Every finding on record at Eden Healthcare Center

Based on observation and interview, the facility failed to ensure resident's personal and medical information was communicated in a way that protects personal privacy and confidentiality for four out of four sampled residents (Resident 1, 2, 3, 4) when Resident 1's medical information, Resident 2's personal information, Resident 3 and Resident 4's first and last name were communicated via a group messaging system involving nursing staff's personal smart phone (a mobile phone that performs many of the functions of a computer, typically having a touchscreen and internet access).This failure resulted in violation of residents' right to a secure and confidential personal and medical information.During a phone interview on 5/28/26 at 10:31 a.m. with Registered Nurse (RN) 1, RN 1 stated some nurses participated in a group chat on their smart phones to communicate resident issues to the Director of Nursing (DON).During a concurrent observation and interview on 5/28/26 at 10:47 a.m. with the DON, the DON touched a green application with a figure of a handset of a telephone from her personal smart phone when questioned about the group chat. The DON stated the application was called WhatsApp. The DON stated the group chat was used by the nurses to communicate with each other regarding what is happening with the residents. The DON stated the process of ensuring resident's personal privacy and confidentiality were maintained during the use of the group chat by not disclosing resident's full names, by only including the resident's room number and only including the first two initials of the resident's first name and the first initial of the last name.During a follow up interview on 5/28/26 at 2:07 p.m. with the DON, the DON stated the facility had no policy and procedure on the use of WhatsApp. The DON stated the staff was already using the group chat when she started her role last October of 2025. The DON stated the Administrator (ADM) was aware of the application being used in the facility.During a concurrent observation and interview on 5/28/26 at 2:23 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 showed the WhatsApp application from her personal smart phone. LVN 1 stated the purpose of the group messaging system was to communicate significant changes with the residents among nurses.During a concurrent observation and interview on 5/29/26 at 9:35 a.m. with LVN 2, LVN 2 opened the WhatsApp application from her personal smart phone by touching the application when asked to show the process of communicating through the group chat. LVN 2 stated there was no username and password to log in to WhatsApp. LVN 2 stated Nursing was the name of the group chat. LVN 2 stated not indicating the resident's whole name in the group chat ensured resident's personal privacy and confidentiality.During an interview on 5/29/26 at 10:08 a.m. with the DON, the DON stated there was no staff in the facility who monitors staff compliance with ensuring the process of maintaining resident privacy and confidentiality was followed during the use of the group chat. The DON stated she had not encountered issues of staff not following the process. The DON stated expecting the staff to not disclose the resident's full names.During a concurrent observation and interview on 5/29/26 at 10:30 a.m. with the DON, a message from the Nursing group chat dated Fri, [DATE], edited at 21:23 showed the first four letters of a last name and the first three letters of a first name with only the fifth letter of the last name and fourth letter of the first name had an asterisk sign. The message also showed that the resident was under hospice care. The DON stated the name in the message was Resident 1's last and first name. The DON stated the message was sent by RN 2.During a concurrent observation and interview on 5/29/26 at 10:32 a.m. with the DON, a message from the Nursing group chat dated Fri, [DATE] at 1:48 p.m. showed the first three letters of a last name and the first three letters of a first name with only the fourth letter of the last name and fourth letter of the first name had an asterisk sign. The message also showed that the resident was conserved (a judge has appointed an individual or institution to manage the personal or financial affairs of someone who is deemed incapable of doing so themselves to make decisions on their behalf). The DON stated the name in the message was Resident 2's last and first name. The DON stated the message was sent by RN 2.During a concurrent observation and interview on 5/29/26 at 10:34 a.m. with the DON, a message from the Nursing group chat dated Fri, [DATE] at 6:55 a.m. showed two individual's first and last names. The message also showed that the two individual's names came back from the Acute Care Hospital (ACH). The DON stated the names in the message were Resident 3 and Resident 4.During an interview on 5/29/26 at 11:43 a.m. with the ADM, the ADM stated expecting the staff to follow the process of ensuring resident's personal privacy and confidentiality were maintained. The ADM stated the WhatsApp was not an official communication tool mandated by the facility. The ADM stated the official and more secure option for communication in the facility was Point Click Care (PCC).

Based on observation, interview and record review, the facility failed to ensure resident care item was cleaned and disinfected (objects treated with chemicals to kill germs, bacteria, and viruses, reducing the risk of infection) according to manufacturer's instructions for one of one sampled resident (Resident 1) when Resident 1's urine collection canister was not fully submerged in a dish soapy solution for cleaning and in 70% isopropyl alcohol (IPA) for disinfection for a minimum of ten minutes.This failure had the potential for Resident 1 to be exposed to infections.During a review of Resident 1's admission Record, dated 2/20/26, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with an admission diagnoses of chronic (a condition or disease that is persistent or otherwise long-lasting in its effects) systolic heart failure (a serious condition that occurs when the left chamber of the heart is unable to pump blood efficiently), acute myocardial infarction (a medical emergency that occurs when blood supply to the heart is blocked), type 2 diabetes mellitus (a chronic condition where the body develops resistance to insulin, a vital hormone produced by the pancreas that regulates blood sugar, causing high blood sugar levels because cells fail to respond to insulin properly).During a record review of Resident 1's Minimum Data Set (MDS, an assessment used to guide plan of care) dated 1/5/26, the MDS indicated Resident 1's Brief Interview for Mental Status (BIMS, is a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information) score was 15 out of 15, indicating intact cognitive response.During a concurrent observation and interview on 2/20/26 at 10:59 a.m. with Resident 1, in Resident 1's room, Resident 1 was pointing at a clear tubing at the right side of his yellow adult briefs connected into a clear canister with a blue cover on a urine collection system machine. Resident 1 stated, the canister was never once disinfected. Resident 1 stated, the canister had been rinsed with only soap and water.During an interview on 2/20/26 at 11:08 a.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 1's urine canister was cleaned with soap and water once or twice a day. CNA 1 stated there was no documentation for the canister cleaning.During a concurrent observation and interview on 2/20/26 at 11:21 a.m. with the Infection Preventionist (IP), in Resident 1's bathroom, an undated document titled, Cleaning Procedure for Purewick Cannister, Tubing, and External Catheter was posted on the wall. The IP stated staff were educated to clean and disinfect the canister with soap and water and to wipe off sediments with a brush. The IP stated there was no documentation for the canister cleaning.During a review of facility provided document titled, Cleaning Procedure for Purewick Cannister, Tubing, and External Catheter, undated, indicated, Disinfecting the Cannister: Will be done daily every shift. 1. Empty urine in the toilet. 2. Clean the canister by scrubbing with soap and water using a brush to remove debris. 3. Dry with a paper towel.During a concurrent interview and record review on 2/20/26 at 12:41 p.m. with the IP, the facility's policy and procedure (P&P) titled, External Catheter for Female Urinary Incontinence Management, dated 3/1/23 was reviewed. The (P&P) indicated, An external female catheter is a noninvasive (not requiring the introduction of instruments into the body) option to manage female urinary incontinence (involuntary loss of bladder control, causing urine leakage that ranges from minor leaks to sudden, uncontrollable accidents) by drawing urine away from the resident and into a collection cannister. Compliance Guidelines: . 7. The female external catheter urine collection system and accessories should be cleaned and disinfected at the time of each use or at a minimum, daily as per manufacturer's instruction. The IP stated creating the Cleaning Procedure for Purewick Cannister, Tubing, and External Catheter document by summarizing the manufacturer's instruction.During a follow up interview and record review on 2/20/26 at 1:25 a.m. with the IP, the manufacturer's instruction titled, Cleaning the Collection Canister, undated, was reviewed. The Cleaning the Collection Canister indicated, Initial Rinse: Rinse the canister and lid thoroughly with cool tap water. While rinsing, remove any excess dirt by wiping the canister and lid with disposable low lint wipes. Cleaning: Prepare a soapy solution by mixing 1 teaspoon (approximately 5 mL) of dish soap with approximately 4 L of cool tap water. Fully submerge canister and lid in the solution. Allow it to sit for a minimum of ten (10) minutes. While submerged, use a soft brush (e.g., toothbrush) to brush all accessible areas of the canister and lid for a minimum of one (1) minute to remove any visible signs of debris or dirt. Rinse: Rinse the canister and the lid thoroughly with cool tap water until there is no visible sign of the cleaning solution. Visual inspection: Inspect the canister and the lid to ensure that all debris and dirt have been removed. If there is any sign of debris or dirt, repeat steps above until there is no sign of debris or dirt remaining on the canister and lid. Disinfection: Fully submerge the canister and lid in 70% isopropyl alcohol (IPA). Allow it to sit for a minimum of ten (10) minutes. Rinse: Rinse the canister and the lid thoroughly with cool tap water. Drying: Dry the canister and lid with a clean low lint towel or cloth. The IP stated, following the manufacturer's instruction in cleaning and disinfecting the canister could prevent the growth of bacteria and fungus and prevent resident exposure to infection. The IP stated the canister would be considered a non-critical care item.During a concurrent interview and record review on 2/20/26 at 1:56 p.m. with the Director of Nursing (DON), Resident 1's Order Summary Report dated 11/11/25 was reviewed. The Order Summary Report indicated, Resident 1 was to use Purewick urine collection system every shift for urine incontinence management. The DON stated, Resident 1 preferred to use external female catheter (a soft, flexible wick that sits outside the body).During a review of the facility's policy and procedure titled, Cleaning and Disinfection of Resident-Care Items and Equipment, undated, indicated, c. Non-critical items are those that come in contact with intact skin but not mucous membranes (the moist, inner lining of some organs and body cavities) . 2. Intermediate and low-level disinfectants for non-critical items include: a. ethyl or isopropyl alcohol.

Based on interview and record review, the facility failed to ensure for one out of four residents (Resident 2), were free from abuse, when Resident 2 had an altercation with Resident 3. Resident 2 had lacerations on right eyebrow and right lower lid, contusion surrounding right eye and right side of the face. This failure resulted in being subjected to physical abuse that caused pain and injuries.Findings:A review of facility's admission Record (AR) indicated Resident 2 was admitted to the facility on [DATE], with diagnoses that included Metabolic encephalopathy (brain dysfunction caused by underlying condition), and pneumonia due to Coronavirus disease 2019. Resident 2's Minimum Data Set (MDS - resident assessment tool) dated 11/08/25 indicated a Brief Interview for Mental Status (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information) score of 12, (BIMS score of 00 - 07: severe impairment; 08 - 12: moderately impaired; and 13 - 15: cognitively intact). During a review of facility's AR indicated Resident 3 was admitted to the facility on [DATE], with diagnoses that included Spinal stenosis (narrowing of the spine that puts pressure on nerves and spinal cord), and unspecified dementia, with unspecified severity, without behavior. Resident 3's BIMS dated 11/06/2025 indicated a score of 12, moderately impaired.During an interview on 02/18/2026 at 01:57 p.m. with Registered Nurse (RN) 1, RN 1 stated Licensed Vocational Nurse (LVN) 1, asked for assistance regarding the incident between Resident 2 and 3. RN 1 stated LVN 1 went to Residents 2 and 3's shared room, and found Resident 2 in the bathroom wiping the blood away for his head.During an interview on 02/19/2026 at 10:22 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated it was around 6 p.m., when Certified Nursing Assistant (CNA) 1 asked her to see Resident 2 in his room. LVN 1 stated Resident 2 stated that his roommate had hit his face. LVN 1 stated Resident 2 had an injury on his forehead. LVN 1 stated that Resident 3 was in the room sitting on his bed, and talking to himself. LVN 1 stated that during the police investigation, Resident 3 had a small drop of blood in his hand. LVN 1 stated that Residents 2 and 3 were ambulatory.During a review of Resident 2's Progress Notes dated 11/01/2025 23:00 stated Room change rendered to keep residents separated due to an altercation. Tx [treatment] rendered and assessment done by supervisor. Steri-strips applied: R. [right] lower lid and R. [right] eyebrows for the injury sustained by the resident to stop further bleeding. Before room change, Steri-strips were noted to be soiled with blood as the resident was getting transferred to his new room. Writer informed NP [Nurse Practitioner] immediately and informed regarding the increased swelling and eye bloodshot in color. NP approved to send to Hospital.A review of Resident 2's Progress Notes dated 11/03/2025 08:07 indicated At approximately 1910, CNA reported to LN that the resident [2], was observed washing his face in the bathroom with visible facial bleeding and an injury to the right eye. Upon assessment of the LN [licensed nurse], the right eye was noted to be swollen, red, and bloodshot, with laceration measuring approximately 4 cm [centimeter] x 0.5 cm on the right eyebrow and another laceration measuring approximately 2 cm x 0.5 cm on the right lower eyelid. The resident [2] verbalized that his roommate, identified as 44C (Resident 3), allegedly made contact with his right eye when he tried to talk to the resident about pacing back and forth in the room while talking on a cell phone, and when he asked 44C [Resident 3] to take the call into the hallway so he could rest, 44C [Resident 3] suddenly raised his arms and made contact with his right eye causing the injury.During a review of Resident 2's Emergency Departments Note dated 11/02/2025 at 01:04, it indicated The patient is here at this time to be evaluated for possible injuries after he was reportedly assaulted by his roommate at this [his] facility. At the time of arrival in the emergency room the patient was awake and responsive to questions. The patient was complaining of pain in his head, face as well as his chest. The patient reports he was not only hit in the face but also his chest. The patient clearly sustained a contusion to the right maxillary soft tissues as well as the soft tissue surrounding his right eye and supraorbital ridge. Discharge Diagnosis: Injury due to physical assault, contusion of face, safeguarding concerning adult.During a review of facility's policy and procedure titled Abuse Prevention Policy dated 03/17/2025 indicated Resident have the right to be free from all forms of abuse. This includes but is not limited to freedom from physical abuse, verbal abuse, mental abuse, neglect, sexual abuse, misappropriation of property, involuntary seclusion, and financial abuse. The facility prohibits and prevents the forms of abuse, involuntary seclusion, neglect, and misappropriation of property.

Based on interviews and record reviews, the facility failed to ensure for one out of four residents (Resident 1), rights were protected. Resident 1 was having increasing pain during prolonged sitting in the Hoyer lift sling, and Resident 1 wished to be transferred back to bed instead of trying to be fitted to his wheelchair. Resident 1 had an emotional outburst due to staff not following his wishes. This failure resulted in Resident 1's right to have dignity being violated during care.Findings:A review of facility's admission Record (AR) indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included Chronic systolic (congestive) heart failure and morbid (severe) obesity due to excess calories. Resident 1's Minimum Data Set (MDS - resident assessment tool) dated 01/06/2026, the MDS indicated a Brief Interview for Mental Status (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information) score of 15, (BIMS score of 00 - 07: severe impairment; 08 - 12: moderately impaired; and 13 - 15: cognitively intact).During an interview on 02/18/2026 at 09:58 p.m. with Resident 1, Resident 1was lying in bed. Resident 1 stated that his bariatric bed was not functioning properly and needed to be changed. Resident 1 stated that during the incident there were several staff involved including the staff from Kaiser for the wheelchair fitting. Resident 1 stated he thought the process would take about five to 10 minutes, and he would be able to tolerate the process. Resident 1 stated he was lifted out of his bed using a sling attached to the Hoyer lift (medical device designed to safely transfer patients with limited mobility). Resident 1 stated the Restorative Nursing Assistant (RNA) 1 operated the Hoyer lift. Resident 1 stated that he started having pain in his left hip. Resident 1 stated a staff from the rehabilitation department helped by supporting him to help decrease the pain. Resident 1 stated that process took longer than expected, and at about 15 - 20 minutes, the pain was increasing. Resident 1 stated that when the bariatric bed was adjusted to fit through the door, and was removed from the room. The new bed was not brought in, but instead, the staff from Kaiser wheeled the wheelchair in the room to try to fit him in the wheelchair. Resident 1 stated that he was having excruciating pain at this point and would rather not be fitted in the wheelchair. Resident 1 stated that he started screaming and cussing since due to excruciating pain, and the staff were not listening to him. Resident 1 stated that wheelchair was removed from his room, and the new bariatric bed was brought in the room. Resident 1 stated that he wanted to go back to bed because he was in so much pain already. Resident 1 stated he could have been readjusted in bed for comfort then try to be fitted in the wheelchair.During a review of Resident 2's Progress Notes dated 06/19/2025, it indicated Resident 1 reported an alleged abuse which happened on 6/18/2025. Per patient around 1 pm, I was in my Hoyer left [lift] transferring to a wheelchair. I changed my mind and wanted to be in bed. I was in pain. The staff member tried to talk me into going to the wheelchair. They did put be back to bed, but I feel this was assault when they didn't put me in bed immediately.During a review of the facility's Resident Abuse Investigation Report Form interview record dated 6/20/2025, it indicated Upon arrival, Hoyer lift transfer had already been initiated. Assisted with bed adjustment so that bed can fit through doorway, during this time patient continues to be in [H][NAME] sling lift, bed also need to be taken out of room in order to be measured for power chair. Upon extended periods of time in [H][NAME] sling patient stated increasing L [left] hip pain with prolonged sitting in sling. [P]atient requested to be return to BTB [back to bed] as soon as possible due to increasing pain. [W][NAME] bed could finally be rolled out of room. Kaiser representative brought the power chair, but patient had become agitated and demanded to be returned BTB due to increasing L [left] hip pain. [A]t this time this therapist attempted to support L [left] Hip in order to reduce risk of increasing pain. Patient continues to become more agitated demanding to return BTB. Kaiser representatives at this point had the power chair by the doorway and in the room in attempts to fit patient into the power chair. [P]atient continued to demand to return BTB due to increasing L[left] hip pain. Finally [K]aiser representatives removed power chair from the room and staff was able to place new bed back into the room. Once patient returned BTB, patient verbalizes displeasure with vulgar comments including the use of profanity regarding increased L[left] hip pain while in [H][NAME] sling.During a review of facility's policy and procedures titled Resident Rights dated 12/5/2025 indicated It is the policy of the facility to fully uphold the rights of all residents as outlined in the California Residents [NAME] of Rights. Residents shall not be denied their rights for any reason, and no staff member may retaliate against a resident who exercise their rights, voices concerns, or file grievance. Procedure/Guidelines. II. Resident Rights a. Dignity, Respect and Freedom i. Be treated with dignity and respect at all times. Ii. Make choices about daily life.

Based on interview and record, the facility failed to ensure two out of six sampled Residents (Resident 2 and 4), were free from abuse, when Residents 2 and 4 had a physical altercation. Resident 2 had multiple skin tears with bleeding and Resident 4's right index finger was bitten. This failure resulted in pain and injuries on residents.During a review of facility's admission Record (AR) indicated Resident 2 was admitted to the facility on [DATE], with diagnoses that included dementia with other behavioral disturbance. Resident 2's Minimum Data Set (MDS - resident assessment tool) dated 05/28/25, the MDS indicated a Brief Interview for Mental Status (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information) score of 05, (BIMS score of 0 - 7, suggest severe cognitive impairment).During a review of facility's AR indicated Resident 4 was admitted to the facility on [DATE], with multiple diagnoses that included unspecified osteomyelitis (infection in the bone). Resident 4's MDS dated [DATE], the MDS indicated a BIMS score of 10, (BIMS score of 8 - 12, suggest moderate cognitive impairment).During a review of facility's Resident 2's eInteract Change in Condition dated 04/20/25 indicated, Patient was noted with multiple scratches on front of face and right arm scratches, minimal bleeding, with skin tear. Charge nurse immediately separated the patients and render a treatment to affected skin. Resident 2's Skin Status Evaluation indicated Multiple scratches on face and right arm area with skin tear.During a review of facility's Resident 4's eInteract Change in Condition dated 04/20/25 indicated, Resident 4 stated I was upset because [Resident 2] is using my wheelchair, she doesn't want to listen, so I scratch her, and [Resident 2] bite her right pointing finger. Resident 4's Skin Status Evaluation noted Skin tear on right point finger.During an interview on 08/14/25 at 04:21 p.m., with Registered Nurse (RN) 1, RN 1 started on 04/20/25, he was doing his rounds, RN 1 was in the area near Residents 2 and 4's shared room. RN 1 stated he heard a commotion in Resident 2 and 4's room. RN 1 when he went to the room, Resident 2 was sitting in her wheelchair, and she was near Resident 4's bed. RN 1 stated that Resident 4 was in her bed, and she was swinging her arms towards Resident 2, and Resident 2 had her arms up trying to defend herself from Resident 4. RN 1 stated other staff came in to help, and RN 1 stated by the time he was able to take Resident 2 away from Resident 4's reach, Resident 2 had a lot of skin tears and had blood on her. RN 1 stated that Resident 2 had multiple skin tears.During a review of facility's policy and procedure titled Abuse Prevention Policy dated 03/17/2025 indicated Resident have the right to be free from all forms of abuse. This includes but is not limited to freedom from physical abuse, verbal abuse, mental abuse, neglect, sexual abuse, misappropriation of property, involuntary seclusion, and financial abuse. The facility prohibits and prevents the forms of abuse, involuntary seclusion, neglect, and misappropriation of property.

Based on interview and record review, the facility failed to ensure for one of three sampled residents (Resident 1), Resident 1 ' s rights were not protected when Seroquel (Quetiapine -medication used to treat illness that affects thoughts and behavior) dosage was increased without physician ' s orders, indication, and no informed consent. Resident 1 ' s Seroquel ' s dose was increased to 50 milligram (mg) tablets given two times a day. This failure resulted in Resident 1 ' s right being violated due to unnecessary increase of medication dose. Findings: During a review of Resident 1 ' s admission Record indicated Resident 1 was admitted on [DATE], with diagnoses that included schizoaffective disorder (mental health disorder that affects mood, thoughts, and behavior), and unspecified dementia. Resident 1 ' s Minimum Data Set (MDS - resident assessment tool) dated 3/22/25, the MDS indicated a Brief Interview for Mental Status (BIMS, a scoring system used to determine the resident ' s cognitive status regarding attention, orientation, and ability to register and recall information) score of 06, (BIMS score of 0 - 7, suggest severe cognitive impairment). During a review of Resident 1 ' s Psychoactive Drug Review and Interdisciplinary Team Meeting (PDRITM) dated 11/12/24 indicated Treatment Intervention: Seroquel Oral tablet 25 mg (Quetiapine Fumarate) Give 25 mg by mouth two times a day for schizophrenia m/b [manifested by] visual and auditory hallucinations leading to distress. Resident 1 ' s PDRITM plan indicated to continue current prescribed medication. During a concurrent interview and record review on 4/30/25 at 12:21 p.m., with Director of Nurses (DON), DON reviewed Resident 1 ' s medication administration records (MAR) for Monitor episodes of Schizoaffective Disorder M/B [manifested by]: Visual Hallucinations Q [every] shift. Enter the # of episodes during your shift, for the months of November and December 2024. DON stated there was no indication that Resident 1 had an increase in episodes of hallucinations. During a review of Resident 1 ' s Order Summary Report for December 2024 indicated Seroquel Quetiapine Fumarate Oral Tablet 50 mg. Give 50 mg tablet by mouth two times a day for anxiety m/b [manifested by] visual and auditory hallucination lading [leading] to distress with an order date of 12/5/2024. The new order did not match the indication and monitoring of schizoaffective disorder manifestation. During a concurrent interview and record review on 4/30/25 at 12:58 p.m., with Assistant Director of Nursing (ADON), ADON stated that she took the verbal order to increase Resident 1 ' s Seroquel 50 mg twice a day and entered the new order to Resident 1 ' s electronic health record. ADON stated that the physician ' s order was given to her during the PDRITM in December 2024. ADON reviewed Resident 1 ' s PDRITM dated 12/17/24, and stated there was no order to increase Seroquel. ADON reviewed Resident 1 ' s electronic health record for December 12/5/2024, and could not find the indication that the physician had ordered to increase Resident 1 ' s Seroquel dose. During a review of facility ' s MAR for the months to 12/24 through 4/25, the MAR indicated Resident 1 was given Seroquel 50 mg tablet one tablet two times per day starting 12/6/2024 through 4/2/2025. During a review of Resident 1 ' s Psychotropic Medication Consent V.2024 dated 02/24/2025 for Seroquel 50 mg tablet given two times a day. The written consent was blank for Resident 1 ' s Responsible Party, and there was no physician signature. During an interview on 4/30/25 at 1:15 p.m., with ADON, ADON stated she obtained verbal consent from Resident 1 ' s RP. ADON reviewed Resident 1 ' s Psychotropic Medication Consent V.2024 dated 02/24/2025, ADON stated she did not obtain and verify the consent with RP until 2/24/25, because the Resident 1 ' s RP was on vacation when Seroquel 50 mg tablet given twice a day was started on 12/6/25. ADON opened the Resident 1 ' s health care records binder, and written notes indicated Resident 1 ' s RP was in town until 12/14/24. During an interview on 4/30/25 at 12:21 p.m., with DON, DON stated after the provider obtained the informed consent from the resident or responsible (RP) party, the facility would verify and get a written consent. DON stated written consent Psychotropic Medication Consent form would be generated from the resident ' s electronic health record, and when the facility obtained the wet signature from the resident or RP, the consent form would be scanned and filed into the resident ' s electronic health record. During a review of facility ' s Psychotropic Medication Use policy statement indicated Residents do not receive psychotropic medication that are not clinically indicated and necessary to treat a specific condition documented in the medical record . Assessment and Evaluation of the Resident. 1. When determining whether to initiate, modify, or discontinue medication therapy, the interdisciplinary team conducts and documents an evaluation of the resident. The evaluation includes the resident ' s: a. physical, behavioral, mental, and psychosocial status; b. comorbid conditions; c. expressions or indications of distress; d. change in functional status; e. resident complaints, behaviors, and symptoms; and f. the state PASARR evaluation.

Based on interview and record review, the facility failed to identify that a licensed nurse (Assisted Director of Nursing, ADON) increased a dose of medication without a physicians ' order. This failure resulted to Resident 1 ' s Seroquel ' s (Quetiapine -medication used to treat illness that affects thoughts and behavior) dose was increased to 50 milligram (mg) tablets given two times a day from 12/2024 through 4/2025 without indication. Findings: Cross reference to F605 During a review of Resident 1 ' s Order Summary Report for December 2024 indicated Seroquel Quetiapine Fumarate Oral Tablet 50 mg. Give 50 mg tablet by mouth two times a day for anxiety m/b [manifested by] visual and auditory hallucination lading [leading] to distress with an order date of 12/5/2024. During a review of facility ' s MAR for the months to 12/2024 through 4/25 indicated Resident 1 was given Seroquel 50 mg tablet one tablet two times per day starting 12/6/2024 through 4/2/2025. During a concurrent interview and record review on 4/30/25 at 12:58 p.m., with ADON, ADON stated that she entered the verbal order to increase Resident 1 ' s Seroquel 50 mg twice to Resident 1 ' s electronic health record. ADON reviewed Resident 1 ' s electronic health record for December 12/5/2024, and could not find the indication that the physician had ordered to increase Resident 1 ' s Seroquel dose. During an interview on 6/5/25 at 3:10 p.m., with Director of Nursing (DON), DON stated they investigated the incident, and it was determined that ADON put in the order to increase Resident 1 ' s Seroquel 50 mg tablet given one tablet twice a day without physicians' orders. DON stated when ADON increased the medication dose, it was beyond the scope of her license (refers to the activities and duties that a professional was legally permitted to perform within their specific field).

Based on observation, interview and record review, the facility failed to ensure staff practiced safe patient handling for one of three sampled residents (Resident 1) when Resident 1 was left on a hoyer lift (a mechanical device used to lift and transfer residents from one place to another) unsupervised for 30 minutes and had only one staff member assist Resident 1 during a hoyer lift transfer. This failure resulted in Resident 1's discomfort during a hoyer lift transfer and had the potential for falls which could lead to injury or death. Findings: A review of Resident 1's admission record indicated Resident 1 was admitted with diagnoses of polymyositis (a chronic disease in which the patient's own immune system attacks the body's muscle tissue resulting in generalized weakness), quadriplegia (paralysis of all extremities) and need for assistance with personal care. A review of Resident 1's minimum data set (MDS, an assessment tool to guide resident care), dated 8/30/24, indicated Resident 1 was totally dependent on staff person for eating, and personal hygiene, and two staff for bed mobility, transfer between surfaces, and toileting. The MDS indicated Resident 1 had a Brief Interview for Mental Status score of 15 (The Brief Interview for Mental Status is an assessment tool for a resident's orientation to time, and capacity to remember. The BIMS has a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status). During a concurrent observation and interview on 10/23/24, at 8:18 p.m., with Certified Nursing Assistant 1 (CNA 1), CNA 1 had exited Resident 1's room. CNA 1 stated Resident 1 was on the hoyer lift suspended over the bed to go to the bathroom. CNA 1 stated there were no other staff in the room, and staff were expected to be with the resident when they were on a hoyer lift. CNA 1 stated the next CNA scheduled for Resident 1's care would lower them down. CNA 1 stated they would not give report to the oncoming CNA because Resident 1 could make their needs known. CNA 1 did not reenter Resident 1's room. During an observation on 10/23/24, at 8:20 p.m., CNA 2 briefly entered and exited Resident 1's room. During a concurrent observation and interview on 10/23/24, at 8:20 p.m., with Resident 1, Resident 1 was in their room on a hoyer lift suspended over their bed without staff present. Resident 1 stated they were on the hoyer lift for toileting and would be finished soon. During a continuous observation on 10/23/24, from 8:20 p.m. to 8:45 p.m., of the entrance to Resident 1's room, staff did not enter Resident 1's room to lower or supervise Resident 1 while they were on the hoyer lift. During an observation on 10/23/24, at 8:50 p.m., CNA 3 entered Resident 1's room to answer a call light to transfer Resident 1 off the hoyer lift. Resident 1 was still suspended over their bed on the hoyer lift. During concurrent observation and interview on 10/23/24, at 8:59 p.m., with Assistant Director of Nursing (ADON), the ADON was in Resident 1's room. The ADON stated hoyer lift transfers required two staff members and staff should remain with the resident while they are on the hoyer lift to prevent falls and to ensure resident comfort. The ADON then left the room. During an observation and interview on 10/23/24, at 9:00 p.m., with Resident 1, CNA 3 was in Resident 1's room with Resident 1 suspended on the hoyer lift. CNA 3 was working alone to transfer Resident 1 to the bed using the hoyer lift. Resident 1 stated they were uncomfortable because their legs were being lowered into an uncomfortable position. CNA 3 did not successfully reposition Resident 1's legs to a comfortable position while simultaneously lowering Resident 1 down to the bed. During an concurrent interview and record review on 1/2/25, at 11:20 a.m., with the Director of Nursing (DON), Resident 1's care plan titled, The resident is at risk for falls and/or injuries related to falls related to quadriplegia, need for assistance for ADLs (activity of daily living such as hygiene, transfers out of bed etc.), request for having BM (bowel movement) while in hoyer lift, history of non-compliance, and threatening behaviors towards staff, dated 7/25/23, was reviewed. The care plan indicated Resident 1 needed hoyer transfer as needed, 2 person assist for transfers. Educate resident on fall prevention and risks of requesting to stay in hoyer for extended time, risks of being in hoyer without direct supervision. The DON stated staff are expected to stay with any resident suspended on a hoyer lift to maintain resident safety regardless of resident preferences. During a review of facility policy and procedure (P&P) titled, Safe Resident Handling/Transfers, dated 7/1/24, the P&P indicated, all residents require safe handling when transferred to minimize risk of injury to themselves and the employees that assist them .staff members are expected to maintain compliance with safe handling/transfer practices .two staff members must be utilized when transferring residents with a mechanical lift.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure food served to residents had an appetizing taste and failed to ensure pureed bread was prepared in accordance with the facility's recipe and in a manner to conserve nutritive value. These findings had the potential to affect all 116 residents receiving meals from the dietary department, including 18 residents with orders for pureed diets. Findings included: 1. A facility policy titled, Food Preparation Guidelines, implemented 03/01/2024, specified, 3. Food and drinks shall be palatable, attractive, and at a safe and appetizing temperature. Strategies to ensure resident satisfaction include: a. Providing meals that are varied in color and texture. b. Using spices or herbs to season food in accordance with recipes. c. Serving hot foods/drinks hot and cold foods drinks cold. d. Addressing resident complaints about foods/drinks. e. Honoring resident preferences, as possible, regarding foods and drinks. During a Resident Council Meeting on 10/01/2024 at 12:51 PM with four residents in attendance, Resident #55 stated the food did not look palatable and lacked variety. Resident #55 also described the food as bland. According to an annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/21/2024, Resident #55 had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident had intact cognition. During the meeting, Resident #43 also described the food as disgusting and horrible and said the food had no flavor or seasoning. According to a quarterly MDS, with an ARD of 07/08/2024, Resident #43 had a BIMS score of 14, indicating the resident had intact cognition. Resident #38 reported their lunch on 10/01/2024 did not have a taste. According to a quarterly MDS, with an ARD of 07/01/2024, Resident #38 had a BIMS score of 14, indicating the resident had intact cognition. During an observation of the lunch meal service on 10/01/2024, a test tray was requested at 1:03 PM. At 1:15 PM, the test tray was plated and left the kitchen. On 10/01/2024 at 1:31 PM, the surveyor tasted the test tray, and the peas and corn were both flavorless, overcooked, and dried out. The chicken was overpoweringly greasy, which dominated any other flavors. The chocolate pudding desert did not taste of chocolate, but it had a flavor of artificial sweetener. During an interview on 10/02/2024 at 1:13 PM, the Dietary Supervisor (DS) stated she ate the facility's prepared lunch meal on a daily basis. The DS described the lunch meal served on 10/01/2024 as bland and stated the chicken was tough. On 10/02/2024 at 12:50 PM, an additional test tray was requested. The test tray was plated at 1:00 PM and left the kitchen for transport to the unit. On 10/02/2024 at 1:17 PM, the surveyor tasted the test tray, and the noodles were chewy. During an interview on 10/05/2024 at 10:01 AM, the Director of Nursing (DON) stated she had never tasted the food at the facility. The DON said it was the DS's responsibility to ensure the food was palatable. During an interview on 10/05/2024 at 10:50 AM, the Administrator stated it was the Registered Dietitian's (RD's) and DS's responsibility to ensure the food was palatable. 2. A facility policy titled, Food Preparation Guidelines, implemented 03/01/2024, specified, 1. The cook, or designee, shall prepare menu items following the facility's written menus and standardized recipes. 2. Foods shall be prepared by methods that conserve nutritive value, flavor, and appearance. This includes, but is not limited to: a. Storing food in a manner to minimize exposure to light and air. b. Preparing foods as directed. c. Cooking foods in an appropriate amount of water (avoid large volumes). d. Minimizing holding time prior to meal service. A recipe titled, Pureed Bread Products, revised 08/20/2018, revealed the recipe called for bread product; broth, milk, or juice; and thickener. The recipe did not call for water or margarine. During an observation of pureed food preparation on 10/02/2024 at 10:22 AM, staff did not follow the recipe for pureed bread. To make the bread, staff used one loaf of sliced bread, a half-cup of margarine, and one quart of water. During an observation of pureed food preparation on 10/02/2024 at 3:01 PM, [NAME] #11 prepared pureed bread by using two loaves of sliced bread, a half-cup of margarine, and two quarts of water. During an interview on 10/02/2024 at 3:55 PM, [NAME] #11 stated staff should review recipes before preparing food and said if they forgot, they could ask the supervisor or review the recipe again. During a follow-up interview on 10/02/2024 at 4:20 PM, [NAME] #11 stated she did not realize using water when preparing pureed bread was a mistake until she reviewed the recipe. [NAME] #11 indicated she always thought the recipe called for water and did not know if using water, instead of broth, milk, or juice as specified by the recipe, would affect nutritive value. During an interview on 10/03/2024 at 9:46 AM, the Dietary Supervisor (DS) confirmed that according to the recipe for pureed bread, staff should use broth, milk, or juice. The DS stated she did not know how using water, instead of what the recipe called for, would affect the nutritive value of the pureed bread. During an interview on 10/03/2024 at 10:22 AM, the Registered Dietitian (RD) stated she expected staff to follow the recipes completely. According to the RD, staff should have reviewed the recipe, gotten everything ready, and then began preparing the food. The RD said preparing the pureed bread with water, instead of how the recipe instructed, affected the nutritive value since there was a small amount of calories or protein omitted by not following the recipe. During an interview on 10/05/2024 at 10:01 AM, the Director of Nursing (DON) stated she had never tasted the food at the facility. The DON said it was the DS's responsibility to ensure the food was palatable and of sufficient nutritive value. The DO further stated that since water had no calories, using it in the pureed recipes would have diluted the nutritional value of the food. During an interview on 10/05/2024 at 10:50 AM, the Administrator stated the RD set the menus and recipes, and it was important that staff follow the recipes to ensure nutritive value. The Administrator said it was the RD's and DS's responsibility to ensure the food was of sufficient nutritive value. The Administrator agreed that substituting water in place of milk, broth, or juice as specified in the recipe, would alter the nutritive value.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure foods brought in by visitors were stored in a sanitary manner. Specifically, the facility failed to ensure 1 of 1 refrigerator used on the units for residents' food items was clean. Additionally, the facility failed to ensure resident food items brought to the facility by visitors were labeled with a date prior to storage in the resident refrigerator. These failures had the potential to affect all 116 residents who resided in the facility at the time of the survey. Findings included: A facility policy titled, Food Brought in From Outside Sources, dated 2023, indicated, 3. All food brought in should be checked by the charge nurse or the Director of Food and Nutrition Services. It must be placed in a tightly sealed container with the resident's name and date on it. During a concurrent observation and interview with Licensed Vocational Nurse (LVN) #6 on 10/02/2024 at 12:38 PM, the resident refrigerator was observed with brown stains and brown liquid in the bottom of the refrigerator. Inside the refrigerator was an undated container of half a cake, an undated bag of Chinese takeaway, an undated takeaway container of an unspecified food, and an undated fast-food bag. LVN #6 confirmed the food items were not dated. LVN #6 said food was supposed to be dated when staff placed it into the refrigerator but indicated they had some residents' family members that placed food into the refrigerator themselves. During an observation on 10/03/2024 at 9:39 AM, the resident refrigerator had an undated sign posted on it that read, Dear staff, Please Date and Label The resident's food. Throw away after 3 days. Thank you, IP [Infection Prevention] Nurse. During an interview on 10/03/2024 at 9:46 AM, the Dietary Supervisor (DS) stated the resident refrigerator on the unit was maintained in coordination with the nursing staff. According to the DS, only the staff, not the residents or their families, were permitted to put food in the unit refrigerator. The DS said housekeeping staff also helped maintain the unit refrigerator and indicated the refrigerator was cleaned every three days and items that were not dated were discarded immediately. During an interview on 10/03/2024 at 1:44 PM, the Infection Prevention Licensed Vocational Nurse (IP LVN) stated she oversaw the unit refrigerator. The IP LVN stated she had informed staff that resident food was supposed to be thrown out every three days, or if it was undated/unlabeled. According to the IP LVN, the refrigerator was not cleaned or checked routinely, only when the IP LVN remembered to tell the janitorial staff to clean it and discard any needed items. During an interview on 10/05/2024 at 10:01 AM, the Director of Nursing (DON) stated when visitors brought in food, they should check with the nurse, and then whoever received the food should ensure the food was labeled with the resident's name and a date. The DON said family members should not have access to the refrigerator. The DON further stated she expected the IP LVN to let housekeeping staff know if the refrigerator needed to be cleaned. During an interview on 10/05/2024 at 10:50 AM, the Administrator stated food brought in by visitors must be labeled and dated and discarded after three days. The Administrator said that whoever received the food was responsible for labeling and dating the food items. The Administrator said janitorial staff were responsible for cleaning the refrigerator, ideally every day, and the Administrator did not know why the refrigerator was observed dirty with undated food items inside of it.

Based on observation, interview, and facility policy review, the facility failed to ensure safe and sanitary disposal of refuse. Specifically, the facility failed to ensure the dumpster was closed to prevent the attraction of vermin. This had the potential to affect all 116 of 116 residents who resided in the facility at the time of the survey. Findings included: An undated facility policy titled, Disposal of Garbage and Refuse indicated, 7. Refuse containers and dumpsters kept outside the facility shall be designed and constructed to have tightly fitting lids, doors or covers. Containers and dumpsters shall be kept covered when not being loaded. Surrounding area shall be kept clean so that accumulation of debris and insect / rodent attractions are minimized. During an observation on 09/30/2024 at 8:30 AM, the facility's garbage dumpster was visible from the street, and the lid of the dumpster was open. During an observation on 10/01/2024 at 11:00 AM, the lid of the dumpster was open, and trash was visible. During an interview on 10/03/2024 at 9:46 AM, the Dietary Supervisor (DS) stated the dumpster was supposed to be closed. During an interview on 10/05/2024 at 10:01 AM, the Director of Nursing (DON) stated the janitorial staff were responsible for maintaining the dumpster. The DON said all trash should be inside the dumpster, and the lid should be closed, which was important for infection control reasons. During an interview on 10/05/2024 at 10:50 AM, the Administrator stated dumpster lids should be closed.

Based on interview, facility document review, and facility policy review, the facility failed to consistently complete infection surveillance checklists as indicated in the facility's antibiotic stewardship program for residents identified with infections that received prescribed antibiotic therapy. This deficient practice had the potential to affect all residents who resided in the facility. Findings included: A facility policy titled, Infection Prevention and Control Program, implemented 07/01/2023, revealed, This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. The policy indicated, 6. Antibiotic Stewardship: a. An antibiotic stewardship program will be implemented as part of the overall infection prevention and control program. b. Antibiotic use protocols and a system to monitor antibiotic use will be implemented as part of the antibiotic stewardship program. A facility policy titled, Antibiotic Stewardship Program, implemented 05/01/2024, revealed, It is the policy of this facility to implement an Antibiotic Stewardship Program as part of the facility's overall infection prevention and control program. The purpose of this program is to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. The policy revealed, 2. The program includes antibiotic use protocols and a system to monitor antibiotic use. The policy revealed, a. Antibiotic use protocols: included, iii. The facility uses McGeer criteria [a set of guidelines for identifying infections] to define infections. A document titled, Infection Preventionist: Tasks/Tools/Training, created in 2023, revealed daily tasks included to, Review all new antibiotic orders, add antibiotic stewardship note and complete McGeer checklist. Document MD [medical doctor] notification and response for all infections (meets and does not meet criteria). The document included copies of the Revised McGeer Criteria for Infection Surveillance Checklist for urinary tract infections, respiratory tract infections, skin and soft tissue infections, and gastrointestinal infections. The facility's Infection Control Data Logs for the timeframe from January 2024 through September 2024, provided by the Infection Prevention (IP) Licensed Vocational Nurse (LVN), revealed resident names with types of infections, locations (units in the facility), antibiotic utilization, but did not indicate if the infections met the McGeer criteria except for one infection, in February 2024. Further review revealed the information provided by the IP LVN did not include any evidence of the McGeer criteria checklist being completed for any of the infections. During an interview on 10/03/2024 at 1:44 PM, the IP LVN stated she did the McGeer criteria in my head. The IP LVN said she was a new IP and was still learning. She stated that she wanted to do it correctly, but she had not had much guidance. During an interview on 10/05/2024 at 9:27 AM, the Director of Nursing (DON) stated her expectation was for the IP LVN to review any resident on an antibiotic following the McGeer criteria; and if they did not fit the criteria, the IP LVN should contact the physician to see whether the physician wanted the antibiotic to be continued. During an interview on 10/05/2024 at 10:51 AM, the Administrator stated he expected the IP LVN to complete the McGeer criteria and contact the physician if the criteria was not met.

Based on observation, interview, record review, and facility policy review, the facility failed to: 1) complete a smoking assessment for Resident #79, 2) provide supervision for Resident #91, a resident who was assessed to require supervision while smoking, and 3) ensure a safety intervention for smoking was implemented for Resident #10. These failures affected 3 (Residents #10, #79, #91) of 5 sampled residents reviewed for smoking. The facility further failed to ensure staff did not leave medications at the bedside for 2 (Resident #58 and Resident #82) of 24 sampled residents. Findings included: A facility policy titled, Resident Smoking Assessment Policy, with an implementation date of 11/01/2023, revealed, Policy It is the policy of this facility to provide a safe and healthy smoke free environment for residents. Policy Explanation and Compliance Guidelines: 1. 1. All residents will be asked about tobacco use during the admission process. 2. Residents who smoke will be further assessed, using a smoking assessment. Residents will be assessed upon admission and as needed. 3. Residents will be further assessed to determine whether or not interventions are needed to help them cope with the 'Smoke Free' policy. 1. An Admission Record revealed the facility admitted Resident #79 on 05/22/2024. According to the Admission Record, the resident had a medical history that included schizophrenia, toxic encephalopathy, muscle weakness, and cognitive communication deficit. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/25/2024, revealed Resident #79 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident had moderate cognitive impairment. Resident #79's medical record revealed no evidence to indicate the resident was assessment by the facility to determine the resident's ability to safely smoke. Resident #79's Progress Note dated 07/04/2024 at 10:57 AM, revealed the resident was seen smoking. During an interview on 10/02/2024 at 4:25 PM, the Medical Director stated residents should be assessed to smoke to ensure they were safe to smoke and what level of supervision was required for the resident to smoke safely. During a concurrent observation and interview on 10/03/2024 at 8:41 AM, Resident #79 was noted in the activity/communal area with seven to eight burn holes in their pants in the genital area. Resident #79 stated they smoked. During an interview on 10/03/2024 at 8:50 AM, Resident #79 stated that the burn holes in their pants occurred four weeks ago while they smoked alone on the facility patio. The resident stated they last smoked on 10/02/2024. During an interview on 10/03/2024 at 8:45 AM, Certified Nurse Assistant (CNA) #21 stated Resident #79 smoked cigarettes. CNA #21 stated she had not seen smoking materials in the resident's room, but had witnessed Resident #79 smoke outside once before. According to CNA #21, the holes and burn marks in Resident #79's pants were caused when the resident dropped a lit cigarette onto their pants. During an interview on 10/03/2024 at 9:02 AM, the Director of Nursing (DON) stated she was not aware Resident #79 smoked. During an interview on 10/04/2024 at 4:02 PM, Registered Nurse (RN) #18 stated that when residents admitted to the facility, she completed the initial nursing assessments for the residents. RN #18 stated she did not ask the resident if they smoked. During an interview on 10/05/2024 at 9:23 AM, the DON stated that if a resident was a smoker, facility staff would complete an assessment, then that information would be added to the care plan and communicated to the nursing staff. The DON stated during the admission process, the nurse should review resident records to determine if a resident smoked. 2. An Admission Record revealed the facility admitted Resident #91 on 07/26/2024. According to the Admission Record, the resident had a medical history that included diagnoses of schizoaffective disorder, bipolar type, polyneuropathy, chronic obstructive pulmonary disease, depression, muscle weakness, and cognitive communication deficit. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/29/2024, revealed Resident #91 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident had intact cognition. Resident #91's Nursing Admission/Readmission Assessment, dated 07/26/2024, revealed the resident wished to smoke. The assessment revealed, Supervised smoking needed. During an observation on 10/02/2024 at 1:31 PM, Resident #91 was noted to be smoking in the facility's courtyard and there were no staff present to supervise the resident. During an interview on 10/02/2024 at 2:10 PM, Licensed Vocational Nurse #12 stated Resident #91 had a history of smoking and was provided a nicotine patch to aid the resident in quitting. During an interview on 10/02/2024 at 2:31 PM, Resident #91 stated they smoked outside in the front and back of the facility. 49044 3. An Admission Record revealed the facility admitted Resident #10 on 12/08/2023. According to the Admission record, the resident had a medical history that included diagnoses of other specified disorders of the brain, cardiac arrest, metabolic encephalopathy, schizoaffective disorder, delirium due to known physiological condition, major depressive disorder, and unspecified mood disorder. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/16/202412/14/2023, revealed Resident #10 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident had moderate cognitive impairment. Resident #10's Smoking Safety assessment, dated 01/26/2024, the safety factors and concerns related to the resident smoking were burns skin, clothing, furniture or other, dropped ashes on self, impaired gait and balance, insufficient fine motor skills needed to securely hold cigarette, was on medication that affected alertness and function, and total or limited range of motion in arms or hands Resident #10's care plan included a focus area initiated 01/26/2024, that indicated the resident was a smoker. Interventions indicated the resident required a smoking apron while smoking (initiated 01/26/2024). During an observation on 09/30/2024 at 4:05 PM, the surveyor noted Resident #10 was outside smoking with Hospitality Aide (HA) #23. The resident was observed not to have a smoking apron on. During an interview on 10/02/2024 at 2:15 PM, HA #23 stated she had been Resident #10's HA since July 2024. HA #23 stated quite often Resident #10 dropped cigarette ashes on themself. HA #23 stated no one ever told her that the resident needed a smoking apron. During an interview on 10/02/2024 at 11:55 AM, HA #22 stated she had not seen any smoking aprons and she did not know of any resident that required an apron. During an interview on 10/02/2024 at 11:14 AM, the Social Services Director (SSD) stated she had not seen any smoking aprons. During a follow-up interview on 10/02/2024 at 3:36 PM, the SSD stated she was told that none of the residents required a smoking apron, only supervision. During an interview on 10/02/2024 at 3:32 PM, the Director of Nursing stated the facility did not have anyone who needed a smoking apron. 45555 4. A facility policy titled, Medication Storage, dated 03/01/2023, specified, c. During a medication pass, medication must be under the direct observation of the person administering medications or locked in the medication storage area/cart. A facility policy titled, Medication Administration, dated 03/01/2023, specified, 15. Observe resident consumption of medication. On 10/05/2024 at 9:18 AM, the Director of Nursing (DON) stated that she was unable to find a facility policy for self-administering medications. An Admission Record indicated the facility admitted Resident #58 on 08/30/2024. According to the Admission Record, the resident had a medical history that included diagnoses of chronic systolic (congestive) heart failure and unspecified cellulitis. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/04/2024, revealed Resident #58 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. An observation on 09/30/2024 at 11:29 AM revealed Resident #58 had a cup containing pills on the over-the-bed table next to their bed. During a concurrent interview, Resident #58 stated the nurses left medications at their bedside often. An observation on 10/01/2024 at 3:02 PM revealed Resident #58 had three large white pills on a blanket over their abdomen. During a concurrent interview Resident #58 stated they were larger pills, and it took longer for the resident to swallow them. Resident #58 stated they thought one of the pills was an antibiotic and the other two were potassium pills. Resident #58 stated that they had not requested to self-administer medications and had not been assessed to do so. Review of Resident #58's health record revealed no assessment to self-administer medications. Resident #58's Progress Notes revealed a note, dated 10/01/2024 at 4:15 PM, that indicated the writer observed the resident unfold a tissue that showed three white pills, and the resident stated they were left by the nurse for the resident to take. The note indicated the resident voiced concerns regarding medication administration, medication availability, and response to concerns. 5. An Admission Record indicated the facility most recently readmitted Resident #82 on 09/10/2024. According to the Admission Record, the resident had a medical history that included diagnoses of encephalopathy (disease that affected the brain), urinary tract infection, sepsis (infection of the blood stream), bacteremia (presence of bacteria in the blood), type 2 diabetes mellitus, essential (primary) hypertension, major depressive disorder, and benign prostatic hyperplasia (BPH). An admission MDS, with an ARD of 09/13/2024, revealed Resident #82 had a BIMS score of 12, which indicated the resident had moderate cognitive impairment. An observation on 09/30/2024 at 11:03 AM revealed Resident #82 had two cups of pills on the over-the-bed table in front of them. During an interview at the time of the observation, the resident stated the nurses left the pills until they were ready to take them. The resident stated they were unsure what medications they took. Review of Resident #82's health record revealed no assessment to self-administer medications. During an interview on 10/04/2024 at 2:28 PM, Licensed Vocational Nurse (LVN) #3 stated medications were not to be left at the bedside. He stated he was unsure about the facility's self-administration assessment and was not aware if Resident #58 or Resident #82 had assessments completed to determine if they were safe to self-administer their own medications. He stated that he did not feel it would be safe for either resident to self-administer medications. During an interview on 10/04/2024 at 2:41 PM, the Infection Preventionist Licensed Vocational Nurse stated medications were never to be left at the bedside, even if a resident was able to self-administer. She stated that if a resident requested to self-administer their medications, then an assessment needed to be completed, which had to be reviewed and approved by the interdisciplinary team (IDT). She stated she was not aware of Resident #58 or Resident #82 having self-administration assessments and stated that their medications should not be left at the bedside. During an interview on 10/05/2024 at 8:24 AM, LVN #6 stated medications should not be left at the bedside. She stated she had to make sure a resident took their medications before she left the room. During an interview on 10/05/2024 at 9:18 AM, the Director of Nursing (DON) stated medications were not allowed to be left at the bedside, and a resident should be assessed prior to self-administering their own medications. She stated they did not have any residents in the facility who were to self-administer medications. She stated that, if they did, the medications would be kept in a locked box. During an interview on 10/05/2024 at 10:51 AM, the Administrator stated medications should not be left at a resident's bedside, and if a resident wanted to administer their own medications, an assessment needed to be done and a physician's order needed to be obtained. He stated all medications should be kept with a nurse.

Based on observation, interview, and facility policy review, the facility failed to ensure medications were labeled and stored properly in medication carts located on 2 (South 2 Unit and North 1 Unit) of 4 units in the facility. Specifically, the South 2 Unit medication cart contained loose pills, and a topical medication and nebulizer solution were not stored separately from medications to be given by mouth, in accordance with the facility's policy. The North 1 Unit medication cart contained a bottle of guaifenesin oral solution (cough medicine) with an illegible expiration date. Findings included: A facility policy titled, Medication Administration, dated 03/01/2023, specified, 1. Keep medication cart clean, organized, and stocked with adequate supplies. The policy also indicated, 12. Identify expiration date. If expired, notify nurse manager. A facility policy titled, Medication Storage, dated 03/01/2023, specified, It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to manufactures recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. The policy also indicated, 3. External Products: Disinfectants and drugs for external use are stored separately from internal and injectable medications. 4. Internal Products: Medications to be administered by mouth are stored separately from other formulations (i.e. [id est, such as] eye drops, ear drops, injectables). An observation of the medication cart on the South 2 Unit with Registered Nurse (RN) #4 on 10/01/2024 at 3:37 PM revealed four loose pills behind the medication cards in the top drawer and one loose pill in the second drawer. The bottom left drawer contained a box of diclofenac topical gel (a topical nonsteroidal anti-inflammatory gel used for pain relief), nebulizer medications, and antidiarrheal medications. During a concurrent observation of the medication cart on the North 1 Unit and interview with Licensed Vocational Nurse (LVN) #7 on 10/04/2024 at 10:28 AM revealed a bottle of guaifenesin oral solution with the expiration date smudged off and illegible. LVN #7 confirmed the expiration date was not visible. During an interview on 10/04/2024 at 10:34 AM, LVN #7 stated it was each charge nurse's responsibility to ensure the medication cart was clean and organized for the oncoming shift, but the nurse managers were responsible for going through the carts to ensure there were no expired medications. She stated she was unsure how often it was done. During an interview on 10/04/2024 at 11:04 AM, RN #10, who also served as the nurse manager for the North Units, stated the charge nurse was responsible for ensuring the medication cart was clean and organized, and it was the responsibility of the nurse managers to check the cart periodically for expired medications and to ensure it was organized appropriately. RN #10 stated if an expiration date on a medication could not be seen, then the medication should be discarded and a new supply obtained. During an interview on 10/04/2024 at 2:28 PM, LVN #3 stated the charge nurse was responsible for the cleanliness and organization of the medication carts and for checking for expired medications. He stated oral medications should not be stored with topical medications. LVN #3 stated if a medication had an expiration date that was not legible, then it should be discarded. During an interview on 10/04/2024 at 2:41 PM, Infection Prevention LVN (IP LVN) stated the cleanliness and organization of the medication carts was the responsibility of the charge nurses, and the charge nurses were also responsible for checking for expired medications. She stated oral medications should not be stored with topical medications. IP LVN stated if a date on a medication could not be seen, then the medication should be discarded. During an interview on 10/05/2024 at 8:24 AM, LVN #6 stated the nurses working on the medication carts were responsible for ensuring they were clean and organized, and the department head checked the medication cart every day at the end of their shift. LVN #6 further stated if an expiration date was rubbed off a medication, the medication should be discarded. During an interview on 10/05/2024 at 9:18 AM, the Director of Nursing (DON) stated the nurses were responsible for the medication carts, and oral medications should be kept away from topical medications. She stated if an expiration date was not able to be seen, then staff should discard it and get new medication. During an interview on 10/05/2024 at 10:51 AM, the Administrator stated the medication carts were the responsibility of the nurses working the cart, and the nurses should ensure expired medications were removed daily. He stated he was unsure what should occur if an expiration date was not visible.

Based on observation, interview, facility document review, and facility policy review, the facility failed to ensure each resident had a safe and homelike environment by ensuring rooms were free of damage for 2 (Resident #112 and Resident #82) of 24 sampled residents. Findings included: A facility policy titled, Safe and Homelike Environment, dated 06/01/2023, revealed, In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. An undated facility policy titled, Maintenance Inspection, revealed, 1. The Director of Maintenance Services or designee will perform routine inspections of the physical plant using the maintenance checklist. The policy revealed, 3. All opportunities will be corrected immediately by maintenance personnel. 1. An Admission Record revealed the facility admitted Resident #112 on 05/06/2024. According to the Admission Record, the resident had a medical history that included a diagnosis of depression. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/15/2024, revealed Resident #112 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. An observation on 10/01/2024 at 10:29 AM, revealed a tennis ball sized hole in the bathroom door in Resident #112's room. The facility's Maintenance Request forms for the timeframe from 05/21/2024 through 09/23/2024, revealed no maintenance request for Resident #112's room. During an interview on 10/01/2024 at 10:30 AM, Certified Nurse Assistant (CNA) #14 stated that she had first seen the hole in the door in Resident #112's room in July 2024. CNA #14 revealed that she had not notified the maintenance staff of the hole in the door. She stated that she should have written a maintenance request. During an interview on 10/02/2024 at 2:56 PM, the Administrator revealed that the maintenance request records were started in May 2024, he stated there was no process to document maintenance requests prior to then. During an interview on 10/04/2024 at 2:08 PM, the Administrator revealed that he had been the acting maintenance director since August 2024. He stated that it was his responsibility to ensure the building was clean and there was a homelike environment for the residents. He stated that things that needed to be fixed must be documented in the maintenance log. The Administrator stated that he was not aware of any maintenance requests for Resident #112's room. The Administrator stated that he expected all the resident rooms to be in good repair. He stated that he expected damage to be reported to him and for the damage to be fixed in a timely manner. During an interview on 10/04/2024 at 2:27 PM, Licensed Vocational Nurse (LVN) #7 revealed that if any resident rooms had holes in the walls, there should be a maintenance request to fix the damage. An observation on 10/04/2024 at 2:37 PM, revealed the bathroom door in Resident #112's room remained with a tennis ball sized hole in it. An observation on 10/05/2024 at 8:53 AM, revealed the bathroom door in Resident #112's room remained with a hole in it. During a concurrent interview, Resident #112 stated that the hole in the door had been there since they had moved to that room. During an interview on 10/05/2024 at 9:23 AM, the Director of Nursing (DON) revealed that when the nursing staff entered residents' rooms, they should document any room damage in the maintenance binder. The DON stated that the maintenance staff checked the binder daily. Per the DON, the residents should have a homelike environment and stated that having a hole in a wall did not create a homelike environment. 49044 2. A facility policy titled, Electrical Cord Safey Policy, dated 06/01/2024, revealed It is our policy to provide a safe and healthful environment. There is an increasing need for electrical equipment in our facility. The intent of this policy is to provide staff with information about our facility's method for ensuring safety as related to electrical wiring and equipment. An Admission Record revealed the facility admitted Resident #82 on 09/10/2024. According to the Admission Record, the resident had a medical history that included diagnoses of difficulty in walking and muscle weakness. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/13/2024, revealed Resident #82 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. During an observation in Resident #82's room on 09/30/2024 at 11:03 AM, the plate cover for the resident's call light appeared to be coming off the wall. An observation of Resident #82's room on 10/02/2024 at 2:45 PM, revealed the cover for the call light electrical box located on the wall behind the resident's bed was crooked and not fully attached, allowing wires to be exposed. During a concurrent interview, Resident #82 stated that in the past, staff had come in and said that their call light was always on and saw that the cover was off. Resident #82 stated that the call light issue was resolved; however, the electrical box had not been repaired. The facility's Maintenance Request forms for the timeframe from 05/21/2024 through 09/23/2024, revealed there were no documented requests to repair the electrical box in Resident #82's room. During an interview on 10/04/2024 at 1:55 PM, Janitor #8 stated he had not seen any rooms with outlet covers askew or coming off. He stated maintenance was responsible for repairs, but they did not have a facility maintenance director at that time. During an interview on 10/04/2024 at 2:08 PM, the Administrator stated he had been the acting maintenance director since August 2024. He stated no one had reported an issue with Resident #82's room. The Administrator stated his expectation was that the facility be up to code on the requirements for electrical wiring and if there were any issues they would call an electrician.

Based on interview, record review, and facility policy review, the facility failed to ensure the physician was notified when blood sugar levels were 350 milligrams per deciliter (mg/dL) or higher in accordance with the facility's Hypoglycemia [low blood sugar levels]/Hyperglycemia [high blood sugar levels] Management policy for 1 (Resident #11) of 5 sampled residents reviewed for unnecessary medications. Findings included: A facility policy titled, Hypoglycemia/Hyperglycemia Management, implemented 06/01/2023 revealed, Policy: It is the policy of this facility to ensure effective management of a resident who experiences a hypoglycemic and hyperglycemic episodes. The policy specified, If the blood sugar reading is 350 mg/dL or higher, the nurse will contact the practitioner to receive further orders for treatment. An Admission Record revealed the facility admitted Resident #11 on 10/16/2014. According to the Admission Record, the resident had a medical history that included diagnoses of type two diabetes mellitus without complications and long-term (current) use of insulin. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/19/2024, revealed Resident #11 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident had intact cognition. The MDS indicated the resident received insulin injections all seven days of the assessment look-back period. Resident #11's care plan revealed a focus area, initiated on 02/02/2024, that indicated the resident had diabetes mellitus. Resident #11's Order Summary Report, listing active orders as of 10/02/2024, revealed an order, started on 08/31/2023, for Novolog 70/30 subcutaneous suspension (a mixture of a rapid-acting and a intermediate-acting insulin), 10 units subcutaneously two times a day for diabetes mellitus. The order also directed staff to monitor and document the resident's blood sugar levels. Resident #11's July 2024 Medication Administration Record (MAR) revealed staff documented Resident #11's blood sugar monitoring daily at 7:00 AM, 9:00 AM, and 5:00 PM. Documentation reflected the resident's blood sugar was 350 mg/dL or higher on 07/09/2024 at 9:00 AM, 07/14/2024 at 9:00 AM, 07/15/2024 at 9:00 AM, 07/16/2024 at 5:00 PM, 07/17/2024 at 5:00 PM, and 07/20/2024 at 5:00 PM. Resident #11's Progress Notes for the timeframe from 07/03/2024 through 08/02/2024 did not include any documentation that indicated the physician was notified when the resident's blood sugar was 350 mg/dL or higher. During an interview on 10/04/2024 at 1:39 PM, Licensed Vocational Nurse (LVN) #3 stated he did not have to call the physician very often about residents' blood sugar levels but would contact the physician if a resident's blood sugar was over 400 mg/dL. During an interview on 10/04/2024 at 3:40 PM, Registered Nurse (RN) #17 stated staff should contact the resident's physician if a resident had a blood sugar over 400 mg/dL to 500 mg/dL. RN #17 stated they did not always call each time a resident had high blood sugar levels, because some resident's tended to have higher levels. During an interview on 10/04/2024 at 3:53 PM, RN #18 stated she was the evening shift supervisor. RN #18 stated if a resident's blood sugar was above 300 mg/dL most physicians wanted to be notified. During an interview on 10/05/2024 at 9:27 AM, the Director of Nursing (DON) stated she did not know at what point the physician should be notified regarding resident's blood sugar levels but indicated the orders should specify. During an interview on 10/05/2024 at 10:51 AM, the Administrator stated there should be an established level for when to contact the physician regarding residents' blood sugar levels, and if a resident's blood sugar met that level, staff should notify the physician.

Based on interview, record review, and facility document and policy review, the facility failed to ensure 1 (Resident #39) of 4 residents reviewed for advance directives had a physician's order that was consistent with the resident's Physician Orders for Life Sustaining Treatment (POLST) form, which indicated the resident elected do not resuscitate (DNR)/no cardiopulmonary resuscitation (CPR). Findings included: A facility policy titled, Communication of Code Status, dated [DATE], revealed, It is the policy of this facility to adhere to residents' rights to formulate advance directives. In accordance with these rights, this facility will implement procedures to communicate a resident's code status to those individuals who need to know this information. The policy revealed, 3. Communication of code status include resident orders and POLST form as applicable. According to the policy, 6. The resident's code status will be reviewed quarterly or as needed and any changes will be documented in the medical record and noted in orders as indicated. An Admission Record revealed the facility admitted Resident #39 on [DATE]. According to the Admission Record, the resident had a medical history that included diagnoses of neuropathy, type 2 diabetes, epilepsy, bipolar type schizoaffective disorder, dysphagia, and cognitive communication deficit. Per the Admission Record, Resident #39 was their own responsible party and had an advance directive that indicated DNR. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed Resident #39 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident had moderate cognitive impairment. A Physician Orders for Life-Sustaining Treatment (POLST), form signed by Resident #39 on [DATE], revealed the resident had elected Do not Attempt Resuscitation/DNR. The POLST revealed the physician signed the form on [DATE]. Resident #39's Order Summary Report, with active orders as of [DATE], contained an order dated [DATE], for Full Code. During an interview on [DATE] at 9:33 AM, Licensed Vocational Nurse (LVN) #12 stated when residents were admitted to the facility, nursing staff addressed the resident's code status. She stated all residents' POLST forms and physician orders should match. LVN #12 stated if the resident's code status changed, the nurse must document in the 24-hour report book. According to LVN #12, nursing staff were responsible for ensuring the resident's correct code status was documented. During an interview on [DATE] at 9:40 AM, LVN #13 stated staff were required to review the POLST form or the resident's admission record for the residents' code status. LVN #13 stated the code status documentation should match. During an interview on [DATE] at 10:13 AM, the Director of Nursing (DON) stated that nursing staff should look at the POLST form to determine a resident's code status. The DON stated the resident or responsible party, and the physician should sign the POLST form and the physician's order should match the POLST order. Per the DON, if there were changes to the POLST form, they should complete a new physician's order. During an interview on [DATE] at 9:21 AM, the DON stated she expected the resident's POLST form and physician order for code status to match. She stated if the physician's order was not clear, the staff should clarify the code status with the physician and the resident. During an interview with the Administrator on [DATE] at 11:45 AM, he stated not having an accurate code status could result in proper action not being taken and resident choices not being upheld.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure medication orders specified the intended dosages for 1 (Resident #32) of 4 residents whose physician's orders were reconciled during the medication administration task. Additionally, the facility failed to ensure nursing staff contacted the physician to obtain order clarifications for Resident #32's incomplete orders. Findings included: A facility policy titled, Medication Administration, dated 03/01/2023, specified, 10. Review MAR [medication administration record] to identify medication to be administered. 11. Compare medication source (bubble pack, vial, etc. [et cetera, and other similar things]) with MAR to verify resident name, medication name, form, dose, route, and time. The policy also indicated, 20. Correct any discrepancies and report to nurse manager, MD [medical doctor] and/or DON [Director of Nursing]. An Admission Record indicated the facility admitted Resident #32 on 03/29/2024. According to the Admission Record, the resident had a medical history that included diagnoses of essential (primary) hypertension, chronic systolic (congestive) heart failure, and alcohol-induced acute pancreatitis without necrosis (cell injury resulting in premature death of body tissue) or infection. Resident #32's Order Summary Report, listing active orders as of 10/03/2024, contained orders dated 07/19/2024 for folic acid, vitamin A, vitamin B6, and vitamin D3 with instructions to give one tablet of each by mouth one time a day for supplement; however, the orders did not specify the dosages of each medication to be given. During an observation of medication pass on 10/02/2024 at 8:46 AM, Licensed Vocational Nurse (LVN) #3 prepared and administered medications for Resident #32, including one tablet of folic acid 1,000 micrograms (mcg), one tablet of vitamin B6 25 milligrams (mg), one tablet of vitamin D3 1,000 international units (IU), and one capsule of vitamin A 3,000 mcg. During an interview on 10/02/2024 at 4:07 PM, LVN #3 stated he used the facility's stock bottles for Resident #32's supplements and confirmed the resident's orders did not specify the ordered dosages. LVN #3 stated he should have contacted the physician to get clarification on the orders. During an interview on 10/04/2024 at 2:41 PM, the Infection Prevention LVN (IP LVN) stated if a medication order did not include the dosage, nursing staff should contact the physician for clarification. During an interview on 10/05/2024 at 8:24 AM, LVN #6 stated if a medication order did not specify the dosage to be given, the nurse needed to contact the physician to clarify the order prior to administering the medication. During an interview on 10/05/2024 at 9:18 AM, the DON stated physician's orders should include the resident's name, the medication, the dose, the route, and the time. The DON further stated nurses needed to check medication orders and contact the physician to clarify the intended dosage, if needed. During an interview on 10/05/2024 at 10:51 AM, the Administrator stated nurses should be following physician's orders and should obtain clarification if needed.

Based on interview, record review, and facility document and policy review, the facility failed to ensure 1 (Resident #39) of 3 residents reviewed for preadmission screening and resident review (PASARR) requirements was referred to the state-designated authority for a Level II PASARR evaluation following a positive Level I PASARR screening. Findings included: A facility policy titled Resident Assessment-Coordination with PASARR Program, implemented 09/01/2023, revealed 1. All applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the State's Medicaid rules for screening. a. PASARR Level I- initial pre-screening that is completed prior to admission i. Negative Level I Screen- permits admission to proceed and ends the PASARR process unless a possible serious mental disorder or intellectual disability arises later. ii. Positive Level II Screen- necessitates a PASARR Level II evaluation. B. PASRR Level II- a comprehensive evaluation by the appropriate state-designated authority (cannot be completed by the facility) that determines whether the induvial has MD [mental disability], ID [intellectual disability], or related condition, determines the appropriate setting for the individual, and recommends any specialized services and/or rehabilitative services the individual needs. 2. The facility will only admit individuals with a mental disorder or intellectual disability who the State mental health or intellectual disability authority has determined as appropriate for admission. The policy also specified, 5. The Social Services Director and/or MDS [Minimum Data Set] Coordinator shall be responsible for keeping track of each resident's PASARR screening status, and referring to the appropriate authority. An Admission Record revealed the facility admitted Resident #39 on 06/14/2024. According to the Admission Record, the resident had a medical history that included a diagnosis of bipolar type schizoaffective disorder. An admission MDS, with an Assessment Reference Date (ARD) of 06/17/2024, revealed Resident #39 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident had moderate cognitive impairment. The MDS indicated Resident #39 had an active diagnosis of schizophrenia. Resident #39's Level I PASARR screening, dated 06/14/2024, revealed the resident had a serious diagnosed mental disorder, specifically schizoaffective disorder. The Level I PASARR screening was positive for a suspected mental illness, and a Level II PASARR evaluation was required. Resident #39's medical record revealed no documented evidence that a Level II PASARR evaluation was completed. During an interview on 10/04/2024 at 11:10 AM, MDS Licensed Vocational Nurse (MDS LVN) #25 stated Resident #39 was not referred to the PASARR office in June 2024 when their Level I PASARR screening was positive. MDS LVN #25 stated a request for a Level II PASARR evaluation was not completed until the surveyor asked about it during the survey. During an interview on 10/05/2024 at 9:17 AM, the Director of Nursing (DON) stated that when a resident had a positive Level I PASARR screening, MDS staff should coordinate with the PASARR office to ensure the evaluation was completed. During an interview on 10/05/2024 at 11:13 AM, the Administrator stated MDS staff were responsible for contacting the PASARR office within a timely manner to ensure Level II PASARR evaluations were completed when indicated.

Based on interview, record review, facility policy review, and review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, the facility failed to ensure Minimum Data Set (MDS) assessments accurately reflected whether 1 (Resident #12) of 3 sampled residents reviewed for Preadmission Screening and Resident Review (PASRR) requirements was considered by the state Level II process to have a serious mental illness, intellectual disability, or a related condition. Findings included: A facility policy titled, Conducting an Accurate Resident Assessment, dated 09/01/2024, revealed, The purpose of this policy is to assure that all residents receive an accurate assessment, reflective of the resident's status at the time of the assessment, by staff qualified to assess relevant care areas. The policy revealed, 6. A registered nurse will sign and certify that the assessment/correction request is completed. Each individual who completes a portion of the assessment will sign and certify the accuracy of that portion of the assessment. Whether the MDS assessments are manually completed, or computer generated following data entry, each individual assessor is responsible for certifying the accuracy of responses relative to the resident's condition and discharge or entry status. The Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.18.11, dated October 2023, revealed section A1500: Preadmission Screening and Resident Review (PASRR) included Coding Instructions that specified to - Code 0, no: and skip to A1550, Conditions Related to ID [intellectual disabilities]/DD [developmental disabilities] Status, if any of the following apply: - PASRR Level I screening did not result in a referral for Level II screening, or - Level II screening determined that the resident does not have a serious MI [mental illness] and/or ID/DD or related conditions, or - PASRR screening is not required because the resident was admitted from a hospital after requiring acute inpatient care, is receiving services for the condition for which they received care in the hospital, and the attending physician has certified before admission that the resident is likely to require less than 30 days of nursing home care. -Code 1, yes: if PASRR Level II screening determined that the resident has a serious mental illness, and/or ID/DD or related condition, and continue to A1510, Level II Preadmission Screening and Resident Review (PASRR) Conditions. An Admission Record indicated the facility originally admitted Resident #12 on 05/22/2014 and most recently admitted the resident on 04/26/2024. According to the Admission Record, the resident had a medical history that included a diagnosis of schizophrenia. A PASRR Level II determination report, dated 07/11/2022, revealed Resident #12 required nursing facility services due to a medical and/or mental health condition. The determination report indicated specialized services were recommended to supplement nursing facility care to address mental health needs. However, Resident #12's annual MDS, with an Assessment Reference Date (ARD) of 06/26/2024, revealed section A1500 was coded as 0, indicating the resident was not considered by the state level II PASRR process to have serious mental illness, intellectual disability, or a related condition. During an interview on 10/03/2024 at 9:51 AM, MDS Licensed Vocational Nurse (LVN) #25 stated that when completing MDS assessments, she reviewed hospital discharge summaries, physician's orders, therapy notes, social services notes, dietary notes, and activity notes. She stated that since Resident #12 had a Level II determination letter, their MDS should have been coded as yes to indicate the resident was considered by the state level II PASRR process to have serious mental illness, intellectual disability, or a related condition. She stated she was not sure why it was missed. During an interview on 10/05/2024 at 9:18 AM, the Director of Nursing (DON) stated MDS assessments needed to be accurate, and the MDS staff were responsible for ensuring the accuracy of the MDS assessments. During an interview on 10/05/2024 at 10:51 AM, the Administrator stated the accuracy of MDS assessments was the responsibility of the MDS staff. He stated MDS assessments needed to be accurate to ensure residents received the appropriate level of care and services.

Based on observation, interview, and record review, the facility failed to ensure one (Resident 2) of three sampled residents was provided one-to-one supervision as ordered for aggressive behaviors. The failure to provide Resident 2 with continual one-to-one supervision resulted in Resident 2 being unsupervised for six minutes and had the potential to result in serious injury to other residents. The Chief Nursing Officer (CNO), the Administrator (Admin), the Administrator In Training (AIT), the Quality Assurance Consultant (QAC), and the Minimum Data Set Consultant (MDSC), were notified of the Immediate Jeopardy (IJ, a situation in which a provider's noncompliance with one or more requirements of participation have caused or is likely to cause serious injury, harm, impairment, or death to a patient/resident), on 12/21/23, at 2:55 p.m., for the facility's failure to provide one-to-one supervision to protect facility residents from abuse by Resident 2, a resident known to have physically aggressive behavior. An acceptable Action Plan was received on 12/21/23. Through observation, interviews and record reviews, an on-site survey on 12/21/23, determined the facility had removed the IJ by: implementation of one-to-one sitter policy which included duties, responsibilities and documentation requirements; immediate education of all clinical staff and sitters on the policy, process, and documentation of one-to-one supervision, including sitter break relief; implementation of monitoring tools and checklists to ensure documentation of necessary tasks/duties of one-to-one sitters are completed. The IJ was removed on 12/21/23, at 4:35 p.m., while onsite with the Chief Nursing Officer (CNO), the Administrator (Admin), the Administrator In Training (AIT), the Quality Assurance Consultant (QAC), and the MDS Consultant (MDSC), and the scope and severity was lowered to an isolated deficiency with no actual harm with the potential for more than minimal harm that is not immediate jeopardy. See tags F 600, F 609, F 940 Findings: During a review of Resident 2's Admission Record, undated, the Admission Record indicated the facility admitted Resident 2 in October 2023. The Admission Record indicated Resident 2 had diagnoses which included mental conditions which made it difficult to think clearly, have normal emotional responses, act normally in social situations, tell the difference between what was real and what was not real, to have firmly held beliefs which were contrary to reality, to have wide or extreme swings in mood from periods of feeling sad and depressed to periods of intense excitement and activity or irritability. The Admission Record indicated Resident 2 had a conservator for healthcare decisions (a person appointed through legal proceedings to make healthcare and/or financial decisions for a person adjudged to be without mental capacity to make such decisions), and a responsible party with financial Power of Attorney (the legal power to make financial decision). During a review of Resident 2's MDS (a comprehensive assessment tool to guide care) dated 10/9/23, the MDS indicated Resident 2 was moderately impaired in the ability to communicate and understand others. The MDS also indicated Resident 2 used a wheelchair for mobility and required only minimal assistance from staff with activities of daily living (eating, toileting, bathing, oral hygiene, personal hygiene, dressing, putting on and off footwear and transferring between surfaces). During a review of Resident 2's care plan titled, The Resident is at Risk for Behavior Problems, initiated 10/6/23, the care plan indicated the behavioral problems were due to medical needs, amputation, mental condition, history of substance abuse, moderately impaired cognition (the abilities to think, reason and remember), and traumatic brain injury. (TBI, injury to the brain resulting from force applied to the brain as in a physical hit or a bullet into the head. TBI can cause temporary or short-term problems with normal brain function, including problems with how the person thinks, understands, moves, communicates, and acts.) Care plan interventions to reach the goal of decreased episodes included: staff were to intervene as necessary to protect the rights and safety of others; approach/speak in a calm manner; divert attention; remove from situation and take to alternate location as needed; provide quiet environment and decreased stimuli to de-escalate behaviors. During a review of Resident 2's Psychiatric Consult Progress Report dated 10/18/23, the Progress Report indicated Resident 2 had been at an inpatient psychiatric facility for three months prior to admission at the facility for treatment of agitation and threatening behaviors. The Progress Report indicated Resident 2 was a high risk for assaultive behaviors. During an interview 12/15/23 at 1:15 p.m., the Administrator stated police had removed Resident 2 from the facility on 12/15/23 around 2:30 a.m., on a 5150 hold. (5150, a legal order for involuntary detention for up to 72 hours for psychiatric evaluation to determine if an individual is a danger to themselves or others.) The Administrator stated staff had suspicions Resident 2 had been involved with injuries sustained by her roommate, Resident 1, who had been found on the floor around midnight, bleeding from a head wound. The Administrator stated there were no witnesses to the event, but Resident 2 had told staff there was blood on her leg because Resident 1 had tried to scratch her. The Administrator stated staff did not believe the blood was due to Resident 1 scratching Resident 2, as Resident 1 was not able to move out of bed without assistance, and Resident 2 did not have any visible wounds. During a review of Resident 2's acute care hospital record, Emergency Department Note, Discharge Plan, dated 12/15/23, the Note indicated Resident 2 had been cleared from the 5150 involuntary hold by psychiatry and was discharged back to the skilled nursing facility on 12/15/23 at 5:30 p.m. During a review of Resident 2's nursing progress notes dated 12/15/23 at 6:30 p.m., the notes indicated Resident 2 returned to the facility on [DATE] at 6:25 p.m. During a review of Resident 2's facility record, Physician's Orders, Order Details, dated 12/15/23 at 7:37 p.m., the Physician's Order indicated an order for one-to-one supervision. During a review of Resident 2's care plan titled, Resident on 1:1 (one-to-one) Supervision, dated 12/15/23, the care plan indicated the goal was for Resident 2 to have no complications related to behavior issues. The care plan included the interventions of one-to-one supervision/sitter 24/7 (24 hours per day, seven days per week) at bedside, and will monitor resident for behavior. During a concurrent observation and interview on 12/21/23, at 11:00 a.m., the entry door to Resident 2's single-occupancy room was unattended; inside the room, there were no occupants in the room except for Resident 2 who lay in bed, the head of the bed elevated, awake. When questioned about the events of 12/15/23, Resident 2 stated on 12/15/23, just past midnight, she became irritated with Resident 1 because Resident 1 was yelling and screaming for the nurses. Resident 1 stated she threw her water bottle at Resident 1, the water bottle struck Resident 1 in the head, and Resident fell off the bed. Resident 2 stated she self-transferred into her wheelchair and went over to try to make Resident 1 be quiet, and Resident 1 defensively attempted to scratch Resident 2. During an observation and interview on 12/21/23, at 11:06 a.m., Hospitality Aide 1 (HA 1) stood in the entry door to Resident 2's room, and stated she was Resident 2's assigned one-to-one sitter. During an interview on 12/21/23, at 12:30 p.m., with HA 1, HA 1 stated Resident 2 did not like to have a sitter present inside Resident 2's room, so the sitter would stay outside the room near the door. HA 1 stated she had left Resident 2's room unattended on 12/21/23, at 11:06 a.m., because she needed to take a personal break for approximately seven minutes. HA 1 stated she told two certified nursing assistants (CNA 2 and CNA 3) assisting another resident inside a nearby room, that she was taking a break from monitoring Resident 2. During an interview on 12/21/23, at 2:25 p.m., with CNA 2, CNA 2 stated she was in resident room B, assisting CNA 3 with resident care at 11 a.m. that morning. CNA 2 stated she was not able to see Resident 2's room or the entry door to Resident 2's room from her location in resident room B. During an interview on 12/21/23, at 2:35 p.m., with CNA 3, CNA 3 stated she had not heard CNA 1 ask for help with supervision of Resident 2 while CNA 1 went on a break. CNA 3 stated she had been in room B with CNA 2, providing resident care and had not been able to see Resident 2's room or entry door. During an interview on 12/21/23, at 2:40 p.m., with the facility's Director of Nursing (DON), the DON stated the expectation for a one-to-one sitter was for the sitter to stay with the resident. The DON stated if the sitter needed a break, the sitter was to endorse supervision to either the assigned certified nursing assistant or a licensed nurse.

Based on observation, interview and record review, the facility failed to protect one (Resident 1) of three sampled residents from abuse when the facility roomed Resident 2, a resident with known angry outbursts and a potential for assaultive behaviors, with Resident 1, a bedridden, vulnerable resident. This failure resulted in Resident 2 physically assaulting Resident 1 within hours of being moved into a shared room with Resident 1. As a result of Resident 2's assault, Resident 1 required admission to the hospital for closure of a scalp laceration (cut) with staples (metallic staples to hold wound edges together until the wound is healed), a fractured (broken) cheek bone, and a concussion. (A brain injury that occurs when the head hits an object, or a moving object strikes the head. A concussion may lead to headaches, changes in alertness, unconsciousness/coma, memory loss, and changes in thinking.) See also F 609 and F 689. Findings: During a review of Resident 1's Admission Record, undated, the Admission Record indicated Resident 1 was admitted in 2021, with diagnoses which included a cerebral infarction (death of an area of brain tissue when a blocked blood vessel prevents delivery of an adequate blood and oxygen supply to the brain), hemiplegia (left sided paralysis or inability to or difficulty to move one side of the body), and anxiety. The Admission Record indicated Resident 1 had a Responsible Party (RP 1) for healthcare decisions. During a review of Resident 1's Minimum Data Set (MDS-a comprehensive assessment tool to guide care) dated 10/18/23, the MDS indicated Resident 1 predominantly used a non-English language, had impaired vision due to partial blindness; was sometimes able to understand what others said, and could sometimes be understood; Resident 1 had problems with short-term and long-term memory. The MDS indicated Resident 1 required staff to provide partial assistance with eating, and maximal assistance for transfers between surfaces (such as bed to wheelchair), and all other activities of daily living (oral hygiene, personal hygiene, toileting, dressing upper and lower body) The MDS indicated Resident 1 had dementia (a loss of brain function that occurs with certain diseases, affecting one or more brain functions such as memory, thinking, language, judgment, or behavior). During a review of Resident 1's care plan, initiated 10/18/23, the care plan indicated Resident 1 had impaired cognition (the abilities to think, reason, and remember) or impaired thought processes related to dementia. The facility's goal for Resident 1 on 11/18/23 was to maintain current level of cognitive function. On 11/10/23, the facility added to Resident 1's care plan, Resident is at risk for falls and/or injuries related to history of falls dementia, incontinence, poor safety awareness. The facility's goal for Resident 1 was to minimize risk for falls. On 11/10/23, the facility added to Resident 1's care plan, Resident requires assistance with ADLs (activities of daily living) related to muscle weakness, stroke, dementia, and hemiplegia. The facility's goal was Resident 1 would not have a decline in self-care. During a review of Resident 2's Admission Record, undated, the Admission Record indicated the facility admitted Resident 2 in October 2023. The Admission Record indicated Resident 2 had diagnoses which included mental conditions which made it difficult to think clearly, have normal emotional responses, act normally in social situations, tell the difference between what was real and what was not real, to have firmly held beliefs which were contrary to reality, to have wide or extreme swings in mood from periods of feeling sad and depressed to periods of intense excitement and activity or irritability. The Admission Record indicated Resident 2 had a conservator for healthcare decisions (a person appointed through legal proceedings to make healthcare and/or financial decisions for a person adjudged to be without mental capacity to make such decisions), and a responsible party with financial Power of Attorney (the legal power to make financial decision). During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2 was moderately impaired in the ability to communicate and understand others. The MDS also indicated Resident 2 used a wheelchair for mobility and required only minimal assistance from staff with activities of daily living (eating, toileting, bathing, oral hygiene, personal hygiene, dressing, putting on and off footwear and transferring between surfaces). During a review of Resident 2''s care plan titled, The Resident is at Risk for Behavior Problems, initiated 10/6/23, the care plan indicated the behavioral problems were due to medical needs, amputation, mental condition, history of substance abuse, moderately impaired cognition, and traumatic brain injury. (TBI, injury to the brain resulting from force applied to the brain as in a physical hit or a bullet into the head. TBI can cause temporary or short-term problems with normal brain function, including problems with how the person thinks, understands, moves, communicates, and acts.) Care plan interventions to reach the goal of decreased episodes included staff were to intervene as necessary to protect the rights and safety of others; approach/speak in a calm manner; divert attention; remove from situation and take to alternate location as needed; provide quiet environment and decreased stimuli to de-escalate behaviors. During a review of Resident 2's Psychiatric Consult Progress Report dated 10/18/23, the Progress Report indicated Resident 2 had been at an inpatient psychiatric facility for three months prior to admission at the facility for treatment of agitation and threatening behaviors. The Progress Report indicated Resident 2 was a high risk for assaultive behaviors. During a review of Resident 2's Medication Administration Record (MAR) dated December 2023, the MAR indicated Resident 2 had verbal and physical angry outbursts seven times on 12/10/23, and six times on 12/14/23. During a review of Resident 2's nursing progress notes dated 12/14/23 at 10:55 a.m., the progress notes indicated the Interdisciplinary Team (IDT, a consulting team that includes staff members from multiple disciplines such as nursing, therapy, physicians, and other advanced practitioners.) had reviewed current room allocations and decided to move Resident 2 into a new room in order to provide a quiet/low stimuli environment as Resident 2's current roommate played loud music, spoke loudly, and had a lot of visitors. The notes indicated the IDT team determined Resident 1's room would be the best choice for Resident 2's new room. During a review of Resident 2's nursing progress notes dated 12/14/23 at 1:30 p.m., the progress notes indicated Resident 2 had moved into the new room, which was shared with Resident 1. During an interview on 12/20/23, at 2:46 p.m., with Registered Nurse 1 (RN 1), RN 1 stated she had been assigned to Resident 1 and Resident 2 on the night shift which started 12/14/23 at 11 p.m. RN 1 stated she had gone into the shared room at 11:15 p.m. to do a visual check: Resident 1 was sleeping, and Resident 2 had told her to turn off the light and leave the room. RN 1 stated the door to Resident 1 and 2's shared room had been closed at 11:45 p.m. RN 1 stated at midnight, she saw Resident 2 at the nursing station talking with Certified Nursing Assistant 4 (CNA 4). RN 1 stated a short time later, she was called into the room shared by Resident 1 and 2, and saw multiple staff members with Resident 1, who was on the floor bleeding from the head. RN 1 stated Resident 1 was opening and closing her eyes and speaking, but her words could not be understood. RN 1 stated she called emergency services for assistance, and paramedics and the police arrived. During an interview on 12/21/23, at 3:08 p.m. with Certified Nursing Assistant 4 (CNA 4), CNA 4 stated when at the nursing station on the early morning of 12/15/23, Resident 2 had come to the nursing station in a wheelchair and said someone was on the floor. CNA 4 stated she saw blood on Resident 2's left leg, and quickly went into the room shared by Resident 2 and Resident 1. CNA 2 stated upon entering the shared room, she saw Resident 1 on the floor, bleeding. CNA 2 stated she called for assistance from the assigned CNA and the licensed nurses. During a review of Resident 2's nursing progress notes dated 12/15/23, at 2:51 a.m., by RN 1, the notes indicated on 12/14/23 at around 11:15 p.m., RN 1 made rounds and saw Resident 1 asleep in the bed. The notes indicated around midnight Resident 2 was in the wheelchair outside the shared room of Resident 1 and 2, and Resident 2 told CNA 4 that Resident 1 had scratched her. The notes indicated CNA 4 noticed blood spots on Resident 2's foot, so went into the shared room of Resident 1 and 2 to check on Resident 1. The notes indicated RN 1 immediately called 911 because Resident 1 was on the floor and bleeding from the head; Resident 2 remained outside the room. The notes indicated the police took Resident 2 to the acute care hospital for psychiatric evaluation under an involuntary detention order. (5150, a legal order for involuntary detention for up to 72 hours for psychiatric evaluation to determine if an individual is a danger to themselves or others.) During a review of the Police Report, dated 12/15/2023, the Police Report indicated Police Officer (PO) was summoned and came to the facility to investigate a report of an assault between two residents. PO reported observing the following: the center of the room had the middle bed pushed aside. On a nearby bed table, PO reported seeing smears of blood on the table and on a plastic cup. On the floor, PO reported seeing a shattered plastic cup. PO said he could not determine if the cup was used as a weapon or if blood smears were caused by Resident 2 or the nurses who'd been cleaning the room prior to his arrival. PO said he could not determine if the broken cup occurred from falling on the ground or if Resident 1 had fallen onto the cup, causing it to shatter. PO reported he had reasonable suspicion to believe Resident 2 assaulted Resident 1, an [AGE] years old, with an unknown weapon, because they (Resident 1 and Resident 2) were the only two subjects in room [ROOM NUMBER]. PO reported Resident 2 suffered from a mental disorder that may have caused her to assault Resident 1. PO resported due to his inability to determine if Residetnt 2 had malicious intent towards Resident 1, he could not develop probable cause to believe Resident 2 knowingly committed the violation of assault. For this reason, PO reported he placed Resident 2 on a 72-hour psychiatric hold, pursuant to 5150 W&l (Welfare & Institution) Code. During a review of Resident 1's nursing progress notes dated 12/15/23, at 3:16 a.m., by RN 1, the notes indicated RN 1 had contacted emergency services after Resident 1 was found on the floor bleeding from a head wound, awake, nonverbal, but moaning. The notes indicated paramedics took Resident 1 by ambulance to acute care hospital. During a review of Resident 1's acute care hospital record, Trauma and Acute Care Surgery History & Physical, dated 12/15/23, the History and Physical indicated Resident 1 met criteria for trauma team activation, as Resident 1's condition/injury had a high probability of imminent or life-threatening deterioration of one or more vital organs/body systems. The History and Physical indicated Resident 1 had dementia, was bed bound, and was brought in by ambulance after being assaulted by another resident at the skilled nursing facility. The History and Physical indicated Resident 1 was struck on her face and head causing a fracture of her right cheek bone, a concussion, facial swelling and bruising, and lacerations to her right ear and right forehead with staples used to close the forehead laceration. The History and Physical indicated Resident 1 was admitted to the intensive care unit for continued care and treatment. During a concurrent observation and interview on 12/21/23, at 11:06 a.m., with Resident 2, in a single-occupancy room, Resident 2 lay in bed with the head of the bed elevated, awake. When questioned about the events of 12/15/23, Resident 2 stated on 12/15/23, just past midnight, she became irritated with Resident 1 because Resident 1 was yelling and screaming for the nurses. Resident 1 stated she threw her water bottle at Resident 1, the water bottle struck Resident 1 in the head, and Resident fell off the bed. Resident 2 stated she self-transferred into her wheelchair and went over to try to make Resident 1 be quiet, and Resident 1 defensively attempted to scratch Resident 2. During a telephone interview on 1/4/24, at 5:46 p.m., with Resident 1's Responsible Party (RP 1), RP 1 stated the facility contacted her on 12/15/23, at 1:18 a.m., and said Resident 1 had been taken to the emergency department at the acute care hospital. RP 1 stated she was contacted at 2:54 a.m. by police who reported Resident 1 had been assaulted and was injured with lacerations to the head. RP 1 stated she contacted a family member (RP 2) to check on Resident 1, as RP 1 was not able to go to the acute care hospital. During a phone interview on 1/4/24, at 7:53 p.m., with RP 2, RP 2 stated she had visited Resident 1 in the hospital the day after the event. RP 2 stated Resident 1 was almost unrecognizable, with her hair matted with dried blood, the right eye swollen shut, and bruising everywhere. RP 2 stated Resident 1 was moaning and would frequently sleep and then awaken crying and in pain. RP 2 stated Resident 1 made a statement that she had been sleeping when she was awakened by being hit and then kicked three times by Resident 2. RP 2 stated Resident 1 said she was afraid to go into a deep sleep. RP 2 stated Resident 1 kept repeating she did not want to return to the skilled nursing facility and that Resident 2 wanted to kill her.

Based on observation, interview, and record review, for one (Resident 1) of three sampled residents at risk of falls, the facility failed to implement an intervention to provide adequate supervision for Resident 1 when walking. The facility failed to implement the Interdisciplinary team (IDT, a group of healthcare professionals from various healthcare disciplines who collaborate to share expertise, knowledge, and skills to influence and improve patient care) intervention of, monitor whereabouts, recommended after Resident 1 fell on [DATE], by not ensuring there was a designated staff member to supervise Resident 1 when the assigned staff were all on a work break. These failures resulted in Resident 1 running into another resident ' s wheelchair while walking unsupervised, causing her to fall and hit the right side of her face, obtaining a facial laceration (cut) on the right side of the forehead and a left nasal bone fracture (partial or complete break in the bone). Resident 1 required transfer to Acute Care Hospital for further evaluation and required two stitches to maintain closure of the laceration wound edges. Findings: During a review of Resident 1 ' s Resident Face Sheet, dated 3/2/23, the Face Sheet indicated Resident 1 was admitted to the facility in 2017, with diagnoses of dementia (memory loss that interferes with activities of daily living) and unsteadiness when walking. During a review of Resident 1 ' s Minimum Data Set (MDS- an assessment tool to guide care) dated 12/27/22, the MDS indicated Resident 1 was not steady walking and required the supervision of one person when walking. The MDS indicated Resident 1 was only sometimes able to understand others and only sometimes was able to be understood. During a record review of Resident 1 ' s care plan titled, Falls, start date 3/31/22, the care plan showed Resident 1 was at high risk for falls related to faulty judgements and diminished mental status. The care plan indicated Resident 1 had a witnessed fall on 12/6/22. The care plan showed the interventions initiated after the 12/6/22 fall were to: notify physician and responsible party, 72-hour check of neurological signs (examination to check for changes in mental status), and IDT meeting to discuss plan of care. During a review of the facility provided document, Facility Observation Summary Report, dated 12/1/22 to 2/28/23, the Facility Observation Summary Report indicated Resident 1 had a witnessed fall on 12/6/22, and another witnessed fall on 2/18/23. During a review of Resident 1 ' s Observation Detail List Report titled, Risk Meeting Notes dated completed 12/30/22, with three signatures of IDT staff, the Risk Meeting Notes indicated Resident 1 ' s 12/6/22 fall was reviewed by IDT. The Risk Meeting Notes section titled, Plan of Care and Recommendations, indicated, Upon IDT review to continue resident plan of care .Monitor resident where abouts . During an observation on 3/2/23, at 10:53 a.m., in Resident 1 ' s room, Resident 1 paced around the room and mumbled words which were not understandable. Resident 1 was unresponsive when asked questions. Resident 1 had yellowish purple discolorations on both cheeks and a cut over the right eye with two (2) black sutures (stitches) holding the edges of the cut together. During an interview on 3/2/23, at 11:20 a.m., with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated she had been assigned to Resident 1 on 2/18/23, with RN 1 as her supervising charge nurse. CNA 1 stated at the time Resident 1 fell , she and RN 1 had been on their lunch break. CNA 1 stated she had not known who had supervised Resident 1 while she and RN 1 had both been on lunch break. CNA 1 stated prior to taking her lunch break, Resident 1 had been pacing in the hallway by herself. During an interview on 3/6/23, at 11:11 a.m., with RN 1, RN 1 stated he was on lunch break when Resident 1 fell on [DATE]. RN 1 stated prior to leaving on his lunch break Resident 1 was in bed watching television, and LVN 1 was at the medication cart next to the North nurse ' s station. RN 1 stated he told LVN 1 and CNA 1 he was going to take his lunch break and left. RN 1 stated he expected LVN 1 to provide supervision to RN 1 ' s assigned residents during his lunch break. RN 1 stated he knew Resident 1 was a fall risk and that Resident 1 walked fast, was confused, and often needed to be redirected. RN 1 stated when he returned from lunch break, LVN 1 reported Resident 1 had fallen and was bleeding a lot so he called an ambulance to transport Resident 1 to the hospital. During an interview on 3/2/23, at 11:01 a.m., with Licensed Vocational Nurse 1 (LVN 1), at the North nurse ' s station, LVN 1 stated on 2/18/23, she and Registered Nurse 1 (RN 1) were charge nurses at the North station. LVN 1 stated she had not witnessed Resident 1 ' s fall but had been the first staff person to respond to Resident 1 ' s fall. LVN 1 stated she was on break inside the charting/copier room at the North nursing station, where she could not see the nursing station area, when she heard residents yelling that Resident 1 had fallen. LVN 1 stated she left the charting/copier room and saw Resident 1 laying on the floor. LVN 1 stated she moved Resident 1 into a wheelchair with the assistance of Certified Nursing Assistant 2 (CNA 2). LVN 1 stated she had been unaware that Resident 1's assigned charge nurse, RN 1, had also been on break during the time of Resident 1's fall on 2/18/23. During a review of Resident 2 ' s Resident Face Sheet, dated 3/2/23, indicated Resident 2 was admitted to the facility in 2019. During a review of Resident 2 ' s MDS assessment, dated 2/27/23, the MDS assessment indicated Resident 2 was able to make himself understood and was able to understand others. During an observation and interview on 3/2/23, at 11:03 a.m., with Resident 2, at the North nurse ' s station, Resident 2 stated on 2/18/23, he and Resident 3 had been sitting in their wheelchairs near the North nurse ' s station when he saw Resident 1 walk by herself toward the North nurse ' s station. Resident 2 stated he saw Resident 1 hit her foot on Resident 3 ' s wheelchair footrest and fall forward. Resident 2 stated as Resident 1 fell , she hit her head on the solid nursing station countertop and continued her fall, hitting her head on the floor baseboard. Resident 2 stated Resident 1 ' s face was bleeding a lot. Resident 2 stated he yelled that Resident 1 had fallen and was bleeding and LVN 1 came out of the charting/copier room at the nurse ' s station, helped Resident 1 into a wheelchair, and used a pillowcase to stop the bleeding. During a concurrent interview and record review on 3/2/23 at 12:11 p.m., with the Director of Nursing (DON), Resident 1 ' s risk meeting notes dated 12/6/22, were reviewed. The DON stated Resident 1 had tripped over another resident while walking and had fallen on 12/6/22. The DON stated Resident 1 was alert, but disoriented and confused, walked fast, and was unaware of personal safety. The DON stated IDT had a meeting on 12/30/22 to discuss Resident 1 ' s falls, and the IDT recommended the intervention for staff to monitor Resident 1 ' s whereabouts. The DON stated she expected certified nursing assistants to know their assigned residents ' care needs, and for licensed nurses to communicate with each other and the DON about when they took their breaks. During an interview and record review on 3/2/23, at 2:05 p.m., with DON, Resident 1 ' s Fall Risk assessment, dated 12/14/22, was reviewed. The fall risk assessment form included the following areas of resident assessment: level of consciousness (measurement of a person ' s arousability and responsiveness to environmental stimuli), history of falls, mobility with elimination, gait/balance, medications, and diagnosis. The DON stated Resident 1 was marked as forgetful, no history of falls in the prior three months, required regular assistance with toileting, had a normal gait, did not take any psychotropic (a medication that affects how the brain works) medications, and had no active diagnosis predisposing her to falls. The DON stated Resident 1 ' s fall risk assessment dated [DATE] should have been marked with a history of one to two falls in the past three months, and that she had been taking the psychotropic medication Buspar (a medication used to treat anxiety) within the last seven days. The DON stated Resident 1 ' s fall risk score should have been 12 instead of six. The DON stated residents with a fall risk score of 10 or higher were considered at high risk for falls. The DON stated Resident 1 would have been placed on the Fall Prevention program if the December fall risk assessment had indicated the correct score of 12. The DON stated it was important to have the correct risk assessment, so the facility developed the correct plan of care for a resident at high risk of falls. During a record review of Resident 1 ' s Emergency Department (ED) discharge report document dated 2/18/23, the report showed Resident 1 obtained a facial hematoma [bruise] requiring sutured wound care and a nasal bone fracture (partial or complete break in the bone) on the left. During a record review of the facility ' s Policy and Procedure (P&P) titled, Fall Prevention (Falling Star), revised 8/9/13, the P&P indicated, Falling Star program is designed to provide the patient/resident who is at an increased risk for falls/injury with adequate supervision and assistive devices to help minimize the risk of injury from falls. Each resident who is at increased risk for falls/injury, as identified from the Fall Risk Assessment, criteria for inclusion in the program, and clinical judgment of the facility ' s IDT, will have a plan of care and interventions implemented to manage falls/injury The following criteria will be utilized by the IDT to determine the appropriateness of Patient/Resident to be included in the program .Patient/Resident has a score of 10 or above from Fall Risk Data Collection .If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions The MDS/IDT Care Conference team will also update the resident ' s care plan accordingly

Based on observation, interview and record review, for one of six (Resident 43) sampled residents who were reviewed for allegations of abuse, the facility failed to ensure Resident 43 was free from physical abuse when Hospitality Aide (HA) 5 punched Resident 43 in the face during an altercation. This failure resulted in Resident 43 sustaining a laceration (a tear, cut or opening in the skin caused by an injury) under the nose and above upper lip that had profuse bleeding and required hospitalization for suturing. Resident 43 returned from the hospital with two sutures below the nose and above the upper lip, and mild swelling on the area. HA 5's physically assault towards Resident 43 had the potential to cause Resident 43 to lose balance and fall on the concrete floor that could likely cause serious head injury and possibly death. The Administrator (ADM), Director of Nursing (DON) and Regional Director of Clinical Operations were notified by the survey team of the Immediate Jeopardy (IJ, a situation in which a provider's noncompliance with one or more requirements of participation have caused or is likely to cause serious injury, harm, impairment, or death to a patient/resident.) on 7/1/21 at 2:48 p.m. The facility failed to ensure Resident 43 was free from physical abuse. During an on-site survey on 7/2/21, and through observation, interviews and record reviews, the facility showed they initiated a plan of correction through immediate training of employees regarding abuse prevention. The IJ was abated on 7/2/21 at 11:21 a.m. Findings: Review of Resident 43's Face Sheet indicated Resident 43 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 43's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 5/6/21 indicated Resident 43 had a Brief Interview for Mental Status (BIMS, an assessment of one's orientation to time and capacity to remember) score of 8. The BIMS score range is from 0-15, with zero as the most impaired. Review of Resident 43's Behavioral Symptoms care plan last reviewed/revised 5/7/21 indicated Resident 43 had behaviors that included rejection of care, was physically and verbally abusive to others including staff. The care plan indicated a long-term goal for Resident 43's behavior to be diverted into a productive and meaningful activity. Approaches identified to achieve this goal included providing support to Resident 43 by allowing Resident 43 to express self without confrontation, encouraging Resident 43 to verbalize feelings and offer understanding and empathy, and removing Resident 43 from triggering environment to a calm and quiet place with supervision. During an interview with Administrator (ADM) on 6/29/21 at 9:38 a.m., ADM stated, on 6/28/21 at 6:45 a.m., a facility staff had summoned ADM about an incident at the back door. ADM stated, Hospitality Aide (HA) 5, who was assigned to watch the back door, was involved in an altercation with Resident 43. ADM stated, immediately after the incident and during interview with HA 5, HA 5 said Resident 43 called HA 5 names, pushed, and hit HA 5 to the point that HA 5 got emotional. ADM stated HA 5 reacted by hitting Resident 43. ADM stated Licensed Vocational Nurse (LVN) 5 witnessed the incident. During an interview and concurrent review of Resident 43's Progress Notes with LVN 5 on 7/1/21 at 9:11 a.m., LVN 5 stated, on 6/28/21 at 6:45 a.m., Resident 43 had just woken up and was in the hallway walking towards the back door. HA 5 was sitting on a chair at the back door. LVN 5 stated, Resident 43 said something incoherent and HA 5 could be heard talking back to Resident 43. LVN 5 stated, she told HA 5 to stop and leave Resident 43 alone but HA 5 did not listen. HA 5 then took his jacket off, stood up from the chair and walked towards Resident 43. Resident 43 punched HA 5 on the upper body and HA 5 punched Resident 43, hitting his face under the nose and above the upper lip. LVN 5 stated there was significant amount of bleeding on Resident 43's face that needed pressure and ice pack. LVN 5 stated the incident happened fast and did not expect HA 5 to react the way he did. LVN 5 stated, when a resident becomes aggressive, staff had to allow them to express how they feel while making sure of their safety. LVN 5 stated a staff should not react in a way that would escalate a resident's behavior. Resident 43's Progress Notes dated 6/28/21 indicated Resident 43 sustained a cut under his nose and was profusely bleeding . [Attending Physician] was notified and received order to transfer resident to the hospital for evaluation and [treatment]. The notes indicated Resident 43 was transferred to the hospital at 7:15 a.m. Review of Resident 43's Patient Visit Information dated 6/28/21 indicated Resident 43 was seen and treated at the Emergency Department for a laceration injury due to physical assault and absorbable sutures were placed. During an interview and concurrent observation with Resident 43 on 6/29/21 at 10:30 a.m., Resident 43 had a cut under the nose above the upper lip with mild swelling. Resident 43 stated somebody hit him in the face with something and when asked if his face hurt, he responded oh yeah. During an interview and concurrent review of HA 5's files with Director of Staff Development (DSD) 1 on 6/30/21 at 11:38 a.m., DSD 1 stated, upon HA 5's hire date on 5/2/18, facility provided HA 5 training on how to deal/manage residents with difficult behaviors, which was part of the dementia (a chronic progressive disease marked by memory loss, personality changes and impaired reasoning) training. DSD 1 stated a test was administered to evaluate HA 5's understanding of the topic. Review of the training document titled Dementia Care: Managing Challenging Behaviors indicated 10 examination questions that required responses from HA 5. DSD 1 stated HA 5 answered nine out of ten questions incorrectly. DSD 1 stated, because HA 5 failed the test, HA 5 needed to be re-trained by having HA 5 watch the video for the second time, discussing why the responses provided were incorrect, and having HA 5 re-take the test. DSD 1 stated there was no documentation that any of these steps were done and there was no documentation that another test was administered to HA 5. DSD 1 stated HA 5's abuse training in 2019 indicated a set of test questions to evaluate whether HA 5 understood abuse prevention protocol. DSD 1 stated HA 5 did not answer the test questions. During a follow-up interview with DSD 1 on 6/30/21 at 2:18 p.m., DSD 1 stated HA 5's files did not show any documentation that abuse training was provided in 2020 and 2021. Review of the facility's policy and procedure titled, Abuse & Neglect Prohibition, last revised May 2013, indicated Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property. The facility's policy indicated, physical abuse includes hitting, slapping, pinching, and kicking. The policy also indicated, under Procedure: Training, each employee will be trained regarding these policies, and such training is provided, During orientation, annually, and more often as determined by the facility.

Based on observation, interview, and record review, the facility failed to adequately supervise and prevent one (Resident 1) of eight sampled residents, from wandering outside the facility grounds near/onto a freeway overpass. The failure to supervise, resulted in Resident 1 eloping from the facility, which placed Resident 1 at risk for injury, serious harm from a potential fall, possible death by wandering into traffic, not receiving needed prescribed medications, and not having shelter, food or water. As a result, Resident 1 incurred a four-day hospitalization on the critical care unit after being found by the local authorities after 36 hours. An Immediate Jeopardy (IJ) situation was called on 2/5/21 at 3:00 p.m. with the Administrator (ADM) and Director of Nursing (DON) present, for failure to adequately supervise Resident 1, and for failure to provide training to employees on how to activate and monitor the back door alarm system. On 2/9/21 at 7:45 a.m., the IJ situation was lifted through observation, interview, and record review, the facility demonstrated they had initiated a plan of action for providing adequate supervision and environmental barriers to prevent elopement. The Administrator showed all residents were assessed for risk of elopement, employees were in-serviced on the functionality of the alarm system and the facility posted a staff by the backdoor twenty-four hours a day to monitor and secure the building. Findings: Review of Resident 1's Face sheet, indicated Resident 1 was admitted to the facility on [DATE] with multiple diagnoses which included altered mental state, and a history of traumatic brain injury (brain damage due to an external force), and substance abuse. Review of Resident 1's initial Admission assessment dated [DATE], indicated Resident 1 was not at risk for elopement. Review of Resident 1's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 2/21/21, reflected a score of eight on the Brief Interview for Mental Status. (BIMS, a scoring system used to determine a resident's cognitive abilities of attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status; a score of eight is an indication of moderate impairment of cognitive skills.) The MDS indicated Resident 1 was able to both understand others and to make himself understood. Review of Resident 1's Medication Administration Record (MAR) dated February 2021, indicated Resident 1 had the following medication orders: two medications for treatment of brain injury (Oxcarbazepine 300 milligrams (mg) twice daily for traumatic brain injury and [MEDICATION(S)] 250 mg, twice daily for an inability to relax); an antipsychotic medication (a group of medications used to treat mental conditions which have some loss of contact with reality; the antipsychotic medication [MEDICATION(S)], 25 mg twice daily for agitation and a desire to leave the facility); a medication to control high blood pressure (Doxazocin once a day); and a medication to control nerve pain (Gabapentin 300 mg three times a day). Review of the physical therapy evaluation dated 11/11/20, indicated Resident 1 was at risk for falls due to physical impairment from a [CONDITION(S)] (loss of oxygen to the brain as a result of impaired blood flow; commonly known as a stroke). Review of the Fall Risk Assessment, dated 12/29/20, indicated Resident 1 was at high risk for falls due to a balance problem and use of [CONDITION(S)] medications (medications which affect brain activities associated with mental processes and behavior). Review of Resident 1's nursing progress notes dated 1/24/21 at 9:45 p.m., indicated staff witnessed Resident 1 attempt an elopement from the facility. The nursing notes reflected Resident 1 had exited through the facility's backdoor at 3:15 p.m., and then went through the perimeter back gate, before being returned to the facility by staff. Review of Resident 1's nursing progress notes dated 1/25/21 at 10:26 a.m., Registered Nurse 1 (RN 1) wrote, suggested wander guard placement [Wander guard is a system to alert caregivers when residents are attempting to exit a facility unsupervised. It is a two-part system: a bracelet worn by the resident, and a sensor installed on an exit. When the bracelet passes across the sensor, an audible alarm sounds.] to alert the staff to redirect the resident from exit doors but the whole team [Inter-disciplinary Team] decided that was not appropriate at this time. Review of Resident 1's care plan titled, Category: Behavioral Symptoms, At Risk for: Elopement and Wandering Out of Facility, dated 1/25/21, indicated that some nursing interventions were to: provide activities to divert resident's attention from wandering, gently redirect resident back to supervised areas, allow resident to move in hallways safely, check resident's whereabouts q [every] fifteen minutes. During a telephone interview with the Certified Nursing Assistant 1 (CNA 1) on 2/7/21 at 1:10 a.m., CNA 1 confirmed she was assigned to Resident 1 on 2/4/21. CNA 1 stated she had assisted Resident 1 in the bathroom around 5:30 a.m. CNA 1 stated Resident 1 had asked for breakfast, but it had not been served yet. CNA 1 stated she had not heard either the backdoor alarm, or back gate alarm that morning. During an interview with the Physical Therapy Assistant 1 (PT 1) on 2/5/21 at 9:40 a.m., PT 1 stated he saw a person that resembled Resident 1 around 6:40 a.m. at the corner gas station about half a mile from the facility. PT 1 stated he had not stopped at the gas station, but continued to the facility, where he asked staff to check on Resident 1's whereabouts. PT 1 stated Resident 1 had weakness on the right side of his body, decreased mobility and flexibility of the right hand, and walked using a cane or walker (a walking aid with three or four upright supports and two handlebars for gripping while ambulating). Review of Resident 1's record titled, Observation Detail List Report, by Licensed Vocational Nurse 1 (LVN 1) dated 2/4/21, indicated, About 6:45 a.m., the receptionist came to North 2 asking if resident was in his room. Writer said, 'I think so, because he was just asking for breakfast 15 minutes ago.' And the writer went into the resident's room right away to check while still talking with receptionist, but unfortunately resident was not in his room. During an interview with Licensed Vocational Nurse 2 (LVN 2) on 2/5/21 at 9:50 a.m., LVN 2 stated she saw someone who resembled Resident 1 by the freeway overpass around 6:55 a.m. LVN 2 stated she continued to the facility and upon entering the facility, asked other staff if Resident 1 was missing. During a telephone interview with the ADM on 2/8/21, at 2:45 p.m., ADM confirmed employees had discovered Resident 1 was missing on 2/4/21, at 6:45 a.m., and were unable to locate the resident despite searching the area on foot and in automobiles. ADM stated police found Resident 1 on 2/5/21, around 7:00 p.m. The police took Resident 1 to the acute care hospital emergency department (ED) because he was combative when confronted by the police. ADM stated he was informed by ED staff that Resident 1 had some difficulty breathing, and was dehydrated (decreased body fluids) when he entered the ED. ADM confirmed Resident 1 had not received any of his scheduled medications for over 36 hours. A review of Resident 1's MAR dated 2/2021, reflected Resident 1 had missed a total of four doses of each of the two [CONDITION(S)] medications, 4 doses of the anti-psychotic medication, two doses of blood pressure medication, and six doses of nerve pain medication during his elopement on 2/4/21 and 2/5/21. A review of Resident 1's ED Provider Notes dated 2/5/21, indicated Resident 1 entered the ED on 2/5/21, at 8:08 p.m. Resident 1 had an elevated temperature of 99.3 degrees (normal value is 98.6 degrees), elevated heart rate of 122 (normal range is 72-80 beats per minute) and an elevated respiratory rate of 40 (normal range of 12-20 breaths per minute). The ED Provider Notes Plan indicated Resident 1 was to be admitted to the critical care unit because of abnormal brain function, agitation, and abnormal values of troponin enzymes (enzymes associated with function of the heart; elevation of the enzymes can be an indication of a heart attack). A review of Resident 1's acute care hospital document titled, Discharge Summary, dated 2/9/21, indicated Resident 1 was discharged from the hospital on 2/9/21. The Summary indicated Resident 1 required intravenous fluids to treat dehydration which was complicated by rhabdomyolysis (muscle breakdown, which can result in damage to the kidneys). The Discharge Summary also indicated Resident 1 had suffered from a type of heart attack known as NSTEMI, which was to be treated medically. During an observation and concurrent interview with Resident 1 on 2/24/21 at 11:20 a.m., Resident 1 lay in bed on his back with his eyes open and responded to questions. Resident 1 stated he was sick of this place and had been hungry, so he left; no one had been at the back door. Resident 1 stated he continued out of the facility through the facility's back gate. During a review of the facility's policy and procedure (PNP) titled, Resident Elopement, dated 8/15/2001, the PNP indicated, Facility will provide a safe environment and preventative measures for elopement. During an observation on 2/5/21 at 9:30 a.m., an employee monitored the front entrance door of the facility. At the back of the building was an unattended glass-paneled backdoor that opened to an outdoor fenced patio. The backdoor exit had a touch keypad and red alarm box with a key, on the right side of the doorframe within arm's reach. On the wall to the right of the door was another touch keypad. During an observation and concurrent interview with the Maintenance Supervisor (MS) on 2/5/21, at 10:50 a.m., MS stated the touch pad on the wall next to the door was an old system and was not operational. MS stated that the new touch pad alarm system [the touchpad on the doorframe] was installed on 12/21/20. MS stated there was a one-time in-service training on the new alarm system conducted on 12/21/20. MS demonstrated how to activate and deactivate the backdoor alarm system by entering a code on the touch keypad. During an observation on 2/5/21, at 11:05 a.m., with MS, the backdoor opened onto a concrete patio enclosed by fencing with an unlocked gate that led to the facility parking lot and city streets. During observations and concurrent interviews on 2/5/21: At 11:15 a.m., Certified Nursing Assistant 2 was unable to demonstrate how to enter the activation code for the new alarm system and stated she had not been trained on the new alarm system. At 11:25 a.m., Certified Nursing Assistant 3 stated she had not been trained on the new alarm system and did not know any of the codes for the keypad. At 11:30 a.m., Certified Nursing Assistant 4 stated she had not been trained on the new alarm system and did not know any of the codes for the keypad. At 11:40 a.m., Housekeeper 1 stated she had not been trained on the new alarm system and did not know any of the codes for the keypad. During a telephone interview with CNA 1 on 2/7/21, at 1:10 a.m., CNA 1 stated she was trained two or three months ago on how to use the keyed box to deactivate the alarm on the backdoor, but had not received any training on the new touch-pad alarm system or the new codes. During an interview with the Administrator (ADM) on 2/5/21, at 2 p.m., ADM confirmed only 36 facility employees out of the 115 total employees had been trained on the new alarm system. A review of the attendance roster for the In-service Training Record titled, Alarm Glass Door Egress . Alarm with Coded Code, dated 12/21/20, reflected 36 employees attended the training. CNA 1, CNA 2, CNA 3, CNA 4, and HK 1's names were not included on the training attendance roster. The Training Record indicated, Alarm to be activated daily and monitored to make sure alarm is on for safety.

Based on interview and record review, the facility failed to provide sufficient supervision for one (Resident 1) of three sampled residents when Resident 1 was left unattended outside the patio with a maximum temperature of 105 degrees Fahrenheit (°F, unit of measurement for temperature) This failure resulted in Resident 1 being found outside with a bloody nose and a body temperature of 101°F (normal body temperature is 97.8°F to 99.1°F), Resident 1 was sent to the emergency room for heat exhaustion (heat-related illness that can occur after exposure to high temperatures). Findings: Review of Resident Face Sheet dated 6/29/17 indicated facility admitted Resident 1 on 11/24/11 with [DIAGNOSES REDACTED]. Record review of the document titled, Minimum Data Set (MDS, an assessment tool), dated 12/25/16, indicated Resident 1 has poor memory. During an interview with Resident 1's family member (FM 1) on 6/29/17 at 8:39 a.m., FM 1 stated it was a hot day on 6/18/17 and another family member visited Resident 1. Upon arrival in the facility the family member could not find Resident 1, they searched the facility and found Resident 1 in the smoking area where Resident 1 passed out. FM 1 further stated that Resident 1 was weak and was sent and treated in the hospital for extreme heat. In an interview with Licensed Vocational Nurse 1 (LVN 1) on 6/29/17 at 11:20 a.m., LVN 1 stated Resident 1's husband visited on 6/18/17 and could not find Resident 1. The facility staff searched and found Resident 1 outside in the smoking area, bleeding from nose and a little confused. In an interview with Activity Staff (AS) on 6/29/17 at 11:50 a.m., AS stated Resident 1 left the activity room at 11:30 a.m. after church service and was not aware where Resident 1 went. In an interview with Certified Nursing Assistant (CNA 1) on 6/29/17 at 12:10 p.m., CNA 1 stated on 6/18/17 during lunch time she was looking for Resident 1 to deliver the lunch tray. CNA 1 found Resident 1 outside in the smoking area and brought her to the room. Review of the Resident Progress Notes, dated 6/18/17, indicated Resident 1 went to the smoking area for smoking, CNA 1 helped to bring Resident 1 back in the room. Resident 1's vital sign were: Temperature= 101°F, Pulse=143 beats per minute (normal range is 60 to 100 beats per minute) and oxygen saturation of 84-88 (normal range is 94-100 %) percent. The note further indicated Resident 1 .is very hot. Bleeding from nose .looks pale & (and) weakness (sic). Record review of the document titled, Emergency Depart. Discharge Instructions, dated 6/18/17, showed Resident 1's final [DIAGNOSES REDACTED]. It further indicated This is heat-related caused by loss of water and electrolytes from the body. It causes excess sweating, extreme fatigue, weakness, dizziness, nausea, vomiting and headache In an interview with the Administrator (ADM) on 6/29/17 at 11:15 a.m., ADM stated facility was aware of the Heat Advisory-All Facilities Letter (AFL, letter from the Licensing and Certification Program to health facilities that are licensed or certified by L&C. The information contained in the AFL may include changes in requirements in healthcare, enforcement, new technologies, scope of practice, or general information that affects the health facility) dated 6/16/17. Review of the All Facilities Letter (AFL) summary date (MONTH) 16, (YEAR) indicated The hottest temperatures are expected Saturday, (MONTH) 17 through Wednesday, (MONTH) 21, with many locations experiencing three digit temperatures, up to 110 degrees .Facilities must remember that the elderly and other health-compromised individuals are more susceptible to extreme temperatures and dehydration .CDPH (California Department of Public Health) recommends facilities implement the following measures to keep residents and clients comfortable during extreme hot weather .Stay indoors and out of sun during the hottest parts of the day . According to the AccuWeather forecast for (MONTH) 18, (YEAR) at Hayward California, it indicated the actual temperature reached as high as 105°F on 6/18/17.

Based on interview and record review, the facility failed to protect one of three sampled residents (Resident 1) from abuse when Certified Nursing Assistant 2 (CNA 2) shoved a spoon far back into Resident 1's mouth and slapped him on the cheek while feeding him breakfast. This deficiency resulted in Resident 1 being physical abused and suffering mental anguish. Findings: According to the undated facesheet, Resident 1 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Review of Resident 1's annual Minimum Data Set (MDS, an assessment tool used to guide care) dated 9/8/16, indicated Resident 1 had a BIMS (brief interview for mental status) score of 15 (cognitively intact). The staff assessed Resident 1 on the 9/8/16 MDS as having the ability to recall events. During an interview with Resident 1 on 7/25/17, at 1:20 p.m., Resident 1 stated CNA 2 was feeding him and shoved the plastic spoon so far into his mouth it hit the hanging thingy, uvula in my throat Resident 1 stated he then began gagging and screamed out repeatedly for someone to help. Resident 1 stated CNA 2 then slapped him on his right cheek. He said I felt mad and scared enough to have physically hurt him if I wasn't paralyzed. Resident 1 stated he asked to speak to the manager of the day, but no one ever came to talk to me. Resident 1 further stated although CNA 2 does not come into his room anymore, he still hears his voice in the hall and it frightens him because he is paralyzed and would not be able to defend himself if he needed to. During a phone interview with CNA 2 on 7/26/17 at 9:14 a.m., CNA 2 admitted to feeding Resident 1's breakfast, but denied slapping Resident 1 or causing him to gag or yell out. Review of a form titled Grievance/Complaint Report, dated 5/24/17 (no time), indicated CNA slap him on his right cheek. Then supervisor talk to the resident he (Resident 2) said .CNA was feeding him and spoon stuck to his throat .then CNA slap him on his Rt (right) cheek . Review of the employee file showed a Disciplinary Action Record dated 5/24/17, it indicated CNA 2 was suspended on 5/24/17 and returned to work on 5/27/17. The record further indicated CNA 2 had received in-service on abuse prevention and reporting and was warned to stay away from Resident 2. The facility's Abuse & Neglect Prohibition policy, last revised October 2004 indicated each resident has the right to be free from mistreatment, neglect, and abuse.

Based on observation, interview and record review, the facility failed to ensure one of one sampled residents (Resident 1) did not have liquid soap on his bedside table. As a result, Resident 1 ingested liquid soap and experienced vomiting, respiratory distress with low oxygen saturation levels (low amounts of oxygen in the blood). Resident 1 required emergent medical treatment and hospitalization at a general acute care hospital. Findings: On 1/14/16, the manufacturer's label for the Apple Strawberry Shampoo/Body Wash showed: For external use only. The manufacturer's website showed, Classification: ACUTE TOXICITY-ORAL-Category 5 .may be harmful if swallowed .Call poison center/doctor . Medical record review for Resident 1 showed he was in his 60's with [DIAGNOSES REDACTED]. Resident 1's MDS (Minimum Data Set for assessment which guides care), dated 11/7/15, showed he had cognitive difficulties and required extensive staff assistance for activities of daily living (eating, bathing, turning and repositioning, and mobility). Resident 1 was on a special diet of nectar thick liquids (for easier swallowing) to prevent aspiration (inhalation of food or liquids into the lungs). On 1/21/16 review of a nursing note titled, SBAR Note, dated 12/16/15 at 7:30 a.m., Licensed Vocational Nurse (LVN 1) wrote the following prior to transferring Resident 1 to the hospital: CNA (CNA 1 certified nursing assistant) noticed resident (1) was vomiting .noticed some bubbles in the vomitus .she (CNA 1) proceeded to check each container on the resident's bedside table .CNA discovered that one unlabeled container had a soapy liquid in it which the resident could have ingested inadvertently .first aid was provided and the resident was transferred to the emergency department for further evaluation .Resident 1 confirmed that he drank some of the contents of that cup .Oxygen saturation at 82% (normal range is 95-100%) .oxygen at 3 liters per minute was started . Also Suction of oral secretions .crackles (abnormal breath sounds usually caused by fluids within the airways) noted all over lung field . The Hospital Transfer Summary, dated 12/24/15, when Resident 1 was transferred back to facility (eight days after the vomiting incident) showed, .Discharge Diagnoses: [REDACTED].man with known history of dementia with underlying psychosis (an abnormal condition of the mind when one loses contact with reality), who was found to have drunk the detergent, which was put in front of his table and then, the exact amount is unknown, approximately 300 ml (10 ounces) and soon after the patient has discomfort and vomiting, and then decreased oxygen saturation, and the patient was rushed to the hospital for evaluation. Presumed aspiration of the detergent. The patient's respiratory failure continued in the hospital with oxygen supplement, nebulizer treatment (liquid medication becomes a mist which can be inhaled into the lungs), and needed BiPAP (face mask and tubing connected to a device that delivers pressurized air and oxygen at two alternating levels to a person's airway), then was brought to the ICU (intensive care unit) .Subsequently, the patient has had leukocytosis (increase in white blood cells signaling infection) with fever, aspiration pneumonia and antibiotic was started . During an interview on 1/14/16 at 9:30 a.m., Administrator (Admin)said the facility completed its investigation and concluded Resident 1 ingested a pink (colored) liquid soap that was left at his bedside, and was sent to the hospital where he was treated for [REDACTED]. Admin added that the morning shift CNA 1 found Resident 1 vomiting with bubbles and discovered an unlabeled cup with liquid soap on Resident 1's bedside table. Admin stated the facility staff did not know soap was in the Styrofoam cup until after Resident 1 drank it and began vomiting. During an interview on 1/14/16 at 9:59 a.m., CNA 1 stated, I saw (Resident 1) vomiting .I went to get the Charge Nurse .(CNA 2) was assigned to care for Resident 1 . CNA 1 stated around breakfast at 7:30 a.m. she was feeding another resident in the same room. CNA 1 stated that Resident 1 was eating breakfast when the vomiting began. During an interview with concurrent record review, on 1/14/16 at 10:17 a.m., the Staffing Coordinator and Central Supply Director (SCD) stated that baths/showers were performed during the 7 a.m.-3 p.m. and 3 p.m.-11 p.m. shifts only. SCD stated the facility's practice was for housekeeping staff to pour the pink-colored apple, strawberry, liquid soap from a gallon-sized container into smaller 8 oz bottles for resident use but not into Styrofoam cups. SCD stated that housekeeping stored the gallon sized containers of soap in a shed outside and that Maintenance brought it inside for soap dispensing at the CNA's request. During an interview on 1/14/16 at 10:35 a.m. LVN 1 stated she was notified by CNA 1 that Resident 1 vomited. LVN 1 stated she saw vomit on Resident 1's clothing and that CNA 1 reported to her, looks like he drank soap . LVN 1 said pink-colored soap used by the facility for baths/showers was kept in gallon-sized containers in the housekeeping closet. LVN 1 also stated that sometimes CNA's brought their own containers, or cups to dispense and carry the soap. She stated that these containers/cups should have written labels, or a photocopy of the exact label from the gallon-sized container on them. LVN 1 confirmed that on 12/16/15, Resident 1 drank from an unlabeled Styrofoam cup of soap. During an interview on 1/14/16 at 10:57 a.m., CNA 2 confirmed that Resident 1 vomited after eating breakfast. CNA 2 said Resident 1 feeds himself and loved to drink liquids/fluids. CNA 2 said monitoring contents of drinking cups was not usually done. LVN 1 confirmed statements from ADMIN, CNA 1 and CNA 2 that they were unaware of the presence of the cup of soap on Resident 1's bedside table until after he drank from it and started vomiting. During a telephone interview, on 1/20/16 at 2:30 p.m., CNA 3 confirmed that baths were not scheduled during the night shifts. CNA 3 also confirmed she did not dispense soap into a cup in preparation for Resident 1's bath scheduled for the 7 a.m.- 3 p.m. shift on 12/16/15. CNA 3 stated that Resident 1 was on a nectar thick diet and she did not place a hydration cup at his bedside. CNA 3 stated that she checked Resident 1's bedside area between 6-6:45 a.m., before ending her shift and there was no cup of soap. During observation and concurrent interview on 1/14/16 at 11:47 a.m., the Acting Director of Nurses (ADON) stated she was not on duty on 12/16/15. ADON described the facility's practice of using white 16 oz Styrofoam cups for hydration passes. ADON stated the cup with soap, on Resident 1's bedside table, was the same as the ones used for hydration. During an interview on 1/14/16 at 12:15 p.m., ADON stated she was not aware that the pink soap was supplied in gallon-sized containers at the facility. During observation and concurrent interviews and accompanied by the ADON, Director of Maintenance (DM) said the facility kept a supply of gallon-sized containers of the apple, strawberry, liquid soap in the locked storage shed, along with the manufacturer-made 8 oz labeled bottles, used for dispensing to the CNA's for residents' baths/showers. DM and ADON accompanied Surveyor to a closet where the housekeeper presented a gallon-sized container of the apple, strawberry soap. There were no 8 oz manufacturer-made, labeled bottles for distributing the pink, liquid soap to the staff. During an interview and concurrent record review, on 1/14/16 at 1 p.m., Admin stated there was no facility policy and procedure that reflected the facility's practice of liquid soap dispensing for bed bath use and monitoring for unlabeled containers. Admin presented a facility memo, dated 12/18/15, which was distributed to all staff with the following instructions: In order to prevent any and all possibilities of accidental ingestion of inappropriate materials by residents .Charge Nurses will verify that CNA's conduct a thorough inventory of all items at the bedside of each resident, especially liquid containers .the inventory shall be conducted at the end of each shift .CNA's will verify that all liquid containers at the bedside of the resident are correctly labeled, dated, and appropriate for that resident .

2. In an interview on 7/15/14 at 2:57 p.m., DA (Dietary Aide) 2 stated that on 7/8/14 during tray line, she was assigned to be side A which meant that she was supposed to call out the allergy, dislikes and other preferences of residents based on what was written on the meal ticket. She added that when she read Resident 17's meal ticket, she got confused because it showed that Resident 17 did not like beef but also showed that Resident 17 liked cheeseburger. DA 2 said that she gave the meal ticket to the Registered Dietician (RD), who was also watching the tray line procedure. DA 2 also added that she told the RD, "what are you guys gonna give this patient?" DA 2 said that she did not remember what happened after she gave the meal ticket to the RD and did not see the meal tray that was taken to Resident 17. DA 2 also stated that she did not see any allergy written on the meal ticket. 3. During tray line observation and concurrent joint interview on 7/9/14 at 12:10 p.m., Dietary Aide (DA) 3 did not shout out Resident 25's allergy to chocolate. This observation was confirmed by Cook 1 and Dietary Manager (DM) who was at the tray line. The DM stated that although shouting out the allergy was part of a correction plan, it was "still a work in progress". DA 3 stated that she thought she only needed to call out the allergy to Cook 1. DM added that he has yet to give in-service to DA 3 later in the afternoon but that he already told her about the concern prior to the tray line. Review of Resident 25's physician's orders [REDACTED]. Review of the In-service Training Report dated 7/8/14 from 3 p.m. to 3:30 p.m. showed that dietary staff will be re-trained on proper tray line procedures that included calling out texture, allergy, dislikes and special requests. The report, however, did not show any signatures of dietary staff who were given the training. Based on observation, interview and record review for one (Resident 17) of 23 sampled residents and one randomly selected resident (Resident 25). For Resident 17 the facility failed to follow the physician's prescribed therapeutic diet order, as evidenced by serving fish to the resident, to which resident was allergic. For Resident 25, the facility did not follow their system to ensure that the tray line staff were aware of food allergies [REDACTED]. The facility had known and documented that Resident 17 had an allergy to fish, and served him fish that was unidentifiable and was not explained to him prior to Resident 17 took a bite of the fish. This failure resulted in Resident 17 to be harmed by the facility's failure to ensure that Resident 17 was free an allergic reaction from a known food allergy, and it was determined to constitute an IJ (Immediate Jeopardy). The definition of immediate jeopardy: is a situation in which the provider'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. After consultation with HFES supervisor, the Administrator and Director of Nursing were notified of the IJ on 7/8/14 at 5:00 p.m. by the survey team. The survey team was confirmed by interviews and record reviews that the facility's plan of correction was initiated through in-service of all dietary and nursing staff present on 7/8/14 to identify and ensure that all residents with food allergies [REDACTED]. In the presence of the survey team, the Administrator and Director of Nursing, the IJ was abated on 7/8/14 at 8:08 p.m. Findings: 1. Review of Resident's 17's "Admission Record" on 7/8/14 showed that Resident 17 had an allergy to fish. Review of Resident 17's "Diet Order and Communication" dated 12/5/13, 1/6/14, and 2/22/14, showed Resident 17 was allergic to "fish products". Review of Resident 17's "Diet History/Food Preference List", dated 12/02/13, showed that Resident 17 had an allergy to fish. Review of Resident 17's diet tray card, dated 7/8/14 showed, "Allergy: FISH". Review of the facility's policy and procedure titled, "Diet (Tray) Card", dated 4/15/2011, stated that, "The diet card's primary purpose is to inform the dietary staff how to assemble the resident's meal tray and to provide caregivers with mealtime information. The diet (tray) card contains the resident's name, room number, ordered diet, allergy information. Ensure that the tray card information is current and that it matches the diet as prescribed by the physician. Ensure that the food items served are consistent with tray card information and the planned menu". Review of Resident 17's care plan titled, "Food Allergy Care Plan", dated on 1/9/14, showed that the facility had a care plan for Resident 17's allergy to fish. The interventions of the care plan included, "Identify food type that resident is allergic to, inform dietary personnel, place an alert notice in the medical record, alert staff of resident's food allergy, check meal intake". In an interview on 7/8/14 at 2:00 p.m., Resident 17 stated, and in an upset and a raised tone of voice, that he had an allergy to fish, but the facility served him fish for his lunch. Resident 17 stated that around noon time, he did not know that he was served fish because the fish was covered with a "breaded" coat, which made it look like a "breaded chicken patty". Resident 17 confirmed that the staff member, who gave him the tray in his room, did not explain to him what the lunch meal was. Resident 17 confirmed that he had spoken to the Social Service Assistant (SSA), Dietary Manager (DTM), Activity Director (ACD), and Registered Nurse Supervisor (RNS) 1 that he had taken a bite of the fish that was served to him for lunch. Resident 17 stated that staff, "did not do anything" after he had bitten the fish, and "this had happened twice since he was admitted " to the facility. Resident 17 stated that his symptoms to an allergic reaction included the tingling of the lips and a burning sensation on the upper part of his tongue. In an interview on 7/8/14 at 2:36 p.m., the ACD confirmed that Resident 17 had fish "patties" for lunch. In an interview on 7/8/14 at 2:47 p.m., the DTM confirmed that Resident 17 had "Pollock Fish" on his meal tray. The DTM confirmed that the dietary aides gave Resident 17 fish for lunch and that the dietary aides should not give him the fish meal for lunch. The DTM confirmed that the dietary aides should call out all the residents' allergies [REDACTED]. In an observation and concurrent interview on 7/8/14 at 3:00 p.m., RNS 1 confirmed that Resident 17 had an allergy to fish. RNS 1 confirmed that Resident 17 did take a bite of the fish, but did not swallow the fish. RNS 1 confirmed that Resident 17 reported that he had a tingling sensation on his lips due to the taste of fish he had bitten. RNS 1 confirmed that he notified Resident 17's doctor and received an order for [REDACTED]. RNS 1 confirmed that Resident 17 should be monitored for 72 hours after he had an allergic reaction to the fish. RNS 1 stated that he would inform Resident 17's nurse to administer the [MEDICATION NAME] as the physician prescribed for Resident 17. RNS 1 approached Registered Nurse (RN) 1 to administer the [MEDICATION NAME] to Resident 17. Review of Resident 17's "Medication Record", dated 7/8/14 at 3:00 p.m., showed that [MEDICATION NAME] 25 mg was given to Resident 17 by mouth for his "tingling on lips". In a phone interview on 7/8/14 at 4:24 p.m., the Medical Director/Primary Physician (MDR/PP) confirmed that Resident 17 had an allergy to fish. The MDR/PP confirmed that the RNS 1 reported to him that Resident 17 had an allergic reaction with a symptom of tingling sensation of his tongue. The MDR/PP confirmed that he had not seen Resident 17 after he was notified by RNS 1. The MDR/PP confirmed that he had ordered [MEDICATION NAME] every four hours when needed (PRN) for the resident. In an interview on 7/8/14 at 4:42 p.m., Resident 17 stated that he already had previous two episodes of allergic reactions due to being served fish since he was admitted to the facility. One was happened on the first week of admission (Resident 17 was admitted on [DATE]) and the other one was happened in February 2014. Resident 17 confirmed that the tingling of the lips and the burning sensation on the upper part of tongue were the same reactions as he had before. A condition of Immediate Jeopardy was identified by the survey team for the facility's failure to ensure that Resident 17 was not harmed from his food allergy. On 7/8/14 at 5:00 p.m., in the presence of the survey team and the ADM and Director of Nursing (DON), an Immediate Jeopardy was announced. In an interview on 7/8/14 at 6:00 p.m., Resident 17 confirmed that staff did not explain to him what the food contents of his lunch were. Resident 17 described that the food was square shaped and breaded, and looked like a "fried chicken patty" or "hot pocket". Resident 17 confirmed that his food always was given to him covered. Resident 17 confirmed that he was given [MEDICATION NAME] on 7/8/14 after he had taken a bite of the fish and had an allergic reaction. Resident 17 stated that the fish was not even supposed to reach him. In an interview on 7/10/14 at 7:40 a.m., the Director of Staff Development (DSD) confirmed that not all staff members, which included the dietary aides and nursing staff, were in-serviced in regards to the facility's plan of correction for the Immediate Jeopardy. In a concurrent interview and review of Sysco's (the facility's food distribution company) fish recipe titled, "Precooked breaded Pollock portions" on 7/10/14 at 8:23 a.m., the DTM confirmed that the "Precooked breaded Pollock Portions" contained fish (Pollock) as stated in the ingredients and that it was the same fish served to Resident 17. In an interview on 7/10/14 at 10:04 a.m., SSA stated that she observed that the resident bit a piece of fish then he spit in a napkin. SSA stated that it was "our fault that (Resident 17) received the fish". In an interview on 7/11/14 at 2:56 p.m., the DTM confirmed that Dietary Aide (DA) 2 did not call out the food allergy for Resident 17 during the lunch time tray line service on 7/8/14. In a phone interview on 7/14/14 at 1:08 p.m., Certified Nurse Aide (CNA) 1 confirmed that she served the food tray, which contained the fish, to Resident 17. CNA 1 confirmed that she did not know what the food contents were on the food tray. She just set it on Resident 17's bed with food content covered. In a phone interview on 7/14/14 at 1:20 p.m., RN 1 confirmed that Resident 17 had an allergy to fish. RN 1 confirmed that it was the nurse responsibility to check the tray card and compare to food before it was given to the resident. In a phone interview on 7/14/14 at 2:20 p.m., CNA 1 confirmed that Resident 17 was in his room and she brought him the food tray, which the plate was covered, and placed it on his bed. CNA 1 confirmed that she did not know what allergies [REDACTED]. Review of Resident 17's "Nurse's Notes", dated 7/8/14 at 3:00 p.m., stated, "Resident was c/o (complaining of) that they (staff) served him fish during lunch time and from the tray he took a bite but did not swallow it but able to spit it out the fish. Called to MD (Medical Doctor) regarding resident's c/o tingling sensation around the lips. MD ordered to give, [MEDICATION NAME] 25 milligrams (mg) P.O. (medication administration by mouth) BID (twice a day) PRN (as needed) and will continue to monitor". Review of Resident 17's "Physician Order", dated 7/8/14, showed that, "[MEDICATION NAME] 25 mg P.O. (By mouth) QBID (every twice a day) allergy PRN, M/B (manifested by) tingling in the lips", was ordered by MDR via telephone order (T.O.). Review of Resident 17's "Nutritional Progress Notes " that was given by MRD on 7/9/14 showed that there were no notes written since 5/8/14. Review of Resident 17's "Change of Condition Notes", dated on 7/8/14 and 7/9/14, showed that his change of condition was due to, "allergic reaction". According to the World Allergy Organization, "What are the symptoms and signs of food allergy?: Symptoms include itching of the lips, tongue, roof of the mouth and throat, with or without facial swelling, and/or tingling of the lips, tongue , roof of the mouth and throat" (Reference: http://www.worldallergy.org/public/allergic_diseases_center/foodallergy/).