Every finding on record at Downey Community Health Center

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), was provided care in accordance with professional standards of practice, by failing to ensure Resident 1 was monitored by the licensed personnel when the resident had increased facial swelling and chest congestion on 8/26/2026 at 1:00 p.m., while waiting to be transferred or for bed availability at a general acute care hospital (GACH).This deficient practice had the potential to delay in identifying Resident 1's worsening condition and delay in implementing necessary care and services the resident potentially need, resulting in severe health complications, including death.Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing) hyperlipidemia (high cholesterol, characterized by elevated levels of cholesterol in the blood) and hypertension (HTN-high blood pressure). During a review of Resident 1's History and Physical examination (H&P) dated 8/21/2026, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Residents 1's Minimum Data Set (MDS - a resident assessment tool) dated 8/23/2026, the MDS indicated Resident 1 had moderate problem with thinking and memory. Resident 1 required dependent assistance on staff with Activities of Daily Living (ADLs) such as dressing, toilet use, transfer and mobility. During a review of Resident 1's Change of Condition (COC) dated 8/26/2026 at 1:00 p.m., the COC indicated Resident 1 had increased facial swelling and chest congestion and the Medical Doctor (MD) was notified. MD ordered Resident 1 to be transferred to a GACH for further evaluation. During a review of Resident 1's Nurses Progress Notes dated 8/26/2026 at 8:16 p.m. (seven hours later), the progress notes did not indicate Resident 1 had been transferred to GACH as ordered 8/26/2026 1 p.m. The progress notes indicated the facility was still waiting for GACH's bed availability. The progress notes indicated the Nurse Practitioner (NP) stated nurses can call 911 (emergency phone number) if Resident 1 becomes unstable. The progress notes indicated to transfer Resident 1 in the morning if GACH bed was not available. The progress notes did not indicate documentation of Resident 1's COC status (increased facial swelling and chest congestion) or if monitoring was conducted after 8/26/2026 1 p.m. until 8/27/2026 at 11 a.m., when Resident 1 was scheduled to be transferred to the GACH. During an interview on 8/27/2026 at 12:40 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated that she endorsed Resident 1's COC and the care needed to the incoming shift nurses on 8/26/2026 because Resident 1 was not sent out to GACH due to bed unavailability (after the COC [face swelling and chest congestion] on 8/26/2026. LVN 1 stated that Resident 1 needed to be monitored for 72 hours after the COC. Each shift nurse was required to monitor and document any changes in Resident 1. LVN 1 emphasized that it was important to follow this procedure because Resident 1 was at risk of worsening condition, and monitoring Resident 1 allowed the nurses to take appropriate next steps in care. During an interview on 8/27/2026 at 1:30 p.m. with Registered Nurse (RN) 2, RN 2 stated residents must be monitored for 72 hours after a COC. RN 2 stated failing to monitor could place Resident 1 at risk of his condition worsening. During a concurrent interview and record review on 8/27/2026 at 3:10 p.m. with the Director of Nursing (DON), the DON stated nurses must monitor the resident after a COC and document every shift. The DON stated that not following the policy and procedure was not appropriate and failing to monitor Resident 1 after the COC was unacceptable. During a review of the facility's P&P titled, Condition Change of Resident, dated 12/2018, the P&P indicated the facility should monitor resident's condition as often as the resident's condition warrants until stable and/or the resident is transferred for further care and to document per facility policy.

Based on observation, interview, and record review, the facility failed to ensure the following food safety and food preparation practices was observed by failing to ensure:1. Foods were stored and/or prepared under sanitary conditions.2. Proper sanitation and food handling practices were maintained to prevent outbreak or foodborne illness.3.Frozen vegetables were dated and labeled to prevent the potential for foodborne illness.4. One bag of hot dog buns, a container of black pepper, tarragon leaves, curry powder, and basil were labeled with an open date.5. Dietary Aide 1 (DA 1) properly explained thermometer calibration and did not reuse the same alcohol pad for multiple probe sanitizations during tray line observation. These failures had the potential for bacterial growth in potentially hazardous foods (PHFs- foods that require strict time and temperature control to prevent the growth of harmful bacteria or the formation of toxins) and increased the risk for food borne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) for 170 residents who consumed food prepared and served from the kitchen.Findings: 1. During a concurrent observation and interview on 6/29/2026 at 8:15 a.m., with the Dietary Supervisor (DS), during the initial kitchen tour, observed an open bag of tortilla and white bread on the kitchen counter without a protective covering or proper storage. The tray line counter contained accumulated crumbs, food debris, and used utensils and plates resting on the tray line surface between food preparation activities. The DS stated the uncovered bread and leftover food after breakfast increased contamination risks. The DS stated used utensils left out could spread germs, cause cross-contamination, and make meals unsafe.During a concurrent interview and record review on 6/29/2026 at 3:15 p.m., with Registered Dietician (RD 1) 1, the facility's Policy and Procedure (P&P) titled, Storage of Food and Supplies, dated 2023, was reviewed. The P&P indicated food will be stored properly in a safe manner and open food items are to be tightly closed, labeled and dated. RD 1 stated these errors could expose residents to unsafe food and unclean meal service areas increasing risk of illness.During a review of the facility's P&P titled, Sanitary, Safe Functional Environment, dated 1/2024, the P&P indicated the facility shall maintain cleanliness and sanitation in kitchen. 2. During a concurrent observation and interview on 6/29/2026 at 8:19 a.m., with the DS, during the initial kitchen tour, observed an uncovered plastic container of sliced fresh tomatoes. A bag of white bread and rolls was unsealed inside the refrigerator. The DS stated uncovered and unsealed food items could increase the risk of cross contamination and spread of bacteria and unsafe meal service to residents.During a concurrent interview and record review on 6/19/2026 at 3:20 p.m., with RD 1, the facility's P&P titled, Procedure For Refrigerated Storage, dated 2023, was reviewed. The P&P indicated leftover will be covered, labelled and dated. RD 1 stated uncovered and unsealed food items put residents at risk of illness from unsafe food and cross-contamination.During a review of the facility's P&P titled, Storage of Food and Supplies, dated 2023, the P&P indicated food and supplies will be stored properly and in a safe manner. 3. During a concurrent observation and interview on 6/29/2026 at 8:23 a.m., with the DS, during the initial kitchen tour, six bags of frozen cut corn, four bags each of mixed vegetables, green beans, and brussels sprouts were observed unlabeled in the freezer. The DS stated Registered Dietician 2 (RD 2) told kitchen staff that labeling each bag of frozen vegetables in the freezer was not required. The DS stated this mistake may place residents at risk for food contamination, spoilage, and possible illness.During a concurrent interview and record review on 6/29/2026 at 3:24 p.m., with RD 2, the facility's P&P titled, Labeling and Dating of Foods, dated 2023, was reviewed. The P&P indicated, all food items in the storeroom, refrigerator, and freezer need to be labeled and dated. RD 2 stated these errors may place residents at risk for foodborne illness, cross-contamination, poor food quality, and unsafe meal service. 4. During a concurrent observation and interview on 6/29/2026 at 8:33 a.m., with the DS, during the initial kitchen tour, one bag of hot dog buns, containers of black pepper, tarragon leaves, curry powder, and basil were labeled with no open dates. The DS stated unlabeled items may place residents at risk for foodborne illness and expired food products.During a concurrent interview and record review on 6/29/2026 at 3:28 p.m., with RD 2, the facility's P&P titled, Labeling and Dating of Foods, dated 2023, was reviewed. The P&P indicated, newly opened food items will need to be closed and labeled with an open date. RD 2 stated these errors may place residents at risk for foodborne illness, cross-contamination, poor food quality, and unsafe meal service. 5. During an observation on 6/30/2026 at 11:46 a.m., in the kitchen, observed meatballs and sauce. DA 1 inserted the facility's thermometer probe in the sauce instead of the meatball preventing an accurate measurement of the food's internal temperature.During an observation on 6/29/2026 at 11:48 a.m., in the kitchen, observed DA 1 insert the thermometer probe into the plate of meatballs, sauce, and pasta. The probe touched the pasta.During an observation on 6/29/2026 at 11:51 a.m., in the kitchen, DA 1 was observed using the same alcohol pad to clean the thermometer probe between multiple food temperature checks. During an interview on 6/30/2026 at 1:26p.m., with DA 1, DA 1 stated, the food thermometer ensured accurate food temperatures which prevented cross-contamination and may reduce the risk of foodborne illness and infection to residents.During a concurrent interview and record review on 6/30/2026 at 1:32p.m., with the DS, the facility's P&P titled, Thermometer Use and Calibration, dated 2023, was reviewed. The P&P indicated, food thermometers are to be used properly and calibrated to ensure accurate temperature reading. The DS stated improper use of the temperature may place residents at risk foodborne illness, cross-contamination, poor food quality, and unsafe meal service.During an interview on 6/30/2026 at 1:47p.m., with Director of Nursing (DON), the DON stated correct thermometer use and probe disinfection were important to ensure food safety and prevent cross- contamination. The DON stated residents may be at risk for foodborne illness and negative health outcome.

Based on observation, interview, and record review, the facility failed to follow infection control measures for four of four sampled residents (Resident 117, Resident 58, Resident 80, and Resident 184) by failing to ensure:1. Hand hygiene was performed between the medication pass of Residents 117 and 58.2. Hand hygiene was performed prior to administering Resident 80's medicated eye drops.3. Hand hygiene was performed prior to Licensed Vocational Nurse (LVN) 2 dispensing the contents of Resident 184's medication capsules into a medication cup.4. Registered Nurse (RN) 3 did not wear gloves while walking in the hallway.These failures had the potential to result in the avoidable spread of bacteria and disease throughout the facility. Findings: 1. During an observation on 6/30/2026 at 9:10 a.m., in the Medication Room, observed Licensed Vocational Nurse (LVN) 1 finish preparing the medications for all the residents in his area. LVN 1 unlocked the medication cart, exited the Medication Room and brought the medication cart to the hallway. LVN 1 did not perform hand hygiene (process of cleaning hands to remove germs) upon exiting the Medication Room and beginning his medication pass. a. During a review of Resident 117's admission Record (Face Sheet, front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 117 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 117's diagnoses included chronic pain (pain that lasts longer than three months) and muscle spasm (a sudden, involuntary contraction of a muscle that cannot relax). During a review of Resident 117's Minimum Data Set (MDS- a resident assessment tool), dated 6/17/2026, the MDS indicated Resident 117's cognitive skills for daily decision making (process of thinking) was intact. The MDS indicated Resident 117 required supervision or touching assistance with eating, oral hygiene, bathing, upper/lower body dressing, and putting on/taking off footwear. During a review of Resident 117's History and Physical (H&P), dated 6/16/2026, the H&P indicated Resident 117 did not have the capacity to understand and make decisions. During an observation on 6/30/2026 at 9:16 a.m., in the hallway, observed Resident 117 approach LVN 1's medication cart requesting his scheduled medication. LVN 1 unlocked his medication cart and removed another medication from a bubble pack (pre-sorted packaging system with medication organized into individual, sealed compartments) into the medication cup. LVN 1 did not perform hand hygiene prior to handing Resident 117 his medication in the medication cup or prior to moving onto the next resident. b. During a review of Resident 58's Face Sheet, the Face Sheet indicated Resident 58 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 58's diagnoses included bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs) and psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality). During a review of Resident 58's MDS, dated [DATE], the MDS indicated Resident 58's cognitive skills for daily decision making was intact. The MDS indicated Resident 58 required supervision or touching assistance with eating, oral hygiene, upper/lower body dressing, and putting on/taking off footwear. During a review of Resident 58's H&P, dated 5/20/2026, the H&P indicated Resident 58 had fluctuating capacity to understand and make decisions. During an observation on 6/30/2026 at 9:20 a.m., in the hallway, observed Resident 58 approach LVN 1's medication cart requesting his scheduled medication. LVN 1 did not perform hand hygiene prior to handing Resident 58 his medication in a medication cup or prior to moving onto the next resident. During an interview on 6/30/2026 at 9:21 a.m., with LVN 1, LVN 1 stated he did not perform hand hygiene prior to administering Resident 117 and 58's medications. LVN 1 stated he touched his medication cart prior to handing the medication cups to Residents 117 and 58. LVN 1 stated hand hygiene was necessary during medication pass to prevent the spread of infection. During an interview on 7/2/2026 at 8:29 a.m., with the Infection Preventionist Nurse (IPN), the IPN stated hand hygiene had to be performed at all times before and after performing a task. The IPN stated objects and highly touched surfaces contain bacteria which could be transmitted to others. The IPN stated prior to administering medications to residents, the licensed nurse was responsible for performing hand hygiene to remove any microorganisms on their hands and prevent the transmission to the resident. During a review of the facility's Policy and Procedure (P&P) titled, Hand Washing/Hand Hygiene, dated 1/19/2023, the P&P indicated, All staff members will wash their hands before and after direct resident care and after contact with potentially contaminated substances to prevent, to the extent possible, the spread of nosocomial infection. 2. During a review of Resident 80's Face Sheet, the Face Sheet indicated Resident 80 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 80's diagnoses included type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing) and glaucoma (disease that damages the optic nerve, which connects the eye to the brain). During a review of Resident 80's MDS, dated [DATE], the MDS indicated Resident 80's cognitive skills for daily decision making was intact. The MDS indicated Resident 80 required maximal assistance (helper does more than half the effort) with oral hygiene, bathing, lower body dressing, and putting on/taking off footwear. During a review of Resident 80's H&P, dated 6/16/2026, the H&P indicated Resident 80 had the capacity to understand and make decisions. During a review of Resident 80's Physician Order, dated 6/15/2026, the Physician Order indicated to administer dorzolamide hydrochloride and timolol maleate ophthalmic solution (eye drop used to lower pressure in the eye for individuals with glaucoma), one drop in both eyes twice a day for glaucoma. During an observation on 7/1/2026 at 8:25 a.m., in Resident 80's room, observed LVN 3 prepare Resident 80's medications which consisted of five pills, one liquid medication, and one drop bottle medication. LVN 3 performed hand hygiene and entered Resident 80's room. LVN 3 handed the medication cup containing five pills to Resident 80 then handed the medication cup with liquid medication. LVN 3 touched Resident 80's bed to lower the head of the bed and repositioned Resident 80's bedside table. LVN 3 did not perform hand hygiene and don (put on) clean gloves. LVN 3 wiped both of Resident 80's eyes with a clean tissue and instilled one drop of dorzolamide hydrochloride and timolol maleate ophthalmic solution into each eye. LVN 3 wiped both of Resident 80's with a clean tissue, doffed (removed) her gloves, and performed hand hygiene prior to exiting the room. During an interview on 7/1/2026 at 8:33 a.m., with LVN 3, LVN 3 stated she did not perform hand hygiene prior to donning gloves and instilling the medicated eye drops to Resident 80's eyes. LVN 3 stated she should have performed hand hygiene to prevent spread of bacteria to Resident 80's eyes. During an interview on 7/2/2026 at 8:34 a.m., with the IPN, the IPN stated hand hygiene should be done prior to administering eye drops, regardless if gloves were worn. The IPN stated LVN 3 touched potentially contaminated surfaces and donned gloves. The IPN stated gloves were a barrier between the hands and Resident 80, however, the bacteria on LVN 3's hands could still be transmitted to Resident 80. The IPN stated hand hygiene was the first defense in preventing the spread of bacteria. During a review of the facility's P&P titled, Medication Administration, dated 5/2016, the P&P indicated hands were washed with soap and water and gloves applied before administering ophthalmic (eye) medication. 3. During a review of Resident 184's Face Sheet, the Face Sheet indicated Resident 184 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 184's diagnoses included psychosis, bipolar disorder, and anxiety disorder (mental health condition characterized by intense, excessive, and persistent worry or fear). During a review of Resident 184's MDS, dated [DATE], the MDS indicated Resident 184's cognitive skills for daily decision making was moderately impaired. The MDS indicated Resident 184 was dependent on staff's assistance with oral hygiene, toileting, putting on/taking off footwear, and personal hygiene. The MDS indicated Resident 184 took anticonvulsant medication (used to treat seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness] and other mood disorders). During a review of Resident 184's H&P, dated 6/19/2026, the H&P indicated does not have the capacity to understand and make decisions. During a review of Resident 184's Physician Orders, dated 6/18/2026, the Physician Orders indicated to administer: 1. Culturelle (probiotic medication to restore gut balance), one capsule by mouth twice a day for supplement. 2. Docusate sodium (stool softener) 100 milligram (mg, metric unit of measurement) by mouth twice a day for bowel management. 3. Gabapentin (an anticonvulsant medication) 400mg by mouth three times a day for anxiety manifested by calm to sudden angry outbursts. During an observation on 7/1/2026 at 8:38 a.m., at LVN 2's medication cart, observed LVN 2 prepare Resident 184's medication by dispensing from the bubble pack or the medication bottle. LVN 2 crushed the medication tablets in a plastic sleeve and dispensed into a medication cup. LVN 2 used her bare hands to open the Culturelle, docusate sodium, and Gabapentin capsules and dispensed the contents into a medication cup. LVN 2 did not perform hand hygiene prior to touching the capsules. LVN 2 mixed the medication with apple sauce, entered Resident 184's room, and administered Resident 184's medication. During an interview on 7/1/2026 at 8:47 a.m., with LVN 2, LVN 2 stated she touched the medication cart, bubble packs, and medication bottles prior to opening the medication capsules. LVN 2 stated she did not perform hand hygiene prior to touching the capsules and dispensing the medication into the medication cup. LVN 2 stated the risk of medication contamination was high because she did not perform hand hygiene. During an interview on 7/2/2026 at 8:37 a.m., with the IPN, the IPN stated LVN 2 should have performed hand hygiene and applied gloves before handling Resident 184's capsules. The IPN stated LVN 2 could have contaminated the medication contents when she opened the capsules without performing hand hygiene. During a review of the facility's P&P titled, Medication Administration, dated 5/2016, the P&P indicated hands were washed with soap and water and donning gloves was preferrable when handling and breaking medication. 4. During an observation on 7/1/2026 at 11:00 AM in the hallway of the facility's Nursing Unit 100, Registered Nurse (RN) 3 walked down the hallway alone while wearing gloves. During an interview on 7/1/2026 at 11:10 AM with RN 3, RN 3 stated that gloves should not be worn in the hallway. RN 3 stated that wearing gloves in the hallway could cause infections to increase in the facility. RN 3 stated, hand hygiene should be completed before and after gloves are worn. During an interview on 7/1/2006 at 11:15 AM with the Director of Nursing (DON), the DON stated that nurses should not wear gloves in the hallway per policy and procedure (P&P) of the facility. The DON stated that not following the P&P could cause an increase in infections and complications among the residents. During a review of the facility's P&P titled, Handwashing-Hand Hygiene, dated January 2023, the P&P indicated, handwashing should be done prior to and after removing gloves. The P&P also indicated that gloves should be worn inside a resident's room and removed prior to leaving the room.

Based on interview and record review, the facility failed to ensure informed consent for psychotropic medication (any prescription drug that alters chemicals in the brain to affect a person's mind, emotions, thoughts, or behavior) was obtained from someone with medical decision-making capacity for one of five sampled residents (Resident 91) reviewed for unnecessary medications. This failure created the potential for Resident 91 to sustain adverse effects related to the administration of risperidone (an antipsychotic medication), including movement disorders, discomfort, hypotension (low blood pressure), gait (manner of walking) disturbance, constipation/impaction, or cognitive/behavioral impairment (trouble with thinking, learning, remembering, and making decisions).Findings: During a review of Resident 91's admission Record, the admission Record indicated Resident 91 was originally admitted to the facility on [DATE] and was most recently readmitted on [DATE]. Resident 91's diagnoses included psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), lack of coordination, abnormalities of gait and mobility, and muscle spasm (a sudden, involuntary contraction or tightening of a muscle). During a review of Resident 91's most recent comprehensive Minimum Data Set (MDS, a resident assessment tool), dated 4/21/2026, the MDS indicated Resident 91 had no cognitive impairment (ability to think and reason). The H&P indicated Resident 91 required partial to moderate assistance from staff for toileting hygiene, showering and bathing, and transitioning from a sitting to standing position. During a review of Resident 91's History and Physical (H&P), dated 7/7/2025, the H&P indicated Resident 91 did not have the capacity to understand and make decisions. During a review of Resident 91's record titled Informed Consent for Treatment - Psychoactive Drugs, dated 7/6/2025, the record indicated staff obtained consent to administer risperidone 0.25 milligrams (mg, a unit of dose measurement) twice a day. The record indicated staff obtained consent from Resident 91. During a review of Resident 91's discontinued physician orders, dated 7/6/2025 to 8/6/2025, the orders indicated staff were to administer risperidone 0.25 mg twice a day. During a review of Resident 91's record titled Informed Consent for Treatment - Psychoactive Drugs, dated 8/6/2025, the record indicated staff obtained consent to administer an increased dose of risperidone. The record indicated staff obtained consent from Resident 91 to administer risperidone 1 mg at bedtime. During a review of Resident 91's discontinued physician orders, dated 8/7/2025 to 3/16/2026, the orders indicated staff were to administer risperidone 1 mg at bedtime. During a review of Resident 91's care plan titled The resident uses psychotropic medications (Risperidone) medications) [related to] Behavior management,. dated 7/5/2025, the care plan indicated goals of care included Resident 91 being/remaining free of psychotropic drug related complications, including movement disorder, discomfort, hypotension, gait disturbance, constipation/impaction or cognitive/behavioral impairment. The care plan indicated there were Black Box Warnings (the strictest safety alert mandated by the U.S. Food and Drug Administration (FDA). Enclosed that alerts patients and healthcare providers to serious, life-threatening, or permanently disabling risks) associated with the administration of risperidone. The care plan indicated staff were to educate the resident/family/caregivers about risks, benefits and the side effects and/or toxic symptoms associated with the medication. During an interview on 7/01/2026 at 1:59 p.m., with Registered Nurse (RN) 2, RN 2 stated staff obtained informed consent from Resident 91 on 7/6/2025 and 8/6/2025 for the administration of risperidone. RN 2 stated Resident 91 did not have the capacity to understand or make decisions at the time he was asked to provide informed consent. RN 2 stated the purpose of informed consent was to ensure the individual providing consent understood the risks and benefits of the medication, understood the plan of care, and knew they had the right to refuse the proposed treatment. RN 2 stated that Resident 91 did not have the ability to understand the information provided to provide informed consent. During a review of the facility's policy and procedure (P&P) titled Psychotropic Use, revised 1/2026, the P&P indicated the resident or designated responsible party had the right to make decisions with regard to their medical condition, and to receive information related to the need for and the risks related to the use of psychotherapeutic drugs. The P&P indicated the resident was to be advised that they have the right to accept or refuse the proposed treatment. The P&P indicated that prior to the use of psychotropic medications, the resident or their RP was to consent to their use.

Based on interview and record review, the facility failed to ensure the fall risk was accurately assessed for one of three sampled residents (Resident 17). This failure created the potential for Resident 17's fall risk assessment to be higher than staff were aware of, and increased her risk of falling and sustaining subsequent injuries.Findings: During a review of Resident 17's admission Record, the admission Record indicated Resident 17 was originally admitted to the facility on [DATE] and was most recently readmitted on [DATE]. Resident 17's diagnoses included generalized muscle weakness, abnormalities of gait and mobility, and extrapyramidal and movement disorder (changes in muscle tone, poverty of voluntary movements [akinesia], or abnormal involuntary movements [dyskinesia]). During a review of Resident 17's Minimum Data Set (MDS, a resident assessment tool), dated 5/19/2026, the MDS indicated Resident 17 had severe cognitive impairment (ability to think and reason). The MDS indicated Resident 17 required partial to moderate assistance from staff for all attempted mobility activities while in and out of bed. During a review of Resident 17's Change of Condition (COC) assessment, dated 5/3/2026, the COC indicated on 5/3/2026, Resident 17 was found on the floor on her right side, next to her bed. The assessment indicated Resident 17 could not state what happened. During a review of Resident 17's COC assessment, dated 5/11/2026, the COC indicated on 5/11/2026, Resident 17 was observed on the floor, on her back, near the foot of her bed. The assessment indicated Resident 17 had tremors and a two (2) centimeter (cm, a unit of measurement) by 0.3 cm laceration (a jagged, irregular tear or cut in the skin or soft body tissue, typically caused by blunt force trauma, a fall, or a harsh strike) above her right eye brow. During a review of Resident 17's Morse Fall Scale assessment, dated 5/11/2026, the assessment indicated staff were to indicate if the resident had ever fallen before. The assessment indicated Resident 17 had not fallen before. During a review of Resident 17's COC assessment, dated 5/16/2026, the COC indicated Resident 17's Certified Nursing Assistant was yelling for help after finding Resident 17 kneeling on the floor. The assessment indicated Resident 17 could not remember what happened. During an interview on 7/1/2026 at 2:06 p.m., Registered Nurse (RN) 2, RN 2 stated the purpose of the fall assessment was to assess the resident's required level of assistance, and to identify the severity of the resident's fall risk. RN 2 stated the assessment should be accurate because it guided the plan of care. RN 2 stated that if the fall assessment was not completed accurately, the resident's calculated fall risk would not be accurate. RN 2 stated this could then increase the risk for the resident to sustain repeat falls. During a review of the facility's policy and procedure (P&P) titled Fall Risk Assessment, reviewed 1/2024, the P&P indicated staff were to identify and document a resident's risk factors for falls and establish a resident-centered falls prevention plan based on relevant assessment information.

Based on observation, interview, and record review, the facility failed to ensure the following for three of three sampled residents (Residents 23, 117, and 182): 1. Licensed Vocational Nurse (LVN) 1 accurately documented Residents 23 and 117's medication refusals.2. Resident 182 received his antibiotics (medication to treat a bacterial infection) at the scheduled time.These failures resulted in incorrect medication administration documentation given to the general acute care hospital (GACH) when Resident 23 was transferred out for evaluation and had the potential for Resident 23 to not receive his required medication. This failure also had the potential to result in the mismanagement of Resident 117's pain. This deficient practice also had the potential for the reduction of the antibiotic's effectiveness, potentially prolong Resident 182's recovery, and increase the risk of complications related to the infection. Findings: 1a. During a review of Resident 23's admission Record (Face Sheet, front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 23 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 23's diagnoses included seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness), psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs). During a review of Resident 23's Minimum Data Set (MDS- a resident assessment tool), dated 5/13/2026, the MDS indicated Resident 23's cognitive skills for daily decision making (ability to think and reason) was moderately impaired. The MDS indicated Resident 23 required moderate assistance (helper does less than half the effort) with toileting, lower body dressing, and personal hygiene. The MDS indicated Resident 23 received antipsychotic (medication that affects the mind, emotions, and behavior) and anticonvulsant medication (used to treat seizures and other mood disorders). During a review of Resident 23's History and Physical (H&P), dated 5/11/2026, the H&P indicated Resident 23 did not have the capacity to understand and make decisions. During a review of Resident 23's Care Plan titled, Episode of Refusing Medications, revised 12/4/2024, the care plan indicated to record Resident 23's medication refusal and notify the physician. During a review of Resident 23's Physician Orders, dated 5/10/2026, the Physician Orders indicated to administer: 1. Docusate sodium (a stool softener) 100 milligrams (mg, a unit of measurement) by mouth twice a day for bowel management. 2. Lamotrigine (an anticonvulsant) 25mg, give two tablets by mouth once a day for bipolar disorder manifested by being calm to angry. 3. Levetiracetam (an anticonvulsant) 100mg per milliliter (mL, a unit of measurement), give 5mL by mouth twice a day for seizure precaution. 4. Clozapine (an antipsychotic) 100mg by mouth twice a day for psychosis manifested by auditory hallucinations (hearing voices not present). During an observation on 6/30/2026 at 8:29 a.m., in the Medication Room, Licensed Vocational Nurse (LVN) 1 prepared Resident 23's clozapine, lamotrigine, and docusate sodium into one medication cup and levetiracetam into another medication cup and set the two medication cups onto a labeled tray next to Resident 23's name. During an observation on 6/30/2026 at 9:04 a.m., in the Medication Room, Registered Nurse (RN) 2 entered the medication room and informed LVN 1 that Resident 23 was ready to be transferred to the general acute care hospital (GACH) and wanted his medications. RN 2 asked LVN 1 which medications were in Resident 23's medications cups, removed the medication cups from the labeled tray, and exited the Medication Room. During an interview on 6/30/2026 at 11:32, with RN 2, RN 2 stated Resident 23 was ready to transfer to the GACH, however, Resident 23 refused to take his medication. RN 2 stated after Resident 23 refused his medication, she returned the medication to LVN 1, who then attempted to administer Resident 23's medication. During an interview on 6/30/2026 at 11:48 a.m., with LVN1 , LVN 1 stated he attempted to administer Resident 23's medication, however, Resident 23 refused the clozapine, lamotrigine, docusate sodium, and levetiracetam. LVN 1 stated after Resident 23 refused the medication, he documented the Resident 23's refusal in the Medication Administration Record (MAR- a daily documentation record used by a licensed nurse to document medications and treatments given to a resident). During a concurrent interview and record review on 6/30/2026 at 11:50 a.m., with LVN1 , Resident 23's MAR, dated 6/1/2026 through 6/30/2026, was reviewed. The MAR indicated, on 6/30/2026, Resident 23 refused clozapine but was administered lamotrigine, docusate sodium, and levetiracetam. LVN 1 stated he did not document in Resident 23's MAR correctly. LVN 1 stated accurate documentation was important because the MAR was reviewed by the GACH to determine if the medication should be offered to Resident 23 again. 1b. During a review of Resident 117's Face Sheet, the Face Sheet indicated Resident 117 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 117's diagnoses included chronic pain (pain that lasts longer than three months) and muscle spasm (a sudden, involuntary contraction of a muscle that cannot relax). During a review of Resident 117's MDS, dated [DATE], the MDS indicated Resident 117's cognitive skills for daily decision making was intact. The MDS indicated Resident 117 required supervision or touching assistance with eating, oral hygiene, bathing, upper/lower body dressing, and putting on/taking off footwear. During a review of Resident 117's H&P, dated 6/16/2026, the H&P indicated Resident 117 did not have the capacity to understand and make decisions. During a review of Resident 117's Physician Order, dated 6/13/2026, the Physician Order indicated to apply a Lidocaine (a numbing medication to block pain signals to the brain) external patch 4 percent (%, strength of medication) to the lower back in the morning and remove at night. During an observation on 6/30/2026 at 8:45 a.m., in the Medication Room, LVN 1 prepared five pills, one liquid, and one lidocaine patch for Resident 117. LVN 1 set the medications onto a labeled tray next to Resident 117's name. During an observation on 6/30/2026 at 9:16 a.m., in the hallway, Resident 117 approached LVN 1's medication cart and requested his scheduled medication. Resident 117 requested to take his pain medication and Lidocaine patch later in the morning. During an interview on 6/30/2026 at 11:48 a.m., with Resident 117, Resident 117 stated he declined the Lidocaine patch because he did not have lower back pain at the time. During an interview on 6/30/2026 at 11:43 a.m., with LVN 1, LVN 1 stated Resident 117 refused the Lidocaine patch and he documented the refusal on Resident 117's MAR. During a concurrent interview and record review on 6/30/2026 at 11:54 a.m., with LVN 1, Resident 117's MAR, dated 6/1/2026 through 6/30/2026, was reviewed. The MAR indicated, on 6/30/2026, a lidocaine patch was applied to Resident 117's lower back. LVN 1 stated he documented incorrectly on the MAR. LVN 1 stated accurate documentation was important to communicate Resident 117's lidocaine patch refusal to the oncoming licensed nurse. LVN 1 stated the lidocaine patch was scheduled to be removed at 9 p.m. LVN 1 stated the MAR indicated the lidocaine patch was applied, and the oncoming licensed nurse would be concerned if there was no patch on Resident 117's lower back. LVN 1 stated the incorrect documentation could affect Resident 117's pain management regimen. LVN 1 stated if Resident 117 complained of additional lower back pain, Resident 117's physician would have incorrect information and believe the Lidocaine patch was ineffective. During an interview on 7/2/2026 at 8:46 a.m., with the Director of Nursing (DON), the DON stated when a resident refused their medication, the licensed nurse was responsible for accurately documenting on the MAR. The DON stated accurate documentation on the MAR was to monitor and to relay the correct information to the physician. The DON stated Resident 23 refused his scheduled medications prior to transfer to the GACH. The DON stated Resident 23's medical records were given to the GACH. The DON stated the receiving GACH did not have accurate information which could affect the medication Resident 23 was administered while at the GACH. The DON stated Resident 117 refused his Lidocaine patch, which could mean the Lidocaine patch was no longer needed to treat Resident 117's pain. The DON stated without accurate documentation, Resident 117's lidocaine patch could be given unnecessarily for nonexistent pain. 2. During a review of Resident 128's Face Sheet, the Face Sheet indicated Resident 128 was admitted to the facility on [DATE]. Resident 128's diagnoses included diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), osteomyelitis (is a severe infection of the bone), and muscle weakness (loss of muscle strength), and sepsis (life threatening body response to and infection). During a review of Resident 128's History and Physical (H&P), dated 6/30/2026, the H&P indicated Resident 128 had the capacity to understand and make decisions. During a review of Resident 128's physician order, dated 6/25/2026, the physician order indicated to administer nafcillin sodium (antibiotic) 2 grams intravenously (IV- into the vein) every 4 hours for bacteremia (bacteria in the blood) and osteomyelitis of the thoracic spine (mid-back region extending from the base of the neck to the bottom of the ribs). During a record review of Residents 128's nafcillin IV antibiotic administration audit for the month of June 2026, the audit indicated the following dates nafcillin IV antibiotic was administered late and not at the scheduled time: a. 6/26/2026 scheduled at 12:00 a.m., administered at 1:29 a.m.b. 6/26/2026 scheduled at 8:00 a.m., administered at 9:34 a.m.c. 6/26/2026 schedule at 4:00 p.m., administered at 5:48 p.m.d. 6/26/2026 scheduled at 8:00 p.m., administered at 9:41 a.m.e. 6/28/2026 scheduled at 12:00 p.m., administered at 1:41 p.m.f. 6/28/2026 scheduled at 4:00 p.m., administered at 5:47 p.m. During an interview on 6/29/2026 at 12:06 p.m., with Resident 128, inside Resident 128's room, Resident 128 stated that she was admitted to the facility on [DATE]. Resident 128 stated that, on more than one occasion since her admission, her scheduled IV antibiotic, nafcillin, had not been administered at the prescribed time. Resident 128 stated that the physician ordered the IV antibiotic to be administered every four hours and that timely administration was important to her, to ensure the effectiveness of the treatment. Resident 128 stated that receiving the medication on time was important because she wanted to recover and be discharged home as soon as possible. Resident 128 stated that she had repeatedly needed to remind the nursing staff that her IV antibiotic was due since it had not been administered at the scheduled times. During an interview on 7/1/2026 at 9:56 a.m., with LVN 2, LVN 2 stated that IV antibiotics must be administered at the physician-ordered scheduled times to maintain a consistent therapeutic level of the medication in the resident's bloodstream and to effectively treat the infection. LVN 2 stated that when an IV antibiotic was ordered every four hours, the medication should be administered every four hours as prescribed unless the physician provided alternate instructions. LVN 2 stated that delaying or missing a scheduled dose could reduce the effectiveness of the antibiotic, potentially delay the resident's recovery, and place the resident at risk for worsening or persistent infection. LVN 2 stated that nursing staff were responsible for monitoring medication administration times and ensuring IV antibiotics were administered as ordered. During a concurrent interview and record review on 7/1/2026 at 3:11 p.m., with the Director of Nursing (DON), the DON stated that IV antibiotics must be administered in accordance with the physician's orders and at the scheduled administration times to maintain therapeutic drug levels and ensure the medication remains effective in treating the resident's infection. The DON stated that an IV antibiotic ordered every four hours should be administered every four hours unless otherwise directed by the prescribing physician. The DON stated that delays in administering scheduled IV antibiotics could reduce the medication's effectiveness, potentially prolong the resident's recovery, and increase the risk of complications related to the infection and/or overdosing the residents. The DON stated that nursing staff were expected to monitor medication administration times and ensure all scheduled IV antibiotics were administered as ordered. During a review of the facility's Policy and Procedure (P&P) titled, Medication Administration, dated 5/2016, the P&P indicated if a medication was refused, the refusal would be documented on the MAR. During a review of the facility's P&P titled Intravenous Administration dated 1/2024, the P&P indicated, The facility shall provide intravenous therapy safely and in accordance with physician or authorized practitioner orders, accepted standards of nursing practice, and applicable federal, state, and local regulations. IV therapy shall be administered by qualified licensed personnel who have demonstrated competency. During a review of the facility's P&P titled Medication Administration, dated 1/2024, the P&P indicated, Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Medications are administered within 60 minutes of schedule time (1 hour before and 1 hour after), except before or after meal order, which are administered based on mealtimes.

Based on interview and record review, the facility failed to ensure Hydrocodone-Acetaminophen (a medication used to treat pain) was administered within the physician ordered parameters (specific, measurable, and objective clinical criteria set by a healthcare provider that dictate when a medication should be given, withheld, or adjusted) for one of two sampled residents (Resident 7). This failure resulted in Resident 7 receiving Hydrocodone-Acetaminophen outside the physician-ordered parameters and had the potential for unnecessary opioid use (narcotics, medications prescribed by doctors to treat persistent or severe pain), adverse medication effects, oversedation (when a patient receives an excessive amount of sedative agents, resulting in a deeper level of consciousness than intended), respiratory depression (when you breathe too slowly or too shallowly), constipation (occurs when your bowel movements become less frequent and stools become difficult to pass), and medication-related harm. Findings: During a review of Resident 7's admission Record, the admission Record indicated Resident 7 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 7's diagnoses included major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), dysphagia (difficulty swallowing), heart failure (a condition when the heart cannot pump enough blood to meet the body's needs), and muscle weakness (loss of muscle strength). During a review of Resident 7's Minimum Data Set ([MDS] - a resident assessment tool), dated 4/16/2026, the MDS indicated Resident 7's cognitive skills for daily decision making (the ability to think and process information) was intact. The MDS indicated Resident 7 was dependent (helper does all the effort) on staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 7's physician order, dated 1/11/2026, the physician order indicated to administer Hydrocodone-Acetaminophen 10-325 milligrams (mg- metric unit of measurement, used for medication dosage and/or amount), one tablet by mouth every six (6) hours as needed for severe pain of 7-10 on a pain scale (pain scale 0=no pain, 1-3=mild pain, 4-6=moderate pain, 7-10= severe pain). During a review of Resident 7's care plan titled Hydrocodone-Acetaminophen dated 6/4/2026, the care plan indicated to administer Hydrocodone-Acetaminophen as ordered by the physician. During a concurrent interview and record review on 7/1/2026 at 10:20 a.m., with Registered Nurse (RN) 1, Resident 7's Medication Administration Record (MAR), dated 4/1/2026 through 6/30/2026, was reviewed. The MAR indicated Resident 7 was administered Hydrocodone-Acetaminophen 10-325 mg for the following pain levels on the following dates:4/27/2026-pain level 0 out of ten.5/2/2026- pain level 0 out of ten.5/4/2026- pain level 6 out of ten.5/10/2026- pain level 0 out of ten.5/12/2026- pain level 6 out of ten.5/20/2026- pain level 6 out of ten.5/22/2026- pain level 6 out of ten.5/23/2026- pain level 0 out of ten.5/31/2026- pain level 6 out of ten.6/13/2026- pain level 0 out of ten.6/14/2026- pain level 0 out of ten.6/19/2026- pain level 6 out of ten.6/20/2026- pain level 0 out of ten. RN 1 stated Hydrocodone-Acetaminophen should be administered according to the physician's order and within the ordered parameters. RN 1 stated Hydrocodone-Acetaminophen was administered when Resident 7's documented pain level did not meet the ordered parameters for severe pain. RN 1 stated this placed Resident 7 at risk for unnecessary opioid use, overdose, adverse medication effects, and medication related harm. During an interview on 7/2/2026 at 8:18 a.m., with the Director of Nursing (DON), the DON stated Hydrocodone-Acetaminophen was administered when Resident 7's pain level was less than 7-10, which was outside the ordered parameters. The DON stated that administering Hydrocodone-Acetaminophen outside the ordered parameters was not consistent with the physician's order and resulted in unnecessary administration of opioid pain medication. The DON stated this placed Resident 7 at risk for unnecessary opioid exposure, oversedation, confusion, and adverse medication effects. During a review of the facility's policy and procedure (P&P) titled Physician Orders, dated 1/2024, the P&P indicated facility licensed nurses must administer medications as ordered by physicians. During a review of the facility's P&P titled Medication Administration, dated 1/2024, the P&P indicated medications must be given as prescribed by the physician.

Based on interview and record review, the facility failed to ensure blood pressure medications were administered as ordered by the physician for two of six sampled residents (Resident 10 and Resident 154). This failure created the potential for Resident 10 and Resident 154 to experience complications related to hypotension (low blood pressure), including dizziness, falls, and increased heart rate. Findings: 1. During a review of Resident 10's admission Record, the admission Record indicated Resident 10 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 10's diagnoses included type 2 diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), falls, peripheral vascular disease (PVD - a slow progressive narrowing of the blood flow to the arms and legs), and hypertensive heart disease (complications caused by long-term unmanaged high blood pressure). During a review of Resident 10's History and Physical (H&P), dated 3/18/2026, the H&P indicated Resident 10 did not have the capacity to understand and make decisions. During a review of Resident 10's physician order, dated 3/17/2026, the physician order indicated to administer amlodipine (high blood pressure medication) 10 milligrams (mg- metric unit of measurement, used for medication dosage and/or amount), 1 tablet in the morning for hypertension (HTN- high blood pressure). Hold medication for systolic (SBP- top number of blood pressure reading) blood pressure less than (<) 110 millimeters of mercury (mmHg). During a review of Resident 10's physician order, dated 3/18/2026, the physician order indicated to administer losartan potassium (high blood pressure medication) tablet 25 mg, 1 tablet by mouth in the morning for HTN. Hold for SBP < 110 mmHg. During a record review of Residents 10's Medication administration record (MAR) for the month of April 2026, the MAR indicated the following: a. On 4/15/2026, Resident 10's blood pressure was 103/54 mmHg. The MAR indicated a dose of amlodipine was administered at 9:00 a.m. b. On 4/20/2026, Resident 10's blood pressure was 103/60 mmHg. The MAR indicated a dose of losartan was administered at 9:00 a.m. During a record review of Residents 10's MAR for the month of June 2026, the MAR indicated the following: a. On 6/6/2026, Resident 10's blood pressure was 108/72 mmHg. The MAR indicated a dose of amlodipine and losartan were administered at 9:00 a.m. b. On 6/7/2026, Resident 10's blood pressure was 109/75 mmHg. The MAR indicated a dose of losartan was administered at 9:00 a.m. During a concurrent interview and record review on 7/1/2026 at 2:52 p.m., with Licensed Vocational Nurse (LVN) 5, Resident 10's physician orders and the MAR for April 2026 and June 2026 were reviewed. The physician's orders indicated staff were to hold the administration of both amlodipine and losartan if the Resident 10's SBP was less than 110 mmHg. The MAR indicated amlodipine and losartan were administered for a SBP less than 110 mmHg. LVN 5 stated that the check marks documented on the MAR indicated the medications were administered on 4/15/2026, 4/20/2026, 6/6/2026, and 6/7/2026, despite the resident's documented SBP being below the physician-ordered hold parameter of 110 mmHg. LVN 5 stated that, based on the physician's orders, both medications should have been withheld on those dates. LVN 5 stated that administering antihypertensive medications when the resident's SBP was below the prescribed parameter was inconsistent with physician orders and accepted standards of nursing practice. LVN 5 stated that nursing staff were expected to review the resident's current blood pressure before medication administration, compare the results with the physician-ordered parameters, and withhold the medication. LVN 5 stated that the medications should not have been administered under those circumstances because doing so could place the resident at risk for hypotension (low blood Pressure), dizziness, falls, decreased organ perfusion, and other adverse outcomes. During an interview on 7/1/2026 at 3:25 p.m., with the Director of Nursing (DON), the DON stated that Resident 10's physician's orders directed staff to hold amlodipine and losartan if the resident's SBP was less than 110 mmHg. The DON stated the medications were administered on 4/15/2026, 4/20/2026, 6/6/2026, and 6/7/2026 despite the resident's documented SBP being below the ordered hold parameters. The DON stated that the medications should have been withheld, and nursing staff were expected to follow physician-ordered medication parameters to ensure resident safety and prevent adverse outcomes associated with hypotension. 2. During a review of Resident 154's admission Record, the admission Record indicated Resident 154 was originally admitted to the facility on [DATE] and was most recently readmitted on [DATE]. Resident 154's diagnoses included HTN, atrial fibrillation (an irregular and often rapid heart rate), abnormalities of gait (manner of walking) and mobility, and generalized muscle weakness. During a review of Resident 154's MDS, dated [DATE], the MDS indicated Resident 154 had severe cognitive skills for daily decision making. The MDS indicated Resident 154 required partial to moderate assistance from staff for all attempted mobility while in and out of bed. During a review of Resident 154's care plan titled The resident has hypertension (HTN), . revised 5/28/2026, the care plan indicated staff were to administer blood pressure medications as ordered, and monitor the resident for side effects such as orthostatic hypotension (a sudden, large drop in blood pressure that occurs when you stand up after sitting or lying down) and increased heart rate. During a review of Resident 154's discontinued physician order, dated 5/23/2025 to 5/21/2026, the order indicated staff were to administer metoprolol (a medication to lower blood pressure) twice a day. Hold for SPB less than 110 mmHg, or if heartrate was less than 60 beats per minute (BPM, a unit of measuring heartrate). During a review of Resident 154's discontinued physician order, dated 5/23/2025 to 5/21/2026, the order indicated staff were to administer lisinopril (a medication to lower blood pressure) in the morning. Hold for SBP less than 110 mmHg. During a review of Resident 154's Electronic Medication Administration Record (EMAR), dated 4/1/2026 to 4/31/2026, the EMAR indicated on 4/8/2026, staff administered metoprolol for a SBP of 95 mmHg. The EMAR also indicated on 4/30/2025, staff administered lisinopril for a SBP of 106 mmHg. During an interview on 7/1/2026 at 2:11 p.m., with Registered Nurse (RN) 2, RN 2 stated holding parameters for blood pressure medications were important to prevent excessive hypotension (low blood pressure). RN 2 stated this can manifest in the resident as dizziness, fatigue, breathing issues, and can also increase the risk for a fall to occur. RN 2 stated that on 4/8/2026 and 4/30/2026, staff administered blood pressure medication outside of the ordered holding parameters and stated this was a safety risk for the resident. During a review of the facility's policy and procedure (P&P) titled Medication Administration dated 1/2024, the P&P indicated, Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. The P&P indicated medications were to be administered in accordance with written orders of the attending physician.

Based on observation, interview, and record review, the facility failed to maintain a safe environment when the water from a plumbing pipe ( a tube that carries water) under the sink was observed draining into the floor drain. The floor drain was uncovered creating steam (is water in the form of a hot gas) and slippery conditions (a surface that us easily to slip on because it is wet). This failure created safety hazards and the potential for burns from the steam.Findings:During an observation on 6/29/2026 at 8:20 a.m., in the kitchen by the dishwasher area, observed a continuous steam of water leaking from a plumbing pipe directly into the uncovered floor drain. The floor was visibly wet.During a concurrent observation and interview on 6/29/2026 at 10:01 a.m., with the Dietary Supervisor (DS), in the kitchen, observed water continuously draining from the pipe into the uncovered floor drain. The area on the floor was wet. The DS stated that an exposed drain with hot water and steam could cause injuries or burns if not fixed.During an interview on 6/30/2026 at 1:48 p.m., with the Director of Nursing (DON), the DON stated an uncovered floor drain with leaking hot water and steam was an unsafe condition that could cause injuries. The DON stated the continuous stream of water into the uncovered drain required immediate correction.During an interview on 6/30/2026 at 2:30 p.m., with the Maintenance Supervisor (MS), the MS stated hot water and steam from an uncovered floor drain could lead to slips, burns, and unsanitary conditions. The MS stated installing a drain cover was recommended for safety.During a review of the facility's policy and procedure (P&P) titled, Sanitary, Safe Functional Environment, revised 1/2024, the P&P indicated, maintenance staff shall ensure the physical environment is safe and functional, including plumbing.

Based on interview and record review, the facility failed to ensure the nursing staff was aware of what the facility used visual identifiers (icons placed by resident to identify special needs or accommodations) meant that were posted in resident rooms.This deficient practice had the potential to result in staff not providing the appropriate care for the residents.Findings:During a review of the facility's Lesson Plan titled Visual Identifier, undated, the Lesson Plan indicated the course content covered what visual identifiers were used in the facility. The visual identifier of a 5- fingers sign meant more than 2-persons assistance during transfer. The evaluation for the Lesson Plan included a question that asked the participants what the 5- fingers visual identifier meant in the facility.During an interview on 8/27/2025 at 10:10am with Certified Nurse Assistant (CNA) 2, CNA 2 was asked if she knew what the visual identifier with 5-fingers on a red hand posted up at the head of a resident's bed meant. CNA 2 stated she was not sure if she had ever seen that sign before and did not know what that visual identifier was meant to signify if it was posted up. During a review of the facility's In-service Training for Certified Nurse Assistants titled, Visual Identifiers, dated 3/10/2025, the In-Service Training for Certified Nurse Assistants indicated CNA 2 attended the Visual Identifiers training on 3/10/2025.During an interview on 8/28/2025 at 2:38 p.m. with the Director of Staff Development, the DSD stated the expectations from staff after receiving an in-service training are that the staff would apply what they have learned in class into practice. The DSD further stated the facility expected the staff to remember what they were taught and apply it during the care for the residents, and it was important to do so because it ensured resident and staff safety.During a review of the facility's policy and procedures (P&P) titled Visual Identifiers, dated 1/2024, the P&P indicated the 5-fingers visual identifier meant a resident required more than 2 persons during transfers and staff should check for visual identifiers before providing care or services, follow any precautions associated with the identifier.

Based on interview, and record review, the facility failed to ensure accurate documentation in accordance with professional standards of practice for one of two sampled residents (Resident 1) by documenting Resident 1 received Restorative Nurse Aide (RNA- a Certified Nursing Assistant with specialized training in restorative care to help residents regain physical and cognitive functions and maintain independence) services when they did not. This deficient practice had the potential to affect future care provided to the resident due to inaccurate documentation practices.Findings:During a review of Resident 1's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 1 was originally admitted on [DATE], and readmitted on [DATE] with diagnoses that included osteoporosis (weak and brittle bones due to lack of calcium and Vitamin D) and rheumatoid arthritis (a chronic progressive disease-causing inflammation in the joints and resulting in painful deformity and immobility). During a review of Resident 1's History and Physical (H&P), dated 3/11/2025, the H&P indicated Resident 1 did not have the capacity to make and understand decisions. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 6/18/2025, the MDS indicated Resident 1 did not have the ability to understand others or make themselves understood. The MDS further stated Resident 1 was severely cognitively impaired (ability to reason, understand, remember, judge, and learn) and did had limitations in range of motion to the upper and lower extremities (related to the arms and legs). During a review of Resident 1's Order Summary Report, dated 7/27/2025, the Order Summary Report indicated Resident 1 had an order for the right and left lower extremity (related to the legs) passive range of motion (PROM- exercises by a therapist to improve mobility, increase circulation, and prevent stiffness, especially for those who cannot move their own limbs) 5 times per week, and a Pressure Relief Ankle Foot Orthosis (PRAFO- a boot used to prevent and treat heel ulcers and muscle tightness in those who spend extended periods in bed) to be applied to the right and left extremities for 3-4 hours per day, 5 days each week. During a review of Resident 1's RNA Program Administration Report, dated 8/2025, the RNA Program Administration Report indicated the ordered tasks assigned to the RNA Program were signed off as performed on 8/18/2025 by RNA 1. During a review of the facility's Interview Record as part of the facility's investigation, dated 8/20/2025, the Interview Record indicated Restorative Nursing Aid (RNA) 1 was not able to see Resident 1 on 8/18/2025. During a concurrent interview and record review on 8/27/2025 at 11:50 a.m. with RNA 1, RNA 1 stated he did not observe Resident 1's lower extremities on 8/18/2025 because he was not able to perform the RNA orders for Resident 1 because there was not enough RNA for the whole building that day. RNA 1 reviewed the RNA Program Administration Report and stated the initial under the date of the RNA task indicated it was performed. RNA 1 stated he just signed off on it, but it should have been noted with a reason why the task was not performed because it looked like the tasks were performed on that day. During an interview on 8/28/2025 at 2:38 p.m. with the Director of Staff Development (DSD), the DSD stated nursing documentation should be accurate. The DSD further stated the nurse should never document a task was performed when it was not, because this could affect future treatment that would be given to the resident later due to inaccurate documentation. During a review of the facility's policy and procedures (P&P) titled Documentation, dated 1/2024, the P&P indicated documentation in the medical record would be objective, complete, and accurate.

Based on interview and record review, the facility failed to ensure a two-person assist was used when using the Hoyer Lift (a mechanical device used to lift and/or transfer a person) for one of three sampled residents (Resident 1).This deficient practice had the potential to result in Resident 1 falling from the Hoyer Lift.Findings:During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included metabolic encephalopathy (a condition where your brain's ability to function properly is impaired by a chemical imbalance in your body), vascular dementia (a progressive state of decline in mental abilities caused by an impaired blood supply to the brain), and cerebral infarction (also known as a stroke, where a loss of blood flow to a part of the brain occurs). During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 5/29/2025, the MDS indicated Resident 1's cognitive skills (process of thinking) for daily decision making was moderately impaired. The MDS indicated Resident 1 was dependent (helper does all the effort or the assistance of two or more helpers is required) on staff's assistance with oral hygiene, bathing, personal hygiene, and chair/bed-to-chair transfer.During a review of Resident 1's History and Physical (H&P), the H&P indicated Resident 1 did not have the capacity to understand and make any decisions.During a review of Resident 1's Care Plan titled, Activities of Daily Living (ADL) Self-Care Performance Deficit, dated 3/18/2025, the Care Plan's interventions indicated to assist in transfers as needed.During a review of Resident 1's Physical Therapy (PT) Discharge summary, dated [DATE], the Discharge Summary indicated Resident 1 was total dependent with transfers.During an interview on 7/29/2025 at 10:32 a.m., with Responsible Party (RP) 1, RP 1 stated, on 7/25/2025, Certified Nursing Assistant (CNA) 1 transferred Resident 1 from the wheelchair to the bed. RP 1 stated CNA 1 did not have another staff member present when CNA 1 transferred Resident 1 back to bed. RP 1 stated she was told Resident 1 required a two-person assist when the Hoyer Lift was used. During an interview on 7/29/2025 at 11:21 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated, on 7/25/2025, RP 1 requested for Resident 1 to be assisted back to bed. LVN 1 stated she informed CNA 1 of RP 1's request and CNA 1 went to Resident 1's room to transfer Resident 1 back to bed. LVN 1 stated CNA 1 used the Hoyer Lift to transfer Resident 1 from the wheelchair to the bed and did not have another staff member to assist him. LVN 1 stated, He should have asked me because a two-person assist was required when operating the Hoyer Lift. LVN 1 stated a two-person assist was required to ensure Resident 1's safety where one person operated the Hoyer Lift while the second person supported and guided Resident 1 to the bed. During an interview on 7/29/2025 at 11:58 a.m., with CNA 1, CNA 1 stated, on 7/25/2025 at 6:45 p.m., he was told to transfer Resident 1 from his wheelchair to the bed. CNA 1 stated he used the Hoyer Lift to transfer Resident 1 back to bed and did not have another staff member to assist him. CNA 1 stated when operating the Hoyer Lift, he was supposed to have another person there to ensure Resident 1 had a safe transfer from the wheelchair to the bed. During an interview on 7/29/2025 at 12:02 p.m., with Registered Nurse (RN) 1, RN 1 stated Resident 1 was very confused and did not always have the awareness of what was happening. RN 1 stated Resident 1 was unable to support himself with his legs therefore the Hoyer Lift was used to transfer Resident 1 from the bed to the wheelchair and vice versa. RN 1 stated due to Resident 1's impaired cognition, a two-person assist was necessary to ensure Resident 1's safety during a Hoyer Lift transfer. RN 1 stated if Resident 1 were to fall from the Hoyer Lift, CNA 1 would not have been able to safely guide Resident 1 to the floor or to his bed. During an interview on 7/29/2025 at 12:15 p.m., with the Director of Nursing (DON), the DON stated the manufacturer's guideline for the Hoyer Lift recommended a two-person assist when operating the Hoyer Lift for the safety of the residents. The DON stated a two-person assist was recommended if the Hoyer Lift was to shift, the second person would be there to help guide the residents to bed or to the chair. The DON stated all residents were at risk for falls and injuries. During an interview on 7/29/2025 at 1:09 p.m., with the Director of Rehab (DOR), the DOR stated a two-person assist was the safest way to operate the Hoyer Lift. The DOR stated Resident 1 was dependent on the staff's assistance with transfers. The DOR stated Resident 1 had poor cognition, often very confused, and had days where Resident 1 may or may not follow commands. The DOR stated due to Resident 1's overall condition, a two-person assist was necessary during Hoyer Lift transfers to ensure Resident 1's safety and to prevent falls and major injuries.During a review of the facility's document titled, Invacare Reliant (brand of Hoyer Lift) Battery-Powered Patient Lift User Manual), dated the year 2023, the document indicated Invacare recommended two assistants be used for lifting preparation and transfers and was based on the evaluation of the healthcare professional for each individual use.

Based on interview and record review, the facility failed to ensure the training provided to all facility staff, specifically related to abuse reporting, was consistent with federal reporting guidelines. This failure had the potential to affect all facility residents due to late reporting of abuse, and delayed investigations by the State Agency. Findings: During a concurrent interview and record review, on 4/10/2025 at 11:27 a.m., with the Director of Staff Development (DSD), the facility's lesson plan titled Abuse Definition, Prevention, Reporting, and Investigation, dated 3/30/2025 to 4/6/2025, was reviewed. The DSD stated the lesson plan indicated allegations of abuse were to be reported to the State Agency within 24 hours, unless the allegation involved injury. The DSD stated he was not sure what the federal requirements were for reporting abuse. The DSD stated this lesson plan was approved by the Director of Nursing (DON) prior to being taught to facility staff. The DSD stated timely reporting of allegations of abuse was to ensure the safety of the facility's residents, and stated delayed reporting could result in repeat incidents of abuse and/or negatively impact the safety of the facility's residents. During an interview on 4/10/2025 at 11:54 a.m., with the DON, the DON stated the DSD was the primary individual responsible for providing abuse training to all facility staff. The DON stated she reviewed the abuse lesson plans created by the DSD to ensure the lesson plan teachings were accurate. The DON stated the lesson plans were based on guidance provided in the All Facilities Letters (AFLs, letters sent from the Center for Health Care Quality (CHCQ), Licensing and Certification (L&C) Program to health facilities, including changes in requirements in healthcare, enforcement, new technologies, scope of practice, or general information that affects the health facility) and the facility's policies and procedures (P&P) for abuse. During a concurrent interview and record review, on 4/10/2025 at 11:57 a.m., with the DON, the facility's lesson plan titled Abuse Definition, Prevention, Reporting, and Investigation, dated 3/30/2025 to 4/6/2025, was reviewed. The DON stated the lesson plan indicated abuse allegations were to be reported within 24 hours if the allegation did not include bodily injury. The DON stated the lesson plan was based on AFL 21-26, dated 7/26/2021, and stated she reviewed it and approved for it to be taught to all facility staff. The DON stated the importance of timely reporting of abuse was to keep the facility residents safe. During an interview, on 4/10/2025 at 12:41 p.m., with the Administrator (ADM), the ADM stated it was the facility's policy and process to report resident-to-resident altercations to the State Agency within two (2) hours. During a concurrent interview and record review, on 4/10/2025 at 12:44 p.m., with the ADM, the facility's P&P titled Prevention, Reporting and Correction of Inappropriate Conduct Including Abuse, Neglect and Mistreatment of Residents and Investigations of Injuries of Unknown Origin, reviewed 2018, was reviewed. The ADM stated the P&P indicated staff were to follow the state and federal guidance for reporting abuse, and stated the federal guidance required abuse to be reported within two (2) hours. During a review of the facility P&P titled Prevention, Reporting and Correction of Inappropriate Conduct Including Abuse, Neglect and Mistreatment of Residents and Investigations of Injuries of Unknown Origin, reviewed 2018, the P&P indicated all allegations of abuse were to be reported in accordance with state and federal regulations. During a review of AFL 21-26, dated 7/26/2021, the AFL indicated the purpose of the letter was to remind facilities of the federally mandated reporting requirements of potential abuse, neglect, exploitation, or mistreatment of elders or dependent adults. AFL 21-26 indicated incidents involving abuse were to be reported to the State Agency, in writing or by electronic report, within two (2) hours.

Based on interview and record review, the facility failed to ensure the Infection Preventionist Nurse (IPN) completed ten hours of continuing education in the field of Infection Prevention and Control on an annual basis. This deficient practice had the potential to result in the IPN being unaware and be unable to educate the facility's staff of updated information regarding Infection Prevention and Control. Findings: During a concurrent interview and record review on 4/8/2025 at 10:18 a.m., with the IPN, the IPN's Nursing Home Infection Preventionist Training Court Certification, dated 11/14/2023, was reviewed. The IPN stated he completed his certification to become the facility's IPN on 11/14/2023 but did not complete any documented continuing education in the filed of Infection Prevention and Control since then. The IPN stated he was responsible for completing at least ten hours of continuing education in Infection Control on an annual basis to keep up to date with all guidelines and protocols. The IIPN stated without the completion of continuing education, he may not be educating the facility's staff on the best way to treat infections in the facility. During a review of the California Department of Public Health (CDPH) All Facilities Letter (AFL, official letter from the CDPH to facilities to keep them informed about changes in regulations, enforcement actions, new technologies, and other important updates), dated 11/4/2020, the AFL indicated, The IP should complete 10 hours of continuing education in the field of [Infection Prevention and Control] on an annual basis. Facilities should provide encouragement and support for IP staff to stay abreast of current news and training sources through a nationally recognized infection prevention and control association. During a review of the facility's Infection Control Coordinator Job Description, undated, the Job Description indicated the Infection Control Coordinator was responsible for promoting professional growth and development by educational activities and participating in educational trainings.

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 142) fully understood the Arbitration Agreement (an agreement between the facility and the resident where they would resolve any disputes through a neutral person rather than going to court) in a language Resident 142 understood. This deficient practice resulted in Resident 142 not fully understanding what entering a binding Arbitration Agreement meant. Findings: During a review of Resident 142's Admission Record, the Admission Record indicated Resident 142 was admitted to the facility on [DATE] with diagnoses that included major depressive disorder (a mood disorder that caused a persistent feeling of sadness and loss of interest) and dementia (a progressive state of decline in mental abilities). The Admission Record indicated Resident 142's primary language was Spanish. During a review of Resident 142's Minimum Data Set (MDS, a resident assessment tool), dated 2/17/2025, the MDS indicated Resident 142's preferred language was Spanish and needed an interpreter to communicate with a doctor or health care staff. The MDS indicated Resident 142's cognition (process of thinking) was moderately impaired. The MDS indicated Resident 142 required supervision with eating, oral hygiene, toileting hygiene, and transferring in-and-out of bed/ chair. The MDS indicated Resident 142 required partial assistance (helper did less than half the effort) with showering/ bathing self and personal hygiene. During a review of Resident 142's History and Physical (H&P), dated 3/11/2025, the H&P indicated Resident 142 had the capacity to understand and make decisions. During a review of Resident 142's Arbitration Agreement, dated 1/22/2024, the Arbitration Agreement indicated Resident 142 signed and entered the binding agreement. The Arbitration Agreement was in English. During an interview on 4/9/2025 at 8:52 a.m. with Resident 142, Resident 142 stated she did not remember the arbitration agreement, and she needed an explanation for what an arbitration was. Resident 142 stated she was unable to read English. Resident 142 stated she would like to have the Arbitration Agreement in Spanish because it was easier for her to understand. During an interview on 4/10/2025 at 9:05 a.m. with the Admission Coordinator, the Admission Coordinator stated the Arbitration Agreement was only available in English. The Admission Coordinator stated she would speak with the resident in Spanish if the resident's preferred language was Spanish. The Admission Coordinator stated she would explain the Arbitration Agreement word by word upon requests. The Admission Coordinator stated the facility should have the Arbitration Agreement in Spanish available for residents, whose primary language was Spanish, because it was resident's right to know what they were signing. During a review of the facility Policy and Procedure (P&P) titled Resident Arbitration, dated 1/2024, the P&P indicated the facility must ensure the agreement is explained to the resident and his or her representative in a form and manner that he or she understands, including in a language the resident and his or her representative understands.

Based on observation, interview, and record review, the facility failed to ensure: 1. Kitchen staff wore a hair covering in the food service or preparation areas of the kitchen. 2. All food items in the storeroom were labeled and dated. These deficient practices had the potential to result in improper food safety practice and could lead to food contamination, and possible food borne illness in residents who received food from the kitchen. Findings: 1. During a concurrent observation and interview on 4/7/2025 at 8:35 a.m., in the kitchen, with Dishwasher 1, observed Dishwasher 1 without the required hair covering while working in the dishwashing area, near the food preparation station. Dishwasher 1 stated he did not realize that his hair netting had fallen, and he believed his hair was still covered. During an interview on 4/7/2025 at 8:45 a.m., in the kitchen, with Dietary Supervisor (DS 1), DS 1 stated a hair covering not properly secured could result in hair falling into the food, clean dishes, or food preparation area, and increased risk of food contamination. 2. During a concurrent observation and interview on 4/7/2025 at 9:00 a.m., in the dry food storage room, with DS 1, observed one large plastic container filled with a powdered substance unlabeled and undated. DS 1 stated the container held powdered nutritional supplement and should have been labeled and dated according to facility protocol. DS 1 stated all items in the storage room should be labeled with both the delivery and expiration dates to ensure safe usage. During a review of the facility's policy and procedure (P&P) titled Infection Control- Dietary, dated 1/2024, the P&P indicated personnel would wear a hair covering in food preparation, food service, and food storage areas. During a review of the facility's P&P titled Labeling and Dating of Foods, undated, the P&P indicated all food items in the storeroom would be labeled and dated. The P&P indicated food delivered to the facility would be marked with a received date.

Based on observation, interview, and record review, the facility failed to promptly notify the physician and the resident's representative (RR 1) of a change in condition (COC) of skin tears (separation of the skin) and bleeding on both forearms for one of four sampled residents (Resident 89). This deficient practice resulted in a delay in medical assessment and treatment for Resident 89 and placed the resident at risk of harm. Findings: During a review of Resident 89's Admission Record, the Admission Record indicated Resident 89 was admitted to the facility on [DATE] with diagnoses which included dementia (a progressive state of decline in mental abilities), cerebrovascular accident ([CVA]- stroke, loss of blood flow to a part of the brain), major depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), diabetes mellitus ([DM]- a disorder characterized by difficulty in blood sugar control and poor wound healing), and hypertension ([HTN]- high blood pressure). During a review of Resident 89's Minimum Data Set ([MDS] - a resident assessment tool), dated 3/26/2025, the MDS indicated Resident 89's cognitive (the ability to think and process information) skills for daily decision making was severely impaired. During a review of Resident 89's History and Physical (H&P), dated 3/10/2025, the H&P indicated Resident 89 did not have the capacity to understand and make decisions. During a review of Resident 89's care plan with a focus of Resident was at risk for skin breakdown related to stroke, dated 3/20/2025, the care plan indicated the facility would monitor Resident 89 for skin breakdown and report injuries to the physician. During an observation on 4/10/2025 at 10:05 a.m., in Resident 89's room, Resident 89 was observed with dressings (materials applied to wounds to promote healing) on her right and left forearms. During a telephone interview on 4/10/2025 at 11:39 a.m., with Resident 89's RR 1, RR 1 stated she has visited Resident 89 daily since the resident's admission to the facility. RR 1 stated on the morning of 4/7/2025 at approximately 12:00 p.m., Resident 89 was observed with dressings on both of her forearms which were not present during her previous visits. RR 1 stated staff were not able to explain what happened. RR 1 stated on 4/7/2025 around 3:00 p.m., upon an assessment by Treatment Nurse (TX 1), Resident 89 was observed with two skin tears on her left forearm, one skin tear on her right forearm with bleeding, and new bruises on both forearms. RR 1 stated TXN 1 was not able to explain how Resident 89 developed skin tears and bruises on her forearms. RR 1 stated she was not made aware of Resident 89's skin tears and new bruises. RR 1 stated she was upset and disappointed the facility failed to notify her of Resident 89's change of condition. During an interview on 4/10/2025 at 11:55 a.m., with TXN 1, TXN 1 stated on 4/7/2025 around 2:30 p.m., she (TXN 1) was notified by Licensed Vocational Nurse (LVN 6) that Resident 89 had dressings to her forearms and needed a skin assessment. TXN 1 stated upon removal of the old dressings she observed Resident 89 with skin tears to the left and right forearms with bleeding and bruises. TXN 1 stated she did not know how Resident 89 developed skin tears on her forearms and who originally applied the dressings. TXN 1 stated she notified the Director of Nursing (DON) regarding Resident 89's change of condition. During a concurrent interview and record review on 4/10/2025 at 1:10 p.m., with LVN 6, Resident 89's Electronic Medical Record (EMR) dated 4/6/2025 to 4/7/2025 was reviewed. LVN 6 stated Resident 89's EMR indicated there was no documented evidence how Resident 89 sustained the skin tears, bleeding, and bruises, and who applied the dressings. LVN 6 stated there was no documentation Resident 89's assigned 11 p.m. to 7 a.m. Certified Nursing Assistant (CNA 2) reported to the licensed nurses regarding the change of condition. LVN 6 stated the physician was not notified until after the concern was brought to the licensed nurses' attention by RR 1 on 4/7/2025 around 2:30 p.m. LVN 6 stated Resident 89's skin tears, bleeding, and bruises was a significant change of condition and staff should have notified the physician and RR 1 immediately to prevent delayed medical assessment, care, and treatment. During a telephone interview on 4/14/2025 at 9:32 a.m., with CNA 2, CNA 2 stated on the morning of 4/7/2025 around 4:00 a.m., while she was providing personal hygiene care to Resident 89, Resident 89 was moving her arms and struck the bed siderails. CNA 2 stated this resulted in skin tears and bleeding to both forearms. CNA 2 stated she applied the dressings to Resident 89's forearms but did not report the incident to the licensed nurse because she was scared and afraid that she would be suspended. CNA 2 stated she should have notified the charge nurse immediately so the resident could receive timely evaluation and treatment. During a review of the facility's policy and procedure (P&P) titled Condition Change of Resident, dated 1/2024, the P&P indicated the facility would observe, record, and report changes in condition to the physician and resident's representative.

Based on observation, interview, and record review, the facility failed to ensure the call light was within reach for one of seven sampled residents (Resident 100). This deficient practice had the potential to result in a delay in meeting the residents' needs for assistance and could lead to falls and accidents. Findings: During an observation on 4/8/2025 at 8:46 a.m., in Resident 100's room, Resident 100 was awake and lying on her bed. The call light cord was observed hanging around the left-upper side rail with the touch pad touching the floor. During an observation on 4/8/2025 at 2:10 p.m., in Resident 100's room, Resident 100 was awake and lying on her bed. The call light touch pad was touching the floor. During a review of Resident 100's Admission Record, the Admission Record indicated Resident 100 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of generalized muscle weakness, dementia (a progressive state of decline in mental abilities), and history of falling. During a review of Resident 100's Minimum Data Set (MDS - a resident assessment tool), dated 2/13/2025, the MDS indicated Resident 100's cognition (ability to think, remember, and reason) was severely impaired. The MDS indicated Resident 100 was dependent (helper did all the effort) with self-care (eating, oral hygiene, toileting hygiene, showering/ bathing self, and personal hygiene) and mobility (rolling left and right, chair/bed-to-chair transfer, and tub/shower transfer). During a review of Resident 100's History and Physical (H&P), dated 2/10/2025, the H&P indicated Resident 100 did not have the capacity to understand and make decisions. During a review of Resident 100's care plan for fall risk, undated, the care plan indicated to ensure the resident's call light is within reach. During a concurrent interview and picture review of Resident 100's call light, on 4/9/2025 at 2:20 p.m. with Certified Nursing Assistant (CNA) 5, the pictures dated 4/8/2025 at 8:46 a.m. and 2:10 p.m. were reviewed. The pictures showed Resident 100's call light touching the floor and not within reach. CNA 5 stated it was not acceptable that Resident 100's call light was not within reach because it was on the floor. CNA 5 stated the call light should be within the resident's reach. CNA 5 stated the purpose of the call light was for emergencies to call for help when needed. CNA 5 stated the call light was for resident safety. CNA 5 stated she checked call light placement visually during rounds every 20 to 30 minutes. CNA 5 stated all staff were responsive to ensure the call light was within reach. During a concurrent interview and picture review on 4/9/2025 at 2:38 p.m., with Licensed Vocational Nurse (LVN) 7, the pictures dated 4/8/2025 at 8:46 a.m. and 2:10 p.m. were reviewed. The pictures showed Resident 100's call light was touching the floor and not within reach. LVN 7 stated the call light touch pad was not reachable to the resident because it was on the floor. LVN 7 stated the purpose of the call light was safety and to address the resident's needs. LVN 7 stated if Resident 100 was not able to press the call light, the call light touch pad needed to be placed on the resident's chest when in bed for easy access. LVN 7 stated she checked the call light placement in the morning, during the medication pass and every time she attended to the residents. LVN 7 stated everyone was responsible for ensuring the call light was within reach. During a review of the facility's Policy and Procedure (P&P) titled, Call Light, dated 1/2024, the P&P indicated Check the placement of call light during rounds. Make sure it is within reach.

Based on interview and record review, facility staff failed to report an allegation of resident-to-resident physical abuse to the State Agency within two (2) hours, for two of four sampled residents (Resident 44 and Resident 42). This failure resulted in delayed notification to the State Agency and increased the potential for additional resident-to-resident abuse incidents to occur. Cross reference F-tag F943. Findings: During a review of Resident 44's Admission Record, the Admission Record indicated Resident 44 was originally admitted to the facility on [DATE] and was most recently readmitted on [DATE]. Resident 44's admitting diagnoses included schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), paranoid schizophrenia (a mental illness that is characterized by disturbances in thought), and psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality). During a review of Resident 44's History and Physical (H&P), dated 10/20/2024, the H&P indicated Resident 44 did not have the capacity to understand or make decisions. During a review of Resident 44's Minimum Data Assessment (MDS, a resident assessment tool), dated 3/3/2025, the MDS indicated Resident 44 did not have cognitive impairments (problems with thinking and memory). The MDS indicated Resident 44 required supervision and/or touch assistance from staff for mobility while in and out of bed. During a review of Resident 42's Admission Record, the record indicated Resident 42 was originally admitted to the facility on [DATE] and was most recently readmitted on [DATE]. Resident 42's admitting diagnoses included schizoaffective disorder, paranoid schizophrenia, anxiety disorder (mental health conditions characterized by excessive fear or worry that interferes with daily life), and psychosis. During a review of Resident 42's MDS, dated [DATE], the MDS indicated Resident 42 did not have cognitive impairments. The MDS indicated Resident 42 exhibited verbal behavioral symptoms one to three days out of seven days observed. The MDS indicated Resident 44 did not have impairments to her upper extremities (shoulder, elbow, wrist, hand) or lower extremities (hip, knee, ankle, foot). The MDS indicated Resident 42 was independent to reposition herself while in bed and required set-up or clean-up assistance from staff (staff set up or clean up, but resident completes the activity) to get out of bed and to walk. During an interview on 4/7/2025 at 9:50 a.m., with Resident 44, Resident 44 stated her previous roommate (Resident 42) threw a chair at her. Resident 44 could not state the date that the altercation occurred. When asked where the alleged incident occurred, Resident 44 stated it occurred in Room A, and stated she was moved to her current room (Room B) after the alleged incident occurred. Resident 44 stated this was her first and only altercation with Resident 42. During a concurrent interview and record review, on 4/8/2025 at 10:05 a.m., with Social Worker (SW) 1, Resident 44's progress note, dated 3/10/2025 at 10:45 a.m., was reviewed. SW 1 stated the progress note indicated Resident 44 was moved to another room on 3/10/2025 due to incompatibility with her roommate. SW 1 stated that on 3/10/2025, Resident 44 did not report Resident 42 threw a chair at her. The State Agency Surveyor informed SW 1 of Resident 44's allegation that Resident 42 threw a chair at her. During an interview on 4/8/2025 at 4:04 p.m., with the facility's Program Director (PD), the PD stated she was made aware on 4/8/2024 of the alleged resident-to-resident altercation between Resident 44 and Resident 42, that occurred on an unspecified date. The PD stated she was responsible for reporting the allegation to the State Agency. The PD stated the allegation was not yet reported to the State Agency District Office because they had 24 hours to report. During a review of the document titled Fax Transmission Details, dated 4/8/2025, the document indicated the SOC-341 (a mandated reporting form used when someone suspects elder or dependent adult abuse or neglect) was sent to the State Agency District Office on 4/8/2025 at 4:52 p.m. During a review of the document titled Report of Suspected Dependent Adult/Elder Abuse (SOC-341), dated 4/8/2025, the SOC-341 indicated it was completed by the PD, and indicated social services staff were made aware of Resident 44's abuse allegation on 4/8/2025 around 10am. During an interview on 4/10/2025 at 11:57 a.m., with the Director of Nursing (DON), the DON stated timely reporting of alleged abuse was important for the safety of the facility residents and stated that failing to report timely could negatively impact the safety of the residents. During an interview, on 4/10/2025 at 12:41 p.m., with the Administrator (ADM), the ADM stated it was the facility's policy and process to report resident-to-resident altercations to the State Agency within two (2) hours. During a review of the facility P&P titled Prevention, Reporting and Correction of Inappropriate Conduct Including Abuse, Neglect and Mistreatment of Residents and Investigations of Injuries of Unknown Origin, reviewed 2018, the P&P indicated all allegations of abuse were to be reported in accordance with state and federal regulations.

Based on interview and record review, the facility failed to ensure one of six sampled residents' (Resident 129) assessment entry on the Minimum Data Set ([MDS], a resident assessment tool) was accurate and included the depression (a mood disorder that causes a persistent feeling of sadness and loss of interest) diagnosis. This deficient practice had the potential to negatively affect Resident 129's plan of care and delivery of necessary care and services related to depression. Findings: During a review of Resident 129's Admission Record, the Admission Record indicated Resident 129 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included psychosis (a state where a person loses touch with reality by experiencing things that are not real), dementia (a progressive state of decline in mental abilities), and schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of Resident 129's MDS, dated [DATE], the MDS indicated Resident 129's cognition (process of thinking) was moderately impaired). The MDS indicated Resident 129 required moderate assistance (helper does less than half the effort) with oral hygiene, toileting, bathing, dressing, and personal hygiene. The MDS indicated Resident 129 received antidepressant medication (medication used to treat depression). During a review of Resident 129's History and Physical (H&P), dated 3/14/2025, the H&P indicated Resident 129 did not have the capacity to understand and make decisions. During a review of Resident 129's Orders, start date 3/14/2025, the Orders indicated to give bupropion (an antidepressant medication) 150 milligrams (mg, a unit of measurement), by mouth, in the morning, for depression as manifested by lack of interest in participating in daily activities. During a review of Resident 129's General Acute Care Hospital (GACH) Psychiatric Evaluation Note (a note recording the findings from a psychiatrist's periodic assessment), dated 2/25/2025, the Note indicated Resident 129 had psychiatric diagnoses that include major depressive disorder and schizophrenia. During a concurrent interview and record review on 4/9/2025 at 1:45 p.m., with the Minimum Data Set Coordinator (MDSC), Resident 129's MDS, dated [DATE], was reviewed. The MDSC stated Resident 129's MDS did not indicate Resident 129 had depression as an active diagnosis. The MDSC stated Resident 129's diagnosis of depression should have been coded in the MDS, dated [DATE], due to Resident 129's use of antidepressant medication and depression diagnosis from the GACH. The MDSC stated an accurate MDS assessment was necessary to capture the needs of the resident and to develop the best patient-centered plan of care for the resident. The MDSC stated Resident 129's inaccurate MDS assessment could negatively impact care planning, which could increase the risk of Resident 129's needs not being fully met. During a review of the facility's policy and procedure (P&P) titled, Resident Assessment, undated, the P&P indicated, It is this facility's policy to provide appropriate care and services to residents by conducting initial and periodical comprehensive assessment of each resident's functional capacity . Each resident assessment must be conducted and coordinated with the appropriate participation of health professionals knowledgeable about the resident's status and needs.

Based on observation, interview, and record review, the facility failed to ensure one of three residents were protected and free from abuse (Resident 1). Resident 1 was struck in the face with a water-filled pitcher by Resident 2. Resident 2, who had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . This deficient practice resulted in Resident 1 being physically assaulted by Resident 2 and sustaining a laceration (deep cut) to the left cheek, requiring wound treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] Findings: a.During a review of Resident 1's Admission Face Sheet, the Face Sheet indicated the resident was admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 1's Minimum Data Set (MDS), a resident assessment and care screening tool, dated 10/30/2020, the MDS indicated Resident 1 had no cognitive impairment (thought process) problems. The MDS indicated Resident 1 was assessed requiring a two-person physical assist for bed mobility and transferring, a one-person assist with locomotion on and off the unit, personal hygiene, toileting, and dressing. According to the MDS, Resident 1 was totally dependent with walking in room and corridor. During a review of the facility's Situation, Background, Assessment and Recommendation ([SBAR] an internal communication form), dated 1/23/2021 and timed at 11:45 a.m., the SBAR indicated the staff called for help due to Resident 2 verbalizing she was tired of Resident 1 talking about her. The SBAR indicated Resident 2 was very upset and suddenly became angry with Resident 1 (Residents 1 and 2 were roommates). Resident 2 assaulted Resident 1 by throwing a filled water pitcher at Resident 1. Resident 1 sustained a 3 x 1.5 centimeter ([cm] unit of measurement) laceration to the left cheek, which was witnessed by the facility's staff during a FaceTime video (allows users to engage in visual video chatting over the internet) call with a family member. According to the SBAR, Resident 2 was redirected and was moved to a single room and placed on one to one staff monitoring. During a review of Resident 1's Nurses Progress Note (NPN), dated 1/23/2021 and timed at 2:53 p.m., the NPN indicated the hospice (end of life care) nurse came to the facility at 2:13 p.m. to see Resident 1 with new physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The wound care treatment included to cleanse the wound with normal saline (solution of salt water), pat dry, apply antibiotic (used for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . b. During a review of Resident 2's Admission Face Sheet, the Face Sheet indicated Resident 2 was admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 2's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 had mild impaired cognitive skills (ability to reason and think) for daily decision-making and usually understood others. The MDS indicated Resident 2 required an extensive assistance of a one-person physical assist for transferring, dressing, and bed mobility. During a review of Resident 2's SBAR, dated 1/23/2021 and timed at 12:21 p.m., the SBAR indicated Resident 2 had physical aggression towards another resident (Resident 1). The SBAR indicated Resident 2 was upset and angry because she believed Resident 1 was talking about her. The SBAR indicated Resident 1 was on a FaceTime video call with a family member and a staff member observed Resident 2 throwing a filled water pitcher striking Resident 1 on the face. The SBAR indicated Resident 2 was transferred to a psychiatric (conditions that affect mood, thinking, and behavior) hospital for a behavioral evaluation. During a review of Resident 2's care plan, initiated on 6/15/2018 and last revised on 8/25/2019, identified Resident 2 receiving [CONDITION(S)] medication (drugs that affects behavior, mood, thoughts, or perception) for [CONDITION(S)] disorder manifested by intense paranoia (involves intense anxious or fearful feelings and thoughts often related to persecution, threat, or conspiracy) with auditory hallucinations, as she states, I hear staff and others talking about me. The goal indicated the resident would have decrease adverse reaction to the medication through the next target date of 4/18/2021. The staff interventions included to monitor and record episodes of behavior, redirect resident's attention as appropriate, and provide reality orientation as needed. During a review of Resident 2's care plan, initiated on 12/8/2020, the care plan identified behavior problem due to increased agitation as evidenced by throwing objects at staff and others, refusing care, and refusing medications. The goal indicated Resident 2 would be able to demonstrate effective coping skills; the resident would have fewer episodes of behavior problems, such as agitation as evidenced by throwing objects, refusing care, and refusing medications by a target date of 4/18/2021. The staff's interventions included to modify the environment, monitor / document any signs or symptoms of Resident 2 posing danger to self or others, and psychiatric consult as indicated. During a review of Resident 2's NPN, dated 12/8/2020 and timed at 7:55 p.m., the NPN indicated Resident 2 was noted with increased agitation as evidenced of throwing objects to staff and other residents, refusing care, and refusing medications. Redirections and counseling rendered but ineffective. During a review of Resident 2's NPNs, dated 12/9/2020, 12/10/2020, 12/11/2020, 12/26/2020, 12/27/2020, 12/28/2020, the NPNs indicated Resident 2 was on close monitoring by staff for episodes of yelling out, verbal aggression, throwing items at others, and refusing care. During an interview, on 2/9/2021 at 12:10 p.m., Resident 1's family member (FM 1) stated on 1/23/2021 while having a FaceTime conversation with her family member (Resident 1), her roommate (Resident 2), was heard cursing, opening the privacy curtain between the residents and threw a filled water pitcher at Resident 1. FM 1 stated Resident 1 was all wet, crying and yelled for assistance from one of the nurses. Resident 1 told FM 1 her roommate (Resident 2) continuously cursed, yelled, and threatened her (Resident 1). FM 1 stated Resident 1 had a cut to the face that may have been prevented, because Resident 1 had complained about Resident 2 before the abuse incident occurred. During an interview, on 2/9/2021 at 2:15 p.m., Licensed Vocational Nurse 1 (LVN 1) stated while sitting at the nursing station a staff member could be heard yelling for help in a resident's room. LVN 1 stated the Activities Assistant (AA) told her Resident 2 suddenly threw a filled water pitcher at Resident 1's face during a FaceTime video call. LVN 1 stated Resident 2 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview, on 2/9/2021 at 2:26 p.m., LVN 2 stated she was called to clean Resident 1's face laceration wound with slight bleeding close to the resident's left eye. LVN 2 stated steri-strips were applied and an ice pack to Resident 1's face. LVN 2 stated LVN 1 reported the incident to the assigned physician. During an interview, on 2/9/2021 at 3 p.m., the AA stated she overheard Resident 1 call out for help and she responded. The AA stated Resident 2 was acting up and she went to call for help. The AA stated Resident 2 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] During a concurrent observation and interview on 2/9/2021 at 3:11 p.m., Resident 1 was seen with a dark purple discoloration to the left cheek and a laceration from the left eyebrow to the left cheekbone with yellow color drainage. Resident 1 was tearful and stated Resident 2 hit her in the face and she was afraid of Resident 2. Resident 1 denied talking about Resident 2. Resident 1 stated there was water and blood all over her face after being hit with the water pitcher. Resident 1 stated she told her family member (FM 1) what occurred. During an interview, on 2/9/2021 at 3:20 p.m., the Social Services Director (SSD) stated Resident 2 was verbally aggressive towards others, but not physically aggressive. During an interview, on 2/9/2021 at 3:45 p.m., the Activities Director (AD) stated she was assisting Resident 1 to talk with FM 1 through FaceTime. The AD stated Resident 2 was initially quiet in bed during Resident 1's FaceTime call with family. The AD stated while standing next to Resident 1 and she noticed Resident 2 moving in bed and suddenly opened the room dividing curtain while throwing the water pitcher at Resident 1. The AD stated Resident 2 was very aggressive and should not have been in the same room with Resident 1. The AD stated Resident 2 has behaviors of paranoia and aggressiveness. During an interview, on 2/9/2021 at 4 p.m., the Director of Nursing (DON) stated Resident 2 was placed in the skilled nursing unit due to a decline in caring for herself, and required staff assisted care. During an interview, on 2/25/2021 at 7:51 a.m., LVN 1 stated Resident 2's behavior was usually delusional, aggressive and would often refuse medications for control of the behaviors. LVN 1 stated Resident 2 believed staff was poisoning her with the prescribed medications. During a review of the facility's policy and procedure (P/P), dated 1/14/2013 and titled, Resident-to-Resident, indicated the facility's staff will monitor residents for aggressive / inappropriate behavior towards other residents, family members, visitors, and or to the staff. Should a resident be observed /accused of abusing another resident, the facility will implement the following actions: remove the aggressor from the situation if the aggressor is still in the area in which the incident occurred. Counsel the resident to determine the cause of the behavior. Evaluate the circumstances/events leading up to the incident; develop a care plan that includes interventions to prevent the recurrence of such incident. Document in the resident's clinical record all interventions and their effectiveness, consult psychiatric services for assistance in assessing the resident and developing a care plan or intervention and management as necessary or as may be recommended by the attending physician or interdisciplinary care planning team.

Based on interview and record review, the facility failed to adhere to physician's orders and a plan of care to provide one to one (1:1) supervision for one of three sampled residents (Resident 1). Resident 1, who had a high risk for falls, had five falls within six months and the fifth fall resulted in serious injuries that included a fracture (broken bone) nose and facial lacerations (deep cuts) and required a transfer to the general acute care hospital (GACH). This deficient practice resulted in Resident 1 having multiple falls and sustaining a laceration to the left eyelid, skin tears to the bridge of the nose and left forearm, and a nasal (relating to the nose) fracture confirmed at the GACH on 2/7/2020. Resident 1 was readmitted to the facility on [DATE] and 20 hours after readmission, Resident 1 had a sixth fall with minor injuries after not being supervised 1:1 as per the physician's order and the resident's plan of care. Resident 1, who used to walk independently (without assistance), required a wheelchair for mobility. Findings: A review of Resident 1's Face Sheet (Admission Record) indicated the resident was originally admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS), dated [DATE] indicated Resident 1 had the ability to usually understand and be understood by others. The MDS indicated Resident 1 had impaired vision, was independent in bed mobility, transfers and toilet use, and required supervision with setup for other activities of daily living (ADL) including walking, locomotion, hygiene and bathing. Resident 1's balance during transition and walking was steady, but unsteady when turning around without the use of mobility devices. Resident 1 was continent (ability to control) of bowel and bladder. The MDS indicated Resident 1 had no falls since admission and/or entry of prior assessment. A review of Resident 1's Morse Fall Scale (fall risk assessment), dated 7/26/19 indicated Resident 1 had a high risk for falls with a score of 45 (a score of 45 and higher indicated high risk). A review of a Situation Background Assessment and Recommendation ((SBAR) an internal communication form) and Nurse's Progress Note, dated 8/7/19 and timed at 12:45 p.m., indicated Resident 1 was seen on his buttocks on the floor next to the chair in the dining room. The resident was alert and oriented to person and place and ambulating (walking) without assistance. There were no injuries observed at time of incident. A review of Resident 1's care plan titled, Actual Fall/Poor Balance, initiated 8/7/19 indicated the staff would do the following: -Attempt to determine and address causative factors of the fall. -Monitor for 72-hours, document and report when necessary to physician, change in mental status, confusion, sleepiness, inability to maintain posture, agitation. -Provide activities that promote exercise and strength building where possible or 1:1 activity if bedbound. A review of Resident 1's Morse Fall Scale, dated 8/7/19 remained unchanged from 7/26/19 with the resident having a high risk for falls. A review of Resident 1's Interdisciplinary Team ((IDT) group of disciplines working together towards a common goal for a resident) Assessment Form, dated 8/7/19 indicated the team met regarding Resident 1's fall incident on 8/7/19. The resident was unable to explain how he got on the floor. The contributing factors included poor safety awareness, [MEDICAL CONDITION] medications (any drug capable of affecting the mind, emotions, and behavior) and behaviors of sitting on the floor and patio. The IDT plan indicated to continue to monitor the resident for any changes of condition (COC), provide a clutter/ hazard free environment and ensure proper footwear when ambulating. A review of Resident 1's care plan titled, Risk for Falls related to poor communication/comprehension, psychoactive (a substance that can change the consciousness, mood, and thoughts (mood altering)) drug use and unaware of safety, initiated on 8/15/19 indicated the staff to do the following: -Visually monitor Resident 1 every hour during rounds and document any (COC). - Provide safe environment with even floors that are free from spills and/or -Review information on past falls and attempt to determine cause of falls. -Educate resident/family/caregiver as to causes. -Anticipate and meet the resident's needs. -Provide verbal cuing when walking by hallway. A review of a SBAR and a nurse's progress note, dated 9/25/19 and timed at 8:47 p.m. indicated Resident 1 was at the nursing station when he suddenly started sliding down onto the floor hitting the back of his head on the counter. The resident was conscious (aware of surroundings) with eyes open and responsive. A review of Resident 1's care plan titled, Witnessed Fall with no Injuries, initiated on 9/25/19 indicated the staff would do a 72-hour monitoring and neuro checks (an evaluation of a person's nervous systems mental status consisting of motor examination; sensory examination; coordination; reflexes; and gait and station) and medicate for temperature and/or pain as needed. A review of Resident 1's Morse Fall scale, dated 9/25/19, after the resident had the second fall, remained unchanged and scored as a high risk for falls. A review of Resident 1's IDT assessment form, dated 9/26/19 indicated the resident fell on [DATE] at approximately 8:30 p.m. while at the nurses' station while waiting for his medication. The IDT form indicated the staff would continue to provide redirection/ prompting and assistance to Resident 1 as needed for safety monitoring and whereabouts. A review of Resident 1's SBAR and nurses progress note, dated 9/30/19 and timed at 4:30 p.m. indicated Resident 1 fell (third fall) outside in the patio. The resident was alert and oriented, with no injuries noted. A review of Resident 1's care plan titled, Witnessed Fall with no Injuries, initiated on 9/30/19 indicated the staff would do frequent visual checks and 72- hour monitoring with vital signs. A review of Resident 1's IDT assessment, dated 10/2/19 indicated Resident 1 had another fall incident on 9/30/19 on the patio where the resident was seen falling into a sitting position (fourth fall). The plan included to follow up with laboratory results and report to the physician. A review of Resident 1's care plan titled, Risk for Falls, initiated 8/15/19 with a revised date of 11/8/19 indicated to ensure Resident 1 was wearing appropriate footwear when ambulating and provide a safe environment. A review of Resident 1's quarterly MDS, dated [DATE] indicated Resident 1 had no falls since admission and/or entry of the prior assessment (sic). A review of Resident 1's care plan titled, ADLs (activity of daily living (such as grooming, toileting, eating etc.)) self-care performance deficit related to poor insight and requiring limited to extensive assist with ADLs, initiated 1/30/2020 indicated the following interventions: - Extensive assist by one staff with ADLs including toilet use and transfers. - Requires limited to extensive assist in toileting. - May use wheelchair as needed. - Encourage resident to use bell to call for assistance. A review of Resident 1's nurse's note, dated 2/7/2020 and timed at 12:20 p.m. indicated at 10:52 a.m. that day, Resident 1 had a fall incident in the dining room (fifth fall). The note indicated Resident 1 stood up from his wheelchair and tripped over the right footrest of the wheelchair and fell forward and hit his face on the floor sustaining a cut on the left upper eyelid measuring three (3) centimeters ((cm) unit of measurement) by 0.5 cm. Resident 1 also sustained a skin tear on the bridge of the nose measuring 1 cm by 0.5 cm and a skin tear to the left forearm measuring 1.5 cm by 1 cm. Resident 1 was transferred to a GACH on the same day at 1:50 p.m. A review of the GACH's emergency room (ER) note, dated 2/7/2020 and timed at 5:07 p.m. indicated Resident 1 was seen in the ER with chief complaint of status [REDACTED]. A computed tomography scan ((CT Scan) x-ray device of detailed images of internal organs) of the head was done and was negative for orbital fractures or bleed. The laceration was cleaned and repaired with Dermabond (skin adhesive that is used to glue the sides of an incision or injury closed) and steri-strips (used to close superficial rather than deep incisions). A review of pictures taken of Resident 1 while in the GACH, provided by the resident's Responsible Party (RP), showed Resident 1 had a repaired laceration to the left eyebrow area, with dark purple bruised areas over the bridge of the nose and under each eyes. A review of Resident 1's Morse Fall Scale, dated 2/7/2020 and timed at 2:48 p.m., indicated the resident had fallen before and now had to use ambulatory aids, such as crutches, cane or a walker. Resident 1 had a weak gait and a change in mental status with overestimating or forgetting his limits. The Morse Fall Scale indicated Resident 1 remained a high risk for falls. A review of Resident 1's care plan titled, Actual Fall and sustained cut to the left upper eyelid, skin tear to nose bridge and skin tear to forearm with [DIAGNOSES REDACTED]. - Neuro checks for 72 hours as per protocol. - Encourage resident to call for assistance. - Educate resident regarding safety precaution. - In-service staff regarding proper monitoring of resident for safety. - Transfer resident to acute hospital for evaluation. A review of Resident 1's Physicians Order, dated 2/8/2020 and timed at 3 a.m. indicated to readmit Resident 1 to the facility and resume all previous orders and treatment. A review of a nurse's progress note dated 2/8/2020 timed 3:14 a.m. indicated Resident 1 was readmitted to the facility with a [MEDICAL CONDITION] bone and a laceration of the left eyebrow. Call light placed within reach with frequent visual checks for safety. The note indicated the same day at 10:25 a.m., Resident 1 was awake and alert to name only, non-verbal as baseline status and up in the wheelchair. The vital signs taken and neuro checks done. A review of Resident 1's care plan titled, Resident at risk for falls related to poor communication/comprehension, psychoactive drugs, unaware of safety needs, poor safety awareness, impaired vision, associated medical Diagnoses: [REDACTED]. A review of a SBAR and nurse's progress note, dated 2/8/2020 and timed at 11:50 p.m., indicated Resident 1 had an unwitnessed fall. During the change of shift the resident was found lying on the floor next to the bed. The SBAR indicated Resident 1 being unsupervised made the condition or symptom worse. The resident's mental status changes included new or worsening behavioral symptoms of restlessness and unable to follow directions. The functional status changes compared to the baseline indicated needs more assistance with ADLs for fall prevention. Resident 1 was placed on 1:1 for safety. A review of Resident 1's Medication Administration Record [REDACTED]. A review of Resident 1's care plan titled, Resident at Risk for Falls, revised on 2/9/2020 indicated to provide Resident 1 with a communication board. A review of Resident 1's care plan titled, Fall Incident, dated 2/8/2020 and initiated on 2/9/2020 indicated the staff's interventions included transferring Resident 1 to a room in front of the nurses' station for close monitoring; neuro checks; and monitoring vital signs. A review of Resident 1's Nurse's Progress Note, dated 2/9/2020 and timed at 4:47 a.m. indicated Resident 1 was being monitored after sustaining two falls in two days. The note indicated Resident 1 was received lying in bed unable to verbalize plan for safety. The physician was notified, neuro checks and 1:1 supervision for safety was ordered. A review of Resident 1's nurse's Progress Note, dated 2/9/2020 and timed at 9:22 a.m. indicated Resident 1 was assessed with [REDACTED]. The note indicated the resident was guarding the site and was unable to verbalize pain. The note also indicated there was discoloration of the resident's right hip. An x-ray was ordered for the hip and wrist. The note indicated at 11:53 a.m., on 2/9/2020, Resident 1 was moved to a room closer to the nurse's station. The results of the x-ray of the right wrist and hip results were received on 2/9/2020 at 3:27 p.m. and were both negative for fractures. On 2/21/2020 at 4:38 p.m., during an interview, Resident 1's Responsible Party (RP) stated Resident 1 fell five times while in the facility. The RP stated Resident 1 was non-English speaking and did not talk much. The RP stated Resident 1 had the ability to walk before having so many falls, but after falling many times and twice in one day, the resident now cannot walk anymore and has to use a wheelchair for mobility. On 2/22/2020 at 8:45 a.m., during an interview, the Registered Nurse Supervisor (RN 1) stated Resident 1 had a fall on 2/7/2020 resulting in a nasal fracture and laceration to the left eyebrow. RN 1 stated Resident 1 was transferred to the GACH and returned to the facility on [DATE] and fell again the same day. RN 1 stated Resident 1 had a high risk for falls. On 2/22/2020 at 2:40 p.m., during an interview Certified Nursing Assistant 1 (CNA 1) stated Resident 1 had been walking without any assistance until after his fall on 2/7/2020. CNA 1 stated Resident 1 continued to fall, became weaker and had to use a wheelchair for mobility. CNA 1 stated Resident 1 did not speak English and would only answer yes or no to questions. CNA 1 stated Resident 1 required much assistance with care to prevent falls. A review of the facility's policy and procedure titled, Falls and Fall Risk, revised 4/2018 indicated for the residents identified as high risk for falls, the facility would initiate standard fall prevention protocol, including close monitoring by staff for safety through resident rounding, meeting the residents' toileting needs, adjusting height of bed (low/lowest), use of floor mats on each side of bed if indicated and if possible place in room close to nursing station.

Based on interview and record review, the facility failed to follow its policy and notify the physician of a resident's change of condition which included the abnormal vital signs (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of essential body functions) and oxygen (O2) saturation ((percentage of O2 (sat)) level for one of three sampled residents (Resident 1). Resident 1 had a low blood pressure at ,[DATE] millimeter of mercury (mmHg) (normal reference range (NNR) = ,[DATE] mmHg) and a low O2 sat of 89 percent ((%) NRR= ,[DATE] %). This deficient practice resulted in a delay in [DIAGNOSES REDACTED]. Resident 1 was transferred to the general acute care hospital (GACH), admitted into the hospital, transferred to intensive care unit (ICU), where Resident 1 went into [MEDICAL CONDITION] (a sudden stop in effective and normal blood circulation due to failure of the heart to pump blood), was intubated (the insertion of a breathing tube into the trachea), placed on a mechanical ventilator (artificial ventilation (breathing) used to assist or replace spontaneous breathing) and expired 3 days later. Findings: A review of a GACH's Adult Assessment, dated [DATE] at 8:03 a.m., prior to being admitted to the facility, Resident 1's systems were assessed to be WDL (within define limits) with negative laboratory results for cardiovascular, respiratory, gastrointestinal, [MEDICAL CONDITION] and the skin all with no abnormalities. Resident 1's chest x-ray report, dated [DATE] indicated there was no acute problems prior to the transfer to the facility. A review of Resident 1's Face Sheet (Admission Record) indicated the resident was admitted to the facility on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS), a standardized assessment a care screening tool, dated [DATE], indicated Resident 1's Brief Interview for Mental Status ((BIMS) mental assessment test)) score was 13 (,[DATE]=cognition intact (thought process)). A review of Resident 1's Nursing Admission Screening/History, dated [DATE] and timed at 8:25 p.m., indicated Resident 1 was alert, had normal lung sounds, pulse rate was regular rhythm, bowel sounds present and abdomen soft and non-tender. Resident 1's vital signs, dated [DATE] at 9:10 p.m., were as follow: Temperature 98.2 normal reference range ((NRR) =97XXX,[DATE].5 °F). Pulse 78 (NRR ,[DATE] beats per minute) Respiration 18 bpm ((breathes per minute) NRR= 12 to 20). Blood Pressure ,[DATE] mmHg (NRR=,[DATE] mmHg) O2 saturation 98% on room air (NRR ,[DATE]%) A review of a Nursing Progress Note, dated [DATE] and timed at 7:50 p.m. indicated Resident 1 was having episodes of vomiting (forceful expulsion of the contents of the stomach via the mouth or sometimes the nose), constipation (bowel movements that are infrequent or hard to pass) with abdominal discomfort. According to the note, the nurse called the physician and received an order at 8:10 p.m., on [DATE], for labs to be drawn, abdominal x-ray, medication for nausea/vomiting, and a laxative and fleet's enema for constipation. A Nursing Progress Note, dated [DATE] and timed at 9:39 a.m., indicated Resident 1 was complaining of nausea/vomiting and difficulty breathing with a low blood pressure of ,[DATE] and O2 sat of 89% on room air. The physician was called and Nurse Practitioner 1 (NP 1 (an Advanced Practice Registered Nurse who has additional responsibilities for administering patient care than RN's) called back and was informed of Resident 1's condition and ordered oxygen via nasal cannula ((N/C) plastic tube inserted into the nostrils to deliver oxygen) at ,[DATE] liters per minute for shortness of breath. A review of Resident 1's abdominal x-ray report, dated [DATE] and timed at 2:19 a.m., indicated the following: 1. Gastric distention (occurs when substances, such as air (gas) or fluid, accumulate in the abdomen causing its expansion) 2. Possibility of gastric outlet obstruction (a medical condition where there is an obstruction at the level of the pylorus, which is the outlet of the stomach) is not excluded 3. Follow-up examination was recommended. A review of Resident 1's Nursing Progress Note, dated [DATE] and timed at 8:55 a.m., indicated FM 1 was made aware of Resident 1's condition and FM 1 requested a transfer to the hospital. The progress note indicated NP 1 was notified and called back at 9:15 a.m., on [DATE] and stated, There was no need to transfer the resident right now. A review of Resident 1's Nursing Progress Note, dated [DATE] and timed at 11:40 a.m., the O2 saturation remained low at ,[DATE]% with 2 liters of oxygen infusing via N/C with heavy breathing. A review of Resident 1's nursing progress note, dated [DATE] and timed at 11:52 a.m., indicated NP 1 called back with orders to transfer the resident to the GACH. Resident 1 was transferred by Basic Life Support ambulance at 2:25 p.m. (over two hours later) and not via 911 (immediate transfer) emergency. A review of a physician's telephone order, dated [DATE] and timed at 11:52 a.m., indicated to transfer the resident to the GACH due to persistent nausea and abnormal lab results. A review of the ambulance Patient Care Report, dated [DATE] indicated a call was received for a basic transport at 12:09 p.m., on [DATE] and they arrived to the facility over two hours later, at 2:46 p.m. As documented, upon the BLS arrival, Resident 1 had rapid, labored breathing (an abnormal respiration characterized by evidence of increased effort to breathe) with an O2 saturation of 87%. The resident's primary complaint was documented as abdominal pain with nausea and vomiting for two days. On [DATE] at 2 p.m., during an interview, FM 1 stated Resident 1 was admitted to SNF for rehabilitation for the hip and elbow fracture, but while in the facility the resident was not given adequate care, which included not being bathed regularly, for which she had expressed her concerns to the social worker, staff and NP. FM 1 stated Resident 1 also developed pressure sores on both heels in her short stay. On [DATE] at 4:15 p.m., during a telephone interview, the Registered Nurse Charge Nurse 1 (RN 1) stated he documented the resident' low blood of ,[DATE] and O2 Sat of 89% on the nursing progress notes on [DATE]. RN 1 stated he also called the NP and was told the resident's condition would need to be reported to the charge nurse, but since he was the charge nurse, it was not reported further. On [DATE] at 12:55 p.m., during a telephone interview, NP 1 stated she received a call from the facility's nursing staff on [DATE] with abnormal lab values and an abdominal x-ray report for Resident 1. NP 1 stated she informed the nursing staff that she would discuss with the physician and together they would go to the facility to see the resident. NP 1 stated the nursing staff did not give her the information that the resident was in any distress or had a low blood pressure and had she known she would had transferred the resident sooner. On [DATE] at 12:30 p.m., during an in-person interview and chart review, NP 1 stated she was not aware of the family's request to transfer Resident 1 to the GACH and was not aware of the delay in transport to the GACH when orders were given to transfer. NP 1 stated she thought the nurses called 911, given the resident's condition. A review of the American Heart Association's (AHA) website, on [DATE], indicated Unlike men, women's most common [MEDICAL CONDITION] symptoms were shortness of breath, nausea/vomiting. The AHA indicated calling 911 was almost always the fastest way to get lifesaving treatment. https://www.heart.org/en/health-topics/heart-failure/warning-signs-of-heart-failure A review of GACH emergency department (ED) record, dated [DATE] and timed at 3:18 p.m., indicated Resident 1 presented with shortness of breath, abdominal pain, N/V and ulcers to bilateral feet. Resident 1's Lab results were as follows: 1. Glucose level 175 (NRR=,[DATE]) 2. Blood Urea Nitrogen ((BUN) indicator of kidney function) 89 (NRR=,[DATE]) kidney function 3. Creatinine (indicator of kidney function) 42 (NRR=0XXX,[DATE].5) 4. [MEDICATION NAME] (indicator of liver and kidney function, and malnutrition) 3.0 (NRR=3XXX,[DATE].2) 5. Brain natriurectic peptide ((BNP) indicator of heart function) (NRR=<450) elevation=[MEDICAL CONDITION]/[MEDICAL CONDITION] 6. Troponin 20.300 (NRR=0XXX,[DATE].045) indicative of cardiac failure 7. White blood count (WBC)16.90 (NRR=3XXX,[DATE].60) 8. Hemoglobin (a protein inside red blood cells that carries oxygen from the lungs to tissues and organs in the body and carries carbon [MEDICATION NAME] back to the lungs) 9.4 (NRR=12XXX,[DATE].00) 9. Liver enzymes; [MEDICATION NAME] aminotransferase (AST) 2076 (NRR=,[DATE]) and [MEDICATION NAME] aminotransderase (ALT) 3362 (NRR=,[DATE]) The GACH ED record indicated Resident 1 was admitted to ICU with [DIAGNOSES REDACTED]. A review of GACH's Discharge Summary, dated [DATE] indicated Resident 1 was admitted to GACH on [DATE] and expired on [DATE], after a [MEDICAL CONDITION] (heart stoppage) and multi-organ failure. The resident was made a do not resuscitate ((DNR) withhold of cardiopulmonary resuscitation (CPR/ procedure to revive the heart and lungs) or advanced cardiac life support (ACLS)), and multi-organ failure. A review of Resident 1's Death Certificate indicated the date of death was [DATE] and the cause of death was listed [MEDICAL CONDITION] (life-threatening response to infection, which can lead to tissue damage, organ failure and death) and non-systemic elevation [MEDICAL CONDITION] infarction (MI/[MEDICAL CONDITION]). On [DATE] at 10:15 a.m., during a telephone interview, the DON stated if it was just a normal change in condition the nurse could call BLS, but in this case, the nurse should have called 911 and not even wait to call the physician. The DON stated they should have called him if they were not sure, especially since the resident was a new admit and they were not that familiar with the resident. The DON stated they did not have a policy regarding when to call BLS or 911, but stated when in doubt the nurse should have called 911. A review of the facility's policy and procedure titled, Acute Condition Changes-Clinical Protocol, indicated the staff would report any and all changes of a resident to the physician, which included vital signs, onset, duration and severity of changes, recent labs and pain level.

Based on interview and record review, the facility failed to ensure all the necessary care and services were provided to a resident, which included sending the resident to the hospital after a change in condition via 911 emergency, and not basic life support ambulance, which took over two hours for one of three sampled residents (Resident 1). Resident 1, who had a change in condition for two days with a low blood pressure at ,[DATE] (normal reference range (NNR) = ,[DATE]) and a low oxygen (O2) saturation of 89 percent ((%) NRR= ,[DATE] %) and nausea and vomiting with stomach pain, needed a higher level of care, but was not sent to the general acute care hospital (GACH) timely for two days, and when sent, it was not by 911 (immediate) emergency transport (crossed referenced to F580). This deficient practice resulted in a delay in [DIAGNOSES REDACTED]. Resident 1 was transferred to the GACH, admitted into the hospital, transferred to intensive care unit (ICU), where Resident 1 went into [MEDICAL CONDITION] (a sudden stop in effective and normal blood circulation due to failure of the heart to pump blood), was intubated (the insertion of a breathing tube into the trachea (tube-like portion of the respiratory tract allowing for the passage of air)), placed on a mechanical ventilator (artificial ventilation (breathing) used to assist or replace spontaneous breathing) and expired 3 days later. Findings: A review of Resident 1's Face Sheet (Admission Record) indicated the resident was admitted to the facility on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS), a standardized assessment a care screening tool, dated [DATE], indicated Resident 1's Brief Interview for Mental Status ((BIMS) mental assessment test)) score was 13 (,[DATE]=cognition intact (thought process)). A review of Resident 1's Nursing Admission Screening/History, dated [DATE] and timed at 8:25 p.m., indicated Resident 1 was alert, had normal lung sounds, pulse rate was regular rhythm, bowel sounds present and abdomen soft and non-tender. Resident 1's vital signs were all within normal limits (WNL). A review of a physician's orders [REDACTED]. On [DATE], another .5 NS two liters at 70 ml/hour (2000 ml). On [DATE], the physician ordered another liter (1000 ml) of .5 NS via IV at 70 ml an hour. A total of 4 liters NS was given via IV for dehydration (too much water lost, not enough water taken in). A review of a physician's progress note, 15 days after admission to the facility, dated [DATE] and timed at 1:40 p.m., indicated Resident 1's family member (FM 1) was not happy with the resident's care and requested a transfer to another SNF (skilled nursing facility). A review of a Nursing Progress Note, dated [DATE] and timed at 4:25 p.m., and signed by the facility's social worker indicated FM 1 would email concerns/grievances to her. A review of a Social Worker Note titled, Resident Grievance/Complaint Form, dated [DATE], indicated an attached letter from FM 1 in regards to concerns about Resident 1's care or lack thereof and dietary issues. A review of a Nursing Progress Note, dated [DATE] and timed at 7:50 p.m., indicated Resident 1 was having episodes of vomiting (forceful expulsion of the contents of the stomach via the mouth or sometimes the nose), constipation (bowel movements that are infrequent or hard to pass) with abdominal discomfort. According to the note, the nurse called the physician and received an order at 8:10 p.m., on [DATE], for labs to be drawn, abdominal x-ray, medication for nausea/vomiting, and a laxative and fleet's enema for constipation. A Nursing Progress Note, dated [DATE] and timed at 9:39 a.m., indicated Resident 1 was complaining of nausea/vomiting and difficulty breathing with a low blood pressure of ,[DATE] and O2 sat of 89% on room air. The physician was called and Nurse Practitioner 1 (NP 1 (an Advanced Practice Registered Nurse who has additional responsibilities for administering patient care than RN's) called back and was informed of Resident 1's condition and ordered oxygen via nasal cannula ((N/C) plastic tube inserted into the nostrils to deliver oxygen) at ,[DATE] liters per minute for shortness of breath. A review of Resident 1's abdominal x-ray report, dated [DATE] and timed at 2:19 a.m., indicated the following: 1. Gastric distention (occurs when substances, such as air (gas) or fluid, accumulate in the abdomen causing its expansion) 2. Possibility of gastric outlet obstruction (a medical condition where there is an obstruction at the level of the pylorus, which is the outlet of the stomach) is not excluded 3. Follow-up examination was recommended. A review of a nursing progress note, dated [DATE] and timed at 8:55 a.m., indicated FM 1 was made aware of Resident 1's condition and FM 1 requested a transfer to the hospital. NP 1 was notified and called back at 9:15 a.m., on [DATE] and stated, There was no need to transfer the resident right now. A review of a Nursing Progress Note, dated [DATE] and timed at 11:40 a.m., the O2 saturation remained low at ,[DATE]% with 2 liters of oxygen infusing via N/C with heavy breathing. A review of Resident 1's nursing progress note, dated [DATE] and timed at 11:52 a.m., indicated NP 1 called back with orders to transfer the resident to the GACH. Resident 1 was transferred by Basic Life Support ambulance (transport for patients who do not require extra support or cardiac monitoring) at 2:25 p.m. (over two hours later) and not via 911 emergency. A review of a physician's telephone order, dated [DATE] and timed at 11:52 a.m., indicated to transfer the resident to the GACH due to persistent nausea and abnormal lab results. A review of the ambulance Patient Care Report, dated [DATE], indicated a call was received for a basic transport at 12:09 p.m., on [DATE] and they arrived to the facility over two hours later, at 2:46 p.m. As documented, upon the BLS arrival, Resident 1 had rapid, labored breathing (an abnormal respiration characterized by evidence of increased effort to breathe) with an O2 saturation of 87%. The resident's primary complaint was documented as abdominal pain with nausea and vomiting for two days. On [DATE] at 2 p.m., during an interview, FM 1 stated Resident 1 was admitted to SNF for rehabilitation for the hip and elbow fracture, but while in the facility the resident was not given adequate care, which included not being bathed regularly, for which she had expressed her concerns to the social worker, staff and NP. FM 1 stated Resident 1 also developed pressure sores on both heels in her short stay. On [DATE] at 4:15 p.m., during a telephone interview, Registered Nurse Charge Nurse 1 (RN 1) stated he documented the resident' low blood of ,[DATE] and O2 Sat of 89% on the nursing progress notes on [DATE]. RN 1 stated he also called the NP and was told the resident's condition would need to be reported to the charge nurse, but since he was the charge nurse, he did not report it further. On [DATE] at 12:55 p.m., during a telephone interview, NP 1 stated she received a call from the facility's nursing staff on [DATE] with abnormal lab values and an abdominal x-ray report for Resident 1. NP 1 stated she informed the nursing staff that she would discuss with the physician and together they would go to the facility to see the resident. NP 1 stated the nursing staff did not give her the information that the resident was in any distress or had a low blood pressure and had she known she would had transferred the resident sooner. At 12:30 p.m., on [DATE] at 12:30 p.m., during an in-person interview and chart review, NP 1 stated she was not aware of the family's request to transfer Resident 1 to the GACH and was not aware of the delay in transport to the GACH when orders were given to transfer. NP 1 stated she thought the nurses called 911, given the resident's condition. A review of the American Heart Association's (AHA) website, on [DATE], indicated Unlike men, women's most common [MEDICAL CONDITION] symptoms were shortness of breath, nausea/vomiting. The AHA indicated calling 911 was almost always the fastest way to get lifesaving treatment. https://www.heart.org/en/health-topics/heart-failure/warning-signs-of-heart-failure A review of GACH emergency department (ED) record, dated [DATE] and timed at 3:18 p.m., indicated Resident 1 presented with shortness of breath, abdominal pain, N/V and ulcers to bilateral feet. Resident 1's Lab results were as follows: 1. Glucose level 175 (NRR=,[DATE]) 2. Blood Urea Nitrogen ((BUN) indicator of kidney function) 89 (NRR=,[DATE]) kidney function 3. Creatinine (indicator of kidney function) 42 (NRR=0XXX,[DATE].5) 4. [MEDICATION NAME] (indicator of liver and kidney function, and malnutrition) 3.0 (NRR=3XXX,[DATE].2) 5. Brain natriurectic peptide ((BNP) indicator of heart function) (NRR=<450) elevation=[MEDICAL CONDITION]/[MEDICAL CONDITION] 6. Troponin 20.300 (NRR=0XXX,[DATE].045) indicative of cardiac failure 7. White blood count (WBC)16.90 (NRR=3XXX,[DATE].60) 8. Hemoglobin (a protein inside red blood cells that carries oxygen from the lungs to tissues and organs in the body and carries carbon [MEDICATION NAME] back to the lungs) 9.4 (NRR=12XXX,[DATE].00) 9. Liver enzymes; [MEDICATION NAME] aminotransferase (AST) 2076 (NRR=,[DATE]) and [MEDICATION NAME] aminotransderase (ALT) 3362 (NRR=,[DATE]) The GACH ED record indicated Resident 1 was admitted to ICU with [DIAGNOSES REDACTED]. A review of GACH's Discharge Summary, dated [DATE] indicated Resident 1 was admitted to GACH on [DATE] and expired three days later, on [DATE], after a [MEDICAL CONDITION] (heart stoppage) and multi-organ failure. The resident was made a do not resuscitate ((DNR) withhold of cardiopulmonary resuscitation (CPR/ procedure to revive the heart and lungs) or advanced cardiac life support (ACLS)), and multi-organ failure. A review of Resident 1's Death Certificate indicated the date of death was [DATE] and the cause of death was listed [MEDICAL CONDITION] (life-threatening response to infection, which can lead to tissue damage, organ failure and death) and non-systemic elevation [MEDICAL CONDITION] infarction ((MI) [MEDICAL CONDITION]). On [DATE] at 3 p.m., during a telephone interview, NP 1 stated she had received complaints from Resident 1's family about care concerns and she had discussed the resident's substandard care with the Director of Nurses (DON). On [DATE] at 10:15 a.m., during a telephone interview, the DON stated if it was just a normal change in condition the nurse could call BLS, but in this case, the nurse should have called 911 and not even wait to call the physician. The DON stated they should have called him if they were not sure, especially since the resident was a new admit and they were not that familiar with the resident. The DON stated they did not have a policy regarding when to call BLS or 911, but stated when in doubt the nurse should have called 911. A review of the facility's policy and procedure titled, Acute Condition Changes-Clinical Protocol, revised ,[DATE], indicated the staff would report any and all changes of a resident to the physician, which included vital signs, onset, duration and severity of changes, recent labs and pain level.

Based on observation, interview, and record review, the facility failed to follow its policy regarding elopement (an act or instance of leaving a safe area or safe premises) and provide the necessary supervision, develop and implement a system to keep residents safe that were at high risk for elopement, for 18 (Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, and 18) of 32 sampled residents. Resident 1, who was identified as high risk for elopement, left the facility three times unsupervised, sustaining a laceration (a deep cut or tear in the skin) during the last elopement. These deficient practices resulted in the facility's system failure to identify the residents who were at risk for elopement, Resident 1 had three actual elopements, one with injury on 6/22/18, and Residents 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, and 18 were at risk for harm related to the resident's unsupervised wandering (traveling aimlessly from place to place) and/or elopement behavior(s). On 8/16/18 at 5:35 p.m., a pattern of systemic failure resulted in an Immediate Jeopardy ((IJ) a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident), which was declared under F 689. The facility's Administrator (ADMIN) and Director of Nursing (DON) were verbally notified of the immediacy and seriousness to the resident's health and safety. On 8/16/18 at 6:55 p.m. the facility submitted an acceptable Plan of Action (POA). The IJ was lifted on Saturday, (MONTH) 18, (YEAR) at 12:40 p.m., after the team verified the POA was implemented through observation, interview and record review as follows: A. Place staff by exit doors by Station 1, room [ROOM NUMBER] & Station 3 corridor by room [ROOM NUMBER] (monitoring rear lobby exit and exit door by Station 3 janitor closet). B. Complete Elopement Risk Assessments on Stations 1 and 3 residents. Paper assessment form will be used until assessment was available on Point Click Care ((PCC) the facility's medical software system). C. Follow the facility's elopement policy and procedure (P & P) for all residents identified as At-Risk and High-Risk for elopement. D. Create list of residents identified at risk and high risk for elopement. E. Ensure that all residents At-Risk and High-Risk have physician's orders [REDACTED]. F. Create a list of residents wearing a Wander Guard bracelet. The list will be reviewed and updated at least every Monday or sooner as needed. G. Maintenance Supervisor contracted with a service company to come to the facility on (MONTH) 17, (YEAR) (the next day), to address the volume of the alarm system throughout the nursing stations. H. All staff will be in-serviced on the Elopement P & P and the list of residents At-Risk and High-Risk for elopement. Findings: a. A review of Resident 1's Admission Record indicated the resident was initially admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 1's [DIAGNOSES REDACTED].(a brain disorder that causes unusual shifts in mood, energy, activity levels, and the ability to carry out day-to-day tasks), and anxiety disorder (feelings of fear, dread, and uneasiness that may occur as a reaction to stress). A review of Resident 1's Minimum Data Set (MDS), a resident assessment and care-screening tool, dated 5/31/18, indicated the resident's Brief Interview for Mental Status Score ((BIMS), a brief assessment of mental status used to screen for cognitive impairment) could not be obtained due to Resident 1's AMS. According to Resident 1's MDS, the resident had short and long-term memory problems. The MDS indicated Resident 1 required limited assistance of one-person physical assist to walk in the room, corridor, and locomotion on and off the unit. A review of Resident 1's History and Physical, dated 7/18/18, indicated the resident did not have the capacity to understand and make decisions. A review of an SBAR ((Situation, Background, Appearance, Recommendation), communication between members of the health care team) Communication Form, dated 4/28/18 and timed at 3 p.m., indicated Resident 1 was observed attempting to leave the facility three times unsupervised. The SBAR indicated Resident 1's Primary Care Physician (PCP 1) recommended applying a Wander Guard on Resident 1 to alert the staff of the resident's attempt to leave the facility unsupervised and to monitor the resident's attempt to leave every shift. A review of a care plan titled Episodes of Attempting to Leave Facility Unattended, dated 4/28/18, indicated the facility staff's interventions included to monitor the resident's whereabouts often, identify pattern of wandering, monitor attempts every shift, and to apply a Wander Guard bracelet on the resident to alert staff. A review of Resident 1's Physician Orders, dated 4/28/18 and timed at 2:50 p.m., indicated to apply a Wander Guard bracelet on the resident to alert staff of the attempts to leave the facility unsupervised. The physician's orders [REDACTED]. A review of Resident 1's Medication Administration Record [REDACTED]. A review of Resident 1's Resident Care Conference Review, dated 6/7/18, indicated a summary of the conference indicating that a Wander Guard would be applied to Resident 1 for the resident's attempt to leave the facility. A review of Resident 1's Psychosocial Note, dated 6/14/18, and timed at 4:45 p.m., indicated that Social Service (SS1) was informed Resident 1 left the facility's building without informing anyone. The Psychosocial Note indicated the Nurses saw the resident and followed the resident outside the facility. A review of Resident 1's Health Status Note, dated 6/22/18 and timed at 3:45 p.m., indicated on 6/22/18 at 9 a.m., the resident exited the facility from the front door. The Note indicated Resident 1's Wander Guard alarmed. As Resident 1 stepped a few steps outside. According to the Note, Resident 1 was reported as uncooperative, combative, and striking out. The Note indicated Resident 1 sustained a laceration (deep skin cut) injury to his left wrist that measured 0.5 centimeters (cm) in length and 1.5 cm in width, during the staff's attempt to return Resident 1 back inside of the facility. The Note indicated Resident 1 was transferred to a local hospital for medical evaluation and treatment of [REDACTED]. A review of Resident 1's Wandering Risk Scale, dated 7/6/18 and timed at 12:57 p.m., indicated Resident 1 was assessed as a high risk to wander, with a score of 13 (a score of 11 and above indicated the a high risk to wander). According to the Wandering Risk Scale, Resident 1 had a history of [REDACTED]. A review of Resident 1's Care Plan titled, Resident at High Risk for Wandering, date initiated 7/6/18, indicated the facility staff's intervention included to monitor the resident's location as often as possible; keep the environment safe and free from all hazards; inform direct caretakers of the resident's tendencies to wander; check the resident's identification (ID) band and Wander Guard bracelet and replace the bracelet accordingly. b. A review of Resident 2's Admission Record indicated the resident was admitted to the facility on [DATE]. Resident 2's [DIAGNOSES REDACTED]. activities) and dementia (a group of thinking and social symptoms that interferes with daily functioning). A review of Resident 2's MDS, dated [DATE], indicated the resident was not able to report the correct year, month, and day of the week. According to the MDS, Resident 2 required extensive assistance of a one-person physical assist with locomotion off the unit and with toilet use. A review of Resident 2's care plan titled, At High Risk for Elopement Related to Two or More Behaviors (Resident States Desire to go Home and Wanders Aimlessly), and Impaired Safety Awareness, date initiated 1/3/18, indicated staff's interventions to apply a Wander Guard to the resident's wrist for safety precaution to prevent the resident from elopement. A review of Resident 2's Order Summary Report, for 8/2018, indicated a physician's orders [REDACTED]. A review of Resident 2's Wandering Risk Scale, dated 7/3/18 and timed at 7:44 a.m., indicated Resident 2 was assessed at risk to wander, with a score of 10 (a score of nine to 10 indicated at risk to wander). c. A review of Resident 3's Admission Record indicated Resident 3 was admitted to the facility on [DATE]. Resident 3's [DIAGNOSES REDACTED]. A review of Resident 3's MDS, dated [DATE], indicated the resident was unable to report the correct year and month. d. A review of Resident 4's Admission Record, indicated Resident 4 was admitted to the facility on [DATE]. Resident 4's [DIAGNOSES REDACTED]. A review of Resident 4's MDS, dated [DATE], indicated the resident was unable to report the correct year, month, and day of the week. The MDS indicated Resident 4 was unable to recall three of three words repeated to the resident. e. A review of Resident 5's Admission Record indicated the resident was admitted to the facility on [DATE]. Resident 5's [DIAGNOSES REDACTED]. A review of Resident 5's History and Physical record, dated 8/10/18, indicated the resident had fluctuating capacity to understand, make decisions, and was high risk for wandering and elopement. f. A review of Resident 6's Admission Record indicated Resident 6 was admitted to the facility on [DATE]. Resident 6's [DIAGNOSES REDACTED]. A review of Resident 6's MDS, dated [DATE], indicated Resident 6 was unable to report the correct year, month, and day of the week. g. A review of Resident 7's Admission Record indicated the resident was initially admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 7's [DIAGNOSES REDACTED]. A review of Resident 7's MDS, dated [DATE], indicated Resident 7 was unable to report the correct year, month, and day of the week. The MDS indicated Resident 7 was unable to recall three of three words repeated to the resident. A review of Resident 7's Wandering Risk Scale, dated 8/9/18 and timed at 12:10 p.m., indicated Resident 7 was assessed as a high risk to wander, with a score of 13. h. A review of Resident 8's Admission Record indicated the resident was admitted to the facility on [DATE]. Resident 8's [DIAGNOSES REDACTED]. A review of Resident 8's MDS, dated [DATE], indicated Resident 8 was unable to report the correct year, month, and day of the week. A review of Resident 8's Wandering Risk Scale, dated 7/3/18 and timed at 7:57 a.m., indicated Resident 8 was assessed as a high risk to wander, with a score of 13. According to the Wandering Risk Scale, Resident 8 had a history of [REDACTED]. A review of Resident 8's Health Status Note, dated 7/21/18 and timed at 8:14 a.m., indicated the resident had episodes of confusion and forgetfulness at times. A review of Resident 8's Health Status Note, dated 7/25/18 and timed at 8:10 p.m., indicated the resident was confused and aggressive toward staff. The Note indicated Resident 8 was noted anxious, attempting to strike staff, removing clothes, and constant scooting herself up and down the halls in a wheelchair. i. A review of Resident 9's Admission Record indicated the resident was admitted to the facility on [DATE]. Resident 9's [DIAGNOSES REDACTED]. A review of Resident 9's MDS, dated [DATE], indicated Resident 8 was unable to report the correct year, month, and day of the week. The MDS indicated Resident 9 was unable to recall three of three words repeated to the resident. A review of Resident 9's Wandering Risk Scale, dated 6/14/18 and timed at 7:32 a.m., indicated Resident 9 was assessed as a high risk to wander, with a score of 13. j. A review of Resident 10's Admission Record indicated the resident was originally admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 10's [DIAGNOSES REDACTED]., and a history of falling. A review of Resident 10's MDS, dated [DATE], indicated the resident's BIMS Score could not be obtained due to Resident 10's altered mental status. A review of Resident 10's Wandering Risk Scale, dated 6/15/18 and timed at 7:47 a.m., indicated Resident 10 was assessed as a high risk to wander, with a score of 13. k. A review of Resident 11's Admission Record indicated the resident was admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 11's [DIAGNOSES REDACTED]. A review of Resident 11's MDS, dated [DATE], indicated the resident was unable to report the correct year and month. The MDS indicated Resident 11 exhibited disorganized thinking and inattention. A review of Resident 11's Wandering Risk Scale, dated 8/3/18 and timed at 8:09 a.m., indicated Resident 11 was assessed as a high risk to wander, with a score of 12. According to the Wandering Risk Scale, Resident 11 had a history of [REDACTED]. l. A review of Resident 12's Admission Record indicated the resident was admitted to the facility on [DATE]. Resident 12's [DIAGNOSES REDACTED]. A review of Resident 12's MDS, dated [DATE], indicated the resident was unable to report the correct year, month and day of the week. The MDS indicated Resident 12 was unable to recall three of three words repeated to the resident. A review of Resident 12's Wandering Risk Scale, dated 6/5/18 and timed at 12:54 p.m., indicated Resident 12 was assessed as a high risk to wander, with a score of 12. m. A review of Resident 13's Admission Record indicated the resident was originally admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 13's [DIAGNOSES REDACTED]. A review of Resident 13's MDS, dated [DATE], indicated the resident was able to report the correct year, month and day of the week. A review of Resident 13's Wandering Risk Scale, dated 6/28/18 and timed at 1:18 p.m., indicated Resident 13 was assessed at risk to wander, with a score of 10. n. A review of Resident 14's Admission Record indicated the resident was originally admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 14's [DIAGNOSES REDACTED]. A review of Resident 14's MDS, dated [DATE], indicated the resident was unable to report the correct month and day of the week. The MDS indicated Resident 14 was unable to recall three of three words repeated to the resident. A review of Resident 14's Wandering Risk Scale, dated 8/6/18 and timed at 12:12 p.m., indicated Resident 14 was assessed as a high risk to wander, with a score of 12. According to the Wandering Risk Scale, Resident 14 had a history of [REDACTED]. o. A review of Resident 15's Admission Record indicated the resident was admitted to the facility on [DATE]. Resident 15's [DIAGNOSES REDACTED]. A review of Resident 15's MDS, dated [DATE], indicated the resident was able to report the correct month and day of the week. According to the MDS, Resident 15 required limited assistance of a one-person physical assist to walk in the corridor, and locomotion on and off the unit. A review of Resident 15's Wandering Risk Scale, dated 8/1/18 and timed at 11:44 a.m., indicated Resident 15 was assessed as at risk to wander, with a score of 10. p. A review of Resident 16's Admission Record indicated the resident was originally admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 16's [DIAGNOSES REDACTED]. A review of Resident 16's MDS, dated [DATE], indicated the resident was unable to report the correct year, month and day of the week. According to the MDS, Resident 16 was unable to recall three of three words repeated to the resident. A review of Resident 16's Wandering Risk Scale, dated 6/8/18 and timed at 12:05 p.m., indicated Resident 16 was assessed at risk to wander, with a score of 9. q. A review of Resident 17's Admission Record indicated the resident was originally admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 17's [DIAGNOSES REDACTED]. A review of Resident 17's MDS, dated [DATE], indicated the resident was unable to report the correct year, month and day of the week. According to the MDS, Resident 17 was unable to recall three of three words repeated to the resident. A review of Resident 17's Wandering Risk Scale, dated 6/20/18 and timed at 11:10 a.m., indicated Resident 17 was assessed at high risk to wander, with a score of 12. r. A review of Resident 18's Admission Record indicated the resident was originally admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 17's [DIAGNOSES REDACTED]. Resident 18's medical [DIAGNOSES REDACTED]. A review of Resident 18's MDS, dated [DATE], indicated the resident's BIMS could not be obtained due to Resident 18's altered mental status. A review of Resident 18's Wandering Risk Scale, dated 8/7/18 and timed at 9:52 a.m., indicated Resident 18 was assessed as at high risk to wander, with a score of 13. On 8/16/2018 at 12:05 p.m., during an observation and staff interview, Licensed Vocational Nurse LVN2 confirmed that Resident 1 did not have on a Wander Guard bracelet. LVN2 stated she was unsure if Resident 1 should have on a Wander Guard device or not, but stated Resident 1 was a risk for wandering and eloping from the facility based on his history of wandering and elopement. On 8/16/2018 at 1:47 p.m., during an observation on Station 1, LVN1 reported that if a resident attempted to elope from the facility, a door alarm would sound off at the nurses' station. LVN1 reported that the alarm would alert staff to take action such as prevent the resident from physically leaving the facility unsupervised and unauthorized. LVN1 stated that in case a resident left the facility already, then the staff would assist in the recovery and return of the resident safely back into the facility. LVN1 stated that if the resident safely recovers and returns inside of the facility, the resident would be physically examined and then the family, physician, and other facility's staff would be notified of the resident's attempt or actual elopement from the facility. LVN1 stated that it was dangerous for any resident to elope from the facility because the resident was at risk for injury or serious harm such as death, especially if they were unsupervised and had impaired cognitive condition(s) such as dementia. LVN1 stated that there was no system in place for readily identifying the residents on Stations 1 and 3 who were At-Risk or High- Risk for elopement or wandering. LVN1 stated that it would be helpful to have a system in place to help communicate among the Interdisciplinary Team ((IDT), a group of health care specialists such as Social Service, Activities, Psychiatry, Physical Therapy .) which residents were at risk for elopement and what actions should be implemented to maintain the resident's safety and elopement risk reduction. LVN1 confirmed that the doors on Station 1 were unlocked but had door alarms. LVN1 reported that when the alarm sounds off at the nurses' station, the staff members should respond by going to the door indicated and look for the resident trying to leave the facility unsupervised. On 8/16/2018 at 1:55 p.m., during an observation, interview and concurrent record review, the Registered Nurse (RN1) stated, I can make a list . of residents who have been assessed as either High Risk for wandering or elopement. After five minutes of attempting to create a list of residents who have been identified (assessed) as High-Risk for elopement, RN1 reported that she had never generated a list from PCC. RN1 and LVN1 both confirmed that there was no hardcopy or electronic system in place that identified which residents were either At-Risk or High-Risk for wandering or elopement, communicated the risk to the IDT, and consistently and comprehensively care planned for each identified resident's safety and need for supervision. RN1 and LVN1 verified there was no communication tool used to communicate the safety needs of at risk residents from shift to shift. LVN1 also confirmed that Resident 1 and the randomly sampled residents who had been assessed as At-Risk or High-Risk for wandering did or did not have consistent or effective care planning inclusive of IDT participation, care plan revision, obtaining or following physician's orders [REDACTED]. LVN1 stated that without a system in place that effectively and consistently identifies which residents were at risk for wandering or elopement, then the staff could not ensure that they met the resident's needs for safety and supervision. RN 1 and LVN 1 both agreed that there should have been a system in place that identified, coordinated, and communicated the level of safety and specific supervisory needs of At-Risk or High-Risk residents on Stations 1 and 3. LVN1 agreed that unidentified residents were still at risk since the staff could not identify whom they were and what care should be provided to keep At-Risk or High-Risk residents safe and free from elopement and subsequent harm. On 8/16/2018 at 12:49 p.m., during an observation tour on Station 3, the Maintenance Supervisor (MS1) set off the unit's door alarm (for testing purposes). The alarm was inaudible to RN2 who was providing direct resident care inside of Resident 13's room. RN2 confirmed that she did not hear and therefore did not respond to the door alarm, but instead continued to work with Resident 13. RN2 stated that if she had heard the door alarm she would have responded to it. MS1 stated that he was unaware that staff could not hear the alarm while providing resident care away from the nurses' station. MS1 stated he would consult with the facility's contractor regarding the audibility of the door alarm. On 8/16/18 at 1:30 p.m., during an interview, LVN4 stated she was unsure if Resident 2 had a Wander Guard bracelet on, but should, have a Wander Guard bracelet if there was a physician's orders [REDACTED].>On 8/16/18 at 1:35 p.m., during an observation and interview, LVN4 stated Resident 2 did not have a Wander Guard bracelet on. LVN4 stated the resident had the ability remove the Wander Guard bracelet. LVN4 stated if the resident had a Wander Guard bracelet, staff should be monitoring for proper placement and documented on the nursing progress notes. At 2:35 p.m., on 8/16/2018., during an interview, and a concurrent record review with the Director of Staffing Development (DSD), stated that she was responsible for staff training and ongoing development. The DSD confirmed that she was also responsible for orientation of new hired staff and provided staff in-services once per week. The DSD stated that the facility had a P & P in place for Elopement but the staff did not implement the elopement protocol on 4/28/18, 6/14/18 or 6/22/18, during the times that Resident 1 eloped from the facility. The DSD stated that the staff should have called a code green to signal other staff of the elopement, in addition to the door alarm or Wander Guard alarm. The DSD also confirmed that there was no system in place for readily identifying which residents on Stations 1 and 3 were At Risk or High Risk for Elopement or Wandering. The DSD stated that it would be best if the staff were trained and demonstrated knowledge of their training on the facility's P & P related elopement. The DSD stated that having an effective system in place for elopement reduction or prevention could help staff reduce the facility's elopements, such as Resident 1's elopement. The DSD verified there was no communication tool that staff used to communicate the safety needs of these at risk residents from shift to shift. At 3:58 p.m., on 8/16/18, during an interview and concurrent record review, RN3 stated on 6/22/18, she heard the sound of the Wander Guard alarm. RN3 stated Resident 1 left the facility through exiting the back door of Nursing Station 3 that led to the facility's back parking lot (for which there was a railroad track behind the parking lot). RN3 stated she could not recall whom the staff members that were present in Nursing Station 3 during the incident. On 8/16/18 at 4:32 p.m., during an interview, LVN 2 stated she was not aware Resident 1 eloped on 4/28/18 and 6/14/18. LVN2 stated Resident 1 had a history of [REDACTED]. LVN2 stated on 6/22/18, Resident 1 was upset and restless, passed through Nursing Station 3 and left the facility through the double doors of Nursing Station 3 and reached the facility's outdoor parking lot. LVN2 stated Resident 1 was found and became combative to staff. On 8/16/18 at 4:52 p.m., during an observation and interview, LVN5 stated Resident 1 did not have a Wander Guard bracelet on. LVN5 stated she was not aware if Resident 1 had a physician's orders [REDACTED]. At 4 p.m. on 8/17/18, during an interview and concurrent record review, the Director of Nurses (DON) stated he was not aware Resident 1 eloped from the facility on 4/28/18, but was aware of the resident's elopement on 6/14/18 and 6/22/18. The DON stated on 6/14/18 and 6/22/18, Resident 1 left the facility and was brought back into the facility by staff members. The DON stated that Resident 1 sustained a laceration to the left wrist after eloping from the facility on 6/22/18 and was unsure if the injury was a result of the resident's combativeness toward the staff. On 8/17/18 at 4:26 p.m., during an interview and concurrent record review, the Social Service Worker (SS1) stated on 6/14/18, he observed a nurse running out of the facility's back door at Nursing Station 3, because Resident 1 had walked out of the facility. SS1 stated prior to the incident, Resident 1 was observed sitting in Nursing Station 3's lobby area. SS1 stated when Resident 1 was returned back to the facility, the resident verbalized that he wanted to go outside of the facility. SS1 stated he could not recall if Resident 1 was wearing a Wander Guard bracelet at the time of the incident on 6/14/18. SS1 stated that eight days later, on 6/22/18, he heard the Wander Guard alarm because Resident 1 eloped a second time from Nursing Station 3's exit double doors. SS1 stated Resident 1 reached the facility's back parking lot and to the side of the facility's building and was brought back inside by staff. At 10:50 a.m. on 8/27/18, during a telephone interview, the Certified Nursing Assistant (CNA1) stated Resident 1 walked out of the facility, but she could not recall the date of incident and stated she did not hear the resident's Wander Guard bracelet alarm. On 8/27/2018 at 11:40 a.m., during a telephone interview and review of the facility's P & P titled, Elopement of Patient dated 6/1/96 and last revised on 5/15/2014, which showed the following: Elopement occurs when a patient leaves the premises without authorization (i.e. order for discharge or LOA) and/or any necessary supervision to do so . The P & P also showed the following: For patients identified as at risk, an interdisciplinary elopement prevention care plan will be developed with family and patient participation .Individual risk factors and patterns will be identified and addressed within the care plan . The DON confirmed that that the facility had not been conducting elopement risk assessments, care planning, or elopement drills either electronic or in non-electronic format in accordance with the facility's P & P. A review of the facility's untitled P & P titled, Wandering, Unsafe Resident, indicated the resident's care plan would indicate the resident is at risk for elopement or other safety issues and interventions to try to maintain safety, such as a detailed monitoring plan. The P & P indicated when the resident returns to the facility, the DON or Charge Nurse should examine the resident for injuries; contact the Attending Physician and report findings and conditions of the resident; complete and file an incident report; and document relevant information in the resident's medical record.

Based on observation, interviews, and record review, the facility failed to follow its policy and procedures and the physician's orders to provide the necessary care and services consistent with professional standards for residents who have arteriovenous shunt ((AV shunts) connection between a vein and an artery) for one of seven residents (Resident 1). The facility's licensed nursing staff were not knowledgeable in how to assess AV shunts. Resident 1, who had an AV shunt and was receiving [MEDICAL TREATMENT] treatments (a method of removing toxic substances from the blood when the kidneys are unable to do so), was not being properly assessed by the nurses. This deficient practice resulted in Resident 1's AV shunt becoming clogged and the resident not being dialyzed, requiring a transfer to a general acute care hospital (GACH). Resident 1 was diagnosed with [REDACTED]. The facility had a total of seven residents who resided in the facility with AV shunts receiving [MEDICAL TREATMENT] which had the potential for complications related to improper assessments of the AV shunts. Findings: A review of Resident 1's Face Sheet (Record of Admission) indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS), a care screening and assessment tool, dated 3/3/17, indicated Resident 1 was able to report the correct year, month, and day of the week. The MDS indicated a brief interview for mental status (BIMS) score of 14 (13-15 means cognition intact), which indicated that Resident 1 had no problems remembering or cognition (thought process). A review of the physician's order summary report, dated 9/1/17 and order date of 1/7/17, indicated for the staff to check Resident 1's AV shunt on the left arm for bruit (turbulent sound heard with the use of a stethoscope (a medical instrument for listening to body sounds) placed over the AV shunt due to abnormal flow of blood in an artery due to partial obstruction (listening for changes)), and thrill (vibration palpated (touched) on the AV access site, which indicate adequate blood flow) every shift. A review of Resident 1's care plan titled, [MEDICAL TREATMENT] related to [MEDICAL CONDITION], dated 8/29/17, indicated Resident 1 would not have any signs and symptoms of complications from the [MEDICAL TREATMENT] through the review date of 11/27/17. The staff's interventions did not indicate to check the AV shunt for bruit and thrill, as per the physician's order. A review of Resident 1's Treatment Assessment Record Sheet (TAR), dated 8/29/17 through 8/31/17, indicated Resident 1's AV shunt was not assessed for the bruit and thrill during on the night shift, per physician's orders every shift. A review of Resident 2's Admission Face sheet indicated the resident was admitted on [DATE] and last readmitted on [DATE]. Resident 2's [DIAGNOSES REDACTED]. A review of Resident 2's 9/2017 Treatment Administration Record (TAR), with an initial order date of 12/19/15, indicated to monitor the bruit and thrill of the AV shunt every shift. Resident 2's quarterly MDS, dated [DATE], indicated the resident's BIMS score was 14 and had no memory problems. On 9/21/17 at 7:43 a.m., during an interview, Resident 2, who had an AV shunt, stated that the nurses' do not check her AV shunt every day. Resident 2 stated that not all the nurses checked her AV shunt. On 9/21/17 at 10:10 a.m., during a concurrent interview and record review, Licensed Vocational Nurse (LVN 2) stated that [MEDICAL TREATMENT] shunts' are assessed daily every shift for the bruit by touching the residents' skin and the thrill by listening with a stethoscope (sic). LVN 2 stated resident's shunts are assessed to check for patency and then documented on the residents' TARs. A review of an online article titled, Arteriovenous (AV) Fistula-the gold standard [MEDICAL TREATMENT] Access, indicated National Kidney Foundation (NKF), Centers for Medicare and Medicaid Services (CMS), and other organizations and experts agree fistulas are the best access for [MEDICAL TREATMENT] treatment. The article indicated the vibration going through the arm was called the 'thrill' and it should be checked several times a day-assessing for clots (if the physician was notified timely the clot could be quickly dissolved). The Bruit can be heard by the sound of blood flowing through the access-if the sound gains in pitch and sounds like a [MEDICATION NAME], it could an indication the blood vessels are tightening (narrowing). http;//www.davita.com/kidney-disease/[MEDICAL TREATMENT]/treatment/arteriovenous-av-fistula-%259 A review of a Licensed Progress Note, dated 9/1/17, and timed at 11:29 a.m., indicated Resident 1 was not dialyzed that day due to the AV shunt access being clotted. The note indicated the nephrologist (a physician who specialized in the care and treatment of [REDACTED]. A review of facility's transfer sheet, dated 9/1/17, indicated Resident 1 was not dialyzed due to the AV access site being clotted. A review of Resident 1's GACH post-operational final report, dated 9/5/17, indicated the resident had a temporary Jugular [MEDICAL TREATMENT] catheter placed on 9/3/17. At 10:05 a.m., on 9/21/17, during an interview and a concurrent observation, LVN 1 stated and demonstrated that bruit is assessed by touching the residents' skin and the thrill was assessed by using a stethoscope to hear if the pulse (heart sounds) was weak or strong (sic). On 9/21/17 at 10:19 a.m., during an interview, LVN 3 was asked how she assessed the residents' AV Shunts, and was not able to state and/or demonstrate how the AV shunt was assessed for patency. LVN 3 stated, I touch the shunt to see if it's intact and in place; and for the thrill, I just look at it to make sure it's not bleeding (sic). On 9/21/17 at 1:20 p.m., during an interview, the facility's Director of Staff Development (DSD), whose job entailed that she train all the licensed nurses, was not able to verbalize how to assess an AV shunt for the bruit and thrill. The DSD stated, I need to go check for the right form for an assessment. On 9/21/17 at 1:27 p.m., during an interview, the Director of Nursing (DON) stated that all the nurses should know how to assess a [MEDICAL TREATMENT] shunt to check for patency. A review of the facility's policy and procedure titled, [MEDICAL TREATMENT], dated 3/2017, indicated the facility staff would check for bruit sounds. The policy did not indicate how to check for thrill. A review of the facility's policy and procedure titled, [MEDICAL CONDITION], Care of a Resident with [MEDICAL CONDITION], dated 9/2010, indicated the facility staff would be able to recognize and care of grafts and fistulas.

Based on observation, interview, and record review, the facility's staff failed to follow physician's orders for one of 29 sampled residents (Resident 10). Resident 10, who had a high risk for pressure sores development, had an order and a plan of care for pressure relieving devices in the wheelchair and bed that was not implemented (cross referenced to F279 b2). This deficient practice resulted in the physician's orders and the resident's plan of care not being followed and put Resident 10 at risk for the development of pressures sores. Findings: On 12/14/16 at 8:35 a.m., Resident 10 was observed asleep in the bed. There was no evidence that the mattress was a pressure relieving device. A review of Resident 10's Admission Face sheet indicated Resident 10 was initally admitted to the facility on [DATE] and most recently readmitted on [DATE]. Resident 10's [DIAGNOSES REDACTED]. A review of Resident 10's Minimum Data Set (MDS), an assessment and care screening tool, dated 11/30/16, indicated Resident 10 usually had the ability to be understood and understands others. According to the MDS, Resident 10 required an extensive assistance in bed mobility, transferring, dressing, and bathing and was totally dependent in eating, toilet use, and locomotion on and off the unit. A review of Resident 10's [MEDICATION NAME] and protein level laboratory results, dated 12/12/16, indicated the levels were low. The [MEDICATION NAME] level was 3.2 (normal reference range (NRR) was 3.7-5.3) and the protein level was low as well at 5.5 (NRR=6.0-8.3). According to the National Pressure Ulcer Advisor Panel (NPUAP), low protein and [MEDICATION NAME] level (indication of poor nutrition) puts residents at risk for development of pressure ulcers. On 12/15/16 at 7:45 a.m., Resident 10 was lying in bed awake waving (Spanish speaking) in an upright position. One floor mat was observed on the left side of the bed on the floor. The side rails were not padded, as per the plan of care and the physician's order. On 12/15/16 at 8:32 a.m., during an interview, a licensed vocational nurse (LVN 8), while at Resident 10's bedside, stated the resident's side rails should be padded as well as the floor mats on both side of the bed. LVN 8 stated the resident was lying on a regular mattress and not a pressure relieving mattress. A review of Resident 10's care plan, dated 8/25/16, and titled, Risk for Development of Pressure Ulcer, as evidenced of a high Braden scale (predictor of pressure sore development), urinary and bowel incontinence, and requiring total assistance with bed mobility. The staff's approach included to place a pressure relieving device on the bed and wheelchair. At 3:35 p.m., on 12/15/16, during a concurrent interview and observation, a registered physical therapist (RPT), stated the cushion in Resident 10's wheelchair after feeling the cushion and stated it was not a pressure relieving cushion, but a regular cushion. A review of Resident 10's Braden Scale, dated 8/25/16 and 11/30/16, indicated Resident 10 had a total score of 12. According to the Braden Scale, a total score of 12 or less represents a high risk for pressure sore development. On 12/16/16 at 8:06 a.m., during an interview, the treatment nurse (a licensed vocational nurse (LVN5)) stated, after reviewing Resident 10's plan of care, Resident 10 was lying on a regular mattress, not a pressure relieving one. LVN 5 stated the MDS nurse was the one who created the care plan for the need of a pressure relieving device on the bed and in the resident's chair. LVN 5 stated he would call the physician and follow-up to get Resident 10 a pressure relieving mattress. A review of the facility's policy titled, Prevention of Pressure Ulcers, indicated the purpose of the policy was to provide information regarding identification of pressure ulcer risk factors and intervention for each specific risk factors.