POA), Social Services, Licensed Nurses (LNs), Case Managers, the DON/ADON, Dietary Manager, and the Activity department head attended as applicable. The DON stated if for example a resident's family wanted to discuss care with the team, had medication concerns, and/ or wanted to provide updates then an IDT Care Conference meeting would be scheduled. The DON further stated the physician did not attend the IDT Care Conference meetings. The DON stated the IDT Care Conference assessment tool and meeting notes were documented in the residents' EMR. The DON further stated care concerns for the resident were also addressed during IDT Care Conference meetings. During a concurrent interview and record review on 4/2/26, at 10:45 a.m., with the DON, Resident 1's IDT Quarterly Care Conference Notes, were reviewed. The DON confirmed that the IDT care conferences were not completed quarterly in 2025 for Resident 1. The DON stated the risk of not completing the IDT care conferences quarterly was that care concerns were not addressed and the resident's care plan was not updated. The DON acknowledged that the facility policy was not followed.b. A review of Resident 2's admission RECORD, indicated that Resident 2 was admitted to the facility in 2025 with diagnoses which included diabetes mellitus (a chronic condition that affects the way the body processes blood sugar) and cerebral infarction (a result of disrupted blood flow of the brain due to problems with blood vessels that supply it, also known as a stroke).A review of Resident 2's IDT Quarterly Care Conference Notes 2025, indicated that Resident 2 had an IDT meeting for a fall incident on 6/30/25, an IDT meeting for weight on 7/22/25, and an IDT Quarterly Care Conference on 11/20/25.During a concurrent interview and record review on 4/2/26, at 10:45 a.m., with the DON, Resident 2's IDT Quarterly Care Conference Notes, were reviewed. The DON confirmed that the IDT care conferences were not completed quarterly in 2025 for Resident 2. The DON stated the risk of not completing the IDT care conferences quarterly was that care concerns would not be addressed and the resident's care plan was not updated. The DON acknowledged that facility policy was not followed.c. A review of Resident 3's admission RECORD, indicated that Resident 3 was admitted to the facility in 2024 with diagnoses which included cerebral infarction (a result of disrupted blood flow of the brain due to problems with blood vessels that supply it, also known as a stroke), and hypertension (a condition in which the force of the blood pushing against the blood vessel walls is consistently too high which causes the heart to work harder to pump blood).A review of Resident 3's IDT Quarterly Care Conference Notes 2025, indicated that an IDT Quarterly Care Conference dated 1/13/25 was not attended by Resident 3 or Resident 3's RP, an IDT Quarterly Care Conference dated 4/16/25 for the Restorative Nursing Aide Program (RNA, nursing aide program that helps residents to maintain their function and joint mobility) was not attended by Resident 3 or Resident 3's RP, an IDT Quarterly Care Conference dated 7/10/25 for weight had no documented attendees listed, and an IDT Quarterly Care Conference dated 7/22/25 for weight was not attended by Resident 3 or Resident 3's RP.During a concurrent interview and record review on 4/2/26, at 10:45 a.m., with the DON, Resident 3's IDT Quarterly Care Conference Notes, were reviewed. The DON confirmed that the IDT care conferences were not completed quarterly in 2025 for Resident 3. The DON stated the risk of not completing the IDT quarterly care conferences was that care concerns would not be addressed and the resident's care plan was not updated. The DON acknowledged that facility policy was not followed.A review of a facility policy and procedure (P&P) titled, Care Planning - Interdisciplinary Team, dated 8/25/21, indicated, .Purpose.Our facility's Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident.Procedure.1. A comprehensive care plan for each resident is developed within seven (7) days of completion of the comprehensive assessment (MDS, Minimum Data Set a comprehensive care assessment tool).2. The care plan.is developed by an Interdisciplinary Team which includes but is not necessarily limited to the following personnel.a. The resident's Attending Physician.b. A registered nurse with responsibility for the resident.c. The Dietary Manager/Dietitian.d. The Social Services Worker responsible for the resident.e. The Activity Director/Coordinator.g. To the extent practicable, the participation of the resident and the resident's representative(s).h. The Charge Nurse responsible for the resident's care.others as appropriate or necessary to meet the needs of the resident or as requested by the resident.3. The resident, the resident's family and/or the resident's representative are encouraged to participate in the development of and revisions to the resident's care plan.4. Every effort will be made to schedule care plan meetings at the best time of the day for the resident and family.A review of a facility P&P titled, Care Plan Comprehensive, effective date 8/25/21, indicated, .8. The Interdisciplinary Team is responsible for evaluating and updating of care plans.d. At least quarterly.

Based on interview, and record review, the facility failed to report to the Department an injury of unknown source in accordance with the facility's abuse policy and procedure (P&P) for one of one resident (Resident 1) when on 2/2/26, Resident 1 was found with an unexplainable left shoulder dislocation (an injury that occurs when the upper arm bone pops out of the cup shaped socket near the shoulder blade).This failure denied the Department the ability to conduct a timely investigation and placed Resident 1 at risk for abuse. In addition, the facility failed to comply with federal and state reporting regulations.Findings:A review of Resident 1's admission RECORD, indicated that Resident 1 was admitted to the facility with diagnoses which included subarachnoid hemorrhage (SAH, a type of stroke characterized by bleeding in the space between the brain and the tissues that cover the brain), traumatic brain injury (a disruption in the normal function of the brain that can be caused by a bump, blow, or jolt to the head or penetrating head injury), and hypertension (a condition in which the force of the blood pushing against the blood vessel walls is consistently too high and causes the heart to work harder to pump blood).A review of Resident 1's Minimum Data Set [MDS, a comprehensive care assessment tool] Section C: Cognitive Patterns, dated 3/9/26, indicated that Resident 1's Brief Interview for Mental Status score was 00 (BIMS, a tool to assess cognition. The total possible BIMS score ranges from 00 to 15. 13 - 15: cognitively intact; 08 - 12: moderately impaired; 00 - 07: severe impairment).A review of Resident 1's MDS Section GG: Functional Abilities and Goals, dated 3/9/26, indicated that Resident 1 required maximal assistance and was totally dependent on others for all care needs.A review of Resident 1's Nurses Progress Notes, dated on 2/1/26, at 1:34 p.m., indicated, .patient [Resident 1] rp [Responsible Party, the person designated to direct the care of a loved one admitted into a nursing facility] stated to writer that patient looked like he did not feel good and pointed to patient left shoulder and stated that something was wrong and that the patient has a bad shoulder. patient appeared to be in some discomfort, writer informed rp that patient was changed and received wound treatment about 30 minutes prior and that patient was most likely recovering from this, rp disagreed and requested.x-ray [a quick painless test that captures images of the structures inside the body particularly bones]. administered PRN [as needed] pain medication and informed MD [medical doctor]. MD ordered.left shoulder x-ray.called [x-ray provider].scheduled left shoulder x-ray for tomorrow 2/2/26. rp at bedside and informed.A review of Resident 1's X-ray Report, indicated, .Date of Exam.02/01/2026 21:54 [9:54 p.m.].HISTORY.STIFFNESS/PAIN.SIGNIFICANT FINDINGS.LEFT SHOULDER X-ray Complete.Multiple views of the left shoulder show anterior [toward the front of the body] shoulder dislocation.There are no acute fractures [broken bones].A review of Resident 1's Nurses Progress Notes, dated 2/2/26, at 2:58 a.m., indicated, .shoulder x-ray result came back with a significant findings Left anterior shoulder dislocation .Called [MD] .send to ER [emergency department at acute care hospital] to fix the shoulder .Called the RP .During an interview on 4/1/26, at 12:20 p.m., with Resident 1's RP in Resident 1's room, the RP stated she asked staff to call the physician for an x-ray when she noticed that Resident 1 grimaced when she touched his shoulder on 2/1/26. The RP further stated staff that day (2/1/26) told her that Resident 1 had recently been cleaned and repositioned after providing incontinent care (skin care after involuntary or accidental leakage of urine or feces). The RP stated the x-ray showed that Resident 1's left shoulder was dislocated.During an interview on 4/1/26, at 4:51 p.m., with the Director of Nursing (DON), the DON confirmed Resident 1's left shoulder injury was an injury of unknown origin. The DON further confirmed Resident 1's injury to the left shoulder was not reported. The DON acknowledged Resident 1's injury of unknown origin should have been reported.During a joint concurrent interview and record review on 4/2/26, at 2:03 p.m., with the Administrator (ADM) and the DON, Resident 1's Progress Notes, were reviewed. The ADM stated he talked to Resident 1's RP and the RP stated that the injury was due to contractures (when muscles, tendons, joints, or other tissues tighten or shorten causing loss of movement). The ADM further stated that he talked with the RP a day or so after the injury to Resident 1's left shoulder was discovered. The ADM stated he asked Resident 1's RP if Resident 1 fell and the RP said No, and the RP also stated that she did not notice any trauma to Resident 1's shoulder. The ADM further stated that he did not document the conversation that he had with Resident 1's RP but he spoke to the DON about it. The ADM stated the RP was happy with Resident 1's care at the facility. The ADM further stated that he followed the RP's lead and it did not lead him to suspect abuse. The ADM acknowledged that Resident 1 was under the facility's care. The ADM confirmed that the injury to Resident 1's left shoulder was not reported to the Department. The ADM and the DON both acknowledged that the cause of Resident 1's left shoulder dislocation should have been investigated to rule out abuse related to the injury of unknown origin.A review of a facility P&P titled, Abuse Prohibition Policy and Procedure, dated 5/23/21, indicated, .Policy.The Center will implement an abuse prohibition program through the following.Identification of possible incidents or allegations which need investigation.Investigation of incidents and allegations; and Reporting of incidents, investigations, and Center response to the results of their investigations.Federal Definitions.Injuries of unknown source are defined as an injury with both of the following conditions.The source of the injury was not observed by any person or the source of the injury could not be explained by the patient.The injury is suspicious because of the extent of the injury or the location of the injury.or the number of injuries observed at one particular point in time or the incidence of injuries over time.Purpose.To ensure that Center staff are doing all that is within their control to prevent occurrences of.injuries of unknown source.Process.1. The Center Executive Director.is responsible for operationalizing policies and procedures that prohibit.injuries of unknown source.6.3 Injuries of unknown origin will be investigated to determine if abuse or neglect is suspected.7. Upon receiving information concerning a report of suspected or alleged abuse.the CED (Center Executive Director) or designee will perform the following.7.2 Report allegations involving neglect, exploitation of mistreatment (including injuries of unknown source) .no later than two (2) hours after the allegation is made if the event results in serious bodily injury. Serious bodily injury is reportable. Only an investigation can rule out abuse, neglect, or mistreatment.7.2.1 Serious bodily injury is defined as an injury involving extreme physical pain; involving substantial risk of death; involving protracted loss or impairment of the function of a bodily member, organ or mental faculty; or requiring medical intervention such as surgery, hospitalization or physical rehabilitation.7.4 Notify local law enforcement, Ombudsman, Licensing District Office.and other agencies as required.7.6 Initiate an investigation within 2 hours of an allegation of abuse that focuses on.7.6.1 Whether abuse or neglect occurred and to what extent.7.6.2 clinical examination for signs of injuries.7.6.3 causative factors 7.6.4 interventions to prevent further injury.7.7 The investigation will be thoroughly documented.interview forms will be kept confidential in a file in the administrative office.9. The CED or designee will.9.2 Report findings of all completed investigations within five (5) working days to the Licensing District office.

Based on interview, and record review, the facility failed to investigate an injury of unknown origin for potential abuse for one of one resident (Resident 1) when Resident 1 was found with an unexplainable left shoulder dislocation (an injury that occurs when the upper arm bone pops out of the cup shaped socket near the shoulder blade) on 2/2/26.This failure placed Resident 1 and other residents in the facility at risk for unidentified abuse and had the potential to hinder protection from ongoing abuse.Findings:A review of Resident 1's admission RECORD, indicated that Resident 1 was admitted to the facility with diagnoses which included subarachnoid hemorrhage (SAH, a type of stroke characterized by bleeding in the space between the brain and the tissues that cover the brain), traumatic brain injury (a disruption in the normal function of the brain that can be caused by a bump, blow, or jolt to the head or penetrating head injury), and hypertension (a condition in which the force of the blood pushing against the blood vessel walls is consistently too high and causes the heart to work harder to pump blood).A review of Resident 1's Nurses Progress Notes, dated on 2/1/26, at 1:34 p.m., indicated, .patient [Resident 1] rp [Responsible Party, the person designated to direct the care of a loved one admitted into a nursing facility] stated to writer that patient looked like he did not feel good and pointed to patient left shoulder and stated that something was wrong and that the patient has a bad shoulder. patient appeared to be in some discomfort, writer informed rp that patient was changed and received wound treatment about 30 minutes prior and that patient was most likely recovering from this, rp disagreed and requested.x-ray [a quick painless test that captures images of the structures inside the body particularly bones]. administered PRN [as needed] pain medication and informed MD [medical doctor]. MD ordered.left shoulder x-ray.called [x-ray provider].scheduled left shoulder x-ray for tomorrow 2/2/26. rp at bedside and informed.A review of Resident 1's X-ray Report, indicated, .Date of Exam.02/01/2026 21:54 [9:54 p.m.].HISTORY.STIFFNESS/PAIN.SIGNIFICANT FINDINGS.LEFT SHOULDER X-ray Complete.Multiple views of the left shoulder show anterior [toward the front of the body] shoulder dislocation.There are no acute fractures [broken bones].A review of Resident 1's Nurses Progress Notes, dated 2/2/26, at 2:58 a.m., indicated, .shoulder x-ray result came back with a significant findings Left anterior shoulder dislocation .Called [MD] .send to ER [emergency department at acute care hospital] to fix the shoulder .Called the RP .During an interview on 4/1/26, at 12:20 p.m., with Resident 1's responsible party (RP) in Resident 1's room, the RP stated she asked staff to call the physician for an x-ray when she noticed that Resident 1 grimaced when she touched his shoulder on 2/1/26. The RP further stated staff that day (2/1/26) told her that Resident 1 had recently been cleaned and repositioned after providing incontinent care (skin care after involuntary or accidental leakage of urine or feces). The RP stated the x-ray showed that Resident 1's left shoulder was dislocated.During a joint concurrent interview and record review on 4/1/26, at 2:51 p.m., with the Director of Nursing (DON), the Social Services Director (SSD), and the Subacute Assistant Director of Nursing (ADON), Resident 1's electronic medical record (EMR) was reviewed. The DON stated there was no investigation into the cause of Resident 1's shoulder dislocation. The SSD stated the facility should have investigated to see if a cause for Resident 1's shoulder dislocation could be found.During a concurrent interview and record review on 4/2/26, at 2:03 p.m., with the Administrator (ADM) and the DON, Resident 1's EMR was reviewed. The ADM stated he knew that Resident 1 had a chronic shoulder issue. The ADM further stated that the shoulder issue was listed in Resident 1's EMR. The ADM stated that he talked with the RP a day or so after the injury to Resident 1's left shoulder was discovered. The ADM further stated that Resident 1's RP stated that Resident 1 had shoulder issues for years and was concerned about his arms being extended when repositioned. The ADM stated that he asked Resident 1's RP if Resident 1 fell and the RP said No, and the RP also stated that she didn't notice any trauma to his shoulder. The ADM further stated that he did not document the conversation that he had with Resident 1's RP but he spoke to the DON about it. The ADM and the DON both stated that they were not sure if the investigation was done to determine the cause of Resident 1's left shoulder dislocation. The ADM stated that he talked with Resident 1's RP during rounds but did not document the conversation. The ADM further stated that the RP was happy with Resident 1's care at the facility. The ADM stated that he followed the RP's lead and it did not lead him to suspect abuse. The ADM acknowledged that Resident 1 was under the facility's care. The ADM further acknowledged that an investigation after the discovery of Resident 1's left shoulder injury was not done. The ADM and the DON acknowledged that the cause of Resident 1's left shoulder dislocation should have been investigated to rule out abuse related to the injury of unknown origin.A review of a facility policy and procedure (P&P) titled, Abuse Prohibition Policy and Procedure, dated 5/23/21, indicated, .Policy.The Center will implement an abuse prohibition program through the following.Identification of possible incidents or allegations which need investigation.Investigation of incidents and allegations; and Reporting of incidents, investigations, and Center response to the results of their investigations.Federal Definitions.Injuries of unknown source are defined as an injury with both of the following conditions.The source of the injury was not observed by any person or the source of the injury could not be explained by the patient.The injury is suspicious because of the extent of the injury or the location of the injury.or the number of injuries observed at one particular point in time or the incidence of injuries over time.Purpose.To ensure that Center staff are doing all that is within their control to prevent occurrences of.injuries of unknown source.Process.1. The Center Executive Director.is responsible for operationalizing policies and procedures that prohibit.injuries of unknown source.6.3 Injuries of unknown origin will be investigated to determine if abuse or neglect is suspected.7. Upon receiving information concerning a report of suspected or alleged abuse.the CED (Center Executive Director) or designee will perform the following.7.2 Report allegations involving neglect, exploitation of mistreatment (including injuries of unknown source) .no later than two (2) hours after the allegation is made if the event results in serious bodily injury. Serious bodily injury is reportable. Only an investigation can rule out abuse, neglect, or mistreatment.7.2.1 Serious bodily injury is defined as an injury involving extreme physical pain; involving substantial risk of death; involving protracted loss or impairment of the function of a bodily member, organ or mental faculty; or requiring medical intervention such as surgery, hospitalization or physical rehabilitation.7.4 Notify local law enforcement, Ombudsman, Licensing District Office.and other agencies as required.7.6 Initiate an investigation within 2 hours of an allegation of abuse that focuses on.7.6.1 Whether abuse or neglect occurred and to what extent.7.6.2 clinical examination for signs of injuries.7.6.3 causative factors 7.6.4 interventions to prevent further injury.7.7 The investigation will be thoroughly documented.interview forms will be kept confidential in a file in the administrative office.9. The CED or designee will.9.2 Report findings of all completed investigations within five (5) working days to the Licensing District office.

Based on interview, and record review, the facility failed to complete and document a significant change in status assessment (Significant Change in Status Assessment, SCSA, refers to a comprehensive assessment that must be completed when the Interdisciplinary Team [IDT, a team of professional staff or a care team consisting of different disciplines who work together towards the goals of their residents] has determined that a resident meets the significant change guidelines for either major improvement or decline) for one of one resident (Resident 1) when Resident 1 was found with a left shoulder dislocation (an injury that occurs when the upper arm bone pops out of the cup shaped socket near the shoulder blade) on 2/2/26.This failure had the potential to result in unmet care needs for Resident 1 when the plan of care for Resident 1 was not current. This failure also had an increased risk on impacting the quality of care and the well-being for Resident 1. Findings: A review of Resident 1's admission RECORD, indicated that Resident 1 was admitted to the facility with diagnoses which included subarachnoid hemorrhage (SAH, a type of stroke characterized by bleeding in the space between the brain and the tissues that cover the brain), traumatic brain injury (a disruption in the normal function of the brain that can be caused by a bump, blow, or jolt to the head or penetrating head injury), and hypertension (a condition in which the force of the blood pushing against the blood vessel walls is consistently too high and causes the heart to work harder to pump blood).A review of Resident 1's Care Plan Report, initiated on 2/2/26, indicated, .Focus.Resident has dislocated left shoulder.Goal.Shoulder shall be fixed after sending to ER [acute care facility emergency department, ED].Date Initiated.02/02/2026.Target Date.05/24/2026.Interventions/Tasks.Administer pain medication.Immobilize [to keep from moving] the left upper extremity to prevent further damage to the left shoulder.Monitor resident for pain, swelling of the shoulder.Send to ER per MD order to fix dislocated left shoulder.A review of Resident 1's Physician Order Summary, indicated, .NO RNA [Restorative Nursing Aide Program, RNA, nursing aide program that helps residents to maintain their function and joint mobility] services to Left shoulder until further notice.Order Status.Active.Order Date.02/03/2026.During a joint concurrent interview and record review on 4/1/26, at 1:30 p.m., with the Physical Therapist (PT), Restorative Nursing Aide (RNA) 1, and RNA 2, RNA treatment forms for Resident 1 were reviewed. The PT and the RNAs stated they were familiar with Resident 1. The PT stated that he updated Resident 1's RNA orders two weeks ago. The PT further stated Resident 1 had upper and lower extremity passive range of motion (PROM, when someone physically moves or stretches a part of your body) ordered, then the order was changed to just lower extremity PROM. The PT stated the orders were changed because Resident 1 had a dislocated left shoulder. The PT further stated that PROM was also provided for Resident 1's right elbow to right wrist. RNA 1 stated Resident 1's RP did not want Resident 1 to have PROM to his upper arms, and no showers because of his left shoulder dislocation. RNA 1 further stated Resident 1 was always repositioned with two-person assistance. RNA 1 stated the staff used a sling beneath Resident 1 to reposition him when needed. RNA 1 further stated that pillows were used and/or a rolled towel to support Resident 1's left arm. RNA 1 stated the sling and pillows were provided by Resident 1's RP. RNA 2 stated the RNAs gave Resident 1's PROM every Monday, Wednesday and Friday. The PT, RNA 1, and RNA 2 stated they did not participate in Resident 1's Interdisciplinary Team Meetings. The PT, RNA 1, and RNA 2 further stated they had therapy plan of care meetings weekly for the RNAs. RNA 1 and RNA 2 stated that the MDS Coordinator (a nurse that collects data related to residents in order to develop and evaluate a comprehensive care plan and to make sure the facility gets payment from Medicare and Medicaid) set up the meetings and documented meeting notes in the residents' electronic medical records (EMRs).During a concurrent interview and record review on 4/1/26, at 2:51 p.m., with the Director of Nursing (DON), the Social Services Director (SSD), and the Subacute Assistant Director of Nursing (ADON), Resident 1's (electronic medical record) EMR was reviewed. The DON stated that she would need to check to see if a SCSA was completed by the MDS Coordinator for the left shoulder dislocation.During a concurrent interview and record review on 4/1/26, at 4:49 p.m., with the MDS Coordinator (MDS-C), Resident 1's EMR was reviewed. The MDS-C shared the Resident Assessment Instrument (Resident Assessment Instrument of MDS, RAI; a comprehensive assessment and care planning process used by the nursing home industry) definition of SCSA for completing the MDS form. The MDS-C stated a SCSA MDS form was completed when there was a fracture, decline in the resident's condition in more than one area, if resident was on a ventilator (a mechanical device that assisted a resident to breathe) or removed from the ventilator, or when a resident had a gastrostomy (G-tube, tube placed for fluids and nutrition for residents who cannot take food by mouth) placed or removed, for example. The MDS-C further stated there was a fourteen-day window to complete the SCSA MDS form. The MDS-C stated the risk of not completing the SCSA MDS form was that Resident 1 could experience pain, discomfort with the RNA Program and Activities of Daily Living (ADLs, tasks of everyday life including eating, dressing, bathing, or showering, and using the bathroom), and that the care plan was not revised. The MDS-C confirmed that a SCSA MDS was not completed for Resident 1's shoulder dislocation.During a concurrent interview and record review on 4/2/26, at 10:35 a.m., with the MDS-C, the MDS RAI Assessment Guidelines document was reviewed. The MDS-C stated the Administrator thought that Resident 1 may not have met criteria for an SCSA. The MDS-C confirmed that Resident 1 had a significant change in status based on the RAI definition. The MDS-C acknowledged that a SCSA should have been completed for Resident 1. The MDS-C further acknowledged that the facility policy was not followed.A review of a facility policy and procedure (P&P) titled, Assessments for the RAI, updated October 2025, indicated, . 03. Significant Change in Status Assessment.The SCSA is a comprehensive assessment for a resident that must be completed when the IDT has determined that a resident meets the significant change guidelines for either major improvement or decline. It can be performed at any time after the completion of an admission assessment, and its completion dates.depend on the date the IDT's determination was made that the resident had a significant change.A significant change is a major decline or improvement in a resident's status that.1. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, the decline is not considered 'self-limiting' (will not resolve without intervention) .2. Impacts more than one area of the resident's health status; and.3. Requires interdisciplinary review and/or revision of the care plan.A SCSA is appropriate when.There is a determination that a significant change (either improvement or decline) in a resident's condition from their baseline has occurred as indicated by comparison of the resident's current status to the most recent comprehensive assessment and any subsequent Quarterly assessments; and.The resident's condition is not expected to return to baseline within two weeks.A review of a facility P&P titled, Care Plan - Baseline, dated August 25, 2021, the P&P indicated, .Purpose.An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, physical, mental and psychosocial needs shall be developed for each resident.Procedure.7. Assessments of residents are ongoing, and care plans are reviewed and revised as information about the resident and the resident's condition change.8. The Interdisciplinary Team is responsible for evaluating and updating of care plans.a. When there has been a significant change in the resident's condition.

Based on interview and record review, the facility failed to provide adequate care and supervision (an intervention and means of mitigating the risk of an accident) for one out of two sampled residents (Resident 1) to ensure resident safety when, the facility staff did not take immediate action to locate Resident 1 when Resident 1 left the facility for more than four hours past his expected return time for a medical appointment on 10/16/25.This failure resulted in Resident 1 eloping from the facility on 10/16/25 and Resident 1 did not return to the facility until approximately 29 hours later. Resident 1 was transferred to hospital, was positive for illicit drug use (use of illegal drugs (e.g., heroin, cocaine) and/or inappropriate use of prescription medications), and missed scheduled intravenous (IV; administering fluids medication directly into a vein using a needle or tube in the hand) Ertapenem medication (an antibiotic used to treat severe infections like pneumonia, and urinary tract infections caused by bacteria) administration, his blood sugar checks, and insulin (injectable medication to lower blood sugar for diabetic patients) dose over a 24 hour period. Resident 1 left the facility with a Right Upper Arm Peripheral Intravenous Central Catheter (PICC; a long flexible tube inserted into a large vein of the upper arm to the heart to give medications, fluids, and for blood draws).Findings: During a record review of Resident 1's admission RECORD, indicated Resident 1 was admitted to the facility in 2025, indicating Resident 1 had diagnoses of acute osteomyelitis (infection in the bone, through the blood stream or nearby infected tissue) right ankle and foot, cellulitis (a deep bacterial infection of the skin, causing, redness, swelling and tenderness) of right lower limb non pressure (a wound not caused by pressure) chronic ulcer of the right heel and foot, type 2 diabetes (when the body cannot use insulin correctly and sugar increase in the blood stream), long term current use of insulin, asthma, difficulty walking, and generalized muscle weakness.During a concurrent interview and record review on 3/6/26, at 12:02 p.m., with the Director of Nursing (DON), Resident 1's Progress Notes were reviewed. The DON confirmed Resident 1 left the faciity on [DATE] for a scheduled medical appointment and did not return to the facility until 10/17/25, at 5:16 p.m.A review of Resident 1's Progress Notes, the Progress Notes indicated, .Effective Date: 10/16/2025 18:00 [6 p.m.]. Type: Nurse Progress Note. LATE ENTRY. Note: Received call from the charge nurse that resident signed out for his appointment with nurse and did not return yet. Charge nurse also stated that he left yesterday too with his friend but did return around 1830pm [6:30 p.m.]. Writer informed the charge nurse to call the resident cell phone and the contact listed on the profile to see and also notified MD [medical doctor] and admin [administrator].During a record review of Resident 1's Progress Notes, the progress note indicated, .Effective Date: 10/17/2025 06:57. Note: Per PM nurse, resident verbalized to AM nurse that he had an appointment on 10/16/25 at 1:30 p.m. which he independently scheduled, including his own transportation. The Resident has not returned to facility since leaving for the appointment. PM nurse attempted to contact resident via cell phone with no answer. Writer also attempted to call resident's cell phone with no answer as well, voicemail left requesting resident return to the facility. Emergency contact [family member] was called but no answer. Writer also contacted resident's other listed contact [family member], no answer. Director of Nursing, Administrator, and [MD] notified and aware.During a record review of Resident 1's Progress Notes, indicated, .Created Date 10/17/2025 23:12:29 [11:12 PM] . SS [Social Services] met with the patient in the hallway after he returned to the facility, as he was heading back to his room. the patient expressed that his experience outside the facility was quite frightening for him .During a review of Resident 1's progress notes titled Situation Background Assessment Recommendations (SBAR), dated 10/17/25, indicated, . the change in condition, symptoms, or signs observed and evaluated is/are: Other change in condition: resident was out of the facility without MD order for extended periods of time. No changes observed. This started on: 10/16/2025 . Primary Care Clinician Notified: Yes, Date: 10/17/2025, Time 5:00 p.m., Testing; other: (describe) toxic screening [toxicology screen or tox screen checks blood, urine, or saliva for drugs, alcohol, and/or toxins].During a review of Resident 1's Emergency Department Discharge Instruction, dated 10/17/25, the document indicated, .reason for visit, drug screening, discharge diagnosis. Encounter for drug screening, foot osteomyelitis [a serious bone infection], right, Methamphetamine use [an illicit drug], Opiate use [a class of natural, semi synthetic and synthetic drug], . drug Screen Panel (10/17/25). Ur [urine] Amphet/Methamphet [Amphetamines/Methamphetamine; powerful, synthetic central nervous system (CNS) stimulants that accelerate messages between the brain and the body] - Positive, Ur Opiates [A substance used to treat pain or cause sleep] - Positive.During an interview on 3/10/26, at 1:27 p.m., with Licensed Nurse (LN) 1, LN 1 stated the day shift nurse endorsed to her Resident 1 had left with his friend for an appointment and was expected to be back at a certain time, between 6 p.m. and 7 p.m. LN 1 further stated Resident 1 had a history and an incident of leaving the facility without staff's knowledge prior. LN 1 stated she did not remember whether she called the Physician when Resident 1 did not come back at 6 p.m., or at his expected time of return. LN 1 further stated it was an unusual occurrence when Resident 1 left on 10/16/25 and did not return at the expected time of return, if it was not approved by the Physician. LN 1 further stated the normal protocol she followed for an unusual occurrence was to have notified the Administrator (ADM) and the DON and to follow whatever instructions they had given to her.During an interview on 3/11/26, at 3:05 p.m., with LN 1, LN 1 confirmed she did not call the police on 10/16/26, when Resident 1 did not return to the facility at his expected time of return to the facility. LN 1 stated by not calling the police could affect Resident 1's safety and facility staff would want to know his whereabout, when he would return, was he ok, and had he been admitted to the hospital.During a record review of resident 1's Interdisciplinary Care Conference notes (IDT), dated 10/20/25, the IDT notes indicated, .Resident had an oop [out on pass] which was initiated on 10/15/2025 for one day pass, MD approved. On 10/16/2025 Resident signed out at the nursing station stating that he was going out for an appointment. Per resident he made his own appointment and already has his transportation set up to be picked up. Resident left the facility at 12:30 p.m., resident returned at 17:16 p.m. [5:16 p.m.], on 10/17/25 accompanied by his friend. As per interviewed with the resident upon his returned, he stated that he did not know that he needed to get another order to go out on pass for 10/16/25 since he already had an order for 10/15/25.Resident educated regarding risk and benefits of going out with an IV line. MD gave order to check the lab. Lab result shows positive for Methamphetamine.During a concurrent interview and record review on 3/6/25 at 12:10 p.m., with the DON, the facility's policy and procedure (P&P), titled, Leave of Absence without Notice, was reviewed. The DON confirmed based on the definition of elopement, it was considered an elopement when Resident 1 left the facility and did not return till the next day on 10/17/25. The DON stated that when a resident left on a out on pass or had left for his appointment and did not return after 4 hours, or at the expected time of return, nursing staff should have immediately followed the facility's policy and first called the administration and Physician, then law enforcement. The DON further stated LN 1 did not call the physician until 10 p.m., on 10/16/25, when Resident 1 left for an appointment and did not return past his expected time of return. The DON stated staff did not call the police until the next day on 10/17/25 at around 7 a.m. The DON further stated the expectation of nurses was to call the patient and family and if they could not reach any of them, to have called the physician and police. The DON admitted nursing staff should have followed up with the community medical center to see whether Resident 1 was there or where he had been. The DON added the facility's process for giving residents an out on pass, they need to have a physician's order to go out. The DON stated if the resident was going to a scheduled appointment, the facility would enter the appointment into the orders, the resident must sign out on the sign out sheet, and the facility should have known where the location was that resident had gone to, the contact number, and who they went with. The DON stated not calling the physician and police immediately when they found out Resident 1 had not returned hours past his appointment time, put Resident 1's safety at risk. The DON added the facility did not know whether something had happened to Resident 1, whether he was at a local hospital, and did not know his whereabouts. The DON confirmed Resident 1 had missed a dose of his Ertapenem antibiotic medication and Resident 1 had a PICC and anything could have happened to the PICC line.During an interview on 3/11/26, at 12:38 p.m., with the Assistant Director of Nursing (ADON), the ADON confirmed the facility did not call the police the night Resident 1 did not return to the facility after his medical appointment. The ADON further stated she had to call the police when she came on her shift at 7 a.m., on 10/17/25. The ADON stated it was expected for the nurse to have called the physician, the DON, the ADM, the family, and then the police. The ADON further stated Resident 1 was under their care and they were trying to keep him safe. The ADON added Resident 1 had left with a PICC line and this posed a very high risk. The ADON further stated there could have been harm to Resident 1, as the facility did not know in which condition Resident 1 was in. The ADON confirmed it was an unusual occurrence when Resident 1 left the facility for a medical appointment, did not return hours past his return time, and the facility was unaware of his wellbeing. The ADON further stated the policy for an unusual occurrence was to notify the supervisor, the ADM, the physician, and law enforcement based on the situation. The ADON stated Resident 1 had a history of leaving the facility on a pass and would not return at the expected time of return.A review of Resident 1's Order Summary Report, indicated, . Ertapenem sodium Injection Solution Reconstituted 1 GM [gram; a unit of measurement] (Ertapenem Sodium) use 1 gram intravenously one time a day for osteomyelitis until 10/28/2026 23:59. Communication Method. Prescriber Written. Order Status Completed. Order Date. 09/23/2025. End Date. 10/28/2025. Heparin Sodium (Porcine) injection Solution 5000 UNIT/ML (Heparin Sodium (Porcine) [blood thinner used to prevent and treat blood clots] injection 1 ml subcutaneously [under the skin] every 8 hours for DVT [deep vein thrombosis, blood clot] prevention. Order Date. 09/22/2025. Start Date 09/22/2025. End Date [none].A review of Resident 1's Care Plan, indicated, . Focus. Resident is at risk for injury or complications related to the use of anticoagulant/antiplatelet therapy. Medication: Heparin. Date initiated: 10/01/2025. Created on: 10/01/2025. Canceled Date: 11/12/2025. Interventions. Anticoagulant to be given as ordered. Monitor for cyanosis and pallor [a pale, reduce color in the skin caused by decreased blood flow]. Date Initiated: 10/02/2025. Revision on: 11/12/2025. Observed for active bleeding, i.e. hematuria [blood in the urine], bruising, . nose bleeds, bleeding gums, etc. Date Initiated: 10/01/2025. Created on: 10/01/2025. Revision on: 11/12/2025.During a review of Resident Medication Administration Record (MAR), indicated, . Insulin Glargine subcutaneous Solution 100 UNIT/ML (Insulin Glargine) Inject 10 unit subcutaneously at bedtime for Type 2 DM -Start Date- 09/22/2025 2100 -D/C Date-10/29/2025 1414.[10/16, 10/17, 10/18 marked as] AW Away from center. Heparin. injection Solution 5000 UNIT/ML. Inject 1 ml subcutaneously every 8 hours for DVT prevention.[10/15, 10/16, 10/17, marked x; not given].During an interview on 3/11/26, at 3:56 p.m., the DON confirmed an X on the MAR meant the medication was not given.During a review of facility's document, titled Location of Administration Report, indicated, . Schedule for [DATE]. Ertapenem Sodium. 1. use 1 gram intravenously one time a day for Osteomyelitis until 10/28/25. [was marked on] 10/17 [as] AW [resident was not available] .A review of facility's policy and procedures (P&P), titled, Wandering and Elopements, revised 2019, the P&P indicated, .Policy statement. The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. 3. If a resident is missing, initiate the elopement/missing resident emergency procedure: . a. Determine if the resident is out on an authorized leave or pass; . b. If the resident was not authorized to leave, initiate a search of the building (s) and premises; and. c. If the resident is not located, notify the Administrator and the Director of Nursing Services, the resident's legal representative, the Attending Physician, law enforcement officials, and (as necessary) volunteer agencies (i.e., Emergency Management, Rescue Squad, etc.) .A review of facility's P&P titled, Out On Pass, revised 4/11/25, the P&P indicated, . Purpose. To provide residents with the opportunity to participate in family and community life in ways that support well-being and optimal functioning.Policy. It is the policy of the Facility to meet residents' physical and psychological needs when going out on pass. The Facility will make reasonable efforts to ensure the resident safety and uphold resident rights. Procedure. 2. If at any time the nursing staff believe the resident's use of the out on pass order conflicts with the resident's plan of care or jeopardizes the resident's health or safety, the nursing staff will hold the out on pass order until the attending physician/psychiatrist (if applicable) are notified. a. A new out on pass order will be obtained once the attending physician/psychiatrist can determine the resident can safely leave the facility. 4. Licensed Nurse. a. Prior to the resident leaving on pass, licensed nurse will assess the resident's physical and mental status and ensure that: .i. The resident and responsible person (if applicable) has been instructed of any special needs of the resident during the pass as applicable. ii. There is a physician order for medication to be given while on pass.

Based on interviews and record reviews, the facility failed to ensure a comprehensive person-centered care plan (a structured document that outlines a patient's healthcare needs, goals and the nursing interventions needed to achieve them), was developed for 1 of 3 sampled residents (Resident 2) when, an elopement care plan was not developed for Resident 2 after Resident 2 was identified as at risk for elopement on 12/24/25.This failure put Resident 2 at risk for elopement.Findings: A review of Resident 2's admission RECORD indicated Resident 2 was admitted to the facility with multiple diagnoses including but not limited to End Stage Renal Disease (the irreversible loss of 85-90% of kidney function, where the kidneys can no longer support life), dependence on renal dialysis (a life-sustaining treatment for kidney failure (renal failure) or advanced chronic kidney disease that filters toxins, waste, and excess fluid from the blood when kidneys can no longer perform these functions), and Sequelae of cerebral infarction (the lasting, long-term physical, cognitive, and psychological effects following an ischemic stroke, often including paralysis (hemiplegia), speech deficits, cognitive decline, and emotional changes).Review of Resident 2's record titled Elopement Evaluation, dated 12/24/25, indicated Resident 2 was .At Risk for Elopement .During a concurrent interview and record review on 2/12/26, at 3:20 PM, Resident 2's care plans were reviewed with the Director of Nursing (DON). The DON confirmed Resident 2 did not have a care plan created for elopement. The DON stated there should have been a care plan for elopement. The DON further stated not having a care plan put Resident 2 at risk of elopement. The DON added that a comprehensive care plan was very important for the staff as it guides them with interventions to care for the residents and be more vigilant and careful if the resident is trying to leave the facility. Review of the facility policy and procedure (P&P) titled Wandering and Elopements, revised 3/19, the P&P indicated, .If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety.

Based on interview and record review, the facility failed to provide comprehensive pain management, for one of three sampled residents (Resident 1) when, Resident 1 had not been given the appropriate pain medication as per the pain assessment scale (a tool used to assess the level of pain) and provided pain medication as ordered by the physician.This failure resulted in Resident 1's pain not being effectively managed and Resident 1's pain not being treated per the physician's orders. Findings:A review of Resident 1's admission RECORD, indicated Resident 1 was admitted to the facility in mid-2024 with diagnoses which included polyneuropathy (a condition characterized by damage to multiple peripheral nerves, usually causing symmetrical numbness, tingling, weakness, and burning pain, often starting in the feet or hands) and gout (a common, painful form of inflammatory arthritis caused by high levels of uric acid in the blood (hyperuricemia) that form needle-like crystals in joints).A review of Resident 1's Order Summary Report, indicated a physician's order for .Acetaminophen Tablet 325MG (Acetaminophen) Give 2 tablet by mouth every 4 hours as needed for Mild Pain. Resident 1's order summary report also indicated another physician's order which indicated, .[Hydrocodone/acetaminophen] Norco [pain relieving medication] Oral, Tablet 5-325 MG (Hydrocodone-Acetaminophen) Give 1 tablet via G-Tube [A gastrostomy tube (G-tube) is a medical device inserted through the abdomen directly into the stomach to provide long-term nutrition, fluids, and medication] every 6 hours as needed for pain level 5-10.[Pain scales are standardized, subjective tools used by healthcare professionals to measure pain intensity, typically ranging from 0 (no pain) to 10 (worst pain imaginable)].During an interview, on 2/17/26, at 3:25 p.m. with Licensed Nurse (LN) 1, LN 1 stated when Resident 1 was in pain, his respirations and heart rate would go up, his eyes and mouth would open and there was grimacing noted on his face. LN 1 stated they use a PAINAD scale (pain assessment in advanced dementia is a validated, 5-item observational tool used by healthcare professionals to measure pain (0-10 score) in patients with severe dementia or communication deficits. It assesses breathing, negative vocalization, facial expression, body language, and consolability) to access Resident 1's pain, after which she would then administer 2 acetaminophen tablets to Resident 1. LN 1 stated it was nursing judgement to determine pain medication to give. LN 1 stated Resident 1 was non-verbal and had a lot of wounds which were painful. LN 1 further stated, she did not like giving hydrocodone/acetaminophen as Resident 1's body would get used to it and the medication would become less effective.A review of Resident 1's Medication Administration Record [MAR], dated for the month of 1/26, Resident 1's administration record for acetaminophen, indicated Resident 1 had a documented pain level of 8 on 1/6/26, 5 on 1/17/26, 6 on 1/21/26, and 7 on 1/30/26 and Resident 1 was given 2 acetaminophen tablets on these dates. Further review of Resident 1's MAR for the month of 1/26, indicated Resident 1's administration record for hydrocodone/acetaminophen, indicated Resident 1 had a documented pain level of 4 on 1/8/26, 0 on 1/26/26 and 0 on 1/31/26 and Resident 1 was given 1 hydrocodone/acetaminophen tablet on these dates. During a concurrent interview and record review, on 2/17/26, at 4 p.m. with the Director of Nursing (DON), Resident 1's MAR, dated for the month of 1/26, was reviewed. The DON confirmed that Resident 1 was given acetaminophen sometimes when his pain level was above 5, and Resident 1 should have received the hydrocodone/acetaminophen pain medication at those times. The DON confirmed that Resident 1 received hydrocodone/acetaminophen sometimes when his pain level was lower, and Resident 1 should have received acetaminophen as per the physician's orders. The DON further stated, staff failed to manage Resident 1's pain properly and put Resident 1 at risk of being overmedicated when his pain was less and undermedicated when he was in more pain. The DON further stated that it was very important to follow the physician's order properly so residents' pain can be managed effectively as it is also the residents' right to get the right medication. Review of Resident 1's record titled Care Plan Report for pain, created on 1/22/25, in the section Focus, the record indicated, [Resident 1] has (acute/chronic) pain r/t [related to] Chronic Physical Disability. Wound STAGE 4 PRESSURE WOUND SACRUM [the most severe form of pressure injury, involving full-thickness tissue loss with exposed fascia, muscle, tendon, and bone; sacrum - the part of the spinal column that is directly connected with or forms a part of the pelvis] . In the section Interventions, indicated, .Administer analgesia [medications designed to relieve pain] ([hydrocodone/acetaminophen]) as per orders.Review of a facility policy and procedure (P&P) titled Administering Medications, revised 4/19, the P&P indicated, The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and write method (route) of administration before giving the medication .

Based on interview and record review, the facility failed to refer one of two sampled residents (Resident 1) to a psychiatrist (a medical doctor who can diagnose and treat mental health conditions) as recommended by the Interdisciplinary Team (IDT, a group of professionals who have a role in the Resident's care) and ordered by the physician after Resident 1 had a behavioral manifestation of agitation during an altercation with another resident (Resident 2) on 10/24/25.This failure could potentially result in increased agitation episodes for Resident 1 and a risk of getting involved in another altercation incident.A review of Resident 1's admission RECORD, indicated Resident 1 was admitted with diagnoses which included muscle weakness and difficulty walking.A review of Resident 1's medical record titled IDT Care Conference dated 10/27/25, indicated, Resident 1 had an altercation with another resident (Resident 2) and the IDT recommended a psychiatric evaluation and treatment for episodes of agitation.A review of Resident 1's Order Summary, dated 10/29/25, indicated, .Psych Evaluation and Treatment # [number of] agitation .During a concurrent interview and record review on 12/26/25, at 2:40 PM, with the Assistant Director of Nursing (ADON), Resident 1's IDT care conference note was reviewed. The ADON stated an IDT meeting was held after the altercation incident and the team recommended a psychiatric evaluation and treatment for episodes of agitation for Resident 1. The ADON stated she was not sure if the psychiatric referral was done. The ADON stated that when a resident was referred for a psychiatric evaluation, they needed to inform the social services department.During a concurrent interview and record review on 12/30/25, at 9:23 AM, with the Social Service Assistant (SSA), Resident 1's electronic health record (EHR) was reviewed. The SSA confirmed that there was an IDT meeting after the altercation incident and it was recommended that Resident 1 was to be referred for a psychiatric evaluation. The SSA stated they had a psychiatrist that would come to the facility. The SSA stated that the Social Services department was responsible for sending the referrals. The SSA stated she was not sure if Resident 1 was seen by the psychiatrist. The SSA stated they had a portal with the contracted company where the psychiatrist made their notes from the visit, but she did not have access to it. The SSA stated that the psychiatrist did not send the notes to the facility and confirmed Resident 1's EHR did not contain any notes from the psychiatrist. During a concurrent interview and record review on 12/30/25, at 10:33 AM, with the Director of Nursing (DON), Resident 1's EHR was reviewed. The DON stated Resident 1 had a history of agitation. The DON further stated that Resident 1 had a verbal argument with Resident 2 and tried to hit Resident 2. The DON confirmed that there was an order for a psychiatric evaluation from the physician for Resident 1 dated 10/29/25. The DON stated it was the responsibility of social services to send the referrals for psychiatric consultations. The DON stated she was not sure if Resident 1 was seen or not, and she did not have access to the psychiatrist's portal. The DON stated that the psychiatrist usually emailed the social services department the visit notes and the social services would upload them into the resident's chart. The DON confirmed she did not see any psychiatric notes in the medical chart of Resident 1. The DON stated that it was important for the facility to know what the recommendations of the psychiatrist were. The DON further stated that the psychiatrist should at least tell the facility what the recommendations were for the resident after their visit. The DON stated that if the facility was not aware of the recommendations of the psychiatrist, the facility would not be compliant with the psychiatric services, and it would affect the resident's psychosocial health.

Based on interview, and record review, the facility failed to provide adequate supervision for one of five sampled residents (Resident 1) when Resident 1's physician order to monitor every 15 minutes for suicidal ideation (thinking about, considering, or being preoccupied with the idea of death and suicide) was not followed. This failure resulted in Resident 1 causing harm to himself by cutting his arms and legs multiple times with a razor blade on 8/8/24 and being admitted to an acute care hospital for treatment. Findings: A review of Resident 1's admission RECORD, indicated, he was admitted to the facility in May of 2024, with diagnoses which included, suicidal ideations, depression (mood disorder that causes a persistent feeling of sadness, low mood, and lack of interest in previously enjoyed activities) and psychoactive substance abuse (misuse or excessive use of substances that affect mental processes and behavior). A review of Resident 1's Minimum Data Set (MDS, a federally mandated resident assessment and screening tool which identifies care needs) Section D-Mood, dated 5/27/24, indicated, .Over the last 2 weeks, have you been bothered by any of the following problems .Feeling down, depressed or hopeless .Symptom Presence 1 [Yes] .Symptom Frequency 3 [12-14 days (nearly every day)] .Feeling bad about yourself-or that you are a failure or have let yourself or your family down .Symptom Presence 1 [Yes] .Symptom Frequency 1 [2-6 days (several days)] . A review of Resident 1's clinical document titled, Progress Notes, dated 8/7/24, at 11:30 AM, indicated, .After resident was assisted back to bed from falling this writer left room to go get residents medications. Another LN [licensed nurse] was in the room with resident and reported that resident took a pair of scissors and held them to his neck and stated, I should just end it all right now. Per LN resident started laughing after. Scissors were taken from resident. Room was checked for any other objects resident could hurt himself with .Resident was placed on q15 min [every 15 minute] checks, and the kitchen was notified to give plastic utensils . A review of Resident 1's clinical document titled, Order Summary Report, order date 8/7/24, indicated, .Change meal utensil to plastic utensil before meals for suicidal ideation .Monitor for suicidal ideation Q 15 every shift . A review of Resident 1's clinical document titled, Care Plan Report, initiated 8/7/24, indicated, .Focus .Resident/Patient is at risk for suicidal impulses/ideations of self-harm related to - 8/7/24- resident held scissors to his neck and stated I should just end it all right now .Goal .Resident/Patient will remain safe from self-harm .Interventions .q 15 min checks x 24 hours .plastic utensils during meals . A review of Resident 1's clinical document titled, Progress Notes, dated 8/8/24, at 4:50 PM, indicated, .11:30am [on 8/8/24] nurse notified by activity staff that resident was actively cutting himself. Nurse quickly went to resident room and when entering room, nurse seen resident attempting to continuously cut left forearm. Nurse then asks resident, can you tell me what's going on? Resident then responding saying, I'm trying to kill myself what does it look like .Nurse asked resident if he would allow staff to dress wounds as he was losing a lot of blood .resident continued to self-harm, resident would ask where is the artery [blood vessel that carries blood away from the heart]?, as he was cutting left arm and behind left leg . A review of Resident 1's clinical document titled, Progress Notes, dated 8/8/24, at 5:03 PM, indicated, .Interdisciplinary [group of healthcare professionals who assess and coordinate care] Progress Notes .On 8/7/24 .resident was noted with a pair of scissors in his hand and was holding the scissors to his neck stating, I should just end it all right now! .Resident was placed on Q15min checks and kitchen was notified for plastic utensils to be given .On 8/8/24, resident was still on Q15 monitoring for suicide watch, resident interacted with staff on 10 occasions from beginning of shift until 11:30, time of incident .Paramedics were called for 5150 [involuntary psychiatric hold for someone who is a danger to self or others] .resident taken to [Hospital Name] for further treatment and evaluation . A review of Resident 1's clinical document titled, ED [emergency department] Note- Physician, with a visit date on 8/8/24, indicated, .History Of Present Illness .Per EMS [Emergency Medical Services] report, patient cut himself multiple times with a razor blade just prior to arrival and had an estimated 500cc [cubic centimeters, a unit of measure, 500cc = approximately 2 cups] of blood loss on scene .Medical Decision Making .[Resident 1] is tearful, states that he is depressed and wanting to end his life. Placed on a 1799 hold [ a short-term, 24 hour psychiatric detention used in California hospitals] for danger to self . A review of Resident 1's clinical document titled, Physician Progress Notes, with a visit date on 8/8/24, indicated, .[Hospital Name] TRAUMA TERTIARY [specialized medical care] SURVEY NOTE .INJURIES FROM admission .Multiple 3-8 inch lacerations [cuts in the skin] along the L [left] anterior [ the front] forearm and the L popliteal fossa [shallow depression at the back of the knee joint] .PHYSICAL EXAM .Upper Extremities [arms]: Several lacerations to the L forearm .with three deep lacerations repaired with .sutures [thread used to close a wound] .Lower Extremities [legs]: Several lacerations to the L popliteal fossa and calf [lower leg], some are sutured .and some remain unsutured with no active bleeding . During an interview on 4/8/25, at 1:25 PM, Activity Assistant (AA) 1 stated on 8/8/24, she walked into Resident 1's room and asked him how he was. AA 1 further stated Resident 1 replied that he was saying goodbye to himself. AA 1 stated Resident 1 had a razor blade and multiple cuts on his arm. AA 1 further stated Resident 1 showed her his arm and sliced it in front of her. During an interview on 4/8/25, at 3:06 PM, LN 2 stated on 8/8/24, he was called into Resident 1's room by AA 1. LN 2 further stated he was not sure how many times Resident 1 had cut himself. LN 2 stated Resident 1 talked about his family and wanting to die. LN 2 further stated he tried talking to Resident 1 to stop the situation from getting worse. LN 2 stated he was not sure how Resident 1 obtained a razor, but it could have been from another resident. LN 2 further stated Resident 1's q 15 minute checks were supposed to be documented by the Certified Nurse Assistants (CNA). During an interview on 4/8/25, at 3:10 PM, LN 3 stated on 8/8/24, she was called into Resident 1's room by AA 1. LN 3 stated when she entered his room Resident 1 laughed, made an odd statement, and cut himself. LN 3 further stated Resident 1 was very mobile and could have obtained razors from another resident. During an interview on 4/8/25, at 4:14 PM, CNA 3 stated she was surprised by Resident 1's behavior on 8/8/24. CNA 3 stated she was not aware Resident 1 could behave like that. CNA 3 further stated Resident 1 was friends with everyone and could have obtained a razor from another resident. A review of a facility provided form, used by staff to document Resdient 1's activities every 15 minutes, titled, [facility name] AM [morning] Shift, dated 8/8/24, indicated, time periods from 7:15 AM - 2:45 PM in 15 minute increments. Further review of the record indicated there was no documentation on the form to indicate the 15 minute checks had been completed. During an interview on 4/9/25, at 3:13 PM, the Administrator (ADM) confirmed the 15 minute check form dated 8/8/24, had no documentation from 7:15 AM -until Resident 1 was sent to the hospital on 8/8/24, to indicate Resident 1 was monitored by staff. The ADM stated staff may have stopped monitoring Resident 1 because he had no further behavioral episodes. The ADM could not state who decided to stop the 15 minute observations. The ADM stated the 15 minute observations were initiated due to Resident 1 acting differently. The ADM was unable to provide documentation to indicate the 15 minute checks were discontinued or that the 15 minute checks were completed on 8/8/24. During an interview on 4/10/25, at 8:20 AM, the Assistant Director of Nurses (ADON) stated on 8/8/25, at approximately 11 AM, as she was leaving the building, she observed Resident 1 headed out the front door. The ADON further stated Resident 1 indicated he wanted to go home. The ADON stated she encouraged Resident 1 to talk with a social worker and directed him back into the building. The ADON further stated when a resident was on 15 minute checks the CNA or LN would check on the resident and document their activity in the allotted time frame on the monitoring form. The ADON stated the purpose for Resident 1's q 15 minute checks was to prevent Resident 1 from having suicidal behaviors. The ADON further stated if the q 15 minute checks were not documented the facility could not show that Resident 1 was monitored during that time. The ADON further stated it was her expectation that the 15 minute documentation would have been completed. During an interview on 4/10/25, at 8:47 AM, Resident 1's Primary Medical Doctor (PMD) stated she had ordered every 15 minute suicidal ideation monitoring on 8/7/24 after Resident 1 threatened himself with scissors. The PMD further stated she was not aware that the monitoring had not continued. The PMD stated the facility staff should have continued to monitor Resident 1 to have prevented the incident from occurring. A review of a facility policy titled, Suicide Threats, revised 2007, indicated, .Resident suicide threats shall be taken seriously and addressed appropriately .If the resident remains in the facility, staff will monitor the resident's mood and behavior and update care plans accordingly, until a physician has determined that a risk of suicide does not appear to be present . A review of a facility job description titled, Licensed Practical (Vocational) Nurse (LPN)/( LVN), revised 2022, indicated, .Duties and Responsibilities .Maintain documentation of all nursing care and services provided to the residents; use nurse's notes, flow sheets and electronic medical records according to facility policy .Safety .Functions .Ensure each resident receives adequate supervision .to prevent accidents .

Based on interview, and record review, the facility failed to ensure one of five sampled residents (Resident 1), received quality of care (health services for individuals and populations increase the likelihood of desired health outcomes) according to professional standards of practice (a set of principles, goals, and expectations that describe the rights and responsibilities of professionals in a specific practice) when a tourniquet (a band of rubber wrapped tightly around the arm for a short period of time to more easily visualize the veins for blood removal needed for testing) was left around Resident 1's right arm for approximately three days and the nursing staff did not perform a detailed skin assessment of Resident 1's skin. This failure resulted in severe swelling (collection of fluid under the skin) and an open wound (sore) on the right arm and the lack of identification of a pressure injury to the buttocks during two skin assessments that could have resulted in further deterioration of the injury. Findings: During a review of Resident 1's clinical record titled, Admission Record, indicated Resident 1's diagnosis included quadriplegia (inability to move or have feeling in the arms and legs). A review of Resident 1's clinical record titled, Lab [Laboratory - department in medicine that examined blood and other test results] Results, indicated the [LABORATORY NAME AGENCY] drew blood from Resident 1 on 6/6/24, at 3:52 p.m. A review of Resident 1's clinical record titled, Progress Notes, dated 6/9/24, at 11:08 a.m., by Licensed Nurse (LN) 4, indicated, Noted with open wound in the Right Upper arm with + [over] edema [buildup of fluid under the skin - edema was rated 1 through 4, with 4 the most severe form of edema]. Res [Resident] stated the Phlebotomist [a healthcare professional who collected blood samples from the resident for testing] forgot to remove the tourniquet in my arm last Thursday [6/6/24] . A review of Resident 1's clinical record titled, Situation Background Assessment Recommendation [SBAR] Communication Form, [a form used to communicate the resident's important information with other care givers] dated 6/9/24, at 12 a.m., by LN 1, indicated, .noted with open wound in the Right Upper arm with + 4 edema .Primary Care Clinician Notified .Recommendations of Primary Clinician .new orders .Cleanse [clean] with NS [normal saline] pat dry, apply Leptospermum honey [cream used to promote wound healing], and cover with boarder dressing [water resistant band-aid used to help protect the wound from dirt or germs] . A review of Resident 1's clinical record titled, Wound Evaluation & [and] Management Summary, dated 6/11/24, at 12:31 p.m., by the Wound Medical Doctor (WMD), indicated Resident 1 had a full thickness (damage extended below the epidermis (outermost layer of skin) and dermis (layer of skin found beneath the epidermis) wound of the right arm that was related to trauma (physical injury of sudden onset and severity which required immediate medical attention). The measurement of the wound was 3.0 centimeters (cm - unit of measurement) in length (L), 25 cm wide (W), and 0.1 cm deep (D). The surface area (SA - size of the wound on the surface) was 75.0 cm. There was 100 percent (% - unit of measurement) granulation tissue (the development of new skin during the healing process) and light serous drainage (clear yellow fluid that leaked from the wound). A review of Resident 1's clinical record titled, Braden Scale For Predicting Pressure Sore Risk Original, (an assessment tool used to predict a resident's risk for pressure ulcers (an injury that breaks down the skin when an area of the body was placed under pressure), dated 3/16/24, indicated Resident 1's risk score was 12 (high risk for pressure ulcers) related to complete immobility, often moist, and confined to a bed. A review of Resident 1's clinical record titled, Section GG, (section of an assessment that determined the resident's usual abilities) dated 6/21/24, at 7:31 p.m., indicated Resident 1 needed maximum assistance with eating, oral hygiene (brushed teeth), toileting hygiene (clean up after voiding (urine) or having a bowel movement (stool), shower or bath, upper and lower body dressing, and put on or take off footwear. The record further indicated Resident 1 was dependent on staff to roll him to the left and right while in bed. A review of Resident 1's clinical record titled, Care Plan, dated 3/15/24, indicated Resident 1 was dependent on the nursing staff for bathing, personal hygiene (body kept clean every day), dressing, eating, bed mobility (movement in bed), transfer (move from one location to another), and toileting related to paralysis (inability to move or feel areas of the body) of all extremities (arms and legs). An intervention included monitoring for complications of immobility, such as pressure ulcers). A review of Resident 1's clinical record titled, Wound Evaluation & Management Summary, dated 6/4/24, indicated Resident 1 had a pressure wound on his buttocks that measured 4.0 cm long, 4.5 cm wide and 0.7 cm deep. A review of Resident 1's clinical record titled, Daily Skin Inspection and Shower Check, dated 7/1/24, signed by a Certified Nursing Assistant (CNA) and Licensed Nurse (LN), indicated Resident 1's skin was intact with no discoloration, skin tears, ulcers (sores) or reddened areas. The diagram of a human body did not have any areas circled on the front or back of the body indicating skin breakdown. A review of Resident 1's clinical record titled, Daily Skin Inspection and Shower Check, dated 7/11/24, signed by a CNA and LN, indicated Resident 1's skin was intact with no discoloration, skin tears, ulcers or reddened areas. The diagram of a human body did not have any areas circled on the front or back of the body indicating skin breakdown. The record did not indicate if a shower, tub or bed bath was given. During an interview on 7/16/24 at 12:35 p.m., with CNA 1, CNA 1 stated Resident 1's skin should have been assessed every time the nurse provided care (repositioning, toileting, brushing teeth, etc.), which was every two hours. During an interview on 7/16/24, at 3:20 p.m., with Resident 1, Resident 1 stated the phlebotomist had left the tourniquet on his right arm for three days. Resident 1 stated his diagnosis included quadriplegia, and he was unable to feel the tourniquet cutting off blood flow to his arm. Resident 1 stated, The nurses missed it when providing care. During an interview on 7/16/24, at 3:25 p.m., with the WMD, WMD stated the tourniquet was on Resident 1's right arm for three days and restricted the blood flow to the arm. WMD further stated if Resident 1 would have been an older man, he could have needed the arm amputated (surgical removal of the dead arm). WMD stated Resident 1 was not able to feel the tourniquet around his arm due to his diagnosis of quadriplegia. WMD further stated Resident 1 was dependent on the staff to meet all his physical and medical needs. During an interview on 7/16/24, at 3:30 p.m., with the Wound Nurse (WN), WN stated it was reported to her that Resident 1 had two open wounds above his right elbow and a brown circular wound around the circumference (closing of a circle) of his right arm where the tourniquet had been left in place for approximately three days. WN further stated all nursing staff should have assessed Resident 1's skin while providing care (changing a soiled diaper or repositioning the resident). WN stated, it's crazy that a tourniquet was left on for three days. WN further stated Resident 1 could have had a very serious injury to his right arm due to the decreased circulation (blood flow). WN stated it was the facility's responsibility to ensure Resident 1 received quality care from all health care professionals. During a phone interview on 7/16/24, at 3:40 p.m., with the Medical Director (MD), MD stated the facility was responsible for the care Resident 1 received from the phlebotomist. MD further stated the nurses were responsible for daily assessments of Resident 1. MD stated the facility should have noticed that the tourniquet was still in place after the blood draw was completed and there was no excuse for the discovery to take nearly three days. MD further stated the tourniquet on Resident 1's right arm was discovered on 6/9/24 after the staff had turned Resident 1 in bed. During a phone interview on 7/16/24, at 4:20 p.m., with [LABORATORY NAME DIRECTOR - LD], LD stated it was their lab technician that left the tourniquet on Resident 1's arm after completing the blood draw. LD stated this resulted in decreased blood flow and skin damage to Resident 1's right arm. During an interview on 7/16/24, at 4:27 p.m., with the Director of Nursing (DON), DON stated the staff should have assessed Resident 1's skin every two hours while providing care and they should have noticed the tourniquet was left on the right arm. The DON verified the tourniquet remained on Resident 1's right arm for approximately three days before it was discovered. During an interview on 7/16/24, at 4:50 p.m., with LN 2, LN 2 stated he was alerted by a CNA that Resident 1's arm did not look good. LN 2 further stated Resident 1's arm had 4+ swelling and looked like a balloon. LN 2 stated there was a skin tear (open sore) above Resident 1's right elbow and yellow liquid coming out of the intravenous (IV - inside the vein) site near the inside of the elbow. LN 2 further stated the area behind Resident 1's elbow was yellow from a rubber burn. LN 2 stated, Everyone missed it, including me. LN 2 stated he took a photo of the wound and sent it to the doctor, but the photo had since been deleted. During an interview on 7/16/24, at 4:55 p.m., with CNA 2, CNA 2 stated Resident 1's skin should have been assessed every two hours when providing care to the resident. CNA 2 further stated when she went into the room, she asked Resident 1 if there were any problems, and he denied any problems. CNA 2 stated she should have looked to see if Resident 1 had any problems with his skin and not just asked him if he was ok. CNA 2 acknowledged Resident 1 could not feel or move his arms and legs and was dependent on staff to meet his needs. During a phone interview on 7/17/24, at 9 a.m., with LN 3, LN 3 stated Resident 1 was a very vulnerable (a person in need of special care, support, or protection because of disability) resident due to his inability to feel his body from the neck down and was dependent on staff to care for all his needs. LN 3 stated skin checks should have been done every time the nurse provided care to the resident. LN 3 stated Resident 1's hospital gown should have been changed every day, and if the gown would have been changed, the staff would have seen the tourniquet around Resident 1's arm. LN 3 stated Resident 1 would have benefited from more frequent skin checks due to his immobility (unable to move independently). During a phone interview on 7/17/24, at 12:08 p.m., with Resident 1's family member (FM), FM stated a tourniquet was left on Resident 1's arm for three days. FM stated she was very upset when she saw the condition of Resident 1's arm and was afraid for his health and safety while at the facility. FM stated the facility was not taking good care of Resident 1. During a phone interview on 7/17/24 at 1:30 p.m., with LN 4, LN 4 stated Resident 1 was supposed to be repositioned every two hours. LN 4 stated Resident 1's arms and the legs were supposed to be floated (lifted on pillows or foam wedge) to have the pressure relieved off the bony areas of the body (heels, elbows, backbone). LN 4 stated he was not sure how the tourniquet got missed by the nurses if Resident 1 was repositioned every two hours. LN 4 stated he was surprised Resident 1's right arm did not get amputated due to the lack of blood flow through the veins. During a joint phone interview on 7/19/24, at 8:10 a.m., with the Administrator (ADM) and DON, ADM stated she became aware of the incident in which a tourniquet was left on Resident 1's right arm when the [DEPARTMENT] arrived at the facility for a complaint investigation on 7/16/24. DON stated she was unsure why the ADM was not made aware of the situation sooner but stated it had been a busy month. ADM stated she should have been informed of the incident prior to the [DEPARTMENT]'s complaint investigation. DON and ADM acknowledged Resident 1's skin injury related to the tourniquet left around his right arm was a preventable injury and the nursing staff should have assessed the skin more thoroughly. DON and ADM acknowledged Resident 1 was at high risk for skin breakdown related to the inability to feel anything from the neck down. ADM stated the facility had the ultimate responsibility to ensure Resident 1 received safe quality care from the contracted staff (health care providers hired by the facility). DON stated the process for skin assessments was that the LN completed a full body skin assessment once a week and both the CNAs and LNs observed residents daily for any sores or discoloration on the skin when a resident got dressed, cleaned, or repositioned in bed. DON and ADM stated Resident 1 was at risk for a right arm amputation due to the lack of blood flow to the arm while the tourniquet remained tied around the right arm. During a phone interview on 7/22/24, at 12:48 PM, with the facility's [NAME] President of Operations (VPO), VPO stated the nursing staff should have noticed the phlebotomist forgot to remove the tourniquet when the nurses provided care to Resident 1. VPO further stated there was no excuse for them to miss the tourniquet on Resident 1's right arm. VPO stated Resident 1's diagnosis included quadriplegia and he should have received additional skin checks due to the high risk of skin breakdown (sores). VPO further stated it was absolutely not acceptable that the tourniquet was missed by the facility staff. During a joint concurrent interview and record review on 7/17/24, at 4 p.m., with the ADM and the DON, the undated facility Policy and Procedure (P&P) titled, Repositioning, was reviewed. The P&P indicated, .Repositioning is a common, effective intervention for preventing skin breakdowns, promoting circulation, and providing pressure relief .Evaluation of a resident's skin integrity after pressure has been reduced .Repositioning is critical for a resident who is immobile or dependent upon staff for repositioning . ADM stated the investigation of the tourniquet that was left on Resident 1's right arm was still ongoing. ADM further stated she could not answer why the investigation had not been completed a month after the incident. ADM and DON would not verify if the P&P was not followed. During a joint concurrent interview and record review, on 7/17/24 at 4:05 p.m., with the ADM and DON, the facility P&P titled, Skin Integrity Management, dated 5/26/21, was reviewed. The P&P indicated, .The implementation of an individual patient's skin integrity management occurs within the care delivery process. Staff continually observe and monitor patients for changes .Nursing staff will observe for any signs of potential or active pressure injury daily while providing care .The ADM and DON stated the expectation was that Resident 1's hospital gown would have been changed daily and during the changing process, the tourniquet would have been discovered. The DON acknowledged it was the facility's responsibility to ensure Resident 1 received safe care from all health care providers, including the laboratory technician (worker). ADM and DON acknowledged it was not safe to have the tourniquet left around Resident 1's arm after the blood draw was completed. ADM and DON would not verify if the P&P was not followed. A review of a facility document titled, Registered Nurse (RN), dated 5/2022, indicated, .Provide oversight of Certified Nursing Assistants (CNA) and licensed nurses .Resident Care Functions .Monitor the skin health of the resident; provide preventative skin care . A review of a facility document titled, Licensed Practical (Vocational) Nurse (LPN)/LVN), dated 5/22, indicated, Work with and oversee Certified Nursing Assistants (CNAs) as directed .Help bed-bound .residents reposition and turn as scheduled. Monitor the skin health of the resident; provide preventative skin care . A review of a facility document titled, Certified Nursing Assistant, dated 10/20, indicated, .Assist residents in accordance to their needs ranging from minimal assistance to total dependent care of activities of daily living [ADL - eating, brushing teeth, toileting] .

Based on interview, clinical record review, and facility policy review, the facility failed to protect one of four sampled residents (Resident 1) from physical abuse when staff failed to redirect Resident 2 before he slapped Resident 1 in the face. This failure resulted in redness and swelling to Resident 1's right eye and cheek, and had the potential to cause psychosocial harm to Resident 1. Findings: A clinical review of Resident 1's clinical record indicated the following documents: An Admission Record, indicated Resident 1 was admitted to the facility in November of 2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An MDS (Minimum Data Set - an assessment tool), dated 6/19/2021, indicated Resident 1 had no potential indicators of [CONDITION(S)], and had no demonstrated physical or verbal behaviors towards others. A Health Status Note Progress Note, dated 8/12/2021 at 9:27 p.m., indicated Resident 1 was hit by another male resident on the face. The note further indicated Resident 1 sustained redness and swelling on right eye and cheeks. The note also indicated Resident 1 complained of pain and swelling on the eye, the doctor was notified, and the resident was sent to the hospital for further evaluation. A clinical review of Resident 2's clinical record indicated the following documents: An Admission Record, indicated Resident 2 was readmitted to the facility in June of 2016 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Focus plan of care listed, Resident has potential to demonstrate physical behavior 3/4/2021. The plan of care listed Hit a CNA [Certified Nurse Assistant] while giving him food to eat, and Has a tendency to hit staff. The plan of care had a revision date of 3/5/2021. The plan of care contained no documented evidence the resident required increased monitoring by staff to prevent further abusive behaviors towards other staff or residents. A Focus plan of care listed, The resident is/has potential to demonstrate verbally abusive behaviors r/t [related to] Poor impulse control. Resident has a behavior of striking out other peer and staff. Additionally, the plan of care included has a hx [history] of altercation with peers. The plan of care had an initiated date of 10/23/2020, and a revision date of 3/29/2021. The plan of care contained no documented evidence the resident required increased monitoring by staff to prevent further abusive behaviors towards other staff or residents. An MDS, dated [DATE], indicated Resident 2 had no potential indicators of [CONDITION(S)], and had demonstrated verbal behaviors towards others (such as threatening others, screaming at others, and cursing at others), occurring every one to three days. A Health Status Note Progress Note, dated 8/12/2021 at 9:02 p.m., indicated a charge nurse witnessed Resident 2 slap female resident across the right side of face. The note further indicated the victim sustained redness and swelling on right eye/cheek. An interview was conducted with Licensed Nurse (LN) 1 on 8/24/2021 at 1:13 p.m. LN 1 stated Resident 2 was known to be aggressive with other staff and residents, both physically and verbally. An interview was conducted with SSD (Social Services Director) on 8/24/2021 at 1:21 p.m. SSD indicated Resident 2 is aggressive about 90% of the time and is very volatile. SSD stated Resident 2 required increased engagement from staff because when ignored, he escalates. SSD stated staff will separate residents before they can reach Resident 2 to keep them safe, and there is a need to keep other residents away from Resident 2. An interview was conducted with Certified Nurse Assistant (CNA) 1 on 8/24/2021 at 1:43 p.m. CNA 1 indicated Resident 2 could be aggressive at times, and he tried to throw his coffee on me this morning. CNA 1 further indicated Resident 2 requires increased supervision when he is out in the hallways to keep other residents safe. CNA 1 stated Resident 2 had hurt other residents before. An interview was conducted with LN 3 on 8/24/2021 at 3:02 p.m. LN 3 recounted the incident between Resident 1 and Resident 2 and stated he heard yelling in the hallway, looked around the corner, and witnessed Resident 2 reach back and swing his arm at Resident 1, hitting the side of her face with the back of his hand. LN 3 stated no other staff were present in the hallway at the time of the altercation. LN 3 indicated Resident 2 is known to be verbally and physically aggressive to other residents and staff, and staff try to increase supervision when he is out and about. LN3 further stated, staff always try to remind other residents to stay away from Resident 2. An interview was conducted with the Director of Nurses on 8/24/2021 at 3:24 p.m. The DON stated Resident 2 usually stays in his room at the end of the hallway to keep him away from other residents, but at this time had been moved to a new room temporarily so repairs could be made to a water leak. The DON stated she had received no recent reports of Resident 2 being physically aggressive to staff. The DON indicated there is nothing else we can do, and continuing to monitor Resident 2 was the only intervention the facility could provide to prevent harm to other residents. The DON confirmed other residents had the right to be free from abuse. A facility obtained policy titled Abuse Prohibition And Prevention Policy and Procedure And Reporting Reasonable Suspicion Of A Crime In The Facility Policy And Procedure, revised 3/2018, was reviewed. The policy indicated, This facility prohibits and prevents abuse, neglect, and exploitation of residents and misappropriation of resident's property. The policy further indicated, Residents must not be subjected to abuse by anyone, including but not limited to, facility staff, other residents .

Based on interviews and clinical record review, the facility failed to provide adequate monitoring, supervision, or assistance when Resident 1 sustained a fall that resulted in bone fractures and required hospitalization . Findings: Resident 1 was [AGE] year old admitted to the facility on [DATE] with dementia and a stroke with paralysis on the left side of the body. Resident 1's Minimum Data Set (MDS, an assessment tool) revealed the resident had short and long term memory problems with signs and symptoms of delirium (inattention and disorganized thinking). Resident 1 was impaired in both legs, one arm, and was totally dependent on one or more facility staff for bed mobility (turning side to side, positioning the body when in bed), all transfers, dressing, toileting, personal hygiene, and bathing. Resident 1 did not ambulate or use a wheelchair. In an interview on 12/26/12 at 1:30 p.m., Resident 1's responsible party (RP) explained her relative resided in the facility for over 2 years after suffering a paralyzing stroke. Resident 1 retained some use of the right arm, but nothing further. Resident 1 was completely dependent on facility staff for everything. Resident 1 was unable to reposition herself and incapable of rolling over on her own. RP stated the facility called at 6:30 p.m. on 10/30/12 to report Resident 1 fell out of bed around 4 p.m. They indicated Resident 1 finished physical therapy earlier that afternoon after which Certified Nursing Assistant (CNA) 1 changed and repositioned her. CNA 1 put the side rails in the full up position when she left. CNA 1 found her on the floor about a half hour later. The nurses assured RP nothing was wrong and Resident 1 was asleep after Tylenol was administered. RP stated, "The administrator said he did an investigation, but no one knew anything about how she fell . He just said she must have rolled out of bed and fallen to the floor. I tried to talk to CNA 1 about this, but she was very nervous and did not say anything the administrator hadn't said. Nobody knew anything. They later did x-rays and found she had broken her arm in the fall. I simply do not believe this could have happened like they say it did. She wasn't physically capable of rolling over on her own, let alone crawling over a side rail." In an interview on 1/3/13 at 1:30 p.m., the Director of Nursing (DON) and Assistant Director of Nursing stated they were both on the Interdisciplinary Team (IDT) that completed an investigation of Resident 1's fall on 10/30/12. They indicated the fall was not witnessed. They confirmed Resident 1 required full assistance for all activities of daily living (ADL's) and transfers. The DON stated, "Resident 1 was unable to move or reposition herself." In an interview on 1/3/13 at 1:40 p.m., Physical Therapist (PT) 1 indicated he had finished physical therapy on Resident 1 approximately 45 minutes before facility staff found Resident 1 on the floor. Resident 1 was [DIAGNOSES REDACTED] (paralyzed) on the left side with contractures (abnormal shortening of muscles) of the trunk. Resident 1's trunk was contracted towards the strong (right) side making repositioning difficult. The resident's condition resulted in a permanent lean to the right. Resident 1 required significant support to maintain position especially when sitting. Resident 1 could not move or reposition without the full assistance of 1 or more staff. PT 1 stated, "After physical therapy, I left Resident 1 in an upright sitting position with the head of the bed and the feet elevated. I padded both sides of the legs and trunk with pillows to maintain position. The resident had padded side rails to protect from bruising. When I left the bedside, I put both side rails in the full up position." Resident 1's clinical record was reviewed on 1/3/13. In a document titled, "Admission Nursing Assessment" dated 10/5/12 at 1:30 p.m. Resident 1 was recorded as Non-weight bearing and Total Assist with transfers. All ADL's were checked as "dependent." In a document titled "Side Rail Evaluation" dated 10/5/11 (admission), and repeated on 5/8/12, 7/24/12, and 10/31/12, the following evaluation factors were indicated on Resident 1: 1) The resident had fluctuations in levels of consciousness or a cognitive deficit (deficit in the ability to think); 2) Was not able to get out of bed; 3) Unable to get out of bed safely, 4) Had problems with balance or poor trunk control, 5) Did not use side rails for positioning or support; 6) There was no possibility the resident would climb over the side rails; 7) There was no reason to believe there would be any desire or reason to get out of bed; 8) The resident received medications that would require safety precautions; and 9) There was no risk to the resident if side rails were used. In the section of this tool labeled "Summary of Findings," both left and right side rails were checked marked, signed, and dated by Licensed Nurses (LN's) for the respective evaluations. In a document titled "Fall Risk Evaluation" and for the dates 1/11/12, 5/12, and 7/25/12, Resident 1 was scored as "High Risk" for falls. The back of the form was a statement that if a resident was high risk, "A prevention protocol should be initiated immediately and documented on the care plan." In the Physician's Progress notes dated 9/21/12 and 10/9/12, MD 1 indicated "fall precautions" as part of the plan for Resident 1. In a document titled "Physical Therapy (PT) Plan of Care" dated 10/26/12 at 12:47 p.m., Physical Therapist 1 recorded Resident 1's current level of functional deficits as, "Balance, static sitting: unable to maintain balance without moderate/maximum support; Bed Mobility, rolling both directions: Dependent, 100% assist; Positioning, positioning self in bed: Dependent, requires 100% physical assistance by one or more persons to position. Even with constant cueing, patient is unable to sustain and perform each gross motor action of positioning." In a PT Daily Treatment Note made at 10/30/12 at 5:12 p.m., PT 1 recorded, "Rolling to involved side and uninvolved side 10 minutes each to facilitate stretch of right side of trunk and cervical (neck) region. Supine (face upward) sit dependent, patient is very restless and is very retropulsive (resistive) with bed mobility. Positioned patient in bed supine with pillows on right and left hip and under the knees." In a Nurses Note dated 10/30/12 at 5 p.m., LN 1 charted, "Resident found on the floor lying on her back at the right side of the bed. Tube feeding was detached to GT (gastrostomy tube, a tube inserted through the abdomen wall and into the stomach for feeding purposes) - Upon assessment noted redness to and slightly swollen to left elbow and redness to left side of the back. Applied ice pack to left elbow. MD notified and ordered to do x-ray to left elbow. RP notified." In a Radiology Interpretation (x-ray) report dated 10/31/12 at approximately 1:55 p.m., MD 2 recorded, "Significant Findings, Left Elbow: ... Question punctate avulsion fracture involving tip of coronoid process of proximal ulna (separation of a small fragment of bone in the middle of the arm opposite the elbow). Clinical correlation requested." In a document titled "Resident Care Plan-Falls (High Risk)" initiated on 1/11/12 and reviewed on 4/12, 8/12, and 10/12, there was no mention of side rails. On 10/31/12 (post fall), the following was penned into the care plan: "Full padded side rails per family request. Bed in lowest position." In a Nurses Note dated 10/31/12 at 1:45 p.m., LN 2 charted, "Patient c/o (complains of) pain on right upper extremity ... Patient's result for left elbow x-ray came back, read result to MD with orders to splint left elbow ... Orders to obtain right elbow and right shoulder (x-ray) related to patient c/o pain, guarding (protective of area) noted on assessment." In a Nurses Note dated 10/31/12 at 7 p.m., LN 3 charted, "Result of right shoulder and right elbow x-ray received and relayed to MD with order to send resident to ER (emergency room ) for evaluation." In a Radiology Interpretation report dated 10/31/12 at approximately 11:30 p.m., MD 3 recorded, "Significant Findings, Right Shoulder: ... Acute fracture humeral head ... (recent fracture of upper arm bone)." In a second x-ray report from the same date and time, MD 3 recorded, "Significant Findings, Right elbow: ... There is deformity of the elbow joint with bony fragmentation of the olecranon (bone fragments of the right elbow)."