Every finding on record at East Terrace Rehabilitation & Wellness Centre, LP

Based on interview and record review, the facility failed to ensure the individual financial record was given quarterly and upon request for one of three sampled residents (Resident 1).This deficient practice had the potential to deny Resident 1 the right to review and manage personal funds, which could interfere with the resident's financial autonomy and self-determination, and increase financial errors or discrepancies would not be identified or corrected in a timely manner.Findings:During a review of Resident 1's Face Sheet, the Face Sheet indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included encephalopathy (a brain condition that causes confusion or does not work normally because of illness or injury), schizophrenia (a mental illness that is characterized by disturbances in thought), and anxiety disorder (a condition where a person feels very worried, nervous, or fearful more often and more strongly than normal).During a review of Resident 1's History and Physical (H&P) dated 3/2/2026, the H&P indicated Resident 1 could make needs known but could not make medical decisions.During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 6/4/2026, the MDS indicated Resident 1 was able to understand and be understood by others. The MDS indicated Resident 1's cognition (ability to think and process) was moderately impaired. The MDS indicated Resident 1 used a wheelchair and required supervision (helper provides verbal cues or touching or contact guard assistance as resident completes activity) from staff for activities of daily living and mobility. During a concurrent interview and record review on 7/7/2026 at 12:09 p.m. with the Business Office (BO), Resident 1's Resident Fund Management Service, dated 12/17/2025, was reviewed. The Resident Fund Management Service indicated the facility was the representative and there were several signatures for the signature of legal representative. The BO stated the facility established a Resident Fund Trust Account for Resident 1, who was unable to make independent decisions. The BO stated the Interdepartmental Team, excluding Resident 1's physician, signed Resident Fund Management Service form. The BO stated the physician did not participate in meetings regarding residents' finances. The BO stated the facility has deposited Resident 1's social security checks into the facility's bank account since February 2026. The BO stated she did not inform Resident 1 about these deposits into the Resident Fund Trust Account and has not provided Resident 1 with quarterly financial statements. The BO stated the statements were not provided because Resident 1 was unable to understand and make medical decisions.During interview on 7/8/2026 at 4:10 p.m. with the Director of Nursing (DON), the DON stated Resident 1's primary physician should have participated in the Interdepartmental Team meeting to determine Resident 1's ability to make financial decisions and co-sign the Resident Fund Management Services document. The DON stated the BO should have ensured Resident 1 signed Appointment of Representative to Manage Personal Funds confirming Resident 1's agreement for the facility to manage her social security funds.During a record review of the facility's policy and procedure (P&P) titled, Resident Funds - General, dated 1/2018, the P&P indicated the facility was committed to providing an individual and confidential accounting of funds received and disbursed on the resident's behalf. The P&P indicated the facility would follow the Surrogate Decision Making policy which can include the facility becoming rep payee to protect the residents' access to their funds. The P&P indicated the facility would provide the resident with a confidential quarterly statement, or upon request.During a record review of the facility's policy and procedure (P&P) titled, Locating a Resident's Surrogate Decision Maker, dated 6/9/2026, the P&P indicated the facility was committed to make efforts to locate the Resident's surrogate decision-maker, which may include contacting Resident's previous and current physician when there was no one identified as a surrogate decision-maker at the time of admission.

Based on observation, interview and record review, the facility failed to report an allegation of abuse to the California Department of Public Health (CDPH) for one of four sampled residents (Resident 3), when Resident 3 reported that Resident 4 hit her on the forehead on 3/30/2026 and Resident 3 sustained a purplish discoloration. This deficient practice resulted in a delay in investigation by the CDPH and placed Resident 3 at risk for continued abuse.Findings: During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was originally admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 3's diagnoses included muscle weakness and dementia (a progressive state of decline in mental abilities). During a review of Resident 3's History and Physical (H&P) dated 12/13/2025, the H&P indicated Resident 3 could make needs known but could not make medical decisions. During a review of Resident 3's Minimum Data Set (MDS - a resident assessment tool) dated 3/21/2026, the MDS indicated Resident 3 was usually able to understand and was understood by others. The MDS indicated Resident 3 required partial/moderate assistance (helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) for Activities of Daily Living (ADLs) such as eating, bed mobility (the ability to roll from lying on back to left and right side, and return to lying back on the bed), sitting to standing and transfers. During a review of Resident 3's Situation, Background, Assessment, Recommendation Summary (SBAR- a communication tool used by healthcare workers when there is a change of condition among the residents) dated 3/30/2026 at 3:28 p.m., the SBAR indicated Resident 3 was noted with a raised, purplish marking to the mid-forehead area. During a review of Resident 3's Interdisciplinary Care Team (IDT-a group of healthcare professionals from different disciplines who work together to manage the resident's care) Note dated 3/31/2026, the IDT Note indicated on 3/30/2026 at approximately 3:00 p.m., Resident 3 stated she was pushed in the head by another resident (Resident 4) and Resident 3 was noted with raised, purplish marking to mid-forehead. The Note indicated given the absence or suspicion for abuse or a reportable allegation, the incident did not meet criteria for reporting to the CDPH. During a concurrent observation and interview on 4/6/2026 at 12:34 p.m., with Resident 3, Resident 3 was observed with a green and yellowish discoloration extending from the top of the hairline to the bridge of nose and from the right upper margin of eye socket to the left eye upper margin of eye socket. Resident 3 stated she was hit on her forehead by Resident 4. Resident 3 stated she did not know why Resident 4 hit her. Resident 3 stated that she informed staff about the incident but could not remember who. During a review of Resident 4's admission Record, indicated Resident 4 was admitted to the facility on [DATE] with diagnoses including muscle weakness and dementia. During a review of Resident 4's SBAR dated 3/30/2026 at 3:53 p.m., the SBAR indicated on 3/30/2026 at approximately 3:00 p.m., Resident 4 had a resident-to-resident contact, and the Physician recommended the resident for psychology/psychiatric consult. During a review of Resident 4's IDT Note dated 3/31/2026 at 1:25 p.m., the IDT Note indicated on 3/30/2026 at approximately 3:00 p.m., Resident 4's roommate (Resident 3) alleged that Resident 4 made contact with Resident 3 and pushed the resident (Resident 3) in the head. The IDT note indicated Resident 4 did not have visible injuries and the resident was unable to provide additional information due to cognitive (ability to think and reason) impairment. During an interview on 4/6/2026 at 1:44 p.m., with LVN 1, LVN 1 stated Resident 3 alleged Resident 4 hit her on the forehead. LVN 1 stated the facility should have reported the incident to the CDPH, ombudsman, and police no later than two hours so the incident could be investigated immediately and keep residents safe. During interviews on 4/6/2026 at 3:54 p.m. and 4/9/2026 at 12:53 p.m., with the Director of Nursing (DON), the DON stated CNA 5 reported to her that Resident 3 alleged Resident 4 hit her on the head. The DON stated the facility did not report the incident (abuse allegation) between Resident 3 and Resident 4 to the CDPH because according to the SOC 341(Report of Suspected Dependent Adult/Elder Abuse - a standard form in California used by mandated reporters to document and report suspected abuse, neglect, or exploitation of an elder [age 65+] or a dependent adult [age 18-64 with limitations]), abuse involving residents with dementia did not have to be reported. The DON stated the facility also did not report the incident because after investigating, the facility determined that no abuse occurred between the residents. During an interview on 4/9/2026 at 10:42 a.m., with CNA 5, CNA 5 stated Resident 3 reported to her that Resident 4 hit her on the forehead with her fist. CNA 5 stated, she could not recall the date of the incident but had immediately reported the allegation to the LVN and DON. During a review of the facility's Policy and Procedure (P&P) titled, Abuse Prevention and Management dated 5/30/2024, the P&P indicated for all allegations of abuse, the Administrator or designated representative will notify law enforcement, by telephone immediately, or as soon as practicably possible, but no longer than (2) hours of an initial report and send a written SOC341 report to the Ombudsman, Law Enforcement, and CDPH Licensing and Certification within (2) hours.

Based on observation, interview, and record review, the facility failed to: 1. Ensure one out of three sampled residents (Resident 10) did not elope (the act of leaving a facility unsupervised and without prior authorization) while wearing a Wander Guard device (a wearable device that tracks movement and triggers alarms when a resident is near a restricted area). This failure resulted in Resident 10 leaving the facility with no arrangements for medical care or housing.Findings:During a review of Resident 10's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses of schizophrenia (a mental illness that is characterized by disturbances in thought), depression (depressed mood or loss of interest), cellulitis (a skin infection that causes swelling and redness), and a local infection of the skin and subcutaneous tissue. During a review of Resident 10's History & Physical (H&P) dated 12/4/2025, the H&P indicated Resident 1 could make needs known but could not make medical decisions. During a review of Resident 10's physician order dated 12/4/2025, the physician order indicated to check the functioning of the Wander Guard (a wearable device that tracks movement and triggers alarms when a resident is near a restricted area) daily every night shift; check the placement of wander guard on right wrist #82B21F every night shift; and to monitor for the following behaviors: verbalizing a desire to go home, packing or collecting personal belongings, exit-seeking behaviors (hovering near exits, testing doors, attempting to leave) every shift. During a review of Resident 10's care plan titled, The resident is an elopement risk, dated 12/15/2025, the care plan interventions indicated to check placement of wander guard on right wrist and to document wandering behavior. During a review of resident 10's psychiatric consultation, dated 3/1/2026, the consultation indicated Resident 10 had a history of Depression and Schizophrenia. The report indicated Resident 10 still presents visual hallucinations, as evidenced by seeing persons not seen by others, along with verbalization of sadness. During a review of Resident 10's Minimum Data Set (MDS, a resident assessment tool), dated 3/11/2026, the MDS indicated Resident 1's cognition (ability to think and reason) was moderately impaired. The MDS indicated Resident 10 was independent for rolling left and right, sitting to lying, sitting to standing, transfers, walking, and using a manual wheelchair. The MDS indicated Resident 10 used a wander/elopement alarm daily. During a review of Resident 10's Elopement Evaluation, dated 3/11/2026, the Elopement Evaluation indicated the resident wandered. During a review of Resident 10's health status note, dated 3/13/2026, the note indicated at 6:21 p.m., the charge nurse was unable to locate Resident 10. During a concurrent observation and interview on 3/19/2026 at 10:59 a.m. with the Maintenance Supervisor (MS), the front entrance gate to the parking lot was timed at 25 seconds to open and 25 seconds to close. The MS stated every door leading directly into the facility had a wander guard alarm, and each alarm was checked and determined audible. The MS stated the two doors at the front, one leading to the street and another leading to the facility parking lot, did not have wander guard alarms. During an interview on 3/20/2026 at 9:54 a.m. with Registered Nurse (RN 1), RN 1 stated no one was assigned to watch the front door monitor at the nursing station. RN 1 stated they conduct rounds in the morning, afternoon, and evening to be sure residents are not missing. RN1 stated there is no official document for the rounds. During a review of the facility's policy and procedure (P&P) titled, Wandering and Elopement, dated 1/31/2023, the P&P indicated the resident's risk for elopement and preventative interventions would be documented in the resident's medical record and would be reviewed and re-evaluated by the Interdisciplinary Team upon admission, readmission, quarterly, and upon change in condition according to the RAI guidelines.

Based on interview and record review, the facility failed to ensure a license staff had the specific competencies and skills set necessary to care for one of three resident's (Resident 1) who was readmitted with wound.This failure had the potential to deliver poor quality nursing care and services and placed Resident 1 and other residents with wounds at risk for poor healing and contribute to its worsening wound conditions.Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included muscle weakness, Stage III pressure ulcer (Full-thickness loss of skin. Dead and black tissue may be visible) of the sacral region, anemia (a condition where the body does not have enough healthy red blood cells), and Alzheimer's disease (a disease characterized by a progressive decline in mental abilities). The admission Record indicated Resident 1 had a responsible party (RP 1). During a review of Resident 1's History and Physical (H&P), dated 11/7/2025, the H&P indicated Resident 1 had fluctuating capacity to understand and make decisions. During a review of Resident 1's care plan titled Resident 1 is at risk for potential impairment to skin integrity related to long term anticoagulant use (blood thinners), poor bed mobility and advance age, initiated on 11/17/2025 (revised 1/26/2026), the care plan indicated interventions to educate resident/ family caregiver of causative factors and measures to prevent skin injury, encourage good nutrition and hydration, follow facility protocols for treatment of injury, keep skin clean and dry. During a review of Resident 1's Braden Scale for Predicting Pressure Ulcer Risk Evaluation, dated 12/14/2025, the evaluation indicated Resident 1's occasionally moist skin, chairfast (ability to walk severely limited or non-existent) activity level, and very limited mobility increased his risk for pressure ulcers. During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 1/2/2026, the MDS indicated Resident 1 was dependent on staff with toileting hygiene, showering/ bathing self. Resident 1 required substantial/ maximal assistance (Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) with the ability to roll from lying on back to left and right side and returning to lying on back position, sit to lying, lying to sitting on side of the bed chair/bed-to-chair transfer and toilet transfer. During a review of Resident 1's Interfacility Transfer Report from General Acute Care Hospital (GACH 2), dated 1/5/2026, the Transfer Report indicated to cleanser Resident 1's Stage III pressure injury on the sacral with vashe (a wound solution), pat dry, apply therahoney (a medical grade honey used for wound care) to wound, cover with optifoam (a type of wound dressing) daily and as needed. During a review of Resident 1's facility Clinical Admission, document dated 1/5/2026 at 9:44 p.m., the Clinical Admission document indicated Resident 1 arrived and was admitted to the facility. Resident 1 had a wound on the sacrum with redness. The assessment did not indicate description (appearance, size/measurement) of the sacral. The section Documented Pressure Ulcer was blank. During a review of Resident 1's Skin & Wound Evaluation, document dated 1/6/2026, the document indicated a medical device related pressure injury in the sacrum, measuring 2 (unit of measurement- unspecified) in length on admission [DATE]); width 1,5; depth 0,1; wound bed epithelial (tissue); purple discoloration; edges attached and blanched surrounding tissue. The primary dressing indicated xeroform (type of wound dressing). During a review of Resident 1's sacral wound care plan after readmission on [DATE], Resident 1 had no care plan with interventions to address the sacral pressure injury. During a review of Resident 1's Physician Orders, dated 1/6/2026, the order indicated to cleanse sacral pressure injury with normal saline (cleansing solution), pat dry, apply Santyl (skin medication), and cover. During a review of Resident 1's skin checks dated 1/11/2026, the sacral pressure ulcer/ injury was unstageable (a full-thickness pressure ulcer whose depth and severity cannot be determined because the wound bed [base of wound] is obscured [covered] by dead tissue, slough, or eschar), measuring 4 centimeters (cm- a unit of measurement) in length and 4.5 cm in width. During a review of Resident 1's Wound Medical Doctor (MD 1) Wound Assessment and Plan, indicate the following wound assessments:1). On 1/9/2026- Resident 1's coccyx (lower back) pressure DTPI (deep tissue pressure injury, onset date 1/5/20256) was intact, measuring 2.2 cm in length and 1.8 cm in width.2). On 1/16/2026, Resident 1's coccyx pressure injury was unstageable, measuring4 cm in length and 4.5 cm in width with depth that could not be determined. The wound bed tissues had 40% epithelial tissues (the regenerated outer layer of skin tissues appearing as thin, pale pink, or translucent tissue, that covers granulating tissues) and 60% slough (dead tissues) with minimal exudate (drainage). The assessment indicated the wound bed exhibited violaceous (violet-colored) skin, manifesting (displaying) risk for decline to nonviable (dead, damaged, or infected tissue lacking blood supply) tissue. The wound MD wrote an order for x-ray of the sacrococcyx to evaluate for evidence of osteomyelitis (infection and inflammation of the bone). During an interview on 2/11/2026 at 2:14 p.m., with the Treatment Nurse (TN 1), the TN 1 stated all licensed nurses are responsible for initiating and implementing resident-centered care plans when wounds are identified. The TN 1 stated Resident 1 had no care plan with interventions for his sacral pressure injury on 1/5/2026. She did not know what violaceous indicated in the wound MD's documentation and could not describe the wound based on the Wound Assessment and Plan. The TN 1 stated violaceous (violet-colored) meant that the skin was reddened. If she did not understand the previous wound assessment, she would not be able to know if the wound was improving or worsening. During a concurrent interview and record review on 3/2/2026 at 1:13 p.m., with TN 1, Resident 1's TAR, for the month of 1/2026, TN 1's Time Card Report, dated 1/1/2026 to 1/15/2026, were reviewed. The TN 1 stated she was off on 1/7/2026 and mistakenly signed Resident 1's TAR indicating a treatment was provided to Resident 1's sacral pressure injury. She did not provide treatment on 1/7/2026 and did not photograph Resident 1's sacral pressure injury at any time during the resident's stay at the facility. She was never trained or provided equipment to photograph Resident 1's pressure injury. During a concurrent interview and record review on 3/3/2026 at 1:08 p.m., with MD 1, Resident 1's Clinical admission Assessment, dated 1/5/2026, Resident 1's Wound Assessment and Plan, dated 1/16/2026, were reviewed. MD 1 stated he had issues with the facility's TN's assessment quality. MD 1 stated the TN 1 could not differentiate between Resident 1's violaceous skin and skin redness. MD 1 stated violaceous skin was unhealthy, nearly necrotic, and required intensive interventions, while reddened skin was less urgent and indicated increased blood perfusion. TN 1 should be in-serviced to improve the quality of their assessment. During an interview on 3/12/2026 at 11:20 a.m., with the Medical Records Director (MRD), the MRD stated Resident 1 did not have photographs of his sacral pressure injury in his medical record. During a review of the facility's P&P titled Medical Records Manual - General Completion and Correction, dated 1/1/2012, the P&P indicated medical records will be correct to provide the highest quality and accuracy in documentation. The P&P indicated treatment administration should be accurately documented. The P&P indicated no event should be documented before it occurred. During a review of the facility's undated Job Description titled, Treatment Nurse, the job description indicated the TN should photograph all newly admitted residents with any skin problems and with Stage 2, 3, and 4 pressure ulcers. The job description indicated the TN will notify the dietary consultant promptly about any need for dietary intervention.

Based on interview and record review, the facility failed to ensure one of three residents (Resident 1), received the necessary services, consistent with professional standards of practice to promote wound healing. The facility failed to:Create a resident-centered plan of care with interventions to manage Resident 1's sacral (lower back) pressure injury (damage to the skin and underlying tissues caused by prolonged pressure, often over bony areas, which can range from mild redness to deep tissue necrosis) when admitted to the facility on [DATE].Update Resident 1's care plan, titled at risk for potential impairment to skin integrity., with interventions to prevent the wound from worsening and promote healing.Implement its policy and procedure (P&P), titled Skin Integrity Management, dated 7/31/2024, which indicated a plan of care should be developed to provide guidelines for the treatment of skin integrity conditions to facilitate healing and update as necessary. This failure resulted in the Resident 1's worsening sacral wound condition and placed the resident at risk for wound infections and other complications, including hospitalizations. Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included muscle weakness, Stage III pressure ulcer (Full-thickness loss of skin. Dead and black tissue may be visible) of the sacral region, anemia (a condition where the body does not have enough healthy red blood cells), and Alzheimer's disease (a disease characterized by a progressive decline in mental abilities). The admission Record indicated Resident 1 had a responsible party (RP 1). During a review of Resident 1's History and Physical (H&P), dated 11/7/2025, the H&P indicated Resident 1 had fluctuating capacity to understand and make decisions.During a review of Resident 1's care plan titled Resident 1 is at risk for potential impairment to skin integrity related to long term anticoagulant use (blood thinners), poor bed mobility and advance age, initiated on 11/17/2025 (revised 1/26/2026), the care plan indicated interventions to educate resident/ family caregiver Of causative factors and measures to prevent skin injury, encourage good nutrition and hydration, follow facility protocols for treatment of injury, keep skin clean and dry. During a review of Resident 1's Braden Scale for Predicting Pressure Ulcer Risk Evaluation, dated 12/14/2025, the evaluation indicated Resident 1's occasionally moist skin, chairfast (ability to walk severely limited or non-existent) activity level, and very limited mobility increased his risk for pressure ulcers. During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 1/2/2026, the MDS indicated Resident 1 was dependent on staff with toileting hygiene, showering/ bathing self. Resident 1 required substantial/ maximal assistance (Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) with the ability to roll from lying on back to left and right side and returning to lying on back position, sit to lying, lying to sitting on side of the bed chair/bed-to-chair transfer and toilet transfer. During a review of Resident 1's Interfacility Transfer Report from General Acute Care Hospital (GACH 2), dated 1/5/2026, the Transfer Report indicated to cleanser Resident 1's Stage III pressure injury on the sacral with vashe (a wound solution), pat dry, apply therahoney (a medical grade honey used for wound care) to wound, cover with optifoam (a type of wound dressing) daily and as needed. During a review of Resident 1's facility Clinical Admission, document dated 1/5/2026 at 9:44 p.m., the Clinical Admission document indicated Resident 1 arrived and was admitted to the facility. Resident 1 had a wound on the sacrum with redness. The assessment did not indicate description (appearance, size/measurement) of the sacral. The section Documented Pressure Ulcer was blank. During a review of Resident 1's Skin & Wound Evaluation, document dated 1/6/2026, the document indicated a medical device related pressure injury in the sacrum, measuring 2 (unit of measurement- unspecified) in length on admission [DATE]); width 1,5; depth 0,1; wound bed epithelial (tissue); purple discoloration; edges attached and blanched surrounding tissue. The primary dressing indicated xeroform (type of wound dressing). During a review of Resident 1's sacral wound care plan after readmission on [DATE], Resident 1 had no care plan with interventions to address the sacral pressure injury. During a review of Resident 1's Physician Orders, dated 1/6/2026, the order indicated to cleanse sacral pressure injury with normal saline (cleansing solution), pat dry, apply Santyl (skin medication), and cover. During a review of Resident 1's skin checks dated 1/11/2026, the sacral pressure ulcer/ injury was unstageable (a full-thickness pressure ulcer whose depth and severity cannot be determined because the wound bed [base of wound] is obscured [covered] by dead tissue, slough, or eschar), measuring 4 centimeters (cm- a unit of measurement) in length and 4.5 cm in width. During a review of Resident 1's Wound Medical Doctor (MD 1) Wound Assessment and Plan, indicate the following wound assessments:1). On 1/9/2026- Resident 1's coccyx (lower back) pressure DTPI (deep tissue pressure injury, onset date 1/5/20256) was intact, measuring 2.2 cm in length and 1.8 cm in width.2). On 1/16/2026, Resident 1's coccyx pressure injury was unstageable, measuring4 cm in length and 4.5 cm in width with depth that could not be determined. The wound bed tissues had 40% epithelial tissues (the regenerated outer layer of skin tissues appearing as thin, pale pink, or translucent tissue, that covers granulating tissues) and 60% slough (dead tissues) with minimal exudate (drainage). The assessment indicated the wound bed exhibited violaceous (violet-colored) skin, manifesting (displaying) risk for decline to nonviable (dead, damaged, or infected tissue lacking blood supply) tissue. The wound MD wrote an order for x-ray of the sacrococcyx to evaluate for evidence of osteomyelitis (infection and inflammation of the bone). During a concurrent interview and record review on 2/12/2026 at 12:20 p.m., with the Treatment Nurse (TN 1), Resident 1's Clinical admission Assessment, dated 1/5/2026, Care Plans for the month of 1/2026, and Resident 1's Care Plan titled Resident 1 at risk for potential impairment to skin integrity, dated 11/17/2025, were reviewed. The TN 1 stated the admission Assessment indicated that Resident 1 had red wound on his sacrum. Resident 1's care plans did not address his sacral wound. Resident 1's turning program and treatments should have been documented in his care plan to prevent new wounds and further breakdown of his existing wound. During a concurrent interview and record review on 2/12/2026 at 3:00 p.m., with the Registered Nurse (RN 1), Resident 1's care plans for the month of 1/2026, was reviewed. RN 1 stated the licensed nurses should have created a Resident 1-specific care plan when admitted to the facility on [DATE], for the management of his sacral pressure injury. The licensed nurses did not update Resident 1's care plan interventions when the sacral pressure injury had increased in size and when the physician's orders were changed on 1/11/2026 and 1/16/2026. During a concurrent interview and record review on 3/3/2026 at 1:08 p.m., with wound MD 1, Resident 1's Clinical admission Assessment, dated 1/5/2026, Resident 1's Skin Check, dated 1/11/2026, Resident 1's Wound Assessment and Plan, dated 1/16/2026, and Resident 1's Physician Orders, dated 1/16/2026, were reviewed. MD 1 stated Resident 1's risk factors of incontinence, muscle weakness, and cognitive limitations placed him at high risk of pressure ulcer development and worsening. MD 1 stated Resident 1's sacral wound was not assessed and measured by nursing staff upon admission to the facility on 1/5/2026. MD 1 stated Resident 1's pressure injury required RD assessment and recommendations, a plan of care created by nursing and interdisciplinary collaboration to heal. MD 1 stated the missing RD recommendations and lack of care plan likely caused Resident 1's wound to double in size from 1/11/2026 through 1/16/2026. During an interview on 3/3/2026 at 9:28 a.m. with the Registered Dietitian (RD 1), RD 1 stated there was no indication that the RD or dietary department addressed Resident 1's pressure injury after it was identified on 1/5/2026. RD 1 stated on 1/5/2026, the RD should have addressed Resident 1's pressure injury, documented her assessment and recommendations, and considered zinc, protein, and hydration supplements to heal Resident 1's pressure injury. RD 1 stated the RD should have reassessed Resident 1's nutritional needs each time his wound worsened. RD 1 stated the care plan intervention to encourage good nutrition was not provided because the RD did not assess or make recommendations to treat Resident 1's sacral pressure injury. During a review of the facility's P&P titled, Skin Integrity Management, dated 7/31/2024, the P&P indicated the facility will identify, evaluate, and intervene to prevent further pressure injury and/or health pressure ulcer. A plan of care will be developed to provide guidelines for the treatment of skin integrity conditions to facilitate healing. A licensed nurse will complete a skin evaluation when there is change in skin integrity and complete the skin evaluation weekly. The P&P indicated the dietary needs of the resident will be evaluated be the RD upon any significant change in skin condition. The licensed nurses will document the effectiveness of the current treatment for skin integrity problems in the resident's medical record on a weekly basis. The IDT will discuss and document recommendations for the skin integrity issues. The residents' care plan will be updated as necessary. During a review of the facility's P&P titled Comprehensive Person-Centered Care Planning, dated 5/22/2025, the P&P indicated the facility must develop and implement a comprehensive person-centered care plan for each resident with measurable objectives and timeframes to meet a resident's physical needs. The care plan must describe the services that are to be furnished, and interventions designed to meet an objective. The care plan will be prepared by an IDT that includes the attending physician, an RN, a nurse aide, a member of the food and nutrition services staff, and other appropriate staff and disciplines as determines by the resident's needs. The resident and the resident representative must attend to the extent practicable, and an explanation for their absence must be documented if it is not practicable for them to attend. During a review of the facility's undated Job Description titled Treatment Nurse, the job description indicated the TN will assess resident's skin condition by doing a complete body assessment on admission and re-admission. The TN will initiate the Nurse's Skin and Wound Progress report upon identification of any skin problem and pressure injury. The TN will notify the dietary consultant promptly about any need for dietary intervention.

Based on observation, interview and record review, the facility failed to report an injury of unknown source (injury of unknown source when all of the following criteria are met: the source of the injury was not observed by any person; and the source of the injury could not be explained by the resident; and the injury is suspicious because of the extent of the injury or the location of the injury [e.g., the injury is located in an area not generally vulnerable to trauma]) for one of five sampled residents (Resident 1).This failure delayed the investigation by the California Department of Public Health (CDPH) and placed Resident 1 at risk for abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish).Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included Chronic Obstructive Pulmonary Disease ([COPD], a chronic lung disease causing difficulty in breathing) and generalized (affecting throughout the body) muscle weakness. During a review of Resident 1's Minimum Data Set ([MDS], a resident assessment tool) dated 12/19/2025, the MDS indicated Resident 1 had moderate (not extreme) cognitive impairment (problems with the ability to think, remember, and solve problems). The MDS indicated Resident 1 was dependent (helper does all the effort) with Activities of Daily Living (ADLs) such as toileting and personal hygiene. The MDS indicated Resident 1 was dependent with staff in rolling from a lying on back position to her left and right side, from sitting to lying position, lying to sitting on side of bed and sitting to standing position. During a concurrent observation and interview on 1/23/2026 at 12:08 p.m. with Resident 1, Resident 1 had yellowish- purplish skin discoloration (any change to the skin's natural color) on her left dorsal hand. Resident 1 stated it (discoloration) happened after someone (unnamed) took her blood pressure (BP) too tight (could not recall when) in the left hand. During an interview on 1/23/2026 at 2:59 p.m., with the Treatment Licensed Vocational Nurse (LVN), the Treatment LVN stated that she first identified redness on Resident 1's left dorsal hand on 1/2/2026 due to a blood pressure (BP) cuff being too tight. Treatment LVN stated that Resident 1, at the time of interview, could not provide when or who did it. The Treatment LVN stated on 1/21/2026, she reassessed Resident 1's left dorsal hand redness but did not document in the resident's progress notes. The Treatment Nurse stated the Wound Physician (MD) examined Resident 1's left dorsal hand on 1/23/2026 as ecchymosis (a type of bruise caused by blood leaking from broken blood vessels into the skin, resulting in a flat, discolored patch). During a concurrent interview and record review on 1/27/2026 at 12:19 p.m., with Certified Nursing Assistant (CNA) 1, Resident 1's left dorsal hand picture taken 1/23/2026 was reviewed. CNA 1 stated Resident 1's left dorsal hand picture taken on 1/23/2026 was like Resident 1's skin color (yellowish-purplish color) she observed on 1/21/2026. CNA 1 stated on 1/21/2026, she (CNA 1) notified LVN 2 about the yellowish-purplish skin discoloration of Resident 1's left dorsal hand. During an interview on 1/27/2026 at 2:04 p.m., with LVN 2, LVN 2 stated that if any staff reported discoloration on a resident's skin, the LVN should notify the Director of Nursing (DON) and Administrator (Admin) for investigation because of the possibility of abuse. During a concurrent interview and record review on 1/28/2026 at 12:28 p.m., with LVN 2, a picture of Resident 1's left dorsal hand taken 1/23/2026 and MD orders were reviewed. LVN 2 stated the bruise seen in the picture on Resident 1's hand was not there last week (date not specified). LVN 2 stated that if the skin was red and became discolored, it could be from an unknown origin. LVN 2 stated a change of condition (COC) should have been created. LVN 2 stated if an injury of unknown origin is not reported, it could delay the care the residents need and safety could be affected. LVN 2 stated Resident 1's physician orders did not indicated she was on any blood thinners (medication that prevents clots from forming, which could lead for bruises to easily form) which could cause easy bruising. During an interview on 1/28/2026 at 1:32 p.m., with the Treatment LVN, the Treatment LVN stated ecchymosis can be an injury of unknown origin and should have been reported to CDPH because of the possibility that Resident 1 was injured by a staff. During an interview on 1/28/2026 at 3:12 p.m., with the DON, the DON stated if a staff saw residents with skin discolorations, the Charge Nurse should assess the resident, ask the resident how it happened, create a COC assessment and notify the MD. The DON stated if the skin discoloration was an injury of unknown origin, the facility must know how it happened and should be reported to the CDPH. During an interview on 1/28/2026 at 4:03 p.m., with the Administrator (Admin), the Admin stated he was not aware of the unexplained bruising of Resident 1. The Admin stated an injury of unknown origin is when the facility is not sure how the injury happened. The Admin stated, we determined how it happened by doing an investigation and asking the resident. The Admin stated if it was brought to his attention, staff would have investigated and assess the bruising to determine where it came from to rule out abuse. If it came out as an alleged abuse, the facility would report it to CDPH. The Admin stated if we conclude it's not abuse, it's not reportable to CDPH. During a review of facility's policy and procedure (P&P) titled, Abuse Prevention and Management, dated 6/12/2024, the P&P defined Injury of Unknown Source as, an injury that meets both of the following conditions: the source of the injury was not observed by any person, and the injury is suspicious because of the extent of the injury, the location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma). The P&P indicated to notify CDPH Licensing and Certification by telephone immediately, or as soon as practicably possible, but no longer than two (2) hours.

Based on observation, interview and record review, the facility failed to investigate an injury of unknown source (injury of unknown source when all of the following criteria are met: the source of the injury was not observed by any person; and the source of the injury could not be explained by the resident; and the injury is suspicious because of the extent of the injury or the location of the injury [e.g., the injury is located in an area not generally vulnerable to trauma]) when one of five sampled residents' (Resident 1) left dorsal hand (back of hand) had yellowish-purplish skin discoloration on 1/21/2026 and ecchymosis (a type of bruise caused by blood leaking from broken blood vessels into the skin, resulting in a flat, discolored patch) on 1/23/2026. This failure placed Resident 1 at risk for severe injuries, including hospitalization and death. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included Chronic Obstructive Pulmonary Disease ([COPD], a chronic lung disease causing difficulty in breathing) and generalized (affecting throughout the body) muscle weakness. During a review of Resident 1's Minimum Data Set ([MDS], a resident assessment tool) dated 12/19/2025, the MDS indicated Resident 1 had moderate (not extreme) cognitive impairment (problems with the ability to think, remember, and solve problems). The MDS indicated Resident 1 was dependent (helper does all the effort) with Activities of Daily Living (ADLs) such as toileting and personal hygiene. The MDS indicated Resident 1 was dependent with staff in rolling from a lying on back position to her left and right side, from sitting to lying position, lying to sitting on side of bed and sitting to standing position. During a review of Resident 1's progress notes from 1/21/2026 to 1/23/2026, the progress notes did not indicate Resident 1's left dorsal hand yellowish-purplish skin discoloration on 1/21/2026 and the ecchymosis on 1/23/2026, were investigated. During a concurrent observation and interview on 1/23/2026 at 12:08 p.m. with Resident 1, Resident 1 had yellowish- purplish skin discoloration on her left dorsal hand (back of hand). Resident 1 stated it (discoloration) happened after someone (unnamed) took her blood pressure (BP) too tight (could not recall when) in the left hand. During a concurrent interview and record review on 1/23/2026 at 2:59 p.m., with the Treatment License Vocational Nurse (LVN), Resident 1's Skin Check notes dated 1/23/2026, were reviewed. The Treatment LVN stated on 1/23/2026, the Wound physician (MD) saw Resident 1's left dorsal hand had ecchymosis. During a concurrent interview and record review on 1/27/2026 at 12:19 p.m., with Certified Nursing Assistant (CNA) 1, Resident 1's left dorsal hand picture taken 1/23/2026 was reviewed. CNA 1 stated Resident 1's left dorsal hand picture taken on 1/23/2026 was like Resident 1's skin color (yellowish-purplish color) she observed on 1/21/2026. CNA 1 stated on 1/21/2026, she (CNA 1) notified LVN 2 about the yellowish-purplish skin discoloration of Resident 1's left dorsal hand. During an interview on 1/27/2026 at 2:04 p.m., with LVN 2, LVN 2 stated that if any staff reported discoloration on a resident's skin, the LVN should notify the Director of Nursing (DON) and Administrator (Admin) for investigation because of the possibility of abuse. During an interview on 1/28/2026 at 3:12 p.m., with the DON, the DON stated if a staff saw residents with skin discolorations, the Charge Nurse should assess the resident, ask the resident how it happened, create a Change of Condition (COC) assessment and notify the MD. The DON stated if the skin discoloration was an injury of unknown origin, the facility must know how it happened and should be reported to the California Department of Public Health (CDPH). During an interview on 1/28/2026 at 4:03 p.m., with the Admin, the Admin stated he was not aware of the unexplained bruising of Resident 1. The Admin stated an injury of unknown origin is when the facility is not sure how the injury happened. The Admin stated, we determined how it happened by doing an investigation and asking the resident. The Admin stated if it was brought to his attention, staff would have investigated and assess the bruising to determine where it came from to rule out abuse. If it came out as an alleged abuse, the facility would report it to CDPH. The Admin stated if we conclude it's not abuse, it's not reportable to CDPH. During a review of facility's policy and procedure (P&P) titled, Abuse Prevention and Management, dated 6/12/2024, the P&P defined Injury of Unknown Source as, an injury that meets both of the following conditions: the source of the injury was not observed by any person and the injury is suspicious because of the extent of the injury, the location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma). The P&P indicated when the Administrator or designated representative received a report of an allegation of an injury of an unknown source, the Administrator or designated representative, should initiate an investigation immediately.

Based on interview and record review, the facility failed to ensure care and services to one of five residents (Resident 1), were provided in accordance with professional standards of practice, by failing to: 1). Ensure Resident 1's left dorsal hand (back of hand) redness was monitored according to the physician 's (MD) order. 2). Ensure a follow-up call was made to the MD regarding Resident 1's change of condition (COC) on 1/20/2026. 3). Ensure Treatment Licensed Vocational Nurse's (LVN) did not change left dorsal hand assessment done on 1/2/2026. These failures had the potential to affect the care and services provided to Resident 1 and the potential to delay care, resulting in complications and hospitalization. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and was readmitted on [DATE]. Resident 1's diagnoses included Chronic Obstructive Pulmonary Disease ([COPD], a chronic lung disease causing difficulty in breathing) and generalized (affecting throughout the body) muscle weakness. During a review of Resident 1's Minimum Data Set ([MDS], a resident assessment tool) dated 12/19/2025, the MDS indicated Resident 1 had moderate (not extreme) cognitive impairment (problems with the ability to think, remember, and solve problems). The MDS indicated Resident 1 was dependent (helper does all the effort) with Activities of Daily Living (ADLs) such as toileting and personal hygiene. The MDS indicated Resident 1 was dependent with staff in rolling from a lying on back position to her left and right side, from sitting to lying position, lying to sitting on side of bed and sitting to standing position. 1). During a review of Resident 1's COC, dated 1/2/2026 at 9:56 a.m., the COC indicated Resident 1 had redness on her left dorsal hand during treatment. The COC indicated Resident 1 stated the blood pressure was too tight on her wrist. The COC indicated Resident 1's MD recommended to monitor resident's skin for any changes (hematoma, skin breakdown). During a review of Resident 1's Order Summary Report (a list of all current MD's orders) dated 1/2/2026, the Order Summary report indicated to monitor left dorsal hand discolorations (changes in the natural skin tone) for hematoma (a collection of blood outside of blood vessels, typically resulting from an injury or trauma that causes blood to leak into surrounding tissues) formation, skin breakdown, pain/discomfort. Document Y if observed and notify MD. Document N if not observed everyday shift for 30 days. During a review of Resident 1's Treatment Administration Record (TAR), for the month of 1/2026, Resident 1's TAR did not indicate a documented Y if observed or N if not observed, as indicated in the MD's order. During a review of Resident 1's progress notes for the month of 1/2026, Resident 1's progress notes did not indicate that Resident 1's left dorsal hand was monitored as per MD orders. 2). During a review of Resident 1's COC dated 1/20/2026 at 10:25 p.m., the COC indicated Resident 1 had self-inflicted laceration (a deep cut or torn wound in the skin) to bilateral (both) lower legs. The COC indicated staff was awaiting MD's response. During a review of Resident 1's progress notes from 1/20/2026, the progress notes did not indicate staff followed up with Resident 1's MD for orders to treat both lower leg wounds. 3). During a concurrent interview and record review on 1/23/2026 at 2:59 p.m., with the Treatment LVN, Resident 1's Skin Checks, dated 1/4/2026, 1/9/2026, 1/16/2026 and skin check notes dated 1/23/2026, were reviewed. The Treatment LVN stated Resident 1's skin checks on all the dates did not indicate status or description of the left dorsal hand redness. The Treatment LVN could not provide explanation why the skin statuses were not documented. The Treatment Nurse stated she changed her skin check notes on 1/23/2026 to ecchymosis (a type of bruise caused by blood leaking from broken blood vessels into the skin, resulting in a flat, discolored patch) to reflect the Wound MD's left dorsal hand assessment of ecchymosis on 1/23/2026 (wound MD notes not provided). The Treatment LVN stated the assessment became inaccurate because it (ecchymosis) was not her original assessment. During an interview on 1/27/2026 at 1:00 p.m., with LVN 1, LVN 1 stated if staff were unable to get hold of the MD during a resident's COC, staff should attempt to reach out to the MD's nurse practitioner (NP) or could contact the facility's Medical Director to obtain orders. LVN 1 stated if still unsuccessful in obtaining orders during their shift, the staff should endorse to the oncoming shift to ensure residents' safety and care are being taken care of. During an interview on 1/27/2026 at 2:04 p.m., with LVN 2, LVN 2 stated Resident 1's progress notes should indicate the care provided to the residents, including follow-up assessments, monitoring or documentations. During a concurrent interview and record review on 1/27/2026 at 3:55 p.m., with the Director of Nursing (DON) the following were reviewed:Resident 1's TAR, for the month of 1/2026Resident 1's progress notes for the month of 1/2026Resident 1's COC, dated 1/20/2026. The DON stated Resident 1's TAR for the month of 1/2026 did not indicate Y or N indicating Resident 1's left dorsal hand discolorations were observed as indicated in the MD's order. The DON stated Resident 1's progress notes did not indicate staff had followed up with the MD after Resident 1's COC on 1/20/2026. The DON stated if the MD did not respond after Resident 1's COC on 1/20/2026, staff should ensure a follow-up call was made to the MD. The DON stated not following up with the MD could possibly delay Resident 1's care. The DON stated regarding assessments, staff should not change original skin assessment to be accurate. The DON stated a clarification (follow-up documentation) can be documented after MD had assessed something different (changes in the skin). During a concurrent interview and record review on 1/28/2026 at 1:32 p.m., with the Treatment LVN, Resident 1's Skin Check created on 1/27/2026, with an effective date of 1/2/2026 was reviewed. The Treatment LVN stated on 1/2/2026's skin assessment, there was redness on Resident 1's left dorsal hand which was not documented on the skin check form. The Treatment LVN stated she created another skin check form on 1/27/2026 to reflect the redness assessed on 1/2/2026. The Treatment LVN stated charting 25 days after an assessment was performed placed the assessment was inaccurate. During an interview on 1/28/2026 at 3:12 p.m. with the DON, the DON stated staff should date the skin assessment on the day the assessment was performed to ensure accurate information. During a review of facility's policy and procedures (P&P) titled, Completion and Correction, dated 1/1/2012, the P&P indicated entries should be written in chronological sequence and recorded promptly as the events or observations occur. The P&P indicated documentation content should include, treatments, observations during treatments and effectiveness of treatments. During a review of facility's P&P titled, Skin Integrity Management, dated 6/27/2024, the P&P indicated, a Licensed Nurse should complete the skin evaluation weekly. The P&P indicated, treatments administered should be documented in the resident medical record and the Licensed Nurses should document the effectiveness of current treatment for skin integrity problems in the resident's medical record on a weekly basis. During a review of facility's policy and procedure (P&P) titled, Change in Condition, dated 8/25/2022, the P&P indicated, Licensed Nurse should notify the resident's MD when there is an incident/accident involving the resident. The P&P indicated documentation should include the time the MD was contacted, the method by which he was contacted, the response time, and whether or not orders were received.

Based on interview and record review, the facility failed to develop a comprehensive person-centered care plan for four of 25 sampled residents (Resident 1, 11, 14, and 53) by failing to develop a comprehensive care plan for:1. Resident 1's significant weight loss (a weight loss greater than 5 percent ([%] unit of measurement) in one month, greater than 7.5% in three months and greater than 10% in 6 months) of 39 pounds ([lb.] unit of weight)/19.7 % in 6 months.2. Resident 11's psychiatric diagnoses (a clinical classification of mental health conditions, identifying patterns of distressing thoughts, emotions, and behaviors).3. Resident 14's colostomy (a surgical procedure that brings one end of the large intestine out through the abdominal wall to allow waste to leave the body) care.4. Resident 53's oxygen therapy. These failures had the potential to place Residents 1, 11, 14, and 53 at risk for delay of care and treatment.Findings: 1. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including protein calorie malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function), congestive heart failure ([CHF] – a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), and bipolar disorder (mood swings that range from the lows of depression to elevated periods of emotional highs). During a review of Resident 1's History and Physical (H&P), dated 9/25/2025, the H&P indicated Resident 1 could make needs known but could not make medical decisions. During a review of Resident 1's Minimum Data Set ([MDS] – a resident assessment tool), dated 11/6/2025, the MDS indicated Resident 1's cognitive (ability to think and reason) skills were moderately impaired. The MDS indicated Resident 1 required substantial assistance (helper does more than half the effort) from staff with toileting hygiene, showering, and upper and lower body dressing. The MDS indicated Resident 1 had a significant weight loss and was not on planned physician-prescribed weight loss regimen. During a concurrent interview and record review on 12/18/2025 at 9:54 a.m. with the Assistant Director of Nursing (ADON), Resident 1's Monthly Weights Report, was reviewed. The ADON stated Resident 1's weight on 5/12/2025 was 198 pounds ([lb.] unit of weight) and Resident 1's weight on 11/5/2025 was 159 lbs. The ADON stated Resident 1 had a significant weight loss of 39 lbs. (19.7 %) in 6 months and the facility did not develop a comprehensive care plan to address his significant weight loss. The ADON stated the interdisciplinary team ([IDT] – a group of healthcare professionals working together to plan the care needed for each resident) were responsible in developing a care plan. The ADON stated a comprehensive care plan should have a problem, goal, and interventions. The ADON stated that without a care plan, Resident 1's health would be jeopardized, and he would continue to lose weight since there were no interventions to address his significant weight loss. 2. During a review of Resident 11's admission Record, the admission Record indicated Resident 11 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including schizophrenia (a mental illness that is characterized by disturbances in thought), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality) and epilepsy (seizures). During a review of Resident 11's H&P, dated 10/14/2025, the H&P indicated Resident 11 was able to make decisions for Activities of Daily Living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 11's MDS, dated [DATE], the MDS indicated Resident 11's cognitive (thinking) skills were intact. The MDS indicated Resident 11 was dependent on staff members with ADLs. During a concurrent interview and record review, on 12/18/2025 at 10:13 a.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated care plans were initiated upon admission, along with a resident's diagnoses and any change of condition for a resident. LVN 1 stated there was no care plan for Resident 11's psychiatric diagnoses. LVN 1 stated Resident 11's psych diagnoses should have had been care planned. LVN 1 stated the risk of not developing a care plan for psych diagnoses could result in possible altercations and not knowing how to care for a resident. 3. During a review of Resident 14's admission Record, the admission Record indicated Resident 14 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including major depressive disorder, a colostomy (a surgical opening created to allow waste products from bowel to pass from intestines), and legal blindness. During a review of Resident 14's H&P, dated 12/7/2025, the H&P indicated Resident 14 was able to understand and make medical decisions. During a review of Resident 14's Order Summary Report, dated 12/6/2025, the report indicated to provide colostomy care daily, every day shift, and as needed. During a concurrent interview and record review on 12/18/2025 at 10:15 a.m., with the Treatment Nurse (TN), Resident 14's open and closed electronic care plans were reviewed. The TN stated when the care plan was closed, that specific care was completed. The TN stated since there is an active order for ostomy care, the care plan should be active so staff would know to provide care for the ostomy. The TN stated if the care was not provided, the ostomy could become infected, and the resident could develop agitation and mood changes. 4. During a review of Resident 53's face sheet, the face sheet indicated Resident 53 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), acute respiratory failure (a life-threatening condition where the lungs suddenly can't get enough oxygen into the blood or remove enough carbon dioxide), dementia (a progressive state of decline in mental abilities) and psychosis. During a review of Resident 53's H&P, dated 10/4/2025, the H&P indicated Resident 53 was able to make needs known but could not make medical decisions. During a review of Resident 53's MDS, dated [DATE], the MDS indicated Resident 53's cognitive skills were moderately impaired. The MDS indicated Resident 53 required partial/moderate assistance from staff with ADLs. During a concurrent interview and record review, on 12/18/2025 at 10:19 a.m., with LVN 1, Resident 53's care plans were reviewed. LVN 1 stated he did not see an oxygen care plan for Resident 53. LVN 1 stated Resident 53 should have had a care plan on oxygen. LVN 1 stated developing an oxygen care plan could result in staff not knowing what the targeted plan of care is for a resident. During a review of the facility's policy and procedures (P&P), titled Person-Centered Care Planning, dated 5/22/2025, the P&P indicated The facility must develop and implement a comprehensive person-centered care plan for each resident consistent with the resident rights, that includes measurable objectives, and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment.

Based on observation, interview and record review, the facility failed to ensure dietary staff did not use one (1) scooper, for two (2) food items, during tray line (a healthcare foodservice assembly system where staff add specific food items, utensils, and condiments to patient meal trays).This deficient practice had the potential to result in cross contamination of food and placed the residents with food allergies at risk for allergic reactions.Findings:During observation on 12/17/2025 at 12:32 p.m., at the facility's tray line in the kitchen, the Dietary Aide 1 (DA 1) was observed used one scooper for the brussels sprouts and corn (vegetables), to be placed on the residents' trays.During a concurrent observation and interview, on 12/17/2025 at 12:35 p.m., with the Dietary Services Supervisor (DSS), the DSS stated one scooper should be used for one food during tray line. The DSS stated one scooper should not be used for different foods. When asked for the risk of using one scooper for two different foods, the DSS stated I didn't think there was a problem with using one scooper for two foods because the two foods are vegetables. I guess it could result in a potential allergic reaction if a resident was allergic to one of the foods and/or food contamination.During a review of the facility's policy and procedures (P&P), titled Dietary Department, dated 6/1/2024, the P&P indicated, the Dietary Manager was responsible for the day-to-day education of dietary staff with regards to topics such as sanitation, food preparation, etc.During a review the facility's P&P titled, Dietary Department- Infection Control, dated 6/4/2024, the P&P indicated, the facility must ensure that the dietary department was maintained in a sanitary condition in order to prevent food contamination and the growth of disease producing organisms and toxins.

Based on observation, interview, and record review, the facility failed to ensure one out of one sampled resident (Resident 102) with long thick elongated (nail plate grows longer than the nail bed) toenails received podiatry (profession dealing with specialized care of the feet) care services.This deficient practice had the potential to result in Resident 102 experiencing discomfort and decline in physical mobility.Findings:During a review of Resident 102's admission Record, the admission Record indicated Resident 102 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), difficulty in walking, and psychosis (a severe mental health condition in which thought, and emotions are so affected that contact is lost with reality).During a review of Resident 102's History and Physical (H&P), dated 12/10/2025, the H&P indicated Resident 102 did not have the capacity to understand and make decisions.During a review of Resident 102's Minimum Data Set ([MDS] - a resident assessment tool), dated 9/8/2025, the MDS indicated Resident 102's cognitive (ability to think and reason) skills was intact. The MDS indicated Resident 102 was independent (resident completes the activity with no assistance from a helper) with oral hygiene, toileting hygiene and upper and lower body dressing.During a review of Resident 102's Order Summary Report (a document containing active orders), dated 12/18/2025, the report indicated the physician placed a telephone order on 12/10/2025 for Resident 102 to have podiatry service as clinically indicated.During a concurrent observation and interview on 12/16/2025 at 11:17 a.m., with Resident 102 in her room, Resident 102 had long thick elongated toenails on both feet. Resident 102 stated she requested to see a foot doctor a long time ago, but nothing had been done.During a concurrent observation and interview on 12/18/2025 at 9:01 a.m., with Certified Nurse Assistant 2 (CNA 2), CNA 2 stated Resident 102 has long thick toenails on both feet. CNA 2 stated she did not endorse Resident 102 to the Social Service Director (SSD) for podiatry care services.During an interview on 12/18/2025 at 9:06 a.m. with the SSD, the SSD stated Resident 102 was not seen by the podiatrist on his visits on 11/20/2025 and 12/11/2025. The SSD stated he was responsible for referring residents who needed foot care to the podiatrist. The SSD stated podiatry care was one of the services offered by the facility to all residents. The SSD stated it was important to refer Resident 102 immediately to the podiatrist because of the risk of foot pain and infection.During a review of the facility's policy and procedure (P&P) titled, Foot Care, dated 1/1/2012, the P&P indicated the facility was to provide hygienic care of the feet to prevent skin breakdown or infection and to promote comfort.During a review of the facility's P&P titled, Grooming Care of the Fingernails and Toenails, dated 10/21/2021, the P&P indicated, High risk residents and residents with hypertrophic, myotic and keratotic toenails are referred to a podiatrist.

Based on observation, interview and record review, the facility failed to ensure oxygen was administered as prescribed for one of 8 sampled residents (Resident 53).This deficient practice had the potential to result in oxygen desaturation for Resident 53.Findings:During a review of Resident 53's admission Record, the admission Record indicated Resident 53 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), acute respiratory failure (a life-threatening condition where the lungs suddenly can't get enough oxygen into the blood or remove enough carbon dioxide), dementia (a progressive state of decline in mental abilities) and psychosis.During a review of Resident 53's history and physical (H&P), dated 10/4/2025, the H&P indicated Resident 53 was able to make needs known but could not make medical decisions.During a review of Resident 53's physician orders, dated 10/4/2025, the physician orders indicated, Oxygen at 2 liters per min via nasal cannula every shift for shortness of breath and COPD.During a review of Resident 53's Minimum Data Set (MDS, a resident assessment tool) dated 10/11/2025, the MDS indicated Resident 53's cognitive skills were moderately impaired. The MDS indicated Resident 53 required partial/moderate assistance from staff with Activities of Daily Living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves).During an observation and interview, on 12/16/2025 at 10:57 a.m., with Resident 53, Resident 53 had an oxygen machine at his bedside that was not running. Resident 53 stated he did not know why he was not receiving oxygen. Resident 53 stated he was to receive oxygen continuously.During a concurrent observation and interview, on 12/18/2025 at 10:01 a.m., with Licensed vocational Nurse 1 (LVN 1), LVN 1 observed Resident 53's oxygen machine and stated Resident 53 was not receiving oxygen.During a concurrent interview and record review, on 12/18/2025 at 10:12 a.m., with LVN 1, LVN 1 stated Resident 53's physician orders indicated Resident 53 was to receive 2 liters of oxygen via nasal cannula every shift. LVN 1 stated Resident 53 was not receiving oxygen upon earlier observation. LVN 1 stated the risk of not applying oxygen to a resident as ordered could result in the resident desaturating (low blood oxygen level).During a review of the facility's policy and procedures (P&P), titled Oxygen Therapy, dated 10/31/2025, the P&P indicated, Administer oxygen and obtain oxygen saturation levels as ordered by the provider.

Based on interview and record review, the facility failed to ensure competency assessment skill (a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics in performing that an individual needs to perform work roles or occupational functions successfully) checks were performed annually for two out of five randomly selected staff.This deficient practice had the potential for the facility not to be able to assess the skills necessary to provide nursing services to assure resident safety and to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident will not be performed within the acceptable standards of practice.Findings:During a concurrent interview and record review on 12/17/2025 at 3:21 p.m., with the Director of Staff Development (DSD), five random employees file were checked. The DSD stated Certified Nurse Assistant 1 (CNA 1) was hired on 7/27/2002 and did not have yearly competency assessment skills check on file. The DSD stated Certified Nurse Assistant 2 (CNA 2) was hired on 12/11/2023 and did not have a yearly competency assessment skills check on file. The DSD stated she was responsible for completing the annual competency skills check for the CNAs. The DSD stated it was important to perform annual staff competency skill checks to assess the knowledge of their job to ensure the safety of the residents and to provide highest quality of care to residents.During an interview on 12/17/2025 at 3:35 p.m., with the Director of Nursing (DON), the DON stated it was important to perform annual competency skills to validate the staff's competency for taking care of the residents.During a review of the facility's Facility Assessment, dated 11/20/2025, the Facility Assessment indicated, Skills competency are done yearly and as needed.

Based on interview and record review, the facility failed to ensure Performance Evaluations (a process that organizations follow to assess an employee's work quality and skills over a specific period) were performed yearly for two out of five randomly selected staff.This deficient practice had the potential to compromise resident care and safety.Findings:During a concurrent interview and record review on 12/17/2025 at 3:26 p.m., with the Director of Staff Development (DSD), five random employees file were checked. The DSD stated Certified Nurse Assistant 1 (CNA 1) was hired on 7/27/2002 and did not have yearly Performance Evaluations on file. The DSD stated Certified Nurse Assistant 2 (CNA 2) was hired on 12/11/2023 and did not have yearly Performance Evaluations on file. The DSD stated she was responsible for validating CNA's Performance Evaluation once a year. The DSD stated she oversaw CNA in-service training. The DSD stated Performance Evaluations are tools to rate the staff's performance and to check their areas of improvement and weaknesses. The DSD stated it was important to conduct yearly staff Peformance Evaluation for the safety and well-being of the residents.During a review of the facility's policy and procedure (P&P) titled, Staff Competency Validation, dated 6/4/2024, the P&P indicated, Competency validation is completed to evaluate an individual's performance, evaluate group performance, meet standards set by regulatory agencies, address problematic issues, and enhance performance reviews.During a review of the facility's Facility Assessment, dated 11/20/2025, the Facility Assessment indicated, Director of Staff Development and/or designee strictly follow the guidelines and facility's protocol in providing training and education and should be ongoing and monitored/validated during staff employment.

Based on interview and record review, the facility failed to ensure one of six sampled residents (Resident 8), who was receiving Quetiapine Fumarate (a psychotropic medication [any drug that affects brain activities associated with mental processes and behavior] to treat certain mental/mood disorder), was monitored for behavior and its side-effects (an effect of a drug that is in addition to or beyond its desired effect).This deficient practice had the potential for Resident 8 using an unnecessary psychotropic medication that could cause be harmful to the resident.Findings:During a review of Resident 8's admission Record, the admission Record indicated Resident 8 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 8's diagnoses included psychosis (a severe mental health condition in which thought, and emotions are so affected that contact is lost with reality), dementia (a progressive state of decline in mental abilities), and gastrostomy tube ([GT] - 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 8's History and Physical (H&P), dated 10/7/2025, the H&P indicated, Resident 8 can make needs known but could not make medical decisions.During a review of Resident 8's Minimum Data Set ([MDS] - a resident assessment tool), dated 11/23/2025, the MDS indicated, Resident 8's cognitive (ability to think and reason) skills for daily decision making were moderately impaired (decisions poor). The MDS indicated Resident 8 had the ability to make self-understood and understand others. The MDS indicated that Resident 8 required substantial assistance (helper does more than half the effort) from staff with oral hygiene, toileting hygiene, and upper and lower body dressing. The MDS indicated Resident 8 had no potential indicators of psychosis such as hallucinations (perceptual experiences in the absence of real external sensory stimuli) and delusions (misconceptions or beliefs that are firmly held, contrary to reality).During a review of Resident 8's Order Summary Report (a document containing active orders), dated 12/18/2025, the Order Summary Report indicated Resident 8's physician placed a telephone order on 10/6/2025 to start on Quetiapine Fumarate 25 milligrams ([mg] - metric unit of measurement, used for medication dosage and/or amount) to take one tablet via GT at bedtime (9 p.m.) for psychosis.During a concurrent interview and record review on 12/18/2025 at 9:49 a.m., with the Assistant Director of Nursing (ADON), Resident 8's Medication Administration Records ([MAR] - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) from 10/6/2025 to 12/17/2025, were reviewed. The ADON stated there was no documented evidence of Resident 8's psychotic behavior was monitored. The ADON stated there was no documented evidence by the licensed nurses that the side-effects of the anti-psychotic medication were monitored. The ADON stated that when residents on psychotropic medications, the facility should monitor behaviors manifested and document the number of episodes on the MAR. The ADON stated, monitoring behaviors was important to prevent increase in behaviors and track if medication needs to be adjusted. The ADON stated psychotropic medications could cause serious side-effects, especially in the elderly that would jeopardize their health and safety.During an interview on 12/18/2025 at 10:30 a.m., with the Director of Nursing (DON), the DON stated monitoring of behaviors and side-effects of psychotropic medication was important to document for the physician to determine if the medication is effective. The DON stated lack of adequate monitoring of psychotropic medication would be considered as unnecessary medication. During a review of the facility's policy and procedure (P&P) titled, Behavior/Psychoactive Medication Management, dated 11/14/2025, the P&P indicated, any order for psychoactive medications must include a specific behavior manifestation. The P&P also indicated resident will be observed and/or monitored for side-effects, and adverse consequences, including sedation.

Based on observation, interview, and record review, the facility failed to label a floor stock medication bottle with an opened date in Medication cart one.This deficient practice had the potential to result in administering an expired medication which could affect the health and condition of the residents.Findings:During a concurrent observation and interview on [DATE] at 7:42 a.m., with Registered Nurse 1 (RN 1) at the Medication Cart 1, RN 1 verified one bottle of Geri-Lanta (medication used to treat the symptoms of too much stomach acid such as stomach upset, heartburn, and acid indigestion) was unlabeled with opened date. RN 1 stated it was important to label the bottle with an opened date to know the validity of the medication. RN 1 stated that when medications are not labeled with an open date, there was a high risk that Geri-Lanta could be expired and the medication could be ineffective and placed the residents receiving Geri-Lanta at risk for possible harm. RN 1 stated she will dispose the one bottle of Geri-Lanta immediately.During a review of the facility's policy and procedure (P&P) titled, Medication Labels, dated 5/2022, the P&P indicated, medications should be labeled in accordance with the facility requirements and the state and federal.

Based on interview and record review, the facility failed to implement the physician's orders to draw monthly laboratory tests (a medical analysis of a body sample (blood, urine, tissue) to check health, diagnose diseases and monitor chronic conditions) for one of one sampled resident, (Resident 1). This deficient practice had the potential to result in the delay of identification of medical concerns, delaying the care and services necessary for the affected resident.Findings:During a review of Resident 1's admission Record, the admission Record indicated, Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included bipolar disorder (mood swings that range from the lows of depression to elevated periods of emotional highs), epilepsy (brain condition that causes recurring seizures), and congestive heart failure ([CHF] - a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling).During a review of Resident 1's History and Physical (H&P), dated 9/25/2025, the H&P indicated, Resident 1 can make need known but could not make medical decisions.During a review of Resident 1's Minimum Data Set ([MDS] - a resident assessment tool), dated 11/6/2025, the MDS indicated, Resident 1's cognitive (ability to think and reason) skills for daily decision making were moderately impaired (decisions poor). The MDS indicated, Resident 102 had the ability to make self-understood and understand others. The MDS indicated, Resident 1 required substantial assistance (helper does more than half the effort) from staff with toileting hygiene, showering, and upper and lower body dressing.During a review of Resident 1's Order Summary Report (a document containing active orders), dated 12/18/2025, the Order Summary Report indicated the a telephone order on 9/10/2025 for Complete Blood Count ([CBC] a blood test that checks the overall health of the blood by measuring the number and types of cells), Comprehensive Metabolic Panel ([CMP] a blood test that measures 14 key substances in the blood, assessing electrolyte balance, kidney, liver function, and blood sugar), and Depakote level (the concentration of the drug [medicine for mental health disorder]) in a patient's bloodstream every month. The Order Summary Report indicated a telephone order on 9/11/2025 to give Depakote 125 milligrams ([mg] - metric unit of measurement) by mouth two times a day (9 a.m. and 5 p.m.) for bipolar disorder (a serious mental illness) manifested by sudden outburst of anger.During a concurrent interview and record review on 12/18/2025 at 10:03 a.m., with the Assistant Director of Nursing (ADON), Resident 1's laboratory results, were reviewed. The ADON stated Resident 1 did not have a CBC, CMP, and Depakote level drawn for the month of November and December 2025. The ADON stated there was no documentation indicating the facility communicated with the physician of Resident 1 that CBC, CMP, and Depakote level were not completed and no documented evidence of follow-up was made with the diagnostic laboratory. The ADON stated it was important to monitor Resident's CBC and CMP to rule out any underlying infection and to check resident's hydration status.During an interview on 12/18/2025 at 10:35 a.m., with the DON, the DON stated it was important for Resident 1's routine blood tests to be completed to monitor and treat his medical diagnoses. The DON stated it was important to monitor Resident 1's Depakote level to keep track of the therapeutic level (amount of a specific medicine or drug present in the blood stream at a particular time) of the Depakote in order to better manage his behavior.During a review of the facility's policy and procedure (P&P) titled, Laboratory Services, dated 1/1/2012, the P&P indicated, the facility should provide laboratory services in an accurate and timely manner to meet the needs of residents per attending physician orders.

Based on observation, interview, and record review, the facility failed to perform hand hygiene (cleansing hands with soap or an alcohol-based rub) prior to putting on personal protective equipment ([PPE] protection equipment that includes face shields, gloves, goggles and glasses, gowns, head covers, masks, respirators, and shoe cover to protect against the transmission of germs through contact and droplet routes) and prior to caring for one of seven residents, Resident 96. This failure had the potential for cross contamination (process by which bacteria or other microorganisms are unintentionally transferred from one object or person to another, with harmful effect) and risk to expose Resident 96 to infectious organisms (germs).Findings:During a review of Resident 96's admission Record, dated 9/25/2025, the admission Record indicated Resident 96 had Metabolic Encephalopathy (a brain dysfunction due to chemical imbalance in the body), Acute Respiratory Failure ( a sudden condition when the lungs cannot get enough oxygen into the blood) with Hypoxia (lack of oxygen), and Severe Protein-Calorie Malnutrition (a severe lack of protein and calories leading to body wasting).During a review of Resident 96's History and Physical (H&P), dated 11/17/2025, the H&P indicated Resident 96 can make needs known but cannot make medical decisions.During a review of Resident 96's Order Summary Report, dated 9/25/2025, the Order Summary Report indicated Resident 96 may sit in a Geri Chair (specialized, large, padded recliner with wheels for individuals with limited mobility) as tolerated.During a review of Resident 96's Care Plan Report, dated 10/15/2025, the Care Plan Report indicated Resident 96 was on Enhanced Barrier Precautions (infection control measure to stop germ spread) and should utilize gowns and gloves for all personal care. The Care Plan Report indicated Resident 96 had limited physical mobility related to weakness.During a concurrent observation and interview on 12/16/2025 at 11:24 a.m., Certified Nurse Assistant (CNA) 3 and CNA 4 were observed putting on isolation gown (a PPE used in healthcare to shield staff and residents from transferring microorganisms, blood, and body fluids during patient care, especially in isolation situations), mask (a PPE used as a physical barrier between the mouth and nose, help protect against larger respiratory droplets, splashes, or germs), and gloves (a PPE used as a physical barrier for the hands against germs) without performing hand hygiene. CNA3 and CNA4 then entered Resident 96's room to transfer Resident 96 back to bed from the Geri Chair. Both CNA3 and CNA4 stated they should have performed hand hygiene before putting on the isolation gown, mask and gloves. CNA3 and CNA4 stated they could transfer an infection to Resident 96 or to themselves. During a review of the facility's policy and procedure (P&P), titled Hand Hygiene, dated 9/1/2020, the P&P indicated facility staff, healthcare personnel, residents, visitors, and volunteers must perform hand hygiene before donning (putting on) and after doffing (removing) Personal Protective Equipment.

Based on interview and record review, the facility failed to revise and provide an updated average daily census of the Facility Assessment Tool (a process for evaluating a facility's resident population and identifying the resources needed to provide care and services).This deficient practice had the potential to place residents at risk for not receiving the appropriate care and services necessary to maintain their highest practicable physical, mental and psychosocial well-being.Findings:During a review of the facility census for 12/17/2025, the facility census indicated 96 residents resided in the facility. During a concurrent interview and record review on 12/17/2025 at 11:03 a.m., with the Director of Nursing (DON), the Facility Assessment Tool updated 11/20/2025, was reviewed. The DON stated the Facility Assessment Tool was last updated on 11/20/2025. The DON stated she was involved in reviewing and updating the Facility Assessment. The DON stated Facility Assessment is a tool to assess the residents' needs. The DON stated the assessment provided was an average daily census of 91 residents. The DON stated the Facility Assessment tool was not accurate because of the average daily census which was below the actual census/residents residing in the facility. The DON stated there were 5 residents not accounted for in the Facility Assessment. The DON stated it was important to indicate the correct average daily census in the Facility Assessment tool so that the facility can adequately plan for staffing needs and provide the highest quality care to the residents.During a review of the facility's policy and procedure (P&P) titled, Facility Assessment, dated 4/15/2021, the P&P indicated, the Administrator should review and update the Facility Assessment annually and as necessary whenever there is, or the facility plans for any change that would require a substantial modification to any part of the assessment.

Based on observation, interview, and record review, the facility failed to ensure staff performed hand hygiene before entering one out of two sampled resident's (Resident 1) room, touching Resident 1's clothing, and exiting the room.This failure had the potential to result in Resident 1 being exposed to infectious organisms and getting sick.Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnosis including psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), dementia (a progressive state of decline in mental abilities), and schizophrenia (a mental illness that is characterized by disturbances in thought).During a review of Resident 1's History & Physical (H&P), dated 10/23/2025, the H&P indicated Resident 1 had fluctuating capacity to understand and make decisions.During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 10/29/2025, the MDS indicated Resident 1's cognition (process of thinking) was moderately impaired. The MDS indicated Resident 1 required substantial to maximum assistance from staff with toileting, shower, and lower body dressing.During a concurrent observation and interview on 12/10/2025 at 10:18 a.m. in Resident 1's room, Central Supply Staff (CSS) 1 entered Resident 1's room without performing hand hygiene. CSS 1 touched Resident 1's bedding and clothing. CSS 1 stated they were just trying to help identify the resident's name. CSS 1 exited the room without performing hand hygiene.During an interview on 12/10/2025 at 12:34 p.m. with the Director of Nursing (DON), the DON stated hand hygiene should be performed before and after touching residents and their clothing and linen. The DON stated if hand hygiene was not performed, residents could be exposed to infectious organisms and be at risk of developing an infection.During a review of the facility's policy and procedure (P&P) titled, Hand Hygiene, dated 9/1/2020, the P&P indicated hand hygiene was required immediately upon entering and exiting a resident room. ations require appropriate hand hygiene: vii. Immediately upon entering and exiting a resident room.

Based on interview and record review the facility failed to provide a two-person assist (one on each side of the bed) for one of three sampled residents (Resident 1), who was dependent on staff for turning and repositioning. Certified Nurse Assistants (CNA 1 and CNA 2) repositioned Resident 1 while both were standing on the left side of the resident's bed. This failure resulted in Resident 1 falling onto the floor, sustaining a femur (thigh bone) fracture (broken bone) experiencing pain and fear, and was transferred to a general acute care hospital (GACH) for evaluation and treatment. Findings: During a review of Resident 1's Admission Record, the Admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE]. The Admission Record indicated Resident 1's diagnoses included morbid (severe) obesity (excessive fat accumulation), bilateral (both sides) osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage) of the knee, chronic pain syndrome (condition of persistent pain, muscle weakness and unspecified lack of coordination (problem with movement, balance or coordination). During a review of the Facility's In-Service (training or education) Meeting titled, Repositioning, Turning dated 1/16/2024, the In-Service indicated CNAs were trained on the procedures to follow when turning and repositioning residents who could not assist and ensuring safety of residents when turning/repositioning. The In-Service lesson plan indicated; CNAs were to perform the procedure (turning/repositioning) positioned on opposite sides of the bed. The In-Service sign-in indicated CNA 1 and CNA 2 attended the In-Service. During a review of Resident 1's History and Physical (H&P) dated 2/13/2025, the H&P indicated Resident 1 had the capacity to understand and make medical decisions. The H&P indicated Resident had a history of paraplegia (paralysis of the legs and lower body) and was bedridden. During a review of Resident 1's Care Plan titled The resident has an ADL self-care performance deficit related to impaired balance and limited mobility dated 2/28/2024, the Care Plan indicated Resident 1 had an Activities of Daily Living, Self-care Performance Deficit related to Impaired Balance and Limited Mobility. The Care Plan Indicated Resident 1 was totally dependent (staff does all the effort, resident does none of the effort to complete the activity or requires two or more staff to complete the activity). The nursing interventions indicated Resident 1 required two staff assistance to turn and reposition the resident in bed. During a review of Resident 1's Minimal Data Set (MDS - a resident assessment tool) dated 3/13/2025, the MDS indicated Resident 1 had no cognitive (ability to think and reason) impairment The MDS indicated Resident 1 was dependent on staff for ADLs such as dressing, personal hygiene and bed mobility (the ability to roll from lying on back to left and right side, and return to lying back on the bed). During a review of Resident 1's Care Plan titled Documented Safety Concerns dated 3/13/2025, the Care Plan goals indicated Resident would remain safe. The Care Plan nursing intervention was to provide safety measures including strategies to reduce the risk of falls and injury. During a review of Resident 1's Change of Condition (COC), dated 3/20/2025, the COC indicated Resident 1 had a witnessed fall on 3/20/2025. The COC indicated Resident 1 sustained a skin tear (unspecified location) and a had pain level of 8 out 10 (pain rating reference 1-3 mild pain; 4-6 moderate pain, 7-10 severe pain) of the right leg/foot. The COC indicated Resident 1 weighed 501.8 pounds ([lbs]unit of measurement). During a review of Resident 1's Progress Note, dated 3/20/2025, the Progress Note indicated Resident 1 slipped out of bed and fell . The Progress Note indicated Resident 1 had an avulsion (tearing of skin from the body) to the right great (big) toe, and a skin tear to posterior (backside of) left knee. During a review of Resident 1's Physician Orders, dated 3/20/2025, the Physician Orders indicated stat (urgent) x-ray (process of taking pictures of the inside of your body to help diagnose conditions or injuries) to the right lower extremity (leg) including right foot to transfer and to transfer Resident 1 to a GACH. During a review of Resident 1's GACH Orthopedic (medical specialty focused on injuries and diseases affecting the musculoskeletal system [bones, muscles, joints and soft tissues]) Surgery Consult H&P dated 3/23/2025, the H&P indicated Resident 1 was admitted for evaluation of a right leg pain. The H&P indicated based on Resident 1's weight, shape of her legs and feet, the resident was unable to stand or walk. The H&P indicated the Resident 1's family (FM 1) reported Resident 1 was dropped by the facility's nursing staff when the staff tried to roll the resident. The H&P indicated Resident 1 of pain (unrated), to the right leg and she had a displaced fracture of the right distal femur. During an interview on 4/8/2025 at 8:33 a.m. with Resident 1, Resident 1 stated on 3/20/2025 (time unknown), she fell off the right side of the bed when CNAs 1 and 2 were trying to turn her in bed during care, while standing on the left side of the resident's bed. Resident 1 stated no staff members were present at the right side of the bed when CNA 1 and 2 were turning and repositioning her. Resident 1 stated after she fell , she was so scared and experienced excruciating right leg pain. During an interview on 4/9/2025 at 8:40 a.m. with CNA 1, CNA 1 stated Resident 1 was dependent on staff to turn and move in bed. CNA 1 stated during Resident 1's ADL care, Resident 1 was lying at the edge of the right side of the bed, while she (CNA 1) and CNA 2 were both standing on the left side of the resident's bed. CNA 1 stated, when she (CNA 1) and CNA 2 pulled Resident 1's draw sheet (a sheet placed across the middle of the bed to facilitate repositioning and moving the resident) towards them, to move the resident to the middle of the bed, Resident 1 fell off the right side of the bed. CNA 1 stated it was not safe for both staff members to be on the left side of the bed, while turning Resident 1 to the opposite direction. CNA 1 stated one of the CNAs (CNA 1 or CNA 2 ) should have stood on the right side of the bed to secure Resident 1 and prevent the resident from falling and sustaining an injury. During an interview on 4/9/2025 at 11:35 a.m., with the Director of Staff Development (DSD), the DSD stated, CNAs have been in-serviced on ADL care, repositioning residents in bed with emphasis on ensuring there was at least one staff member on each side of the bed when turning and cleaning dependent residents such as Resident 1. During an interview on 4/9/2025 at 12:40 p.m., with CNA 2, CNA 2 stated she (CNA ) and CNA 2 were standing on the left side of the bed when Resident 1 fell (on the right side of the bed). CNA 2 stated this technique was not safe. CNA 2 stated Resident 1's fall could have been prevented if safe techniques were used and one of them (CNA 1 or CNA 2) stood on the right side of Resident 1's bed when the resident was repositioned. During a concurrent interview and record review on 4/9/2025 at 3:10 p.m. with the Director of Nursing (DON), Resident 1's IDT Note, dated 3/25/2025 was reviewed. The DON stated the IDT Note indicated two CNAs were standing on the left side of the bed while they turned and cleaned Resident 1. The DON stated no staff were present on the right side of the bed when Resident 1 fell out of the bed. The DON stated the CNAs were unsafe and at least one staff member should have been on each side of the bed to prevent falls. The DON stated staff's unsafe patient handling resulted in Resident 1's fall and injury. The DON stated Resident 1's fall on 3/20/2025 resulted in femur fracture, severe pain, and hospitalization . During an interview on 4/16/2025 at 2:50 p.m., with the Orthopedic Physician (Ortho), the Ortho stated, Resident 1 sustained an acute (new) fracture of the distal femur (lower end of the thigh bone) close to the knee. The Ortho stated Resident 1's fracture was caused by a traumatic mechanism from the fall and was very painful. The Ortho stated the fracture was inoperable due to Resident 1's large size and being bedbound (someone who is confined to the bed). During a review of the facility's Policy and Procedure (P&P) titled, Fall Management Program dated 3/13/2021, the P&P indicated the purpose of facility's Fall Management program was to provide residents a safe environment that minimized complications with falls. The P&P indicated the facility will implement a fall management program that supported providing an environment free from fall hazards.

Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1), who had diagnoses including hypertension (HTN-high blood pressure), diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), depression (a mental health condition that involves a prolonged low mood or loss of interest in activities), anxiety (intense, excessive, and persistent worry and fear about everyday situations), and suicidal ideation (intrusive thoughts and preoccupation with death and dying), who was brought to the facility by the paramedics to be admitted on [DATE] at 9:50 p.m. was not left unattended, by failing to: 1. Provide Resident 1 with orientation of the facility. 2. Implement its policy and procedure (P&P) titled Resident Initial Admission Assessment which indicated, upon admission to the facility the licensed nursing staff would complete an initial admission assessment, identify the residents' needs and develop plans of care. 3. Implement its P&P titled Admission and Orientation of Residents, which indicated, the facility would only admit residents for whom they could provide adequate care. 4. Implement its P&P titled Admission and Orientation of Residents, which indicated, the admission coordinator/designee would notify the Director of Nursing (DON), upon a resident's arrival, promptly notify the physician, provide a Standard Admission Agreement, and create an admission record for the resident. 5. Ensure the DON assigned a licensed vocational nurse (LVN) to conduct Resident 1's initial assessment. 6. Provide activities of daily living (ADLs- routine tasks/activities such as bathing, dressing, and toileting a person performs daily to care for themselves) to Resident 1 for approximately 22 hours. 7. Assess and monitor Resident 1 who required mediations for diabetes, hypertension, depression, and anxiety. 8. Ensure there was adequate staffing to meet the needs of the residents. 9. Ensure staff were in-serviced on the admission process. These failures resulted in Resident 1 calling 911 on 12/21/2024 at 7:30 p.m. (22 hours after arriving to the facility) to be transferred back to a general acute care hospital (GACH) for further evaluation and treatment. On 12/27/2024 at 6:20 p.m., an Immediate Jeopardy ([IJ] a situation in which the facility's noncompliance with one or more requirements of participation had caused, or was likely to cause serious injury, harm, impairment, or death to a resident) was called in the presence of the Director of Staff Development (DSD) due to the facility's failure of not providing the appropriate care and services to Resident 1 such as orientation to the facility, completing an initial admission record, assessing/monitoring the needs of the resident, identifying care needs and developing a plan of care. On 12/29/2024 at 4:58 p.m., the facility submitted an acceptable IJ Removal Plan (IJRP). After verification of the IJRP implementation through observation, interview, and record review, the IJ was removed on 12/29/2024 at 5:40 p.m., in the presence of the facility's Senior Regional Quality Management Consultant (RQMC). The IJRP included the following immediate actions: 1. On 12/27/24, beginning on the 3-11 p.m. shift through the 12/28/2024 3-11 p.m. shift, the DSD/designee initiated immediate education to Licensed Nurses, certified nursing assistants (CNAs) on every shift and Department Managers on the following facility's policies and procedures: a. Resident Initial Admission Assessment- with emphasis on completing an initial admission assessment, identifying the resident's needs and documentation in the resident's medical record. b. Admission and Orientation of Residents- with emphasis the admission coordinator/designee will notify the DON upon a resident's arrival, promptly notify the physician, provide a Standard Admission Agreement, and create an admission record for the resident. Also, a review of the admission process for direct care staff. c. Admission Criteria- with emphasis on admitting Residents who meet the criteria for adequate care within the facility. 2. The DON will assign an LVN to conduct the initial assessment of new residents. 3. The facility will attempt to replace the nursing staff who called off from their scheduled shift by calling other nursing staff who are not scheduled and are available to work, including licensed department managers, to ensure adequate staffing. 4. Staff were in-serviced on the new admission process beginning on 12/29/2024 3-11 p.m. shift by the DSD. Findings: During a review of Resident 1's Admission Record, the Admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including HTN, DM, depression, anxiety, and suicidal ideation. During a review of the facility's Census Report dated 12/20/2024, the Census Report indicated 95 residents were listed in the facility. During a review of Resident 1's History and Physical (H&P) from the transferring hospital (GACH 1), dated 12/12/2024, the H&P indicated Resident 1 could answer all questions appropriately. During a review of the facility's Nursing Assignment Sheet, dated 12/20/2024 (no time specified), the Nursing Assignment Sheet indicated there were three LVN Charge Nurses scheduled to work the 3 p.m. - 11 p.m. shift. The Nursing Assignment Sheet indicated one LVN called off (did not work). During a review of the Los Angeles City Fire Department (LAFD) report titled LAFD Patient Care Report, dated 12/21/2024, the LAFD report indicated on 12/21/2024 at 7:37 p.m., Resident 1 was transported to GACH 2 with chief complaints of weakness and dizziness for 24 hours and diabetic problem. The report indicated on 12/21/2024, at 7:16 p.m. Resident 1's blood pressure (BP) was 195/91 millimeters of mercury ([mmHg] unit of measurement, normal BP is less than 120 over less than 80 mmHg), heart rate (HR) 74 beats per minute (bpm, normal HR is between 60-100 bpm), respiratory rate (RR) of 14 breaths per minute (normal RR 12-20 breaths per minutes), oxygen saturation level (O2 sat- a measurement of how much oxygen the blood is carrying as a percentage) of 97 percent (%) (normal oxygen saturation 93-100%) and blood sugar (BS) level of 240 milligrams per deciliter ([mg/dl] a unit of measurement, normal blood glucose level is 70-100 mg/dl). The LAFD report indicated Resident 1 was in mild distress. The LAFD report indicated Resident 1 stated she was admitted to the facility approximately 24 hours ago after being discharged from GACH 1. The LAFD report indicated Resident 1 stated she was denied her routine medications like insulin (medicine for diabetes) and hypertensives (medicine to treat HTN) in the 24 hours while at the facility. The LAFD report indicated when the emergency medical service (EMS- a system that provides emergency medical care) staff asked the facility staff (staff not identified) why Resident 1 did not receive her medications, the staff became unprofessional and confrontational, raised his voice at the EMS staff and Resident 1's family member (FM 1) and walked away. During a review of Resident 1's GACH 2 records, titled Emergency Documentation (ED), dated 12/23/2024 at 9:31 p.m., the notes indicated Resident 1 presented to the ED with altered level of consciousness (a change in a person's state of awareness and alertness) and mild confusion. The ED notes indicated Resident 1 had elevated liver enzymes (sign of inflamed or damaged cells in the liver) and hyponatremia (a condition where the level of sodium in the blood is too low). The notes indicated Resident 1 was given fluids for hydration and one gram (g, unit of measurement) of sodium chloride tablet (medicine to elevate sodium level). Resident 1 was admitted to the GACH 2's Telemetry unit (a floor in a hospital where patients undergo continuous cardiac monitoring) for further monitoring. During a telephone interview on 12/26/2024 at 2:10 p.m. with LAFD Paramedic 1 (LAFDP 1), LAFDP 1 stated on 12/21/2024 at 6:56 p.m., he and another paramedic personnel responded to the call from Resident 1's FM 1. LAFDP 1 stated FM 1 reported that Resident 1, who was at the facility, did not receive medications nor had a diaper change. LAFDP 1 stated upon arrival at the facility, An unidentified male staff member was confrontational. LAFDP 1 stated he assessed Resident 1 and transported her (Resident 1) to GACH 2 per the resident's request. During an interview on 12/26/2024 at 4:50 p.m., with LVN 1, LVN 1 stated Registered Nurse (RN) 1 informed her (LVN 1) of Resident 1's pending arrival at the beginning of the 3 -11 p.m., shift on 12/20/2024. LVN 1 stated RN 1 relayed the report RN 1 received about Resident 1 from GACH 1. LVN 1 stated Resident 1 arrived at the facility on 12/20/2024 at 10 p.m. LVN 1 stated Resident 1 was not oriented to the facility and there was no initial resident assessment done for Resident 1. LVN 1 stated she left Resident 1's the initial assessment for the in-coming 11 p.m. - 7 a.m. LVN to complete it because she (LVN 1) did not know how to do an initial assessment. LVN 1 stated she did not notify any physician that Resident 1 was in the facility for admission orders. LVN 1 stated no medications were ordered for the resident, and she (LVN 1) did not document anything in Resident 1's Electronic Health Records (EHR) because she did nothing for the resident and there was nothing for her to document. LVN 1 stated the nurse for the incoming 11p.m. - 7 a.m. shift on 12/20/2024 called off. LVN 1 stated she continued to work from 11 p.m. on 12/20/2024 until 7 a.m. on 12/21/2024 because the facility was short staffed and had no one to replace her. LVN 1 stated she did not offer Resident 1 anything to eat or drink and did not know if any staff did. LVN 1 stated there was only one other LVN (LVN 3) who worked the 11 p.m.- 7 a.m., shift on 12/20/2024. LVN 1 stated she checked Resident 1's blood sugar level but did not document it. LVN 1 stated Resident 1 had two visitors during that evening (time unknown) on 12/21/2024. LVN 1 stated one of the visitors asked LVN 1 multiple times why Resident 1 did not receive any medications since her arrival to the facility. LVN 1 stated she called LVN 4 on the telephone for assistance and LVN 4 told LVN 1, she would send an RN to assist because LVN 1 did not know how to complete an admission and never received training. LVN 1 stated the visitor was very upset and called 911 stating he wanted Resident 1 to go back to the GACH. During a concurrent interview and record review on 12/27/2024 at 4:12 p.m. with RN 1, a handwritten report titled Admission Report dated 12/20/2024 at 2:53 p.m., signed by RN 1, was reviewed. RN 1 stated on 12/20/2024 at 2:53 p.m., RN 1 received a report from a RN at GACH 1 regarding Resident 1 being transferred to the facility. RN 1 stated the handwritten report indicated Resident 1 had diagnoses of hyponatremia (low sodium level), HTN, and stroke (a medical emergency that occurs when blood flow to the brain is disrupted). RN 1 stated the report indicated Resident 1 was to receive a regular, carbohydrate controlled (CCHO, meal plan that involves eating a consistent amount of carbohydrates each day) diet. The handwritten report indicated Resident 1's latest untimed vital signs (measurements of the body's basic functions, such as temperature, breathing rate, blood pressure, and pulse rate), were as follows BP 148/72 mmHg, HR 70, Temperature 36.9 degrees Fahrenheit (F, measurement of temperature), RR 16, O2 sat 96%, and a BS level of 217. RN 1 stated she gave a copy to LVN 1 and the kitchen, indicating Resident 1's diet order from the hospital, before creating a paper chart for Resident 1. During a telephone interview on 12/28/2024 at 10:17 a.m. with Resident 1's Emergency Contact (EC) provided on the admission sheet, the EC stated he visited Resident 1 at the facility on 12/21/2024 around 5:00 p.m., accompanied by his assistant. The EC stated Resident 1 was sitting on the bed with feces (the material in a bowel movement) soiling the sheet and her gown. The EC stated Resident 1 told him she (Resident 1) was in pain and had not received pain medicine or insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication). The EC stated he spoke to LVN 1, who called LVN 4 and was told by LVN 4 she would send a RN to assist in entering orders and administering Resident 1's medications. During an interview on 12/28/2024 at 5 p.m., with the DSD, the DSD stated she had not in-serviced staff on the admission process in 2 years. The DSD stated she was not aware if all licensed staff knew what to do when a resident was to be admitted to the facility. The DSD stated the facility did not have any staffing agency to use in case of staffing shortage. During an interview on 12/28/2024 at 5:46 p.m., LVN 4 stated LVN 1 called her (LVN 4) regarding EC's concern that Resident 1 had not received any medications or care since arriving to the facility on [DATE]. LVN 4 stated she tried to find another staff to assist the LVN 1 and LVN 4 on 12/21/2024 3:00 p.m. - 11:00 p.m. but was unsuccessful. LVN 1 stated the facility did not have any staffing registry. LVN 1 stated the Director of Nursing (DON) was on vacation. During a review of the facility's undated Job Description titled, Director of Staff Development Job Description, the job description indicated the DSD was responsible for coordinating and conducting an effective on-going in-service plan to all employees. During a review of the facility's undated Job Description titled, Charge Nurse, the job description indicated the charge nurse will assume responsibility and oversight of an assigned nursing unit including assignment and coordination of nursing care. The job description indicated the charge nurse will coordinate resident admissions, transfers, and discharges. During a review of the facility's P&P titled, Admission and Orientation of Residents, dated 10/2017, the P&P indicated when a new resident arrives at the facility, the facility will promptly notify the resident's attending physician of the resident's admission to the facility. The P&P indicated, upon admission, the resident's attending physician will provide the order for skilled nursing care, the type of diet the resident requires, medication orders, including a medical condition or problem associated with each medication and routine care orders to maintain or improve the resident's function. The P&P indicated, the Director of Nursing will assign a LVN to conduct the initial assessment of the resident and prepare the chart for admission. The P&P indicated, the LVN will document the initial assessment in the resident's medical records and initiate the relevant care plan for the resident. During a review of the facility's P&P titled, Resident Initial Admission Assessment, dated 3/23/2023, the P&P indicated the licensed nursing staff will complete an initial admission assessment upon admission to the facility to identify the residents' needs and develop plans of care. The P&P indicated the assessment will be documented in the medical record.

Based on interview and record review, the facility failed to: 1. Follow the minimum data set ([MDS] a standardized assessment and care screening tool), which indicated two staff members will assist in providing care for one of two sampled residents (Resident 1) 2. Ensure Resident 1 ' s physician order, dated 11/10/2023, which indicated half siderails on both upper parts of the bed was implemented as ordered. These deficient practices caused Resident 1 to fall face down, from the bed, sustain a cut with bleeding to the right upper lip that required the resident to be transferred to a General Acute Care Hospital (GACH) for evaluation and treatment. Findings: A review of Resident 1 ' s admission record (Face sheet), indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1 ' s diagnosis included seizures (a disruption of electrical activity in the brain), muscle weakness, difficulty walking, lack of coordination dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) and restlessness (inability to rest or relax) and agitation (restless moving, twitching, or jerking of the body.) A review of Resident 1 ' s fall risk evaluation dated 11/10/2023, indicated Resident 1 was at risk for fall. A review of Resident 1 ' s care plan titled, The resident is at risk for falls related to confusion, gait/ balance problems, incontinence, poor communications/ comprehension, dated 11/10/2023, indicated staff will anticipate and meet Resident 1 ' s needs, educate caregivers about safety reminders, follow the facility ' s fall protocols, review information on past falls, determine the cause of falls and educate caregivers as to causes. A review of Resident 1 ' s physician orders dated 11/1/2023 indicated half side rails on both upper part of the bed as enabler for turning, repositioning, safety, and seizure precaution. A review of Resident 1 ' s history and physical (H&P) dated 11/11/2023, indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1 ' s MDS dated [DATE], indicated Resident 1 could sometimes understand and sometimes be understood by others. The MDS indicated Resident 1 was dependent (required assistance of two or more staff) on staff for activities such as dressing, toilet use, personal hygiene, transfer (moving between surfaces to and from bed, chair, and wheelchair) and bed mobility (how resident moves from lying to turning side to side). The MDS indicated Resident 1 was incontinent of bowel and bladder. The MDS indicated Resident 1 used a wheelchair for mobility. A review of the facility ' s weekly bed siderail log (lists of residents with bedrails monitored) for the months of November and December 2023, did not indicate Resident 1 ' s bedrail was monitored. A review of Resident 1 ' s Progress Notes dated 12/01/2023, at 5:55 a.m., indicated Resident 1 was disoriented at times and had a history of falls. A review of Resident 1 ' s Progress Notes dated 12/01/2023, at 10:20 a.m., indicated Resident 1 was found on the floor awake, confused, and disoriented. The notes indicated Resident 1 sustained a right upper lip laceration and had no verbal or behavioral expressions of pain. The notes indicated Resident 1 was to be transferred to a GACH for evaluation and treatment. A review of Resident 1 ' s COC dated 12/1/2023, indicated on 12/2/2023 at 5:55 a.m., a Certified Nurse Assistant (CNA) 1 prepared Resident 1 for morning care. The COC indicated CNA 1 went to Resident 1 ' s restroom to wet towels and while in the restroom, CNA 1 heard a sound and found Resident 1 on the floor. The COC indicated Resident 1 sustained an upper lip laceration (cut) with some bleeding. The COC indicated Resident 1 ' s upper lip laceration was cleansed, and pressure applied to control bleeding. A review of Resident 1 ' s GACH emergency documentation (ED) physician notes dated 12/1/2023, indicated Resident 1 arrived the GACH emergency room (ER) on 12/1/2023, after a fall, with blunt (forceful) head trauma, subdural (space between skull and brain) hematoma (blood clots) and avulsion (forcible tear of skin) of the lip. A review of Resident 1 ' s GACH ' s computerized tomography ([CT] noninvasive procedure performed by taking pictures of internal structures such the head, skull, brain, and eye sockets, to assess the brain for tumors and injuries) of the head dated 12/1/2023, indicated probable small acute subdural hemorrhage (collection of blood at the outermost part surrounding the brain). The CT report indicated there was no surgical intervention performed. A review of Resident 1 ' s GACH operative and procedure reports dated 12/2/2023, indicated Resident 1 ' s large right upper lip avulsion was surgically repaired. During an interview on 2/2/2024 at 3:45 p.m. with CNA 1, CNA 1 stated Resident 1 ' s siderails were down when he (CNA 1) received Resident 1 from the night shift (3p.m. to 11p.m.). CNA 1 stated Resident 1 was awake and in the middle of the bed. CNA 1 stated Resident 1 ' s bed was elevated to a position slightly below his (CNA 1 ' s) waist to prepare for morning care (hygiene routine). CNA 1 stated he lowered Resident 1 ' s siderails, left Resident 1 in the elevated bed and went to Resident 1 ' s restroom to grab wet towels. CNA 1 stated while in the restroom, he suddenly heard a loud thud (fall). CNA 1 stated he rushed to Resident 1 ' s room and observed Resident 1 on the floor, face down, and the resident was bleeding on the right upper lip. CNA 1 stated Resident 1 ' s body was on the floor mat, and Resident 1 ' s face was on the floor outside the mat. CNA 1 stated he was by himself when morning care was provided to Resident 1. CNA 1 stated he was not aware Resident 1 needed two persons to assist with care. During an interview on 2/13/2024 at 12:00 p.m. with the Director of Nursing (DON), the DON stated Resident 1 required side rails, and a two-person assist when providing care because Resident 1had repeated falls. The DON stated Resident 1 ' s fall on 2/1/2023, was the facility ' s fault. The DON stated Resident 1 had no side rails and side rails were not in place when the resident fell off the bed. The DON stated given Resident 1 ' s history of falls and diagnoses, the resident should have been placed on a one-to-one supervision, to prevent further falls and injuries. The DON also stated Resident 1 ' s MDS indicated two staff was supposed to assist Resident 1 during care, but CNA 1 did not call for help prior to performing care on Resident 1. During an interview on 2/13/2024 at 1:10 p.m. with the Maintenance Supervisor, the Maintenance Supervisor stated Resident 1 was not on the facility ' s weekly bed side rails log, provided by the Nurse Supervisor. A review of the facility ' s undated policies and procedures (P&P) titled, Fall Management Program,, indicated the facility will provide residents a safe environment and implement a fall management program that supported providing an environment free from fall hazards. The P&P indicated, if a fall risk factor was identified, staff would document interventions on the resident ' s care plan regardless of fall risk evaluation score. A review of the facility ' s P&P titled, Resident Safety, dated April 15, 2021, indicated, to observe the safety and wellbeing of the residents, a resident check will be made at least every two hours around the clock by nursing service personnel.

Based on interviews and record reviews, the facility failed to: 1. Verify admission inquiry (resident's facility documents seeking admission) from the transferring facility for accuracy to reflect Resident 1's wandering (going from place to place without a plan or purpose) and exit seeking behavior, and to ensure resident did not elope (when a resident who is cognitively, physically, mentally, emotionally, and/or chemically impaired leaves a care-giving facility or environment unsupervised, unnoticed, and/or prior to their scheduled discharge) from the admitting facility on 1/25/2024, for one of three sampled residents (Resident 1). 2. Follow Resident 1's physician orders from the transferring facility dated 1/17/2024, upon admission, which indicated to monitor episodes of wandering and elopement risk and document resident's location every hour. 3. Follow their policy and procedure (P&P) titled, Resident Safety, which indicated, the facility will provide a safe and hazard free environment to the resident. 4. Follow their P&P titled, Elopement Risk Reduction Approaches, which indicated facility will provide new residents with additional staff assistance until the residents were comfortable with their new environment. 5. Ensure the entrance and exit doors were monitored to prevent the resident from leaving the facility unattended. As a result, one of 3 residents, Resident 1, left the facility unsupervised and was exposed to harsh environmental conditions such as cold and hot weather and rain, had a potential of being hit by a car, and a potential for medical complications such as hyperglycemia (high blood sugar), hypoglycemia (low blood sugar), hypertensive crisis (sudden, severe increase in blood pressure), and death. There was a potential for Resident 1 to be without medications from 1/25/2023 to 2/4/2024, a total of ten (8) days. Resident 1's whereabouts are still unknown. On 1/29/2024 at 5:11 p.m., an Immediate Jeopardy ([IJ] a situation in which the facility's noncompliance with one or more requirements of participation has cause, or is likely to cause serious injury, harm, impairment, or death to a resident) was called in the presence of Director of Nursing (DON) and Administrator (Admin) due to the facility's failure to properly assess and closely monitor Resident 1's whereabouts to prevent Resident 1 from leaving the facility unsupervised. On 1/31/2024 at 3:11 p.m., the facility submitted an acceptable IJ removal plan ([IJRP] interventions to immediately correct the deficient practices). After verification of IJRP implementation through observation, interview, and record review, the IJ was removed onsite on 2/1/2024 at 4:11 p.m., in the presence of the Admin and Nurse Consultant (NC). The IJRP included the following immediate actions: 1. On 1/29/24, the DON/designee reviewed inquiries for potential residents to be admitted to facility to identify red flags so the facility will be able to accommodate residents' needs to ensure safety. 2. The Licensed Nurse will obtain a verbal report about the status and high-risk areas related to the potential resident who will be admitted to the facility, for continuity of care, between the discharging facility or hospital and receiving facility. 3. On 1/29/24, the Admin and DON reviewed Resident 1's Physician's order from the discharging facility which indicated monitoring of episodes of wandering hourly for wandering/elopement risks which the admitting nurse was not able to carry over to the new admission orders and care plan of Resident 1 during the admission on 1/24/24. 4. The licensed nurses/admitting nurses and/or DON/Registered Nurse (RN) Supervisor began reviewing Inquires of new admissions/readmissions including the History and Physical (H&P) and Physician's Orders from the discharging general acute care hospital (GACH) or other discharging facilities, to identify history of elopement/wandering behavior, and any physician's orders for monitoring residents for elopement prevention and ensure the findings were incorporated in the resident's assessment and care plan for residents' safety. 5. On 01/25/24, the Elopement Code (Code White) was activated to search and attempt to locate Resident 1. 6. On 1/25/24, Resident 1's Physician and Responsible Party/Conservator were notified of the incident. 7. On 1/25/24, investigation was initiated immediately by the Admin. 8. On 1/25/23, the Local Law Enforcement was notified by the Admin & continued to search neighboring hospitals. 9. On 1/30/24, a one to one (1:1, person to person) in-service education was provided to the Licensed Nurse who admitted Resident 1 on 1/24/24, regarding elopement, admission of a resident with a known history of elopement and carrying out physician's orders upon admission. 10. On 1/30/2024, the Admin/Designee, initiated in-service education to all staff, regarding Resident Safety Policy & Procedure which indicated, the facility will provide a safe and hazard free environment. 11. On 1/30/24, the Admin assigned Certified Nurse Assistants (CNA) 24 hours/7 days a week to the main exit doors (front door and back laundry exit door) to monitor and ensure residents did not leave the facility without proper supervision/authority to leave the premises. 12. On 1/30/24, the Administrator assigned a staff member (RN Supervisor) for all shifts to conduct rounds throughout the facility to ensure that doors are closed, and alarms are always engaged. 13. The Maintenance Supervisor will conduct doors and door alarm check for all exit doors leading to inside and outside of the facility to ensure all alarms are engaged and functional, twice a week for one (1) month, weekly for 1 month, bi-monthly for 1 month, then monthly for three (3) months. 14. On 1/25/24, 1/26/24 and 1/30/14, the Admin/DON/Director of Staff Development (DSD) initiated an in - service education to all staff, on the facility's policy and procedures (P&P) on Wandering/Elopement, and Resident Safety with emphases on: a. Accurate review by the Licensed Nurse/Admitting nurse and/or DON/RN Supervisor of the Inquires including H&P and Physician's Orders from the Hospital or other Discharging facilities to identify history of elopement/wandering behavior and any physician's orders for monitoring of resident for elopement prevention if ordered to ensure safety of residents. b. Residents who are at risk for Elopement and Wandering will be monitored based on individual needs and care plan based on assessment, interdisciplinary team ([IDT] group of healthcare professionals working together to provide residents with the care they need) recommendations and physician's orders such as (i.e., 1:1, every 15-minute checks, hourly monitoring) and will be based on resident's behavior and safety risks. At a minimum, residents will be monitored to ensure safety at least every two (2) hours and increase of supervision will be dependent upon the resident's assessment and risks. The care plan will be updated of the risks and interventions minimize/prevent elopement episodes and ensure safety of residents. c. Accurate completion of Resident Elopement Risk Assessment upon admission/re-admission, quarterly and upon change of condition d. Updating Resident's care plans to reflect the appropriate intervention for elopement prevention. e. Ensuring that no residents exit or leave the facility, unless with proper supervision/authority to leave the premises. Monitoring plan for the exit doors. f. Location of Elopement Risk Binders (binder that contain lists of residents at risk for eloping) and its contents. g. Additional in-services related to Discharge Against Medical Advice P&P, & Out on Pass P&P were also included. 15. On 1/29/24, the Administrator contacted a vendor to obtain a quote for possible installation of wander guard door system (door alarm system) for all exits of the facility. Findings: During a review of Resident 1's Face Sheet (admission record), dated 1/26/2024, the face sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnosis including schizoaffective disorder (a disorder that affects a person's ability to think, feel, and behave clearly), encephalopathy (disease of the brain where functioning is affected by a condition or toxins), heart failure (when the heart doesn't pump enough blood for the body's needs), anxiety (intense, excessive, and persistent worry and fear about everyday situations), hypertensive heart disease (high blood pressure that affects the heart) type 2 diabetes mellitus (abnormal blood sugar ) and muscle weakness. During a review of Resident 1's Minimum Data Set ([MDS], a standardized assessment and care screening tool), dated 1/10/24, from the transferring facility, the MDS indicated Resident 1 was able to understand and be understood by others. The MDS indicated Resident 1 required limited assistance for eating, oral hygiene, toileting hygiene, upper body dressing, lower body dressing, putting on taking off footwear, and required partial/moderate assistance (helper provides less than half the effort) such as shower, bathe self, and personal hygiene). The MDS indicated Resident 1 had antipsychotic medication (medication to manage schizophrenia). During a review of Resident 1's care plan, titled Resident at risk for wandering/exit seeking, related to history of wandering, diagnosis anxiety and schizoaffective disorder from the transferring facility, dated 1/10/2023, the interventions indicated administer medications as ordered. During a review of Resident 1's wandering risk observation/assessment dated [DATE], from the transferring facility, the assessment indicated Resident 1 was at risk of wandering and elopement. During a review of Resident 1's physician's order dated 1/24/2024, the physician's order indicated quetiapine fumarate (medication to treat certain mental/mood disorders such as schizophrenia) 25 milligram ([mg] unit of measurement), three times daily (TID), amlodipine besylate (high blood pressure medication) 10 mg, 1 tablet daily (QD), carvedilol (high blood pressure medication) 25 mg 1 tablet TID, digoxin (medication for heart failure) 125 mg QD, hydralazine HCL (high blood pressure medication) 50 mg TID, losartan potassium (high blood pressure medication) 50 mg TID, metformin HCL (medication to treat high blood sugar) 500 mg, BID, olanzapine (medication to treat certain mental/mood disorders such as schizophrenia) 15 mg BID, spironolactone (medication for high blood pressure/chronic swelling of the lungs) 25 mg QD. During an interview on 1/26/2024 at 11:46 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 1 was alert and had a flat affect (did not show emotions). LVN 1 stated Resident 1 was admitted to the facility less than 24 hours ago. LVN 1 stated Resident 1 was not at risk for elopement and did not have any history of elopement and was not monitored for elopement risk. LVN 1 stated on 1/25/2024 around 8:45 a.m., Resident 1 walked to the nurse's station, and asked for the social services (SS). LVN 1 stated she directed Resident 1 to the SS office. LVN 1 stated, five (5) minutes later she observed Resident 1 going back to his room. LVN 1 stated around 10:00 a.m., 911 (emergency phone number) was called for another resident, and all entrance/exit doors to the facility were opened. LVN 1 stated all the doors remained open until 10:10 a.m. when the paramedics (emergency medical care personnel) left the building. LVN 1 stated Resident 1 might have left the building when the paramedics were in the facility and facility doors were kept open. LVN 1 stated the alarm system to the main door of the facility was not activated (turned on) because the receptionist was at the reception area. LVN 1 stated Resident 1 had no care plans, MDS or H&P, because he was just admitted to the facility. LVN 1 stated Resident 1 would not be safe out in the community because Resident 1 did not have any medications or food with him. LVN 1 stated Resident 1 could become sick or hit by a car, on the busy streets outside the facility. During an interview on 1/26/2024 at 12:56 p.m., with the Director of Nursing (DON), the DON stated that Resident 1 was last seen by LVN 1 on 1/25/2024 at 9:00 a.m. and the Rehabilitation Director was the one who noticed Resident 1 was missing on 1/25/2024 at 12 noon when she was about to start Resident 1's physical therapy. During an interview on 1/26/2024 at 1:42 p.m., with the Admissions Director (AD), the AD stated the DON was in charge of reviewing residents' admission inquiry records to determine whether a resident was to be admitted to the facility or not. During an interview on 1/29/2024 at 10:33 a.m., with the DON of the transferring facility, (DON 2), DON 2 stated that Resident 1 was confused and at risk for wandering and elopement. DON 2 stated, a CNA was always assigned to monitor and document the resident's location every hour. DON 2 stated Resident 1 would wander into other resident's rooms. During a phone interview on 1/29/2024 at 10:56 a.m., with the DON, the DON stated she (the DON) reviewed residents' admission inquiry records, including the discharge summary, physician orders, H&P, face sheet, progress notes, medication, and insurance information to determine if the facility could meet the resident's needs, before accepting the resident for admission to the facility. The DON stated she reviewed the admission inquiry from the transferring facility for Resident 1 and approved the resident's admission to the facility. The DON stated Resident 1 was admitted to the facility, for physical and occupational therapy ([PT and OT] physical methods to treat disease, injury, or deformity, such as massage, heat treatment, and exercise rather than by drugs or surgery) because Resident 1's previous facility did not have the services. The DON stated she (the DON) reviewed Resident 1's face sheet, physician's order and vaccination records from the admission inquiry from the transferring facility and did not go to the facility or inquire whether Resident 1's previous facility was a locked (equipped with security devices) or secured facility (with locked entrances and exit doors). The DON stated there was no need to ask questions or verify the accuracy of what was written in the inquiry report. The DON stated if the facility was aware Resident 1 was at risk for elopement, staff could have monitored the resident closely, to prevent him from eloping. During a concurrent interview and record review on 1/29/24 at 4:38 p.m., with the DON, the physician's order dated 1/17/2024, from the transferring facility was reviewed. The DON stated, the physician orders from the transferring facility dated 1/17/2024, upon admission indicated to monitor episodes of wandering and elopement risk and document resident's location every hour. The DON stated residents with wandering behaviors were at risk of elopement. The DON stated she did not verify Resident 1's orders from the admitting physician and staff did not monitor the resident for elopement risk. The DON stated, the facility did not monitor Resident 1 or any newly admitted residents, for at least 72 hours post admission to the facility per the facility's P &P on elopement risk reduction approaches. The DON stated the facility did not follow the orders written from the previous facility. During an interview on 1/30/2024 at 12:35 p.m., with Registered Nurse (RN) 1, RN 1 stated when resident was being monitored for wandering behavior, would mean resident had a wandering history. RN 1 stated she (RN 1) was not aware Resident 1 was at risk for elopement. RN 1 stated if she knew, Resident 1 had a history of wandering and elopement, Resident 1's assessment could have indicated Resident 1 was at risk of elopement. RN 1 stated the staff could have monitored Resident 1 at least every hour to prevent the resident from leaving the facility unattended. RN 1 stated without Resident 1's diabetic medications, Resident 1 could suffer hypo/hyperglycemia, and loss of consciousness. RN 1 stated without Resident 1's antihypertension medications, Resident 1 could suffer hypertensive crisis, or stroke. During an interview on 1/30/2024 at 1:21 p.m., with Director of Staff Development (DSD), the DSD stated the facility did not have an assigned staff to cover the front desk on 1/25/2024, because the receptionist was off duty. The DSD stated the department heads were supposed to cover the front desk. During an interview on 1/30/2024 at 1:54 p.m., with Housekeeper (HK 1), HK 1 stated, on 1/25/2024, between 11 a.m. to 1 p.m. she did not see any staff monitoring the front desk. During an interview on 1/30/2024 at 1:56 p.m., with HK 2, HK 2 stated that on 1/25/2024, between 6 a.m. to 2 p.m. she did not see a receptionist or any staff monitoring the front desk. During a review of the facility's P&P titled Elopement Risk Reduction Approaches, dated 4/15/2021, the P&P indicated the facility would plan and provide new residents to the facility, wing, unit, with additional staff assistance until the residents were comfortable in their new environment. The P&P indicated the facility staff needed to know the resident's propensity to wander, the triggering conditions and the consequences of unsafe wandering, and protocols to follow, to minimize residents' successful exiting the facility. During a review of the facility's P&P titled Wandering and Elopement, dated 2/10/2023, the P&P indicated the Licensed Nurse, in collaboration with the Interdisciplinary Team (IDT), will assess residents upon admission. The P&P indicated residents with a history of elopement or for whom the IDT assessed to be at risk for elopement, will have a photograph maintained in their medical record. During a review of the facility's P&P titled Resident Safety, dated 1/2012, the P&P indicated the facility would provide a safe and hazard free environment for the residents. The P&P indicated residents would be evaluated on admission, quarterly and whenever there was a change in condition to identify circumstances that pose a risk for the safety and wellbeing of the Residents. During a review of the Los Angeles Accuweather forecast report from 1/25/2024 to 2/7/2024 at Los Angeles, CA Monthly Weather | AccuWeather, indicated the temperature was in the low 48's degree Fahrenheit ([ F] unit of measurement) to high 80's F. It also indicated some days were, rainy, cloudy and with warnings of flooding. During a review of the Los Angeles city's overall crime grade for violent crimes for zip code where the facility was located at https://crimegrade.org/murder-90018, the crime grade for violent crimes indicated a D (dangerous).

Based on observation, interviews, and record reviews, the facility failed to provide supervision to smoking residents who were assessed having either a limited range of motion ([ROM] to move a joint with staff's assistance), insufficient motor skills to hold smoking paraphernalia (equipment such as cigarettes) or unable to light tobacco, during smoking time for three of 16 sampled smoking residents in the facility (Resident 1, 3 and 4). The facility failed to: 1.Ensure Resident 1, 3, and 4 were supervised while smoking in the patio, to prevent cigarettes burns and other injuries related to smoking per care plan titled The Resident is a Smoker. All three residents had the same care plan. 2. Ensure Resident 1, who had insufficient fine motor skills needed to securely hold cigarettes and was unable to light cigarettes safely, did not have smoking paraphernalia in personal possession. 3. Ensure the interdisciplinary team ([IDT] a group of healthcare providers from different fields who work together or toward the same goal to provide the best care or best outcome for residents) developed an individualized residents' plan for safe storage and use of smoking paraphernalia for all 14 residents who smoked, and documented in the residents smoking assessment, care plan, and discussed with the residents or their responsible party per the facility's policy titled (P&P) titled Smoking by Residents. These deficient practices placed Resident 1, 3, and 4 at risk for injuries related to unsupervised smocking and placed all residents at the facility at risk for injuries due to potential fire. At the time of investigation, the facility's census was 89 residents. On 7/5/2023, an unannounced visit was made to the facility to investigate a facility reported incident (FRI) regarding a resident-to-resident altercation. 1. On 7/7/2023 at 2:45 p.m., the facility's Administrator (Admin) was notified that 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(s) was identified due to the facility's failure to supervise residents during smoke breaks. An IJ was called in the presence of the Admin. On 7/7/2023 at 11:35 p.m., the facility submitted an acceptable IJ Removal Plan (IJRP). While onsite, the IJRP's implementation was validated through observation, interview, and record review, the IJ was removed on 7/8/2023 at 12:45 p.m., in the presence of the Admin, Director of Nursing (DON) and Nursing Consultant (NC). The IJRP included the following immediate actions: 1. On 7/5/23 and 7/6/23, the Director if Nursing (DON) and the licensed nurses immediately completed the Smoking Evaluations of 16 residents who smoked including Residents 1, 3, and 4. The assessment included a safe storage and safekeeping of smoking paraphernalia, supervision or assistive device required, smoking apron and developed a resident-centered care plan to address residents' current assessments, including needs for supervision needs, safe storage or smoking paraphernalia, and assistance to light the cigarettes. 2. On 7/7 /23, the Admin and IDT met with the residents who smoke, and discussed the Smoking Policy and Procedures, including the process for safe storage and safekeeping of smoking materials. 3. On 7/7/23, Resident Council was held with the Resident Council President and Smokers together with the Administrator and Activity Director and reviewed the Smoking Policy and Safety of Residents including the New Process for Smoking Supervision and Safe Storage of Smoking Materials both cigarettes and lighting materials. 4. On 7/7/23, the Medical Director was notified of the smoking policy of the facility, the new process and the correction action plan. 5. On 7/7/23, the DON/Designee conducted an audit of residents who smoke to ensure that Smoking Evaluations and Care Plans have been completed. There are a total of 16 residents who smoke in the facility. Out of the 16 residents who smoke, there were 5 residents who were identified to require supervision. Out of the 16 residents who smoke, there were 3, residents who utilizes Smoking Apron while smoking. 16 out of 16 residents Smoking Evaluations and Person-Centered Care Plans for Smoking have been completed. 6.On 7/7 /23, the DON/Designee initiated education to the Licensed Nurses, Certified Nursing Assistants (CNAs), Department Managers, and the rest of the facility staff in all departments on the Smoking Policy and Procedures, with emphasis on safe storage and safekeeping of their smoking materials, assessment to determine if residents require supervision and/or assistive devices while smoking, use of apron while smoking and without supervision, and development of individualized care plan. 7. A facility smoking schedule has been established and updated 8. Residents in the smoking area will be supervised by designated staff members during scheduled smoking hours. 9. Residents' cigarettes and smoking paraphernalia will be kept in the Smoking Storage Lock Box and attended and secured by facility staff. 10. During Morning Clinical Meeting Mondays to Fridays, the IDT will review residents who are newly admitted , residents who are due for their quarterly assessments, residents with significant change in condition to ensure that Smoking Evaluations and Person-Centered Care Plans are completed for those residents who currently smokes and those who have expressed the desire to smoke including vaping. Identified concerns will be immediately addressed and reported to the Administrator and DON for resolution as warranted. 11. The Department Managers will conduct rounds and observe residents who smoke in their assigned rooms weekly for 4 weeks then bimonthly for 2 months to ensure that residents who smoke adhere to smoking policy and procedures, lighting and smoking materials are safely stored according to the residents' care plan and residents who require supervision and/or assistance are provided assistance by the staff and no lighting material in their possession, and Smoking Aprons are worn by residents according to their care plans and assessments. Identified concerns during the observation will be immediately addressed and reported to the Administrator and DON for resolution as warranted. Findings: 1. During a review of Resident 1's face sheet (Admission Record), dated 6/27/2023, the face sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including muscle weakness (decreased strength in the muscles) and unspecified sequelae of cerebral infarction (residual effects after blood supply to part of the brain is disrupted). During a review of Resident 1's History and Physical (H&P), dated 7/22/2022, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set ([MDS], a standardized assessment and care screening tool), dated 6/14/2023, the MDS indicated Resident 1 was able to understand and be understood by others. The MDS indicated Resident 1 required supervision from staff for activities of daily living (ADLs) such as bed mobility, eating, and movement on and off the unit. The MDS indicated Resident 1 required limited assistance from staff for ADLs such as dressing, toileting, and personal hygiene. During a review of Resident 1's care plan, titled The resident is a smoker, initiated 6/6/2022, the care plan intervention included to provide Resident 1 required supervision while smoking and observe the resident's clothing for signs of cigarette burns. During a review of Resident 1's Smoking and Safety Report, dated 7/6/2023, the report indicated Resident 1 used tobacco products and had balance problems while sitting or standing, limited or no range of motion in arms or hands, insufficient fine motor skills needed to securely hold cigarettes, and was unable to light cigarettes safely. 2. During a review of Resident 3's face sheet, dated 7/6/2023, the face sheet indicated Resident 3 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including epilepsy (a disorder that causes seizures or unusual sensations and behaviors), hemiplegia (paralysis of one side of the body ) and hemiparesis (muscle weakness on one side of the body), and schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly). During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3 usually understood and was usually understood by others. The MDS indicated Resident 3 required extensive assistance from staff for ADLs such as bed mobility, walking, dressing, and personal hygiene. The MDS indicated Resident 3 required supervision from staff for ADLs such as movement on and off the unit and eating. During a review of Resident 3's care plan, titled The resident is a smoker, initiated 6/22/2023, the care plan intervention indicated Resident 3 required a smoking apron while smoking, and required supervision while smoking and staff would observe his skin for signs of cigarette burns. During a review of Resident 3's smoking and safety report dated 7/6/2023, the report indicated Resident 3 used tobacco products and had poor vision or blindness, balance problems while sitting or standing, limited or no ROM in arms or hands, insufficient fine motor skills needed to securely hold cigarettes, and was unable to light, hold, extinguish, or use the ashtray to extinguish cigarettes safely. 3.During a review of Resident 4's face sheet, dated 7/6/2023, the face sheet indicated Resident 3 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including hemiplegia and hemiparesis, dementia (a condition characterized by progressive or persistent loss of intellectual functioning), and functional quadriplegia (complete inability to move due to severe disability or frailty caused by another medical condition without physical injury or damage to the spinal cord). During a review of Resident 4's H&P, dated 5/8/2023, the H&P indicated Resident 4 could make needs known but not make medical decisions. During a review of Resident 4's MDS, dated [DATE], the MDS indicated Resident 4 was able to understand and be understood by others. The MDS indicated Resident 4 required extensive assistance from staff for ADLs such as transferring, toileting, and personal hygiene. The MDS indicated Resident 4 required supervision from staff for ADLs such as movement on and off the unit and eating. During a review of Resident 4's care plan, titled The Resident is a smoker, initiated 6/6/2022, the care plan indicated Resident 4 required supervision while smoking and staff would observe his skin for signs of cigarette burns. During a review of Resident 4's smoking and safety report, dated 7/6/2023, the report indicated Resident 4 used tobacco products and had limited ROM in the arms or hands and required supervision during smoking session. On 7/5/2023 at 4:16 p.m., Residents 1, 3, and 4 were observed smoking cigarettes in the designated smoking patio without staff presence to supervise the residents while smoking. Resident 3 was not wearing an apron. Two Certified Nursing Assistants (CNA) 1 and 2 were observed sitting across the hallway from the glass patio door with their backs turned away from Residents 1, 3 and 4 while the residents smoked. During an interview with CNA 1 on 7/5/2023 at 4:17 p.m., CNA 1 stated she was not supervising the smoking patio. CNA 1 stated she helped open the door for the residents who went in and out of the smoking patio and had no time to watch the residents. CNA 1 stated the facility used to have someone supervising the residents smoking in the patio but not anymore. During an interview with CNA 2 on 7/5/2023 at 4:28 p.m., CNA 2 stated everyone by the nurses' station supervised the patio, but no staff was assigned to supervise the residents smoking in the patio. CNA 2 stated, usually someone from activities supervised the residents smoking in the patio, but the activities staff was not there. CNA 2 stated staff would leave the patio if the residents requested them to do so. During an interview with the Activity Director (AD) on 7/6/2023 at 11:05 a.m., the AD stated all staff oversaw supervision of the residents in the smoking patio. The AD stated she had seen nurses sit outside the patio to chart but nurses sitting by the patio were not really supervising because their backs were facing the patio. The AD stated supervision meant to stay with residents until the residents finished smoking and to assist the residents light or hold the cigarettes. The AD stated without supervision and assistance while smoking the residents could drop the cigarettes on their body, have cigarettes burns and get their clothes to catch on fire, create panic, and create fire. The AD confirmed the residents kept their own cigarettes and lighters with them. During an observation of the smoking patio on 7/6/2023 at 1:20 p.m., six residents were observed smoking in the patio and two CNAs were sitting outside of the patio charting, in the hallway across the smoking patio with their backs toward the smoking patio. Concurrently, during an observation, CNA 3 was interviewed. CNA 3 stated she was watching the residents and finishing up with her charting. CNA 3 stated she was watching the residents to make sure they were not fighting and if they needed an assistance. During an observation of the smoking patio on 7/6/2023 at 1:28 p.m., CNA 3 was sitting with her back towards the smoking patio and charting. During an observation and concurrent interview with Resident 1 in Resident 1's room on 7/6/2023 at 1:39 p.m., Resident 1 stated she kept her own cigarettes and lighter. Resident 1 pulled out a pack of cigarettes and a lighter from her pockets. Resident 1 had a burn mark on her shirt and the resident stated the burn was from cigarettes, a few days ago. During an interview with the Social Services Director (SSD) on 7/6/2023 at 2:22 p.m., the SSD stated staff that supervise the patio could stay inside the building, but they need to face the patio door and not sit with their backs toward the door. The SSD stated someone always had to supervise the residents in the smoking patio for their safety. During an interview with the Registered Nurse Supervisor (RN) 1, on 7/6/2023 at 2:49 p.m., RN 1 stated all residents were not allowed to keep cigarettes and lighters with them. RN 1 stated if the residents kept cigarettes and lighters in their rooms, the residents could smoke or accidentally start a fire. During an interview and concurrent record review with the Director of Staff Development (DSD) on 7/6/2023 at 3:40 p.m., Resident 1's smoking and safety report was reviewed. The DSD stated Resident 1 had safety concerns and so, required supervision while smoking The DSD stated there were no scheduling or delegation of supervision for the smoking patio. The DSD stated no staff was required to be in the smoking patio all the time unless a resident needed supervision. The DSD stated residents were not supposed to keep their own lighters. During an interview with the Director of Nursing (DON) on 7/6/2023 at 4:10 p.m., the DON stated supervision of the patio depended on who was in the patio because not all residents needed supervision while smoking. The DON stated residents should not have lighters with them because it can be a high safety hazard. The DON stated when CNAs turn their backs towards the patio, it was not considered supervision. During an interview with the Admin on 7/7/2023 at 1:59 p.m., the Admin stated if a resident's care plan indicated the resident required supervision while smoking, the resident was not allowed to smoke without supervision. The Admin stated residents were not allowed to keep both lighters and cigarettes with them. During a review of the facility's policy and procedure (P&P), titled Smoking by Residents, dated 1/2017, the P&P indicated its purpose was to provide a safe environment for residents, staff, and visitors. The P&P indicated as identified by the Smoking Assessment, residents who required assistance and/or monitoring for smoking, were not allowed to smoke unsupervised. The P&P indicated the IDT would develop an individualized plan for safe storage, use of smoking materials, assistance and required supervision for residents who smoke, and it will be documented in the resident smoking assessment, care plan, and discussed with the resident or responsible party.

Based on observation, interview and record review the facility failed to provide an effective pain management treatment for one of one sampled resident (Resident 18), after Resident 18 had reported, he did not want to take Norco (strong pain medication) 5/325 milligrams ([mg] unit of measurement) because it made him dizzy and shaky. This deficient practice caused Resident 18 to be in pain for 7 days, without any pain management. Findings: During a review of Resident 18's admission record (Face Sheet), the face sheet indicated Resident 18 was admitted on [DATE] with a diagnosis that included dislocation (injury in which the ends of the bone and forced out of position) of the right hip, kidney disease (damaged kidneys), and heart failure (condition in which the heart muscle is unable to pump enough blood to the body). During a review of Resident 18's history and physical (H&P), dated 12/16/2021 the H&P indicated Resident 18 had the capacity to understand and make medical decisions. During a review of Resident 18's minimum data set ([MDS] a standardized care assessment and care screening tool), dated 9/8/2022, the MDS indicated Resident 18's cognitive skills (thought process) was moderately impaired. The MDS indicated Resident 18 could understand and be understood by others. The MDS indicated Resident 18 required limited to extensive assist with one person assist with activities such as bed mobility, transfer (moving between surfaces to and from bed, chair, wheelchair), dressing, toilet use, and personal hygiene. The MDS indicated Resident 18 required physical help in bathing and is dependent on a walker for mobility. During a review of Resident 18's physician orders for the month of November 2022, Resident 18 had the following orders for pain management: 1. Acetaminophen ([Tylenol] pain medicine) 325 mg. Give every 4 hours as needed for pain level of 1 to 4 for pain (mild pain). 2. Norco 5/325 mg. Give 1 tablet every 6 hours as needed for moderate pain on a level of 5 to 7 (moderate pain). 3. Norco 5/325 mg. Give 2 tablets every 6 hours as needed for severe pain on a level of 8 to 10 (severe pain). During a review of Resident 18's medication administration record (MAR) for the month of November 2022, the MAR indicated Resident 18 received Norco 5/325 mg on 11/7/2022 at 8:14 a.m. for a pain level of 8/10. During a review of Resident 18's care plan titled At risk for adverse drug reaction ([ADR] unintended, harmful effects from the use of medicines) related to the use of Norco dated 7/31/2022. The care plan's interventions included to monitor Resident 18 for signs and symptoms of ADR such as constipation, nausea, vomiting and dizziness. During a review of Resident 18's care plan titled At Risk for pain and discomfort due to dislocation of right hip, dated 11/8/2022, the care plan's interventions included monitor and documenting side effects of pain medication such as constipation, confusion, nausea, vomiting, dizziness, and falls. During an interview on 11/1/2022 at 1:40 p.m. with Resident 18, Resident 18 stated he was waiting for an update on his pain medication because he had reported to the nurses that Norco made him feel dizzy. Resident 18 stated his pain was a 10/10, on a scale of 0-10, with 10 being the worse pain. Resident 18 stated he had generalized pain, especially on his shoulders and right hip. Resident 18 stated he does not have a preference to a pain medication because the nurses only offered him Norco. Resident 18 stated he was upset that the nurses did not notify his physician to change his pain medication from Norco. During a concurrent observation and interview on 11/1/2022 at 1:54 p.m. at the nursing station, License Vocational Nurse 1 (LVN 1) stated Resident 18 did not report to her that Norco made him feel dizzy. LVN 1 stated she had not administered Norco and the resident had not complained of pain. LVN 1 stated she will notify the Registered Nurse Supervisor (RN Supervisor) 1 that the resident preferred another pain medication. LVN 1 was observed reporting to RN Supervisor 1 of Resident 18's reaction to Norco. During a concurrent medication pass observation and interview on 11/8/2022 at 9:45 a.m., Resident 18 was observed to tell LVN 2 that he had pain 8/10 all over his body. LVN 2 offered Norco to Resident 18. Resident 18 became upset and stated I told you guys I do not want Norco. I am in pain, and Norco gets me dizzy and shaky. And I do not want Tylenol (medication used to treat minor aches and pains) either, that does nothing for me. During an interview with LVN 2, LVN 2 stated she was not aware the resident felt dizzy and shaky from Norco. LVN 2 further stated she did not know Resident 18 had asked LVN 1 and RN Supervisor 1 for a change in his pain medication. During a concurrent interview and record review on 11/8/2022 at 10:35 a.m., RN Supervisor 1 stated she sent a text message to the pain specialist on 11/1/2022, to evaluate Resident 18 for pain management. RN Supervisor 1 stated the pain specialist did not see Resident 18 until 11/7/2022. RN Supervisor 1 stated she did not notify Resident 18's attending physician of the resident's reaction to Norco and his wishes to have a different pain medication. RN Supervisor 1 stated Resident 18's Norco was not discontinued after the resident had reported on 11/1/2022 that Norco made him feel dizzy because Resident 18 did not complain of pain often and there were other underlying issues that could contribute to Resident 18's dizziness. RN Supervisor 1 stated that Resident 18 had Tylenol and nurses also offer non-pharmacological methods (the management of pain without medications) to alleviate pain. During an interview on 11/8/2022 at 12:00 p.m. with Resident 18, Resident 18 stated when he is in pain, he had a difficult time eating and opening his supplemental protein drink because the pain is predominantly on his shoulder and on the joints of his fingers. Resident 18 stated he was not able to recall if Norco alleviated his pain or not because he felt too awful to even notice if his pain went away. Resident 18 stated Norco made him feel dizzy and shaky. Resident 18 stated the nurses offered Tylenol, but Tylenol does not help his pain. During a review of the facility's policy and procedure (P&P) titled, Pain Management with a revision date of November 2016, the P&P indicated, A resident receiving analgesic medications, especially opioids may experience increased risk for falls due to dizziness, lightheadedness, or lower blood pressure. The P&P indicated, if there is a new onset of pain, if the pain has changed in nature, or the pain has not been relieved with current medication, the license nurse will notify the attending physician. During a review of the facility's undated LVN job description, the job description indicated the LVN will evaluate response and report adverse reactions to medications or treatments in accordance with the policy. During a review of the facility's undated RN staff nurse job description, the job description indicated the RN will evaluate response and report adverse reactions to medications or treatments in accordance with the policy. It also indicated the RN will conduct daily resident rounds to assess and evaluate the resident's physical, medical, and emotional status and to implement or revise nursing interventions to the resident plan of care.

Based on observation, interview, and record review, the facility failed to provide wound care services to prevent and treat pressure injury (pressure ulcer, injury to skin and underlying tissue resulting from prolonged pressure on the skin and/or underlying soft tissue usually present over a bony prominence) for two of four sampled residents (Residents 3 and 4) by failing to: a). Provide treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] ?filled blister due to damage of underlying soft tissue from pressure and/or shear) identified upon admission on 7/12/2022. The treatment started on 7/28/2022, 15 days after Resident 3 was admitted to the facility. b). Identify and treat a facility acquired Stage 2 pressure ulcer (Damage to an area of the skin caused by constant pressure on that area for a long time) to the left sacral buttock (tailbone and fleshy surrounding area) area including turning and repositioning every two hours, for Resident 4 c. Develop a care plan upon admission to address Resident 3 and 4's high risk for skin breakdown assessment. These deficient practices resulted in Resident 3 transfer to the General Acute Care Hospital (GACH) where the resident was diagnosed with an infected sacral decubitus ulcer and [CONDITION(S)] (life threatening infection) where the resident underwent [MEDICAL RECORD OR PHYSICIAN ORDER] Resident 4 developed a Stage 2 pressure ulcer that was not identified and treated by the facility's staff and had the potential to lead to further skin break down, delayed wound healing and possible [CONDITION(S)]. Findings: a). During a review of Residents 3's admission record, the admission record indicated Resident 3 was admitted to the facility on [DATE] from the general acute care hospital (GACH) with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 3's Braden Scale for Predicting Pressure Ulcer Risk dated 7/12/2022 Braden scale indicated Resident 3 was at high risk for pressure ulcers. During a review of Resident 3's medical record titled Skin Only Evaluation dated 7/13/2022, the evaluation indicated Resident 3 had the following skin issues: 1). Left lateral hip surgical wound which measured 11.5 cm with epithelial (thin layer of skin). 2). Discoloration to both (bilateral) hands. 3). Eschar (death tissue that falls off healthy tissue) on the nose with a necrotic (dead) wound bed. During a review of Resident 3's H/P dated 7/15/2022, indicated Resident 3 could make needs known but could not make medical decisions. During a review of Resident 3's Minimum Data Set ([MDS] a care screening and assessment tool), dated 7/19/2022, the MDS indicated Resident 3 usually had the ability to understand and usually was understood by others. The MDS indicated Resident 3 required one-person assist for transfers, bed mobility, bed transfer, locomotion (the power to move from one place to another), bed mobility, eating, toilet use and personal hygiene, eating, toilet use and personal hygiene. The MDS indicated Resident 3 was frequently incontinent of urine and always incontinent of bowel. The MDS indicated Resident 3 had a pressure ulcers or DTI. The MDS did not indicate any skin and ulcer/injury treatments, including a turning and repositioning program, or pressure reducing devices for Resident 3. During a review of the Change of Condition Evaluation (COC) dated 7/27/2022 indicated Resident 3's skin wound, or ulcer started in the morning. Resident 3's skin changes included a pressure ulcer/injury to the sacrum DTI- purple discoloration which measured 6 by 6 cm. The COC indicated during morning care a DTI was observed on Resident 3's sacrum and Resident 3's physician gave orders to cleanse Resident 3's wound with normal saline, pat dry and apply [MEDICATION(S)] then cover with a dry dressing daily and as needed for 30 days. During a review of the Treatment Administration Record (TAR) dated July 2022 and initiated on 7/28/2022, indicated treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of the Nurse's Notes dated 8/2/2022 at 1:25 p.m., the Nurse's Notes indicated while providing care, Resident 3's family was present and noticed the wound on Resident 3's sacral area and requested for Resident 3 to be transferred to the hospital. The doctor was informed and ordered to transfer Resident 3 to the GACH upon family request. During a review of Case Manager (CM) notes for an Interdisciplinary Team ([IDT] team members from different disciplines working together ensure residents receive the best care) meeting with Social Service Director (SSD) dated 8/2/2022 at 7:39 p.m., Resident 3's daughter and granddaughter were upset and were inquiring about Resident 3's DTI after seeing the affected area. The CM offered to provide Resident 3 with DTI care and offered to continue with IDT meetings, but Resident 3's daughter and granddaughter demanded Resident 3 be transferred to the hospital. During a review of GACH H/P dated 8/3/2022 at 1:59 a.m., the H/P indicated Resident 3 was presented to the hospital for an evaluation of the sacral wound and an altered mental status. On physical exam Resident 3's sacral area was noted with a large necrotic sacral decubitus ulcer (bedsore between lower back and tail bone) with foul-smelling purulent (pus) discharge. The H/P included a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of the GACH's General Surgery Consult (GSC) dated 8/3/2022 at 10:17 a.m. the GSC's note indicated Resident 3 had a stage II (ulcer that expands into deeper layers of the skin) or a possible stage III (full thickness ulcer that extends into the tissue beneath the skin forming an opening) sacral decubitus which measured approximately 15cm by 10 cm. The GSC indicated Resident 3 will continue receiving topical (on the skin) wound care. During a review of the GACH's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of the GACH's Discharge Instructions (DI) dated 8/10/2022 at 4:39 p.m., the DI indicated Resident 3's discharge diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The DI also indicated Resident 3 was discharged home with family on hospice (program that focuses on care, comfort, and quality of life when a person is approaching their end of life). During an interview with Licensed Vocational Nurse (LVN 1) on 8/24/2022 at 10:50 a.m., LVN 1 stated she physically went to see Resident 3 to assess the skin and she did not note a DTI on the sacrum upon admission to facility. LVN 1 stated a DTI can be developed when a person remains on the same position for 24 to 48 hours. LVN 1 stated the skin might remain closed for a few days and would not be able to know if it were superficial or if it had reached muscle or bone until the skin broke open. LVN 1 stated the skin doesn't always break (open) with a DTI sometimes it would heal. LVN 1 stated it was reported to her on 7/27/2022 for the first time that Resident 3 had a black area on her buttocks (fleshy part on which a person sits) that measured six (6) cm by 6 (cm). LVN 1 stated she called the family and the doctor regarding the DTI and obtained orders to treat the wound. LVN 1 also stated Resident 3 did not have a wound care treatment and wound care consult for the sacral DTI prior to 7/27/2022 because Resident 3 was not admitted with a DTI to her sacrum. LVN 1 further stated that if a wound went untreated it could deteriorate, become bigger, had the risk of becoming infected and the wound could be fatal. During a concurrent interview and record review of Resident 3's Medical Record with the Director of Nursing (DON) on 8/17/2022 at 11:43 a.m., the medical record indicated there was no care plan for Resident 3's DTI. The DON stated no care plan was developed to indicate Resident 3 had a DTI and that the resident was at risk for developing pressure ulcers. The DON stated the purpose of a care plan was to direct the type of care needed by residents. b). A review of Residents 4's admission record, indicated Resident 4 was admitted to the facility on [DATE], with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 4's H/P dated 11/10/2021, the H/P indicated Resident 4 did not have the capacity to understand and make decisions. During a review of Resident 4's MDS, dated [DATE], the MDS indicated Resident 4 rarely or never had the ability to understand and be understood by others. The MDS indicated Resident 4 required one-person assist for bed mobility, locomotion (the power to move from one place to another), dressing, eating, toilet use, personal hygiene and two-person assist for transfers. The MDS indicated Resident 4 was always incontinent of urine and bowel. The MDS further indicated Resident 4 had one unstageable pressure Injury presenting as deep tissue injury (DTI). Additionally, the MDS indicated Resident 4 was receiving skin and ulcer/injury treatments, was on a turning and repositioning program, used reducing devices for the chair and bed, and was on a nutrition, hydration, and pressure injury program per the boxes that were checked. During a review of Resident 4's Braden Scale for Predicting Pressure Ulcer Risk dated 7/26/2022 Braden Scale indicated Resident 4 was at high risk for developing pressure ulcers. During an observation on 8/17/2022 at 9:50 a.m., 10:30 a.m., 11:00 a.m., 12:20 p.m., 1:00 p.m., and 2:20 p.m., Resident 4 was observed laying on her back, Resident 4 did not have the capacity to reposition herself. During a concurrent interview and observation with CNA 2 and the DON on 8/17/2022 at 2:40 p.m., CNA 2 stated she had turned Resident 4 to the side, and she did not remember the last time she turned Resident 4. She thought she had turned Resident 4 after breakfast, and she had turned Resident 4 without a pillow or an assistive device to keep her to her side. CNA 2 sated that turning resident without a pillow was not an effective method of turning because Resident 4 was not able to remain on her side and caused her to end up on her back. CNA 2 was asked to look at Resident 4's skin. When CNA 2 removed Resident 4's diaper the diaper was very heavy and full of yellow urine. CNA 2 stated Resident 4 urinated a lot and she had just changed the resident after lunch and did not know what time that was. Once the diaper was removed with the DON present, Resident 4's skin was observed with a wound measuring about 1.5 cm by 1.5 cm on the sacral area towards the left buttock. The DON stated it looked like a stage two pressure ulcer. Resident 4's skin had a film of bright red blood and yellowish spots. CNA 2 stated she did not report the wound because it was not a new wound. CNA 2 stated she did not know how long the wound had been on Resident 4. The DON stated she did not have records of a sacral wound on her logs for Resident 4, she only had the DTI on Resident 4's left heel which Resident 4 was admitted with and that she (DON) did not know how long the sacral pressure ulcer had been there. The DON also stated the pressure ulcer should have been reported and treated as soon as it was identified because it could have led to deterioration of the wound. During an interview with Licensed Vocational Nurse (LVN 1) on 8/24/2022 at 10:50 a.m., LVN 1 stated that Resident 4 did not have a pressure ulcer the last time she saw Resident 4 on 8/10/2022. LVN 1 stated she returned on 8/24/2022 from vacation and she was informed Resident 4 had developed a Stage 2 pressure ulcer to her left buttocks sacral area and she (LVN 1) did not assess Resident 4 because Resident 4 had gone to GACH due to vaginal bleeding. LVN 1 stated the facility had treatment orders for Resident' s 4 left heel ulcer which was noted on admission but there was no treatment prior to 8/17/2022 for sacral ulcer because it was new. During a concurrent interview and record review of Resident 4's Medical Record with the Director of Nursing (DON) on 8/17/2022 at 2 p.m., the medical record indicated there was no care plan for Resident 4's Stage 2 pressure ulcer. The DON stated no care plan was developed to indicate Resident 4 was at risk of developing pressure ulcers. The DON stated it was important to have a care plan for residents at risk of pressure ulcer, especially residents with limited mobility. The DON also stated that Resident 4 had limited mobility, and should have a care plan, but the facility did not develop any. The DON added that pressure ulcers could lead to poor quality of life, pain, discomfort and if not treated, could lead to infection and hospitalization . During a review of the facility's policy titled Pressure Injury and Skin Integrity Treatment dated 8/12/2016, the policy indicated Treatments to pressure injuries or other skin integrity problems will be ordered and provided as ordered by the physician. The policy indicated the physician and family will be notified when there was a change in the condition of the pressure injury or skin integrity problem in order to ensure that treatments and interventions were appropriate. During a review of the facility's policy tilted Comprehensive Person-Centered Care Planning dated 11/2018, policy indicated the facility will provide a person-centered, comprehensive and interdisciplinary care that reflects best practice standards for meeting heath, safety, psychosocial, behavioral and environmental needs of residents in order to obtain or maintain the highest physical, mental and psychosocial wellbeing. During a review of the facility's policy tilted Pressure Injury Prevention, dated 9/1/2020, the policy indicated the facility will provide interventions for Residents identified as high risk for developing pressure injuries. The policy indicated residents at risk developing pressure injuries would have skin assessments completed upon admission, weekly, for four consecutive weeks after admission, quarterly and when there was a significant change in condition.

Based on interview and record review, the facility failed to effectively manage one of three residents (Resident 3) pain by failing to: a) Administer [MEDICATION(S)] (pain medication) 75 milligrams ([mg] unit of measurement) 1 capsule by mouth every eight hours for neuropathic (nerve) pain as ordered by the physician. b) Immediately notify and consult with the physician when Resident 3 complained of severe pain and the medication was ineffective. c) Assess Resident 3 ' s pain. These deficient practices resulted in untreated pain and a delay in treatment, and services for Resident 3. Findings: A review of Residents 3 ' s admission record, indicated Resident 3 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 3 ' s Order Summary Report dated 6/1/2022, the order summary report indicated Resident 3 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Other sensations include sharp, lightening-like pain; or a burning, throbbing, or stabbing pain). The order summary report indicated staff will assess Resident 3 for pain every shift and chart the intensity of the of pain by using a pain scale of 1-10 (0= no pain, 1-4 =mild pain, 5-7 = moderate pain, 8-9 = severe pain and 10 = excruciating (extreme) pain. During a review of Resident 3 ' s History and Physical (H/P) dated 6/4/2022, the H/P indicated Resident 3 had the capacity to understand and make decisions. During a review of Resident 3's minimum data set ([MDS] an assessment and care screening tool) dated 6/8/2022, the MDS indicated Resident 3 had the ability to understand and be understood by others. The MDS indicated Resident 3 required setup help only for bed mobility, locomotion (moving from place to place), and eating. The MDS indicated Resident 3 required two-person assist for transfer and one-person assist for walking, dressing, eating, toilet use and personal hygiene. During a review of Resident 3 ' s Care plan titled Alteration in Comfort Secondary to [CONDITION(S)] updated 6/22/2022, the care plan ' s interventions indicated to: 1. Ask and assess the resident ' s pain symptoms. 2. Evaluate and document the nature and severity of pain. 3. Refer the resident to a specialist to manage the residents' pain. 4. Provide nerve pain medication as ordered. During a review of Resident 3 ' s Care plan titled Chronic Pain dated 6/2/2022, the care plan ' s interventions indicated: 1. Anticipate the resident's need for pain relief. 2. Respond immediately to any complaint of pain. 3. Evaluate the effectiveness of pain interventions (specify frequency). 4. Review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, and impact on functional ability and impact on cognition. During a review of Resident 3 ' s physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview with Resident 3 on 7/13/2022 at 7:22 a.m., Resident 3 stated on 7/12/2022 at 11:30 p.m., he had severe pain and requested [MEDICATION(S)] 75mg as ordered by his doctor, but the nurses gave him [MEDICATION(S)] 50 mg. Resident 3 stated he woke up at 2 a.m. on 7/13/2022 with severe pain, requested a Licensed Vocational Nurse (LVN1) to call his doctor to get [MEDICATION(S)] 75 mg, but the nurse just brushed me off. Resident 3 stated at 7:55a.m., he pressed the call light and at 8:20 a.m., LVN2 arrived. Resident 3 complained of pain to LVN2, LVN2 stated she was getting his medications and rushed out of the room without assessing Resident 3 for pain. During a concurrent interview and record review on 7/13/2022 at 8:26 a.m., with LVN 2, Resident 2 ' s pill card (a flat piece of material that is made of plastic and paper from the front and the back is a combination of thin paper or foil that holds medications) was reviewed and the pill card indicated [MEDICATION(S)] 50 mg capsule, 1 capsule by mouth twice a day for [CONDITION(S)] pain. A review of the electronic medical record (e-MAR), dated July 2022 indicated [MEDICATION(S)] capsule 50 mg, was discontinued on 7/11/22 and [MEDICATION(S)] 75 mg was ordered on 7/11/2022 at 5 p.m. The e-Mar record indicated [MEDICATION(S)] 75 mg was administered on 7/11/2022 at 5:00 p.m., on 7/12/2022 at 9:00 a.m., and on 7/12/2022 at 5:00 p.m. LVN 2, stated Resident 3 ' s [MEDICATION(S)] was just increased to 75 mg and there was no pill card for [MEDICATION(S)] 75 mg, LVN 2 further stated she did not know why the nurses documented the medication ([MEDICATION(S)] 75 mg) as given, when the facility did not have the medication/pill card on hand. During an interview with a Pharmacy Representative (RX 1) on 7/13/2022 at 8:33 a.m., RX 1 stated the nurses were supposed to call the pharmacy to refill all controlled medications because the pharmacy could not provide the medications unless notified by the facility ' s staff. There was no order for [MEDICATION(S)] 75 mg. received by the pharmacy. During an interview with Registered Nurse Supervisor (RN) 1 on 7/13/2022 at 8:52 a.m., RN 1 stated the facility did not have [MEDICATION(S)] 75 mg. RN 1 stated the facility was supposed to have an active order for [MEDICATION(S)] 75 mg, but they did not. RN 1 stated the prescriptions automatically went to the pharmacy once entered the computer. RN 1 stated not managing Resident 3 ' s pain accordingly could lead to a poor quality of life and discomfort. RN 1 also stated pain could prevent Resident 3 from enjoying activities or participate in physical therapy which would lead to deterioration of psychosocial and physical health. During an interview with RN 2 on 7/13/2022 at 9:05 a.m., RN 2 stated Resident 3 had requested [MEDICATION(S)] 75 mg on 7/12/2022 but RN 2 did not have the medication at hand. RN 2 stated he only had [MEDICATION(S)] 50 mg, and was supposed to give [MEDICATION(S)] 75 mg. RN 2 stated he gave Resident 3 [MEDICATION(S)] 50 mg. RN 2 stated he was should have called the doctor, to inform the doctor that Resident 3 ' s pain was not relieved and obtain a new order, but he did not call the doctor. RN 2 further stated he did not have time to call the doctor. RN 2 stated he did not know why he charted he gave [MEDICATION(S)] 75 mg when he only gave [MEDICATION(S)] 50 mg to Resident 3. During an interview with Resident 3 on 7/13/2022 at 10:38 a.m., Resident 3 stated he had not received any pain medication. Resident 3 stated he was dying of pain. Resident 3 described his pain level as a 10 on a scale of 0 to 10 with 10 being the highest pain level. Resident 3 stated he had throbbing pain from the left side of his neck to his left toe. Resident 3 stated due to the pain his blood pressure (BP) would go up and with an elevated BP, physical therapy will not work on him because of the risk of him having another stroke (when something blocks blood supply to part of the brain or when a blood vessel in the brain bursts). Resident 3 stated having an elevated BP made him stressed out and anxious. Resident 3 stated he was furious, and he was worked up because he was in so much pain and he was powerless in managing his pain. Resident 3 stated the facility did not ask what his pain was like. The resident stated on 7/11/2022 at 3:00 a.m., he complained of pain rated at 10, and again at 9:30 a.m., nurses told him the [MEDICATION(S)] 75 mg was ordered but the Resident 3 was given [MEDICATION(S)] 50 mg at 10:45 a.m. During an interview with LVN2 on 7/13/2022 at 11:00 a.m., LVN2 stated when assessing pain, nurses were required to ask for the location of the pain, pain level and intensity of pain, but she did not ask the level or intensity of pain because she already knew where the pain was and that was all she needed to know. During a phone interview with Pharmacy Receptionist (PR 1) on 7/18/2022 at 4:31 p.m., the PR 1 stated the pharmacy receives orders by fax or phone, and all orders were handled in a timely manner. PR 1 stated the prescription for [MEDICATION(S)] 75 mg twice a day was not called in until 7/13/2022, and it was delivered to the facility on [DATE], at 11:19 a.m. PR 1 stated Resident 3 had a previous prescription for [MEDICATION(S)] 50 mg that was due on June 30th and was delivered on July 2nd. PR 1 also stated refills for controlled substances had to be called in for refill and all non-controlled substance refills were done automatically. PR 1 further stated if the facility needed a medication urgently, the facility ' s staff should have called the pharmacy so it could be delivered the same day. During a phone interview with RN 1 on 7/18/2022 at 4:31 p.m., RN 1 stated when a resident ' s pain was not managed properly, the nurses had to call the doctor, inform the doctor, and obtain a new order and create Situation, Background, Assessment and Recommendation ([SBAR] tool to aid to communicate between nurses and doctors). RN 1 stated nurses did not follow this process for Resident 3. RN 1 stated she entered the order for [MEDICATION(S)] capsule 75 mg, by mouth two times a day for [CONDITION(S)] pain but did not know she was supposed to fax the order to the pharmacy. RN 1 stated it was important to assess pain properly to treat it accordingly and to maintain a good quality of life for the resident. During a review of the facility ' s undated Pain Management Policy, the policy indicated the purpose of the policy was to ensure facility staff help residents attain or maintain their highest level of well-being while working to prevent or manage the resident ' s pain. The Policy indicated a licensed nurse would assess each resident for pain upon admission, quarterly and when there was a new onset of pain, exacerbation of pain or when there was a significant change in status. The policy indicated the pain assessment flow sheet was to be initiated for residents who required pain management. The policy indicated after medications/interventions were implemented, the licensed nurse would re-evaluate the resident ' s level of pain within one hour. The policy further indicated the licensed nurse would administer pain medication as ordered and document medication administered on the medication administration record. The shift pain score would indicate the highest pain level that occurred on that shift if the pain was not relived with the current medication and the licensed nurse would notify the attending physician, in addition the interdisciplinary team would review the resident ' s pain.

Based on interview and record review, the facility failed to provide adequate supervision and reduce the risk of accident hazards for one of one sampled resident (Resident 1) while out on pass (OOP) by failing to: 1. Ensure Resident 1 was assessed prior to leaving the facility to go out on pass in accordance with the facility's Out on Pass policy 2. Ensure the Attending Physician's order included whether Resident 1 should be accompanied by a responsible person while out on pass or may leave the facility unaccompanied. 3. Ensure Resident 1 was always accompanied when going OOP per policy 4. Ensure Resident 1 went OOP for therapeutic purposes only per policy As a result, Resident 1 was beaten and robbed, and sustained a facial laceration and a left orbital fracture which required Resident 1 be transferred to a general acute care hospital (GACH) where he underwent surgery to repair his eye injuries. Findings: During a review of Resident 1's admission record, the admission record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included diabetes (disease that affects how the body uses blood sugar), post-traumatic stress disorder (disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event), muscle weakness and difficulty in walking. During a review of Resident 1's physician orders dated 7/8/2021, the orders indicated Resident 1 required skilled nursing care. During a review of Resident 1's Fall Risk assessment dated [DATE], Resident 1 was assessed as having a high risk for falls. During a review of Resident 1's Minimum Data Set (MDS), a comprehensive standardized assessment and care-screening tool, dated 7/12/2021, indicated Resident 1 required supervision for bed mobility (how resident moves to and from lying position, turns side to side), locomotion (how resident moves between locations), and eating, and required limited assistance (resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight bearing assistance) for transfers (how resident moves between surfaces including to or from bed chair, standing position), dressing, toilet use and personal hygiene and required extensive assistance (resident involved in activity; staff provide weight-bearing support) for walking. The MDS further indicated Resident 1 was not steady, but able to stabilize without staff assistance, had an impairment on one side of his lower extremity and normally used a cane/crutch for mobility. During a review of Resident 1's plan of care dated 7/9/2021, Resident 1 was At risk for falls d/t limited mobility, lack of awareness, unsteady gait, and impulsive behavior. The care plan interventions included to provide an environment that supports minimized hazards over which the facility has control. During a review of the physician's order dated 7/19/21, Resident 1 could go out on pass (OOP) as long as he had a telephone and for four hours only. During a review of the Out on Pass Log, dated 7/23/21, indicated Resident 1 had signed out of the facility at 3 p.m., with an expected time to return of 6 p.m. The log noted Resident 1 returned to the facility on [DATE] at 7:20 a.m. During a review of Resident 1's Situation Background Assessment and Recommendation (SBAR) note dated 7/24/2021 at 7:00 p.m., the SBAR indicated Resident 1 returned from being out on pass and stated he had been beaten up and robbed. The SBAR indicated Resident 1 left the facility at 4:00 p.m. and was expected to return to the facility at 7:00 p.m. However, Resident 1 did not return to the facility, as expected. The SBAR further indicated Resident 1 called the facility at 11:00 p.m. and said he had been beaten and robbed, which resulted in a left swollen bleeding eye. At around 7:00 a.m. Resident 1 returned to the facility and was ambulatory with a swollen discolored left eye which had two steri-strips (thin adhesive bandage) below his lower eyelid. During a review of Resident 1's general acute care hospital GACH emergency room records dated 7/24/2021, the records indicated the resident was brought in by paramedics after an assault by an unknown assailant in the eye and Resident 1 had extensive soft tissue (type of cells that work together to connect and support surrounding structures) swelling around the left eye, ecchymosis (bruising), and a laceration beneath the left eye. A computed tomography ([CT scan] a medical imaging technique that uses a computer to process multiple x-rays from different angles) of the facial bones was obtained, which indicated the resident had an acute (sudden onset) blowout fracture (a break of one or more of the bones that surround the eye) of the left orbit. According to the acute hospital 1 (AC1) emergency room record, Resident 1 was discharged from the acute hospital on 7/24/2021, to return to the facility. According to the progress notes dated 7/24/21 at 4:35 p.m., Resident 1 came back to the facility at 7:20 a.m. The physician was made aware at 8 a.m. and gave orders to transfer Resident 1 to acute hospital 2 (AC2) for further evaluation and treatment. On 7/24/21, Resident 1 was seen and evaluated at acute Hospital 2 (AC2) for [MEDICATION(S)] trauma to his face from two days ago. A computerized Tomography without contrast was done on 7/24/21. The impression indicated Resident 1 had an approximately 8 mm inferiorly depressed blowout fracture of the floor without entrapment of the extraocular muscles and a 2 mm medially displaced blowout fracture of the medial wall of the left orbit and a hematoma of the left cheek. During a review of the facility's in-house investigation report, Resident 1 returned to the facility on [DATE] at 9:30 a.m. with an order for Ophthalmologist re-evaluation in three to five days. With a plan of care to call the clinic to schedule an ophthalmology consult and follow-up. On 8/4/2021, Resident 1 was seen by the Ophthalmologist (a specialist in the branch of medicine concerned with the study and treatment of disorders and diseases of the eye) for follow-up for his orbital fracture (when there is a break in one of the bones surrounding the eyeball (called the orbit, or eye socket). Usually, this kind of injury is caused by [MEDICATION(S)] force trauma when something hits the eye very hard) and reported occasional double vision and occasional pain. The Ophthalmologist recommend repair of the left orbital floor fracture with implant conjunctivoplasty (eye surgery to repair a defect), and canthoplasty (an eyelid surgery). On 8/20/21, Resident 1 underwent surgery as recommend by the Ophthalmologist. During a review of the Operative Report dated 8/20/2021, Resident 1 underwent a left eye open treatment of the orbital blowout fracture with an implant (device or tissue placed in the body), left eye forced ductions (test of eye muscle function) and left eye conjunctivoplasty. During an interview on 12/6/2021 at 4:53 p.m. with Certified Nurse Assistant (CNA 1), CNA 1 stated she worked from 3:00-11:00 p.m. on 7/23/2021 and saw Resident 1 leaving the facility, but he did not return by the end of her shift. CNA 1 stated Resident 1 had gone OOP ([OOP] temporary permission of a resident to leave the facility at a specified time) before by himself using a bus, taxi, or Uber. During an interview on 12/7/2021 at 2:29 p.m. with Licensed Vocational Nurse (LVN 1), LVN 1 stated Resident 1 was not in the facility when he started his shift. Resident 1 called the facility stating someone had hit him and he needed a ride back to the facility. LVN 1 stated the Administrator (ADM) arranged for transportation, but Resident 1 kept missing it. LVN 1 stated the resident had gone out on pass during his shift and would leave the facility by himself. LVN 1 stated staff did not have time to verify who the resident was going out with most of the time. LVN 1 stated an assessment which includes vitals check needed to be completed before a resident goes OOP and this is to be documented in the nurse notes, but sometimes this was not done for the resident. During an interview and concurrent record review on 12/7/2021 at 4:34 p.m. with the Director of Nursing (DON), the DON stated the physician's order dated 7/19/2021, indicated Resident 1 may go OOP for four (4) hours. The DON stated the physician's order did not specify whether the resident could go unaccompanied. The DON stated the OOP log indicated the resident had gone OOP by himself to the bank on 7/21/2021, CV Estate/Hospital on 7/22/2021 and RCS bank on 7/23/2021. The DON stated the resident also went to visit his son and wife on 7/23/2021, while OOP and there was no documentation that the resident was assessed prior to leaving the facility. During a review of the facility's Policy and Procedure (P/P), last revised on 1/11/2016 titled, Out on Pass the P/P indicated the Attending Physician's order should include whether the resident should be accompanied by a responsible person while out on pass or may leave the facility unaccompanied. In the absence of a specific order that indicates the resident may go out on pass unaccompanied, the resident must be accompanied by a responsible person. The P&P also indicated If the resident is receiving skilled service, the resident may go out on pass for a therapeutic purpose only. The Therapeutic reason and benefit to the resident must be documented in the clinical record. Prior to the resident leaving on pass, a Licensed Nurse will assess the resident's physical and mental status to ensure that the resident and responsible person has been instructed of any special needs of the resident during the pass and the resident is provided with required assistive devices (walker, wheelchair, cane)

Based on observation, interview and record review, the facility failed to ensure one of 39 sampled resident (Resident 1), who were at high-risk for falls, was free from physical restraints (physical or mechanical device, material or equipment which restricts freedom of movement or access to one's body) when a certified nurse assistant (CNA 1) used a bedsheet to restrain Resident 1 to the wheelchair (WC) to prevent Resident 1's recurrent falls. This deficient practice resulted in the restriction of Resident 1's movement and violated Resident 1's right to be free from physical restraints, with a potential for emotional distress, humiliation, embarrassment, and injury and death when attempting to free himself from the restraint. On 7/7/2021 at 2:11 p.m., the Administrator (ADM), the Interim Director of Nursing (IDON) and the Regional Quality Measure Consultant (RQMC), were notified 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) situation was called for the facility's inability to protect Resident 1 from being physically restrained. The facility's ADM, DON and RQMC were notified of the immediacy and seriousness of the residents' health and safety being threatened. On 7/9/2021 at 1:59 p.m., the ADM, the IDON and RQMC submitted an acceptable Plan of Action (POA) and the IJ situation was removed after verifying and confirming on-site the implementation of the POA which included: 1. On 7/7/2021, Resident 1's fall risk assessment was completed by the Director of Nursing (DON) and the plan of care for fall prevention was updated to include one-on-one (1:1, one staff to one resident) supervision, a physical therapy (PT, focuses on improving a resident's ability to perform a movement of the body) and occupational therapist (OT, focuses on improving a resident's ability to perform activities of daily living) evaluation, a medical regimen reviewed, and the implementation of activities (sensory stimulation, morning exercises, daily walks, movie watching, daily visits by RP and music therapy) to enhance mobility. 2. On 7/7/2021, Resident 1 was immediately provided with 1:1 staff supervision to ensure Resident 1's safety until further physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The interdisciplinary team (IDT, a group of health care professionals with various areas of expertise who work together toward the goals of their residents) will continually monitor Resident 1's progress with therapeutic exercises, gait training, behavior management and wheelchair management to provide adequate and safe interventions for the resident quarterly. 3. On 7/7/2021, the IDT (DON, DOR, Charge nurse, certified nurse assistants (CNA), Social Services Director [SSD] and Activities Director [AD]) reviewed Resident 1's Fall Prevention Plan and new interventions were implemented, and care plan was updated with new interventions. 4. On 7/7/2021, the Pharmacist completed a medication regimen review (MMR). The pharmacists recommendations were communicated to the Primary Physician, Psychiatrist and the responsible party. 5. On 7/7/2021, the DOR re-evaluated Resident 1 and discussed recommendations with the responsible party. Resident 1 was evaluated for the use of a merry walker (a walker/chair combination that encourages a resident who would normally be placed in a wheelchair to get up and walk independently. A seat directly behind the resident is handy when the resident feels unsteady or tired) and close supervision advised until the assistive device is available. 6. On 7/7/2021, the DON/licensed nurses reviewed the Fall Risk Assessments of 87 residents. 39 residents were identified to be at high-risk for falling. A fall prevention plan of care was implemented to ensure adequate supervision and to ensure safety of residents in accordance with the 39 residents' risk assessments. A star will be posted on each room for residents that are identified as high-risk for falls. 7. On 7/7/2021, the DOR re-evaluated the 39 residents identified as high fall risk for additional recommendations and measures to prevent fall incidents. 8. On 7/7/2021, the ADM, the SSD, and the AD conducted interviews of the 71 residents who could be interviewed and assessed 17 residents who could not be interviewed to ensure that residents were not restrained inappropriately. 9. On 7/7/2021, the DON and the Assistant Director of Nursing (ADON) reviewed fall incidents for the past 30 days for the completion of fall risk assessment, development and implementation of care plans with meaningful interventions to prevent recurrent falls, and rehabilitation screening and evaluations. 10. On 7/7/2021, the DON and ADON initiated re-education to all staff and the IDT team on the Policy and Procedures (P/P) for fall management, abuse prevention, and physical restraints. 11. On 7/7/2021, the medical records staff was provided with one-on-one in-service by the DON on the policy and procedures for fall management, abuse prevention, and restraints. 12. Upon admission to the facility, a Licensed Nurse and/or the IDT will complete the Physical Restraint/Device Assessment (NP-115-Form A-Physical Restraint/Device Assessment) to ensure all restraints are used properly and only when necessary. 13. All residents will be reassessed by the licensed nurse and update the fall risk evaluation and update the plan of care as necessary after each fall. The IDT will review and update the resident's fall risk status and care plan at the following intervals: on admission, quarterly, annually, upon identification of a significant change of condition and post-fall. 14. During daily shift huddles, the registered nurse (RN) supervisor and charge nurse will discuss and review the list of residents that are high risk for fall, any new fall incidents, any new fall interventions for identified high risk residents and any change of condition that places a resident at risk for fall. The RN supervisor and charge nurse will ensure that preventive interventions are in place. 15. During morning stand-up meeting (short meeting to discuss daily tasks) and clinical meetings from Monday through Friday, the IDT will review residents who are new admissions, new fall incidents, abuse incidents including those that have been reported to have been physically restrained inappropriately to ensure accurate assessments and care plans and to ensure no residents are restrained inappropriately. 16. The ADM and DON will present the results of the Fall, Abuse or Physical Restraints reviews and findings to the QAPI committee for review and recommendations weekly for 1 month then monthly for three (3) months or until substantial compliance is achieved. Completion date: 7/9/2021 Cross reference F689. Findings: During a review of Resident 1's admission record, the admission record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 1's Minimum Data Set (MDS), a standardized care screening and assessment tool, dated 6/2/2021, the MDS indicated Resident 1 usually understands or was understood. The MDS indicated Resident 1 required extensive assistance with one-person physical assistance for bed mobility, transfer, eating, and personal hygiene. The MDS indicated Resident 1 did not use trunk restraints while in bed, chair or out of bed. During a review of Resident 1's psychologist (a person who studies normal and abnormal mental states) note, dated 6/19/2021, the note indicated Resident 1 was restrained physically in his wheelchair by his caregiver, Resident 1 suffered three falls in one day, caregiver or CNA 1 prevented Resident 1 for further falls by tying Resident 1 onto his wheelchair. During an interview on 7/2/2021 at 2:05 p.m., the Activity Assistant (Act Asst), Resident 1's 1:1 staff, stated on 6/17/2021 at around 8:00 a.m., Act Asst observed Resident 1 restrained to the WC with a bedsheet. The bedsheet was wrapped around Resident 1's body and tied to the WC. Act Asst immediately informed a licensed vocation nurse (LVN 1), who began investigating the situation. Act Asst stated LVN 1 interviewed two CNAs (CNA 1 and 2) regarding Resident 1's physical restraints. Act Asst stated CNA 2, Resident 1's day-shift CNA, received Resident 1 from CNA 1, Resident 1's night-shift CNA, already restrained. Act Asst stated CNA 1 denied restraining Resident 1 to the WC with a bedsheet. Act Asst stated she reported immediately to the charge nurse because it was Not right, (Resident 1) was tied like an animal in the wheelchair using a bedsheet. During an interview on 7/2/2021 at 3:14 p.m. with RN 1, RN 1 stated she not aware that Resident 1 was restrained to the WC since he was on 1:1 supervision. RN 1 stated Resident 1 was not supposed to be physically restrained. RN 1 stated she observed Resident 1's physical restraints on the facility's surveillance footage. During an interview on 7/2/2021 at 3:50 p.m., with RN 1. RN 1 stated applying anything that restricts movement to any resident in the facility was considered a restraint. RN 1 stated the bedsheet wrap around Resident 1 was considered a restraint and the resident should have not been on restraints since the facility was a restraint-free facility. RN 1 stated a consent and physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The IDT must also develop and implement a care plan addressing the physical restraints. RN 1 confirmed that a consent and physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . RN 1 confirmed the IDT did not care plan the physical restraints. During an interview and concurrent record review of the medical record on 7/2/2021 at 4:55 p.m. with the (IDON), the IDON stated Resident 1's restraint incident occurred on 6/17/2021. The IDON stated Resident 1's body being tied to the wheelchair with a bedsheet was considered a physical restraint. The IDON stated prior to the use of physical restraints a consent and physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The IDON confirmed there was no documented evidence Resident 1 had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During a record review of Resident 1's Situation, Background, Assessment and Recommendation ([SBAR] an internal communication form), dated 6/17/2021 and timed at 7:45 p.m., the SBAR indicated at 7:30 a.m., Resident 1 was up on his wheelchair in front of the nurses' station with a one-to-one staff. Resident 1 was found with a white sheet around his waist tied at the back of the wheelchair while the sitter was having a break. The white sheet was removed by charge nurse. During an interview on 7/7/2021 at 3:52 a.m. with LVN 2, LVN 2 stated Resident 1 was placed on a 1:1 because he was confused and attempted to get up. LVN 2 stated a flat sheet or bedsheet used to tie a resident to the WC was not acceptable because it was considered a restraint. During an interview on 7/7/2021 at 6:30 a.m. with the ADM, the ADM stated during his investigation he confirmed Resident 1 was restrained on his wheelchair using a bedsheet. The ADM stated CNA 1 applied the restraint on Resident 1. The ADM stated after the review of the facility's video surveillance, it was observed that Resident 1 was by the nursing station and a white sheet was observed hanging from the side of Resident 1's wheelchair. The ADM further stated CNA 1 restrained Resident 1 with a bedsheet, which was an old practice and inexcusable kind of restraint. During an interview on 7/7/2021 at 7:05 a.m. with the ADON, the ADON stated the usual process for restraining a resident was to obtain a consent, physician order, physical assessment to see if the resident needs the restraints. The ADON confirmed there was no documented evidence Resident 1 had a consent, physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The ADON stated CNA 1 restrained Resident 1 to prevent recurrent falls. During an interview on 7/7/2021 at 8:11 a.m. with LVN 1, LVN 1 stated, on 6/17/2021, Resident 1 was tied with a bedsheet with a knot to Resident 1's WC. LVN 1 stated she removed the restraints from Resident 1. During a review of facility's surveillance video camera in the presence of the Medical Records Director (MRD) on 7/7/2021 at 8:52 a.m., the video showed Resident 1 was being wheeled by CNA 2 in the hallway and a white sheet tied around Resident 1's body and wheelchair. During an interview on 7/7/2021 at 3:30 a.m. with Resident 2, Resident 2 stated he remembered (date unknown) Resident 1 was in the hallway early morning with a blue blanket on him that fell to the floor. Resident 2 stated he picked the blanket up and was trying to tuck it around Resident 1's body. Resident 2 noticed Resident 1 was tied up with a white sheet wrapped around his body and tied wheelchair. Resident 2 stated Resident 1 was asking for help to be put back to bed, but no one was available. Resident 2 stated he attempted to help Resident 1, but the resident was restrained. During a review of Resident 2's undated admission record, the admission record indicated Resident 2 was admitted to the facility on [DATE]. Resident 2's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 was able to understand others and was understood by others. During a review of Policy and Procedure (P/P) titled, Restraints, revised 1/1/2012, indicated physical restraint meant the use of a manual hold to restrict freedom of movement of all or part of a resident's body, or to restrict normal access to the person's body, and were used as behavioral restraint. Physical restraint did not include briefly holding a resident without undue force to calm or comfort. Acceptable forms of physical restraint are cloth vest, soft ties, soft cloth mittens, seat belts and trays with spring release devices. Unless otherwise specified by the Attending physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . When a physical restraint was used, the licensed nurse would document the following information in the resident's care plan: a. The medical symptoms requiring the use of restraints. b. The treatment team's goals in using the restraint. c. Systematic and gradual approaches for minimizing or eliminating the concerning behavior and restraint use. d. The type and time of restraint use. e. The nurse's approach to using the restraint including frequent observation and release every two hours for toileting and or repositioning and checking the condition of skin and impaired circulation if indicated. The P/P further indicated that the facility honors the resident's right to be free from any restraints that are imposed for reasons other than that of treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on interview and record review, the facility failed to prevent recurrent falls for one of 39 residents (Resident 1), by failing to: 1. Complete an incident report after each fall. 2. Complete an SBAR (Situation, Background, Assessment and Recommendation (SBAR, a communication tool) to document a change of condition after a fall. 3. Complete a post-fall risk assessment after each fall. 4. Notify the physician after each fall. 5. Notify all other staff of the fall with a post-fall huddle after each fall. 6. Update the care plan in accordance with interdisciplinary team (IDT, a group of health care professionals with various areas of expertise who works together towards goals for better care of Residents) recommendations with useful interventions after each fall. This deficient practice resulted in Resident 1's falls and transfer to the general acute care hospital (GACH), a swollen right shoulder and ankle, and skin abrasions, with the potential for pain, decline in mental well-being, fractures, and death. On 7/7/2021 at 2:11 p.m., the Administrator (ADM), the Interim Director of Nursing (IDON) and the Regional Quality Measure Consultant (RQMC), were notified 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) situation was called for the facility's inability to protect Resident 1 from being physically restrained to prevent recurrent falls. The facility's ADM, IDON and RQMC were notified of the immediacy and seriousness of the residents' health and safety being threatened. On 7/9/2021 at 1:59 p.m., the ADM, the IDON and RQMC submitted an acceptable Plan of Action (POA) and the IJ situation was removed after verifying onsite observations, interview, and record review the implementation of the POA which included: 1. On 7/7/2021, Resident 1's fall risk assessment was completed by the Director of Nursing (DON) and the plan of care for fall prevention was updated to include one-on-one (1:1, one staff to one resident) supervision, a physical therapy (PT, focuses on improving a resident's ability to perform a movement of the body) and occupational therapist (OT, focuses on improving a resident's ability to perform activities of daily living) evaluation, a medical regimen reviewed, and the implementation of activities (sensory stimulation, morning exercises, daily walks, movie watching, daily visits by RP and music therapy) to enhance mobility. 2. On 7/7/2021, Resident 1 was immediately provided with 1:1 staff supervision to ensure Resident 1's safety until further physician orders were obtained. Resident 1's ability to transfer and to safely ambulate will be continually evaluated by the Director of Rehabilitation (DOR) weekly. The interdisciplinary team (IDT, a group of health care professionals with various areas of expertise who work together toward the goals of their residents) will continually monitor Resident 1's progress with therapeutic exercises, gait training, behavior management and wheelchair management to provide adequate and safe interventions for the resident quarterly. 3. On 7/7/2021, the IDT (DON, DOR, Charge nurse, certified nurse assistants (CNA), Social Services Director [SSD] and Activities Director [AD]) reviewed Resident 1's Fall Prevention Plan and new interventions were implemented, and care plan was updated with new interventions. 4. On 7/7/2021, the Pharmacist completed a medication regimen review (MMR). The pharmacist's recommendations were communicated to the Primary Physician, Psychiatrist, and the responsible party. 5. On 7/7/2021, the DOR re-evaluated Resident 1 and discussed recommendations with the responsible party. Resident 1 was evaluated for the use of a merry walker (a walker/chair combination that encourages a resident who would normally be placed in a wheelchair to get up and walk independently. A seat directly behind the resident is handy when the resident feels unsteady or tired) and close supervision advised until the assistive device is available. 6. On 7/7/2021, the DON/licensed nurses reviewed the Fall Risk Assessments of 87 residents. 39 residents were identified to be at high-risk for falling. A fall prevention plan of care was implemented to ensure adequate supervision and to ensure safety of residents in accordance with the 39 residents' risk assessments. A star will be posted on each room for residents that are identified as high-risk for falls. 7. On 7/7/2021, the DOR re-evaluated the 39 residents identified as high fall risk for additional recommendations and measures to prevent fall incidents. 8. On 7/7/2021, the ADM, the SSD, and the AD conducted interviews of the 71 residents who could be interviewed and assessed 17 residents who could not be interviewed to ensure that residents were not restrained inappropriately. 9. On 7/7/2021, the DON and the Assistant Director of Nursing (ADON) reviewed fall incidents for the past 30 days for the completion of fall risk assessment, development, and implementation of care plans with meaningful interventions to prevent recurrent falls, and rehabilitation screening and evaluations. 10. On 7/7/2021, the DON and ADON initiated re-education to all staff and the IDT team on the Policy and Procedures (P/P) for fall management, abuse prevention, and physical restraints. 11. On 7/7/2021, the medical records staff was provided with one-on-one in-service by the DON on the policy and procedures for fall management, abuse prevention, and restraints. 12. Upon admission to the facility, a Licensed Nurse and/or the IDT will complete the Physical Restraint/Device Assessment (NP-115-Form A-Physical Restraint/Device Assessment) to ensure all restraints are used properly and only when necessary. 13. All residents will be reassessed by the licensed nurse and update the fall risk evaluation and update the plan of care as necessary after each fall. The IDT will review and update the resident's fall risk status and care plan at the following intervals: on admission, quarterly, annually, upon identification of a significant change of condition and post-fall. 14. During daily shift huddles, the registered nurse (RN) supervisor and charge nurse will discuss and review the list of residents that are high risk for fall, any new fall incidents, any new fall interventions for identified high risk residents and any change of condition that places a resident at risk for fall. The RN supervisor and charge nurse will ensure that preventive interventions are in place. 15. During morning stand-up meeting (short meeting to discuss daily tasks) and clinical meetings from Monday through Friday, the IDT will review residents who are new admissions, new fall incidents, abuse incidents including those that have been reported to have been physically restrained inappropriately to ensure accurate assessments and care plans and to ensure no residents are restrained inappropriately. 16. The ADM and DON will present the results of the Fall, Abuse or Physical Restraints reviews and findings to the Quality Assurance/Performance Improvement (QAPI, programs are critical to improving the quality of life, and quality of care and services) committee for review and recommendations weekly for 1 month then monthly for three (3) months or until substantial compliance is achieved. Completion date: 7/9/2021 Cross-reference F604. Findings: During a review of Resident 1's admission record, the admission record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnoses included major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest) muscle weakness, unspecified lack of coordination, and long-term use of anticoagulants (medicines to help prevent blood clot). During a review of Resident 1's Minimum Data Set (MDS), a standardized care screening and assessment tool, dated 6/2/2021, the MDS indicated Resident 1 usually understands or was understood. The MDS indicated Resident 1 required extensive assistance with one-person physical assistance for bed mobility, transfer, eating, and personal hygiene. The MDS also indicated Resident 1 has had several falls in the last 2 to 6 months. During a review of the Morse Fall Risk Assessment (a tool use to assess a resident's risk for falls), dated 5/29/21, the Morse Fall Risk Assessment indicated Resident 1 had fall risk score of 65. The Morse Fall Risk Assessment further indicated that Resident 1 is at high-risk for falls and to implement high-risk fall interventions. During a review of the Morse Fall Risk Assessment, dated 6/7/21, the Morse Fall Risk Assessment indicated Resident 1 had fall risk score of 80. The Morse Fall Risk Assessment further indicated that Resident 1 is at high-risk for falls and to implement high-risk fall interventions. During a review of the Morse Fall Risk Assessment, dated 6/11/21, the Morse Fall Risk Assessment indicated Resident 1 had fall risk score of 50 [sic]. The Morse Fall Risk Assessment further indicated that Resident 1 is at high-risk for falls and to implement high-risk fall interventions. During a review of nurse's notes on 6/07/2021, the nurse's note indicated at around 12:30 a.m., Resident 1 was found on floor next to a (resident's room) with a swollen right shoulder and ankle. During a review of nurse's notes dated 6/11/2021 at 11:25 pm, the nurse's note indicated that Resident 1 slipped from his wheelchair. During a review of nurse's notes dated 6/16/2021, the nurse's note indicated Resident 1 fell out of his wheelchair. During a review of resident 1's care plan descriptions, the care plans indicated the following: a. On 5/30/21 the resident fell and was sent to the acute care hospital for treatment. b. On 6/7/21 the resident had an unwitnessed fall with no visible injuries. c. On 6/11/21 the roommate notified nursing that the resident fell from his wheelchair with no visible injuries. d. On 6/16/21 the resident fell off the toilet and sustained skin abrasions. During a review of Resident 1's psychologist notes dated 6/19/2021 indicated according to staff, Resident 1 was restrained physically in his wheelchair by his caregiver. The resident suffered three falls in one day (no dates were noted). The report further disclosed CNA 1 prevented Resident 1 from further falls by tying Resident 1 onto his wheelchair. During an interview on 7/2/2021 at 2:05 p.m., the Activity Assistant (Act Asst), Resident 1's 1:1 staff, stated on 6/17/2021 at around 8:00 a.m., Act Asst observed Resident 1 restrained to the WC with a bedsheet. The Act Asst stated Resident 1 was physically restrained due to recurrent falls. During an interview on 7/2/2021 at 3:14 p.m. with RN 1, RN 1 stated Resident 1 had fallen three (3) or four (4) times. During an interview on 7/2/2021 at 3:55 p.m. with the IDON, the IDON stated that falls are an unusual occurrence. The DON stated after each fall, the charge nurse must complete an incident report, complete an SBAR to document a change of condition, complete a post-fall risk assessment, notify the responsible party, notify the physician, notify all other staff of the fall with a post-fall huddle, and update the care plan in accordance with IDT recommendations with useful interventions. The IDON confirmed that there is no documented evidence that an incident, SBAR, notification of responsible party, notification of physician, notification of the fall with a post-fall huddle, and an update to the care plans in accordance with the IDT recommendations with useful interventions was completed for the after the falls occurring on 5/30/2021, 6/7/2021, 6/11/2021, and 6/16/2021. The IDON confirmed there was no documented evidence a fall-risk assessment was completed after the falls occurring on 5/30/2021 and 6/16/2021. During an interview and a concurrent record review of Resident 1's medical record on 7/2/2021 at 4:00 p.m. with the DON, the DON stated Resident 1 had fallen 4 times. The DON stated only three incident reports were written for the falls occurring on 6/7/2021, 6/11/2021 and 6/16/2021. The DON stated Resident 1 fell on [DATE], but the charge nurse did not write an incident report but should have written one. During an interview on 7/7/2021 at 11:26 am with the DOR, the DOR said post-fall evaluations were not done for Resident 1 after each fall. The DOR stated there is no documented evidence the facility completed a post-fall evaluation for Resident 1 for the falls occurring on 5/30/2021, 6/7/2021, 6/11/2021, and 6/16/2021. A review of the policy and procedure (P/P) titled Fall Management Program, revised 3/13/2021, the (P/P) indicated the facility will implement a fall management program that supports providing an environment free from fall hazards. A. As part of the admission assessment, the licensed nurse will complete a fall risk evaluation. If a fall risk is identified, document interventions on the resident's care plan. Document interventions for every resident regardless of fall risk evaluation score. B. A licensed nurse will conduct a new fall risk evaluation quarterly, annually, upon identification of a significant change of condition, post fall and as needed. C. The IDT and/or Licensed Nurse will develop a care plan according to the identified risk factor and root cause per Care Area Assessment guideline. Post Fall Response: A. Following every resident fall, the licensed nurse will perform a post fall evaluation and update, initiate, or revise the Resident's care plan as necessary B. For an unwitnessed fall with suspected or known head injury, the license nurse will complete neurological checks for 72 hours following the fall incident. Post Fall Huddle: A. Within 15- 20 minutes after a fall, the licensed nurse will initiate a Post-fall Huddle as part of the facility's internal quality assurance (QA) process.

Based on observation, interview, and record review, the facility failed to maintain an emergency electrical power system that would supply power adequate at least for lighting to all entrances and exits; equipment to maintain the fire detection, alarm, and extinguishing systems; and life support systems in the event the normal electrical supply is interrupted. At the time of the observation, the facility census was 91 and a licensed capacity of 99 beds. Findings: On January 12, 2017 at 9:00 a.m., a review of Los Angeles Fire Department Fire Protection Equipment Performance Report Emergency Power Generator Test documentation dated December 12, 2016 revealed, System Defects Found. Additional documentation identified the following defects: 1. Transfer time to secondary power is within 10 seconds of primary power loss. 2. Standby power up and operation within 60 seconds. 3. All Life Safety systems continued to operate properly for the duration of the test. 4. Generator ran a minimum of 30 minutes. A review of the documentation dated January 4, 2016, indicated repairs to the generator had been conducted. On January 12, 2017, at 9:15 a.m. a review of this documentation revealed, The generator may not carry a load for an extended amount of time. The facility may need a temporary generator to ensure proper emergency coverage. A telephone interview was conducted with the facility administrator on January 12, 2017 at 10:00 a.m., and the evaluator informed the administrator of concerns regarding the generator repair documentation dated January 4, 2016, which indicated the generator may not carry a load for extended amount of time and a temporary generator would need to be installed to ensure proper emergency coverage. The administrator informed the evaluator a new generator would need to be purchased. On January 12, 2017 at 2:00 p.m., an investigation was conducted and the evaluator requested to speak with the facility administrator and was informed the administrator was not in the facility. The evaluator met with the facility's Director of Nurses' (DON) and informed the DON the facility's failure to ensure and maintain an alternate source of power separate and independent from the normal source established a concern that raises to a Severity Level 4 and an Immediate Jeopardy to the health and safety of residents now exists. Due to the facility's failure to ensure and maintain an alternate source of power separate and independent from the normal source that will be effective for a minimum of 1 ½ hours after loss of the normal source (NFPA 99 3-6), an Immediate Jeopardy was called on January 12, 2017 at 2:00 p.m., with the facility's Director of Nurses'. The evaluator was informed by the DON the facility would now initiate Fire Watch Policies and Procedures. The DON contacted the administrator by telephone and informed the administrator in the presents of the evaluator. The evaluator was directed to the telephone and informed the administrator of the Department's concern and the urgency of Severity Level 4 and the established Immediate Jeopardy to the health and safety of residents. The administrator informed the evaluator that a temporary generator would be acquired as soon as possible and that Fire Watch Policies and Procedures would be continued until a temporary generator is installed. On January 13, 2017, a revisit investigation was conducted and a temporary generator had been installed. The temporary generator was tested for 30 minutes under load and was found to supply power adequate at least for lighting all entrances, exits and equipment to maintain the fire detection, alarm, and extinguishing systems; and life support systems in the event the normal electrical supply is interrupted. As a result, the Immediate Jeopardy was abated.

Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1) was not verbally abused by CNA 1, who cursed at him and called him a Son of a [***] for putting on his call light for assistance to the bathroom. This deficient practice resulted in Resident 1 crying, feeling fearful to ask for assistance, and very bad about the whole situation. Findings: On August 31, 2016 a complaint investigation was initiated regarding a Certified Nurse Assistance (CNA 1) calling Resident 1 Hijo de Puta (son of a [***] ). As a result, the resident was scared to ask for assistance and on August 29, 2016, during the early morning the resident had a fall because he was afraid to ask the staff for help. During an interview on August 31, 2016 at 3:20 p.m., Resident 1 stated on August 28, 2016, he used the bathroom several times because he was having diarrhea (a condition in which feces are discharged from the bowels frequently and in a liquid form). The resident stated when he put on the call light for assistance, CNA 1 yelled hijo de la gran puta (son of a [***] ). CNA 1 told Resident 1 he was bothered, and very busy, and was not going to change him any more. The resident stated CNA 1 then put him back into the wheelchair. The resident stated when he needed to use the bathroom on August 29, 2016, again, he did not want to ask for help because he thought CNA 1 was going to get mad at him again. Resident 1 stated when he attempted to use the bathroom on his own without assistance, he leaned on the little table and his wheelchair, and fell . He further stated stated he sustained a cut on his eyebrow. According to the resident, after the incident CNA 1 asked why he didn't put on the call light for assistance. Resident 1 replied, because you got mad at me. Resident 1 stated CNA 1 made him feel very bad which made him cry. A review of Resident 1's admission record indicated the resident was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A review of the care plan dated April 14, 2016, for requiring extensive assistance with toileting included to assist with toileting needs. The care plan for potential injury related to fall risk as evidenced by presence of fall risk factors indicated to remind/encourage the resident to call for assistance when needed. A review of the Minimum Data Set (MDS, a standardized assessment and care screening tool), dated June 8, 2016, indicated Resident 1 had a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident was cognitively intact, and needed extensive assistance from staff for bed mobility, transfers, walking, dressing, and toilet use. During an interview with the Director of Nursing on August 31, 2016 at 4:00 p.m., during an interview with the Activity Director she sated no one had complained to her about CNA 1 or about the call lights not being answered at night. On August 31, 2016 at 4:05 p.m., the Director of Nursing (DON) stated she was not aware of any complaints regarding CNA 1 or staff not answering call lights. On August 31, 2016, at 4:15 p.m., the administrator stated the facility investigated the incident between CNA 1 and Resident 1. A review of the facility's CNA Report of Misconduct report (CNA Certification Board, license and certification section), dated August 29, 2016, indicated on August 28, 2016 during the 11 p.m. to 7 a.m. shift Resident 1 placed his call light on to obtain assistance to go the restroom and when CNA 1 entered his room, the CNA 1 yelled at the Resident 1 and called him a son of a [***] . As a result, the resident stated he was scared to ask for further assistance. On August 29, 2016, during the 11 p.m. to 7 a.m. shift Resident 1 was assigned the same CNA, and needed assistance but did not call because he was scared, which resulted in the resident attempting to go to the restroom without help and consequently, had a fall which resulted in an injury (Please specify what type of injury). A review of the facility's undated Abuse - Prevention Program indicates the facility does not condone any form of resident abuse, neglect and or mistreatment. Verbal Abuse is defined as any use of oral language that willfully includes disparaging and derogatory terms directed to the residents. Neglect is defined as failure to provide goods and services necessary to avoid physical harm or mental anguish. Mental abuse is defined as, but is not limited to humiliation, threats of punishment or withholding of treatment or services. CNA 1 was not available for an interview during the investigation; however, a review of the facility's Corrective Action Memo notes dated 8/29/16, indicated CNA 1 was suspended due to the allegation of verbal abuse and refused to sign the corrective action memo. A review of the facility's policy titled Call light - Answering, indicated the purpose of this policy is to meet the resident's needs and requests within an appropriate time frame. It is the only mechanism at the resident's beside where by residents are able to alert nursing personnel to their needs.

Based on observation, interview, and record review, the facility's nursing staff failed to promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality for two of four residents (3 and 4). Resident 4, who was assessed continent of both bowel and bladder functions, was placed on a diaper and was not changed promptly. Resident 3, who was determined by the Interdisciplinary Team to be provided trial toileting program, was not provided the service. The resident was placed on a diaper. This deficient practice also led to Residents 3 and 4 having to urinate in a diaper because the staff took too long (30-40 minutes) to provide assistance with toilet use. Resident 4 stated it really made her feel bad. Findings: 1. On April 28, 2011 at 10 a.m., a complaint investigation was conducted for an allegation regarding residents not having their diapers changed in a timely manner. On April 28, 2011, a review of Resident 4's clinical record indicated the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS), an assessment tool, dated April 20, 2011, indicated Resident 4 had good short and long term memory with no impairment in cognitive skills for daily decision making, able to understand or be understood. The resident required extensive assistance/ staff provides weight bearing assistance, with one person physical assistance for ambulation, dressing, hygiene, bathing, toilet. This MDS also indicated the resident was always incontinent (lacking control) of urine and bowel. The Nursing Admission Assessment, dated April 14, 2011, indicated Resident 4 was continent of bowel and bladder function. The Bowel and Bladder Assessment, dated April 14, 2011, indicated Resident 4 was always continent of bowel and bladder. The Bowel and Bladder Tracking Document was blank and the rest of the information was left blank. There was no documentation in the medical record the resident was monitored every 2 hours for voiding pattern. The Interdisciplinary Team Notes, dated April 20, 2011, indicated Resident 4 had requested that her call light be answered in a timely manner. On April 28, 2011 at 3:35 p.m., during an interview, Resident 4 stated, "I am wet and I need to be changed. I told a CNA (certified nurse assistant) and she said she would tell my nurse that was 10 minutes ago. I can feel when I have to go use the bathroom but by the time the nurse gets to me, it is too late. Sometimes you have to wait 30-40 minutes before a nurse comes." It was observed at 3:39 p.m., the resident put her call light on. Two minutes later, a CNA came in and said the nurse was coming. According to the resident, that was the same CNA she had told earlier. It was not until 4:20 p.m. (31 minutes later) did the CNA come in to change the resident's diaper. The resident further stated it really made her feel bad to have to use a diaper when all she needed was a little assistance to use the bathroom. On May 3, 2011 at 8:30 a.m., Resident 4 stated, "I wet the diaper one time and I wanted the diaper changed. The CNA showed the diaper to the central supply staff person. The central supply staff person told me to use the diaper 4 or 5 times because they are good diapers. I know when I have to go and I should not have to wear a diaper at all." On May 3, 2011 at 11 a.m., the director of nursing (DON) stated Resident 4 should have been assessed for bladder function and not have to wear diapers at all." 2. On April 28, 2011, a review of Resident 3's clinical record indicated the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS), an assessment tool, dated December 17, 2010, indicated Resident 3 had good short and long term memory with no impairment in cognitive skills for daily decision making, able to understand and be understood, required extensive assistance with one person physical assistance for ambulation, dressing, hygiene, bathing and toileting. This MDS also indicated the resident was frequently incontinent of urine and was continent of bowel. The Bowel and Bladder Assessment, dated September 22, 2010, December 28, 2010, and March 17, 2011, indicated Resident 3 was incontinent from 8 months to a year and was always incontinent of bowel and bladder (inconsistent with MDS). The Interdisciplinary Team Notes, dated September 22, 2010, indicated Resident 3 has been incontinent at home for 8 months to a year. The Interdisciplinary Team agreed to do a trial toileting program to maintain if not improve the current level of continence. There was no documentation of the trial toileting program that was conducted for Resident 3 in the clinical record. The care plan for incontinence, dated September 22, 2010, identified the resident was at risk for skin breakdown and urinary tract infection [MEDICAL CONDITION]. Interventions included to check the resident every 2 hours and prn (whenever necessary) for incontinence, however this was not done. On April 28, 2011 at 3 p.m., during an interview, Resident 3 stated, "I can feel when I have to go use the bathroom but by the time the nurse gets to me, it is too late. So, that is why I wear the diaper." Review of the facility's policy titled, "Bowel and Bladder Training Programs", revised May 2005, indicated it is the policy of the facility to restore resident's normal bowel and bladder function as much as possible. The purpose of Bowel and Bladder Training/Toileting Program is to ensure that a resident who is incontinent of bowel and/or bladder receives appropriate treatment and services to prevent urinary tract infection and to restore as much normal bowel and/or bladder function as possible in order to prevent skin breakdown/irritation, improve resident's morale, and restore resident's dignity and self-respect. The above policy indicated Bowel and Bladder Training Program uses a timed schedule for voiding/bowel movement based on resident's identified need and routine in order to regain control of bowel and bladder function. On May 3, 2011 at 11 a.m., the director of nursing (DON) stated the resident should have been on a bowel and bladder program.