Every finding on record at Dreier's Nursing Care Center

Based on observation and interview, the facility failed to store, prepare, distribute and serve food for 47 sampled residents in accordance with professional standards and the facility's policy and procedures for food service safety by ensuring the facility were properly labeled and dated with the product name, date product was opened or prepared and to be use by date for the following: 1. 17 cups of milk that were not labeled and dated 2. 30 cups of juice (including red and yellow-colored juices) not labeled and dated As a result of these deficient practices exposed residents to the risk of widespread foodborne illness (infections caused by consuming contaminated food, beverages, or water containing harmful microbes, pathogens [disease causing organism] or toxins). Findings: During an initial kitchen observation conducted with the Dietary Supervisor (DS) on 7/14/2026 at 9:10 AM, Refrigerator #1 revealed multiple cups of milk and juice stored on pink meal trays without resident identifiers, preparation dates, or discard dates. There were approximately 17 cups of milk, and 30 cups of juice (including red and yellow-colored juices) covered with plastic wrap or lids; however, none were labeled to identify the date and time the beverages were prepared. During an interview on 7/14/2026 at 9:12 AM with the DS, DS stated that without appropriate labeling and dating, dietary staff were unable to verify the age of the beverages or ensure they were discarded within safe food storage timeframes. The DS stated that they did not ensure properly label and dated resident beverages which would increase the risk of residents being served expired or contaminated food items, compromising food safety and infection prevention practices. During a review of the facility P&P titled Food Receiving and Storage revised 11/2022, indicated that all foods stored in the refrigerator or freezer are covered, labeled and dated (use by'' date). The P&P indicated refrigerated foods are labeled, dated and monitored so they are used by their use-by date, frozen, or discarded.

Based on interview and record reviews, the facility failed to ensure the prescribers obtained informed consent (communication process where a healthcare provider explains the risks, benefits, and alternatives of a treatment so a resident can choose whether to agree) from the resident or the resident's representative before administering psychotropic medications (medications that affects mood and behavior) for two of the five sampled residents (Residents 3 and 5) in accordance with the facility's policy and procedures titled Informed Consent. This deficient practice had the potential for Resident 3 and 5 to receive psychotropic medications without proper consent, which could result in unwanted treatment and violation of resident rights. Furthermore, this exposed residents to psychotropic medications without being fully informed of risks, benefits, and side effects, which may increase the likelihood of unrecognized or unmanaged adverse drug reactions. Findings: 1. During a review of Resident 5's admission Record (AR), the AR indicated the resident was admitted to the facility on [DATE], with diagnoses that included Parkinson's disease without dyskinesia (a disorder of the nervous system that affects movement), schizophrenia (a mental illness that was characterized by disturbances in though). During a review of Resident 5's History and Physical (H&P) dated 10/24/2025, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 5's Physician's Order dated 7/16/2026, the order indicated to administer one tablet of Ativan 0.5 mg (a unit of measurement), by mouth every 8 hours as needed [PRN] for Anxiety manifested by inability to calm down for 14 days with a start date of 7/09/2026. During a review of Resident 5's Psychotherapeutic Drug Informed Consent form for Ativan 0.5 mg every 8 hours as needed for 14 days, orally for anxiety disorder, the form was reviewed with the prescriber's name written on it, dated 7/08/2026. However, the prescriber's required signature section was blank. During a review of Resident 5's progress notes dated 7/09/2026 authored by Licensed Vocational Nurse (LVN) 4, the note indicated writer spoke to Resident 5's Responsible Party (RP), verbal consent obtained for Resident 5's Ativan 0.5 mg every 8 hours continuation for 14 days. The Psychotherapeutic Drug Informed Consent form for Ativan 0.5 mg was completed and signed by LVN 4 and witnessed by the Registered Nurse Supervisor. During a telephone interview on 7/16/2026 at 12:28 PM with Resident 5's Responsible Party (RP 1), RP 1 stated she remember receiving a call from a facility nurse asking for consent for Ativan 0.5 mg medication for [Resident 5]. RP 1 stated she always gets phone calls from the facility nurses for medication informed consents. RP 1 stated she had never spoken to a facility provider [prescribing physician] for consents she only receives calls from the nurses. During a concurrent interview and record review of Resident 5's Psychotherapeutic Drug Informed Consent for Ativan 0.5 mg with the Director of Nursing (DON), the DON stated that per facility policy, the prescribing physician must sign and date psychotropic medication consents immediately upon obtaining consent from the resident or resident representative. The DON stated the consent should be obtained by the prescribing physician and not the facility nurses. 2. During a review of Resident 3's admission record, the record indicated the facility initially admitted Resident 3 on 1/30/2026 and re-admitted on [DATE]. with diagnoses that included encephalopathy (a group of conditions that cause brain dysfunction, with symptoms such as altered mental state ranging from mild confusion to coma), hemiplegia (severe or complete paralysis of one entire side of the body, usually caused by damage to the brain or spinal cord resulting from a stroke, traumatic brain injury, or other causes) and hemiparesis (partial weakness or reduced control on one side of the body) following cerebral infarction (a type of ischemic stroke that occurs when a blocked blood vessel deprives brain tissue of oxygen and vital nutrients, causing cell death), aphasia (a neurological language disorder caused by damage to the brain's language centers (most commonly after a stroke or head injury) which impairs a person's ability to comprehend, speak, read, or write, with symptoms including trouble with expressing oneself). During a review of Resident 3's informed consent forms, Resident 3 had two such forms for lorazepam (a psychotropic medication that is used to treat anxiety), dated 6/18/2026 and 7/9/2026. Both forms were missing the prescriber's signatures indicating the prescriber did not obtain an informed consent from the resident or the responsible party. During a concurrent interview on 7/16/2026 at 10:41 AM, the director of nursing (DON) stated the prescriber for Resident 3's lorazepam was the psychiatric nurse practitioner (NP 1). DON stated the informed consent forms for Resident 3 indicated a facility nurse obtained consent from the responsible party. During an interview on 7/16/2026 at 12:09 PM, the registered nurse (RN 1) stated the process of informed consent was that facility nurses obtained the consent from the residents or responsible parties (RP). RN 1 stated nurse provide information on psychotropics to the residents or RP. If the doctor (or prescriber) had obtained consent from the resident/RP, the doctor would let the nurses know and document it in the progress note. During an interview on 7/16/2026 at 12:22 PM, and a concurrent review of Resident 3's Nurses' Notes (dated 7/9/2026 at 8:08 AM), RN 1 stated the notes indicated the nurse obtained the consent from Resident 3's family. During an interview on 7/16/2026 at 12:28 PM, and a concurrent review of Resident 3's Nurses' Notes (dated 4/27/26 at 9:33 PM), RN 1 stated the nurse author of the note obtained the consent from Resident 3's family. During an interview on 7/16/2026 at 2:39 PM, DON acknowledged the licensed practitioner who prescribed or ordered the psychotropic meds should be the person obtaining consent from the resident or the family. During a review of the facility's policy and procedures, the policy titled, Informed Consent (dated 7/2011) indicated the facility to . Request the physician to obtain informed consent for the appropriate treatment (psychotherapeutic drug). Inform the physician to notify nursing with the treatment order upon receipt of the informed consent. Document the following . Date, time, name of physician called.

Based on observations, interviews, and record review, the facility failed to provide pharmacy services that ensure non-controlled medication disposition log (log used for drugs that do not have a high risk of abuse or dependence and are not regulated by special government schedules) was completed with the date of disposition and with witnessing nurse's signature. The facility also failed to keep a separate record of emergency drug supplies emergency kit (E-kit- a targeted supply of prescription drugs or emergency gear used for urgent medical needs, severe acute symptoms, or home hospice care) usage. These deficient practices had the potential of misappropriation (misuse or unauthorized taking, use, or sharing of prescription drugs) of medications, and/or medication loss and errors. Findings: 1. During an interview and record review on 7/14/2026 at 11:35 AM, the registered nurse (RN 1) stated the night shifts performed the task of conducting the non-controlled medication disposition process. During a review of the facility's non-controlled medication disposition log, the top page of the log (dated 7/13) had 1 nurse's signature. Then, after a few pages, and in between pages dated 6/25 and 6/30, there was a page without a disposition date. During a concurrent interview, RN 1 stated there should be a date. During a review of the facility's policy and procedures, the policy titled, Discarding and Destroying Medications (dated in 2001), indicated Non-controlled and Schedule V (non-hazardous) substances are disposed of in accordance with state regulations. The medication disposition record contains. date medication destroyed. signature of witnesses. During the review of the state regulations, California Cod of Regulations Title 22 section 72371(c)(2), the state regulation indicated Drugs not listed under Schedules II, III or IV of the Federal Comprehensive Drug Abuse Prevention and Control Act of 1970 shall be destroyed by the facility in the presence of a pharmacist or licensed nurse. The name of the patient, the name and strength of the drug, the prescription number if applicable, the amount destroyed, the date of destruction and the signatures of the person named above, and one other person shall be recorded . 2. During an interview on 7/14/2026 at 11:44 AM, RN 1 she did not know where the facility E-kit usage log was. RN 1 stated she could not find such log in the one (1) of 1 medication room, nor at the nursing station. During an interview on 7/14/2026 at 12 PM, the Director of Nursing (DON) stated the licensed nurses would fill out the E-kit slip (which has a carbon copy), leave the copy in the e-kit for pharmacy record, and keep the original to be filed by medical record. DON stated there was no separate log for the E-kit usage. During an interview on 7/15/2026 at 12:01 PM, DON stated the facility could not reconcile (compare medication list) or verify medication that were removed from the E-kits, which included controlled substances (a chemical or medication that are strictly used and regulated by the government due to their potential for abuse, addiction, and physical or psychological dependence), without knowing who accessed the E-kit at what time, removed which medication, and for which resident. DON stated the facility's policy did not mention keeping such record. During a review of the facility's policy and procedures, the policy titled, Emergency Pharmacy Service and Emergency Kits (no date provided) indicated the Pharmaceutical Services Committee and Quality Assessment and Assurance Committee are responsible for ensuring the use of emergency supply is in compliance with applicable state regulations. During a concurrent review of the California Cod of Regulations Title 22 section 72377(b)(5) with the DON, the state regulations indicated Separate records of use shall be maintained for drugs administered from the [emergency] supply .

Based on observation, interview, and record review, the facility failed to prevent the spread of multidrug-resistant organism (MDRO- infection-causing organisms that are resistant to one or more medications that treat infection) ) for one out of five sampled residents (Resident 3) who was placed on for enhanced barrier precautions (EBP, an infection control strategy used in nursing homes and skilled nursing facilities) in accordance with the facility's policy and procedure (P&P) titled Enhanced Barrier Precautions. The facility failed to ensure: 1. Two Certified Nursing Assistants (CNAs) don (put on) an isolation gown (or gown, a piece of clothing that is worn to protect both the wearer and the residents from the transfer of microorganisms and bodily fluids) while repositioning Resident 3 in bed. 2. The facility placed an order for EBP when Resident 3 was readmitted to the facility on [DATE]. This deficient practice placed Resident 3 and other residents at risk spreading and contracting infections (a condition when bacteria, viruses, or other microorganisms enter the body and grow) at the facility. Findings: During a review of Resident 3's admission Record (AR), the AR indicated that the resident was originally admitted on [DATE], and readmitted on [DATE], with diagnoses that included dysphagia (difficulty in swallowing), gastrostomy (a surgical opening created in the abdominal wall and stomach to insert a feeding tube (a medical device used to deliver liquid food, fluids, and medicines directly to the resident's stomach or intestine), and sepsis (the body's extreme, life-threatening response to an infection). During a review of Resident 3's History and Physical (H&P), dated 4/28/2026, the H&P indicated that the resident does not have the capacity to understand and make decisions. During a review of Resident 3's Minimum Data Set (MDS, a resident assessment tool), dated 5/28/2026, the MDS indicated that the resident has severely impaired cognition (the ability to process thoughts and emotions). The MDS also indicated that the resident is dependent (the helper does all the effort) on activities such as personal hygiene, bathing, and rolling in bed left and right. The MDS also indicated that the resident has a feeding tube. During a review of Resident 3's physicians order, dated 4/27/2026, the order indicated Enteral Order: [G-Tube] Site: Cleanse with [Normal Saline] (a sterile liquid solution that is often used for cleaning open wounds), pat dry, cover with dry dressing everyday shift. During a review of Resident 3's entire physicians orders as of 7/16/2026, the orders did not include an order to implement enhanced barrier precautions. During an observation on 7/14/2026 at 10:51 AM in front of the entrance to Resident 3's room, the wall next to the door into the resident's room had a signage, titled Enhanced Barrier Precautions. The signage indicated that providers and staff must wear gloves and a gown for high contact resident care activities. During an observation on 7/14/2026 at 11:12 AM inside Resident 3's room, CNA 2 and CNA 3 were observed changing Resident 3's position in bed. CNA 2 and CNA 3 did not wear a gown. Both CNAs were observed in close contact with Resident 3, and the CNA's clothes were observed in physical contact with Resident 3's body and clothing. During a follow-up interview on 7/14/2026 at 11:13 AM with CNA 2 and CNA 3, the CNA's stated that they forgot to wear a gown. The CNA's stated that they should have worn a gown because the resident is on EBP. During an interview on 7/14/2026 at 11:14 AM with Licensed Vocational Nurse (LVN) 3, LVN 3 stated that staff must wear gloves and a gown when providing care to Resident 3 because Resident 3 was on EBP which aids in the prevention of the spread of bacteria and viruses. During a concurrent interview and record review on 7/16/2026 at 3:25 PM with Registered Nurse (RN) 1, Resident 3's physician's orders were reviewed. RN 1 stated that there was no physician's order to place Resident 3 on EBP. RN 1 stated that there should have been a physician's order for EBP upon Resident 3's admission. RN 1 stated that there should be a physician's order for EBP so that staff are aware of the need to use the proper equipment when taking care of Resident 3. RN 1 stated that Resident 3 had a G-tube when the resident was readmitted [DATE]. During an interview on 7/16/2026 at 3:45 PM with the Infection Preventionist Nurse (IPN), the IPN stated that residents with a G-tube who are admitted to the facility must have an order for EBP upon admission. The IPN stated that EBP is used to prevent the spread of infections to other residents. During an interview on 7/17/2026 at 10:18 AM with the Director of Nursing (DON), the DON stated that residents who are admitted to the facility with a G-tube must be placed on EBP. The DON added that an order must be placed for EBP to notify staff that EBP must be used when caring for the resident. The DON further added that staff are expected to wear gloves and a gown when repositioning residents who are on EBP. The DON further stated that EBP is used to prevent the likelihood of spreading infections to staff and residents. During a review of the facility's policy and procedure (P&P), titled Enhanced Barrier Precautions, revised 3/2024, the P&P indicated that EBPs are utilized to reduce the transmission of multi-drug-resistant organisms (infection-causing organisms that are resistant to one or more medications) to residents. The P&P indicated that gloves and gowns are applied prior to performing the high contact resident care activity. The P&P indicated that EBP is indicated for residents with indwelling medical devices such as feeding tubes. The P&P also indicated that EBP is to remain in place for the duration of the resident's stay or until the discontinuation of the indwelling medical device.

Based on observation, interview, and record review, the facility failed to provide information on their rights to formulate an advanced directive (AD-a written legal document that explains your choices for medical care if you become unable to speak or make decisions for yourself) for one out of eleven sampled residents (Resident 5) in accordance with the facility's policy and procedure (P&P) Advance Directives. This deficient practice had the potential for the facility not to honor the resident's preference and/wishes for their medical care and treatments when they can no longer have the capacity to make their own decisions. Findings: During a review of Resident 5's admission Record (AR), the AR indicated that the resident was originally admitted [DATE], and readmitted on [DATE], with diagnoses that included depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), schizophrenia (a mental illness that affects how a person thinks, feels, and acts, characterized by key signs like hallucinations, delusions, and disorganized thinking), and hypertension (elevated blood pressure). During a review of Resident 5's History and Physical (H&P), dated 10/24/2025, the H&P indicated that the resident does not have the capacity to understand and make decisions. During a review of Resident 5's Minimum Data Set (MDS, a resident assessment tool), dated 4/15/2026, the MDS indicated that the resident has intact cognition (the ability to process thoughts and emotions). The MDS also indicated that Resident 5 has not completed an advanced directive. During a review of Resident 5's Advance Directive Acknowledgement (ADA), the ADA document indicated for the resident to place an initial on each statement. The ADA included a statement that indicated if the resident has been informed of their rights to formulate AD. Further review of the document indicated that Resident 5 has neither placed her initials on the document nor signed the ADA. During a concurrent interview and record review on 7/15/2026 at 1:38 PM with the Social Services Director (SSD), Resident 5's medical records, including the document titled, Advance Directive Acknowledgement, was reviewed. The SSD stated that the document was not complete because there were no initials and signatures on the document. The SSD stated that the AD should have been completed upon admission. The SSD added that she has not offered Resident 5 the choice to formulate an advanced directive. The SSD stated that the advanced directive was important because the AD instructs staff on how to care for the resident if the resident no longer has the capacity to make their own decisions. During an interview on 7/15/2026 at 3:40 PM with Resident 5, Resident 5 stated that she does not recall if the facility has offered to help her formulate an advanced directive. During an interview on 7/17/2026 at 101:18 AM with the Director of Nursing (DON), the DON stated that an advanced directive is a document where residents place their wishes on how they would want to be treated or cared for when they can no longer make decisions for themselves. The DON stated that if the resident was not offered the opportunity to formulate an advanced directive, the resident's care may not be what they would want it to be when they can no longer make their own decisions. During a review of the facility's policy and procedure (P&P) titled, Advance Directives, revised 9/2022, the P&P indicated that the resident has the right to formulate an advance directive. The P&P indicated that prior to or upon admission of a resident, the social services director or designee inquires of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives. The P&P also indicated that the resident or representative is provided with written information concerning the right to formulate an advance directive if he or she chooses to do so.

Based on observation, interview, and record review, the facility failed to promote a homelike environment for one out of five sampled residents (Resident 45) in accordance with the facility's policy and procedure titled Homelike Environment when the wall clock in Resident 45's room did not show the correct time. This deficient practice had a potential to disorient Resident 45, which could lead to agitation. Findings: During a review of Resident 45's admission Record (AR), the AR indicated that the resident was originally admitted on [DATE] , and readmitted on [DATE], with diagnoses that included psychosis (a mental state where a person loses touch with reality), insomnia (a sleep disorder that involves trouble falling asleep, staying asleep, or waking up too early), and visual hallucinations. During a review of Resident 45's History and Physical (H&P), dated 2/14/2026, the H&P indicated that the resident does not have the capacity to understand and make decisions. During a review of Resident 45's Minimum Data Set (MDS, a resident assessment tool), dated 5/19/2026, the MDS indicated that the resident has severely impaired cognition (the ability to process thoughts and emotions). During a concurrent observation and interview on 7/14/2026 at 11:20 AM with Registered Nurse (RN) 1 inside Resident 45's room, Resident 45's wall clock was observed. RN 1 stated that the wall clock is not showing the correct time because it is showing 10:20 AM and not 11:20 AM, which is one hour late. RN 1 stated that a wrong clock could potentially disorient the resident. During an interview on 7/17/2026 at 10:18 AM with the Director of Nursing (DON), the DON stated that when providing care to a resident who is cognitively impaired such as Resident 45, it is important to ensure that clocks show the correct time. The DON further stated that clocks that are not set to the correct time could disorient the resident further, which could lead to agitation. During an interview on 7/17/2026 at 10:55 AM with the Maintenance Supervisor (MS), the MS stated that he is responsible for ensuring that clocks show the correct time. The MS stated that the clock in Resident 45's room is an old clock that needs to be replaced. During a review of the facility's policy and procedure (P&P) titled, Homelike Environment, revised 2/2021, the P&P indicated that residents are provided with a safe, clean, comfortable and homelike environment. The P&P indicated that facility staff maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting such as a clean, sanitary and orderly environment.

Based on interview and record review, the facility failed to ensure a psychotropic (chemical substances that alter brain function, affecting perception, mood, behavior, and consciousness) medication prescribed for as needed (PRN, not routine) usage had adequate indication for its use and treat specific behaviors, documented descriptions on significant episodes, and documented reasons to administer the as needed psychotropic for one (1) of 5 sampled residents (Resident 3). This deficient practice had the potential to use medications, and/or chemical restraints, unnecessarily. Findings: During a review of Resident 3's admission record, the record indicated the facility initially admitted Resident 3 on 1/30/2026 and re-admitted on [DATE] with diagnoses that included, encephalopathy (a group of conditions that cause brain dysfunction, with symptoms such as altered mental state ranging from mild confusion to coma), hemiplegia (severe or complete paralysis of one entire side of the body, usually caused by damage to the brain or spinal cord resulting from a stroke, traumatic brain injury, or other causes) and hemiparesis (partial weakness or reduced control on one side of the body) following cerebral infarction (a type of ischemic stroke that occurs when a blocked blood vessel deprives brain tissue of oxygen and vital nutrients, causing cell death), aphasia (a neurological language disorder caused by damage to the brain's language centers (most commonly after a stroke or head injury) which impairs a person's ability to comprehend, speak, read, or write, with symptoms including trouble with expressing oneself, though it does not affect a person's general intelligence). During a review of Resident 3's History and Physical (H & P) dated 4/28/2026, the H&P indicated Resident 3 was nonverbal, aphasic (language or communication disorder caused by brain damage from strokes, tumors, or head injuries) due to CVA. During an interview on 7/16/2026 at 10:41 AM, the director of nursing (DON) stated Resident 3 had a history of cerebrovascular accident (CVA, also known as stroke) which resulted in severe cognitive impairment and Resident 3 could not express or verbalize their needs. During a review Resident 3's Minimum Data Set (MDS, a Federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes) dated 4/27/2026, MDS indicated Resident 3 had unclear speech (slurred or mumbled words), rarely or never made self understood, rarely or never understood others, and fully dependent on others for everyday activities. During a review of Resident 3's medication order, an order dated 7/9/2026 indicated lorazepam (a psychotropic medication that is used to treat anxiety) 0.5 milligrams (mg, unit to measure dosage), every 6 hours as needed (PRN) for anxiety manifested by excessive restlessness for 14 days. During a review of Resident 3's medication order, an order dated 5/5/2026 at 10:23 AM indicated to administer quetiapine (generic for Seroquel, an antipsychotic medication to manage psychosis, severe behavioral disorders) 25 mg half a tablet (12.5 mg) via G-tube every 6 hours for psychosis manifested by paranoia, physical outburst. During an interview on 7/16/2026 at 2:29 PM, and a concurrent review of Resident 3's electronic medication administration record (eMAR) for July 2026 under the medication lorazepam, the DON stated that there were 10 behavior episodes marked and one dose of lorazepam 0.5 mg administered on 7/12/2026 at 5 PM. The DON reviewed Resident 3's nurses' notes and stated there was no documentation describing what the behavior was or what might have triggered the behavior that led to administering the lorazepam. During the same interview, the DON stated that on 7/14/2026, there were four behavior episodes noted and two doses of lorazepam administered. The DON also stated there was no documentation supporting the reason for administering lorazepam on that date. The DON acknowledged there was a lack of documentation regarding what occurred on those dates, what non pharmacological interventions were attempted, whether those interventions were effective, and a lack of a documented reason or need to administer lorazepam as needed. Regarding the indications anxiety manifested by excessive restlessness and psychosis manifested by paranoia, the DON could not provide information defining Resident 3's baseline restlessness or what was considered excessive restlessness. The DON also could not describe Resident 3's paranoia. During a review of Resident 3's psychiatric evaluations dated 4/20/2026, 5/25/2026, and 6/22/2026, the sections for medical history were blank in all three evaluations. There was no documentation indicating that Resident 3's underlying medical conditions, such as aphasia, had been considered, reviewed, or ruled out as a possible underlying cause of the resident's behaviors. Additionally, there was no documentation describing Resident 3's paranoia or how Resident 3 non verbally expressed paranoia. During a review of the facility's policy and procedures, the policy titled, Administering Medications (dated in 2001), indicated . As required or indicated for a medication, the individual administering the medication records in the resident's medical record. any complaints or symptoms for which the drug was administered, any results achieved and when those results were observed. During a review of the facility's policy and procedures, the policy titled, Psychotropic Medication Use (dated in 2001), indicated that Residents will not receive medications that are not clinically indicated to treat a specific condition. Consideration of the use of any psychotropic medication is based on comprehensive review of the resident. This includes evaluation of the resident's signs and symptoms in order to identify underlying causes. Psychotropic medications are not prescribed or given on a PRN basis unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record. When determining whether to initiate, modify, or discontinue medication therapy, the IDT conducts an evaluation of the resident. The evaluation will attempt to clarify whether other causes or symptoms (including symptoms that mimic a psychiatric disorder) have been ruled out; signs and symptoms are clinically significant enough to warrant medication therapy.

Based on interview and record review the facility failed to report to the State agencies and police department and thoroughly investigate an abuse (intentional actions or practices that cause one's harm and distress) allegation as required for 1 out 1 sampled resident (Resident 59), who alleged that on 7/11/26, Certified Nursing Assistant (CNA) 1 struck Resident 59's right foot while stopping his wheelchair that rapidly rolled down a ramp towards his room in accordance with the facility's policy and procedure titled Abuse, Neglect, Exploitation (treating a person unfairly to gain an advantage) or Misappropriation (misuse of funds)- Reporting and Investigating. This deficient practice resulted in delayed reporting that can potentially hinder the timely investigation and protection of Resident 59 due to preservation of evidence, collection of witness statements, and prompt determination of whether abuse had occurred.Findings: During a review of Resident 59's admission Record (AR), the AR indicated Resident 59 was readmitted to the facility on [DATE] with a diagnosis fracture (broken bone) of lower end of right femur (largest bone in the body) and psychoactive substance abuse (the harmful or excessive use of any chemical substance-such as drugs or alcohol-that alters brain function). During a review of Resident 59's History and Physical (H&P) signed and dated 7/6/2026, indicated that Resident 59 had the capacity to understand and make decisions. During a review of Resident 59's MDS dated [DATE], the MDS indicated that Resident 59 had an intact cognition (ability to think and reason and thought process). During a review of Resident 59's Change of Condition (COC) dated 7/11/2026, indicated the Resident 59 did not follow staff instructions to wait for assistance before wheeling himself down a ramp. The COC indicated that Certified Nursing Assistant (CNA 1) intervened in an attempt to prevent a fall and maintain Resident 59's safety. The COC indicated that Resident 59 had alleged that the CNA 1 struck his right foot during the intervention; however, the assessment documented that Licensed Vocation Nurse (LVN 2) had witnessed the incident and reported no contact with the resident's right foot. The COC indicated that an RN completed an assessment following the allegation and documented no new changes or injuries. During a review of Resident 59's COC dated 7/13/2026, indicated that Resident 59 had alleged that a CNA 1 struck his right foot while intervening after the Resident 59 wheeled himself down the Station 2 ramp without assistance. The COC indicated that LVN 2 had witnessed the incident and reported that the CNA 1 did not make contact with the resident's right foot. The COC indicated that the primary clinician was notified and recommended following the facility's abuse allegation protocol and monitoring the resident for signs and symptoms of emotional distress or sudden physical changes pending hospital transfer for evaluation of the resident's right lower leg surgical wound. During an interview on 7/14/2026 at 11:40 AM with Resident 59, the resident stated that on 7/11/2026 between approximately 3 PM to 4 PM., he was attempting to wheel himself down the ramp to use the restroom when CNA 1 rushed toward him to stop him. Resident 59 alleged that CNA 1 struck his right foot while attempting to stop the wheelchair. During an observation on 7/14/2026 at 11:44 AM of Resident 59's right lower extremity, which had an external fixator (a medical device used to stabilize broken bones and/or lengthen the limb) in place, revealed no visible injuries, redness, or swelling. During an interview on 7/14/2026 at 12:45 PM with the Social Services Designee (SSD), the SSD stated that Resident 59, who was admitted on [DATE] with a history of substance abuse and behavioral issues, rapidly propelled his wheelchair down the ramp on 7/11/2026. The SSD stated that CNA 1 stopped the resident's wheelchair by holding the footrest (a flat plate on the wheelchair used to put the foot) of the wheelchair to prevent injury. The SSD stated that the facility did not initiate its abuse investigation until 7/13/2026 and SSD was unable to explain why the investigation was not started on 7/11/2026. The SSD acknowledged that the delay may have allowed staff to discuss the incident before being interviewed, potentially influencing or altering their recollection of events to determine if the allegation of abuse was substantiated or not. During an interview on 7/14/2026 at 1:30 PM with Resident 38, Resident 38 stated that Resident 59 frequently used profanity toward residents and staff. Resident 38 stated that he observed Resident 59 propel his wheelchair rapidly toward the stairwell and observed CNA 1 stop the wheelchair by holding the footrest. Resident 38 stated that CNA 1 did not strike Resident 59's foot and that Resident 59 subsequently yelled and directed profanity toward CNA 1. During a review of Resident 38's AR, the AR indicated Resident 38 was admitted to the facility on [DATE] with a diagnoses that included type 2 diabetes mellitus (DM - body does not produce enough insulin to control blood sugar levels) and atrial fibrillation (abnormal heart rhythm). During a review of Resident 38s H&P signed and dated 6/7/2026, indicated that Resident 38 had the capacity to understand and make decisions. During an interview on 7/16/2026 at 3:30 PM with CNA 1, CNA 1 stated that he had observed Resident 59 attempting to rapidly propel his wheelchair down the ramp while requesting to use the restroom. CNA 1 stated that he intervened by stopping the resident's wheelchair to prevent further injury to the resident's surgically repaired right leg. CNA 1 stated that Resident 59 responded by shouting racial slurs, sexist remarks, and profanity. CNA 1 stated that after ensuring the resident was safe, he assisted Resident 59 to the restroom. CNA 1 further stated that he was not suspended on 7/11/2026 pending the outcome of the facility's investigation. During an interview on 7/16/2026 at 3:56 PM with LVN 2, LVN 2 stated that she was the charge nurse on 7/11/2026 during the 3 PM-11:00 PM. shift and witnessed the entire incident involving Resident 59 and CNA 1. LVN 2 stated that Resident 59 requested assistance to use the restroom and was informed that CNA 1 was assisting another resident and would help him shortly. LVN 2 stated that Resident 59 became impatient, directed profanity toward her, and rapidly propelled his wheelchair down the ramp. LVN 2 stated that, due to the resident's erratic wheelchair movements and surgically repaired right leg, CNA 1 intervened by stopping the wheelchair while holding the underside of both wheelchair footrests. LVN 2 stated that Resident 59 then loudly alleged that CNA 1 had almost hit him before accusing CNA 1 of striking his foot. LVN 2 further stated that the DON was notified of the incident; however, the allegation was not reported to the State agencies, and the facility investigation was not initiated until 7/13/2026. During an interview on 07/16/2026 at 4:15 PM with the Director of Nursing (DON), the DON stated that Resident 59 alleged CNA 1 struck his right foot while staff attempted to stop the resident from propelling his wheelchair rapidly down the facility ramp without assistance. The DON stated that Resident 59 had previously been instructed not to use the ramp independently because of safety concerns and non-weight-bearing (placing zero weight on affected extremity) restrictions. The DON stated that witness statements indicated no contact occurred between CNA 1 and the resident's right foot and that the RN assessment completed on 7/11/2026 identified no significant changes or injuries related to the allegation. The DON stated that monitoring orders and a care plan were initiated, and Resident 59 had been observed for changes in condition. The DON stated that the facility initiated an abuse investigation on 7/13/2026 and notified the physician, psychiatrist, California Department of Public Health (CDPH), the Ombudsman, and local law enforcement. The DON stated that the allegation of physical abuse occurring on 7/11/2026 was not reported to CDPH or the Ombudsman until 7/13/2026. The DON acknowledged that the allegation should have been reported within two hours or within 24 hours of an allegation of abuse that did not result in serious bodily injury, in accordance with abuse reporting requirements but could not recall why the report was delayed. The DON stated that the delayed reporting did not comply with facility policy or regulatory requirements and could have delayed regulatory oversight, timely staff interviews, preservation of witness recollections, and identification of corrective actions, including staff re-education and suspension pending the investigation. During a review of the facility P&P titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating revised 9/2022, indicated that if resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. The P&P indicated that the administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: the state licensing/certification agency responsible for surveying/licensing the facility and the local/state ombudsman. The P&P indicated that the reporting within two hours of an allegation involving abuse which resulted in serious bodily injury; or within 24 hours of an allegation of abuse that did not result in serious bodily injury.

Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS-a resident assessment and care-screening tool) assessment was completed and submitted timely to the Centers for Medicare and Medicaid Services (CMS) system for 1 of two sampled residents (Resident 36 and Resident 40) in accordance with the facility's policy and procedure titled Electronic Transmission of the MDS. This deficient practice had the potential to result in confusion regarding the care and services provided to the residents, and a potential to affect the facility's quality of care monitoring system that measures the effective, safe, efficient, patient's centered, equitable (fair), and timely care. Findings: During a review of Resident 36's admission Record (AR), the AR indicated the resident was admitted to the facility on [DATE] with diagnoses including asthma (a condition that causes your airways to swell, narrow and fill with mucus), lymphedema (a condition in which lymph builds up in tissues and causes swelling). During a review of resident 36's MDS Summary, indicated Discharge-return not anticipated MDS with assessment reference date (ARD-date should be completed) of 3 /21/2024, but was completed on 3/07/2026, but was not transmitted to CMS when completed. During a review of Resident 40's admission Record (AR), the AR indicated the resident was admitted to the facility on [DATE] with diagnoses including peripheral vascular disease (reduced circulation of blood to a body part), type 2 diabetes mellitus (your body doesn't use insulin well and can't keep blood sugar at normal levels.) During a review of resident 40's MDS Summary, indicated Discharge-return not anticipated MDS with assessment reference date (ARD-date should be completed) of 3 /17/2026, but was completed on 3/03/2026, but was not transmitted to CMS when completed. During an interview and concurrent record review of Resident 36 and Resident 40's Discharge MDS on 7/16/2026 at 3:50 PM with the MDS Nurse (MDSN), MDSN stated she was responsible to make sure all the residents' MDS assessments were completed. The MDSN stated once the Resident 36 and 40's MDS were completed the facility had 14 days from Resident 36 and 40's discharge to complete and submit Resident 36 and 40's Discharge MDS to CMS. MDSN stated Resident 36 and Resident 40's discharge MDS had been completed on time, but the Director of Nursing (DON) had signed and chosen the option to not transmit Resident 36 and 40's MDS to CMS. The MDSN stated the late transmission of the MDS's would delay the accuracy of the resident's assessment and affect resident's care negatively. During an interview and concurrent record review of Resident 36 and Resident 40's Discharge MDS on 7/16/2026 at 4:12 PM with the DON, DON stated Resident 36 and Resident 40's Discharge MDS should have been transmitted immediately after it was completed. DON stated she did not notice that she chooses the option to not transmit Resident 36's and 40's Discharge MDS to CMS when she reviewed them as complete. During a review of the facility's Policy and Procedure (P&P), titled Electronic Transmission of the MDS, with a revision date of October 2023, the P&P indicated, All MDS assessments (e.g. admission, annual, significant change, quarterly review, etc.) and discharge and re-entry records are completed and electronically encoded into our facility's MDS information system and transmitted to CMS Internet Quality Improvement and Evaluation System (IQIES) in accordance with current OBRA regulations governing transmission of MDS data.

Based on observation, interview, and record review the facility failed to develop a comprehensive care plan for one out of five sampled residents (Resident 3) who had a diagnosis of cerebrovascular accident (CVA, also known as stroke) and who was also placed on enhanced barrier precautions (EBP, an infection control strategy used in nursing homes and skilled nursing facilities to prevent the spread of multidrug-resistant organisms) in accordance with the facility's policy and procedure (P&P) titled Care Plans, Comprehensive Person-Centered. This deficient practice placed Resident 3 at risk of receiving care that is not consistent with the resident's goals and health status. 1. During a review of Resident 3's admission Record (AR), the AR indicated that the resident was originally admitted on [DATE], and readmitted on [DATE], with diagnoses that included dysphagia (difficulty in swallowing), gastrostomy (a surgical opening created in the abdominal wall and stomach to insert a feeding tube), and sepsis (the body's extreme, life-threatening response to an infection). During a review of Resident 3's History and Physical (H&P), dated 4/28/2026, the H&P indicated that the resident does not have the capacity to understand and make decisions. During a review of Resident 3's Minimum Data Set (MDS, a resident assessment tool), dated 5/28/2026, the MDS indicated that the resident has severely impaired cognition (the ability to process thoughts and emotions) and was dependent (the helper does all the effort) on activities such as personal hygiene, bathing, and rolling in bed left and right. The MDS also indicated that the resident has a feeding tube. During a review of Resident 3's physicians order, dated 4/27/2026, the order indicated Enteral Order: [G-Tube] Site: Cleanse with [Normal Saline] (a sterile liquid solution that is often used for cleaning open wounds), oat dry, cover with dry dressing everyday shift. During a concurrent interview and record review on 7/16/2026 at 3:25 PM with Registered Nurse (RN) 1, Resident 3's care plans were reviewed. RN 1 stated that there was no care plan developed for EBP. RN 1 stated that a care plan for EBP should have been initiated upon Resident 3's admission on [DATE] because the resident had a G-tube upon admission. RN 1 added that care plans are used by staff as a guide to know what interventions to implement when providing care to the resident. During an interview on 7/16/2026 at 3:45 PM with the Infection Preventionist Nurse (IPN), the IPN stated that when a resident with a G-tube is admitted to the facility, the admitting nurse must initiate a care plan for EBP. The IPN stated that EBP is used to prevent the spread of infections to other residents. The IPN further indicated that the care plan for EBP should include interventions such as for staff to wear gloves and a gown prior to providing care to the resident. During an interview on 7/17/2026 at 10:18 AM with the Director of Nursing (DON), the DON stated that residents who are admitted to the facility with a G-tube must have a care plan for EBP. The DON added that care plans are important because care plans guide staff on how to render care to the resident. The DON stated that not following EBP increases the likelihood of the spread of infections to residents. During a review of the facility's policy and procedure (P&P), titled Enhanced Barrier Precautions, revised 3/2024, the P&P indicated that EBPs are utilized to reduce the transmission of multi-drug-resistant organisms (infection-causing organisms that are resistant to one or more medications) to residents. The P&P indicated that gloves and gowns are applied prior to performing the high contact resident care activity. The P&P indicated that EBP is indicated for residents with indwelling medical devices such as feeding tubes. The P&P also indicated that EBP is to remain in place for the duration of the resident's stay or until the discontinuation of the indwelling medical device. During a review of the facility's P&P, titled Care Plans, Comprehensive Person-Centered, revised 3/2022, the P&P indicated that a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The P&P indicated that the comprehensive, person-centered care plan is developed within seven days of the completion of the required MDS assessment and no more than 21 days after admission. The P&P also indicated that the care plan describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. 2. During a review of Resident 3's admission record, the record indicated the facility initially admitted Resident 3 on 1/30/2026 and re-admitted on [DATE]. Resident 3's admitting diagnoses included, but not limited to: encephalopathy (a group of conditions that cause brain dysfunction, with symptoms such as altered mental state ranging from mild confusion to coma), hemiplegia (severe or complete paralysis of one entire side of the body, usually caused by damage to the brain or spinal cord resulting from a stroke, traumatic brain injury, or other causes) and hemiparesis (partial weakness or reduced control on one side of the body) following cerebral infarction (a type of ischemic stroke that occurs when a blocked blood vessel deprives brain tissue of oxygen and vital nutrients, causing cell death), aphasia (a neurological language disorder caused by damage to the brain's language centers (most commonly after a stroke or head injury) which impairs a person's ability to comprehend, speak, read, or write, with symptoms including trouble with expressing oneself, though it does not affect a person's general intelligence). During an interview on 7/16/2026 at 10:41 AM, the director of nursing (DON) stated Resident 3 had a history of cerebrovascular accident (CVA, also known as stroke) which resulted in severe cognitive impairment and Resident 3 could not express or verbalize their needs. During an interview on 7/16/2026 at 2:36 PM, and a concurrent review of Resident 3's care plan regarding non-pharmacological intervention, DON stated there was a lack of documentation on the types of non-pharm intervention catered to Resident 3 that would reduce or alleviate anxiety, or underlying conditions that triggered physical behavior (such as severe cognitive impairment due to stroke). DON acknowledge the interventions listed in Resident 3's care plan was generic. During a review of the facility's policy and procedures, the policy titled Care Plans, Comprehensive Person-Centered (dated March 2022) indicated when possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers.

Based on interviews and record reviews, the licensed nursing staff and physician failed to act upon the pharmacist's recommendations documented in the Medication Regimen Review (MRR)-a comprehensive evaluation of a resident's medication regimen intended to promote positive outcomes and minimize adverse effects-for one of five sampled residents (Residents 5) reviewed for MRR. The facility failed to follow the pharmacists' recommendation to clarify the diagnosis for Resident 5's aspirin EC (a form of aspirin with a special enteric coating designed to resist stomach acid) 81 mg (a unit of measurement). This deficient practice had the potential for delayed identification of clinical changes, ineffective medication administration, and adverse effects that could lead to acute medical events requiring emergency care or hospitalization. Findings: During a review of Resident 5's admission Record (AR), the AR indicated the resident was admitted to the facility on [DATE]. During a review of Resident 5's History and Physical (H&P) dated 10/24/2025, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 5's Consultant Pharmacist's MRR dated 5/18/2026 to 5/19/2026, the pharmacist recommended to clarify the resident's diagnosis for Aspirin EC 81 mg and assess and consider clarifying the diagnosis. During a review of Resident 5's Physician's Order dated 7/16/2026, the order indicated Aspirin EC oral tablet delayed release 81 mg, give 1 tablet by mouth one time a day for Cardiovascular prophylaxis with an order start date of 5/20/2026. During a concurrent interview and record review of Resident 5's MRR on 7/16/206 at 4:35 PM, the Director of Nursing (DON) stated that Resident 5's Aspirin EC 81 mg order did not include a proper diagnosis. DON stated the current orders indication of Cardiovascular prophylaxis was not appropriate because Cardiovascular is a system not a diagnosis. The DON further stated that failure to follow the Pharmacist's recommendations posed a potential risk of harm to Resident 5 if she was not assessed and prescribed the correct medication for her current diagnoses. During a review of the facility's Policy and Procedure (P&P), titled Medication Therapy, with a revision date of April 2007, the P&P indicated, each resident's medication regimen shall include only those medications necessary to treat existing conditions and address significant risk.

Based on interview and record review the facility failed to accurately and document in the Dialysis (a medical procedure of removing toxins and excess fluid in the blood with the use of a specialized machine) Communication log (a form used by the facility to communicate the resident's condition to the dialysis center prior to receiving dialysis) for one of three residents (Resident 35) the blood glucose (sugar) levels on 7/4/2026, 7/8/2026, and 7/14/2026 in accordance with the facility's policy and procedure titled Care of a Resident with End-Stage Renal Disease. This deficient practice had the potential for Resident 35 to be at risk of miscommunication between the facility and the dialysis provider and potentially affecting continuity of care, such as delayed identification of signs and symptoms of hypoglycemia (low blood sugar) or hyperglycemia (high blood sugar), placing the resident at risk for confusion, dizziness, falls, loss of consciousness, or death if left untreated.During a review of Resident 35's admission Record (AR), the AR indicated Resident 35 was readmitted to the facility on [DATE] with a diagnosis of type 2 diabetes mellitus (DM - body does not produce enough insulin to control blood sugar levels) and End Stage Renal Disease (ESRD- failure of the kidney to remove toxins and excess fluid in the body). During a review of Resident 35's History and Physical (H&P) signed and dated 10/4/2025, indicated that Resident 35 had the capacity to understand and make decisions. The H&P further indicated that Resident 58 had a history type 2 DM. During a review of Resident 35's MDS dated [DATE], the MDS indicated that Resident 35 had an intact cognition (thinking). During a review of Resident 35's Order Summary Report dated 7/2026, the summary report indicated Resident 35 had dialysis every Tuesdays, Thursdays and Saturdays. During a review of Resident 35's Dialysis Communication Forms dated 7/4/2026, 7/8/2026, and 7/14/2026, indicated no documented evidence the blood sugar was checked, the section on the form designated for Blood Sugar if Diabetic were left blank. During a concurrent interview and record review on 7/16/2026 at 2:03 PM with Licensed Vocational Nurse (LVN 1), Resident 35's Dialysis Communication Forms dated 7/4/2026, 7/8/2026, and 7/14/2026 were reviewed. LVN 1 stated that the Blood Sugar if Diabetic section was left blank on each form. LVN 1 confirmed that the Resident 35's blood glucose levels were not documented on those dates. LVN 1 stated that failure to document blood glucose levels could delay the identification of hypoglycemia or hyperglycemia, placing the resident at risk for confusion, dizziness, falls, loss of consciousness, or death if left untreated. During a concurrent interview and record review on 7/16/2026 at 2:20 PM with the Director of Nursing (DON), Resident 35's Dialysis Communication Forms dated 7/4/2026, 7/8/2026, and 7/14/2026 were reviewed. The DON stated that she acknowledged and confirmed that Resident 35's blood glucose levels were not documented. The DON stated that without documented blood glucose levels, nursing staff would be unable to effectively identify if the resident had episodes of hypoglycemia or hyperglycemia. The DON further stated that incomplete dialysis communication documentation could lead to communication between the facility and the dialysis provider, affect coordination of the resident's care, and limit the interdisciplinary team's ability to monitor the resident's diabetes management and identify clinical trends over time. During a concurrent interview and record review on 7/16/2026 2:03 PM, LVN 1 and concurrent record review with of Resident 35's clinical record (Hard Chart) indicated that Resident 35 had a diagnosis of Type 2 diabetes mellitus, ESRD and was dependent on Dialysis. Review of the Resident 35's Dialysis Communication Forms dated 7/4, 7/8, and 7/14 with LVN 1 indicated that the Resident 35's blood glucose levels were not documented on those dates in the communication form. LVN 1 stated that he confirmed that the blood glucose values were not recorded on the Dialysis Communication Forms. LVN 1 stated that failing to record blood glucose levels would create several clinical risks, like by not being able to identify hypoglycemia (low blood sugar), which may lead to confusion, dizziness, falls, loss of consciousness, or death if untreated. During an interview with the DON and concurrent record review 07/16/2026 2:20 PM - with of Resident 35's clinical record (Hard Chart) indicated that Resident 35 had a diagnosis of Type 2 diabetes mellitus, ESRD and was dependent on Dialysis. Review of the Resident 35's Dialysis Communication Forms dated 7/4/2026, 7/8/2026, and 7/14/2026 with LVN 1 indicated that the Resident 35's blood glucose levels were not documented on those dates in the communication form. DON stated that confirmed that the blood sugars were not recorded of the dialysis communication form. DON stated by failing to record Resident 35 blood sugar level, the nursing staff would not be able to identify if Resident 35 was having blood sugar issues such as hyperglycemia and hypoglycemia. DON stated that inaccurate or incomplete communication between the nursing facility and the dialysis center, which may affect coordination of the resident's care and Incomplete clinical documentation would limit the ability of the interdisciplinary team to monitor diabetes management and identify trends over time. During a review of the facility P&P titled End-Stage Renal Disease, Care of a Resident with revised 9/2010, indicated agreements between this facility and the contracted ESRD facility include all aspects of how the resident's care will be managed, including: how information will be exchanged between the facilities. During a review of the facility P&P titled Documentation Principles dated 1/2004, indicated that resident's health record shall be current and kept in detail consistent with good medical and professional practice based on the service provided to each resident.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was informed in writing of the findings of the investigations and the corrective actions needed after grievances (a formal, written or verbal expression of dissatisfaction regarding the quality of care, services, or treatment from a provider or health plan) were received in accordance with facility's Policy and Procedures (P&P) titled Filing Grievances/Complaints. This deficient practice violated Resident 1's right to be informed of the outcome and actions required from the facility after a grievance was filed to address Resident 1's concerns and had the potential for needs to be unresolved. Findings: During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was initially admitted on [DATE] with diagnoses including following (condition after a specific event or procedure) surgical amputation (surgical removal of the portion), acute osteomyelitis (sudden inflammation of bone or bone marrow, usually due to infection) of right ankle and foot, and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). A review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 1/6/2026, the MDS indicated that Resident 1's had intact cognitive function (thought process or decision consistent/reasonable). The MDS also indicated that Resident 1 did not exhibit any physical or verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others). During a review of the nine (9) Grievance/ Complaint/ Theft and Loss (GCT) Forms filed by Resident 1, including stapled attachments dated from 8/25/2025 to 1/26/2026 each GCT form indicated documentation of grievance, investigation including recommended corrective action, and resolutions of grievance. The GCT form did not indicate the investigation findings, the date and documentation that Resident 1 was informed of the investigation findings as well as corrective actions that would be taken. The GCT form did not indicate a date when Resident 1 signed the form. During a concurrent interview and record review on 2/10/2026 at 2:45 PM with Resident 1, Resident 1 stated that he signed the GCT forms when social service director (SSD) 1 originally presented him with the forms. Resident 1 stated SSD no longer worked in the facility and the forms were provided to Resident 1 to sign. Resident 1 stated he was never informed of the investigation findings and actions taken. During a concurrent interview and record review on 2/10/2026 at 3:50 PM with Director of Nursing, Resident 1's GCT Forms and Social Service Progress Note (SSPN) were reviewed. DON stated there were no documented findings during the investigation written in the GCT forms, SSPN, and Resident 1's medical record that indicated Resident 1 was informed of the findings, and what the corrective actions were based on the investigation. DON stated SSD 1 should have dated the GCT form on the date the grievance was resolved and should have provided a copy of the written summary of the investigation to Resident 1 and document the resolution on Resident 1's medical record. The DON stated Resident 1 signed the form when the grievance was filed by Resident 1, however signed in the wrong place that indicated resolution, therefore no follow up actions were relayed to Resident 1 regarding the filed grievance. During a review of the facility's Policy and procedure (P&P) revised in 11/2010, the P&P indicated that upon receipt of a grievance and/or complaint, the identified department will investigate the allegations and submit a written report of such findings to the Administrator within five (5) working days of receiving the grievance and/or complaint. The P&P also indicated that the resident or person filing the grievance and/or complaint on behalf of the resident, will be informed of the findings of the investigation and the actions that will be taken to correct any identified problems. The Administrator, or his or her designee, will make such reports orally within 7 (seven) working days of the filing of the grievance or complaint with the facility. A written summary of the investigation will also be provided to the resident, and a copy will be filed in the Social Service office.

Based on interview and record review, the facility failed to report an alleged resident to resident altercation within two (2) hours for one of three sampled residents (Resident 1 ) to the California Department of Public Health (CDPH) in accordance with the facility's Policy and Procedure (P&P) titled, Abuse Neglect, Exploitation or Misappropriation-reporting and Investigating. This deficient practice resulted in the facility underreporting alleged abuse and had the potential for the facility to not report future allegations of abuse.Findings: A review of Resident 1's admission Record (AR), indicated that Resident 1 was originally admitted to the facility on [DATE] and most recently re-admitted on [DATE] with diagnoses including, Fracture of Right patella ( a break in the knee cap) and acute (sudden ) respiratory failure with hypoxia (the lungs cannot get enough oxygen into the blood). A review of Resident 1's History and Physical (H&P) dated 6/13/2025, indicated that Resident 1has the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 10/15/2025, indicated Resident 1 was cognitively intact ( normal thinking and memory). A review of Resident 1's Change in Condition Evaluation (COC) dated 1/09/2026, the COC indicated Resident 1 had behavioral changes: false allegations toward staff. A review of Resident 1's Progress Notes dated 1/07/2026 at 2:49 PM and written by Social Service Director (SSD) indicated, SSD received a call from Resident 1's Resident Representative (RP 1) who stated she received a call from the Dialysis Center explaining Resident 1 made the following claims: the walking ladies hit her to force her to walk. The Note indicated after the facility notified RP 1, RP 1 stated I know it's not true, she is losing her mind, I asked them to disregard it. RP 1 stated she explained to them that family sees my mom on a daily basis and have never seen any signs of that. The Note indicated Interdisciplinary Team (IDT) was made aware. A review of Resident 1's Progress Notes dated 1/07/2026 at 8:30 PM and written by Registered Nurse (RN 1), RN 1 indicated, At 8:30 PM the Police department arrived at the facility. Police officer explained to RN 1 that they had received a report from Adult protective services (APS) that Resident 1 reported to the Dialysis center that three female members of the facility physical therapy department were forcing her to walk. During an interview on 1/08/2026 at 9:45 AM with Director of Nursing (DON), the DON stated, the facilities Social Services Director (SSD) had reported that Resident 1's RP 1 had notified RP 1 that the Dialysis center had called RP 1 and stated Resident 1 had stated she was forced to walk and was hit by facility staff. The DON stated she was also notified last night (1/07/26) by RN 1 that the police department came to the facility to investigate an abuse report they had received from Adult protective services. The DON stated the facility had began to conduct an internal investigation. During an interview with 1/08/2026 at 10:54 AM with SSD, SSD stated yesterday 1/7/2026 she received a call from Resident 1's RP who notified SSD that she received a call from the Dialysis center stating Resident 1 told them while she was in Dialysis that the walking ladies at the facility hit her and had forced her to walk. The SSD stated the call was made yesterday (1/6/26) a little before 3 pm and Resident 1 was not in the facility so she did not get a chance to interview Resident 1. SSD stated she informed the DON regarding the incident of Resident 1 stating she was forced to walk and hit by facility staff. A review of the facility's P&P, titled Abuse Neglect, Exploitation or Misappropriation-reporting and Investigating dated September,2022, indicated All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) . The policy further states that 1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and other officials according to state lad immediately as defined as a. within two hours of an allegation involving abuse or result in serious bodily injury During an interview and record review on 1/08/2026 at 12:47 PM of the facility's P&P for Abuse Neglect, Exploitation or Misappropriation-reporting and Investigating with DON, the DON stated the facility's P&P was not followed because the incident was not reported to CDPH within 2 hours because Resident 1 was not at the facility at the time they received the allegation. The DON stated it was important to follow the policy to ensure the resident was safe and to remain free from abuse.

Based on observation, interview, and record review the facility failed to ensure one of five sampled residents ( Resident 4 ), whose preferred language was Farsi, was provided communication and interpretation services to accurately assess Resident 4. This deficient practice had the potential to result in emotional distress and prevent Resident 4 from being provided care and services based on Resident 4's specific care and needs.During a review of the admission record (AR), the AR indicated Resident 4 was originally admitted to the facility on [DATE], with a diagnosis of fracture of the right patella(small bone in front of knee) , acute respiratory failure(sudden condition where the lungs can't get enough oxygen into the blood or remove enough carbon dioxide) , and diabetes (high blood sugar). During a review of Resident 4's History and Physical ( H&P), dated 06/13/2025, the H&P indicated the resident has the capacity to understand and make decisions. During a review of Resident 4's Minimum Data Set (MDS- a resident assessment tool) dated 10/15/2025, the MDS indicated Resident 4 was cognitively intact, requiring only verbal cues for most activities of daily life. During a review of Resident 4's comprehensive Care Plans dated 04/16/2025 to 12/15/205, indicated no care plan that addressed Resident 4's communication needs and language preference of Resident , indicating Resident 4's preferred language was Farsi. During a review of Resident 4's Psychosocial assessment dated [DATE],the Assessment indicated Resident 4's primary language / interpreter was Armenian. During an interview on 12/15/2025 at 10:40AM, with Social Service Designee (SSD) , SSD stated when she spoke with Resident 4 that Resident 4 seemed ok. SSD stated Resident 4 could not communicate in English well and could only respond with simple yes or no and used hand gestures. During an interview on 12/15/2025 at 11:15AM, with Certified Nurse Aid (CNA) 4, CNA 4 stated Resident 4 spoke Armenian and that CNA 4 was only able to minimally converse with Resident 4. CNA 4 stated the facility did not have an Armenian interpreter. During an interview 12/15/2025 at 11:16 AM with Resident 4, Resident 4 stated not speaking English but Farsi. During an interview on 12/15/2025 at 11:17AM, with SSD, SSD stated when she met with Resident 4, SSD assumed Resident 4 was OK, based on her mannerism. SSD stated at the time of interview no attempts to call Resident 4's family for interpretation was utilized. SSD stated a translator should have been used when speaking with Resident 4 to properly assess Resident 4's needs. During a review of the facility's policy and procedure (P&P) titled, Translation and / or interpretation of Facility Services, revised on 2020, indicated that the facility provides access to services for translation by either a staff member who is trained and competent in the skill of interpreting , contracted interpreter service, or a voluntary community interpreter who is trained and competent in the skill of interpreting ensuring LEP resident 's needs and questions are accurately communicated to the staff. The policy indicated that the coordinator of this facility's language access program is the director of social services, or his or her designee.

Based on interview and record review, the facility failed to treat one of three sampled residents (Resident 1) with respect and dignity by failing to get permission prior to entering Resident 1's room on 8/12/2025, in accordance with the facility's policy & procedure (P&P) on Dignity, and the resident's care plan that indicated facility staff is to knock and request permission before entering a residents' room. Furthermore, the facility failed to assist Resident 1 in maintaining dignity, well-being, manage emotional needs and monitor for further emotional distress, due to the anxiety and stress brought about by a facility staff (Housekeeper [HK] 1) when HK 1 entered Resident 1's room without permission on 8/12/2025, while the resident was dressing up, opened the privacy curtain and looked at Resident 1 while she was naked. HK 1 was again assigned to clean Resident 1's room on 8/13/2025 and 8/14/2025, after Resident 1 complained and requested HK 1 not to be assigned around her room anymore. This deficient practice had the potential to negatively affect the residents' psychosocial and psychological well-being. As a result, Resident 1 was very upset, yelling out, crying, and verbalized feeling isolated, mistreated, and discriminated against on 8/12/2025 and 8/13/2025. During a review of Resident 1's admission Record (AR), the AR indicated that Resident 1 was admitted to the facility on [DATE] with diagnoses including Diabetes Mellitus ( high blood sugar), major depressive disorder (a mental illness constant feeling of sadness), and acute respiratory disorder (a sudden, life-threatening condition where the lungs cannot adequately exchange oxygen and carbon dioxide, leading to dangerously low oxygen levels in the blood or excessive carbon dioxide buildup, require medical intervention). During a review of Resident 1's care plan, initiated on 3/18/2025, the care plan indicated that Resident 1 prefers to keep the curtain closed at all times. The care plan included a goal that Resident 1's preferences will be honored, and her privacy and comfort will be respected. The environment will be conducive to her emotional and physical well-being. The care plan intervention indicated that if the room needs to be entered for emergency purposes, the resident should be informed, and any necessary adjustments to the environment should be made easily. During a review of Resident 1's History and Physical (H&P) dated 5/14/2025, the H& P indicated Resident 1 had the capacity to make medical decisions. During a review of Resident 1's Minimum Data Set (MDS), a resident assessment tool, dated 7/3/2025, the MDS indicated that Resident 1's Brief Interview for Mental Status (BIMS)-a brief screener used to detect cognitive impairment-had a score of 15 [A score between 13 and 15 indicates that cognitive skills for daily decision-making are intact]. During a review of Resident 1's progress note dated 8/12/2025 at 10:03 AM, the note indicated the following information:The SSD was made aware by Certified Nurse Assistant (CNA) 1 that the resident was very upset and yelling out. The SSD went to the resident's room and asked to speak with her, and the resident agreed. Upon entering the room, the resident was sitting at the edge of the bed, staring out the window-not yelling or appearing in distress. The SSD explained that she had been informed the resident was upset and wanted to follow up and offer assistance. At that moment, [Resident 1] turned and began yelling, ‘I'm so fu***ng tired of this! I'm done! I need to be respected!' The note indicated [Resident 1] explained that she had just showered and was about to dress when she heard a knock on the door. [Resident 1] stated that she said out loud, ‘I'm changing,' but then heard the housekeeper enter the room. [Resident 1] noted that her curtain was fully drawn, covering her. The note indicated [Resident 1] said, ‘Why do they need to come into the room when they see the curtain drawn? I'm fed up. I can't take this anymore.' The note indicated [Resident 1] continued to express her frustration by yelling, repeating herself multiple times, and not responding to redirection attempts. The SSD encouraged the resident to verbalize her feelings and provided emotional support but was unsuccessful in calming her down. The SSD apologized for the incident, assured the resident that her concerns would be followed up on, and asked if she was okay at that moment. The resident, still visibly upset, did not respond to SSD. Instead, she called someone on her phone and began yelling again, repeating the same complaint. When asked again, the resident stated she was ‘fine' and continued yelling on the phone. The SSD exited the room to give her privacy and indicated follow-up is pending. During a review of Resident 1's Progress Note dated 8/12/2025, at 11:16 AM, the note indicated: Resident is still on a phone call, yelling and stating, ‘I'm f**ing tired.'* The note further indicated that the SSD provided the resident with space and privacy to continue her phone call and would continue to follow up. During a review of Resident 1's Progress Note dated 8/12/2025, at 3:34 PM, the Progress Note indicated that the SSD attempted to discuss the earlier incident and provide a follow up, but [Resident 1] declined at the moment and stated she was upset about missing a doctor's appointment. The Note indicated SSD to follow up. During a review of Resident 1's grievance dated 8/12/2025 (time not specified), the grievance form indicated that Resident 1 had a complaint regarding housekeeping [HK 1]. [Resident 1] explained that she was in her room after showering when she heard a knock on the door. [Resident 1] stated that she said aloud, I am changing, but still heard [HK 1] enter her room. The grievance form indicated that the DON, Social Services Director (SSD), and Housekeeping Supervisor were the department heads designated to take action on the concern. The grievance form indicated under Action Taken: The Housekeeping Supervisor was made aware of the incident and a one-on-one in-service training was requested. During a review of Resident 1's Progress Note dated 8/13/2025, at 1:13 PM, the note indicated the following information: [The] SSD met with the resident in her room and inquired about the earlier incident. The resident verbalized, feeling upset with the housekeeper [HK 1] that day. She [Resident 1] stated that she went out for a walk with [RNA 1] and, upon returning, asked for the floor to be dried before entering. She [Resident 1] reported that CNA 4 dried the floor for her and expressed frustration that the housekeeper [HK 1] did not do it instead. The SSD encouraged [Resident 1] to express her feelings and provided emotional support. The SSD explained that the concerns had been reported to the Housekeeping Supervisor and [HK 1] would receive one-on-one training on resident rights and customer service. Additionally, since [Resident 1] had verbalized that she does not want to see him [HK 1], [HK 1] would be reassigned and would no longer be present around [Resident 1's] room or area. [Resident 1] verbalized understanding and agreed with the plan, although she remained visibly upset and angry. When asked if there was anything else that could be done to assist her or make her feel better, the resident did not respond directly but stated, I'm just done with all this shit! I don't know who he thinks he is. I'm done with this place. The SSD encouraged [Resident 1] to continue expressing her feelings and suggested breathing exercises to help her calm down. The SSD also discussed available options and resources for returning to the community. The SSD noted that one-on-one visits would be provided as needed to support Resident 1's emotional and psychosocial well-being. During an interview on 8/14/2025, at 1:52 PM, Resident 1 stated that on 8/12/2025, around 10 AM, Resident 1 had just gotten out of the shower. While she was changing and the curtains were closed, Resident 1 heard a knock on the door. Resident 1 stated she called out loudly, I am changing, do not enter. A few minutes later, a housekeeper (HK 1) entered the room, opened the curtain, and looked at her while she was naked. Resident 1 stated that she yelled at him (HK 1) to leave. Resident 1 further stated that a few minutes later (approximately five minutes), [HK 1] returned to the room, pretending he needed to retrieve an extension cord from the wall next to her bed. Resident 1 stated that again, [HK1] opened the curtain and looked at her while she was naked. Resident 1 reported that she informed the facility's social worker [SSD] of the incident within a few minutes and filed a grievance. During the same interview, on 8/14/2025, at 1:52 PM, Resident 1 stated that the next day, on 8/13/2025, when she returned to her room after walking with RNA 1, Resident 1 saw HK 1 mopping the floor inside her room. Resident 1 stated she did not enter the room because HK 1's presence made her uncomfortable. Resident 1 expressed feeling violated, humiliated, and ignored. Resident 1 stated that after reporting the incident, her concerns were dismissed, and she was told she would be transferred to another facility. Resident 1 stated she felt isolated, mistreated, and discriminated against in how her complaint was handled. During the interview, Resident 1 became emotional and began crying. During an interview on 8/14/2025, at 2:14 PM, the Social Services Director (SSD) stated that on 8/12/2025, around 10 AM, she went to Resident 1's room. The SSD reported that Resident 1 was angry because a housekeeper (HK 1) had entered her room on 8/12/2025 without permission while she was changing. The SSD stated that Resident 1 was angry and yelling. The SSD stated she attempted to provide emotional support but was not successful. The SSD stated that she reported the incident the same day to the Director of Nursing (DON) and the Housekeeping Supervisor. The SSD stated that Resident 1 remained angry and upset throughout the day, so she decided to give her space and not disturb her further. The SSD emphasized that staff should not enter any resident's room without permission, in order to respect their rights and dignity. During an interview on 8/14/2025, at 3 PM, RNA 1 stated that on 8/12/2025, at around 10 AM, she heard Resident 1 yelling and expressing anger. Resident 1 reported to her that a housekeeper (HK 1) had entered her room without permission while she was changing. RNA 1 stated that Resident 1 remained upset and angry throughout the day during her shift, from 10:00 AM to 3:00 PM. RNA 1 mentioned that she did not intervene because she saw the SSD and LVN 1 already present in Resident 1's room. RNA 1 further stated that on 8/13/2025, in front of Resident 1's room, Resident 1 observed HK 1 mopping the floor of Resident 1's room. Resident 1 asked HK 1 to dry the floor before she entered the room because the floor was wet. RNA 1 stated HK 1 did not respond and remained standing there, so CNA 4 dried the floor to allow Resident 1 to enter the room. RNA 1 stated that Resident 1 became very angry and upset upon seeing HK 1. During an interview on 8/15/2025, at 3:49 PM, with HK 1, HK 1 stated that he does not understand or speak English. When asked if he understood the phrase I am changing, do not enter the room, he responded that he did not understand. HK 1 stated that on 8/12/2025, at around 9 AM, he noticed that Resident 1 was lying in bed. Around 10:00 AM, he knocked on Resident 1's door. The curtains were closed, and he did not hear a response, so he entered the room. While mopping the floor, the dust pad hit Resident 1's bed. At that point, HK 1 stated he heard Resident 1 yelling. HK 1 stated that he did not understand what Resident 1 was saying, so he left the room. HK 1 further stated that he was not aware of the facility's policy regarding what to do if a resident does not respond after a knock on the door. During the same interview on 8/15/2025, at 3:49 PM, HK 1 stated that on 8/13/2025, while mopping the floor in Resident 1's room, Resident 1 was ambulating with RNA 1. HK 1 stated Resident 1 asked him to do something, but he did not understand. HK 1 stated, CNA 4 then dried the floor so Resident 1 could enter the room. HK 1 stated that on 8/13/2025, he received an in-service training instructing staff not to enter any resident's room without permission. HK 1 also stated that, as of the time of the interview, his assignment had not changed and he was still assigned to clean Resident 1's room. During an interview on 8/14/2025, at 4:38 PM, the DON stated that on 8/12/2025, around 10 AM, she heard Resident 1 yelling and appearing angry. The DON reported that the SSD informed her that Resident 1 had reported a housekeeper entered her room without permission while she was changing. The DON stated that she did not enter Resident 1's room or inquire further about the incident. She mentioned that throughout the day, she heard multiple instances of Resident 1 being angry. However, she did not speak with Resident 1 about the incident, as she was waiting for her (Resident 1) to calm down before initiating a conversation. The DON acknowledged that Resident 1's yelling and anger represented a change in condition, but staff did not initiate a care plan, complete an SBAR, or monitor Resident 1 for emotional distress. She also confirmed that no psychiatric evaluation was scheduled for the 8/12/2025 incident, and the physician was not notified. The DON stated that no in-service training was provided to housekeeping staff on 8/12/2025 because the training was conducted the following day by the Housekeeping Supervisor. The DON stated she was unsure whether the Housekeeping Supervisor had changed the housekeeper's assignment. The DON emphasized that staff should not enter any resident's room without permission, as it is essential to respect the resident's dignity and rights. The DON stated that she should have initiated a care plan, completed an SBAR, monitored Resident 1 for emotional distress, and provided emotional support on 8/12/ 2025. During an interview on 8/15/2025, at 10:03 AM, LVN 1 stated that she was assigned to Resident 1 on 8/12/2025. LVN 1 stated that sometime between 10 AM and 12 PM, she heard that Resident 1 was very angry and upset. LVN 1 stated that she was informed by the DON that HK 1 had entered Resident 1's room without permission while she was changing. During her shift from 10 AM to 3 PM, LVN 1 stated she observed that Resident 1 appeared upset. However, she did not ask about the reason and did not initiate a care plan or Change of Condition (COC) documentation, as she was under the impression that the DON had already completed the COC and addressed Resident 1's concerns. LVN 1 stated that there is no psychiatric evaluation scheduled for Resident 1 at this time. She added that if a resident is experiencing outbursts of anger or emotional distress, the facility should create a change in condition assessment, develop a care plan, and monitor the resident for emotional distress for 72 hours. LVN 1 stated that no care plan or COC was initiated for Resident 1 on 8/12/2025. During an interview on 8/15/2025, at 11:05 AM, the Housekeeping Supervisor stated that he was informed about the incident by the Social Services Director (SSD) on 8/12/2025. He was told that HK 1 had entered Resident 1's room without permission while she was changing. He stated that he provided in-service training to HK 1 on 8/13/2025. Despite this, HK 1 was assigned again to Resident 1's room on both 8/13/2025 and the afternoon of 8/14/2025. During an interview on 8/15/2025, at 12:28 PM, CNA 2 stated that she was assigned to Resident 1 on 8/12/2025, from 7 AM to 3 PM. Around 9:30 AM to 10 AM, she assisted Resident 1 with a shower and helped her return to her room. Later, between 10 AM and 10:30 AM, CNA 2 stated she heard Resident 1 yelling and noticed that she appeared upset. CNA 2 stated that Resident 1 reported to her that housekeeping had entered the room without permission while she was changing. CNA 2 added that Resident 1 remained very upset and angry for the rest of the day, from 10 AM to 3 PM on 8/12/2025. During a review of the facility's Policy and Procedure titled Dignity, revised February 2021, the P&P indicated that: Each resident shall be cared for in a manner that promotes and enhances their sense of well-being, satisfaction with life, and feelings of self-worth and self-esteem. Residents are to be treated with dignity and respect at all times. Staff are expected to knock and request permission before entering a resident's room. During a review of the facility's Policy and Procedure titled Quality of Life - Accommodation of Needs, revised November 2010, the P&P indicated that the facility's environment and staff behaviors are directed toward assisting residents in maintaining and/or achieving independent functioning, dignity, and well-being. The P & P indicated to accommodate individual needs and preferences, staff attitudes and behaviors must support residents in maintaining independence, dignity, and well-being to the extent possible and in accordance with the residents' wishes. Staff shall interact with residents in a manner that accommodates their physical or sensory limitations, promotes communication, and preserves their dignity. During a review of the facility's Policy and Procedure titled Resident Rights, revised February 2021, it was indicated that:Employees shall treat all residents with kindness, respect, and dignity.Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to:Be treated with respect, kindness, and dignity.Be free from abuse, neglect, misappropriation of property, and exploitation.Privacy and confidentiality.Voice grievances to the facility or to another agency that hears grievances, without discrimination, reprisal, or fear of retaliation.Have the facility respond to his or her grievances. During a review of the facility's document titled Job Description - Social Services, dated 2023, the P&P indicated that the duties and responsibilities of Social Services include:Assisting residents and their families with emotional problems, including anxieties and stress caused by illness and admission to the facility, difficulties coping with residual physical disabilities, fears related to helplessness and death, and the need for institutional and specialized care.Interpreting the social, psychological, and emotional needs of the resident and/or family to the medical staff, attending physician, and other members of the resident care team.Assisting in obtaining resources from community social, health, and welfare agencies to meet the needs of the resident.Providing consultation to staff members, community agencies, and others in efforts to address the needs and problems of residents through the development of social service programs.Demonstrating the ability to seek out new methods and principles and a willingness to incorporate them into existing social services. During a review of the facility's Policy and Procedure titled Care Plan, revised in March 2022, the P&P indicated that: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements this care plan. The comprehensive, person-centered care plan:Includes measurable objectives and timeframes.Describes the services to be furnished in order to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.Includes the resident's stated goals upon admission and desired outcomes.Builds on the resident's strengths.Reflects currently recognized standards of practice for identified problem areas and conditions.Services provided or arranged by the facility and outlined in the care plan must be delivered by qualified personnel. Care plan interventions are selected only after thorough data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision-making.Whenever possible, interventions should address the underlying source(s) of the problem areas, not just the symptoms or triggers. Resident assessments are ongoing, and care plans are revised as new information becomes available or as the resident's condition changes.The interdisciplinary team reviews and updates the care plan:When there has been a significant change in the resident's condition.When the desired outcome is not met.

Based on interview and record review the facility failed to develop a person-centered care plan (a treatment plan that focused on the needs and preferences of a resident or individual) for five of 14 sampled residents (Resident 47, Resident 44, Resident 56, Resident 41, and Resident 14) by failing to: 1. Develop a resident specific care plan for Resident 47 ' s specific food preferences and dietary needs. 2. Develop a resident specific care plan for Resident 44, 56, and 41 oxygen therapy. 3. Develop a resident specific care plan for Resident 14's epilepsy medications: Lacosamide (medication used to control certain types of seizures in people with epilepsy), Keppra (medication used to treat seizures caused by epilepsy), and Lamictal (medication primarily used as an anticonvulsant, often prescribed for epilepsy). These deficient practices had the potential for a lack of individualized care and to affect the quality of services provided to Resident 44, Resident 56, Resident 41, and Resident 14, and negatively impact Resident 47's nutritional status and place the resident at risk for weight loss. Findings: 1. During a review of resident 47's admission Record (AR), indicated the resident was admitted on [DATE] with a diagnosis of chronic pulmonary edema (fluid accumulation in the tissue or spaces of the lungs) and acute respiratory failure (a condition where you don ' t have enough oxygen in the tissues in your body). During a review of Resident 47's History and physical (H&P), dated 5/18/2025, indicated the resident has the capacity to understand and make decisions. During a review of Resident 47's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 5/12/2025, indicated the resident ' s cognition (ability to reason and think normally) was intact. During a review of Resident 47's Weight and Vitals Summary report indicated from 5/8/2025 to 6/11/2025 Resident 47 had a 75.4 lbs. weight loss. During a review of Resident 47' Intake of meals indicated from 5/19/2025 to 6/17/2025 Resident 47 ate an average 25 - 50 % of all meals. During a review of Resident 47's Nutritional Screening record on admission dated 5/13/2025, did not include to indicate resident ' s food preferences. During a review of Resident 47's Comprehensive Nutritional Screening record, dated 6/1/2025, the record did not indicate the resident ' s food preferences. During an interview on 6/17/2025 at 12:04 PM with Resident 47, the resident stated, No one has ever asked what food I like Resident 47 explained he does not like the food at the facility because it was not cooked right. During a concurrent interview and record review on 6/17/2025 at 12:13PM with the Director of Nursing (DON), Resident 47 ' s care plans (CP) dated 5/13/2025, titled Nutritional Status were reviewed. The DON stated no CP for food preferences was created for Resident 47. The DON stated Resident 47 ' s CP did not include interventions specific to the resident ' s food preferences or detail how staff should accommodate or monitor the resident ' s food preferences and acceptance of meals. During a concurrent interview and record review on 6/17/2025 at 12:13 with the DON, Resident 47 ' s Nutritional Screening on admission dated 5/13/2025 and reevaluation dated 6/4/24 was reviewed. The DON stated the Registered Dietitian (RD) did not include Resident 47 ' s food preferences in the CP. During an interview with on 6/17/2025 at 12:59PM with the Dietary Supervisor (DS), the DS stated he was responsible for creating nutritional CP, but he did not create a CP for Resident 47 ' s food preferences. During a review of the facility ' s policy and procedure ( P&P) titled, Care plans, Comprehensive person- Centered, dated 2025, the P&P indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident ' s physical, psychosocial and functional needs is developed and implemented for each resident. 2a. During a review of Resident 44 ' s AR, indicated the resident was admitted to the facility on [DATE] and readmitted to the facility on [DATE], with diagnoses that included acute respiratory failure with hypoxia (a sudden and life-threatening condition where the respiratory system cannot adequately exchange gases, resulting in insufficient oxygen or excessive carbon dioxide in the blood), end stage renal disease (ESRD, the final, irreversible stage of chronic kidney disease [CKD, kidneys were so damaged and could not filter blood as well as they should have]), and heart failure (a condition where the heart was unable to pump enough blood to meet the body ' s needs). During a review of Resident 44's H&P, dated 1/17/2025, the H&P indicated the resident had capacity to understand and make decisions. During a review of Resident 44's MDS, dated [DATE], indicated the resident ' s cognition was intact (sufficient judgment and self-control to manage the normal demands of the environment). The MDS indicated the resident ' s health conditions included shortness of breath (SOB) or trouble breathing with exertion (e.g., walking, bathing, and transferring), when sitting at rest, and when lying flat. During a review of Resident 44's Physician ' s Order (PO) dated 6/4/2025 at 1:28 PM, the PO indicated oxygen (O2) therapy (routine): May administer O2 at 3 liters per minute (L/min) via nasal cannula. Goal saturation (the percentage of hemoglobin [protein found in red blood cells] in your blood that was carrying oxygen) greater than 92%. During a review of Resident 44 ' s Comprehensive (Complete) Care Plan (CP) for 6/4/2025, the CP indicated there was no oxygen care plan initiated after Resident 44 ' s oxygen order was placed. During an interview on 6/17/2025 at 4:18 PM, Licensed Vocational Nurse (LVN) 4 stated Resident 44 did not have a care plan for oxygen but there should have been one. LVN 4 stated if there was no care plan for oxygen, there could be a delay in care and the resident would be at risk for hypoxemia (when your body or parts of your body were not getting enough oxygen) and lead to several things like distress and cause cardiac dysrhythmias (a condition where the heart ' s rhythm was irregular, either too fast, too slow, or with an uneven pattern). During a concurrent interview and record review of Resident 44 ' s Comprehensive CP on 6/18/2025 at 9:26 AM, the DON stated there should have been an oxygen CP for Resident 44. The DON stated without a CP the facility staff would not know the resident ' s whole oxygen therapy and not know the specific plan of care, interventions, and what the goals were for the resident which could lead to respiratory issues like low oxygen saturation or shortness of breath. 2b. During a review of Resident 56 ' s AR, the AR indicated the resident was admitted to the facility on [DATE], with diagnoses that included dementia (a progressive state of decline in mental abilities), type 2 diabetes (a condition where the body did not use insulin properly, meaning the body could not get enough sugar from the blood into cells for energy), and hypothyroidism (a condition where the thyroid gland did not produce enough thyroid hormones). During a review of Resident 56 ' s H&P dated 5/9/2025, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 56 ' s MDS dated [DATE], the MDS indicated the resident had severe cognitive impairment (problems with a person ' s ability to think, learn, remember, use judgement, and make decisions). The MDS indicated the resident required substantial/maximal assistance (helper did more than half the effort) from facility staff for oral/toileting hygiene, rolling from the left and right side and was dependent (helper did all of the effort) from facility staff for showering and personal hygiene. During a review of Resident 56 ' s PO dated 5/30/2025 at 6:08 PM, the PO indicated oxygen therapy, as needed (PRN): May administer O2 at 2 L/min via nasal cannula as needed for SOB or O2 saturation lower than 92%. May titrate to achieve O2 saturation above 92%. During a review of Resident 56 ' s Comprehensive CP for 5/30/2025, the CP indicated there was no oxygen care plan initiated after Resident 56 ' s oxygen order was placed. During a concurrent interview and record review of Resident 56 ' s Comprehensive CP on 6/18/2025 at 1 PM, the DON stated Resident 56 did not have an oxygen CP but should have had one. The DON stated if the resident did not have a CP, Resident 56 might not receive the full regimen for oxygen therapy and could develop respiratory issues like low oxygen saturation or SOB. 2c. During a review of Resident 41 ' s AR, the AR indicated the resident was admitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing), dependence on supplemental oxygen, and atherosclerosis (a condition where fatty deposits [plaque] build up in the inner lining of the arteries). During a review of Resident 41 ' s H&P dated 11/1/2024, the H&P indicated the resident had capacity to understand and make decisions. During a review of Resident 41 ' s MDS dated [DATE], the MDS indicated the resident ' s cognition was intact. The MDS indicated the resident ' s health conditions included shortness of breath (SOB) or trouble breathing with exertion, when sitting at rest, and when lying flat. The MDS indicated the was receiving oxygen therapy. During a review of Resident 41 ' s PO dated 5/30/2025, the PO indicated oxygen therapy (routine): May administer O2 at 2 L/min via nasal cannula every shift for SOB or hypoxia. May titrate to achieve O2 saturation above 92%. During a review of Resident 41 ' s Comprehensive CP for 5/30/2025, the CP indicated there was no oxygen care plan initiated after Resident 41 ' s oxygen order was placed. During a concurrent interview and record review of Resident 41 ' s Comprehensive CP on 6/18/2025 at 1:05 PM, the DON stated Resident 41 did not have an oxygen CP but should have had one. The DON stated if the resident did not have a care plan, Resident 41 might not receive the full regimen for oxygen therapy and could develop respiratory issues like low oxygen saturation or SOB. 3. During a review of Resident 14 ' s AR, the AR indicated the resident was admitted to the facility on [DATE], with diagnoses that included chronic COPD, epilepsy (a brain disorder characterized by recurrent, unprovoked seizures [a sudden uncontrolled surge of electrical activity in the brain that could cause a range of symptoms from brief lapses in awareness to convulsions]), and gastro-esophageal reflux disease (GERD, a condition where stomach acid frequently flows back into the esophagus, causing irritation and discomfort). During a review of Resident 14 ' s H&P dated 2/8/2025, the H&P indicated the resident had capacity to understand and make decisions. During a review of Resident 14 ' s PO dated 3/11/2025 at 5:11 AM, the PO indicated Lacosamide oral tablet 200 milligrams (mg, unit of measurement), give one tablet by mouth every 12 hours for seizure. During a review of Resident 14 ' s Comprehensive Care Plan for 3/11/2025, the Care Plan indicated there was no care plan for Lacosamide initiated after Resident 14 ' s Lacosamide order was placed. During a review of Resident 14 ' s PO dated 3/27/2025 at 10 AM, the PO indicated Keppra oral tablet 500 mg, give one tablet by mouth two times a day for seizure, do not crush. During a review of Resident 14 ' s Comprehensive CP for 3/27/2025, the CP indicated there was no CP for Keppra initiated after Resident 14 ' s Keppra order was placed. During a review of Resident 14 ' s MDS dated [DATE], the MDS indicated the resident ' s cognition was intact. The MDS indicated the resident required supervision or touching assistance (helper provided verbal cues and/or contact guard assistance) from facility staff for toileting hygiene, showering, and transfers. The MDS indicated the resident was independent with eating, oral/personal hygiene, and upper body dressing. During a review of Resident 14 ' s PO dated 6/4/2025 at 10:16 PM, the PO indicated Lamictal oral tablet 25 mg give three tablets by mouth two times a day for seizures. During a review of Resident 14 ' s Comprehensive CP for 6/4/2025, the CP indicated there was no care plan for Lamictal initiated after Resident 14 ' s Lamictal order was placed. During a concurrent interview and record review of Resident 14 ' s Comprehensive CP on 6/18/2025 at 12:30 PM, the DON stated Resident 14 did not have a care plan for Lacosamide, Keppra, and Lamictal but should have had one to know what side effects to monitor for. The DON stated if the resident did not have a care plan there was risk for Resident 14 to experience adverse side effects or reactions and develop a change of condition related to the medications. During a review of the facility ' s policy and procedure (P&P) titled, Oxygen Administration dated February 2014, the P&P indicated in preparation of oxygen administration, the facility must Review the resident ' s care plan to assess for any special needs of the resident. The P&P indicated to Verify that there is a physician ' s order for this procedure. Review the physician ' s orders or facility protocol for oxygen administration. During a concurrent interview and record review with the DON on 6/18/2025 at 1:27 PM of the facility ' s P&P titled, Care Plans, Comprehensive Person-Centered dated March 2022 , the P&P indicated The comprehensive, person-centered care plan: includes measurable objectives and timeframes; describes the services that are to be furnished to attain or maintain the resident ' s highest practicable physical, mental, and psychosocial well-being; and includes the resident ' s stated goals upon admission and desired outcomes. The P&P indicated Assessment of resident are ongoing, and care plans are revised as information about the residents and the resident ' s conditions change. The interdisciplinary team reviews and updates the care plan: when there has been a significant change in the resident ' s condition, when the desired outcome is not met, when the resident has been readmitted to the facility from a hospital stay, and at least quarterly. The DON stated the facility was not following the facility ' s P&P but should have been. The DON stated otherwise there would be potential gaps on the resident ' s care and the resident may potentially not receive the care that was specific to their diagnosis or medication.

Based on observation, interview and record review the facility failed to safely store, discard drugs and biologicals in accordance with the professional standard of practice and facility ' s policy and procedure for two of two sampled residents (Resident 2 and 25) by failing to: 1. Medication Cart (MC) 1 was found to have one insulin pen (a device used to inject insulin, a medication that is used to control the blood sugar), belonging to Resident 25, that was not labeled with the opened date. 2. MC 2 was found to have 2 bottles of over-the-counter medications, Naproxen Sodium (an over-the-counter pain medication) 220 mg (unit of measuring weight) and Vitamin B1 (a supplement) 100 mg, that were not labeled with the opened dates. These deficient practices had the potential for staff to administer potentially expired medications to residents and the insulin pens, which may have less efficacy, could lead to the mismanagement of the blood sugar of Resident 25. Findings: 1. During a review of Resident 25 ' s admission Record, indicated the resident was admitted on [DATE] with diagnoses that included diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control, or high blood sugar and result in poor wound healing) and pressure ulcer (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence). During a review of Resident 25 ' s History and Physical (H&P), dated 5/30/2025, indicated the resident does have the capacity to understand and make decisions. During a review of Resident 25 ' s Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 6/4/2025, indicated the resident has moderately impaired cognition (ability to process thoughts). The MDS also indicated that the residents receive medications that lower the blood sugar, such as insulin. During a review of Resident 25 ' s physician orders for June 2025, included insulin Regular Human Injection Solution, inject as per sliding scale, administer subcutaneously (a method of administering medication into the fatty tissue layer just beneath the skin, but not into the muscle) before meals and at bedtime for DM. During a concurrent observation of MC 1 and interview on 6/17/2025 at 1:40 PM with Licensed Vocational Nurse (LVN) 5, one opened Insulin pen labeled with Resident 25 ' s name was without a label for the date it was first opened or when the Insulin will be discarded. LVN 5 stated she was not aware who opened the medication first because all medications, including insulin, must be labeled with the opened date. LVN 5 stated insulin must be discarded 28 days after the insulin was opened because insulin loses efficacy over time. 2. During a concurrent observation of MC 2 and interview on 6/17/2025 at 1:24 PM with LVN 5, the facility ' s MC 2 was inspected and one bottle of Naproxen Sodium 220 mg and Vitamin B1 100 mg was observed opened, without label indicating the date the medications were opened. LVN 5 stated the bottles of medications must be labeled with opened date because some medications need to be discarded earlier than the manufacturer-printed expiration date once they have been opened. During an interview on 6/18/2025 at 1:31 PM with the Director of Nursing (DON), the DON stated multi-dose medications (medication container that holds enough medication for more than one use or patient) must be labeled with the date they were opened. The DON stated insulin must be discarded 28 days after the initial opened date because insulin loses efficacy over time. The DON added if insulin with decreased efficacy is administered, it could lead to the mismanagement of the resident ' s blood sugar. During a review of the facility ' s P&P titled, Medication Labeling and Storage, revised 2/2023, indicated nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. The P&P also indicated labeling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices. The P&P also indicated multi-dose vials that have been opened or accessed are dated and discarded within 28 days unless. During a review of the facility ' s P&P titled, Administering Medications, revised 4/2019, indicated the expiration date on the medication label is checked prior to the administration of medications. The P&P also indicated when opening a multi-dose container, the date opened is recorded on the container.

Based on observation, interview, and record review, the facility failed to store food in accordance with professional standards of practice for food service safety by failing to: 1. Monitor and document in the temperature log the refrigerator and dry storage room temperatures to ensure temperatures were within the federal guidelines. 2. Ensure that refrigerated prune juice in the jar was discarded after five days after opening in accordance with the facility ' s policy and procedure titled, Dry Goods Storage Guidelines. These deficient practices placed the facility ' s residents at risk for foodborne illness (an illness that comes from eating contaminated food) by serving expired fruit juice and due to inconsistent refrigerator temperature monitoring and documentation. Findings: During an initial kitchen tour on 6/16/2025 at 8:10 AM, the walk-in refrigerator, one regular refrigerator, and one regular freezer were observed in the kitchen were observed with one thermometer inside. Two Refrigerator/ Freezer Temperature Log, Kitchen dated June 2025 were observed hanging on the door of the regular refrigerator and freezer, and the temperature logs were filled through 6/15/2025 and no temperature was logged for 6/26/2025. During the same observation on 6/16/2025 at 8:11 AM, a plastic jar with liquids labeled prune dated 6/3/25 was observed in the regular refrigerator. During the same observation on 6/16/2025 at 8:12 AM, a plastic container with food labeled apple sauce and dated 6/12/25 was observed in the regular refrigerator. During an interview with the Dietary Supervisor (DS) on 6/16/2025 at 8:15 AM, the DS stated the [NAME] who worked in the morning (Cook 1) was assigned to check all the temperature in the refrigerators and freezers and document in the temperature log every morning. The DS stated he was not sure if [NAME] 1 checked the refrigerator and freezer, but he should have not missed daily inspection and logging the temperature. The DS stated he was not sure whether the dates labeled for the prune juice and apple sauce were the date opened or the use-by date. The DS stated every staff should label and write appropriately, clearly open or use-by date. The DS stated the prune juice should have been discarded after five days. The DS also stated he was responsible for checking the logs, overseeing the food storage, and supervising the staffs for keep the log to ensure all the temperature in the refrigerators and freezers being monitored, and food is stored following the food code for safe food storage. During an interview on 6/17/2025 at 8:29 AM with [NAME] 1, [NAME] 1 stated meal preparation activity started at 5 AM. [NAME] 1 stated it ' s her responsibility to monitor and log the temperature when she starts her shift. The [NAME] 1 also stated she checked the temperatures including dry storage room, the refrigerators, and freezer but she forgot to log some of the temperatures yesterday (6/16/2025) and today (6/17/2025). During an interview with the Dietary Supervisor (DS) on 6/17/2025 at 8:35 AM, the DS stated that daily inspection before meal preparation activity like checking temperatures and logging should never be missed. The DS also stated it was necessary to ensure all food were stored at appropriate temperature to prevent foodborne illnesses on the residents. During a review of the facility ' s Policy and Procedure (P&P) titled, Dry Goods Storage Guidelines dated 2018, the guideline indicated that This storage length is to be followed unless you have manufacturers recommendation showing it can be kept longer. This guideline also indicated that opened fruit juices may be stored refrigerated up to five days. During a review of the facility's P&P titled, Food Receiving and Storage, revised in 11/2022, the P&P indicated the following: Unused portions of canned fruits and vegetables must be transferred to clean, approved storage containers. Do not store in open cans. Remove any serving utensils and cover tightly. Label and date container. Functioning of the refrigeration and food temperatures are monitored daily and at designated intervals throughout the day by the food and nutrition services manager or designee and documented according to state-specific requirements.

Based on observation, interview and record review, the facility failed to maintain appropriate infection prevention and control practices for two of six sampled residents (Resident 35 and 109) by failing to: 1. Ensure Resident 35 who was on contact precautions for a multidrug – resistant organism (MDRO) had alcohol- based hand sanitizer that was readily available and accessible at the point of care. 2. Ensure Resident 109 ' s peripheral IV (Intravenous- a tube inserted into a needle used to infuse medication into the vein) line port that inserted into the IV was uncapped (not covered) after the administration of intravenous antibiotics (medication used to treat infection) and was touching the bedside curtain. 3. Ensure the port of Resident 22 ' s enteral nutrition administration set [known as gastrostomy tube (GT) feeding, a tube surgically inserted into the stomach to allow access for food fluids and medications] was covered and exposed when not in use while hanging on the IV (intravenous, administered within or into a vein) pole. These deficient practices had the potential for cross- contamination (spread of infection from one area to another) and increased the risk for the residents to acquire infection that could be spread into the bloodstream. Findings: 1. During a review of resident 35 ' s admission Record (AR) indicated the resident was admitted to the facility on [DATE] with diagnosis that included acute osteomyelitis (inflammation or swelling of bone tissue), left ankle and foot. During a review of resident 35 ' s History and Physical (H&P), dated 1/20/2025 indicated the resident has the capacity to understand and make decisions. During a review of resident 35 ' s Minimum Data Set (MDS – a standardized assessment and screening tool), indicated the resident is cognitively intact (ability to think normally). During a review of Resident 35 ' s Order Summary Report (OSR), dated 6/5/2025, indicated the resident was placed on contact isolation for extended spectrum beta – lactamase ESBL - (producing bacteria that can ' t be killed by many of the antibiotics that doctors use to treat infections) of foot wound. During an observation on 6/16/2025 at 10:22 AM of Resident 35 ' s room, a signage indicated Contact Isolation Precaution (infection control measure used by healthcare setting to prevent spread of germs that could be contacted by direct or indirect contact) for MDRO was posted outside of Resident 35 ' s room. The observation revealed that inside the Resident 35 ' s room, the alcohol-based hand sanitizer was not functional. Additionally, the pump lever fell off when trying to use the hand sanitizer dispenser. During an interview on 6/16/2025 at 10:35 AM with Licensed Vocational nurse (LVN) 2. LVN 2 stated the importance of having a functional hand sanitizer is to protect the staff and residents and prevent the spread of infection. During an interview on 6/16/2025 at 10:38 AM with Registered Nurse (RN) 1, RN1 stated that the hand sanitizer should be working in the resident ' s room. RN 1 also stated it is important for infection control and to prevent spread of germs. During an interview on 6/17/2025 at 08:52AM with the Activity Director (AD), the AD stated in a Contact Isolation room, we take off our personal protection by removing our gloves, gown and mask and then use the hand sanitizer in room prior to exiting. During a review of the Facility ' s policy and procedure (P&P) titled, Hand washing/ Hand Hygiene, dated 2023, indicated this facility considers hand hygiene the primary means to prevent the spread of healthcare -associated infections and to promote hand hygiene the hand hygiene products and supplies such as alcohol-based hand rub will be readily accessible and convenient for staff use to encourage compliance with hand hygiene policies. Dispensers are placed in areas of high visibility and consistent with workflow throw-out the facility. 2. During a review of Resident 109 ' s AR, the AR indicated resident 109 was admitted on [DATE] with a diagnosis including Acute osteomyelitis (infection of the bone) or the right and left ankle and foot. During a review of Resident 109 ' s H&P, dated 5/30/2025, indicated Resident 109 has the capacity to understand and make his own decisions. During a review of Resident 109 ' s MDS, dated [DATE] indicated, Resident 109 ' s cognition was intact (no mental impairment). During a review of Resident 109 ' s OSR, dated 5/29/2025, indicated resident 109 was contact Isolation due Methicillin Resistant Staphylococcus aureus MRSA (a type of bacteria resistant to medications that used to treat infection) of the left leg. During a review of Resident 109 ' s OSR, dated 6/6/2025, indicated IV tubing will be changed every 24 hours. During a review of Resident 109 ' s OSR, dated 5/29/2025, indicated Linezolid (a medication to treat infection) IV solution 600 mg to be administered intravenously every 12 hours for left foot wound ESBL. During a review of Resident 109 ' s Care plan titled The resident is on antibiotic therapy dated 5/29/2025, with a goal the resident will be free of any discomfort or adverse side effects (undesired effect) of antibiotic therapy through the review date of 7/5/2025. During an observation on 6/16/2025 at 10:47 AM, Resident 109 ' s IV tubing was uncapped and hanging from IV pole without protective cover on the distal end that was touching the beside curtains. During a concurrent observation and interview on 6/16/2025 at 11:03 AM with Registered Nurse 1 (RN) 1, RN1 stated there was no cap on tip of Intravenous line. RN1 stated there should be a cap on the end of line for infection control and stated the resident could be infected by the contaminated IV. RN1 stated the reason she did not place a cap on the line was because she could not find one. During a review of Facility ' s policy and procedure, undated, indicated all administration set connections will be secured with tape, a Luer locking system (typically used with male connectors on syringes and female connectors on needles or other medical devices. These connectors can be twisted together, creating a secure and leak-proof connection), or a line- connection securing device. 3. During a review of Resident 22 ' s AR, the AR indicated that Resident 22 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing) with acute exacerbation (a sudden worsening of symptoms), dysphagia (difficulty swallowing), and gastrostomy status (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). During a review of Resident 22 ' s Physician Orders dated 5/6/2025, the Physician Orders indicated to continue GT feeding of Jevity 1.5 Formula (a product containing calorically-dense, high-protein, fibre-fortified liquid formula) at 60cc/hr [cubic centimeter (unit of volume) per hour (unit of time)] x (for) 20 hours to provide 1200cc 1800 Kcal (kilocalories, unit of energy) in 24 hours via enteral feeding pump. During a review of Resident 22 ' s MDS, dated [DATE] indicated that Resident 22 was severely cognitively impaired (a condition that makes it very difficult for a person to think, learn, and remember). The MDS also indicated Resident 22 required substantial/maximal assistance (helper does more than half the effort) on personal hygiene, rolling left and right, sitting to lying, and lying to sitting on side of bed. During a review of Resident 22 ' s Care Plan dated 4/27/2025, the care plan indicated Resident 22 was placed on Enhanced Barrier Precautions with a feeding tube, and the interventions included to adhere to facility guidelines on infection control protocol. During an observation on 6/17/2025 at 11:01 AM in Resident 22 ' s room, Resident 22 ' s GT administration set, labeled with the resident's name and dated 6/17/2025, was connected to a GT feeding pump that was turned off. Resident 22 ' s GT administration set was not connected to the resident ' s GT site and was hanging on an IV pole while the GT administration tube port was uncapped/uncovered. During the same concurrent observation and interview on 6/17/2025 at 11:10 AM with the Licensed Vocational Nurse (LVN) 2 in Resident 22 ' s room, LVN 2 stated the uncapped/uncovered GT administration tube port would be reconnected to Resident 22 when feeding was to be resumed at 12:30 PM as ordered. LVN 2 stated she did not cap or cover GT port to ensure it was not exposed to prevent contamination and infection as she was responsible to. During an interview on 6/18/2025 at 11:55 AM with the Director of Nursing (DON), the DON stated that all licensed nurses need to follow the facility ' s infection prevention and control protocol included proper and safe handling of Resident 22's feeding tube and feeding bag, such as the GT administration tube port should be properly covered/capped when not in use. The DON stated any likely contaminated equipment should never be used on residents due to concerns of infections. During a review of the facility ' s Policy and Procedure (P&P) titled Enteral Tube Feeding via Continuous Pump revised in 11/2018. The P&P indicated to use aseptic technique when preparing or administering enteral feedings.

Based on interviews and record reviews, the facility failed to ensure one of four sampled residents (Resident 1), who had severely impaired cognition (thought process), severe contractures (a permanent tightening of the muscle, tendon, skin, and nearby tissues that cause the joints to shorten and become very stiff) to the upper and lower extremities, was free from accidents and hazards by failing to: 1. Ensure Licensed Vocational Nurse [LVN] 1 and Registered Nurse (RN) 1 provided report and informed Certified Nurse Assistant (CNA) 1 on potential accident hazards concerning Resident 1's activities of daily living [ADL- fundamental skills that people need to do every day to care for themselves independently], including transfers from bed to chair and bathing, in accordance with the facility's policies and procedures [P&P] titled, Activity of Daily Living. 2. Ensure a care plan was developed to address Resident 1's specific needs for ADL assistance to monitor interventions and mitigate [make less severe] accident hazards identified is developed for Resident 1's bathing and transfer needs, in accordance with the facility's P&P Safety and Supervision of Residents, and Care Plans, Comprehensive Person-Centered. 3. Ensure CNA 1 identify and report to LVN 1 and RN 1 potential accident hazards to prevent avoidable accidents on 7/17/2024, after observing Resident 1 had severe contractures to both upper and lower extremities and stiffness [tightness or pain in the muscles, which can make it difficult to move] between the legs, prior to showering the resident on 7/17/2024. On 7/17/2024, CNA 1 placed Resident 1 from the bed to the shower chair (movable chairs designed to be used for bathing and placed inside the shower stall) alone and washed between the resident's legs by stretching the resident's lower extremities. As a result, Resident 1 complained of severe pain on 7/17/2024 after the shower. The facility transferred Resident 1 to the General Acute Care Hospital (GACH) 2 via 911 emergency services and was treated in GACH 2 Intensive Care Unit (ICU - specialized unit and treatment given to individuals who are acutely unwell and require critical medical care). Resident 1 sustained injuries to the lower extremities which included closed displaced fracture [a type of bone fracture where the bone breaks completely and moves out of alignment, creating a gap, but the skin does not break] of left acetabulum (socket of the hipbone [large bone between the waist and your legs], into which the head of the femur [thigh bone] fits), multiple pelvic fractures (break or crack open in one or more of the bones that make up the pelvis [(basin-shaped complex of the bones between the hips that connects the trunk and the leg]), marked widening of the pubic symphysis [a joint that connects the left and right pelvic bones], and hematoma [a pool of mostly clotted blood that forms in an organ, tissue, or body space caused by a broken blood vessel damaged by an injury] to the abdomen. Findings: During a review of Resident 1's Face Sheet (admission record), the Face Sheet indicated the facility admitted the resident on 1/15/2024 with diagnoses including contractures, and inactivity. During a review of Resident 1's History and Physical (H&P - a formal assessment of a patient and their medical condition performed by a healthcare provider, usually during an initial visit) dated 7/15/2024, indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1's General Acute Care Hospital (GACH) 1 H&P dated 1/9/2024, indicated that prior to admission to the facility, Resident 1 was bed to wheelchair bound with pre-existing contractures to all joints. The GACH 1 H&P indicated Resident 1 had Decrease mobility due to severe bilateral [both] upper and lower extremities contractures and wound, severe disability [significantly limits your ability to perform basic work activities], bedridden [confined to bed], incontinent (having no or insufficient control over urination or defecation), and required constant nursing care and attention . During a review of Resident 1's Minimum Data Set (MDS, a standardized resident assessment and care screening tool) dated 7/12/2024, the MDS indicated the resident's cognition (thought process) was severely impaired [a condition that significantly limits the individual's physical or mental abilities, so that he or she is unable to perform basic work activities]. The MDS indicated Resident 1 had unclear speech (slurred or mumble words). Resident 1 has rarely/never has ability to express ideas and wants and ability to understanding others. The MDS indicated Resident 1's functional limitation in range of motion (ROM- capacity for movement at a given joint) was impaired to both sides for upper and lower extremity. The MDS indicated Resident 1 was dependent (helper does all the effort. and resident does none of the effort to complete the activity, requiring assistance of two or more helper is required for the resident to complete the activity) to facility staff for shower/bathing (including washing, rinsing ,and drying self), upper body dressing, lower body dressing, personal hygiene, rolling to the left and right, sit to lying, lying to sitting on side of the bed, sit to stand, chair/bed-to-chair transfer, and toilet transfers (the ability to get on and off the toilet). The MDS further indicated for tub/shower transfers (the ability to get in and out of a tub/shower), Resident 1's assist level was Not applicable (not attempted and the resident did not perform the activity prior to the current illness). During a review of Resident 1's Physical Therapy (PT) record, titled Joint Mobility assessment dated [DATE] signed by Physical Therapist (PT) 1 indicated Resident 1's joint mobility limitations. The facility's Joint Mobility Assessment indicated the appropriate percentage (%) description for each resident's joint mobility limitation indicating Moderate limitation (50% to 75%), and severe (75% to 100%) limitation. Resident 1's Joint Mobility Assessment indicated Resident 1's left, and right shoulder had moderate joint mobility limitation, left and right elbow had moderate joint mobility limitation, left and right hip had severe joint mobility limitation, left and right knee had severe joint mobility limitation. During a review of Resident 1's facility records titled, Physical Therapy Discharge Summary dated 3/26/2024 indicated Resident 1 had contracted muscle to the right and left lower leg, required maximum assistance for wheelchair mobility, bed to wheelchair transfers, sit to stand, but stand to sitting position was Not applicable. During a review of a facility document titled Nursing Service Assignment dated 7/17/2024, indicated Certified Nursing Assistant (CNA) 1 was assigned to Resident 1 on 7/17/2024 (7 AM to 3 PM). During a review of a facility document titled Nursing Care Shower Schedule indicated Resident 1's shower days were scheduled for Wednesdays and Saturdays. During a review of Resident 1's Activities of Daily Living [ADL] worksheet under the Task Shower/Bathe Self indicated a check mark for 7/3/2024, 7/5/2024, 7/6/2024, 7/10/2024, 7/12/2024, 7/13/2024, and 7/17/2024. The ADL worksheet indicated Resident 1 was totally dependent (helper does all the effort. Resident does none of the effort to complete the activity requiring assistance of two or more helper for the resident to complete activity) with staff during showering/bathing. The ADL worksheet did not indicate the type of shower or bath provided to Resident 1. During a review of Resident 1's Progress Notes dated 7/17/2024 and timed at 1:40 PM, documented by License Vocational Nurse (LVN) 1, indicated CNA [1] gave Resident 1 a shower (no time indicated). The Progress Notes indicated at 12:55 PM, Resident 1 was observed sweating and pale . The Progress Notes indicated a vital signs [V/S- clinical measurements of a person's essential body functions] 90/62 [blood pressure-BP], 97 beats/minute [heart rate -HR], 95.6 degrees Fahrenheit [temperature], and oxygen saturation [amount of oxygen in the blood] of 90 to 91 % [normal levels between 95 to 100%] on room air [the normal air we breathe in everyday environment]. The Progress Notes indicated Resident 1 stated I have chest pain when asked for pain or discomfort and was moving his head and up and down [nodding]. The Progress Notes indicated at 1 :02 PM, Registered Nurse (RN) 1 called 911 emergency services and Resident 1 was transferred to the general acute care hospital (GACH 2) on 7/17/2024. During a review of Resident 1's Situation, Background, Assessment, and Recommendation (SBAR, a technique used to facilitate prompt and appropriate communication) form dated 7/17/2024 and timed at 12:04 PM, indicated that LVN 1, who was the charge nurse for Resident 1 on 7/17/2024 wrote that at around 12: 55 PM, Resident 1 was noted sweating and pale . The SBAR form indicated LVN 1 asked Resident 1 if he has pain or chest pain in the resident's native language to move his head up and down. The SBAR form indicated Resident 1 responded by moving his head up and down . During a review of the facility's typewritten investigation report dated 7/22/2024, authored by the Director of Nursing (DON), the investigation report indicated Resident 1 was alert and oriented to self and able to understand simple phrases and follow simple instructions. The investigation report indicated LVN 1 was alerted by the CNA to Resident 1's room around 12:55 PM on 7/17/2024, because Resident 1 was pale and the scrotum (a part of the male reproductive system. It is a sac-like structure located behind the penis and contains the testicles) was swollen. The investigation report indicated the physician ordered the resident be transferred to GACH 2 for further evaluation via 911 emergency services. The investigation report indicated that facility staff was later notified by GACH 2 staff that Resident 1's x-ray (XR- a type of electromagnetic radiation used for imaging the inside of objects, including the human body) result indicated a fracture of the pelvis. During a review of the facility's undated handwritten investigation by the DON, indicated a telephone interview was conducted with CNA 1 on 7/18/2024. The handwritten investigation indicated that on 7/17/2024, LVN 1 informed CNA 1 that Wednesdays (7/17/2024) was Resident 1's shower day. The handwritten investigation indicated CNA 1 reported having Another CNA (CNA 2) assist him. The handwritten investigation indicated CNA 1 Attempted to wash between the Resident 1 legs with towel and there was resistance, so he did not try any harder. The handwritten investigation indicated that Resident [1] started to clench (close tightly) his legs/thighs, then put a diaper on the resident. The handwritten investigation further indicated He (CNA 1) needed assistance when putting diaper on Resident 1. The handwritten investigation indicated that at Approximately 12:55 PM, he (CNA 1) called LVN 1 because Resident [1] was pale, holding on his chest and sweating . The handwritten investigation indicated Later that evening [GACH 2 staff] notified [the] charge nurse that Resident [1] had sustained a pelvic fracture. During a review of Resident 1's GACH 2 records titled, Reason for Visit dated 7/17/2024, indicated the resident sustained a Closed displaced fracture [a type of bone fracture where the bone breaks completely and moves out of alignment, creating a gap, but the skin does not break] of left acetabulum (socket of the hipbone, into which the head of the femur [thigh bone] fits), contracture of joint of multiple sites, multiple pelvic fractures, nonverbal, severe dementia [the loss of cognitive (relating to the mental processes of perception, memory, judgment, and reasoning) functioning - thinking, remembering, and reasoning]. During a review of Resident 1's GACH 2 records titled, Physical Exam dated 7/17/2024, indicated [Resident 1] Appears in pain. In fetal position [the body lies curled up on one side with the arms and legs drawn up and the head bowed forward]. Initial concern for sepsis [a serious condition in which the body responds improperly to an infection (invasion and growth of germs in the body)], suspect likely intraabdominal [within the belly] source given abdominal pain. During a review of Resident 1's GACH 2 records and titled ED [Emergency Department] management dated 7/17/2024, indicated No history reported from [facility] of fall .Patient's (Resident 1) primary issue is open book pelvic [a type of fracture when the front of the pelvis breaks and separates into two or more pieces, often caused by trauma such as in an elderly fall] fracture. The orthopedic surgeons [doctors who specialize in surgery of bones, joints, and muscles], unable to treat these fractures here, recommend transfer to trauma center. During a review of Resident 1's GACH 2 records dated 7/17/2024 and titled, XR [x-ray] Hip Left 2 to 3 View, indicated, Reidentification of fractures of the left acetabulum and left pubis with marked widening of the pubic symphysis. During a review of Resident 1's GACH 2 records dated 7/17/2024 and titled, CT abdomen with Pelvis w Contrast indicated, there is anterior pelvic inflammatory stranding and presumed hematoma. During an interview on 8/1/2024 at 12:05 PM, CNA 1 stated he was assigned to care for Resident 1 on 7/17/2024, during the 7 AM to 3 PM shift. CNA 1 stated he was from a Nursing Registry [a business or agency that provides nursing staff to hospitals], and it was his first-time taking care of Resident 1. CNA 1 stated that on 7/17/2024, at around 7 AM, LVN 1 informed him it is Resident 1's shower day. CNA 1 stated he was not informed by facility staff if Resident 1 required one person or two people assistance. CNA 1 further stated he was not informed by LVN 1 if Resident 1 should be bathed using the shower chair or a shower gurney (a mobile, waterproof stretcher used for safely bathing patients who cannot stand or sit up. It features an adjustable frame and secure straps) or be provided with a bed bath (a technique for washing a bedridden patient using a damp washcloth or sponge and water while lying in bed) in his room. CNA 1 stated he observed Resident 1 to have contractures. CNA 1 stated around 10 AM, on 7/17/2024, he started to prepare Resident 1 for a shower. CNA 1 stated that since Resident 1 was contracted in both upper and lower body, CNA 1 called CNA 2 for help to transfer Resident 1 in the shower chair. CNA 1 stated he held Resident 1's armpits and CNA 2 held Resident 1's legs and transferred (moved) the resident to the shower chair. CNA 2 stated he wheeled Resident 1 on the shower chair to the Shower Room and showered Resident 1 while sitting up on the shower chair. CNA 1 stated, while giving Resident 1 a shower, Resident 1 was squeezing both thighs together as CNA 1 tried to clean between his legs. CNA 1 stated Resident 1 did not open his legs, so he did not try to open resident's legs any harder. CNA 1 stated Resident 1 was not able to bear weight in both upper and lower extremities. After giving Resident 1 a shower, CNA 1 wheeled Resident 1 back to the resident's room. During the same interview, on 8/1/2024 at 12:05 PM, CNA 1 stated he brought Resident 1 back to the resident's room and called CNA 2 to help him transfer Resident 1 from the shower chair back to the resident's bed. CNA 1 stated that if he received a report that Resident 1 was supposed to receive only bed baths while in bed and to not transfer or move the resident onto the shower chair to bathe in the Shower Room, he would not have transferred Resident 1 in the shower chair. CNA 1 stated he would have provided Resident 1 with bed bath only. CNA 1 stated no one had informed him about Resident 1's routine or care plan for bathing. CNA 1 stated he was not aware if Resident 1 was able to sit on a regular wheelchair or shower chair. During an interview on 8/1/2024 at 12:54 PM, LVN 1 stated she was assigned to care Resident 1 on 7/17/2024, during the 7 AM to 3 PM shift. LVN 1 stated she was familiar with Resident 1 and was aware the resident is dependent [a person who depends on or needs someone or something for aid, support] on all ADLs. LVN 1 stated the facility staff started to give Resident 1 bed baths one month ago because of the resident having severe contractures. The reason for giving the resident bed baths was to ensure resident's safety to prevent the resident from falling and sustaining an injury or fracture. LVN 1 stated she could not find documented evidence of a care plan developed for Resident 1 to be provided with bed baths only due to the severity of his contractures. LVN 1 stated she informed CNA 1 of Resident 1's shower day on 7/17/2024 but did not give a detailed instruction that Resident 1 should be given a bed bath. LVN 1 stated during the beginning of the 7 AM to 3 PM shift, Resident 1 was doing well and without distress [unusual or exaggerated emotional responses]. LVN 1 stated another CNA (CNA 3), called LVN 1 on 7/17/2024 at around 12:55 PM to report that Resident 1 was pale and in pain . During an interview on 8/1/2024 at 1:28 PM, CNA 3 stated she was familiar with Resident 1 and had been assigned to care for Resident 1 in the past. CNA 3 stated Resident 1 required total assistance [staff performs the entire activity of daily living without participation by the resident] with ADLs. CNA 3 stated she had not given a shower to Resident 1 in the Shower Room for more than 3 weeks, instead she provided Resident 1 bed baths in his room. CNA 3 stated Resident 1's body slides down when sitting on the shower chair, that is why the facility's CNAs do not use the shower chair and provide Resident 1 with bed baths. CNA 3 stated that Resident 1 would not be able to sit still on a shower chair. During an interview with RN 1 and record review of Resident 1's care plans from 1/15/2024 to 7/17/2024, on 8/1/2024 at 1:40 PM, RN 1 stated there was no care plan developed for Resident 1 to specifically address how the resident would be provided with shower or bathing. RN 1 stated the facility staff had been providing Resident 1 with a bed bath due to severe contractures. RN 1 stated she was the RN Supervisor on 7/17/2024, during the morning shift and recalled informing CNA 1 on 7/17/2024, to give Resident 1 a bed bath in the room and not to transfer or move Resident 1 to the shower chair. During an interview on 8/2/2024 at 10:54 AM, Physical Therapist [PT] 1 stated Resident 1 should not use a shower chair because Resident 1 required a type of wheelchair with a high back and adjustable back rest due to severe contractures. PT 1 stated that the regular shower chair [low back] with wheels was similar to a regular wheelchair that can be unstable when used for a resident with severe contractures. PT 1 stated each facility staff should be instructed about Resident 1's limitations to ensure proper care. During an interview on 8/2/2024 at 11:12 AM, the Director of staff Developer (DSD) stated when Registry Staff [staff personnel provided by a placement service on a temporary or on a day-to-day basis, in a facility] works at the facility, there should be a shift huddle [a brief meeting that takes place at the beginning or end of a shift to share information] to get report for each residents' status and limitations. The DSD stated he could not find documented evidence in the resident's records that indicated Resident 1's bathing needs to be done in bed and not in a shower chair. The DSD stated he was not aware that facility staff had been providing bed baths to Resident 1. The DSD stated there was no specific care plan developed that indicated how Resident 1 should be showered or bathe given the resident's severe contractures. During an interview on 8/6/2024 at 2:25 PM, CNA 2 stated she worked at the facility on 7/17/2024, during the 7 AM to 3 PM shift. CNA 2 stated on 7/17/2024, between 11 to 11:30 AM, CNA 1 asked for her help to transfer Resident 1 from the shower chair to the bed. CNA 2 stated when she assisted CNA 1, CNA 1 already gave Resident 1 a shower. CNA 2 stated she did not help CNA 1 transfer Resident 1 from the bed to the shower chair prior to the shower and did not assist CNA 1 during Resident 1's shower. CNA 2 stated she helped CNA 1 transfer Resident 1 from the shower chair to the bed while holding on to Resident 1's legs. CNA 2 stated that during the transfer, Resident 1 was holding on to the shower chair very hard. During an interview on 8/2/2024 at 12:09 PM, the DON stated Resident 1 was bed bound (are not able to move around safely or comfortably). The DON stated the facility only had a shower chair and does not have a shower bed for Resident 1 to use in the Shower Room. The DON stated the facility did not have a list of residents for facility staff to know who gets a bed bath or shower in the Shower Room. The DON stated he could not find documented evidence that a care plan was developed by the licensed nurses of Interdisciplinary Team (IDT) for Resident 1's shower/bathing activities for safety and comfort, due to contractures and being bedbound. The DON stated CNA 1 informed her that he attempted to wash Resident 1 between the legs with a towel and there was resistance (a force, such as friction, that operates opposite the direction of motion of a body), so CNA 1 did not try to wash between the legs any harder. The DON stated CNA 2 assisted CNA 1 in transferring Resident 1 back to bed on 7/17/2024. During a review of the facility's policy and procedure (P&P) titled Safety and Supervision of Residents, revised Year 2017, indicated Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. The P&P stated that the facility-oriented approach to safety addresses risks for groups of residents. Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes . Employees shall be trained on potential accident hazards and demonstrate competency on how to identify and report accident hazards and try to prevent avoidable accidents .Staff shall monitor interventions to mitigate [make less severe] accident hazards in the facility and modify as necessary . The P&P further indicated that certain resident risk factors and environmental hazards included bed safety, safe lifting and movement of residents and falls. During a review of the facility's P&P titled, Activity of Daily Living, revised Year 2018, indicated, Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the appropriate services necessary with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with hygiene (bathing, dressing, grooming, and oral care), mobility [transfer and ambulation (walking), including walking], elimination [toileting] . The P&P further indicated that If residents with cognitive impairment or dementia resist care, staff will attempt to identify the underlying cause of the problem and not just assume the resident is refusing care . During a review of the facility's P&P titled, Care Plans, Comprehensive Person-Centered, revised Year 2022, indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The interdisciplinary team, in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident . Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change. The interdisciplinary team reviews and updates the care plan: when there has been a significant change in the resident's condition, when the desired outcome is not met .

Based on interview and record review, the facility failed to implement the facility's policy and procedure titled Change in a Resident's Condition or Status, and Pain Assessment and Management, by ensuring the physician was immediately notified for one of three sampled residents (Resident 53), who had a significant change of condition when noted with decreased blood pressure (BP) from baseline, increased heart rate (HR), new pain, moaning, fidgeting and agitated by failing to: 1. Ensure Licensed Vocational Nurse (LVN) 1 notified Registered Nurse (RN) 1 and Physician 1 for a significant change from baseline of Resident 53's blood pressure (pressure of circulating blood against the walls of blood vessels) of ,d+[DATE] (reference range ,d+[DATE]) and heart rate (HR) of 106 beats per minute ([bpm] reference range ,d+[DATE] bpm) from baseline BP ,d+[DATE] and a HR of 82 beats per minute.?on [DATE] at 5:47 PM. 2. Ensure LVN 1 notified Physician 1 and Registered Nurse 1 regarding Resident 53's was observed fidgeting, agitated and with pain assessed at level of 7 out of 10 (on a pain scale from 0 to 10, where 0 is no pain and 10 is the worse pain possible) on [DATE] at 9:03 PM. 3. Ensure LVN 1 notified Physician 1 of Resident 54's pain level of 7 to determine if other assessment and interventions are needed to determine the source of pain and to relieve the pain. 4. Ensure LVN 2 did not wait 13 minutes before calling LVN 3 for assistance and call the paramedics ( a personal that responds to medical emergency) when Resident 53 was found without BP and unreponsive and respiratory rate of 8 per minute. 5. Ensure LVN 2 immediately notified Physician 1 when Resident 53's was noted unresponsive to tactile and verbal stimuli, blood pressure could not be read and obtained, respiration was diminished with respirations rate (RR) of 8 breaths per minute. As a result of these deficient practices Resident 53 did not receive the immediate care and emergency interventions to ensure the residents vital signs (measurement of the blood pressure, heart rate, respirations and body temperature) returns to baseline status, thereby increasing the blood supply to the resident's body. Resident 53's vital signs and mental status continued to decline which was no rechecked and was pronounced dead by the paramedics on [DATE] at 12:43 AM. On [DATE] at 8:35 PM, during the facility's Annual Recertification Survey, an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirement of participation have caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified regarding the facility's failure to notify Physician 1 regarding significant changes in Resident 53's vital signs (measurement of the blood pressure, heart rate and body temperature), in accordance with the facility's policy on Change of Condition Notification and assessment for a change of condition. The IJ was called in the presence of the Director of Nursing (DON) and the Director of Staff Development (DSD). On [DATE] at 8:31 PM, while onsite, the survey team removed the IJ after the surveyors verified and confirmed the facility implemented the IJ Removal Plan (a detailed plan to address the IJ findingsby observation, interview, and record review. The IJ was removed in the presence of the Administrator (ADM), DSD, and Compliance Consultant (CC). The acceptable IJ Removal Plan included the following: 1. Current licensed nurses were re-in serviced in person on [DATE] regarding identifying abnormal vital signs and documentation for a change of condition, including changes in pain level, respiratory status, oxygen saturation rate, and out of range blood pressure. The DSD/Designee will in-service licensed staff in person by [DATE] to complete 100% in-service to licensed staff. 2. Current licensed nurses were re-in serviced in person on [DATE] on timely notification of a RN or the Director of Nursing (DON) regarding a change of condition, including changes in vital signs. The DSD/Designee will in-service license staff in person by [DATE] to complete 100% in-service licensed staff. 3. A follow up in-service will be conducted on [DATE] to determine knowledge retention for timely notification of a RN and physician regarding a change of condition. 4. Licensed nurses will be assessed for documentation competency, including notification of RN and physician for a change in condition, using the Documentation Competency Checklist, beginning [DATE]. Competencies for all licensed staff will be completed within 30 days from initiation of Documentation Competency Checklist, 90 days after first licensed staff evaluation, and then annually thereafter. 5. Licensed nurses will be in-serviced in person by DON/DSD/Designee regarding new Documentation Competency Checklist beginning on [DATE]. DON/DSD/Designee will in-service license staff in person by [DATE] to complete a 100% in-service to license staff. 6. Competency Checklist will be added to all new hire LVN/RN orientation. 7. Policy and Procedure will be updated to reflect new audit tool, including elements to be incorporated into the audit such a documentation of changes in condition notification of RN and physician, and completion of appropriate assessments. 8. Policy and Procedure will be updated to reflect procedure for documentation of change in condition, including parameters for notifying RN or physician. 9. DSD/Designee will complete random audits to test knowledge of in-service regarding notification of changes to RN and physician. Results will be logged on the spot check tool. Audits will be complete 3 times per week for 4 weeks, then weekly for 4 weeks, then monthly for 4 months. 10. LVN 1 will be provided an additional 1:1 in-service on proper notification of a physician and the RN for any changes in condition. 11. LVN 1 will meet with the DON/Designee on a regular basis to review any changes in condition during the scheduled shift for the next 30 scheduled workdays. 1:1 in-service will be provided as needed. 12. Certified Nursing Assistants (CNAs) were re-in-serviced on [DATE] regarding reporting of changes in condition to the supervisor or charge nurse. 13. A follow up in-service will be conducted on [DATE] to determine knowledge retention for reporting of changes in condition. 14. Residents with any changes in condition will be reviewed in morning meeting by the IDT. Any findings on the audit tool (Exhibit 1.1) will be addressed, 1:1 in-service will be provided as needed. 15. Review of documentation of changes in condition, including notification of RN and physician, will be completed at various times weekly by DON/Designee for the next 30 days then semi-monthly for 1 month then monthly for 1 month. Issues noted will be resolved. 1:1 in-service will be provided as needed. Information for which charts to review will be based on the audit tool (Exhibit 1.1). 16, Consultant will review a random sampling of resident charts, based on audit tool (Exhibit 1.1) on a regular basis for 30 days or CDPH revisit, whichever is longer, to verify that documentation has been completed for patients with any changes in condition, including notification to RN and physician. Issues noted will be resolved and additional in-services will be provided as needed. Cross Reference to F684 Findings: A review of Resident 53 's Admission Record indicated resident was originally admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses that included aftercare following surgery on the digestive system, insertion of gastrostomy ([G-tube] a soft tube surgically placed into the stomach for the introduction of nutrition and medication), and dysphagia (difficulty swallowing) following cerebral infarction. A review of Resident 53's History and Physical Examination dated [DATE] indicated resident did not have the capacity to understand and make decisions. A review of the Minimum Data Set (MDS) dated [DATE], Resident 53 had severe cognitive (ability to process information) impairment and required set up and clean up help with eating and maximum assistance with personal hygiene. A review of Resident 53's Portable Orders for Life Sustaining Treatment (POLST - a portable medical order form that records patients' treatment wishes so that emergency personnel know what treatments the patient wants in the event of a medical emergency) signed by the responsible party for Resident 53 on [DATE] and signed by Physician 1 but not dated, indicated the medical interventions to be performed if the resident was found with no pulse and not breathing. The POLST indicated to do not attempt cardiopulmonary resuscitation (CPR - an emergency procedure used to restart a person's heartbeat and breathing after one or both have stopped), instead selected to receive care for comfort to relieve pain and suffering with medication, use oxygen, suction, and manual treatment of airway obstruction. A review of the General Acute Care Hospital (GACH) Discharge Summary, dated [DATE] indicated, Resident 53 was admitted to the GACH on [DATE] for evaluation of the resident's altered mental status after a fall at the facility. The GACH record indicated at baseline Resident 53 was able to answer yes or no but at the time of the assessment in the GACH Resident 53 was nonverbal (unable to talk) and unable to provide medical history. The GACH record indicated Resident 53 had acute to subacute small infarct in the brain likely due to atrial fibrillation, myocardial infraction (MI-) which most likely due to hypotension (low blood pressure) causing the fall. A review of Resident 53's care plans dated from [DATE] to [DATE] indicated no documented evidence that a care plan was developed to address interventions related for CVA (stroke also called ischemic stroke, occurs when the blood supply to part of the brain is blocked or reduced), Atrial fibrillation and hypotension. A review of Resident' 53's Order Summary Report from [DATE] to [DATE] indicated the following: 1. On [DATE] at 5:22 PM a physician order for Tylenol (Acetaminophen) 325 mg 2 tablets via G-tube every 4 hours as needed for mild pain (,d+[DATE]) not to exceed 3 grams ([gm] unit of measure) every 24 hours of Acetaminophen. 2. On [DATE] at 6:13 PM a physician order for Ativan (Lorazepam) one?tablet by mouth every 4 hours as needed for anxiety for 60 days manifested by physical aggression towards staff. A review of Resident 53's Weight and Vitals Summary Report from [DATE] to [DATE] indicated Resident 53 had a blood pressure and heart rate as follows: 1. On [DATE] at 4:55 AM Resident 53 BP was ,d+[DATE] and a HR of 82 beats per minute (BPM) 2. On [DATE] at 6:27 AM Resident 53's BP was ,d+[DATE] and a HR of 61 BPM. 3. On [DATE] at 7:24 AM Resident 53's BP decreased to ,d+[DATE] and HR increased to 101 BPM. 4. On [DATE] at 5:47 PM, the BP decreased to ,d+[DATE] and HR increased to 106 BPM. No documented evidence in Resident 53;s clinical record that Physician 1 was notified of the resident's significant change in the BP and HR. 5. On [DATE] at 4:11 AM, Resident 53 was unresponsive to tactile stimuli and no BP when checked and RR was 8 breaths per minute. After 13 minutes on [DATE] Resident 53 had no pulse and not breathing. 6. On [DATE] at 7:09 AM, Resident 53 was pronounced dead by the paramedic and taken to the morgue. 7. On [DATE] timed at 7:09 AM, LVN 2 wrote Physician 1 was notified of Resident 53's death. A review of Resident 53's Medication Administration Record (MAR) for ,d+[DATE], indicated on [DATE] at 9:03 PM, Resident 53 was given Tylenol 325 mg for a pain level of 7 out of 10. A review of Resident 53's Progress notes indicated the following: On [DATE] timed at 3:51 AM LVN 2 wrote Resident 53 will try to interfere with staff when attending to G-Tube, seen putting hands out trying to keep staff from accessing G-tube. Vital Signs obtained and within normal limits, needs met and anticipated. Will reach out to Medical Doctor for stronger pain medication. Will continue to monitor. On [DATE] timed at 11:56 PM, LVN 2 wrote Resident 53 received in bed, eyes open, appearing weak, no moaning during initial rounds. Per LVN 1, Resident 53 had been moaning earlier in her shift. On [DATE] timed at 4:11 AM, LVN 2 wrote at 12:30 AM LVN 2 assessed Resident 53's vital signs and noted Resident 53 had diminished respirations at 8 breaths per minute with an oxygen saturation level of 95% in room air. Resident 53's eyes were closed, and resident was not responding to tactile stimuli or verbal commands. The note indicated LVN 2 was not able to obtain Resident 53's blood pressure and so raised the foot of the bed and re-checked Resident 53's blood pressure several times and provided oxygen therapy 2 liters (L, unit of measure) via nasal cannula. The note indicated after about 13 minutes, LVN 2 noted Resident 53's respirations ceased and resident did not have a pulse. The note indicated LVN 2 sent immediately for crash cart, applied CPR board to Resident 53's back, and began CPR (due to POLST not being signed by Physician 1, Resident 53 was still considered a full code despite it having been marked as do not resuscitate (DNR), at LVN 3 called 911. The note indicated LVN 2 continued to perform CPR until paramedics pronounced Resident 53 expired at 12:43 AM. The note did not indicate Physician 1 was notified of Resident 53 change in condition. On [DATE] timed at 7:09 AM, LVN 2 wrote Physician 1 was notified of Resident 53's death. A review of the Death Certificate indicated Resident 53 expired on [DATE] at 00:43 AM, with the primary cause of death of cerebrovascular disease, atrial fibrillation and hypertension. During a telephone interview on [DATE] at 1:46 PM, LVN 2 stated on [DATE] at around midnight she checked Resident 53 in her room to give the resident her medications. LVN 2 stated she took Resident 53's blood pressure and the blood pressure did not register a BP reading on the pressure gauge (the part of the blood pressure device that show the measurement of the BP reading). LVN 2 stated Resident 53 was staring at the ceiling and was not responsive when spoken to or touched, and the resident's breathing was diminished. LVN 2 stated when she could not obtain Resident 53's blood pressure, she elevated Resident 53's legs. LVN 2 stated she called LVN 3 to help, and then she placed a pulse oximeter (a non-invasive medical device to measure the amount of oxygen in the blood) on Resident 53's finger which read oxygen saturation level read of 100%, and the heart rate was 70 bpm, but resident's breathing continued at less than 12 breaths per min. LVN 2 stated she used an electrical and manual BP checking device to check Resident 53's blood pressure and she could not get a BP reading. LVN 2 stated she gave Resident 53 an oxygen therapy via nasal cannula because it was one of our (the facility's) protocols. LVN 2 stated the biggest thing was how I could not get her blood pressure and after 13 minutes, Resident 53's respirations ceased and went full on cardiac arrest. LVN 2 stated she did not immediately notify Physician 1 of Resident 53's change in condition because I was doing my nursing interventions. During an interview on [DATE] at 3:32 PM, LVN 1 stated during the 3 PM to 11 PM shift on the night of [DATE], Resident 53's family member (Family) 1 requested for LVN 1 to administer pain medication to Resident 53 because, Resident 53 was crying a lot, moaning, and fidgeting with her hands. LVN 1 stated she asked Resident 53 about her pain level, but the resident moaned and moved her arms around. LVN 1 stated she took Resident 53's vital signs (VS), but she did not document the VS and she could not recall what they were. LVN 1 stated she did not notify Physician 1 when she observed Resident 53 moaning. LVN 1 stated she gave Resident 53 a pain medication Tylenol and the resident stopped moaning. LVN 1 stated she did not document Resident 53's behavior of moaning, but she should have. During a concurrent interview and record review of the VS records on [DATE] at 4:37 PM with LVN 1, LVN 1 stated Resident 53's last blood pressure was at ,d+[DATE] on [DATE] at 5:47 PM. LVN 1 stated she did not notify Physician 1 or monitored and rechecked the BP when Resident 53's BP was trending down and lower from baseline BP, which could have been the cause of the significant change in the resident's condition. LVN 1 stated on [DATE] at around 9 PM, she assessed Resident 53 and Resident 53 was having pain at a evel of 7 out of 10. LVN 1 stated she administered Tylenol to Resident 53, which was ordered by the physician for the resident's pain level of ,d+[DATE]. LVN 1 stated she did not notify Physician 1 about Resident 53 having the pain level of 7 out of 10 even when Resident 53 did not have any physician order for pain medication stronger than Tylenol at the time. LVN 1 also stated Family 1 was content with the Tylenol and the results of the Tylenol. LVN 1 stated she could not recall why she did not notify Physician 1. During a telephone interview with Physician 1 on [DATE] at 9:20 AM, Physician 1 stated if a resident's blood pressure continues to decrease, he would expect to be notified by the facility's staff. Physician 1 stated the staff should have monitored Resident 53's blood pressure. Physician 1 stated he could not recall if he was informed that Resident 53's pain level went above a 3 on the pain scale. The Physician 1 stated if Resident 53's pain was not controlled, he would expect to be notified by the facility staffs. Physician 1 stated if there were other things happening while Resident 53 was observed with pain like if resident's heart was going up from 60 bpm to 100 bpm, Physician 1 stated he would expect to be notified. During a telephone interview on [DATE] at 2:07 PM, RN 1 stated if she was notified by LVN 1 of Resident 53's pain level of 7 out of 10, she would check Resident 53's orders to see what medication covered the pain level of 7. RN 1 also stated when the physician did not prescribe a pain medication to Resident 53 to control the pain level of 7, she could let Physician 1 know. RN 1 stated if she was notified of Resident 53's significant change in condition, she would have done a full head to toe assessment and reassessed and monitored the VS of Resident 53 herself. During an interview with the Director of Nursing (DON) on [DATE] at 5:48 PM, the DON stated a significant change of condition was anything that was not normal or not at the resident's baseline condition. The DON stated if there was a significant change of condition on the resident's baseline status, the nurses need to assess and do a full head to toe assessment on the resident, notify the physician, document a change of condition, and initiate a care plan. The DON stated LVN 1 should have checked Resident 53's stomach and checked for bowel sounds since resident had a new G-tube. The DON stated if Resident 53 was already restless, sometimes you need to think further, why is resident doing this? She was probably in pain and required further assessment. The DON stated the physician should be informed of the results of the assessment and document the assessment that was conducted. During an interview with the DON and concurrent record review [DATE] at 6:01 PM, Resident 53's vital signs and pain levels, the DON stated for Resident 53's blood pressure of ,d+[DATE] and heart rate of 106 bpm on [DATE] at 5:47 PM, the vital signs should have been rechecked. The DON stated if the vital signs remained the same, the nurse should have called Physician 1 because the pulse was high and the diastolic (measures the pressure the blood is pushing against the artery [blood vessel that distributes oxygen-rich blood to the entire body] walls while the heart muscle rests between beats) was low and that Resident 53 was in distress. The DON stated LVN 1 should have called RN 1, to perform a full body assessment. The DON stated when Resident 53's pain level was assessed at a 7 out of 10, it was considered moderate to severe pain, and the licensed nurse should have notified Physician 1 because there was no medication ordered for the pain level of 7 and that the resident was moaning and in distress. During a concurrent interview and record review of Resident 53's Progress Note written by LVN 2 dated [DATE] timed at 4:11 AM with the DON on [DATE] at 6:08 PM, the DON stated LVN 2 did not notify Physician 1 as soon as possible. The DON stated LVN 2 needed to notify the Physician 1 and RN 1 so RN 1 could assess Resident 53. The DON stated LVN 2 should have had LVN 3 call Physician 1 to get an order for further care. The DON stated she could not find documented evidence in Resident 53's progress notes from [DATE] to [DATE] for a change of condition. During a concurrent interview and record review of Resident 53's Assessments with the DON on [DATE] at 6:12 PM, the DON stated she could not find documented evidence of a change of condition assessment from [DATE] to [DATE] for Resident 53. A review of the facility's policy and procedure (P&P) titled, Pain Assessment and Management, dated ,d+[DATE] indicated pain management is a multidisciplinary care process that includes the following: assessing the potential for pain; identifying and using specific strategies for different levels and sources of pain; monitoring for the effectiveness of interventions; and modifying approaches as necessary. The P&P indicated to conduct a comprehensive pain assessment upon admission to the facility, at the quarterly review, whenever there is a significant change in condition, and when there is onset of new pain or worsening of existing pain. The P&P indicated to assess the resident's pain and consequences of pain at least each shift for acute pain or significant changes in levels of chronic pain and at least weekly in stable chronic pain. The P&P indicated to monitor the resident by performing a basic assessment with enough detail and as needed, with standardized assessment tools and relevant criteria for measuring pain management. The P&P indicated if pain has not been adequately controlled, the multidisciplinary team, including the physician, shall reconsider approaches and make adjustments as indicated. The P&P indicated to report the following information to the physician or practitioner: significant changes in the level of the resident's pain. A review of the facility's policy and procedure (P&P) titled, Change in a Resident's Condition or Status, dated ,d+[DATE] indicated the facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status. The P&P indicated the nurse will notify the resident's Attending Physician or physician on call when there has been a(an): accident or incident involving the resident; significant change in the resident's physical/emotional/mental condition; and need to alter the resident's medical treatment significantly. The P&P indicated the nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status.

Based on interview and record review, the facility failed to reassess, monitor for the signs and symptoms of Cerebral Vascular Accident (CVA or stroke also called ischemic stroke, occurs when the blood supply to part of the brain is blocked or reduced) and Transient Ischemic Attack ([TIA] a short period of symptoms similar to those of a stroke, caused by a brief blockage of blood flow to the brain),) and exhibited new pain for one of three sampled residents (Resident 53) who was recently hospitalized for change in mental status and was diagnosed with TIA and CVA, in accordance to the facility's policy and procedures, and professional standard of practice the facility failed to: 1. Ensure Licensed Vocational Nurse 1 (LVN 1) and LVN 2 assessed and monitored Resident 53 for signs and symptoms of TIA and Stroke such as change in mental status, baseline BP, HR, RR and mental status such 2. Ensure Licensed Vocational Nurse (LVN) 1 and LVN 2 assessed and monitored Resident 53 for lower than baseline Blood Pressure) (BP) and increased Heart Rate (HR), change in mental status and decreased respiratory rate (RR) from baseline. 3. Ensure LVN 1 assessed and notify the Physician 1 and Registered Nurse (RN1) when Resident 53 was observed, decreased BP from ,d+[DATE] mm Hg (millimeter mercury) and HR of 82 beats per (BPM) minute to ,d+[DATE] mm Hg and HR increased to 101 BPM and to ,d+[DATE] mm Hg and HR increased to 106 BPM to provide necessary interventions for the significant change in VS (measurement of the BP, HR, RR and body temperature). 4. Ensure LVN 1 assessed Resident 53's the source of pain resident when the resident exhibited a pain at level of 7 out of 10 (on a pain scale from 0 to 10, where 0 is no pain and 10 is the worse pain possible). 5. Enusre LVN 2 did not wait 13 minutes before calling LVN 3 and the paramedics ( medical personnel who responds to medical emergencies) after Resident 53 was found unresponssive and no BP reading could not be obtained. 6. Ensure LVN 2 immediately notified Physician 1 on [DATE] at 12:30 AM, when Resident 53 was found unresponsive to tactile (touch) and verbal stimuli, with no BP reading and diminished respirations of eight (8) breaths per minute. 7. Ensure to develop a plan of care for Resident 53 to address how the resident will be monitored and assessed for TIA and Stroke and A-Fib. On [DATE] at 8:35 PM, during the facility's Recertification Survey, an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirement of participation have caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified regarding significant changes in Resident 53's vital signs, in accordance with the facility's policy on Change of Condition Notification and assessment for a change of condition. On [DATE] at 8:31 PM, the IJ was removed after the surveyors verified and confirmed the facility's IJ Removal Plan (a detailed plan to address the IJ findings) while onsite by observation, interview, and record review. The IJ was removed in the presence of the Administrator (ADM), Director of Staff Development (DSD), and Compliance Consultant (CC). The acceptable IJ Removal Plan included the following: Current licensed nurses will be re-in serviced in person on [DATE] regarding assessment, monitoring, evaluation for a history of TIA and stroke. DSD/Designee will in-service licensed staff in person by [DATE] to complete a 100% in-service to licensed staff. DSD/Designee will complete random audits to test knowledge of in-service regarding assessment, monitoring, and evaluation for a history of transient ischemic attack and stroke. Results will be logged on the spot check tool. Audits will be completed 3 times per week for 4 weeks, then weekly for 4 weeks, then monthly for 4 months. LVN 1, LVN 2, and RN 1 will be provided an additional 1:1 in-service on assessment, monitoring, and evaluation for a history of TIA and stroke, including documentation for any changes. Residents with any changes in condition, including those with TIA and stroke will be reviewed in morning meeting by the Interdisciplinary Team (IDT-a team of staff that works in team to develop the plan of care for the residents). Any findings on the audit tool will be addressed, 1:1 in-service will be provided as needed. Review of documentation, including assessment, monitoring, and evaluation for a history of TIA and stroke associated with a change in condition, will be completed at various times weekly by DON/Designee for the next 30 days then semimonthly for 1 month then monthly for 1 month. 1:1 in-service will be provided as needed. Consultant will review a random sampling of resident charts, based on a list provided by the facility, on a regular basis for 30 days or California Department of Public Health (CDPH) revisit, whichever is longer, to verify that appropriate assessment, monitoring, and evaluation for a history of transient ischemic attack and stroke associated with a change in condition has been documented. Issues noted will be resolved and additional in-services will be provided as needed. As a result of these deficient practices Resident 53 did not receive the immediate care and emergency interventions to ensure the residents vital signs (measurement of the blood pressure, heart rate, respirations and body temperature) returns to baseline status, thereby increasing the blood supply to the resident's body. Resident 53's vital signs and mental status continued to decline which was no rechecked and was pronounced dead by the paramedics on [DATE] at 12:43 AM. Cross Reference to F580 Findings: A review of Resident 53 's Admission Record indicated resident was originally admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses that included aftercare following surgery on the digestive system, insertion of gastrostomy ([G-tube] a soft tube surgically placed into the stomach for the introduction of nutrition and medication), and dysphagia (difficulty swallowing) following cerebral infarction. A review of Resident 53's History and Physical Examination dated [DATE] indicated resident did not have the capacity to understand and make decisions. A review of the Minimum Data Set (MDS) dated [DATE], Resident 53 had severe cognitive (ability to process information) impairment and required set up and clean up help with eating and maximum assistance with personal hygiene. A review of Resident 53's Portable Orders for Life Sustaining Treatment (POLST - a portable medical order form that records patients' treatment wishes so that emergency personnel know what treatments the patient wants in the event of a medical emergency) signed by the responsible party for Resident 53 on [DATE] and signed by Physician 1 but not dated, indicated the medical interventions to be performed if the resident was found with no pulse and not breathing. The POLST indicated to do not attempt cardiopulmonary resuscitation (CPR - an emergency procedure used to restart a person's heartbeat and breathing after one or both have stopped), instead selected to receive care for comfort to relieve pain and suffering with medication, use oxygen, suction, and manual treatment of airway obstruction. A review of the General Acute Care Hospital (GACH) Discharge Summary, dated [DATE] indicated, Resident 53 was admitted to the GACH on [DATE] for evaluation of the resident's altered mental status after a fall at the facility. The GACH record indicated at baseline Resident 53 was able to answer yes or no but at the time of the assessment in the GACH Resident 53 was nonverbal (unable to talk) and unable to provide medical history. The GACH record indicated Resident 53 had acute to subacute small infarct in the brain likely due to atrial fibrillation, myocardial infraction (MI-) which most likely due to hypotension (low blood pressure) causing the fall. A review of Resident 53's Care Plans from [DATE] to [DATE] indicated no documented evidence that a care plan was developed to address interventions related for TIA, MI, CVA, Atrial fibrillation and hypotension. A review of Resident' 53's Order Summary Report dated [DATE], indicated the following: a. On [DATE] at 5:22 PM a physician order for Tylenol (Acetaminophen) 325 mg 2 tablets via G-tube every 4 hours as needed for mild pain (,d+[DATE]) not to exceed 3 grams ([gm] unit of measure) every 24 hours of Acetaminophen from all sources. b. On [DATE] at 6:13 PM a physician order for Ativan (Lorazepam-a medication used to treat anxiety [the condition of being afraid of the unknow])) one?tablet by mouth every 4 hours as needed for anxiety for 60 days manifested by physical aggression towards staff. c. The order summary report did not include a physician order to monitor Resident 53 for change in conditions related to MI, CVA and TIA. A review of Resident 53's Weight and Vitals Summary Report, dated [DATE] to [DATE], indicated Resident 53 had a blood pressure and heart rate range as follows: a.On [DATE] at 4:55 AM Resident 53 BP was ,d+[DATE] and a HR of 82 beats per minute. b.On [DATE] at 6:27 AM Resident 53's BP was ,d+[DATE] and a HR of 61 BPM. c.On [DATE] at 7:24 AM Resident 53's BP decreased to ,d+[DATE] and HR increased to 101 BPM. d.On [DATE] at 5:47 PM, the BP decreased to ,d+[DATE] and HR increased to 106 BPM. There was no documented evidence the Physician 1 was not notified of the resident's significant change in the BP and HR from [DATE] to [DATE]. a. On [DATE] at 4:11 AM, Resident 53 was unresponsive to tactile stimuli and no BP when checked and RR was 8 breaths per minute. After 13 minutes on [DATE] Resident 53 had no pulse and not breathing. b.On [DATE] at 7:09 AM, Resident 53 was pronounced dead by the paramedic and taken to the morgue. c. On [DATE] timed at 7:09 AM, LVN 2 wrote Physician 1 was notified of Resident 53's death. A review of Resident 53's Medication Administration Record (MAR) indicated on [DATE] at 9:03 PM, Resident 53 was given Tylenol 325 mg for a pain level of 7 out of 10. A review of Resident 53's Progress notes, dated [DATE] to [DATE], indicated the following: On [DATE] timed at 3:51 AM LVN 2 wrote Resident 53 observed with frowned face, facial grimacing with intermittent crying like sounds unable to respond to LVN 2. Resident 53 will try to interfere with staff when attending to G-Tube, seen putting hands out trying to keep staff from accessing G-tube. Vital Signs obtained and within normal limits, needs met and anticipated. Will reach out to Medical Doctor for stronger pain medication. Will continue to monitor. On [DATE] timed at 11:56 PM, LVN 2 wrote Resident 53 received in bed, eyes open, appearing weak, no moaning during initial rounds. Per LVN 1, Resident 53 had been moaning earlier in her shift. On [DATE] timed at 4:11 AM, LVN 2 wrote at 12:30 AM LVN 2 assessed Resident 53's vital signs and noted Resident 53 had diminished respirations at 8 breaths per minute with an oxygen saturation level of 95% in room air. Resident 53's eyes were closed, and resident was not responding to tactile stimuli or verbal commands. The note indicated LVN 2 was not able to obtain Resident 53's blood pressure and so raised the foot of the bed and re-checked Resident 53's blood pressure several times and provided oxygen therapy 2 liters (L, unit of measure) via nasal cannula. The note indicated after about 13 minutes, LVN 2 noted Resident 53's respirations ceased and resident did not have a pulse. The note indicated LVN 2 sent immediately for crash cart, applied CPR board to Resident 53's back, and began CPR (due to POLST not being signed by Physician 1, Resident 53 was still considered a full code despite it having been marked as do not resuscitate (DNR), at LVN 3 called 911. The note indicated LVN 2 continued to perform CPR until paramedics pronounced Resident 53 expired at 12:43 AM. The note did not indicate Physician 1 was notified of Resident 53 change in condition. On [DATE] timed at 7:09 AM, LVN 2 wrote Physician 1 was notified of Resident 53's death. A review of the Death Certificate, dated [DATE], indicated Resident 53 expired on [DATE] at 00:43 AM, with the primary cause of death of cerebrovascular disease and atrial fibrillation. During a telephone interview on [DATE] at 1:46 PM, LVN 2 stated on [DATE] at around midnight she checked Resident 53 in her room to give the resident her medications. LVN 2 stated took Resident 53's blood pressure and the blood pressure did not register a BP reading on the pressure gauge (the part of the blood pressure device that show the measurement of the BP reading). LVN 2 stated Resident 53 was staring at the ceiling and was not responsive when spoken to and touched and, the resident's breathing was diminished. LVN 2 stated when she could not obtain Resident 53's blood pressure she elevated Resident 53's legs. LVN 2 stated she called LVN 3's help, and then she placed a pulse oximeter (a non-invasive medical device to measure the amount of oxygen in the blood) on Resident 53's finger and resident's oxygen saturation level read at 100%, and the heart rate was 70 bpm, but resident's breathing continued at less than 12 breaths per min. LVN 2 stated she used an electrical and manual BP checking device to check Resident 53's blood pressure and she could not get a BP reading. LVN 2 stated she gave Resident 53 an oxygen therapy via nasal cannula because it was one of our (the facility's) protocols. LVN 2 stated the biggest thing was how I could not get her blood pressure and after 13 minutes, Resident 53's respirations ceased and went full on cardiac arrest. LVN 2 stated she did not notify Physician 1 of Resident 53's change in condition because I was doing my nursing interventions. During an interview on [DATE] at 3:32 PM, LVN 1 stated during the 3 PM to 11 PM shift on the night of [DATE], Resident 53's family member (Family) 1 requested for LVN 1 to administer pain medication to Resident 53 because, Resident 53 was crying a lot, moaning, and fidgeting with her hands. LVN 1 stated she asked Resident 53 about her pain level, but the resident moaned and moved her arms around. LVN 1 stated she took Resident 53's vital signs, but she did not document the VS and she could not recall what they were. LVN 1 stated she did not notify Physician 1 when she observed Resident 53 moaning. LVN 1 stated she gave Resident 53 a pain medication Tylenol and the resident stopped moaning. LVN 1 stated she did not document Resident 53's behavior of moaning, but she should have. During a concurrent interview and record review of the Vital Signs (VS) records on [DATE] at 4:37 PM with LVN 1, LVN 1 stated Resident 53's last blood pressure was ,d+[DATE] was on [DATE] at 5:47 PM. LVN 1 stated she did not notify Physician 1 and monitored and rechecked the BP when Resident 53's BP was trending down lower from baseline BP and when the HR increased which could have been the cause of the significant change in the resident's condition. LVN 1 stated on [DATE] at around 9 PM, she assessed Resident 53 as having a pain level of 7 out of 10. LVN 1 stated she administered Tylenol to Resident 53, which was ordered by the physician for the resident's pain level of ,d+[DATE]. LVN 1 stated she did not notify Physician 1 about Resident 53 having the pain level of 7 out of 10 because, Resident 53 did not have any physician order for pain stronger than Tylenol at the time. LVN 1 also stated Family 1 was content with the Tylenol and the results of the Tylenol. LVN 1 stated she could not recall why she did not notify Physician 1. During a telephone interview with Physician 1 on [DATE] at 9:20 AM, Physician 1 stated if a resident's blood pressure continues to decrease, he would expect to be notified by the facility's staff. Physician 1 stated the staff should have monitored Resident 53's blood pressure. Physician 1 stated he could not recall if he was informed that Resident 53's pain level went above a 3 on the pain scale. The Physician 1 stated if Resident 53's pain was not controlled, he would expect to be notified by the facility staffs. Physician 1 stated if there were other things happening while Resident 53 was observed with pain like if resident's heart was going up from 60 bpm to 100 bpm, Physician 1 stated he would expect to be notified. During a telephone interview on [DATE] at 2:07 PM, RN 1 stated if she was notified by LVN 1of Resident 53's pain level of 7 out of 10, she would check Resident 53's orders to see what medication covered the pain level of 7. RN 1 also stated if the physician did not prescribe a pain medication to Resident 53 to control the pain level of 7, she would let Physician 1 know. RN 1 stated if she was notified of Resident 53's significant change in condition, she would have done a full head to toe assessment and reassessed and monitored the VS of Resident 53 herself. During an interview with the Director of Nursing (DON) on [DATE] at 5:48 PM, the DON stated a significant change of condition was anything that was not normal or at the resident's baseline condition. The DON stated when there is a significant change of condition on the resident's baseline status, the nurses need to assess and do a full head to toe assessment on the resident, notify the physician, document a change of condition and initiate a care plan. At 5:51 PM, the DON stated LVN 1should have checked Resident 53's stomach and checked for bowel sounds since resident had a new G-tube. The DON stated if Resident 53 was already restless, sometimes you need to think further, why is resident doing this? She was probably in pain and required further assessment. During the same interview and concurrent record review [DATE] at 6:01 PM of Resident 53's vital signs and pain levels, the DON stated for Resident 53's blood pressure of ,d+[DATE] and heart rate of 106 bpm on [DATE] at 5:47 PM, the vital signs should have been rechecked. The DON stated if the vital signs remained the same, the nurse should have called Physician 1 because the pulse was high and the diastolic (measures the pressure the blood is pushing against the artery [blood vessel that distributes oxygen-rich blood to the entire body] walls while the heart muscle rests between beats) was low and that Resident 53 was in distress. The DON stated LVN 1 should have called RN 1, to perform a full assessment. The DON stated when Resident 53's pain level was assessed at a 7 out of 10, it was considered moderate to severe pain, and the licensed nurse should have notified Physician 1 because there was no medication ordered for the pain level of 7 and that the resident was moaning and in distress. During a concurrent interview and record review with the DON on [DATE] at 6:08 PM, the DON stated there was no documented evidence in LVN 2's documentation in the Resident 53's Progress Note that on [DATE] timed at 4:11 AM that LVN 2 notified Physician 1 of Resident 53's change in condition. The DON stated LVN 2 should have notified Physician 1 and RN 1 to assess Resident 53's change of condition. The DON stated LVN 2 should have had LVN 3 call Physician 1 to get an order for further care. The DON stated she could not find documented evidence in Resident 53's progress notes from [DATE] to [DATE] that Resident 53 had a change of condition. During a concurrent interview and record review of Resident 53's clinical records, such the progress notes, change of condition report, care plans and pain assessment with the DON on [DATE] at 6:12 PM, the DON stated she could not find documented evidence that Resident 53 's change of condition was reassessed for the significant change in the VS, pain, agitated behavior and moaning to determine the probable cause of increased heart rate and decreased BP and immediately call the Physician1 to determine appropriate interventions. The DON stated a care plan should had been developed for resident with history of hypotension, MI, CVA, TIA and A-fib. A review of the facility's policy and procedure (P&P) titled Pain Assessment and Management, dated ,d+[DATE] indicated pain management is a multidisciplinary care process that includes the following: assessing the potential for pain; identifying and using specific strategies for different levels and sources of pain; monitoring for the effectiveness of interventions; and modifying approaches as necessary. The P&P indicated to conduct a comprehensive pain assessment upon admission to the facility, at the quarterly review, whenever there is a significant change in condition, and when there is onset of new pain or worsening of existing pain. The P&P indicated to assess the resident's pain and consequences of pain at least each shift for acute pain or significant changes in levels of chronic pain and at least weekly in stable chronic pain. The P&P indicated to monitor the resident by performing a basic assessment with enough detail and, as needed, with standardized assessment tools and relevant criteria for measuring pain management. The P&P indicated if pain has not been adequately controlled, the multidisciplinary team, including the physician, shall reconsider approaches and make adjustments as indicated. The P&P indicated to report the following information to the physician or practitioner: significant changes in the level of the resident's pain. A review of the facility's policy and procedure (P&P) titled Change in a Resident's Condition or Status, dated ,d+[DATE] indicated the facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status. The P&P indicated the nurse will notify the resident's Attending Physician or physician on call when there has been a(an): accident or incident involving the resident; significant change in the resident's physical/emotional/mental condition; and need to alter the resident's medical treatment significantly. The P&P indicated the nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. According to the National Library of Medicine, dated [DATE], a transient ischemic attack (TIA) is a stroke that lasts only a few minutes. It happens when the blood supply to part of the brain is briefly blocked. Symptoms of a TIA are like other stroke symptoms, but do not last as long. They happen suddenly, and include: Numbness or weakness, especially on one side of the body Confusion or trouble speaking or understanding speech Trouble seeing in one or both eyes Difficulty walking Dizziness Loss of balance or coordination Most symptoms of a TIA disappear within an hour, although they may last for up to 24 hours. Because you cannot tell if these symptoms are from a TIA or a stroke, you should go to the hospital right away. https://medlineplus.gov/transientischemicattack.html A review of the Centers for Disease Control and Prevention (CDC) website titled Signs and Symptoms of Stroke, dated [DATE] indicated the signs of stroke in men and women include: numbness or weakness in the face, arm, or leg, especially on one side of the body; confusion or trouble speaking or understanding speech; trouble seeing in one or both eyes; trouble walking, dizziness, or problems with balance; and severe headache with no known cause. The website indicated if any of the following signs appear suddenly, to call [DATE] right away. [https://www.cdc.gov/stroke/signs-symptoms/index.htm

Based on observation, interview, and record review, the facility failed to provide adequate supervision and safe environment to four of four sampled residents (Residents 1, 2, 3, and 4) who had elopement (leaving the facility unnoticed and unsupervised) risk, including; 1. Failing to provide one to one (1 to 1 direct staff monitoring) supervision to Resident 1 as required. 2. Failure to ensure the Wander Guard alarm system (a system equips each wandering resident/patient with a triple technology device that immediately notifies staff when the patient wanders into a pre-defined unsafe area, for example outside of the facility) was properly functioning to ensure Residents 1, 2, 3, and 4 would not leave the facility unnoticed by the staff. 3. Failure to ensure Resident 1 and all residents (Residents 2, 3, and 4) at risk for elopement were identified to ensure their safety. 4. Failure to implement the facility's policy on Safety and Supervision of Residents by not training Certified Nursing Assistants on safety risks and residents supervision. As a result, Resident 1 eloped from the facility and required hospitalization after found by the paramedics. Residents 2, 3, and 4 were at risk for leaving the facility and subject to harm from unsafe environment. On 7/2/18 at 2:57 p.m., 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 or residents) situation was identified in the presence of the facility's Director of Nursing (DON) for the facility's failure to implement safety measures to protect the health and safety of Residents 2, 3, and 4. The IJ situation was lifted on 7/3/18 at 3:26 p.m., in the presence of the facility's administrator and the DON after the surveyor received the written Plan of Actions (POA). The facility's POA indicated the following: 1. The facility ordered a replacement unit from the Wander Guard alarm system supplier and expected delivery on 7/5/18 via express delivery. 2. Resident 2's elopement risk was re-assessed and the Physician deemed the resident was no longer at risk for elopement. The Physician discontinued the Wander Guard use on 7/3/18 at 10:43 a.m. 3. On 7/3/18, at 2:34 a.m. Resident 3 was sent to a General Acute Care Hospital (GACH) for evaluation due to a change of condition. 4. As of 7/3/18 at 3:25 p.m., Resident 4 was sent a GACH for evaluation due to a change of condition. Findings: On 7/2/18 at 12:06 p.m., an announced visit was made to the facility to investigate a complaint regarding quality of care issues. During an observation and a concurrent interview with Licensed vocational Nurse 1 (LVN 1), on 7/2/18 at 12:11 p.m., she stated the facility was not a locked facility. LVN 1 stated four of five exit doors were equipped with Wander Guard alarm (an alarm system activated when a resident wearing a Wander Guard band to the wrist or ankle goes through the alarmed door) and the in-house census of the residents was 52. During an interview on 7/2/18 at 1:42 p.m., Registered Nurse 1 (RN 1) and LVN 1 stated they did not know which residents are at risk for elopement with Wander Guard bands. RN 1 stated the only way of knowing was by checking each resident's physician orders in the computer one by one. On 7/2/18 at 1:45 p.m., RN 1, LVN 1, and the Medical Record Designee (MRD) stated that according to the facility's Order Listing Report, Resident 2 was the only resident in the facility with a physician's order for a Wander Guard. A review of the facility's Weekly Checklist Wander Guard Series Door Modules, dated 7/2/18, indicated there was no signal for the Wander Guard monitor in the front office exit door. During an interview on 7/3/18 at 3:27 p.m., the facility's administrator stated that the facility did not have a written policy and procedure with respect of the wander guard. a. A review of the Admission Record indicated Resident 1 was admitted to the facility, on 3/8/18, from GACH 1, with [DIAGNOSES REDACTED]. levels). A review of GACH 1's documents brought with Resident 1 on admission (3/8/18), indicated Resident 1 required a 1:1 (one-to-one) sitter (direct supervision by a staff member to monitor the resident at all times for safety). GACH 1's Progress Notes dated 3/7/18 (a day before Resident 1 was admitted to the facility) indicated Resident 1 was agitated and tried to get on the elevator to leave the floor. On 3/8/18, a psychiatrist (a physician who specializes in the prevention, diagnosis, and treatment of [REDACTED]. A review of the facility's Resident Admission form dated 3/8/18, indicated Resident 1 was oriented to person, place and had difficulty communicating some words. Resident 1 had delayed response and required prompting. A review of the Brief Interview for Mental Status, dated 3/8/18, indicated Resident 1 had severe impairment in cognitive skills (ability to think and reason). A review of the Wandering Assessment form, dated 3/8/18, indicated Resident 1 scored nine (at risk for wander). A review of the nursing Progress Notes dated 3/11/18, and timed at 8:01 a.m., indicated from 5:45 a.m. to 6:15 a.m., Resident 1 was not seen inside and outside of the facility. At 6:42 a.m., the police were called, and a missing person report was filed. At 8:45 a.m., the police returned Resident 1 to the facility and the Physician ordered a Wander Guard band. At 11:45 a.m., the note indicated Resident 1 was on a 1:1 monitoring. A review of the Wandering assessment dated [DATE] indicated Resident 1 was at high risk of wandering. A review of the nursing Progress Notes dated 3/12/18, timed at 1:56 p.m., indicated Resident 1 had an episode of elopement and had a 1:1 sitter for safety. A review of the nursing Progress Notes dated 3/13/18 timed at 1:22 a.m., indicated Resident 1 eloped through the back door, and a Certified Nursing Assistant (CNA, unidentified) found the resident on the street. Resident 1 became agitated and the police brought the resident back inside the facility. A review of the Care Plan developed, on 3/13/18, for Resident 1's risk of elopement and wandering related to history of attempts to leave the facility unattended, impaired safety awareness, and cognitive deficits, included the interventions to have a 1:1 sitter and a Wander Guard (band) in place. A review of the nursing Progress Notes, dated 3/14/18, timed at 11:45 a.m., indicated Resident 1 walked out of the facility, refused to cooperate and walked further down the street. The notes indicated Resident 1 left against medical advice (AMA) and the Physician was made aware. The Notes did not indicated Resident 1 signed out AMA. A review of the nursing Progress Notes dated 3/14/18 and timed at 11:45 a.m. RN 1 indicated Resident 1 was not discharged AMA because he was confused and was supposed to be on a 1:1 monitoring. During an interview on 7/2/18 at 2:12 p.m., CNA 1 stated on 3/14/18 when Resident 1 eloped, there was no staff assigned to monitor the resident 1:1. CNA 1 stated, Whoever had time, would observe the resident. A review of the Prehospital Care Report Summary (Paramedic Report), dated 4/11/18, indicated Resident 1 was found by a bystander on the street with altered level of consciousness. Resident 1 required hospitalization due to the resident was found unresponsive. b. A review of the Admission Record indicated Resident 2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS - standardized assessment and care-planning tool) dated 5/1/18, indicated Resident 2 was able to make decisions and required extensive assistance with locomotion on and off unit. A review of the nursing Progress Notes dated 5/24/18, timed at 1:50 p.m., indicated Resident 2 left the facility through a back alley and was later found by staff. A review of the Wandering assessment dated [DATE], timed at 1:57 p.m., indicated Resident 2 was at risk for wandering and could move without assistance while in the wheelchair. The assessment indicated on the same date, the Physician ordered a Wander Guard band and for staff to check the functioning of the Wander Guard daily. A review of the physician's order, dated 5/4/18, indicated to have wander guard in place to remind Resident 2 of facility's boundaries. During an observation on 7/2/18, at 1:50 p.m., Resident 2 was awake sitting in a wheelchair and had a Wander Guard band on his left ankle. Three of the four exits equipped with the Wander Guard alarm system did not alarm when RN 1 wheeled Resident 2 out through the doors. During a concurrent interview, RN 1 stated the alarms should have went off. During an interview on 7/2/18, at 1:54 p.m., the maintenance supervisor stated the Wander Guard alarm system was old, since 2005, and the door did not detect the Wander Guard bands. At 2:05 p.m., the maintenance supervisor explained Wander Guard alarm to the facility's main entrance (by a busy city street) did not work either (four of the four doors equipped with Wander Guard alarms). The maintenance supervisor stated the alarm system needed to be repair. On 7/2/18 at 4:22 p.m., during an interview with CNA 4, who was assigned to care for Resident 2, she stated Resident 2's ankle band was a heart monitor. CNA 4 stated she was not aware Resident 2 was at risk for elopement and was not familiar with the Wander Guard alarm system. c. On 7/2/18 at 2:20 p.m., Resident 3 was lying in bed with a Wander Guard band on his right wrist. During an interview on 7/2/18 at 4 p.m., CNA 3 sated Resident 3 was confused and required supervision. CNA 3 stated Resident 3 had tried to leave the facility. A review of the Admission Record indicated Resident 3 was admitted to the facility on [DATE], and was re-admitted on [DATE], with [DIAGNOSES REDACTED]. A review of the MDS assessment dated [DATE], indicated Resident 3 had severe impairment in cognitive skills and required extensive assistance in walking. A review of the Care Plan dated 6/21/18, indicated Resident 3 was at risk of wandering related to impaired safety awareness. The goal was for Resident 3 not to leave the facility without staff. On 7/3/18 at 12: 51 p.m., during a review of Resident 3's clinical record with LVN 1, there was no physician's order for the Wander Guard. During a concurrent interview, LVN 1 stated the use of a Wander Guard band required the physician order and a consent from the resident's responsible party. d. On 7/2/18 at 2:22 p.m., Resident 4 was observed in bed with a Wander Guard on his right ankle. During an interview on 7/2/18 at 4:08 p.m., CNA 3 stated Resident 4 has attempted to leave the facility by opening the exit doors. CNA 3 stated that Resident 4 was confused and needed supervision to prevent the resident from leaving the facility. On 7/3/18, at 10:30 a.m., during an interview, the Activities Assistant stated Resident 4 pointed at the exit doors indicating that he wanted to leave the facility. A review of the Admission Record indicated Resident 4 was admitted to the facility on [DATE], and re-admitted on [DATE], with [DIAGNOSES REDACTED]. A review of the MDS assessment dated [DATE] indicated Resident 4 was severely impaired in cognitive skills for daily decision making (never/rarely made decisions) and required extensive assistance with locomotion. A review of the Wandering assessment dated [DATE] indicated Resident 4 could not communicate; the resident had history of wandering, and was assessed as risk for wandering. A review of the Care Plan dated 5/30/18, developed for Resident 4's wandering risk had a goal for Resident 4 to be safe. The interventions included to provide a Wander Guard alert device for Resident 4. A review of the nursing Progress Notes dated 6/21/18, timed at 7:57 p.m., indicated Resident 4 was attempting to leave the facility. On 7/3/18 at 12:38 p.m., during a review of Resident 4's clinical record with LVN 1, there was no physician's order for the Wander Guard and no evidence to indicate the date the Wander Guard band was placed on Resident 4. During a concurrent interview, LVN 1 stated the use of a Wander Guard band required a physician orders and a consent from the resident's responsible party. A review of the facility's policy revised 12/2017 titled, Safety and Supervision of Residents, indicated residents safety, supervision, and assistance to prevent accidents were facility-wide priorities. Safety risks and environmental hazards were identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes. Resident supervision was a core component of the systems approach to safety and that the type and frequency of resident supervision was determined by the individual resident's assessed needs. A review of the facility's policy revised 8/2014 titled, Wandering, Unsafe Resident, indicated the facility would strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who were at risk for elopement, and staff would identify residents who were at risk for harm because of unsafe wandering. A review of the facility's policy revised 12/2007 titled, Elopements, indicated staff should investigate and report all cases of missing resident.